Canadian Tertiary Care Centre Research Articles

D.6 Neurological care and outcomes of pregnant patients with epilepsy in a Canadian tertiary care center (2014-2020)

Background: Limited data exists on neurological care and outcomes of Canadian pregnant patients with epilepsy (PPWE). This study provides Canadian data to inform practice patterns and observed outcomes for PPWE at a tertiary care center. Methods: PPWE receiving care at the University Health Network (Toronto, Canada) epilepsy clinic from January 1, 2014 to November 20 2020 were retrospectively identified with demographics and neurological data and outcomes collected. Results: A total of 195 cases were identified, with a median maternal age of 32 years (SD 4.58), a median age at first seizure of 17 years (range 1 month – 36 years old), 52% were diagnosed with genetic generalized epilepsy and 50% endorsed 6 months of seizure freedom prior to conception. In pregnancy, 93% took ASM(s) with 77% receiving therapeutic drug monitoring (TDM) and drug dose adjustments reported in 69%. Most cases (73%) maintained a stable seizure frequency. Conclusions: This study provides new Canadian data on PPWE at a tertiary care center. PPWE are overall well controlled, more likely to have young adult onset, genetic generalized epilepsy with nearly all taking ASM(s) during pregnancy. While high rates of TDM and drug dose adjustments were observed, most experienced seizure stability in pregnancy.

Umbilical cord blood culture for early onset sepsis in preterm infants.

Umbilical cord blood culture (UCBC) may have a diagnostic utility for early onset sepsis (EOS) detection in preterm infants. It may prevent sampling the newborn and collect a higher volume of blood for pathogenic identification. Retrospective analysis at a tertiary care center in Canada of preterm infants ≤ 34 0/7 weeks' gestation with UCBC taken at birth. Of 505 admitted infants, 195 had UCBC. 170 UCBCs were negative; 44 of these had also negative neonatal blood culture (NBC). No infants with negative UCBC showed EOS symptoms in the first week of life. 25 UCBCs were positive: 18 were contaminants (all with negative NBC) and 7 were confirmed as EOS. 18 infants with UCBC contaminants remained asymptomatic. 7 EOS cases were identified, with varying bacteriological profiles; 5 displayed sepsis symptoms while 2 were asymptomatic. Risk of EOS increased with prolonged rupture of membranes. UCBC effectively detected EOS establishing it as a method with possibly better diagnostic performance than NBC in high-risk neonates. Further studies are needed to improve UCBC technique and lower contamination rates. Umbilical cord blood culture has a higher bacterial identification rate than peripheral venous blood culture for the early identification of early-onset sepsis in preterm infants. Umbilical cord blood cultures that showed no growth were reliable predictors of not developing early onset sepsis. Umbilical cord blood culture should be considered as part of the evaluation for early onset sepsis in the preterm infants.

The Activity Management Inventory for Pain (AMI-P): Initial Development and Validation of a Questionnaire Based on Operant Learning and Energy Conservation Models of Activity Management.

Activity management is an important treatment component in chronic pain programs. However, there are shortcomings in measures of this construct, leading to inconsistencies in research findings. Here, we describe the development of the Activity Management Inventory for Pain (AMI-P). The AMI-P was developed by a group of international researchers with extensive expertise in both chronic pain and activity management. The initial evaluation of the AMI-P items included 2 studies that were both conducted in Canadian tertiary pain care centers. The resulting 20-item measure has 3 behavior scales (Rest, Alternating Activity, and Planned Activity), and 4 goal scales (Feel Less Pain, Get More Done, Complete the Task, and Save Energy). The behavior scales evidenced marginal to good internal consistency and test-retest reliability, and a moderate positive association with an existing pacing measure. The Rest and Alternating Activity scales were associated with greater pain interference, the Alternating Activity and Planned Activity scales were associated with less satisfaction with social roles, and the Planned Activity scale was associated with fewer depressive symptoms. The Alternating Activity scale increased significantly from pretreatment to posttreatment. All goal scales were positively associated with all behavior scales. The Feel Less Pain goal scale was positively associated with measures of avoidance and pain interference, while the Get More Done goal scale was negatively associated with measures of depressive symptoms and overdoing. The findings support the reliability and validity of the AMI-P scales, while also highlighting the complexity and multidimensional aspects of activity management.

