Publications by authors named "Forough Farrokhyar"

252 Publications

Retrospective Review of the Clinical Outcomes of Surgically Managed Patients with Intracranial Abscesses: A Single-Center Review.

World Neurosurg 2022 Jul 5. Epub 2022 Jul 5.

Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

Objective: This study analyzed patient, radiologic, and clinical factors associated with operative brain abscesses and patients' functional outcomes.

Methods: A retrospective analysis was conducted of neurosurgical cases of brain abscesses from 2009 to 2019 at a Canadian center. Functional outcome was recorded as Modified Rankin Scale score and Extended Glasgow Outcome Scale score. Multivariate analysis was conducted to identify relevant prognostic factors.

Results: We identified 139 patients managed surgically for brain abscesses. Resection alone was performed in 64% of patients, whereas 26.6% underwent aspiration alone. Most were adults (93.2%) and male (68.3%). Immunocompromise risk factors included diabetes (24.5%), cancer (23.7%), and immunosuppressive therapy (11.5%). Likely sources were postoperative (17.3%), systemic spread (16.5%), and poor dentition (12.9%). Microorganisms cultured from abscess samples were mixed growth (28%), Streptococcus anginosus (24.5%), and Staphylococcus aureus (7.9%). Disposition was home (42.4%) or repatriation to a home hospital (50.4%). By Extended Glasgow Outcome Scale, 25.2% had an unfavorable outcome including a mortality of 11.5%. Factors on multivariate analysis associated with poor outcome included diabetes (odds ratio, 2.8; 95% confidence interval [CI], 1.2-5.0) and ventricular rupture (odds ratio, 5.0; 95% CI, 1.7-13.5; hazard ratio, 12; 95% CI, 3.9-37.0). Supratentorial superficial eloquently located abscess was also associated with poor outcome (hazard ratio, 5.5; 95% CI, 1.8-16.7). Outcomes were similar with surgical excision and aspiration.

Conclusions: Ventricular rupture and diabetes are significant risk factors for poor outcomes in intraparenchymal brain abscesses. No clear difference in outcomes was found between surgical excision or aspiration in our retrospective cohort.
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http://dx.doi.org/10.1016/j.wneu.2022.06.126DOI Listing
July 2022

Review and Quality Assessment of Systematic Reviews and Meta-analyses on the Management of Pediatric Inguinal Hernias: A Descriptive Study.

J Surg Res 2022 Oct 18;278:404-417. Epub 2022 Jun 18.

Professor of Epidemiology and Biostatistics Research Director, Department of Health, Evidence, Impact, McMaster University, Ontario, Canada.

Introduction: Research quality in pediatric surgery has been challenged by multiple factors, including the low incidence of some congenital pathologies and rare event rates. With the rapid increase of pediatric surgical literature, there is a need for systematic reviews to synthesize evidence. It is important to assess the quality of these systematic reviews.

Objective: This study aims to examine the reporting of systematic reviews and meta-analyses, using inguinal hernia repair as an index diagnosis.

Methods: MEDLINE, Embase, and CINAHL databases were searched for systematic reviews and/or meta-analyses of interventions on inguinal hernia in the pediatric population. The quality reporting was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2 tools.

Results: Of 1449 unique reports, 21 studies were included (15 meta-analyses and six systematic reviews). Median percent reported items for PRISMA and AMSTAR 2 were 72.2% and 70.5%, respectively. The least reported items in PRISMA were protocol registration (27.6%), synthesis of results (13.0%), and a risk of bias across studies (20.6%). For AMSTAR 2, the least reported items were reporting of source of funding (14.3%), appropriate methods for statistical combination of results (25.0%), and pre-establishment of protocol (28.6%). All critical items were completely or partially fulfilled in 5/21 (23.8%) of the studies and completely absent in 1/21 (4.8%) studies.

Conclusions: The results of this study highlight relatively good reporting quality, yet a poor methodological quality of systematic reviews/meta-analyses in the pediatric surgery literature on inguinal hernia management.
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http://dx.doi.org/10.1016/j.jss.2022.04.008DOI Listing
October 2022

Preoperative Angiography for Free Fibula Flap Harvest: A Case Series.

Plast Surg (Oakv) 2022 May 5;30(2):108-112. Epub 2021 May 5.

Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

Purpose: To assess if preoperative angiography of the lower extremity is necessary to detect abnormalities that alter operative planning of a free fibula flap (FFF). The secondary objective is to determine whether abnormalities are identified on physical examination.

Methods: A retrospective case series of patients receiving preoperative lower extremity angiography for FFF was performed. Between November 2004 and July 2016, patients assessed for FFF reconstruction by a single surgeon were reviewed. Outcomes analyzed were preoperative physical examination, angiography findings, changes in operative plan, and perioperative complications including flap failure and limb ischemia. Level of agreement between physical examination and angiography findings was analyzed.

Results: A total of 132 consecutive patients were assessed for FFF, of which 70 met the inclusion criteria. Mean age was 60.9 (range: 22-88) years old. All patients underwent aortic angiogram runoff, except for 2 who received computed tomography angiography. The surgical plan was altered based on angiography findings in 9 (12.9%) patients, and 7 (77.8%) of these cases had a normal physical examination. A further 6 (8.6%) patients had physical examination findings precluding the use of FFF, whereas imaging demonstrated the contrary. Physical examination demonstrated low predictability of aberrant vascular anatomy, with a sensitivity of 22.2%. There were no limb ischemia complications.

Conclusions: Routine preoperative angiography of the lower extremity for all patients being evaluated for FFF is important to ensure safety and success of the procedure. Physical examination alone is insufficient to detect vascular abnormalities that may result in limb or flap compromise.
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http://dx.doi.org/10.1177/2292550321996960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9096851PMC
May 2022

Job Satisfaction Among Plastic Surgery Residents in Canada.

Plast Surg (Oakv) 2022 May 27;30(2):151-158. Epub 2021 Apr 27.

Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

Objective: Resident wellness is a focus of medical training and is prioritized in both Canadian and American accreditation processes. Job satisfaction is an important component of wellness that is not examined in the literature. The purpose of this study was to analyze job satisfaction in a national sample of plastic surgery residents, and identify factors that influence satisfaction.

Methods: We designed a cross-sectional survey adapted from existing instruments, with attention to thorough item generation and reduction as well as pilot and clinical sensibility testing. All plastic surgery residents at Canadian institutions were surveyed regarding overall job satisfaction as well as personal- and program-specific factors that may affect satisfaction. Predictors of satisfaction were identified using multivariable regression models.

Results: The response rate was 40%. Median overall job satisfaction was 4.0 on a 5-point Likert scale. Operative experience was considered both the most important element of a training program, and the area in most need of improvement. Senior training year ( < .01), shorter commute time ( = .04), fewer duty hours ( = .02), fewer residents ( < .01), and more fellows ( < .01) were associated with significantly greater job satisfaction.

