Publications by authors named "Nancy N Baxter"

252 Publications

A Protocol for a Pan-Canadian Prospective Observational Study on Active Surveillance or Surgery for Very Low Risk Papillary Thyroid Cancer.

Front Endocrinol (Lausanne) 2021 10;12:686996. Epub 2021 Jun 10.

Department of Otolaryngology and Head and Neck Surgery, University Health Network and University of Toronto, Toronto, ON, Canada.

Background: The traditional management of papillary thyroid cancer (PTC) is thyroidectomy (total or partial removal of the thyroid). Active surveillance (AS) may be considered as an alternative option for small, low risk PTC. AS involves close follow-up (including regularly scheduled clinical and radiological assessments), with the intention of intervening with surgery for disease progression or patient preference.

Methods: This is a protocol for a prospective, observational, long-term follow-up multi-centre Canadian cohort study. Consenting eligible adults with small, low risk PTC (< 2cm in maximal diameter, confined to the thyroid, and not immediately adjacent to critical structures in the neck) are offered the choice of AS or surgery for management of PTC. Patient participants are free to choose either option (AS or surgery) and the disease management course is thus not assigned by the investigators. Surgery is provided as usual care by a surgeon in an institution of the patient's choice. Our primary objective is to determine the rate of 'failure' of disease management in respective AS and surgical arms as defined by: i) AS arm - surgery for progression of PTC, and ii) surgical arm - surgery or other treatment for disease persistence or progression after completing initial treatment. Secondary outcomes include long-term thyroid oncologic and treatment outcomes, as well as patient-reported outcomes.

Discussion: The results from this study will provide long-term clinical and patient reported outcome evidence regarding active surveillance or immediate surgery for management of small, low risk PTC. This will inform future clinical trials in disease management of small, low risk papillary thyroid cancer.

Registration Details: This prospective observational cohort study is registered on clinicaltrials.gov (NCT04624477), but it should not be considered a clinical trial as there is no assigned intervention and patients are free to choose either AS or surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fendo.2021.686996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237853PMC
June 2021

Proceedings of the Canadian Thyroid Cancer Active Surveillance Study Group 2019 national investigator meeting.

J Otolaryngol Head Neck Surg 2021 Jun 25;50(1):40. Epub 2021 Jun 25.

Department of Medicine, Division of Endocrinology, University Health Network, University of Toronto, Toronto, Canada.

Active surveillance (AS) in the management of small, low risk papillary thyroid cancer (PTC) as an alternative option to thyroidectomy, is an area of active research. A national Canadian study is proposed to evaluate the long-term outcomes of patients with small, low risk PTC who choose AS or surgery. This letter describes the proceedings of a national investigator meeting to plan the study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40463-021-00514-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8228934PMC
June 2021

Rectal Cancer Incidence is Low Following Rectal Diversion or Subtotal Colectomy for IBD: Results of a Population-based Study.

J Crohns Colitis 2021 May 17. Epub 2021 May 17.

Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background And Aims: Following subtotal colectomy or diversion for medically refractory inflammatory bowel disease [IBD], completion proctectomy has been recommended to reduce the risk of rectal cancer. However, this recommendation is based on low-quality evidence. Our objectives were to estimate the cumulative incidence of rectal cancer and evaluate if surveillance endoscopy reduces the risk of rectal cancer.

Methods: We performed a population-based retrospective cohort study in Ontario, Canada, of all patients undergoing either subtotal colectomy or diversion for medically refractory IBD over 1991-2015. We excluded patients with a previous history of colorectal cancer or previous rectal resection, and those with <1 year of observation. We calculated the rate of incident rectal cancer using a competing risks model, and evaluated the effect of surveillance endoscopy on the rate of rectal cancer.

Results: In all, 3700 patients were included with a median follow-up of 4.3 years. Of this cohort, 47% underwent rectal resection or restoration of gastrointestinal [GI] continuity during the observation period; 40 patients were diagnosed with rectal cancer, with a cumulative incidence of rectal cancer of 0.81% (95% confidence interval [CI] 0.53%, 1.20%) and 1.86% [95% CI 1.29%, 2.61%] at 10 and 20 years, respectively. Surveillance endoscopy was associated with a lower rate of rectal cancer (subhazard ratio [sHR] 0.37, 95% CI 0.16, 0.82, p = 0.014].

Conclusions: Among patients with a retained rectum following surgery for IBD, the risk of rectal cancer is low and appears to be lower when surveillance endoscopy is performed. Expectant management with surveillance endoscopy may be a reasonable alternative to completion proctectomy in selected patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ecco-jcc/jjab090DOI Listing
May 2021

Impact of the model of long-term follow-up care on adherence to guideline-recommended surveillance among survivors of adolescent and young adult cancers.

Cancer Med 2021 Jun 15. Epub 2021 Jun 15.

University of Toronto, Institute of Medical Science, Toronto, Canada.

Purpose: Adolescent and young adult cancer survivors require lifelong healthcare to address the late effects of therapy. We examined the impact of different provider models of long-term follow-up (LTFU) care on adherence to recommended surveillance.

Methods: We conducted a retrospective cohort study using administrative health databases in Ontario, Canada. Five-year survivors were identified from IMPACT, a database of patients aged 15-20.9 years at diagnosis of six cancers between 1992 and 2010. We defined three models of LTFU care hierarchically: specialized survivor clinics (SCCs), general cancer clinics (GCCs), and family physician (FP). We assessed adherence to the Children's Oncology Group surveillance guidelines for cardiomyopathy and breast cancer. Multistate models assessed adherence transitions and impacts of LTFU attendance.