Consecutive Microsurgical Cases Performed by Single Surgeon at a Canadian Tertiary Care Center: A Retrospective Review

Background: The practice of a microsurgeon evolves over time with experience, changes in clinical interest, and practice setting. Previous reports suggest that complication rates may be influenced by years of practice. The aim of this study was to analyze consecutive microsurgical cases performed by a single surgeon during the first half of their career in a broad microsurgical practice at a Canadian academic tertiary care center. Methods: A retrospective chart review of all free tissue transfers between 2007 and 2020 completed by a single academic plastic surgeon was performed. The primary outcomes were the odds of postoperative complications and free flap failure. The secondary outcomes included the annual number and type of free flap cases over time. Results: The surgeon performed 795 free flaps on 537 patients. There were a total of 131 postoperative complications. There was no statistically significant association between the years in practice and odds of a complication. Overall, there were 26 flap failures, yielding a 96.7% success rate. There was no association between flap failure and years in practice. The most common type of reconstruction was breast, followed by lower extremity and head and neck. There was a significant change in the type of reconstruction cases over time ( P < 0.005). Conclusion: The type and volume of free flap reconstruction conducted by the surgeon has changed over time. In this single surgeon career, surgical experience did not have a significant impact on free flap complications. At our center, free tissue transfer remains a valuable tool for reconstruction in both low and high-risk patients.

Management of Pediatric Patients With Spontaneous Pneumomediastinum: A Retrospective Chart Review

PurposeGiven the paucity of data on pediatric spontaneous pneumomediastinum (SPM), management is largely informed by extrapolation from adult studies or personal clinical experience, resulting in significant heterogeneity. The purpose of this study was to describe how pediatric patients with SPM are clinically managed at our institution and propose a treatment algorithm. MethodsRetrospective chart review of pediatric patients with SPM from April 2002 to December 2021 at a single Canadian tertiary care center. Data on medical history, presentation characteristics, clinical management, and complications were gathered. Descriptive and inferential statistics were used to analyze data. ResultsWe identified 63 patients for inclusion, median age was 15 years. Twenty-nine patients were transferred from another facility. Most common presenting symptoms were chest pain (72.3%), shortness of breath (44.6%), and subcutaneous emphysema (21.5%). Initial workup included chest x-ray (93.6%), CT scan (20.6%), and upper GI series (7.9%). There was no difference in the number of initial tests between admitted and discharged patients (p = 0.10). Of admitted patients (n = 35), 31.4% had primary SPM (no underlying comorbidity/inciting event) and 68.8% were secondary SPM (underlying comorbidity/inciting event). No patients with primary SPM developed complications or recurrences. In contrast, 16.7% of those with secondary SPM developed complications and 54.2% had at least one additional intervention after admission. DiscussionThere is significant variability in diagnostic investigation and treatment of pediatric SPM at our center. Amongst primary SPM, additional tests did not change complication rate or recurrence, including those transferred from another facility. An expeditious treatment algorithm is warranted. Type of StudyRetrospective Cohort Study. Level of EvidenceIII.

Breaking boundaries: Unraveling metabolic dysfunction-associated steatotic liver disease in children of India and Canada

Background: Non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD) is a major cause of chronic liver disease in children. Its prevalence is rising globally, yet it is uncertain if its onset and severity vary between countries. We aimed to compare pediatric NAFLD in two Canadian and Indian tertiary care centers. Methods: This study was conducted as a retrospective cohort study and patient related details were retrieved from the electronic records and reviewed. Results: The study analyzed a total of 184 children with NAFLD/MASLD (94 from the Indian site and 89 from the Canadian site) with concordance between NAFLD and MASLD definitions. The Indian children had a higher proportion of symptomatic presentations and family history of metabolic disorders ( p = 0.0001) while the Canadian children had higher median weight, BMI, blood pressure, and waist circumference ( p < 0.05). Indian children had higher hepatic transaminases and low density lipoprotein levels, while the Canadian site had higher serum insulin, blood glucose, homeostasis model assessment of insulin resistance, high density lipoprotein cholesterol levels, liver stiffness, and controlled attenuation parameter values ( p < 0.05). Majority (78%) of the Canadian children who underwent liver biopsy had significant fibrosis (>stage 2). In the overall cohort, waist circumference could be identified as an independent risk factor, irrespective of country of origin, predicting hepatic fibrosis. Conclusions: The study found significant differences between cohorts. Canadian children showed higher obesity grades and greater hepatic steatosis and fibrosis severity. To comprehend the underlying causes, future studies are imperative.

