York General Hospital

IntroductionA total hip replacement is a common procedure performed by trauma and orthopaedic surgeons. Successful outcomes in arthroplasty surgery have significantly contributed to more hip replacement procedures being performed annually. This has also increased the incidence of femoral periprosthetic fractures, leading to more revision hip replacement procedures being performed.MethodsThis is a retrospective cohort study carried out at a district general hospital in the United Kingdom. Theatre records were reviewed from 2018 to 2022 to identify patients with a femoral periprosthetic fracture. Following the data collection, the patients were split into two groups. The first group analysed the patient outcomes through the type of surgical intervention they had, and the second group analysed the patients according to the timing of surgical intervention.ResultsThere were 88 patients included in the study, out of which 49 had revision surgery and 39 had fixation for the femoral periprosthetic fracture. No statistically significant difference was observed in 30-day mortality and one-year mortality for the patients having revision or fixation surgery. Similarly, the results were not found to be significant in 30-day mortality and one-year mortality for the patients having surgery within 36 hours or after 36 hours of diagnosis.ConclusionOverall, the findings of this study are in keeping with the literature. Input from the specialist arthroplasty team is often required for the management of femoral periprosthetic fractures. There is no significant impact on mortality with a delay in surgical intervention for femoral periprosthetic fractures, unlike hip fractures. Medical optimisation and careful planning lead to better patient outcomes for this group of patients.

Background: The molecular and epidemiological landscape of C. difficile infection (CDI) has evolved markedly in the last decade; however, limited information is available contrasting differences between adult and pediatric populations. We describe a multicenter study evaluating healthcare-associated (HA) and community-associated (CA) adult and pediatric-CDI identified in the Canadian Nosocomial Infection Surveillance Program (CNISP) network from 2015 to 2022. Methods: Hospitalized patients with CDI were identified from up to 84 hospitals between 2015–2022 using standardized case definitions. Cases were confirmed by PCR, cultured, and further characterized using ribotyping and E-test. We used two-tailed tests for significance (p≤0.05). Results: Of 30,817 cases reported, 29,245 were adult cases [HA-CDI (73.2%), CA-CDI (26.8%)] and 1,572 were pediatric cases [HA-CDI (77.7%), CA-CDI (22.3%)]. From 2015 to 2022, HA-CDI rates decreased 19.7% (p=0.007) and 29.4% (p=0.004) in adult and pediatric populations, respectively (Figure 1). CA-CDI rates remained relatively stable in the adult population (p=0.797), while decreasing 60.7% in the pediatric population (p=0.013). Median ages of adult and pediatric patients were 70 (interquartile range (IQR), 58–80) and seven (IQR, 3–13) years, respectively. Thirty-day all-cause mortality was significantly higher among adult vs. Pediatric CDI patients (11.0% vs 1.4%, p < 0.0001). No significant differences in other severe outcomes were found. Ribotyping and susceptibility data were available for 4,620 samples: 3,558 adult (77.0%) and 1,062 pediatric (23.0%). The predominant adult and pediatric ribotypes (RT) were 106 (12.2/16.2%), 027 (11.4/3.2%), and 014 (8.8/8.2%). Overall, RT027 prevalence significantly decreased from 17.9% in 2015 to 3.2% in 2022 (p=0.003), while RT106 increased from 8.5% to 14.4%. Resistance rates among adult and pediatric isolates were similar for all antimicrobials tested except moxifloxacin (16.2% vs. 6.2%, p < 0.0001, respectively). Adult moxifloxacin resistance decreased from 30% to 6.3% from 2015 to 2022 (p=0.006). Adults with moxifloxacin-resistant CDI were older (median: 74 vs. 69 years, p < 0.001) and had higher thirty-day all-cause mortality (13% vs. 9.8%, p=0.041) and recurrence (10% vs. 5.7%, p < 0.001) compared to those with moxifloxacin non-resistant CDI, while these trends were not observed in pediatric patients. Among RT027 strains, moxifloxacin resistance decreased from 91.0% in 2015 to 7.1% in 2022. There was one metronidazole-resistant pediatric sample in 2018 and no resistance to vancomycin or tigecycline in either population. Conclusion: We have found differences in the epidemiological and molecular characteristics of adult and pediatric CDI, with higher thirty-day all-cause mortality among adults. Overall, RT106 has replaced RT027 as the predominant ribotype with a concomitant decrease in fluoroquinolone resistance.

Rhinoscleroma is a granulomatous infectious disease that typically affects the nasopharynx and upper respiratory tract. Non-endemic (e.g., North American) and laryngeal cases are rare. This case highlights the importance of pathognomonic Mikulicz cells for diagnosis.