Conclusions: This is the first study to gather cross-sectional data on job satisfaction from a national sample of plastic surgery residents. The results from this study can inform programs in making tangible changes tailored to their trainees' needs. Moreover, our findings may be used to inform a prospectively studied targeted intervention to increase job satisfaction and resident wellness to address North American accreditation standards.
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http://dx.doi.org/10.1177/22925503211007237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9096853PMC
May 2022

Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study.

Can J Surg 2022 Jan-Feb;65(1):E97-E103. Epub 2022 Feb 8.

From the Department of Thoracic Surgery, McMaster University, Hamilton, Ont. (Minervini, Hanna, Farrokhyar, Coret, Hughes, Schneider, Lopez-Hernandez, Agzarian, Finley, Shargall); the Department of Thoracic Surgery, St. James University Hospital, Leeds, UK (Brunelli, Miyazaki); the Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ont. (Farrokhyar); the Department of Oncology, Thoracic Surgery Unit, AUSL Bologna Maggiore Teaching Hospital, Bologna, Italy (Bertolaccini); and the Department of Thoracic Surgery, San Gerardo Hospital Monza, Italy (Scarci)

Background: Prolonged air leaks are increasingly treated in the outpatient setting, with patients discharged with chest tubes in place. We evaluated the incidence and risk factors associated with readmission, empyema development and further interventions in this patient population.

Methods: We undertook a retrospective cohort analysis of all patients from 4 tertiary academic centres (January 2014 to December 2017) who were discharged home with a chest tube after lung resection for a postoperative air leak lasting more than 5 days. We analyzed demographics, patient factors, surgical details, hospital readmission, reintervention, antibiotics at discharge, empyema and death.

Results: Overall, 253 of 2794 patients were analyzed (9.0% of all resections), including 30 of 759 from centre 1 (4.0%), 67 of 857 from centre 2 (7.8%), 9 of 247 from centre 3 (3.6%) and 147 of 931 from centre 4 (15.8%) ( < 0.001). Our cohort consisted of 56.5% men, and had a median age of 69 (range 19-88) years. Despite similar initial lengths of stay ( = 0.588), 49 patients (19.4%) were readmitted (21%, 0%, 23% and 11% from centres 1 to 4, respectively, = 0.029), with 18 (36.7%) developing empyema, 11 (22.4%) requiring surgery and 3 (6.1%) dying. Only chest tube duration was a significant predictor of readmission ( < 0.001) and empyema development ( = 0.003), with a nearly threefold increased odds of developing empyema when the chest tube remained in situ for more than 20 days.

Conclusion: Discharge with chest tube after lung resection is associated with serious adverse events. Given the high risk of empyema development, removal of chest tubes should be considered, when appropriate, within 20 days of surgery. Our data suggest a potential need for proactive postdischarge outpatient management programs to diminish risk of morbidity and death.
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http://dx.doi.org/10.1503/cjs.006420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8834240PMC
March 2022

When to believe a subgroup analysis: revisiting the 11 criteria.

Eye (Lond) 2022 Jan 31. Epub 2022 Jan 31.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.

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http://dx.doi.org/10.1038/s41433-022-01948-0DOI Listing
January 2022

Antibiotic Prophylaxis in Alloplastic Breast Reconstruction: Regimens and Outcomes.

Plast Surg (Oakv) 2022 Feb 19;30(1):25-31. Epub 2021 May 19.

Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada.

Purpose: Surgical site infections (SSI) in prosthesis-based breast reconstruction can have a significant impact on patient outcome. Despite current guidelines recommending 24 hours of postoperative antibiotics, various perioperative antimicrobial regimens are reported in the literature. Consensus on the optimal duration of antibiotics remains unclear. In this study, the aim is to compare the incidence of surgical site infections following different antibiotic durations in alloplastic breast reconstruction.

Methods: In this retrospective cohort study, all consecutive patients who underwent expander/implant-based breast reconstruction between January 2009 and December 2014 at a tertiary centre were included. Data on patient demographics, risk factors, operative time, choice and timing of antibiotic used before surgery, and the duration of postoperative antibiotic use were collected. The primary outcome, SSI, is defined according to CDC criteria.

Results: A total of 507 consecutive expander/implant-based cases were included. Minimum follow-up time was 1 year. The overall infection incidence was 14% (95% CI: 11%-17%), and the rate of subsequent explantation was 8%. Of the infected cases, 80% (45/56) received 1 week of postoperative antibiotic, while 20% (11/56) had a prolonged course of antibiotics (2-3 weeks; = .003, odds ratio [OR] = 2.9; 95% CI: 1.4-5.8). Most infections were superficial (65%). Prior history of radiation treatment was identified as a risk factor for developing surgical site infection ( = .02).

Conclusion: Overall infection rate and risk factors for infections are in keeping with current literature. Prescribing one week of postoperative antibiotic was found to be associated with a higher incidence of SSI compared to a more prolonged antibiotic regimen.
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http://dx.doi.org/10.1177/2292550321995730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8793750PMC
February 2022

Elevated international normalized ratio is correlated with large volume transfusion in pediatric trauma patients.

J Pediatr Surg 2022 May 14;57(5):903-907. Epub 2022 Jan 14.

McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada.

Background: Pediatric trauma patients may benefit from a balanced transfusion strategy, however, determining when to activate massive transfusion protocols remains uncertain. The purpose of this study was to explore whether certain scoring systems can predict the need for large volume transfusion.

Methods: We conducted a retrospective review of pediatric trauma patients who presented to our center and required a transfusion of packed red blood cells. Baseline laboratory and clinical data were used to calculate Trauma Associated Severe Hemorrhage (TASH) score and a previously reported composite of acidosis and coagulopathy.

Results: We identified 518 pediatric trauma patients who presented to our center between January 1, 2013 and December 31, 2018. These patients were less than 18 years of age (mean 9.6 years) and had an injury severity score ranging from 1 to 50 (mean 11.3). Forty-three patients (8.3%) received a transfusion within 24 hours of presentation, ranging from 4 to 139 mL/kg of packed red blood cells (mean 23.1 mL/kg). Transfusion volume was associated with acidosis and coagulopathy scores (r = 0.37, p = 0.033) and international normalized ratio (INR) (r = 0.34, p = 0.03) but not TASH (p = 0.72). Patients with INR≥1.3 received a higher mean volume of packed red cells compared to those with normal values (34 versus 18 mL/kg, p = 0.046).

Conclusion: Pediatric trauma patients who undergo transfusion of packed red blood cells are likely to require large volume transfusion if their baseline INR is ≥1.3. These patients may benefit from a balanced transfusion strategy, such as utilization of massive transfusion protocols or whole blood.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.12.050DOI Listing
May 2022

Use of breast milk in infants with uncomplicated gastroschisis: A retrospective cohort study.