Results: A total of 1574 survivors were followed for a mean of 9.2 years (range 4.3-13.9 years) from index (5-year survival). The highest level of LTFU attended in the first 2-years post-index was a GCC (47%); only 16.7% attended a SCC. By the end of study, 72% no longer attended any of the models of care and only 2% still attended an SCC. Among 188 survivors requiring breast cancer surveillance, 6.9% were adherent to their first required surveillance testing. Attendance at a SCC in the previous year and higher cumulative FP or GCC visits increased the rate of subsequently becoming adherent. Among 857 survivors requiring cardiomyopathy surveillance, 11% were adherent at study entry. Each subsequent SCC visit led to an 11.3% (95% CI: 1.05-1.18) increase in the rate of becoming adherent.

Conclusion: LTFU attendance and surveillance adherence are sub-optimal. SCC follow-up is associated with greater adherence, but few survivors receive such care, and this proportion diminished over time. Interventions are needed to improve LTFU attendance and promote surveillance adherence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cam4.4058DOI Listing
June 2021

Bias estimation in study design: a meta-epidemiological analysis of transcatheter versus surgical aortic valve replacement.

BMC Surg 2021 Jun 7;21(1):285. Epub 2021 Jun 7.

Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.

Background: Paucity of RCTs of non-drug technologies lead to widespread dependence on non-randomized studies. Relationship between nonrandomized study design attributes and biased estimates of treatment effects are poorly understood. Our purpose was to estimate the bias associated with specific nonrandomized study attributes among studies comparing transcatheter aortic valve implantation with surgical aortic valve replacement for the treatment of severe aortic stenosis.

Results: We included 6 RCTs and 87 nonrandomized studies. Surgical risk scores were similar for comparison groups in RCTs, but were higher for patients having transcatheter aortic valve implantation in nonrandomized studies. Nonrandomized studies underestimated the benefit of transcatheter aortic valve implantation compared with RCTs. For example, nonrandomized studies without adjustment estimated a higher risk of postoperative mortality for transcatheter aortic valve implantation compared with surgical aortic valve replacement (OR 1.43 [95% CI 1.26 to 1.62]) than high quality RCTs (OR 0.78 [95% CI 0.54 to 1.11). Nonrandomized studies using propensity score matching (OR 1.13 [95% CI 0.85 to 1.52]) and regression modelling (OR 0.68 [95% CI 0.57 to 0.81]) to adjust results estimated treatment effects closer to high quality RCTs. Nonrandomized studies describing losses to follow-up estimated treatment effects that were significantly closer to high quality RCT than nonrandomized studies that did not.

Conclusion: Studies with different attributes produce different estimates of treatment effects. Study design attributes related to the completeness of follow-up may explain biased treatment estimates in nonrandomized studies, as in the case of aortic valve replacement where high-risk patients were preferentially selected for the newer (transcatheter) procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12893-021-01278-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186071PMC
June 2021

Lung Cancer Inequalities in Stage of Diagnosis in Ontario, Canada.

Curr Oncol 2021 May 23;28(3):1946-1956. Epub 2021 May 23.

Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC H3N 1X9, Canada.

Lung cancer is the most common cancer and cause of cancer death in Canada, with approximately 50% of cases diagnosed at stage IV. Sociodemographic inequalities in lung cancer diagnosis have been documented, but it is not known if inequalities exist with respect to immigration status. We used multiple linked health-administrative databases to create a cohort of Ontarians 40-105 years of age who were diagnosed with an incident lung cancer between 1 April 2012 and 31 March 2017. We used modified Poisson regression with robust standard errors to examine the risk of diagnosis at late vs. early stage among immigrants compared to long-term residents. The fully adjusted model included age, sex, neighborhood-area income quintile, number of Aggregated Diagnosis Group (ADG) comorbidities, cancer type, number of prior primary care visits, and continuity of care. Approximately 62% of 38,788 people with an incident lung cancer from 2012 to 2017 were diagnosed at a late stage. Immigrants to the province were no more likely to have a late-stage diagnosis than long-term residents (63.5% vs. 62.0%, relative risk (RR): 1.01 (95% confidence interval (CI): 0.99-1.04), adjusted relative risk (ARR): 1.02 (95% CI: 0.99-1.05)). However, in fully adjusted models, people with more comorbidities were less likely to have a late-stage diagnosis (adjusted relative risk (ARR): 0.82 (95% CI: 0.80-0.84) for those with 10+ vs. 0-5 ADGs). Compared to adenocarcinoma, small cell carcinoma was more likely to be diagnosed at a late stage (ARR: 1.29; 95% CI: 1.27-1.31), and squamous cell (ARR: 0.89; 95% CI: 0.87-0.91) and other lung cancers (ARR: 0.93; 95% CI: 0.91-0.94) were more likely to be diagnosed at an early stage. Men were also slightly more likely to have late-stage diagnosis in the fully adjusted model (ARR: 1.08; 95% CI: 1.05-1.08). Lung cancer in Ontario is a high-fatality cancer that is frequently diagnosed at a late stage. Having fewer comorbidities and being diagnosed with small cell carcinoma was associated with a late-stage diagnosis. The former group may have less health system contact, and the latter group has the lung cancer type most closely associated with smoking. As lung cancer screening programs start to be implemented across Canada, targeted outreach to men and to smokers, increasing awareness about screening, and connecting every Canadian with primary care should be system priorities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/curroncol28030181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161737PMC
May 2021

Decreased Colorectal Cancer Incidence and Incidence-Based Mortality in the Screening-Age Population of Ontario.

J Can Assoc Gastroenterol 2021 Jun 15;4(3):146-155. Epub 2020 Oct 15.

Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

Background And Aims: We aimed to evaluate trends in Ontario, Canada, 2002 to 2016, in uptake of colorectal evaluative procedures, colorectal cancer (CRC) incidence and incidence-based mortality in the colorectal screening-age population.