We describe a unique population of IgG + memory B cells poised to switch to IgE that contains high affinity allergen-specific clones in peanut allergy.

Abstract Background: Proportional assist ventilation with load-adjustable gain factors (PAV+) is a mechanical ventilation mode that delivers assistance to breathe in proportion to the patient's effort. The proportional assistance, called the gain, can be adjusted by the clinician to maintain the patient's respiratory effort or workload within a normal range. Short-term and physiological benefits of this mode compared to pressure support ventilation (PSV) include better patient-ventilator synchrony and a more physiological response to changes in ventilatory demand. Methods: The objective of this multi-centre randomized controlled trial (RCT) is to determine if, for patients with acute respiratory failure, ventilation with PAV+ will result in a shorter time to successful extubation than with PSV. This multi-centre open-label clinical trial plans to involve approximately 20 sites in several continents. Once eligibility is determined, patients must tolerate a short-term PSV trial and either (1) not meet general weaning criteria or (2) fail a 2 minute- Zero Continuous Positive Airway Pressure (CPAP) Trial using the rapid shallow breathing index, or (3) fail a spontaneous breathing trial (SBT), in this sequence. Then, participants in this study will be randomized to either PSV or PAV+ in a 1:1 ratio. PAV+ will be set according to a target of muscular pressure. The weaning process will be identical in the two arms. Time to liberation will be the primary outcome; ventilator-free days and other outcomes will be measured. Discussion: Meta-analyses comparing PAV+ to PSV suggest PAV+ may benefit patients and decrease healthcare costs but no powered study to date has targeted the difficult to wean patient population most likely to benefit from the intervention, or used consistent timing for the implementation of PAV+. Our enrolment strategy, primary outcome measure and liberation approaches may be useful for studying mechanical ventilation and weaning and can offer important results for patients.

The linkage of Electronic Medical Records, Administrative and other data sources is highly valuable for research and health system monitoring. Once linked, combined resources can be analyzed to provide the answers to a variety of health questions that otherwise could not be answered. However, legislative and administrative barriers, including lengthy processes for data sharing agreements, may preclude timely linkage which is a key requirement during pandemics. ObjectiveTo develop a method using a patient’s health trajectory to probabilistically link primary care Electronic Medical Record (EMR) data with administrative and other data, without the need to transfer large datasets or identifiable information. To determine the legislative feasibility, accuracy and validity of this linkage process. Study DesignIdentify data strings that do not directly identify patients and could be used as unique linkage variables. The data strings, which we are calling dataprints, are sufficiently similar over time in different databases. One example in Ontario, Canada, is the pattern of submitted health claims. For every patient seen by a family physician, there exists a unique pattern of dates/billing codes/diagnoses over time. These unique patterns are reasonably similar in EMR and administrative datasets. We will apply an algorithm which turns the string in the selected dataprints to an irreversibly hashed code for each person. The hashed code and no additional information will be provided by both data controllers to a trusted-third party who will determine which records match and send a mapping table to both. This enables analyses to be run in parallel, without divulging any direct person identifiers. DatasetIndividuals contained in the University of Toronto Practice Based Research Network (UTOPIAN). Outcome MeasuresLinkage quality will be assessed by the number of true matches and represented by sensitivity, specificity and positive and negative predictive values. ResultsThe method will be evaluated against a validated, deterministically linked reference standard at North York General Hospital using de-identified EMR and hospital data. Results will inform processes to enable analyses across datasets while adhering to privacy legislation.

