Sunnybrook Health Sciences Centre Research Articles

Anesthesia considerations of magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: a case series.

Essential tremor (ET) is a common movement disorder with disability in voluntary actions such as eating and writing. First-line treatment involves pharmacological agents, although efficacy is limited by side effects. In these patients, functional neurosurgery can be considered. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) thalamotomy offers a non-invasive solution for treatment. This paper examines an original cohort of ET patients undergoing MRgFUS thalamotomy and discusses the anesthetic management of these cases. We retrospectively reviewed the anesthetic records of all MRgFUS thalamotomy cases from 15 May 2012 to 16 July 2015 at our centre (Sunnybrook Health Sciences Centre, Toronto, Canada) to expand a data set provided by the focused ultrasound system manufacturer (Insightec, Tirat Carmel, Israel) from a prior phase-II regulatory approval study. Specific drug and procedural details were listed including aspects of the patients' experience. A total of 82 patients were included in the analysis, 78 from a phase-II trial (16 were from the local site) and four local non-trial cases. No patient required general anesthesia and only 29% of cases required sedation to tolerate the procedure. The most frequent medications required were antiemetics and analgesics. Headache (31%) was the most frequent perioperative symptom. Transient intra-procedural paresthesia symptoms were a common occurrence (32%). The use of MRgFUS for thalamotomy provides a non-invasive and well-tolerated method for treating ET, which usually only requires monitored anesthesia care sedation. Nevertheless, there are several predictable side effects that require contingency planning including the personnel and means to resolve them.

A virtual care program for outpatients diagnosed with COVID-19: a feasibility study.

In patients who are discharged home to self-isolate while coronavirus disease 2019 (COVID-19) test results are pending, there is no formal method for physician assessments or counselling to occur if the result returns positive. Our aim was to develop and test the feasibility of a virtual care program for self-isolating outpatients diagnosed with COVID-19. In preparation for this gap in health care, the COVID-19 Expansion to Outpatients (COVIDEO) program was developed at the Sunnybrook Health Sciences Centre, Toronto, Ontario, to provide ongoing care for outpatients diagnosed with COVID-19. As part of a feasibility study, we describe our experiences with the first 50 patients managed using this program from its inception (Mar. 1, 2020) until Mar. 27, 2020. All 50 people who tested positive for COVID-19 at the Sunnybrook Health Sciences Centre and were discharged home to self-isolation during the study period were assessed through the COVIDEO program. Thirty-two patients (64%) were assessed via the Ontario Telemedicine Network virtual care platform, and the remainder by telephone. The median time from viral swab collection to first COVIDEO program assessment was 2 (interquartile range [IQR] 1-2) days. Among the 26 patients for whom further follow-up care through the COVIDEO program was discontinued by the end of March 2020, the median duration of virtual care was 12.5 (IQR 8.75-16) days. During the study period, 6 patients required transfer to hospital for assessment, of whom 4 required admission. We have shown that a virtual care program can be used in the management of outpatients diagnosed with COVID-19. Further studies evaluating its sustainability and impact on health outcomes are underway.

Editorial introductions

Editorial introductions

A148 EFFICIENCY IN THE ENDOSCOPY UNIT: CAN WE ‘TURN AROUND’ ROOM TURNOVER?