A131 OUTCOMES AND COMPLICATIONS OF THERAPEUTIC ERCP IN DIFFERENT AGE GROUPS

Abstract Background Endoscopic Retrograde Cholangiopancreatography (ERCP) is a vital procedure for hepatobiliary disease management. Though it boasts high overall success rates, the impact of patient age on outcomes remains uncertain, especially amongst elderly patients. With an aging population, it is crucial to determine the efficacy and safety of ERCP in different age groups. Aims This study assesses ERCP success and complication rates across age groups. Our objective is to investigate whether ERCP remains a reliable and safe procedure for patients of all ages, particularly the elderly. Methods A database with retrospective data from consecutive patients undergoing ERCP at a Canadian tertiary care centre between 2011 and 2020 was utilized. Baseline patient characteristics and indications for ERCP were collected. Outcomes included procedural success, complications, and procedure duration. Patients were categorized into four age groups: ampersand:003C40, 40-65, 65-80, and ampersand:003E80, with a specific sub-analysis for patients ampersand:003C80 and ampersand:003E80. Results This study included 6132 patients. Significant disparities were observed in comorbid conditions (pampersand:003C0.0001), ASA status (pampersand:003C0.0001), and the use of anticoagulants or antiplatelet agents (pampersand:003C0.0001). The most common indications for ERCP were gallstones (45.1%), jaundice (19.2%), and ductal lesions (12.8%), with no significant variation among the age groups (p=0.5983). There was a significant difference in procedural success (p=0.0005), with declining success in older age groups (ampersand:003C40 = 91.3%, 40-65 = 87.4%, 65-80 = 86.2%, ampersand:003E80 = 84.9%), and this difference remained significant in the ampersand:003C80 and ampersand:003E80 sub-analysis (p=0.0133). While mean procedure duration was longer in older age groups (pampersand:003C0.0001), incidence of complications did not vary across all groups (p values [EH1] = 0.1532-0.7622) or patients ampersand:003C80 and ampersand:003E80 (p= 0.0769-0.7128). Conclusions ERCP maintains a high success rate and safety profile across all age groups; however, success rates decline and procedure times increase significantly in older patients. ERCP outcomes across age groups Funding Agencies None

Combined Interval Cytoreductive Surgery and Carboplatin-Based Hyperthermic Intraperitoneal Chemotherapy in Advanced Primary High-Grade Serous Ovarian Cancer.

Combining interval cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) improves survival in advanced epithelial ovarian carcinoma (EOC). Although limited, growing evidence regarding carboplatin-based HIPEC highlights its potential. This retrospective study included all patients with advanced primary high-grade serous ovarian cancer who underwent interval CRS combined with carboplatin-based HIPEC at our Canadian tertiary care center between 2014 and 2020. We identified 40 patients with a median age of 61 years. The median peritoneal cancer index was 13 and complete cytoreduction was achieved in 38 patients (95%). Median hospital stay was 13 days and there were four admissions to the intensive care unit (10%) and six readmissions (15%). Severe adverse events occurred in eight patients (20%) and there was no perioperative death. Recurrence was seen in 33 patients (82%) with a median DFS of 18.0 months and a median overall survival of 36.4 months. Multivariate analyses showed that age, peritoneal cancer index, completeness of cytoreduction, occurrence of severe complications, and bowel resection did not significantly impact DFS or OS in our cohort. Interval CRS combined with carboplatin-based HIPEC for advanced primary EOC is associated with acceptable morbidity and oncological outcomes. Larger studies are required to determine the long-term outcomes.