Methods: We defined the screening age-eligible population as persons 51 to 74 years of age with ≥1 year eligibility for the Ontario Health Insurance Plan, excluding those with a diagnosis of CRC in the Ontario Cancer Registry (OCR) prior to age 50 or January 1, 2002. We computed annual up-to-date status with colorectal evaluative procedures from billing claims, and CRC incidence from the OCR. In order to compute incidence-based CRC mortality, we included persons with a first diagnosis of CRC between the ages of 51 and 74, diagnosed between January 1, 1992 and December 31, 2001, still alive and <75 years of age on January 1, 2002, based on cause of death from the OCR. Overall, age-stratified and sex-stratified trends were evaluated by Cochran-Armitage trend tests.

Results: Persons up to date with colorectal evaluative procedures increased from 628,214/2,782,061 (22.6%) in 2002 to 2,584,570/4,179,789 (62.2%) in 2016. CRC incidence fell from 129.3/100,000 in 2002 to 94.54/100,000 in 2016, and incidence-based CRC mortality fell from 40.8/100,000 to 24.1/100,000. Decreasing trends in overall and stratified incidence and mortality were all significant, except among persons 51 to 54 years old.

Conclusions: There was continued increase in persons up-to-date with colorectal evaluative procedures, and significant decrease in CRC incidence and incidence-based CRC mortality from 2002 through 2016.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jcag/gwaa035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8158646PMC
June 2021

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits.

CMAJ 2021 05;193(21):E753-E760

Division of General Surgery (Gomez, Nantais), St. Michael's Hospital, Unity Health Toronto; ICES Central (Gomez, Simpson, de Mestral, Wilton, Urbach, Austin, Baxter); Department of Obstetrics and Gynecology (Simpson), St. Michael's Hospital, Unity Health Toronto; Department of Surgery (Sue-Chue-Lam, de Mestral, Dossa, Urbach), Faculty of Medicine, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia.

Background: Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients.

Methods: We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1-Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11-June 30, 2020), compared with a historical control period (Jan. 1-July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes.

Results: Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61-0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions.

Interpretation: Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.202821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177921PMC
May 2021

Perinatal Outcomes During the COVID-19 Pandemic in Ontario, Canada.

JAMA Netw Open 2021 05 3;4(5):e2110104. Epub 2021 May 3.

Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2021.10104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116980PMC
May 2021

Hyaluronate carboxymethylcellulose sheets for the prevention of adhesive complications: a model-based cost-utility analysis.

Colorectal Dis 2021 May 11. Epub 2021 May 11.

Department of Surgery, University of Toronto, Toronto, ON, Canada.

Aim: Clinical trials suggest that hyaluronate carboxymethylcellulose (HA/CMC) prevents adhesion-related complications after intra-abdominal surgery, but at a high upfront cost. This study evaluated the cost-effectiveness of HA/CMC for patients undergoing curative-intent open colorectal cancer surgery.

Methods: Using a Markov Monte Carlo microsimulation model, we conducted a cost-utility analysis comparing the cost-effectiveness of HA/CMC at curative-intent open colorectal cancer surgery versus standard management. We considered a scenario where HA/CMC was used at the index operation only, as well as where it was used at the index operation and any subsequent operations. The perspective was that of the third-party payer. Costs and utilities were discounted 1.5% annually, with a 1-month cycle length and 5-year time horizon. Model input data were obtained from a literature review. Outcomes included cost, quality-adjusted life-years (QALYs), small bowel obstructions (SBOs) and operations for SBO.

Results: Using HA/CMC at the index operation results in an incremental cost increase of CA$316 and provides 0.001 additional QALYs, for an incremental cost-effectiveness ratio of CA$310,000 per QALY compared to standard management. In our simulated cohort of 10,000 patients, HA/CMC prevented 460 SBOs and 293 surgeries for SBO. Probabilistic sensitivity analysis found that HA/CMC was cost-effective in 18.5% of iterations, at a cost-effectiveness threshold of CA$50,000 per QALY. Results of the scenario analysis where HA/CMC was used at the index operation and any subsequent operations were similar.

Conclusions: Hyaluronate carboxymethylcellulose prevents adhesive bowel obstruction after open colorectal cancer surgery but is unlikely to be cost-effective given minimal long-term impact on healthcare costs and QALYs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/codi.15724DOI Listing
May 2021

Delay of Pregnancy Among Physicians vs Nonphysicians.

JAMA Intern Med 2021 Jul;181(7):905-912

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada.

Importance: Women physicians may delay childbearing and experience childlessness more often than nonphysicians, but existing knowledge is based largely on self-reported survey data.

Objective: To compare patterns of childbirth between physicians and nonphysicians.

Design, Setting, And Participants: Population-based retrospective cohort study of reproductive-aged women (15-50 years) in Ontario, Canada, accrued from January 1, 1995, to November 28, 2018, and observed to March 31, 2019. Outcomes of 5238 licensed physicians of the College of Physicians and Surgeons of Ontario were compared with those of 26 640 nonphysicians (sampled in a 1:5 ratio). Physicians and nonphysicians were observed from age 15 years onward.

Exposures: Physicians vs nonphysicians.

Main Outcomes And Measures: The primary outcome was childbirth at gestational age of 20 weeks or greater. Cox proportional hazards models were used to examine the association between physician status and childbirth, overall and across career stage (postgraduate training vs independent practice) and specialty (family physicians vs specialists).