J Pediatr Surg 2022 May 13;57(5):840-845. Epub 2022 Jan 13.

Division of Pediatric Surgery, McMaster University, Hamilton, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster University, Hamilton, Canada. Electronic address:

Background: Infants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy.

Methods: We conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality.

Results: We identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age <32 weeks, birth weight <1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1-16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037).

Conclusion: Exclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.12.045DOI Listing
May 2022

Image-Guided versus Freehand Ventricular Drain Insertion: Systematic Review and Meta-analysis.

World Neurosurg 2022 Apr 13;160:85-93.e5. Epub 2022 Jan 13.

Neurosurgery Division, Surgery Department, McMaster University, Hamilton, Ontario, Canada.

Background: Ventricular drain insertion is a common neurosurgical procedure, typically performed using a freehand approach. Use of image guidance during drain insertion could improve accuracy and reduce the incidence of drain failure. This review aims to assess the impact of image guidance on drain placement accuracy, failure rate, and number of ventricular cannulation attempts.

Methods: We searched MEDLINE, Embase, and Cochrane Library databases from inception to February 2021 for studies comparing image-guided versus freehand ventricular drain insertion. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias and quality of evidence. Pooled data were reported using random effects model. The ROBINS-I tool was used to assess risk of bias and the GRADE approach was used to assess quality of evidence.

Results: Of 1102 studies retrieved, 17 were included for a total of 3404 patients. All included studies were of non-randomized design. Pooled data on drain accuracy and drain failure rates showed favorable effect of image guidance, with risk ratio of 1.31 (95% confidence interval [CI] 1.13-1.51, low quality evidence) and 0.63 (95% CI 0.48-0.83, moderate quality evidence), respectively. Pooled data were equivocal for number of attempts with mean difference score of -0.14 times (95% CI -0.44 to 0.15, very low-quality evidence). Heterogeneity was substantial for drain accuracy and failure rate outcomes.

Conclusions: In patients undergoing ventricular drain insertion, the use of image guidance may enhance drain accuracy and reduce drain failure rate. The use of image guidance probably does not decrease the number of drain insertion attempts.
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http://dx.doi.org/10.1016/j.wneu.2022.01.036DOI Listing
April 2022

Routine systematic sampling versus targeted sampling during endobronchial ultrasound: A randomized feasibility trial.

J Thorac Cardiovasc Surg 2022 07 4;164(1):254-261.e1. Epub 2021 Dec 4.

Division of Thoracic Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada. Electronic address:

Objective: Triple normal lymph nodes, appearing benign on computed tomography, positron emission tomography, and endobronchial ultrasound, have less than a 6% probability of malignancy. We hypothesized that targeted sampling (TS), which omits biopsy of triple normal lymph nodes during endobronchial ultrasound, is not an inferior staging strategy to systematic sampling (SS) of all lymph nodes.

Methods: A prospective randomized feasibility trial was conducted to decide on the progression to a pan-Canadian trial comparing TS with SS. Patients with cN0-N1 non-small cell lung cancer undergoing endobronchial ultrasound were randomized to TS or SS. Lymph nodes in the TS arm crossed over to receive SS. Progression criteria included recruitment rate (70% minimum), procedure length (no significant increase for TS), and incidence of missed nodal metastasis (<6%). Mann-Whitney U test and McNemar's test on paired proportions were used for statistical comparisons.

Results: The progression criterion of 70% recruitment rate was achieved early, triggering a planned early stoppage of the trial. Nineteen patients were allocated to each arm. The median procedure length for TS was significantly shorter than SS (3.07 vs 19.07 minutes; P < .001). After crossover analysis, 5.45% (95% confidence interval, 1.87-14.85) of lymph nodes in the TS arm were upstaged from N0 to N2, but this incidence of missed nodal metastasis was below the 6% threshold. During surgical resection, the nodal upstaging incidence from N0 to N2 was 0% for 15 lymph nodes in each arm.

Conclusions: Progression criteria to a pan-Canadian, noninferiority crossover trial comparing TS with SS have been met, and such a trial is warranted.
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http://dx.doi.org/10.1016/j.jtcvs.2021.11.062DOI Listing
July 2022

Comparison of Two Drainage Systems on Chronic Subdural Hematoma Recurrence.

J Neurol Surg A Cent Eur Neurosurg 2021 Nov 16. Epub 2021 Nov 16.

Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada.

Background:  Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage, especially among the elderly, with a recurrence rate as high as 33%. Little is known about the best type of drainage system and its relationship with recurrence. In this study, we compare the use of two drainage systems on the recurrence rate of CSDH.

Methods:  We retrospectively analyzed the charts of 172 CSDH patients treated with bedside twist drill craniostomy (TDC) and subdural drain insertion. Patients were divided into two groups: group A ( = 123) received a pediatric size nasogastric tube [NGT]), whereas group B ( = 49) had a drain commonly used for external ventricular drainage (EVD). Various demographic and radiologic data were collected. Our main outcome was recurrence, defined as symptomatic re-accumulation of hematoma on the previously operated side within 3 months.

Results:  In all, 212 cases of CSDH were treated in 172 patients. The majority of patients were male (78%) and had a history of previous head trauma (73%). Seventeen cases had recurrence, 11 in group A and 6 in group B. The use of antiplatelet and anticoagulation agents was associated with recurrence ( = 0.038 and 0.05, respectively). There was no difference between both groups in terms of recurrence (odds ratio [OR] = 1.42; 95% confidence interval [CI]: 0.49-4.08;  = 0.573).

Conclusion:  CSDH is a common disease with a high rate of recurrence. Although using a drain postoperatively has shown to reduce the incidence of recurrence, little is known about the best type of drain to use. Our analysis showed no difference in the recurrence rate between using the pediatric size NGT and the EVD catheter post-TDC.
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http://dx.doi.org/10.1055/a-1698-6212DOI Listing
November 2021

Corrigendum to: Refining evidence-based retinopathy of prematurity screening guidelines: The SCREENROP study.

Paediatr Child Health 2021 Nov 20;26(7):444. Epub 2021 Aug 20.

Canadian Neonatal Network, Toronto, Ontario.

[This corrects the article DOI: 10.1093/pch/pxz085.].
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http://dx.doi.org/10.1093/pch/pxab065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8581521PMC
November 2021

Contemporary trends in the level of evidence in general thoracic surgery clinical research.

Eur J Cardiothorac Surg 2022 05;61(5):1012-1019

Department of Surgery, Division of Thoracic Surgery, McMaster University, Hamilton, ON, Canada.

Objectives: The large volume of scientific publications and the increasing emphasis on high-quality evidence for clinical decision-making present daily challenges to all clinicians, including thoracic surgeons. The objective of this study was to evaluate the contemporary trend in the level of evidence (LOE) for thoracic surgery clinical research.