Venous Thromboembolism in Hematopoietic Stem Cell Transplantation

Background: Venous thromboembolism (VTE) is an underappreciated complication seen amongst allogeneic and autologous hematopoietic stem cell transplant (HSCT) patients and a major cause of morbidity and mortality. Despite these challenges, VTE in HSCT remains understudied, with a paucity of established guidelines on thrombosis surveillance, prevention, and treatment. Balancing risk of bleeding and thrombosis is particularly challenging as HSCT patients are concurrently pancytopenic and coagulopathic. We aimed to describe the incidence, predictors, and adverse events of VTE amongst patients at 90 days post-HSCT. Methods: We conducted a retrospective cohort study of adult patients, age >18-years-old, who underwent HSCT for a hematological malignancy between January 1, 2011 and December 31, 2021 at a tertiary care centre in Canada. Patients were followed from transplant until Day 90 post-transplant, or death. Baseline, transplant, laboratory, and cancer characteristics were analyzed. Results: Four Hundred and Seventy Six (476) HSCT patients were included (age range 18 - 74), 285 (59.9%) of our patients were male, and 191 (40.1%) were female. Three Hundred and Seventeen (317) (66.6%) patients underwent autologous transplant, and 159 (33.4%) patients underwent allogeneic transplant ( Table 1). Forty Seven (47) patients (9.8%) suffered from VTE within 90 days post-HSCT; 74.5% were catheter related. 9.43% of allogeneic, versus 10.09% autologous patients were diagnosed with VTE (p=0.820). 11.9% of allogeneic, versus 4.1% of autologous patients (p=0.001) suffered from bleed unrelated to anticoagulation. There was significant association of VTE post-HSCT with history of unprovoked DVT (p = 0.026), previous treatment with steroids (p = 0.032), infectious complications (including bacteremia (p = 0.025), and skin and soft tissue infection (p < 0.001)), use of peripherally-inserted central catheters (PICCs (p <0.001), left-sided CVC placement (p = 0.007), second central venous line insertion (due to complications from the first) (p < 0.001), and blocked or malfunctioning central venous catheter (p = 0.003). There was no significant association of VTE post-HSCT with transplant graft (autologous versus allogeneic), underlying hematological malignancy, age, BMI, or sex. Mortality rate at 90 days amongst VTE patients was 14.89%, versus 3.27% in non-VTE patients (p < 0.001) ( Figure 1). Conclusion: The majority of VTE post-HSCT were catheter-related and were more frequently associated with use of PICCs. VTE post-HSCT was associated with higher mortality. VTE prophylaxis or active surveillance could be considered in patients with the above-mentioned risk factors balancing the risk of bleeding, particularly in allogeneic stem cell transplant patients, and those who are concurrently thrombocytopenic.

Development of a Combined Risk Assessment Model for Venous Thromboembolism and Bleeding in Hematopoietic Stem Cell Transplantation Patients

Background: Venous thromboembolism (VTE) and bleeding are common complications amongst allogeneic and autologous hematopoietic stem cell transplant (HSCT) patients. Balancing risk of bleeding and thrombosis in this population is particularly challenging as HSCT patients are concurrently pancytopenic and coagulopathic. However, risk factors for bleeding and thrombosis in HSCT patients are understudied. We aimed to derive a combined bleeding and VTE risk assessment tool to be used in the immediate post-transplant period (90 days). Methods: We conducted a retrospective cohort study of adult patients who underwent allogeneic or autologous HSCT between January 1, 2011 and December 31, 2021 at a tertiary care centre in Canada. The risk models patients were followed from transplant until occurrence of the event of interest with last follow up at Day 90 post-transplant, or death. Primary outcome for VTE was the occurrence of a confirmed thrombosis including proximal upper and lower extremity deep vein thrombosis, pulmonary embolism, or thrombosis of unusual sites, including cerebral and splanchnic. Primary outcome for bleeding was the occurrence of a major or clinically significant non-major bleeding event, not related to anticoagulation, as per the definition of the International Society of Thrombosis and Hemostasis. Group characteristics were compared using chi-square, Fisher's exact, or Student's T-tests as appropriate. Potential predictors for VTE and bleed amongst our patients were evaluated using single variable logistic regression and confirmed with multiple variable logistic regression with forward selection. For continuous variables, optimal cut-off points were estimated using ROC curves. Final VTE and bleed risk scores were derived based on weighted variables and compared using Cox regression with non-parametric bootstrapping used for internal validation. Results: A total of 476 patients (317 autologous, 159 allogeneic) were included. 47 patients (9.8%) suffered from VTE, and 32 patients (6.7%) suffered from bleed unrelated to anticoagulation within 90 days post-HSCT. A VTE risk assessment tool was derived, and internally validated, and it included: second central venous catheter insertion (due to complications from first central line) (2 points), and previous cancer treatment with steroids (1 point). The overall cumulative incidence of VTE was 31.8% in the high-risk group (>2 points) versus 7.6% in the low-risk group (0-1 points). The high-risk group was associated with higher mortality at 90 days (15.9% versus 3.2%, p <0.001; Figure 1). A bleeding risk assessment tool was also derived, and internally validated, and it included: baseline (day 0 of transplant) platelet count of <90 (1 point), and baseline hemoglobin of <96 (1 point). The overall cumulative incidence of bleed was 17.2% in the high-risk group (2 points), versus 4.3% in the low-risk group (0-1 points). The high-risk group was associated with higher mortality at 90 days (12.6% versus 2.6%, p<0.001). Amongst the low-risk bleed group, overall cumulative incidence of VTE was 10.03%, with 31.03% in the high-risk VTE group versus 8.33% in the low-risk VTE group (p<0.001). The positive VTE group was associated with higher mortality at 90 days (10.26% versus 1.72%, p=0.001; Figure 2). Amongst the high-risk bleed group, overall cumulative incidence of VTE was 9.19%, with 33.33% in the high-risk VTE group, versus 4.17% in the low-risk VTE group (p<0.001). The positive VTE group was associated with higher mortality at 90 days (37.5% versus 10.13%, p=0.026). Conclusion: We derived a predictive score, VTE and Bleeding in Marrow Transplant (VBMT) - risk score, for both VTE and bleeding in the immediate post-transplant period (90 days), to be used in conjunction with other criteria for bleeding and thrombosis. Amongst the low-risk bleed patients, we recommend strong consideration of chemical VTE prophylaxis, especially amongst the high-risk VTE group. These risk assessment models will help stratify patients based on bleed and thrombosis risk, and ultimately help guide VTE prophylaxis and surveillance strategies amongst HSCT patients.