Results: All physicians (n = 5238) and nonphysicians (n = 26 640) were aged 15 years at baseline, and 28 486 (89.1%) were Canadian-born. Median follow-up was 15.2 (interquartile range, 12.2-18.2) years after age 15 years. Physicians were less likely to experience childbirth at younger ages (hazard ratio [HR] for childbirth at 15-28 years, 0.15; 95% CI, 0.14-0.18; P < .001) and initiated childbearing significantly later than nonphysicians; the cumulative incidence of childbirth was 5% at 28.6 years in physicians and 19.4 years in nonphysicians. However, physicians were more likely to experience childbirth at older ages (HR for 29-36 years, 1.35; 95% CI, 1.28-1.43; P < .001; HR for ≥37 years, 2.62; 95% CI, 2.00-3.43; P < .001), and ultimately achieved a similar cumulative probability of childbirth as nonphysicians overall. Median age at first childbirth was 32 years in physicians and 27 years in nonphysicians (P < .001). After stratifying by specialty, the cumulative incidence of childbirth was higher in family physicians than in both surgical and nonsurgical specialists at all observed ages.

Conclusions And Relevance: The findings of this cohort study suggest that women physicians appear to delay childbearing compared with nonphysicians, and this phenomenon is most pronounced among specialists. Physicians ultimately appear to catch up to nonphysicians by initiating reproduction at older ages and may be at increased risk of resulting adverse reproductive outcomes. System-level interventions should be considered to support women physicians who wish to have children at all career stages.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamainternmed.2021.1635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094034PMC
July 2021

An inverse stage-shift model to estimate the excess mortality and health economic impact of delayed access to cancer services due to the COVID-19 pandemic.

Asia Pac J Clin Oncol 2021 Aug 10;17(4):359-367. Epub 2021 Feb 10.

Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.

Aim: Decreased cancer incidence and reported changes to clinical management indicate that the COVID-19 pandemic has delayed cancer diagnosis and treatment. This study aimed to develop and apply a flexible model to estimate the impact of delayed diagnosis and treatment on survival outcomes and healthcare costs based on a shift in the disease stage at treatment initiation.

Methods: A model was developed and made publicly available to estimate population-level health economic outcomes by extrapolating and weighing stage-specific outcomes by the distribution of stages at treatment initiation. It was applied to estimate the impact of 3- and 6-month delays based on Australian data for stage I breast cancer, colorectal cancer, and lung cancer patients, and for T1 melanoma. Two approaches were explored to estimate stage shifts following a delay: (a) based on the relation between time to treatment initiation and overall survival (breast, colorectal, and lung cancer), and (b) based on the tumor growth rate (melanoma).

Results: Using a conservative once-off 3-month delay and considering only shifts from stage I/T1 to stage II/T2, 88 excess deaths and $12 million excess healthcare costs were predicted in Australia over 5 years for all patients diagnosed in 2020. For a 6-month delay, excess mortality and healthcare costs were 349 deaths and $46 million over 5 years.

Conclusions: The health and economic impacts of delays in treatment initiation cause an imminent policy concern. More accurate individual patient data on shifts in stage of disease during and after the COVID-19 pandemic are critical for further analyses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ajco.13505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014813PMC
August 2021

Adolescents and young adult acute myeloid leukemia outcomes at pediatric versus adult centers: A population-based study.

Pediatr Blood Cancer 2021 Aug 8;68(8):e28939. Epub 2021 Feb 8.

Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.

Background: Adolescents and young adult (AYA) acute myeloid leukemia (AML) outcomes remain poor. The impact of locus of care (LOC; adult vs pediatric) in this population is unknown.

Procedure: The IMPACT cohort comprises detailed data for all Ontario, Canada, AYA aged 15-21 years diagnosed with AML between 1992 and 2012, linked to population-based health administrative data. We determined the impact of LOC on event-free survival (EFS) and overall survival (OS), treatment-related mortality (TRM), and relapse/progression.

Results: Among 140 AYA, 51 (36.4%) received therapy at pediatric centers. The five-year EFS and OS for the whole cohort were 35.0% ± 4.0% and 53.6% ± 4.2%. Cumulative doses of anthracycline were higher among pediatric center AYA [median 355 mg/m , interquartile range (IQR) 135-492 vs 202 mg/m , IQR 140-364; P = 0.003]. In multivariable analyses, LOC was not predictive of either EFS [adult vs pediatric center hazard ratio (HR) 1.3, 95% confidence interval (CI) 0.8-2.2, P = 0.27] or OS (HR 1.0, CI 0.6-1.6, P = 0.97). However, patterns of treatment failure varied; higher two-year incidence of TRM in pediatric centers (23.5% ± 6.0% vs.10.1% ± 3.2%; P = 0.046) was balanced by lower five-year incidence of relapse/progression (33.3% ± 6.7% vs 56.2% ± 5.3%; P = 0.002).

Conclusions: AYA AML survival outcomes did not vary between pediatric and adult settings. Causes of treatment failure were different, with higher intensity pediatric protocols associated with higher TRM but lower relapse/progression. Careful risk stratification and enhanced supportive care may be of substantial benefit to AYA with AML by allocating maximal treatment intensity to patients who most benefit while minimizing the risk of TRM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pbc.28939DOI Listing
August 2021

Intersection of Race and Gender in Surgical Training-Reply.

JAMA Surg 2021 May;156(5):499-500

Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2020.6951DOI Listing
May 2021

Decision-making in Surgery or Active Surveillance for Low Risk Papillary Thyroid Cancer During the COVID-19 Pandemic.

Cancers (Basel) 2021 Jan 20;13(3). Epub 2021 Jan 20.

Princess Margaret Cancer Centre, Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, University Health Network and University of Toronto, Toronto, ON M5G 2C4, Canada.

