Thinkpath Engineering Services (Canada)

Ankle arthritis is estimated to affect 1% of the world's adult population, with total ankle replacement (TAR) being a surgical option for patients with ankle arthritis who have failed conservative management. Newer implants have markedly improved TAR survivorship, however periprosthetic osteolysis causing aseptic loosening continues to be a main cause of TAR failure. Furthermore, the presence of periprosthetic osteolysis varies immensely in the literature. The HINTEGRA prosthesis is a mobile-bearing, three component TAR with survivorship being comparable to other third-generation TARs, but with fewer implant failures and reduced additional surgery for implant loosening. The objective of this study was to review the HINTEGRA TAR experience at a single institution specifically evaluating the radiographic formation, location and progression of cysts and the relation between cysts and prosthesis alignment, reoperations and implant survivorship. Retrospective study including all HINTEGRA TARs completed by one experienced foot and ankle surgeon from 2006 to 2014 using a direct anterior approach. Weight bearing anteroposterior (AP) and lateral preoperative, postoperative, 1-year postoperative and long-term weight bearing radiographs were reviewed, assessing for implant alignment as well as presence, location and progression of cysts. Implant survivorship and reoperations were reported to analysis any relationship with the alignment and presence of osteolysis. There were 51 TARs identified with radiographic and clinical follow up of 5.8 ± 3.5 years and 8.6 ± 3.0 years, respectively. The most common indication for surgery was posttraumatic arthritis found in 38 (75.0%) of patients. Eighty-four cysts were detected in 37 patients, with increasing number and size of cysts being correlated to length of time from surgery. The most common location for cysts to develop was the posterior tibia. Thirteen patients had enlarging cysts identified over time with the lateral malleolus being the most common location. Six patients met criteria for malaligned prosthesis, five of which were in the sagittal plane and did not appear to have any effect on development of osteolysis or implant survival. The one patient with coronal malalignment had a progressive talar cyst develop requiring reoperation. Seven patients met definition for a loosening prosthesis, two of which required reoperation because of osteolysis, and two others due to infection and impingement respectively. A total of 12 (23.5%) patients required a reoperation, two (3.9%) related to presence of osteolysis, four (7.8%) for deep infections and two (3.9%) required revision due to implant failure. Osteolysis is a very common finding after TAR using the HINTEGRA prosthesis, specifically on long-term radiographic follow up although most cysts do not appear clinically significant with no effect on outcomes. Progressive cysts termed “ballooning/expansile” and prosthesis coronal malalignment appear to be risk factors for developing osteolysis, prosthesis loosening and reoperation. This study also shows excellent and reliable outcomes of the HINTEGRA TAR compared to designer surgeons with acceptable complication and revision rates.

ABSTRACTThis tutorial focuses on how to get started with considering health equity in systematic reviews of interventions. We will explain why health equity should be considered, how to frame your question, and which interest‐holders to engage. This is the first tutorial in a series on health equity. The second tutorial focuses on implementing health equity methods in your review.

The Healthcare Management and Information Systems Society Electronic Medical Record Adoption Model (HIMSS EMRAM) score is a widely-used metric of digital maturity. In this single-centre study, we explore how a hospital can have a high formal HIMSS EMRAM score, despite clinicians reporting poor real-world digital maturity. Using a workflow analysis approach, we examine pain points and physician tasks to develop novel metrics of true digital maturity, which better capture clinician experience. In addition to developing a quantitative approach to digital maturity that may be of use at other sites, this approach reveals key limitations of the HIMSS EMRAM score. These include its inability to account for clinician preference for non-EMR workarounds when electronic medical record configurations are available but impractical, and its inability to account for key clinical workflows not captured in the predefined HIMSS scoring system.

O Ministério da Saúde define infecção do sítio cirúrgico (ISC) como "um processo infeccioso que afeta tecidos, órgãos e cavidades acessados durante um procedimento cirúrgico". Assim se tornando uma razão comum para a permanência hospitalar mais longa de um paciente e por conseguinte altos custos hospitalares devido a infecção. É mais frequente nos primeiros 5 à 7 dias após a cirurgia e pode ser limitada ao local cirúrgico em 60% a 80% dos casos ou afetar o paciente em nível sistêmico. O objetivo deste estudo é evidenciar a importância do profissional de enfermagem na prevenção da infecção de sitio cirurgico. Trata-se de uma pesquisa bibliográgica do tipo revisão integrativa da literatura, após a leitura de títulos foram excluídas 4.833 pesquisas duplicadas, e que estavam presentes em duas ou mais bases de dados ou que estavam completamente fora da temática abordada. Esse número foi reduzido para 188 artigos, que seguiram para análise de resumos. A partir dessa análise, foram excluídos 134, restando apenas 55 artigos a serem lidos na íntegra. Destes, 49 artigos foram excluídos por não serem condizentes com o tema da pesquisa e não correspondiam aos objetivos deste estudo. Desse modo, após a leitura aprofundada e completa, foram selecionados 5 artigos para compor a amostra, os quais correspondiam com o objetivo do estudo. O estudo possibilitou identificar que o enfermeiro ocupa uma posição mais próxima ao paciente, sendo assim eles precisam estar devidamente treinados e aptos para avaliar e prestar uma assistência adequada baseada em evidência e identificar precocemente os fatores de risco que desencadeiam para as infecções do sítio cirúrgico.