Abstract Background Endoscopy units across Canada are being challenged to meet the growing demand for procedures despite limited resources, highlighting the need to optimize endoscopy unit efficiency. Earlier studies have found that non-procedural factors, such as room turnover, represent an ideal target to improve efficiency. Aims The objective of this research project was to identify practices that will improve efficiency for routine outpatient gastrointestinal (GI) procedures at Sunnybrook Health Sciences Centre (SHSC). There were 2 sub-aims: 1) to understand practices at Toronto hospitals that shorten room turnover time and 2) to describe the variation in room turnover time at SHSC. Methods Sub-aim #1: A survey of endoscopy units at five other Toronto hospitals was completed. Questions were designed to gain a better understanding of routine practices and any initiatives undertaken to improve room turnover efficiency. Sub-aim #2: Median room turnover time from April 2018 to March 2019, defined as ‘patient out’ to ‘patient in’, was reported in an anonymized fashion for the following categories: 1) by endoscopist, 2) by nurse, and 3) by unique endoscopist-nurse pair. Only data from routine outpatient endoscopic procedures (e.g. colonoscopy, gastroscopy, flexible sigmoidoscopy) were included. In order to evaluate turnover times by endoscopist-nurse pair, consecutive cases not performed by the same pair were excluded. Procedures affected by patient- and transportation-related delays were also excluded. Results Of the five centers surveyed, three allocated 5 minutes for turnover and two allocated 10 minutes. All centers reported tracking turnover time and four centers reported undertaking initiatives to decrease turnover time such as involving a flow team, hiring team attendants, and sharing performance data. Over the 12-month period, 2504 routine outpatient GI endoscopic procedures were performed at SHSC, with 803 cases meeting inclusion criteria. Median turnover time for the unit was 6 minutes, ranging from 5 to 9 minutes across endoscopists, 5 to 7 minutes across nurses, and 3 to 10 minutes across unique endoscopist-nurse pairs (Figure 1). Efficiency of endoscopist-nurse pairs did not correlate with the number of cases performed as a pair over the 12-month period. Conclusions Endoscopy room turnover times at SHSC are similar to those reported by other local centers, with important variation across endoscopists and nurses. The next phase of this study will involve directly observing each of the most and least efficient individuals and pairs and recording common practices. It is anticipated that these findings will enable us to identify efficient practices that should be incorporated into standard operating procedures and training for endoscopy room personnel. Funding Agencies None

A183 UPPER GASTROINTESTINAL CAUSTIC INJURIES: A SINGLE CENTRE CASE SERIES

Abstract Background Caustic esophageal and gastric injury is a rare, but potentially lethal event. The 2017 American Association of Poison Control reported only 193,000 cases of caustic ingestion (1). Caustic agents are acidic or alkaline. The pH of the ingested substance dictates the type of injury and the area of the gastrointestinal track most at risk. The most common culprit agents are alkaline including, for example, bleaches, drain openers and dishwashing detergents. Due to the rarity and natural history of this disease there are very few high-quality studies for clinicians to refer to when managing these patients. Aims We present three cases of caustic ingestion and provide a review of current best practice standards. Methods Between August and September 2019, three patients were admitted to Sunnybrook Health Sciences Centre at the University of Toronto for caustic injury. All three patients were referred to the gastroenterology service and underwent an esophagogastroduodenoscopy (EGD) to assess the degree of esophageal and gastric injury. Patients were followed both in hospital and in the outpatient setting for ongoing surveillance and repeated endoscopic evaluation. Patient demographics, treatment, endoscopic findings and outcomes were collected. Results Three patients intentionally ingested caustic agents, were admitted to hospital and managed by the gastroenterology service. Patients were a mix of ages, genders and ethnicities. All ingestions were strong alkali agents including sodium hydroxide and sodium hypochlorite. All patients underwent an EGD within 24 hours of presentation and caustic injury was graded using the Zargar classification (2). All patients were started on intravenous proton pump inhibitor therapy. All patients were initially made nothing per mouth and ability to resume feeds was assessed based on symptoms. Patient 1, Zargar grade 1, was able to resume oral intake within 48 hours and progressed to a regular diet without complications. Patient 2, Zargar grade 2a, required 5 days of TPN and bowel rest after which a liquid diet was initiated and advanced without complications. The third patient, had a severe injury (Zargar grade 3b), requiring a prolonged hospital stay. He was on TPN for three weeks before transitioned to tube feeds. Conclusions Caustic mucosal injuries are an infrequent, but potentially lethal event requiring urgent assessment and management by a team including gastroenterologists, thoracic and abdominal surgeons, dieticians and intensivists. High-quality evidence to guide management of caustic injuries remains limited. In our case series, there was a wide spectrum of degree of mucosal injury. All 3 patients were managed in a consistent fashion based on current recommendations. Two of three cases had a rapid recovery with the ability to resume oral intake and return home. The third patient remains in hospital, requiring a high level of supportive care. Funding Agencies None

Abstract P5-08-08: Risk reducing mastectomy in average and high risk patients with locally advanced triple negative breast cancer