Obstetrical Use of Intravenous Immunoglobulin at a Tertiary Care Canadian Center: A 14-Year Retrospective Study

Introduction: Intravenous immunoglobulin (IVIG) has gained widespread acceptance for the treatment of various medical conditions. However, its availability is limited, it incurs substantial costs, and reports of shortages have raised concerns regarding patient access. Additionally, adverse events with IVIG use underscore the need for prudent administration. While IVIG is approved for specific indications, its off-label use remains significant. Prior studies have addressed the general use of IVIG use and called for measures to ensure its appropriate application, research specific to the obstetrical use of IVIG is lacking. Understanding how IVIG is used in pregnancy could guide future research endeavours and shape policies aimed at optimizing patient care, minimizing unwarranted exposure, and containing healthcare costs. The objectives of this study are three-fold: (1) to assess the frequency, volume, and indications of IVIG use in pregnancy, (2) to assess the congruent use of IVIG with the approved Canadian indications and the approved conditions by the Ontario Immunoglobulin Utilization Management Guidelines, and (3) to compare the volume of IVIG used in pregnancy to the total volumes of IVIG use. Methods: This retrospective cohort study used administrative data and chart reviews to analyze all pregnant individuals between 2007 and 2020 who received IVIG during their pregnancy and delivered at a large tertiary care academic center with high-risk obstetrical care in Ontario, Canada. Data were collected on IVIG volumes, administration regimens, indications, and timing of administration during pregnancy. A descriptive analysis was performed to present the findings. Results: The study cohort comprised 122 pregnant patients, accounting for 136 deliveries. The cumulative volume of IVIG used across all obstetrical patients amounted to 41,107.50 grams, representing 1.6% of the total consumption of IVIG (2,575,766.50 grams) at our center. Among the indications for IVIG administration during pregnancy (Table 1), the most prevalent were maternal thrombocytopenia (77/136 deliveries, 56.6%) and antenatal therapy for Fetal/Neonatal Alloimmune Thrombocytopenia (F/NAIT) (22/136 deliveries, 16.2%). The highest IVIG consumption was observed in F/NAIT, with a total of 26,435 grams (64.3%) used in all pregnancies and a median of 1015 grams per pregnancy (IQR = 542.5, 1938.75). Maternal thrombocytopenia followed, accounting for a total of 6,952.50 grams (16.9%) used in all pregnancies and a median of 70 grams per pregnancy (IQR = 40, 90). We observed an overall increase in the trend of IVIG use in pregnancy and average volumes per delivery, but this remains a small proportion of total IVIG use (Figure 1). In terms of congruent use of IVIG, 38.2% of deliveries (52/136) did not meet the Canadian licensed indications for IVIG use, accounting for a large amount (33,025 grams, 80.3% of total volume used). However, 17.6% of deliveries (24 out of 136) did not adhere to the Ontario guidelines' indications for IVIG use, which constituted a total of 5,475 grams (13% of total volume used). Conclusions: The obstetrical use of IVIG represents a minor proportion of the total volume used at a large Canadian tertiary care center. Hematologic conditions, particularly F/NAIT and maternal thrombocytopenia, are the predominant drivers of IVIG administration during pregnancy. Recent reports on IVIG use in the general population demonstrated similarly high prescribing patterns of IVIG among hematologists, but also neurologists. Rational prescribing and dose minimization are important strategies to improve judicious and cost-effective use of IVIG. However, implementation of such strategies for obstetrical use of IVIG may be limited as evidence generally stems from small, retrospective, observational studies, and reaching a consensus among various specialists may sometimes prove difficult. There is a pressing need for prospective multicenter studies in pregnant individuals, particularly for conditions with high IVIG consumption. These studies would help to examine the efficacy and safety of IVIG during pregnancy and provide essential guidance for appropriate IVIG use in this unique patient population.