Introduction: Patients with a diagnosis of transient ischemic attack (TIA) or minor stroke with an acute infarction on brain imaging are at higher risk of subsequent stroke. Our goal was to establish if the Canadian TIA Score (CTS) could predict infarction on magnetic resonance imaging (MRI) when a computed tomography (CT) scan was negative for stroke and aimed to identify clinical factors predictive of a positive MRI. Methods: Patients were selected from the prospective cohort used for the validation of the CTS in 13 centers. Patients with negative CT scans who underwent MRI within 7 days were analyzed. The main outcome was cerebral infarction defined as MRI diffusion-weighted imaging (DWI) positivity. Associations between confirmed stroke and demographic characteristics, clinical features, laboratory findings, and medications were determined using a multivariate logistic regression model. Subsequent stroke rate at 7, 30, and 90 days was analyzed. Results: From 11,507 patients, 1,048 met inclusion criteria. MRI positivity was 15.4%, 30.4%, and 50.0% for the low, medium, and high-risk CTS groups, respectively. Subsequent stroke/TIA rates were higher with confirmed ischemic lesions on MRI at 90 days: twice (10.0%) in the low-risk group, 51 (22.3%) in the medium-risk group, and 20 (24.7%) in high-risk patients. 1.7% of DWI negative patients had a subsequent stroke. Predictive factors in multivariable models for DWI positivity in the medium-risk group were male (OR=1.53; 95% CI 1.11-2.12), hypertension (OR=1.63; 95% CI 1.17-2.27), clinical history of unilateral weakness (OR=2.09; 95% CI 1.50-2.91), language disturbance (OR=1.43; 95% CI 1.03-1.97), and the presence of pronator drift on examination (OR=2.18; 95% CI 1.37-3.47). Conclusion: The CTS helps predict MRI findings and confirmed ischemic lesion is a predictor of the recurrence risk of stroke. The low-risk group showed few positive MRIs and had a lower recurrence rate justifying less urgent MRI. In the medium-risk group, we highlighted findings that should raise the suspicion of an ischemic lesion and these patients should be prioritize for rapid investigation of stroke etiology. In the high-risk group, patients are at risk for stroke despite negative imaging and MRI should not delay management.

BackgroundAs of May 2022, Ontario has seen more than 1.3 million cases of COVID-19. While the majority of individuals will recover from infection within 4 weeks, a significant subset experience persistent and often debilitating symptoms, known as “post-COVID syndrome” or “Long COVID.” Those with Long COVID experience a wide array of symptoms, with variable severity, including fatigue, cognitive impairment, and shortness of breath. Further, the prevalence and duration of Long COVID is not clear, nor is there evidence on the best course of rehabilitation for individuals to return to their desired level of function. Previous work with chronic conditions has suggested that the addition of electronic case management (ECM) may help to improve outcomes. These platforms provide enhanced connection with care providers, detailed symptom tracking and goal setting, and access to relevant resources. In this study, our primary aim is to determine if the addition of ECM with health coaching improves Long COVID outcomes at 3 months compared to health coaching alone.MethodsThe trial is an open-label, single-site, randomized controlled trial of ECM with health coaching (ECM+) compared to health coaching alone (HC). Both groups will continue to receive usual care. Participants will be randomized equally to receive health coaching (± ECM) for a period of 8 weeks and a 12-week follow-up. Our primary outcome is the WHO Disability Assessment Scale (WHODAS), 36-item self-report total score. Participants will also complete measures of cognition, fatigue, breathlessness, and mental health. Participants and care providers will be asked to complete a brief qualitative interview at the end of the study to evaluate acceptability and implementation of the intervention.DiscussionThere is currently little evidence about the optimal treatment of Long COVID patients or the use of digital health platforms in this population. The results of this trial could result in rapid, scalable, and personalized care for people with Long COVID which will decrease morbidity after an acute infection. Results from this study will also inform decision making in Long COVID and treatment guidelines at provincial and national levels.Trial registrationClinicalTrials.gov NCT05019963. Registered on 25 August 2021.