Abstract Background: Women with locally advanced triple negative breast cancer (LA-TNBC) have a high risk of disease recurrence and are monitored clinically and with annual mammograms. High risk women, such as BRCA1/2 carriers, are additionally monitored for second primary breast cancers (BC) with annual MRIs and may opt for risk reducing mastectomy (RRM) as a prophylactic measure. Our aim was to explore the clinical outcomes of patients (pts) with average BC risk and high BC risk (known BRCA1/2 carriers) who undergo RRM at the time of LA-TNBC diagnosis. Methods: We included 78 consecutive LA-TNBC pts, stages IIB and III, with resectable unilateral disease, treated at the Sunnybrook Health Sciences Centre from 2009 to 2018. Pts who did not undergo systemic chemotherapy and surgical treatment were excluded, as well as pts with a history of prior BC. Medical records were reviewed for clinical outcomes, pathology and germline BRCA1/2 testing results. Log rank test was used to determine the time to recurrence (TTR) and overall survival (OS) differences among women who underwent RRM and those who did not. Results: Median age at diagnosis of LA-TNBC was 49 years (range 27-82) and 14 (18%) pts were BRCA1/2 carriers. All pts underwent neoadjuvant chemotherapy with 27 (35%) presenting complete pathological response. Fifteen pts underwent RRM, out of which seven were BRCA1/2 carriers. Mean follow up time was 34 (2-86) months, during which 25 pts (32%) were diagnosed with distant disease recurrence and none with second primary BC. Median TTR was 10 months (range 1-48) and median OS was 18 months (range 2-86). RRM was not associated with TTR (p=0.45) and OS (p=0.98). Presence of germline BRCA1/2 also did not correlate with TTR (p=0.16) and OS (p=0.21). Conclusions: In our cohort of pts with LA-TNBC, the prognosis was driven by the risk of recurrence rather than the risk of second primary BCs. RRM was not associated with improved clinical outcomes, regardless the BRCA1/2 status and larger studies are required to support this procedure at the time of diagnosis of LA-TNBC. Citation Format: Neda Stjepanovic, Danilo Giffoni, Sonal Gandhi, Katarzyna Jerzak, Sharon Lemon, Karen Ott, Rossanna Pezo, Kathleen Pritchard, Samuel Tabbarah, Maureen Trudeau, Ellen Warner, William Tran, Andrea Eisen. Risk reducing mastectomy in average and high risk patients with locally advanced triple negative breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-08-08.

A single-arm, phase II study of intrahepatic chemotherapy in patients with unresectable colorectal liver metastases.

162 Background: In Canada, the standard of care for patients with unresectable colorectal liver metastases (uCRLM) is systemic chemotherapy and/or best supportive care. Intrahepatic chemotherapy using floxuridine (FUDR), in addition to systemic chemotherapy, is available in the United States but its adoption outside major centers has been limited. Methods: A single-center, prospective study of intrahepatic chemotherapy for the treatment of patients with uCRLM was initiated at Sunnybrook Health Sciences Centre in 2014. Patients underwent implantation of a hepatic infusion pump with resection of their primary tumor (if in place). Patients were treated with FUDR in addition to systemic chemotherapy (FOLFIRI or FOLFOX). Study objectives include the rate of conversion to complete resection, time to progression (TTP), disease-free survival (DFS), time to progression in liver, overall survival (OS), andresponse rate (RR). Results: From 2014 to present, 46 patients have been enrolled. Median age at the time of HAIP placement was 51 years (30-72 years). Males accounted for 61% (28/46). All patients received at least one cycle of systemic chemotherapy prior to surgery. 44 patients received a minimum of one cycle of FUDR, with the median number of cycles of FUDR received being 7.5 (0-28 cycles). Only one patient was unable to receive any FUDR after surgery. Response rate was 80% (n = 37/46). Three patients are too early for assessment. Eight (17.4%) patients have undergone liver resection. Median number of cycles of FUDR prior to resection was 7 (4-13 cycles). TTP, DFS, time to progression in liver, OS, and safety will be presented. Conclusions: The addition of intrahepatic chemotherapy to best systemic therapy may provide an increase in the rate of conversion to complete hepatic resection in patients with uCRLM. Clinical trial information: ON1233.