Preoperative mediastinal staging in early-stage lung cancer: Targeted nodal sampling is not inferior to systematic nodal sampling

ObjectiveTo determine whether targeted sampling (TS), which omits biopsy of triple- normal lymph nodes (LNs) on positron emission tomography, computed tomography, and endobronchial ultrasound (EBUS), is noninferior to systematic sampling (SS) of mediastinal LNs during EBUS for staging of patients with early-stage non–small cell lung cancer (NSCLC). MethodsPatients who are clinical nodal (cN)0-N1 with suspected NSCLC eligible for EBUS based on positron emission tomography/computed tomography were enrolled in this prospective, multicenter trial. During EBUS, all patients underwent TS and then crossed over to SS, whereby at least 3 mediastinal LN stations (4R, 4L, 7) were routinely sampled. Gold standard of comparison was pathologic results. Based on the previous feasibility trial, a noninferiority margin of 6% was established for difference in missed nodal metastasis (MNM) incidence between TS and SS. The McNemar test on paired proportions was used to determine MNM incidence for each sampling method. Analysis was per-protocol using a level of significance of P < .05. ResultsBetween November 2020 and April 2022, 91 patients were enrolled at 6 high-volume Canadian tertiary care centers. A total of 256 LNs underwent TS and SS. Incidence of MNM was 0.78% in SS and 2.34% in TS, with an absolute difference of 1.56% (95% confidence interval, −0.003% to 4.1%; P = .13). This falls within the noninferiority margin. A total of 6/256 LNs from 4 patients who were not sampled by TS were found to be malignant when sampled by SS. ConclusionsIn high-volume thoracic endosonography centers, TS is not inferior to SS in nodal staging of early-stage NSCLC. This results in change of clinical management for a minority of patients.

The impact of an antibody investigation algorithm emphasizing specificity on reducing potential false-positive warm autoantibody detection at a Canadian tertiary care centre.

To reduce potential false-positive warm autoantibody (WAA) by solid-phase red cell adherence assay (SPRCA), our centre implemented a new antibody investigation algorithm (AIA) by classifying cases with panreactive SPRCA but negative saline-indirect antiglobulin test as 'antibody of undetermined significance' (AUS) after excluding clinically significant antibodies. We assessed the effects of the new AIA and subsequent alloantibody formation in patients with AUS. Samples from patients with positive SPRCA screens between 1 September 2017 and 31 August 2021 were selected for the study. Frequencies of antibodies classified by the old and new AIAs were compared using Fisher's exact test. Patient demographics, transfusion history and antibody formation in cases of AUS were collected. A significant reduction in potential WAA frequencies from 127/1167 (11%) to 53/854 (6%) was observed (p < 0.001) when compared between the old and new AIAs among 2021 positive SPRCA antibody screens. While no patients with AUS later transitioned to potential WAA using the new AIA, four patients developed alloantibodies, including anti-E, anti-C, both anti-C and anti-E, and anti-Wra . A significant reduction in the frequencies of potential false-positive WAA detection at our centre was observed after implementing the new AIA, leading to less resource and phenotypically matched red blood cell (RBC) use. Some patients still developed subsequent RBC alloimmunization, so clinically relevant alloantibodies should be carefully excluded before determining AUS, taking forming or evanescent antibodies into consideration.

Complete circumferential endoscopic submucosal dissection for early Barrett’s neoplasia

Background and aimsEndoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of esophageal neoplasia in the western world. Contrary to Asia, the majority of esophageal cancers in North America are associated with Barrett’s esophagus. Patients with circumferential advanced neoplasia were previously managed by esophagectomy. Increased experience with ESD has allowed for an endoscopic alternative. We aim to present our experience with complete circumferential esophageal ESD at a North American referral center. MethodsAll patients undergoing 100% circumferential esophageal ESD between Oct 2016 and Jan 2023 at a single tertiary care center in Canada were included in the cohort. Demographic, procedural data and lesion characteristics are presented in this series. ResultsEleven patients underwent 100% circumferential esophageal ESD during this period for Barrett’s neoplasia. All patients had technically successful procedures with en bloc resection. Nine patients (82%) had R0 resections, defined as clear lateral and deep margins on histologic examination. Two patients had positive deep margins on histologic examination and proceeded to esophagectomy. Seven patients (64%) had adenocarcinoma on final pathology, of which 6 (86%) had upstaging from their initial biopsy.The median area of resected specimen was 48cm2 (IQR 26-80) and the median procedure time was 231 minutes (IQR 180-246). Procedural efficiency was 4.0 min/cm2 (IQR 2.7-5). Two patients (18%) developed refractory strictures following the procedure, which were endoscopically managed to resolution. ConclusionMultifocal dysplastic Barrett’s esophagus remains a challenging entity to treat. Circumferential ESD is a possible therapeutic option, with high procedural success and low adverse outcomes. This should be balanced against the risk of stricture development, as the optimal post procedural prophylaxis regimen is investigated.