To the Editor: Although Shah et al (1) seek to address whether cardiopulmonary resuscitation is proportionate (2), their methodology is misleading and has the potential to promote therapeutic nihilism for patients who are critically ill with the novel coronavirus disease 2019. The authors report 100% in-hospital mortality in the 63 patients for whom resuscitation was attempted and deaths in an additional 86 patients for whom a do-not-resuscitate (DNR) order was written. Although these data would seem dispositive for the futility of the intervention, the authors do not report on the overall survival rates for all patients who had a DNR order. While we are told that 86 patients died with a DNR order in place, that is not the complete picture. Were there other patients with a DNR order who did not have a cardiac arrest who survived to discharge during the study period? Reporting on how many of similarly situated patients who were made DNR survived to discharge would have helped contextualize institutional DNR practices. Prospective data on the outcomes on all patients with DNR orders would provide a fuller picture of prognosis for this critically ill cohort, not simply reporting deaths in those who arrested. Why is this important? First, appreciating the full denominator of all patients with a DNR order is important as one could draw the false inference that all patients who are ill enough to have a DNR order will have an arrest and die. Some patients with DNR orders may have survived to discharge and never progressed to cardiac arrest. The problem with the data by Shah et al (1) is that it does not address this critical question. Second is the effect that the presence of a DNR order can have on the aggressiveness of care. Although this study describes what happened to the 63 patients who were resuscitated, it cannot tell us what “would have happened” if resuscitation had been attempted in the other 86 patients. In addition, Shah et al (1) report that of the 18 patients who had return of spontaneous circulation after resuscitation, DNR orders were written for eight patients before they passed. This raises the question of whether orders about life-sustaining therapy become a self-fulfilling prophecy about futility. Such was the case in a 2011 study of in-hospital mortality of patients with severe traumatic brain injury (3). Overall mortality was 31.2%, but 70% of those deaths were due to a withdrawal of life-sustaining therapy. Here, death was not due to the natural history of brain injury but rather due a decision about withdrawal of life-sustaining therapy, which, while possibly justified, might have precluded more salubrious outcomes. In the face of the pandemic surge, experts called for early and aggressive goals of care discussions (4). In retrospect, we now know that many of these discussions occurred without good prognostic data (5). Given this legacy, it is critical that our ethical stance toward the futility—or utility—of resuscitation not hinge upon data from a retrospective chart review.

This article was migrated. The article was marked as recommended. Background and objectives:Overprescribing of antibiotics in primary care is a prominent concern in the context of increasing antimicrobial resistance worldwide. Medical trainees are a key group to deliver thoughtful antimicrobial stewardship training. This study examined the factors influencing antibiotic prescribing for upper respiratory tract infections (URTI) by family medicine residents in order to identify educational interventions. Methods: Using purposive sampling of family medicine residents, semi-structured interviews were conducted until thematic saturation was reached. Interviews were coded into the domains of the Theoretical Domains Framework (TDF). Belief statements were created to characterize each domain and categorized as enablers or barriers to appropriate prescribing. Domains were plotted on the Behaviour Change Wheel (BCW) and intervention functions identified. Results:Twelve participants were interviewed. Nine domains of the TDF were relevant to antibiotic prescribing. Social influence was a prominent theme with the preceptor and patient being key influences on resident prescribing. Learning goals were also a key theme including the desire to strengthen independent clinical decision-making skills and improve antibiotic knowledge. Residents' beliefs about capabilities were challenged when faced with diagnostic uncertainty. Additional domains included: professional role; environmental context and resources; intentions; beliefs about consequences and capabilities, and knowledge. Using the BCW, nine intervention functions were identified to change antibiotic prescribing behaviour. Conclusion: This study found nine domains of the TDF were relevant to family medicine resident antibiotic prescribing for URTI. Nine intervention functions could be used to guide intervention design.

A 23-year-old female presents with right lower quadrant pain that has been intermittent for the past several days. The pain suddenly worsened 1 hour ago. She denies vaginal bleeding or discharge, dysuria, fever, and back pain, but she has had several episodes of nausea with nonbloody, nonbilious vomiting. On examination, she is tender in the right lower quadrant, but her abdomen is not rigid.

Abstract Objective: To assess the quality of recommendations from 161 CPGs using AGREE-REX-D (Appraisal of Guidelines REsearch and Evaluation – Recommendations Excellence Draft).Design: Cross-sectional studySetting: International CPG community.Participants: 322 international CPG developers, users, and researchersIntervention: Participants were assigned to appraise one of 161 CPGs selected for the study using the AGREE-REX prototype toolMain outcome measures: AGREE-REX-D scores of 161 CPGs (7-point scale, maximum 7).Results: Recommendations from 161 CPGs were appraised by 322 participants using the AGREE-REX-D. CPGs were developed by 70 different organizations. The total overall average score of the CPG recommendations was 4.23 (standard deviation (SD)=1.14). AGREE-REX-D items that scored the highest were (mean; SD): Evidence (5.51; 1.14), Clinical relevance (5.95; SD 0.8), and Patients/population relevance (4.87; SD 1.33), while the lowest scores were observed for the Policy values (3.44; SD 1.53), Local applicability (3,56; SD 1.47) and Resources, tools and capacity (3.49; SD 1.44) items. CPGs developed by government-supported organizations and developed in the UK and Canada had significantly higher recommendation quality scores with the AGREE-REX-D tool (p<0.05) than their comparators. Conclusions. We found that there is significant room for improvement of some CPGs such as the considerations of patient/population values, policy values, local applicability and resources, tools and capacity. These findings may be considered a baseline upon which to measure future improvements in the quality of CPGs.