We describe our experience conducting a prospective observational cohort study on the management of small, low risk papillary thyroid cancer during the COVID-19 pandemic. Our study participants are given the choice of active surveillance (AS) or surgery, and those in the AS arm are followed at the study center, whereas surgical patients undergo usual care. During the pandemic we have transitioned from in-person research patient visits to largely virtual care of patients under AS. As of 30 October 2020, we had enrolled 181 patients enrolled in our study (including 25 during the pandemic), of which 92.3% (167/181) consented to telephone communication and 79.0% (143/181) consented to secure videoconferencing communication. Prior to the pandemic, 74.5% (117/157) of our patients chose AS over surgery, whereas during the pandemic, 96.0% (24/25) chose AS. Of the 133 study patients who were under AS within the timeframe from 12 March 2020, to 30 October 2020, the percentage of patients who missed appointments was 8.3% (11/133, for neck ultrasound and physician visits, respectively) and delayed appointments was 23.3% (31/133). This preliminary data suggests that prospective observational research on AS of thyroid cancer can safely continue during the pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/cancers13030371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864172PMC
January 2021

Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations.

BMC Gastroenterol 2021 Jan 7;21(1):22. Epub 2021 Jan 7.

Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Background: Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures.

Methods: We systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded. We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool.

Results: We identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations.

Conclusions: Recommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12876-020-01561-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792218PMC
January 2021

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study.

Am J Obstet Gynecol 2021 06 24;224(6):585.e1-585.e30. Epub 2020 Dec 24.

Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia. Electronic address:

Background: Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown.

Objective: This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research.

Study Design: We conducted a population-based retrospective cross-sectional study of adult women (≥20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45-54, ≥55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications.

Results: Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not. In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingo-oophorectomy (median odds ratio, 2.00-2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingo-oophorectomy in women aged 45-54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and ≥55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17-1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16-1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records.

Conclusion: Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2020.12.1206DOI Listing
June 2021

Postcolonoscopy colorectal cancer: in defence of quality.

Colorectal Dis 2021 Apr 22;23(4):1003-1004. Epub 2021 Feb 22.

Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/codi.15493DOI Listing
April 2021

Implementation of Critical Care Response Teams in Ontario: Impact on the Outcomes of Surgical Patients.

Ann Surg 2020 Nov 17. Epub 2020 Nov 17.

Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Objective: To evaluate whether introduction of Critical Care Response Teams (CCRTs) reduced mortality rates among patients who developed a post-operative complication, also referred to as failure to rescue (FTR).

Background: CCRTs were introduced to improve patients' post-operative outcomes. Its effect on FTR continues to be actively investigated.

Methods: We conducted a population-based retrospective cohort study using administrative data from Ontario, Canada. We identified 810,279 patients admitted to hospital for major surgical procedures between January 2004 and December 2014, with a washout period consisting of the 9 months before and after the implementation of CCRTs in January 2007. Difference-in-differences analysis among patients who developed a post-operative complication (n=148,882) was used to estimate the association between CCRT implementation and FTR before and after CCRT implementation in hospitals that did- vs. did not- implement CCRT during the study period.

Results: A total of 810,279 patients were included, of whom 148,882 (18.4%) developed a post-operative surgical complication. Among patients who developed a post-operative complication, the overall proportion of FTR was 9.2% (n=13,659). Among patients in hospitals that introduced CCRT, the relative risk (RR) of FTR was 0.84, (95% confidence interval (CI) 0.78-0.90) after implementation of CCRT, while over the same time period, the RR was 0.85 (95% CI 0.80-0.91) in hospitals that did not implement CCRT. The relative risk ratio (difference-in-differences) was 0.99 (95% CI 0.89-1.09). Among patients undergoing orthopedic surgery, the relative risk ratio was 0.84 (95% CI 0.75-0.95).

Conclusion: While implementation of CCRTs in hospitals in Ontario, Canada, did not reduce FTR among all surgical patients having surgery, CCRTs may reduce the risk of FTR among patients having orthopedic surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004629DOI Listing
November 2020

Morbidity and mortality after major large bowel resection of non-malignant polyp among participants in a population-based screening program.

J Med Screen 2020 Nov 5:969141320967960. Epub 2020 Nov 5.

Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada.

Background And Aims: Colonoscopy following positive fecal occult blood screening may detect non-malignant polyps deemed to require major large bowel resection. We aimed to estimate the major inpatient morbidity and mortality associated with major resection of non-malignant polyps detected at colonoscopy following positive guaiac fecal occult blood screening in Ontario's population-based colorectal screening program.

Methods: We identified those without a diagnosis of colorectal cancer in the Ontario Cancer Registry ≤24 months following the date of colonoscopy prompted by positive fecal occult blood screening between 2008 and 2017, who underwent a major large bowel resection ≤24 months after the colonoscopy, with a diagnosis code for non-malignant polyp, in the absence of a code for any other large bowel diagnosis. We extracted records of major inpatient complications and readmissions ≤30 days following resection. We computed mortality within 90 days following resection.

Results: For those undergoing colonoscopy ≤6 months following positive guaiac fecal occult blood screening, 420/127,872 (0.03%) underwent major large bowel resection for a non-malignant polyp. In 50/420 (11.9%), the resection included one or more rectosigmoid or rectal polyps, with or without a colonic polyp. There were one or more major inpatient complications or readmissions within 30 days in 117/420 (27.9%). Death occurred within 90 days in 6/420 (1.4%).

Conclusions: Serious inpatient complications and readmissions following major large bowel resection for non-malignant colorectal polyps are common, but mortality ≤90 days following resection is low. These outcomes should be considered as unintended adverse consequences of population-based colorectal screening programs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0969141320967960DOI Listing
November 2020

Should Complex Cancer Patients Requiring High-Risk Surgery Shoot for the Stars?

JNCI Cancer Spectr 2020 Oct 7;4(5):pkaa061. Epub 2020 Jul 7.

Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jncics/pkaa061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583161PMC
October 2020

Reproductive patterns, pregnancy outcomes and parental leave practices of women physicians in Ontario, Canada: the Dr Mom Cohort Study protocol.