Moving in for Renovations: An Innovative Solution for Replacing End-of-Life Capital Equipment. The Michael Garron Hospital-Sunnybrook Collaborative Catheterization Laboratory Project.

Replacement of an end-of-life cardiac catheterization laboratory ("cath lab") can pose a significant challenge to a hospital, particularly in single-cath-lab institutions. The disruption in patient care requires innovative approaches to minimize the inconvenience and ensure ongoing quality of care. We describe a unique approach whereby Michael Garron Hospital (MGH) "leased" a cath lab within Sunnybrook Health Sciences Centre for a 12-week period during a cath lab replacement project at MGH. The MGH cath lab and patient recovery bay remained a completely separate entity staffed by MGH nurses and physicians, with electronic connection to the home hospital. A total of 420 patients underwent cardiac catheterization with no adverse outcomes while maintaining system efficiency and high patient and staff satisfaction. Cath lab leasing involving two cooperating hospitals is an innovative and safe way to bridge a cath lab replacement.

A Mobile Phone-Based Telemonitoring Program for Heart Failure Patients After an Incidence of Acute Decompensation (Medly-AID): Protocol for a Randomized Controlled Trial.

BackgroundPatients with heart failure (HF) are at the highest risk for hospital readmissions during the first few weeks after discharge when patients are transitioning from hospital to home. Telemonitoring (TM) for HF management has been found to reduce mortality risk and hospital readmissions if implemented appropriately; however, the impact of TM targeted for patients recently discharged from hospital, for whom TM might have the biggest benefit, is still unknown. Medly, a mobile phone–based TM system that is currently being used as a standard of care for HF at a large Canadian hospital, may be an effective tool for the management of HF in patients recently discharged from hospital.ObjectiveThe objective of the Medly-After an Incidence of acute Decompensation (Medly-AID) trial is to determine the effect of Medly on the self-care and quality of life of patients with HF who have been recently discharged from hospital after an HF-related decompensation.MethodsA multisite multimethod randomized controlled trial (RCT) will be conducted at 2 academic hospitals and at least one community hospital to evaluate the impact of Medly-enabled HF management on the outcomes of patients with HF who had been hospitalized for HF-related decompensation and discharged during the 2 weeks before recruitment. The trial will include 144 participants with HF (74 in each control and intervention groups). Control patients will receive standard of care, whereas patients in the intervention group will receive standard of care and Medly. Specifically, patients in the intervention group will record daily weight, blood pressure, and heart rate and answer symptom-related questions via the Medly app. Medly will generate automated patient self-care messages such as to adjust diuretic medications, based on the rules-based algorithm personalized to the individual patient, and send real-time alerts to their health care providers as necessary. All patients will be followed for 3 months. Primary outcome measures are self-care and quality of life as measured through the validated questionnaires Self-Care of Heart Failure Index, EQ-5D-5L, and the Kansas City Cardiomyopathy Questionnaire-12. Secondary outcome measures for this study include cost of health care services used and health outcomes.ResultsPatient recruitment began in November 2018 at the Sunnybrook Health Sciences Centre, with a total of 35 participants recruited by July 30, 2019 (17 in the intervention group and 18 in the control group). The final analysis is expected to occur in the fall of 2020.ConclusionsThis RCT will be the first to assess the effectiveness of the Medly TM system for use following discharge from hospital after a HF-related decompensation.Trial RegistrationClinicalTrials.gov NCT03358303; https://clinicaltrials.gov/ct2/show/NCT03358303International Registered Report Identifier (IRRID)DERR1-10.2196/15753

Articles That May Change Your Practice: Prone Position Ventilation

Acute respiratory distress syndrome (ARDS) in critically ill patients is a burden to health care worldwide because it carries a mortality rate of about 40%. In ARDS, diffuse and progressive inflammatory changes in the lung alveoli eventually lead to alveolar injury. This results in impaired gas exchange, leading to hypoxemia. Russell D. MacDonald, MD, MPH, FCFP, FRCPC, is the medical director at Ornge Transport Medicine; medical director at Toronto Paramedic Services; an associate professor in the Faculty of Medicine at the University of Toronto; and an attending staff member at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. He can be reached at [email protected] Yuen Chin Leong, MD, MEmMed, is an emergency physician in Malaysia. He is currently pursuing the Emergency Medical Services Fellowship at Sunnybrook Center for Prehospital Medicine, University of Toronto, Canada.