The mixed lineage kinase domain-like protein (MLKL) was first discovered in 2012 as the executioner of necroptosis. In line with this, we showed that MLKL knockdown ( Mlkl KD) by administration of antisense oligonucleotides to atherosclerotic-prone Apoe -knockout ( Apoe -/-) mice did indeed decrease necroptosis and necrotic core in the atherosclerotic plaque. However, there were no changes in overall plaque area, suggesting additional roles of MLKL during atherosclerosis. During atherogenesis, the spleen allows for the expansion of hematopoietic stem and progenitor cells (HSPCs) and mature myeloid cells that drive atherogenesis. Accordingly, we observed splenomegaly with an expansion of splenic HSPCs and mature myeloid cells upon Mlkl KD. However, bone marrow transplantation studies revealed that MLKL did not impact hematopoiesis through its expression in hematopoietic cells. Within hematopoietic reservoirs such as the spleen, HSPCs are regulated by their interaction with microenvironmental cell types, including endothelial cells. We thus hypothesized that MLKL preserves the microenvironment to repress hematopoiesis in the spleen during atherosclerosis. Flow cytometry and immunofluorescence staining during a time course of atherosclerosis revealed a progressive decrease of splenic endothelial cells that was correlated with a reduction of MLKL endogenously or by Mlkl KD, suggesting that splenic MLKL modulates the endothelial cells known to regulate hematopoiesis. RNA sequencing of these splenic endothelial cells revealed two major pathways that were perturbed upon Mlkl KD, including cell cycle and factors related to leukocyte differentiation. Adoptive transfer of CD45.1 HSPCs to CD45.2 Apoe -/- mice during Mlkl KD revealed an expansion of mature immune cells in the spleen as compared to control, together demonstrating the influence of MLKL on the splenic microenvironment and subsequently hematopoiesis. In conclusion, we here demonstrate a novel role for MLKL in regulating the balance of hematopoiesis, specifically through preservation of splenic endothelial cells that promote HSPC quiescence, and more generally highlight the contributions of the spleen and its impact on inflammatory pathways that potentiate atherogenesis.

Genome-Wide Association studies (GWAS) have identified more than 200 common genetic variants that cumulatively account for approximately 50% of individual risk for coronary artery disease (CAD). This information is relevant to CAD risk assessment but may also provide new insights into the underlying biology of atherosclerosis. The vast majority of these common single nucleotide polymorphisms (SNPs) are in non-coding regions of the genome and distal from protein coding genes; thus mechanistically linking GWAS identified SNPs to CAD is challenging. Here, we have investigated the relationship of rs667920, identified as a top CAD associated SNP in a recent GWAS, to CAD. Conditional analysis, using lipid traits and other phenotypes as covariates, is consistent with the hypothesis that hypercholesterolemia mediates the impact of rs667920 on CAD risk. Although rs667920 is intronic to STAG1, originally denoted as a possible risk gene, it is not associated with altered expression of STAG1 in CAD relevant tissues according to GTEx. Chromatin immunoprecipitation data indicate the presence of enhancer activity overlapping rs667920 in fibroblast and muscle cells, consistent with cis regulation Indeed, this SNP is a significant expression quantitative locus (eQTL) for a neighboring gene, PCCB, encoding the Propionyl-CoA carboxylase beta subunit, in vascular tissues and whole blood, with the common allele rs667920_T being linked to increased expression of PCCB, circulating lipids and CAD, suggesting that lower expression of PCCB may be beneficial. Although its eQTL relationship with rs667920 was considerably weaker, mendelian randomization analysis of whole blood datasets prioritized NCK1, another local gene. Additional experiments are currently underway in our laboratory to validate and complement these preliminary findings.

<p>The calculation, analysis and interpretation of seismic attributes is an important tool in reservoir seismology and has been used since the 1950’s to improve the characterization of oil and gas fields around the world.</p><p>Recent applications of seismic attributes in the near surface use the coherency attribute to detect faults as well as average and normalized frequencies and similarity to map ground instability and image sinkholes. Seismic attributes are also used to assess unconsolidated oil sand reservoirs, to evaluate ocean/lake bottom responses from unconsolidated sediments, and to visualize the internal structure of mass transport deposits. In unconsolidated near-surface sediments seismic attributes are rarely used. This is likely due to the high variability present in the near surface.</p><p>Combined P-/S-attributes are difficult to obtain because of the large difference between P-wave and S-wave velocity, as well as frequency and resolution. Therefore, the most important step to obtain these combined attributes is performing depth conversions for the P- and S-wave reflection profiles that perfectly match horizons and features in the depth domain.</p><p>We present commonly used attributes calculated from a shear-wave reflection profile imaging the dome structure of an esker. Attributes calculated from the compressional-wave reflections are compared to the shear-wave attributes which benefit from higher resolution than P-wave attributes. We highlight the attributes which best enhance the general subsurface structure and list new information gained from different attributes.</p>

Identification of large-volume, short-duration mafic magmatic events of intraplate affinity in both continental and oceanic settings on the Earth and other planets provides invaluable clues for understanding several vital geological issues of current concern. Of particular importance is understanding the assembly and dispersal of supercontinents through Earth's history, dramatic climate change events including mass extinctions, and processes that have produced a wide range of large igneous province (LIP)-related resources, such as Ni–Cu–PGE, Au, U, base metals and petroleum. This volume comprises 21 contributions on the latest developments and new information on LIPs and their plumbing systems and presents methodical studies on different components of LIP plumbing systems. These articles are especially helpful in understanding continental break-up events, regional domal uplift and a variety of metallogenic systems, as well as the temporal and spatial distribution of LIPs, their origin and their likely links to mantle plumes/superplumes.