BMJ Open 2020 10 21;10(10):e041281. Epub 2020 Oct 21.

Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Ontario, Canada

Introduction: Surveys and qualitative studies suggest that women physicians may delay childbearing, be at increased risk of adverse peripartum complications when they do become pregnant, and face discrimination and lower earnings as a result of parenthood. Observational studies enrolling large, representative samples of women physicians are needed to accurately evaluate their reproductive patterns, pregnancy outcomes, parental leave practices and earnings. This protocol provides a detailed research plan for such studies.

Methods And Analysis: The Dr Mom Cohort Study encompasses a series of retrospective observational studies of women physicians in Ontario, Canada. All practising physicians in Ontario are registered with the College of Physicians and Surgeons of Ontario (CPSO). By linking a dataset of physicians from the CPSO to existing provincial administrative databases, which hold health data and physician billing records, we will be able to retrospectively assess the healthcare utilisation, work practices and pregnancy outcomes of women physicians at the population level. Specific outcomes of interest include: (1) rates and timing of pregnancy; (2) pregnancy-related care and complications; and (3) duration of parental leave and subsequent earnings, each of which will be evaluated with regression methods appropriate to the form of the outcome. We estimate that, at minimum, 5000 women physicians will be eligible for inclusion.

Ethics And Dissemination: This protocol has been approved by the Research Ethics Board at St. Michael's Hospital in Toronto, Ontario, Canada (#18-248). We will disseminate findings through several peer-reviewed publications, presentations at national and international meetings, and engagement of physicians, residency programmes, department heads and medical societies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2020-041281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580071PMC
October 2020

Cross-sectional analysis of bibliometrics and altmetrics: comparing the impact of qualitative and quantitative articles in the .

BMJ Open 2020 10 21;10(10):e040950. Epub 2020 Oct 21.

Department of Surgery, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.

Objectives: In comparison to quantitative research, the impact of qualitative articles in the medical literature has been questioned by the BMJ; to explore this, we compared the impact of quantitative and qualitative articles published in BMJ.

Design: Cross-sectional survey.

Setting: Articles published in the BMJ between 2007 and 2017.

Main Outcome Measures: Bibliometric and altmetric measures of research impact were collected using Web of Science, Google Scholar, Scopus, Plum Analytics and ProQuest Altmetric. Bibliometric measures consisted of citation numbers, field weighted citation impact and citation percentile. Altmetric measures consisted of article usage, captures, mentions, readers, altmetric attention score and score percentile. Scores were compared using the Wilcoxon Rank-sum test.

Results: We screened a total of 7777 articles and identified 42 qualitative articles. Each qualitative article was matched to 3 quantitative articles published during the same year (126 quantitative articles). Citation numbers were not statistically different between the two research types; the median number of citations (google scholar) per quantitative article was 62 (IQR 38-111) versus 58 (IQR 36-85) per qualitative article (p=0.47). Using Plum Analytics, qualitative articles were found to have a significantly higher usage, with a median of 984 (IQR 581-1351) versus 379 (IQR 177-763) for quantitative (p<0.001). The Altmetric Attention Score was higher for quantitative articles at 16 (IQR 7-37) versus qualitative articles at 9 (IQR 5-23, p=0.05), as was the Altmetric Score percentile 93 (IQR 87-96) versus 88 (IQR 76-95; p=0.02).

Conclusion: Qualitative and quantitative articles published in the BMJ between 2007 and 2017 both have a high impact. No article type was consistently superior in terms of bibliometric or altmetric measures, suggesting that type of article is not the major driver of impact.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2020-040950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580064PMC
October 2020

Firearm-related injuries and deaths in Ontario, Canada, 2002-2016: a population-based study.

CMAJ 2020 Oct;192(42):E1253-E1263

Division of General Surgery (Gomez, Greene, Ahmed), Department of Surgery, University of Toronto; Division of General Surgery (Gomez, Ahmed), St. Michael's Hospital, Unity Health Toronto; Li Ka Shing Knowledge Institute (Gomez, Ahmed, Baxter), St. Michael's Hospital, Unity Health Toronto; ICES (Gomez, Saunders, Santiago, Baxter); Division of Pediatric Medicine (Saunders), The Hospital for Sick Children; Department of Pediatrics (Saunders), University of Toronto; Institute of Health Policy, Management and Evaluation (Saunders, Baxter), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Australia.

Background: Firearm-related injury is an important and preventable cause of death and disability. We describe the burden, baseline characteristics and regional rates of firearm-related injury and death in Ontario.

Methods: We conducted a population-based cross-sectional study using linked data from health administrative data sets held at ICES. We identified residents of Ontario of all ages who were injured or died as a result of a firearm discharge between Apr. 1, 2002, and Dec. 31, 2016. We included injuries classified as assault, unintentional, self-harm or undetermined intent secondary to handguns, rifles, shotguns and larger firearms. The primary outcome was the incidence of nonfatal and fatal injuries resulting in an emergency department visit, hospital admission or death. We also describe regional and temporal rates.

Results: We identified 6483 firearm-related injuries (annualized injury rate 3.54 per 100 000 population), of which 2723 (42.3%) were fatal. Assault accounted for 40.2% (1494/3715) of nonfatal injuries and 25.5% (694/2723) of deaths. Young men, predominantly in urban neighbourhoods, within the lowest income quintile were overrepresented in this group. Injuries secondary to self-harm accounted for 68.0% (1366/2009) of injuries and occurred predominantly in older men living in rural Ontario across all income quintiles. The case fatality rate of injuries secondary to self-harm was 91.7%. Self-harm accounted for 1842 deaths (67.6%).