26 How Are We Addressing Health Equity in the Paediatric Tertiary Care Setting? An Environmental Scan of Approaches across Canada

Abstract Background Increasingly, paediatricians are asserting the urgent need for effective practices and policies to address child health inequities. Yet there is a paucity of data on the current approaches implemented in Canadian paediatric tertiary care centres. According to the Institute of Health Improvement (IHI), health equity is paramount for a just society that moves toward better well-being for all. The IHI framework lists five priorities to guide health equity initiatives: make health equity a strategic priority; develop structures and processes to support health equity work; deploy specific strategies to address the multiple determinants of health on which health care organizations can have a direct impact; decrease institutional racism within the organization; and develop partnerships with community organizations. Objectives The objectives of this study were to: 1) Map out current initiatives addressing health equity, and 2) Explore the facilitators and barriers to achieving health equity, in the tertiary paediatric health care setting in Canada. Design/Methods We conducted an environmental scan using in-depth, semi-structured interviews as well as a review of the grey and published literature. We interviewed at least one paediatric resident and one staff (including paediatricians, allied health professionals, and administrators involved in health equity) at all 17 paediatric tertiary care centres in Canada. The interview guide was structured using the IHI framework, to characterize initiatives, as well as facilitators and barriers, to address health equity. We performed a thematic analysis using NVivo. Codes were generated using an inductive and deductive approach, from which themes were identified, refined, and finalized. Results We conducted 41 interviews from Fall 2021 to Fall 2022. Recent events, including Black Lives Matter and the COVID pandemic, fuelled health equity initiatives at the hospital- and university-levels. Most institutions were in a reactionary state, with few having formal strategic approaches to address inequities. The initiatives served a variety of priority populations: Indigenous, Black, migrants, rural communities, and children with disabilities, with the focus differing based on geography and the unique challenges faced by each institution. To achieve equity throughout an organization, equity at the staffing level was identified as being a necessity. The barriers to implementing health equity initiatives included lack of accountability, lack of leadership support, limited resources, and lack of institutional awareness. The facilitators included leadership support, health equity champions, and increasing awareness and resources. Conclusion A myriad of health equity initiatives are taking place in Canadian paediatric tertiary care centres, which are evolving.

44. LONG-TERM OUTCOMES OF PERORAL ENDOSCOPIC MYOTOMY FOR PATIENTS WITH ACHALASIA: A SINGLE-CENTRE STUDY

Abstract Background and study aims: The short-term outcomes of Peroral endoscopic myotomy (POEM) for achalasia are well described, however, there is limited long-term data in the literature. This study aims to retrospectively assess the long-term outcomes of the POEM in a Canadian tertiary care centre. Methods All patients who underwent POEM for treatment of Achalasia with minimum follow-up of at least 4 years at a tertiary care centre were enrolled in this study. The primary outcome of the study was clinical success defined as a post-POEM Eckardt score ≤ 3 at ≥48 months. Secondary outcomes included changes in body mass index (BMI), incidence of gastroesophageal reflux disease (GERD), adverse events and length of hospital stay. Result Thirty-eight patient (aged 53.9 ± 17.9) underwent POEM, with a median follow-up period of 61 months (48–79). The mean Eckardt score was significantly reduced from 7.7 ± 1.9 to 1.2 ± 0.6 (P &amp;lt; 0.001). All patients achieved post-POEM Eckardt scores of ≤3 at ≥48 months. BMI increased from 27.4 ± 6.5 pre-POEM to 29.4 ± 6.7 (P &amp;lt; 0.003) post-POEM. Twelve (31.5%) patients developed pathologic reflux. Conclusion POEM is an effective and safe procedure for achalasia with durable long-term outcomes. Larger series with longer follow-up are required to confirm these results.

Patterns of alaryngeal voice adoption and predictive factors of vocal rehabilitation failure following total laryngectomy.