Methods: All clinical research articles published between January 2010 and December 2017 in 3 major general thoracic surgery journals were reviewed. Five authors independently reviewed the abstracts of each publication and assigned a LOE to each of them using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme. Data extracted from eligible abstracts included study type, study size, country of primary author and type of study designs. Three auditing processes were conducted to establish working definitions and the process was validated with a research methodologist and 2 senior thoracic surgeons. Intra-class correlation coefficient was calculated to assess inter-rater agreement. Chi-square test and Spearman correlation analysis were then used to compare the LOE between journals and by year of publication.

Results: Of 2028 publications reviewed and scored, 29 (1.4%) were graded level I, 75 (3.7%) were graded level II, 471 (23.2%) were graded level III, 1420 (70.2%) were graded level IV and 33 (1.6%) were graded level V (lowest level). Most publications (94.9%) were of lower-level evidence (III-V). There was an overall increasing trend in the lower LOE (P < 0.001). Inter-rater reliability was substantial with 95.5% (95%, confidence interval: 0.95-0.96) level of agreement between reviewers.

Conclusions: General thoracic surgery literature consists mostly of lower LOE studies. The number of lower levels of evidence is dominating the recent publications, potentially indicating a need to increase the commitment to produce and disseminate higher-level evidence in general thoracic surgery.
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http://dx.doi.org/10.1093/ejcts/ezab460DOI Listing
May 2022

Robotic vs Thoracoscopic Anatomic Lung Resection in Obese Patients: A Propensity-Adjusted Analysis.

Ann Thorac Surg 2021 Nov 3. Epub 2021 Nov 3.

Division of Thoracic Surgery, McMaster University, Hamilton, Ontario, Canada.

Background: Minimally invasive lung resections can be particularly challenging in obese patients. We hypothesized robotic surgery (RTS) is associated with less conversion to thoracotomy than video-assisted thoracoscopic surgery (VATS) in obese populations.

Methods: The Society of Thoracic Surgeons General Thoracic Surgery Database, Epithor French National Database, and McMaster University Thoracic Surgical Database were queried for obese (body mass index ≥30 kg/m) patients who underwent VATS or RTS lobectomy or segmentectomy for clinical T1-2, N0-1 non-small cell lung cancer between 2015 and 2019. Propensity score adjusted logistic regression analysis was used to compare the rate of conversion to thoracotomy between the VATS and RTS cohorts.

Results: Overall, 8108 patients (The Society of Thoracic Surgeons General Thoracic Surgery Database: n = 7473; Epithor: n = 572; McMaster: n = 63) met inclusion criteria with a mean (SD) age of 66.6 (9) years and body mass index of 34.7 (4.5) kg/m. After propensity score adjusted multivariable analysis, patients who underwent VATS were >5-times more likely to experience conversion to thoracotomy than those who underwent RTS (odds ratio, 5.33; 95% CI, 4.14-6.81; P < .001). There was a linear association between the degree of obesity and odds ratio of VATS conversion to thoracotomy compared with RTS. VATS patients had a longer mean length of stay (5.0 vs 4.3 days, P < .001), higher rate of respiratory failure (2.8% [168 of 5975] vs 1.8% [39 of 2133], P = .026), and were less likely to be discharged to their home (92.5% [5525 of 5975] vs 94.3% [2012 of 2133]; P = .013) compared with RTS patients.

Conclusions: In obese patients, RTS anatomic lung resection is associated with a lower rate of conversion to thoracotomy than VATS.
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http://dx.doi.org/10.1016/j.athoracsur.2021.09.061DOI Listing
November 2021

Quality of reporting for pilot randomized controlled trials in the pediatric urology literature-A systematic review.

J Pediatr Urol 2021 Dec 24;17(6):846-854. Epub 2021 Sep 24.

McMaster University/Department of Surgery/Urology, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada; Clinical Urology Research Enterprise (CURE) Program, McMaster Children's Hospital, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.

Background: The conduct and reporting of pilot studies is important to assess the feasibility of future randomized controlled trials (RCT). The Consolidated Standards of Reporting Trials (CONSORT) statement extension to pilot/feasibility studies addresses the reporting quality of the pilot studies (Summary Table 1). The aims of this systematic review are (1) to assess the reporting quality of pilot studies in pediatric urology and (2) to explore the factors that are associated with the reporting quality of these studies.

Methods: A comprehensive search was conducted through MEDLINE® and EMBASE® to identify pilot RCTs from 2005 to 2018. Two reviewers independently performed title and abstract screening and full text review, with discrepancies resolved by consensus. CONSORT extension reported items were summarized and overall proportion of reported items for each article was estimated. A linear regression model was conducted to determine factors associated with higher reporting quality. Publication year, biostatistician/epidemiologist support, sample size justification and journal impact factor were collected.

Results: Of the 1463 titles duplicates were removed and 1347 were screened, 36 studies were included. Overall, 36 pilot studies reported about 8-9 of 17 items [51% (95% CI: 46 - 56%)]. The most reported items were contact details for the corresponding author (97%), title identification of study as randomised pilot or feasibility trial (95%), eligibility criteria and setting (81%), both interventions (78%), and specific objectives of the pilot trial (75%). Less fulfilled items were blinding (11%), registration of the trial (11%), randomization details (28%), detailing recruitment status in the pilot study (19%), trial design (31%), and source of funding for pilot trial (34%). Interpretation of the results of pilot trial and their implications for the future definitive trial was reported by 34% of the studies. Factors associated with higher reporting quality were the presence of biostatistician or epidemiologist (P = 0.004), and if the sample size for the pilot study was justified (P = 0.002).

Discussion: Overall reporting quality of pilot studies in pediatric urology literature from 2005-2018 was suboptimal. The quality of pilot RCTs included in the present review were lower than that observed in the orthopedic literature, however, it appears to be consistent with the trends regarding OQS in chronic kidney disease and allopathic medicine. While we endeavoured to maintain utmost rigidity of this systematic review, there are inherent limitations. The CONSORT 2010 extension for pilot RCTs was published in 2016. Clinical trials can take several years, many pilot studies published pre-2016 would not have had the guidance of the extension during designing phases. Not all pilot RCTs are published, so this could potentially reduce the generalizability of the findings from this review. Only studies in English, published in full peer-reviewed journals were included, and this review only addressed the reporting quality of pilot studies in pediatric urology.

Conclusion: This review demonstrated that reporting quality of pilot studies in pediatric urology is currently suboptimal. Including biostatistician and/or epidemiologist, can ameliorate the quality of future pilot studies. Implementing CONSORT 2010 extension by journals as a prerequisite for submission of pilot or feasibility trials is recommended to improve the robustness and transparency of future pilot studies.
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http://dx.doi.org/10.1016/j.jpurol.2021.09.012DOI Listing
December 2021

Improving the Patient Decision-Making Experience for Cataract Surgery During the COVID-19 Era.

Can J Ophthalmol 2021 Aug 25. Epub 2021 Aug 25.