Interpretation: We found that young urban men were most likely to be injured in firearm-related assaults and that more than two-thirds of self-harm-related injuries occurred in older rural-dwelling men, most of whom died from their injuries. This highlights a need for suicide-prevention strategies in rural areas targeted at men aged 45 or older.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.200722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588199PMC
October 2020

Medical Immunosuppression and Outcomes in Cutaneous Melanoma: A Population-Based Cohort Study.

Ann Surg Oncol 2021 Jun 16;28(6):3302-3311. Epub 2020 Oct 16.

Department of Surgery, University of Toronto, Toronto, ON, Canada.

Background: Melanoma and the immune system are intimately related. However, the association of immunosuppressive medications (ISMs) with survival in melanoma is not well understood. The study evaluated this at a population level.

Methods: A cohort of patients with a diagnosis of invasive cutaneous melanoma (2007-2015) was identified from the Ontario Cancer Registry and linked to identify demographics, stage at diagnosis, prescription of immunosuppressive medications (both before and after diagnosis), and outcomes. The demographics of patients with and without prescriptions for ISM were compared. Patients eligible for Ontario's Drug Benefit Plan were included to ensure accurate prescription data. The primary outcome was overall survival. Cox Proportional Hazards Regression models identified factors associated with mortality, including use of ISM as a time-varying covariate.

Results: Of the 4954 patients with a diagnosis of cutaneous melanoma, 1601 had a prescription for ISM. The median age of the patients was 74 years. Overall, 58.4% of the patients were men (60.5% of those without ISM and 54% of those using ISM; p < 0.001). The use of oral immunosuppression was associated with an increased hazard of death (hazard ratio, 5.84; 95% confidence interval, 5.11-6.67; p < 0.0001) when control was used for age, disease stage at diagnosis, anatomic site, comorbidity, and treatment. Other factors associated with death were increasing age, male sex, increased disease stage, truncal location of primary melanoma, and inadequate treatment. In sensitivity analysis with steroid-only ISM use excluded, survival did not differ significantly (p = 0.355).

Conclusions: The use of immunosuppressive steroids for melanoma is associated with worse overall survival. Use of steroids should be limited when possible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-09224-9DOI Listing
June 2021

Clinical and endoscopist factors associated with post-colonoscopy colorectal cancer in a population-based sample.

Colorectal Dis 2021 Mar 17;23(3):635-645. Epub 2020 Nov 17.

Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Aim: Factors associated with verified post-colonoscopy colorectal cancers (PCCRC) have not been well defined and survival for these patients is not well described. We aimed to assess the association of patient, tumour and endoscopist characteristics with PCCRC.

Methods: Using population-based data, we identified individuals diagnosed with CRC from 1 January 2000 to 31 December 2005 who underwent a colonoscopy within 3 years prior to diagnosis. Detected cancers were those diagnosed ≤6 months following colonoscopy; PCCRC were diagnosed >6 months to ≤3 years following colonoscopy. Post-colonoscopy and detected cancers were verified through chart review using a hospital-based simple random sampling frame. We used multivariable conditional logistic regression to determine the association of patient, tumour and endoscopist factors with PCCRC and compared overall survival using Cox proportional hazard models.

Results: Using the random sampling frame, we identified 498 patients with PCCRC and 498 with detected CRC; we obtained records and confirmed 367 patients with PCCRC and 412 with detected cancers. In multivariable analysis, patient age (OR 1.01; 95% CI 1.00-1.03) and tumour location (distal vs. proximal OR 0.36; 95% CI 0.25-0.53) were associated with PCCRC; endoscopist quality measures were not significantly associated with PCCRC. We did not find significant differences in overall survival between PCCRC and detected cancers (hazard ratio 1.12; 95% CI 0.92-1.32).

Conclusion: Although endoscopic quality measures are important for CRC prevention, endoscopist factors were not associated with PCCRC. This study highlights the need for further research into the role of tumour biology in PCCRC development.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/codi.15400DOI Listing
March 2021

Proportion of Female Speakers at Academic Medical Conferences Across Multiple Specialties and Regions.

JAMA Netw Open 2020 09 1;3(9):e2018127. Epub 2020 Sep 1.

Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Importance: Women in medicine have been underrepresented at medical conferences; however, contributing factors have not been well studied.

Objective: To examine the distribution of invited conference speakers by gender and factors associated with representation of women as speakers.

Design, Setting, And Participants: This cross-sectional analysis used medical conference programs from March 2017 to November 2018 across 20 specialties in 5 regions (Australasia, Canada, Europe, the UK, and the US) that were obtained online or from conference conveners.

Exposures: Gender of invited lecturers, panelists, and planning committee members for each conference based on name or picture and publicly available data on compositions of specialties by gender for included regions.

Main Outcomes And Measures: Outcomes included the proportion of female speakers (invited lecturers and panelists), the number of single-gender panels, and the proportion of female speakers compared with the specialties' gender composition. Correlations between the gender composition of conference planning committees and the proportion of female speakers were assessed. Multivariable regression models were used to evaluate factors independently associated with the proportion of female speakers at conferences.

Results: A total of 8535 sessions (panels and invited lectures) with 23 440 speakers across 98 conferences were identified. Women accounted for 7064 (30.1%) of speakers; 1981 of 5409 panels (36.6%) consisted of men only, and 363 (6.7%) consisted of women only. The proportion of women speakers varied by region and specialty from 5.8% to 74.5%. In general, specialties with low baseline proportions of women (<20%) had a ratio of female speakers to female specialists greater than 1, whereas specialties with high baseline proportions of women (>40%) had a ratio of female speakers to female specialists less that 1. There was a strong positive correlation between the proportion of women on planning committees and conference representation of female speakers (r = 0.67; P < .001). The association remained statistically significant after controlling for other variables, including the regional gender balance of the specialty (odds ratio, 1.10; 95% CI, 1.04-1.15; P < .001 for every 10% increase in the proportion of women on the planning committee).