We aimed to determine patterns of alaryngeal voice acquisition and predictive factors of vocal rehabilitation (VR) failure following total laryngectomy (TL) at a large Canadian tertiary care center. All consecutive patients having undergone a TL between January 1st, 2011 and December 31st, 2019, at the Centre Hospitalier de l'Université de Montréal were included. One hundred and ninety-seven laryngectomized patients were identified. Successful VR was achieved in 86 (59.0%) patients, while 59 (41.0%) failed to use a method of alaryngeal voice as their principal means of communication at 1 year postoperatively. The use of tracheoesophageal puncture (TEP) was associated with higher VR success rates (70.6%) when compared with the artificial larynx (48.6%), and esophageal voice (18.8%). The only independent predictor of VR failure on multivariate analysis at all time points was a low socioeconomic status. Failure to adopt an alaryngeal voice following TL is highly prevalent, despite comprehensive and free speech language pathologist services being offered at our center. A low resort to TEP at our institution and a poor acceptability and accessibility of alternative VR methods may contribute to this trend. The challenges of VR may be further exacerbated by the barriers linked to a lower socioeconomic status, which in turn may contribute to reduced candidacy for TEP.

How does the antimicrobial stewardship provider role affect prospective audit and feedback acceptance for restricted antibiotics in a Canadian tertiary-care center?

Of 731 restricted antimicrobial prescriptions subject to antimicrobial stewardship program (ASP) prospective audit and feedback (PAF) over a 3-year period, 598 PAF recommendations (82%) were fully accepted. Physician auditors had an increased odds of PAF recommendation acceptance, reinforcing the complementary role of the ASP physician in the multidisciplinary ASP team.

Obstetrical Outcomes of Patients with Epilepsy in a Canadian Tertiary Care Center (2014-2020).

There is a paucity of data on the obstetrical outcomes of Canadian pregnant patients with epilepsy, which may differ from the average Canadian pregnancy and from other populations of pregnant patients with epilepsy. Pregnant patients with epilepsy were identified from a prospectively collected database of patients seen at the maternal-fetal medicine obstetrics program of Mount Sinai Hospital (Toronto, Canada) between January 1, 2014, and November 20, 2020. Pregnancy, delivery, and neonatal outcome data were retrieved from this database and described using 95% binomial confidence intervals. Comparisons of obstetrical outcomes over the same period among the Canadian population average, obtained from publicly available national health data, were done using one-proportion Z-tests for nominal variables and one-sample t-tests for continuous variables. In total, 282 pregnancies, from 224 patients, were included, which resulted in 274 live births. Mean maternal age was 32.8 years (s.d. = 4.6; population average [μ] = 30.9; p < 0.01), and 53% were primiparous (CI95% = 49%-61%; μ = 43%; p < 0.01). The observed rates of obstetrical complications were gestational hypertension 9% (CI95%=6%-13%; μ=7%; p=0.19), gestational diabetes 5% (CI95% = 3%-8%; μ = 9%; p = 0.02), cesarean section 44% (CI95% = 38%-50%; μ = 28%; p < 0.01), postpartum hemorrhage 5% (CI95% = 3%-8%; μ = 0.5%; p < 0.01), stillbirth 1% (CI95% = 0%-2%; μ=1%; p > 0.99), and prematurity 9% (CI95% = 6%-13%; μ = 8%; p = 0.44). In this cohort of Canadian pregnant patients with epilepsy from an urban tertiary care center, observed rates of obstetrical complications were rare and no higher than in the Canadian population over the same period, with the exception of cesarean section and postpartum hemorrhage. Future prospective studies that include primary care and rural settings are needed to increase the generalizability of those results.

Anticipation or avoidance: internal medicine resident experiences performing invasive bedside procedures.

Internal Medicine (IM) residents are required to perform bedside procedures for diagnostic and therapeutic purposes. Residents' experiences with procedures vary widely, for unclear reasons. To explore IM residents' experiences with performing bedside procedures and to identify barriers and facilitators to obtaining sufficient experience. Using an inductive, thematic approach, we conducted five individual semi-structured interviews and one focus group with seven IM residents (12 residents in total) during the 2017-2018 academic year at a Canadian tertiary care centre. We used iterative, open-ended questions to elicit residents' experiences, and barriers and facilitators, to performing bedside procedures. Transcripts were analyzed for themes using Braun and Clarke's method. We identified four themes 1) Patient-specific factors such as body habitus and procedure urgency; 2) Systems factors such as time constraints and accessibility of materials; 3) Faculty factors including availability to supervise, comfort level, and referral preferences, and 4) Resident-specific factors including preparation, prior experiences, and confidence. Some residents expressed procedure-related anxiety and avoidance. Educational interventions aimed to improve procedural efficiency and ensure availability of supervisors may help facilitate residents to perform procedures, yet may not address procedure-related anxiety. Further study is required to understand better how procedure-averse residents can gain confidence to seek out procedures.