Division of Surgery, Department of Ophthalmology, McMaster University, Hamilton, Ont.. Electronic address:

Objective: To explore whether video-based patient decision aids (VBPDAs) for cataract surgery consultation can enhance a patient's decision-making process while upholding safety regulations during the coronavirus disease 2019 (COVID-19) pandemic.

Design: Single-centre consecutive case study.

Participants: 147 patients, with an average age of 70 years, who came in for a cataract surgery consult were enrolled in this study.

Methods: All patients watched part 1 of the VBPDA outlining the process of cataract surgery and the decisions involved. Patients then underwent cataract surgery consultation with an ophthalmologist. Afterward, if the patient was indicated for surgery, part 2 of the VBPDA was played. At the end of the visit, all patients completed a survey assessing the effects of COVID-19 safety precautions on their appointment. In addition, patients who had gone forward with surgery complete the Decisional Conflict Scale (DCS).

Results: For patients proceeding with cataract surgery, the median DCS score was 9.38 (range, 0-54.69, min-max) on a scale from 0 to 100 (low-high decisional conflict). A DCS score <25 indicates low decisional conflict (n = 76, 68.47%) and a score >25 indicates feeling unsure (n = 35, 31.53%). The DCS also can be separated into various subscales: the informed subscale (median = 8.33; min-max = 0-66.67), values subscale (16.67, 0-58.33), support subscale (8.33, 0-50.00), uncertainty subscale (8.33, 0-83.33), and effective decision subscale (0, 0-37.50).

Conclusion: Our study found VBPDAs to be an effective tool to enhance the patient decision-making process for cataract surgery during the COVID-19 era.
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http://dx.doi.org/10.1016/j.jcjo.2021.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384583PMC
August 2021

Evaluating the literature on preoperative androgen stimulation for hypospadias repair using the fragility index - can we trust observational studies?

J Pediatr Urol 2021 Oct 9;17(5):661-669. Epub 2021 Aug 9.

Department of Health Research, Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; Division of Urology, McMaster University, Hamilton, ON, Canada; McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, ON, Canada. Electronic address:

Background: Preoperative androgen stimulation (PAS) is typically used in hypospadias repair for patients with a proximal meatus or small glans size. Hypospadias PAS literature suffer from small sample sizes and lack of power to claim robust conclusions. Small changes in the number of events may completely change the statistical significance, making the conclusions drawn unreliable. Fragility index (FI) is the number of additional events needed to occur in either the control or experimental group to turn a statistically significant result to a non-significant result. The objective of the report was to assess the quality of available literature revolving around PAS use in hypospadias repair and its effects on post-operative complication rates using FI.

Methods: A comprehensive search of MEDLINE, EMBASE, and grey literature (ESPU and SPU abstracts) was conducted to identify RCTs and observational studies investigating the effect of PAS on complications post-hypospadias repair between 1990 and 2020. The FI was calculated for each study. Postoperative complications were defined as: fistula, stricture/stenosis, diverticula, and dehiscence. The odds ratio (OR), 95% confidence intervals (CI), corresponding p-values was calculated for each study. A random effects mixed model was implemented to combine the ORs for each study design.

Results: Fourteen studies qualified for inclusion, of which nine were observational studies and five were RCTs (Figure 1). The median sample size was 110 patients (IQR 69-171). The summary ORs for observational studies was 1.74 (95% CI: 1.10 to 2.74; p = 0.020) and for RCTs was 0.71 (9% CI: 0.34 to 1.47; p = 0.350). The median FI was 0 (IQR 0-2) of the included studies.

Discussion: PAS use does not appear to significantly affect complication rates shown in RCTs, however, observational studies cumulatively suggested significantly greater odds of complications after PAS. The FI is best used for RCTs with 1-to-1 randomization and binary data. Observational studies are rarely balanced for demographics and comorbidities with unequal sample size between comparable groups. The study was limited by substantial variability in how PAS was delivered to patients, leading to restricted comparability.

Conclusion: Strong conclusions regarding the influence of PAS on hypospadias repair outcomes cannot be properly drawn based on the current literature due to deficits from either a statistical or methodological standpoint. The current PAS literature has shown inconclusive results, calling for well-designed RCTs, involving standardized surgical techniques and PAS protocols, to evaluate the true effect of PAS on complications post-hypospadias repair.
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http://dx.doi.org/10.1016/j.jpurol.2021.07.027DOI Listing
October 2021

An Artificial Intelligence Algorithm to Predict Nodal Metastasis in Lung Cancer.

Ann Thorac Surg 2022 07 8;114(1):248-256. Epub 2021 Aug 8.

Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada. Electronic address:

Background: Endobronchial ultrasound (EBUS) has features that allow a high accuracy for predicting lymph node (LN) malignancy. However their clinical application remains limited because of high operator dependency. We hypothesized that an artificial intelligence algorithm (NeuralSeg; NeuralSeg Ltd, Hamilton, Ontario, Canada) is capable of accurately identifying and predicting LN malignancy based on EBUS images.

Methods: In the derivation phase EBUS images were segmented twice by an endosonographer and used as controls in 5-fold cross-validation training of NeuralSeg. In the validation phase the algorithm was tested on new images it had not seen before. Logistic regression and receiver operator characteristic curves were used to determine NeuralSeg's capability of discrimination between benign and malignant LNs, using pathologic specimens as the gold standard.

Results: Two hundred ninety-eight LNs from 140 patients were used for derivation and 108 LNs from 47 patients for validation. In the derivation cohort NeuralSeg was able to predict malignant LNs with an accuracy of 73.8% (95% confidence interval [CI], 68.4%-78.7%). In the validation cohort NeuralSeg had an accuracy of 72.9% (95% CI, 63.5%-81.0%), specificity of 90.8% (95% CI, 81.9%-96.2%), and negative predictive value of 75.9% (95% CI, 71.5%-79.9%). NeuralSeg showed higher diagnostic discrimination during validation compared with derivation (c-statistic = 0.75 [95% CI, 0.65-0.85] vs 0.63 [95% CI, 0.54-0.72], respectively).

Conclusions: NeuralSeg is able to accurately rule out nodal metastasis and can possibly be used as an adjunct to EBUS when nodal biopsy is not possible or inconclusive. Future work to evaluate the algorithm in a clinical trial is required.
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http://dx.doi.org/10.1016/j.athoracsur.2021.06.082DOI Listing
July 2022

Delay to TKA in Patients Treated with a Multimodal Approach Using High Molecular Weight, Biologically Derived Hyaluronic Acid.

J Long Term Eff Med Implants 2021 ;31(3):45-50

Department of Orthopaedics and Rehabilitation, New York Presbyterian Queens, Weill Medical College of Cornell University, NY, USA.