An Interprofessional Approach in Caring for a Patient on Maintenance Hemodialysis with COVID-19 in Toronto, Canada: An Educational Case Report.

Rationale:Hemodialysis patients are at significant risk from COVID-19 due to their frequent interaction with the health care system and medical comorbidities. We followed up the trajectory of the first COVID-19–positive maintenance hemodialysis patient at Sunnybrook Health Sciences Centre in Toronto. We present the lessons learned and changes in practices that occurred to prevent an outbreak in our center.Presenting concerns of the patient:The patient, a 66-year-old woman on in-center hemodialysis, initially presented with a 2-day history of a productive cough. She subsequently developed a fever, was placed on contact and droplet isolation, and admitted to hospital.Diagnoses:On March 13, 2020, the patient tested positive for COVID-19. Within the next 48 hours, she developed hypoxia and acute respiratory distress syndrome as a complication of her illness requiring an extended critical care stay. This extended critical care stay resulted in critical illness–associated secondary sclerosing cholangitis.Interventions:An interprofessional team was established, performing rapid Plan-Do-Study-Act quality improvement cycles to improve screening practices and promote the safety of patients and staff in the hemodialysis unit.Outcomes:We present here the lessons learned, the changes to our screening protocols, and the clinical course of our first in-center hemodialysis patient with SARS-CoV-2.Teaching points:Regular review of the infection screening processes is paramount in preventing outbreaks of COVID-19, particularly in hemodialysis units. Hospital admission should be arranged if a patient exhibits any clinical signs of hemodynamic compromise or hypoxia. Early education for health care practitioners caring for patients with COVID-19 and refresher information regarding personal protective equipment helped promote the safety of staff and prevent health care–associated outbreaks.

Appropriate use of CT for patients presenting with suspected renal colic: a quality improvement study

IntroductionCT use for renal colic has increased costs, radiation exposure and frequently does not alter management. Consequently, choosing wisely (CW) recommends avoiding CT imaging of otherwise healthy patients younger than...

Ultrahypofractionation Should be a Standard of Care Option for Intermediate-Risk Prostate Cancer

Ultrahypofractionation Should be a Standard of Care Option for Intermediate-Risk Prostate Cancer

Filling the Gap for Obsessive-Compulsive Disorder Services in Canada: Implementing an Intensive Care Program.

Obsessive-compulsive disorder (OCD) is a significant psychiatric illness that can impact an individual in terms of their quality of life, functional abilities, and interpersonal relationships. Until recently, services for individuals with severe symptoms of OCD were limited within Canada. The Frederick W. Thompson Anxiety Disorders Centre at Sunnybrook Health Sciences Centre in Toronto, Canada, recently launched an intensive services program for individuals with severe symptoms of OCD. This article provides an overview of the steps that were taken to develop this program. Methods involved incorporation of information gathered from both service users and service providers of these models of treatment within North America and beyond. This article provides a potential treatment model for residential psychiatric treatment that can be applied to OCD and possibly other severe treatment refractory psychiatric illnesses in terms of methods used and generalizable key ingredients.

Identifying Patterns of Inappropriate Plasma Transfusion Practices Using a Novel Multicenter Electronic Data Audit: Over 80 Percent of Plasma Transfused Is Inappropriate