Conclusions And Relevance: In this cross-sectional study, the proportion of female speakers at medical conferences was lower than that of male speakers, and more than one-third of panels were composed of men only. Increasing the number of women on planning committees may help address gender inequities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2020.18127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522699PMC
September 2020

Reoperation cascade in postmastectomy breast reconstruction and its associated factors: Results from a long-term population-based study.

J Surg Oncol 2020 Dec 15;122(7):1300-1306. Epub 2020 Sep 15.

Division of Plastic and Reconstructive Surgery, University Health Network, Toronto, Ontario, Canada.

Background: Unplanned surgeries following postmastectomy breast reconstruction (PMBR) may be required to treat complications or to revise the reconstructed breast. The primary objective of this study was to examine factors that influenced unplanned reoperations after PMBR.

Methods: A retrospective cohort study using provincial databases in Ontario, Canada, was completed. Patients with breast cancer underwent mastectomy between April 2002 and March 2012 followed by immediate or delayed PMBR. Primary outcome was time from PMBR to unplanned reoperations measured in years. The Anderson-Gill counting process model was used to estimate the risk of recurrent unplanned reoperations over time. Univariate and multivariate analyses were completed to examine the association between covariates.

Results: A total of 3066 women underwent PMBR and 51.7% had at least one unplanned reoperation. Unplanned breast reoperation was significantly associated with microsurgical tissue vs implant-based reconstruction (hazard ratio [HR]: 1.27), radiation after PMBR (HR: 1.22), surgery at a nonteaching hospital (HR: 1.16), patient comorbidity score (HR: 1.02), and prior unplanned reoperations (HR: 1.25).

Conclusions: Our study provides important long-term population-level data regarding factors influencing unplanned reoperations after PMBR. Patients undergoing microsurgical PMBR or postmastectomy radiation had a higher rate of additional procedures. Every additional reoperation also increases the likelihood of unplanned reoperations resulting in a "reoperation cascade."
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jso.26166DOI Listing
December 2020

Morbidity and mortality following major large bowel resection for colorectal cancer detected by a population-based screening program.

J Med Screen 2020 Sep 20:969141320957361. Epub 2020 Sep 20.

Institute for Healthcare Policy, Management and Evaluation, University of Toronto, Toronto, Canada.

Background And Aims: In 2008, Ontario initiated a population-based colorectal screening program using guaiac fecal occult blood testing. This work was undertaken to fill a major gap in knowledge by estimating serious post-operative complications and mortality following major large bowel resection of colorectal cancer detected by a population-based screening program.

Methods: We identified persons with a first positive fecal occult blood result between 2008 and 2016, at the age of 50-74 years, who underwent a colonoscopy within 6 months, and proceeded to major large bowel resection for colon cancer within 6 months or rectosigmoid/rectal cancer within 12 months, and identified an unscreened cohort of resected cases diagnosed during the same years at the age of 50-74 years. We identified serious postoperative complications and readmissions ≤30 days following resection, and postoperative mortality ≤30 days, and between 31 and 90 days among the screen-detected and the unscreened cohorts.

Results: Serious post-operative complications or readmissions within 30 days were observed among 1476/4999 (29.5%) cases in the screen-detected cohort, and among 3060/8848 (34.6%) unscreened cases. Mortality within 30 days was 43/4999 (0.9%) among the screen-detected cohort, and 208/8848 (2.4%) among the unscreened cohort. Among 30 day survivors, mortality between 31 and 90 days was 28/4956 (0.6%) and 111/8640 (1.3%), respectively.

Conclusion: Serious post-operative complications, readmissions, and mortality may be more common following major large bowel resection for colorectal cancer between the ages of 50 and 74 among unscreened compared to screen-detected cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0969141320957361DOI Listing
September 2020

Non-pharmacological interventions to improve the patient experience of colonoscopy under moderate or no sedation: a systematic review protocol.

BMJ Open 2020 09 13;10(9):e038621. Epub 2020 Sep 13.

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Introduction: The patient experience is a critical dimension of colonoscopy quality. Sedative and analgesic drugs are commonly used to improve the patient experience of colonoscopy, with predominant regimens being deep sedation, typically achieved with propofol, and moderate sedation, typically achieved with an opioid and a benzodiazepine. However, non-pharmacological interventions exist that may be used to improve patient experience. Furthermore, by identifying non-pharmacological interventions to increase the quality of patient experience under moderate sedation, jurisdictions facing rising use of deep sedation for colonoscopy and its significant associated costs may be better able to encourage patients and clinicians to adopt moderate sedation. Advancing either of these aims requires synthesising the evidence and raising awareness around these non-pharmacological interventions to improve the patient experience of colonoscopy.

Methods And Analysis: A systematic review will be conducted that searches multiple electronic databases from inception until 2020 to identify randomised controlled trials evaluating what, if any, non-pharmacological interventions are effective compared with placebo or usual care for improving the patient experience of routine colonoscopy under moderate or no sedation. Two reviewers will independently perform a three-stage screening process and extract all study data using piloted forms. Study quality will be assessed using the Cochrane Risk of Bias Tool V.2.0. Where multiple studies evaluate a single intervention, evidence will be quantitatively synthesised using pairwise meta-analysis, otherwise narrative syntheses will be undertaken.

Ethics And Dissemination: This is a review of existing literature not requiring ethics approval. The review findings will be included in future efforts to develop an implementation strategy to reduce the use of deep sedation for routine colonoscopy. They will also be published in a peer-reviewed journal, presented at conferences and contribute to a doctoral thesis.

Prospero Registration Number: CRD42020173906.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2020-038621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488806PMC
September 2020
-->