Background: The primary objective of this study was to determine the effect of single versus multiple rounds of intra-articular hyaluronic acid (IA-HA) in delaying the need for total knee arthroplasty (TKA) in patients with knee OA, and if additional benefits were seen when used in conjunction with other multimodal treatment options.

Methods: This study was a retrospective claims analysis of a large commercial database containing more than 100 million patients with continuous coverage from October 1, 2010 through September 30, 2015. Time to TKA for patients who received one course of Euflexxa (IA-BioHA) were compared to patients who received two or more courses of IA-BioHA and patients who received no IA-HA. Assessment of multimodal treatment effects was done between the following groups: IA-BioHA injections alone, IA-BioHA and bracing, IA-BioHA and corticosteroid injection, and IA-BioHA with both corticosteroids and bracing.

Results: A total of 26,727 patients were included in the analysis of treatment courses, and 31,034 in the analysis of multimodal treatment combinations. The use of IA-BioHA demonstrated a delay of TKA that was prolonged with repeated courses of treatment (1.411 years, interquartile range [IQR]: 1.44). The greatest delay to TKA was observed for the patients who had received all three treatment options (1.5 years, IQR: 1.52) in the multimodal analysis.

Conclusions: These results confirm that treatment of knee OA should consider the use of multimodal therapy instead of focusing on individual treatment options. Additionally, the use of repeated courses of IA-BioHA should be considered for prolonged benefit for patients with symptomatic knee OA.
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http://dx.doi.org/10.1615/JLongTermEffMedImplants.2021037770DOI Listing
October 2021

Third Nerve Palsy Due to Intracranial Aneurysms and Recovery after Endovascular Coiling.

Can J Neurol Sci 2022 07 24;49(4):560-568. Epub 2021 Jun 24.

Department of Surgery, McMaster University, Hamilton, ON, Canada.

Introduction: The modality of treatment of third nerve palsy (TNP) associated with intracranial aneurysms remains controversial. While treatment varies with the location of the aneurysm, microsurgical clipping of PComm aneurysms has generally been the traditional choice, with endovascular coiling emerging as a reasonable alternative.

Methods: Patients with TNP due to an intracranial aneurysm who subsequently underwent treatment at a mid-sized Canadian neurosurgical center over a 15-year period (2003-2018) were examined.

Results: A total of 616 intracranial aneurysms in 538 patients were treated; the majority underwent endovascular coiling with only 24 patients treated with surgical clipping. Only 37 patients (6.9%) presented with either a partial or complete TNP and underwent endovascular embolization; of these, 17 presented with a SAH secondary to intracranial aneurysm rupture. Aneurysms associated with TNP included PComm (64.9%), terminal ICA (29.7%), proximal MCA (2.7%), and basilar tip (2.7%) aneurysms. In general, smaller aneurysms and earlier treatment were provided for patients for ruptured aneurysms with a shorter mean interval to TNP recovery. In the endovascularly treated cohort initially presenting with TNP, seven presented with a complete TNP and the remaining were partial TNPs. TNP resolved completely in 20 patients (55.1%) and partially in 10 patients (27.0%). Neither time to coiling nor SAH at presentation were significantly associated with the recovery status of TNP.

Conclusion: Endovascular coil embolization is a viable treatment modality for patients presenting with an associated cranial nerve palsy.
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http://dx.doi.org/10.1017/cjn.2021.145DOI Listing
July 2022

Laser Trabeculoplasty Perceptions and Practice Patterns of Canadian Ophthalmologists.

J Curr Glaucoma Pract 2020 Sep-Dec;14(3):81-86

Department of Ophthalmology, McMaster University, Hamilton, Ontario, Canada.

Aim: To describe the current practice patterns and perceptions of Canadian ophthalmologists using laser trabeculoplasty (LTP).

Materials And Methods: A cross-sectional survey of 124 members of the Canadian Ophthalmological Society (COS) who perform LTP was conducted. Descriptive statistics and Chi-square comparative analyses were performed on anonymous self-reported survey data.

Results: Of the 124 respondents, 34 (27.4%) completed a glaucoma fellowship. Use of selective laser trabeculoplasty (SLT) (94.4%) was preferred over argon laser trabeculoplasty (ALT) (5.6%). The most frequently cited reasons for SLT preference was less damage to trabecular meshwork (30.7%), availability (16.2%), and repeatability (16.2%). In all, 47.6% of the respondents performed LTP concurrently with medical treatment, 33.9% used it after medical treatment, and 17.7% used it as first-line treatment. Majority (87.1%) of the respondents believed that SLT is effective when repeated. In suitable patients, 41.9% of the respondents stated on average they repeat SLT once, 26.6% twice, and 19.4% greater than 2 times, respectively. Of those who repeat SLT on patients, 80.7% found repeat SLT treatments have good outcomes for patients. In all, 105 (84.7%) ophthalmologists responded they would benefit from an LTP practice guideline. Significantly more ophthalmologists without glaucoma fellowships perceived they would benefit from a practice guideline ( value <0.001).

Conclusion: This survey provides valuable practical information on how LTP is used in the treatment of glaucoma in Canada.

Clinical Significance: The findings may serve as a baseline survey to trend future practices.

How To Cite This Article: Lee EY, Farrokhyar F, Sogbesan E. Laser Trabeculoplasty Perceptions and Practice Patterns of Canadian Ophthalmologists. J Curr Glaucoma Pract 2020;14(3):81-86.
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http://dx.doi.org/10.5005/jp-journals-10078-1283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8028031PMC
April 2021

Delay to TKA and Costs Associated with Knee Osteoarthritis Care Using Intra-Articular Hyaluronic Acid: Analysis of an Administrative Database.

Clin Med Insights Arthritis Musculoskelet Disord 2021 22;14:1179544121994092. Epub 2021 Mar 22.

Virginia Mason Orthopedics and Sports Medicine, Seattle, WA, USA.

Background: Total knee arthroplasty (TKA) is a surgical treatment for patients with knee osteoarthritis (KOA) that no longer experience symptom relief from non-operative or pharmacologic treatments. Non-operative KOA management aims to address patient symptoms and improve function, as well as forestall or mitigate the large costs associated with TKA. The primary objective of this study was to examine the relationship between intra-articular hyaluronic acid (IA-HA) treatment and delaying TKA in patients with KOA compared to patients not receiving IA-HA, as well as to identify differences in KOA-related costs incurred among patients who received or did not receive IA-HA.

Methods: This was a retrospective analysis of an administrative claims database from October 1st, 2010 through September 30th, 2015. Kaplan-Meier survival analysis was conducted to determine the TKA-free survival of patients who received IA-HA, stratified by the number of injection courses received versus those who did not receive any IA-HA. Median KOA-related costs per year were calculated for 2 comparisons: (1) patients who received IA-HA versus patients who did not receive IA-HA, among patients who eventually had TKA, and (2) patients who received IA-HA versus patients who did not receive IA-HA, among patients who did not have TKA.