Importance: Plasma is frequently transfused to patients who are bleeding or require an invasive procedure and have a deficiency of coagulation factors. Despite published guidelines delineating optimal plasma use, two recent audits have suggested that over 50% of the plasma transfused is unnecessary. Inappropriate utilization of plasma has numerous adverse consequences for the recipient, as well as the health care system. Objective: To determine the proportion of inappropriate plasma use with a multicenter electronic data audit and identify focused areas for intervention to reduce inappropriate use. Setting: 3 tertiary care academic sites across Ontario, Canada: Hamilton Health Sciences Centre (Hamilton, Ontario), Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario). Participants: All adult inpatients receiving plasma during the time period January 1, 2017 and December 31, 2017. Design: Four areas of inappropriate plasma use in adult patients were defined: (1) patients with a normal INR <1.5 and who were not actively bleeding or moderate bleeding only (1 unit RBC transfused within 24 hours before or after plasma transfusion or 20 g/L drop in hemoglobin); (2) elevated INR >1.5, without active bleeding or procedures in 6 hours after plasma transfusion (1 calendar day when time of procedure was not available); (3) no INR drawn before or after plasma infusion; (4) inappropriate non-therapeutic plasma dose of plasma (≤ 2 units) . Results: A total 4,385 plasma transfusion events occurred in 1,844 inpatient admissions. Appropriate indication and dosing was found in 813 (18.5%) of the events. Inappropriate compliance occurred in 3,572 (81.5%) of the events: 608 (13.9%) events occurred in the pre-specified criteria (1-3) above; inappropriate dosing alone occurred in 1,583 (36.1%) events; and, a combination of inappropriate dosing in addition to any 1-3 pre-defined categories occurred in 1,381 (31.5%) transfusion events. Patients transfused with a documented INR (81.5%) in the 24 hours preceding plasma transfusion had a mean INR value 1.8+1.7 (INR + SD). The mean overall reduction after 1-24 hours of plasma transfusion was -0.5+1.6 . Conclusions and Relevance: A significant amount of plasma is transfused inappropriately, leading to potential patient harm, significant unnecessary costs, and diversion of plasma away from fractionation impacting the supply of intravenous immunoglobulin. This study will inform a large quality improvement study aimed at reducing unnecessary plasma transfusion. Disclosures Heddle: Novartis: Research Funding. Arnold:Principia: Consultancy; Bristol-Myers Squibb: Research Funding; Novartis: Honoraria, Research Funding; Rigel: Consultancy, Research Funding. Hsia:Amgen: Honoraria; Jansen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees.

Articles That May Change Your Practice: Dexmedetomidine

Sedation is commonly used in the intensive care unit (ICU) to reduce patient discomfort, improve tolerance with mechanical ventilation, reduce metabolic demands during respiratory and hemodynamic instability, and prevent accidental device removal. Delirium is a serious complication and has been associated with increased morbidity, prolonged hospital stay, worse functional recovery, and long-term decline in cognitive function. Moreover, recent studies showed that delirium was associated with increased short- and long-term mortality in patients admitted to ICUs. For decades, gamma-aminobutyric acid (GABA) receptor agonists (including propofol and benzodiazepines) have been the standard of care for sedation in the ICU. However, evidence suggests these agents may increase the risk of delirium. Russell D. MacDonald, MD, MPH, FCFP, FRCPC, is the medical director at Ornge Transport Medicine; medical director at Toronto Paramedic Services; an associate professor in the Faculty of Medicine at the University of Toronto; and an attending staff member at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. He can be reached at [email protected] Adam Greene, BHSc, CCP, is the critical care paramedic unit chief at British Columbia's Emergency Health Services in Vancouver, British Columbia, Canada.

2998 Reproductive Outcomes after the use of Tourniquet in Abdominal Myomectomy

Study Objective To determine whether the pregnancy rate and live birth rate is similar in women of childbearing age undergoing abdominal myomectomy (AM) in two major Canadian urban centers with the use of a peri-cervical tourniquet compared to women undergoing AM without the use of a tourniquet. Design A multi-center retrospective cohort study was conducted, consisting of a retrospective chart review and a self-administered study questionnaire on reproductive outcomes. Setting Sunnybrook Health Sciences Center and St. Michael's Hospital, two tertiary care centers affiliated with the University of Toronto. Patients or Participants Women of childbearing age (18-45 years old) who underwent AM between June 2002 and 2012 were consecutively sampled. 1099 patients met inclusion criteria and 144 returned the study questionnaire. After excluding patients who did not attempt to conceive post-operatively, 82 patients were included in the final statistical analysis. Interventions Use of a peri-cervical tourniquet during AM. Measurements and Main Results Unadjusted and multivariable regression analysis was used to compare the groups of patients. Mean age of patients at time of surgery was 36 years. 28% of surgeries involved use of peri-cervical tourniquet. There was no significant association between the use of tourniquet and live birth rate (p=0.35). Similarly, there was no significant difference between the use of tourniquet and length of time attempting conception after surgery (p=0.91). Data analysis is ongoing and further results will be presented. Conclusion Our study suggests no significant association between use of tourniquet and live birth outcomes. Concerns about the tourniquet's impact on fertility may therefore be unfounded, and a more widespread uptake of peri-cervical tourniquet during AM may contribute to limiting surgical blood loss. Further prospective research is warranted with a larger sample size.

UPSTREAM EFFECTS OF TRANSCATHETER MITRAL VALVE REPAIR : IMPACT ON TRICUSPID VALVE REGURGITATION

Trans-catheter mitral valve repair (TMVr) with MitraClip (Abbott, Menlo Park, CA) has become the standard of care for patients with severe symptomatic mitral regurgitation (MR) who are inoperable or considered ‘high risk’ for conventional surgery. Up to 50% of patients who are candidates for TMVr also have concomitant functional tricuspid regurgitation (TR), posing a challenge to clinicians with little data to guide management. While the hypothesis that reduction in MR leads to lower right ventricular afterload and an improvement in TR has face validity, whether this actually occurs remains unknown. As such, our objective was to determine whether patients with MR who undergo TMVr experience a concomitant reduction in TR. A retrospective observational cohort study was performed at Sunnybrook Health Sciences Centre (Toronto, Canada) including patients who underwent TMVr between April 2011 and February 2018. All patients who had a follow-up echocardiogram available after successful TMVr were included. A detailed chart abstraction was performed including clinical characteristics, echocardiographic parameters and procedural characteristics. The primary outcome was change in TR after TMVr (comparing baseline to 3 month follow-up). Paired t-tests and Wilcoxon signed rank test were used to determine statistical significance. The final study cohort included 197 patients. The median age was 79 years (interquartile range, (IQR) 72-84); 36.4% were females (see Table). Most patients were NYHA class III and IV and the mean STS score was 7.4%-5.9% (standard deviation, SD). The mitral valve pathology was functional in 51.8%, degenerative in 40.6% and mixed in 7.6%. A mean of 1.9-0.6 (SD) clips were used per patient. At follow-up, moderate or less MR was present in 185 patients (93.9%; p < 0.001 as compared to baseline) and the mean gradient was 4 mmHg (median; IQR 3 – 6). There was a significant reduction in right ventricular systolic pressure (RVSP, 49-16 (SD) mmHg at baseline vs 43-17 (SD) mmHg post-TMVr; p < 0.001). A significant overall reduction in TR was observed (see Figure). 82 patients (41.6%) experienced a reduction; 70 patients (40.1%) had no change; and, 36 patients (18.3%) had worsening of TR after TMVr. Of the 36 patients who had worsening TR, only 4 had moderate-severe or severe MR. Patients who undergo TMVr experience a significant concomitant improvement in TR perhaps in part mediated by a reduction in RVSP. Future work should seek to identify which patients are most likely to experience this reduction and the associated clinical outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

66 - Impact of Postoperative Neurosurgery Order Sets on Glycemic Control and Surgical Site Infections: A Quality-Improvement Initiative

Uncontrolled hyperglycemia is common in the perioperative period and is associated with postoperative complications, including surgical site infection (SSI). A new postoperative order set for neurosurgical patients, including glycemic monitoring for high-risk patients, was implemented in April 2017 at Sunnybrook Health Sciences Centre (SHSC). This study investigated the impact of this order set on glycemic monitoring, measures of glycemic control and incidence of SSI.

68 - Exploring Remedial Factors Associated With Hospital Readmissions in Patients With Diabetes

At Sunnybrook Health Sciences Centre (SHSC), the 2017-2018 readmission rate for patients with diabetes was 10.9% compared to 7.4% for those without. This is higher than the national and provincial rates, suggesting that there might be factors contributing to the risk of readmission among patients with diabetes. Given the significant costs and morbidity involved, it is prudent to understand the remedial factors within the control of the inpatient care team that may be associated with such readmissions.