Results: A total of 744 734 patients were included in the analysis. A delay to TKA was observed after IA-HA treatment for patients treated with IA-HA compared to those who did not receive IA-HA. At 1 year, the TKA-free survival was 85.8% (95% CI: 85.6%-86.0%) for patients who received IA-HA and 74.1% (95% CI: 74.0%-74.3%) for those who did not receive IA-HA. At 2 years, the TKA free survival was 70.8% (70.5%-71.1%) and 63.7% (63.5%-63.9%) in the 2 groups, respectively. Patients treated with multiple courses of IA-HA demonstrated an incremental increase in delay to TKA with more courses of IA-HA, suggesting that the risk of TKA over the study time period is reduced with additional IA-HA courses. The hazard ratio for the need of TKA was 0.85 (95% CI 0.84-0.86) for a single course and 0.27 (95% CI 0.25-0.28) for ⩾5 courses, both compared to the no IA-HA group. In patients that eventually had TKA, the median KOA-related costs were lower among those who received IA-HA before their TKA ($860.24, 95% CI: 446.65-1722.20), compared to those who did not receive IA-HA ($2659.49, 95% CI: 891.04-7480.38). For patients who did not have TKA, the median and interquartile range (IQR) KOA-related costs per year were similar for patients who received IA-HA compared with those who did not.

Conclusion: These results demonstrate that within a large cohort of KOA patients, individuals who received multiple courses of IA-HA had a progressively greater delay to TKA compared to patients who did not receive IA-HA treatment. Also, for patients who progressed to TKA, IA-HA treatment was associated with a large reduction in KOA-related healthcare costs. Based on these results, multiple, repeat courses of IA-HA may be beneficial in substantially delaying TKA in KOA patients, as well as minimizing KOA-related healthcare costs.
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http://dx.doi.org/10.1177/1179544121994092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989120PMC
March 2021

A systematic review of the efficacy of surgical intervention in the management of symptomatic Tarlov cysts: a meta-analysis.

Br J Neurosurg 2021 Mar 23:1-12. Epub 2021 Mar 23.

McMaster University, Hamilton, ON, Canada.

Tarlov cysts (TC) are sacral perineural cysts that are often found incidentally during spinal imaging. In a small fraction, symptomatic TC can cause pain, bowel, bladder and/or sexual dysfunction, as well as motor and sensory deficits. While many surgeons regard TCs as a non-operative entity, there have been suggestions that operative intervention in carefully selected symptomatic patients may be beneficial. The aim of this meta-analysis is to identify whether surgical treatment for symptomatic TCs is beneficial with an acceptable complication profile. The authors conducted a systematic outcome analysis of symptomatic TCs treated either with surgery or conservatively managed. Sixteen studies (N = 238) met the inclusion criteria for final meta-analysis. The literature search was performed using PubMed, Ovid MEDLINE, CINAHL, and EMBASE databases up to September 2017 and with an updated search in April 2019. The post-operative complication rate in patients undergoing surgical intervention was 16.9 (11.8 to 22.7) and cyst recurrence was 8.5 (3.5 to 15.4). When a complication occurred, the most frequent complication of surgical intervention was the development of a surgical site infection and/or CSF leak. Of the 15 studies reporting long-term follow-up, 81.0 (74.0-88.0) of patients remained symptom-free for more than 1 year (Mean: 27.5 months, SD = 11.5). We rigorously analyse the efficacy of open surgical decompression and repair of symptomatic TCs and corroborate the findings of sustained long-term resolution of symptoms.
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http://dx.doi.org/10.1080/02688697.2021.1874294DOI Listing
March 2021

Does UV Light as an Adjunct to Conventional Treatment Improve Healing and Reduce Infection in Wounds? A Systematic Review.

Adv Skin Wound Care 2021 Apr;34(4):1-6

At McMaster University, Hamilton, Ontario, Canada, Jeyanth Inkaran, BMSc, and Adam Tenn, BMSc, are Medical Students. At Hamilton General Hospital, Amanda Martyniuk, BSc, MSc, is Neurosurgery Research Coordinator; Forough Farrokhyar, MPhil, PhD, is Research Director; and Aleksa Cenic, MSc, MD, FRCSC, is Neurosurgeon. The authors have disclosed no financial relationships related to this article. Submitted February 24, 2020; accepted in revised form May 5, 2020.

Objective: To examine the effect of UV light on wound healing and infection in patients with skin ulcers or surgical incisions. Outcomes of interest included healing time, wound size and appearance, bacterial burden, and infection.

Data Sources: Ovid MEDLINE, Embase, Cochrane, PubMed, CINAHL, and Web of Science.

Study Selection: Comparative and noncomparative clinical studies were considered, including observational cohort, retrospective, and randomized controlled studies. They addressed the research question: "Does the use of UV light as an adjunct to conventional treatment help improve healing and reduce infection in wounds?" Selection criteria included any English language study in adults who used UV light to improve wound healing and prevent or treat wound infection.

Data Extraction: Authors extracted information pertaining to patient demographics, treatment protocols, and the following wound outcomes: appearance, healing time, infection, and bacterial burden.

Data Synthesis: The search yielded 30,986 articles, and screening resulted in 11 studies that underwent final analysis. Of these (N = 27,833), seven (64%) demonstrated an improvement in healing outcomes with adjunctive UV therapy, and the results of four (36%) achieved statistical significance.

Conclusions: There is limited research on the utility of adjunctive UV therapy to improve wound healing outcomes in humans. The majority of literature included in this review supported improved wound healing outcomes with adjuvant UV therapy. Future well-designed randomized controlled trials will be essential in further determining the benefit and utility of UV therapy in wound healing.
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http://dx.doi.org/10.1097/01.ASW.0000734384.52295.92DOI Listing
April 2021

Double Blind Pilot Randomized Trial Comparing Extended Anticoagulation to Placebo Following Major Lung Resection for Cancer.

Semin Thorac Cardiovasc Surg 2021 11;33(4):1123-1134. Epub 2021 Mar 11.

Division of Thoracic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of Thoracic Surgery, St. Joseph's Healthcare Hamilton, Firestone Institute for Respiratory Health, Hamilton, Ontario, Canada.

Venous thromboembolism (VTE), which comprises pulmonary embolus (PE) and deep vein thrombosis (DVT), is a significant cause of postoperative morbidity and mortality. This pilot randomized control trial (RCT) evaluated the feasibility of a full-scale RCT investigating extended thromboprophylaxis in patients undergoing oncological lung resections. Patients undergoing oncological lung resections in 2 tertiary centers received in-hospital, thromboprophylaxis and were randomized to receive post-discharge low-molecular-weight heparin (LMWH) or placebo injections once-daily for 30 days. At 30 days postoperatively, all patients underwent chest computed tomography with PE protocol and bilateral leg venous ultrasound. Primary outcomes included feasibility and safety; VTE incidence and 90-day survival were secondary outcomes. Between December 2015 and June 2018, 619 patients were screened, of whom 62.7% (165/263) of eligible patients consented to participate, and 133 (81%) were randomized. One-hundred and 3 patients, (77.4%), completed the 90-day study follow-up. Reasons for non-participation pre-randomization included patient discomfort and LMWH/placebo administration challenges. Post-randomization withdrawals were due to patient preference, surgeon preference and minor adverse events. Six asymptomatic VTE events (5 PE and 1 DVT) were detected within 30 days (3 in each group), for an overall incidence of 7%. There were 3 minor and no major adverse events. This study is the first to demonstrate the feasibility and safety of a full-scale extended thromboprophylaxis RCT in thoracic surgical oncology. Our results demonstrate that, while recruitment and retention rates were modest, the study design is feasible and with minimal adverse events and no intervention-related mortality.
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http://dx.doi.org/10.1053/j.semtcvs.2021.02.032DOI Listing
March 2022

In Reply to the Letter to the Editor Regarding "Determining the Diagnostic Utility of Lumbar Punctures in CT Negative Suspected Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis".

World Neurosurg 2021 03;147:249

Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.

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http://dx.doi.org/10.1016/j.wneu.2020.12.151DOI Listing
March 2021

Safety of Early Mobilization in Patients With Intraoperative Cerebrospinal Fluid Leak in Minimally Invasive Spine Surgery: A Case Series.

Oper Neurosurg (Hagerstown) 2021 06;21(1):1-5

Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada.

Background: Cerebrospinal fluid (CSF) leak is a common complication in spine surgery. Repairing durotomy is more difficult in the setting of minimally invasive spine surgery (MISS). Efficacy of postoperative bed rest in case of dural tear in MISS is not clear.

Objective: To assess the safety and efficacy of our protocol of dura closure without changing access, early mobilization, and discharge in cases of intraoperative CSF leak in MISS.

Methods: A retrospective review from 2006 to 2018 of patients who underwent MISS for degenerative and neoplastic diseases with documented accidental or intentional durotomy was conducted. The primary outcome of interest was readmission rate for repair of persistent CSF leak. Secondary outcomes captured included development of pseudomeningocele, positional headache, and subdural hematoma.

Results: A total of 80 patients were identified out of 527 patients. Of these, intentional durotomy was performed in 28 patients and unintentional durotomy occurred in 52 patients. Mean follow-up period was 80.6 mo. Most of the patients were discharged on postoperative day 0 (within 4 h of surgery) without activity restrictions. A total of 2 (2.5%) patients required readmission and dural repair for continuous CSF leak and 3 patients (3.75%) developed pseudomeningocele. No lumbar drain insertion, meningitis, or subdural hematoma was reported.

Conclusion: Early mobilization and discharge in cases of intraoperative CSF leak in MISS appear to be safe and not associated with higher rate of complications than that of reported literature.
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http://dx.doi.org/10.1093/ons/opab041DOI Listing
June 2021

Pregnancy outcomes in women with ankylosing spondylitis: a scoping literature and methodological review.

Clin Rheumatol 2021 Sep 19;40(9):3465-3480. Epub 2021 Jan 19.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.

In this scoping review, we sought to summarize the types of outcomes collected in pregnant patients with ankylosing spondylitis (AS), and to identify some methodological limitations related to pregnancy research in these patients. A comprehensive search was done to identify relevant articles in MEDLINE and Embase. We included 21 studies assessing pregnancy outcomes in AS. Most studies reported disease flare during pregnancy, and few reported improved disease activity or stable disease. Disease flare occurred in 25-80% of patients during pregnancy and in 30-100% during the postpartum. There was no increased risk of pre-eclampsia across all studies. Based on two case-control studies, there was an increased risk for prematurity and small for gestational age in AS pregnancies, pooled odds ratio (95% confidence interval) 1.99 (1.30-3.05) and 2.41 (1.22-4.77), respectively. The etiologies of cesarean section were not related to joint issues from AS but were related to other causes like pre-eclampsia and prematurity. Some key methodological issues were related to the study design, selection of study participants, disease classification, choice of control participants, and outcome measures. Based on the current literature review, some key areas for future research should evaluate the disease state at conception, effects of pharmacological treatment for AS during pregnancy, and long-term outcomes of children born to women with AS. The use of pregnancy registers and validated measurement tools in pregnancy will help to improve the state and quality of evidence in this field. Key Points • Disease flare during pregnancy in patients with ankylosing spondylitis (AS) occurred in 25-80% of the cases in the various studies, and in 30-100% of the cases during the postpartum period. • There was an increased risk for prematurity, and no increased risk of pre-eclampsia or small for gestational age. Etiologies of cesarean section were not related to the hip or sacroiliac joint affection of the disease but to other causes like pre-eclampsia and prematurity. • This study provides a comprehensive overview of issues related to research on pregnant women with ankylosing spondylitis (AS). We addressed methodological issues related to the study design, selection of study participants, disease classification, control choice, assessment of outcomes measures, and statistical analysis. • The use of pregnancy registers and validated disease activity measurement tools for pregnancy can enhance pregnancy research in women with AS.
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http://dx.doi.org/10.1007/s10067-021-05588-9DOI Listing
September 2021

Rate of Second Primary Head and Neck Cancer With Cannabis Use.

Cureus 2020 Nov 14;12(11):e11483. Epub 2020 Nov 14.

Otolaryngology - Head and Neck Surgery, McMaster University, Hamilton, CAN.

Objective To determine whether there is an association between cannabis use and developing a second primary cancer in head and neck cancer patients, as well as determining the prevalence of cannabis use amongst head and neck cancer patients. Study design This retrospective cohort study investigated patients from the Hamilton Region Head and Neck Cancer Database who were enrolled prospectively between 2011 and 2015, with follow-up data up to November 2018. Patients were contacted to confirm current cannabis and tobacco smoking status. Setting All patients were enrolled from a single tertiary cancer center in Hamilton, Ontario. Subjects and methods Consecutive patients with a newly diagnosed head and neck cancer were prospectively enrolled between 2011 to 2015. Cannabis users and controls were compared using standard modes of comparison. The odds ratio from a multivariable logistic regression model was then determined. Results A total of 513 patients were included in this study: 59 in the cannabis group and 454 in the control group. In terms of baseline characteristics, there was no significant difference between cannabis users and controls except that cannabis users were more likely to develop primary oropharyngeal cancer (p=0.0046). Two of 59 (3.4%) cannabis users developed a second primary cancer, in comparison to 23 of 454 (5.1%) non-cannabis users. The odds ratio for cannabis use on the second primary cancer was 0.19 (95% CI [0.01-3.20], p=0.25). Conclusion This study suggests that cannabis use behaves differently than tobacco smoking, as the former may not be associated with field cancerization.
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http://dx.doi.org/10.7759/cureus.11483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735528PMC
November 2020
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