Toronto General Hospital Research Articles

Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart disease

ObjectivesA quality improvement initiative was introduced to the adult congenital cardiac surgery program at Toronto General Hospital in January 2016. A dedicated Adult Congenital Anesthesia and intensive care unit team was introduced within the cardiac group. The use of factor concentrates was introduced. The study compares perioperative mortality, adverse events, and transfusion burden before and after this process change. MethodsWe performed a retrospective analysis of all adult congenital cardiac surgeries from January 2004 to July 2019. Two groups were analyzed: patients undergoing operation before and after 2016. The primary outcome was in-hospital mortality. One-year mortality and prevalence of key morbidities were analyzed as secondary outcomes. A separate analysis looked at patients who had and had not attended an anesthesia-led preassessment clinic. ResultsIn-hospital mortality was significantly reduced in patients undergoing operation after 2016 (1.1% vs 4.3%, P = .003) despite a higher risk profile. One-year mortality (1.3% vs 5.8%, P = .003) and ventilation times (5.5 hours [3.4-13.0] vs 6.3 hours [4.2-16.2], P = .001) were also reduced. The incidence of stroke and renal failure was similar between groups. Blood product exposure was comparable, but the incidence of chest reopening decreased (1.8% vs 4.8%, P = .022), despite more patients with multiple previous chest wall incisions, on anticoagulation, and with more complex cardiac anatomy. There were no significant outcome differences between those who did or did not attend the preassessment clinic. ConclusionsBoth in-hospital and 1-year mortality were significantly reduced after the introduction of a quality improvement program, despite a higher risk profile. Blood product exposure remained unchanged, but there were less chest reopenings.

A Reflection on Nursing in Neurosurgery

Around the world in many countries, May is “Nurses Month” and May 12, International Nurses Day (Florence Nightingale's birthday). Thinking about this a few months ago led me to think how little we spend in the pages of this journal and others, on the value of nursing in neurosurgery. The cover this month highlights the partnership of nurses and neurosurgeons from years past and the present. My dear friend Dan Leksell shared this image of his father Lars Leksell performing air ventriculography, while his nurse assists with the imaging. Can we even think about the performance of neurosurgery without nursing support, whether in the office, the research environment, the operating room, the hospital wards, or the rehabilitation centers that often help our patients in their recoveries? Do we just take for granted that complex and challenging surgeries will be followed by excellent nursing care that lasts all night, the next day, and the day after that? Nurses talk to our patients when we are not there, reiterate our messages, and clarify and answer patient's questions. They become as familiar with new surgical techniques as we do, to understand their indications and potential outcomes. Then they work to make those outcomes possible. In the surgical suite, they must become familiar with new devices and do so expeditiously to meet our high standards. It is truly a wonder how over the course of their own career they evolve as we evolve, as our field evolves. Neurosurgical nursing is its own calling. As for any of us, the path is different from person to person. To become involved in the care of patients with challenging and debilitating neurological disorders, in one or more different clinical settings, is a commitment toward excellence. I personally think of our work as more a vocation than a career. We are so fortunate to have nurses in the practice setting who help us bring patients and families to an understanding of their own medical challenges and to help them navigate what is assuredly an anxious time. Their calm, unhurried demeanor can help them through a potentially frustrating interaction with the health care system, lessening worry and sleepless nights, at least to some degree. Nurses on the hospital wards provide the surgical aftercare of recovery, hopefully to a prompt return home, but sometimes toward an extended care stay that may develop into more personal contacts with patients, friends, and family. The hands-on, personal interactions involved are truly special and go far beyond the expectations of a “job.” In the surgical suite, our nurses have the same commitment to professionalism, communication, care, and error reduction as we do. This is displayed time and again, each time a new patient enters the room. And last, a personal note. Many years ago now, I married a neurosurgical nurse who had worked on the neurosurgery floor at the Toronto General Hospital and then in the operating room there. She later worked in the OR at the University of Pittsburgh Medical Center. She understood the field, the disorders we treat, and the personalities involved. Her nursing skills were also crucial to our family, including structure, planning, fearlessness, and tenderness. As my dear friend John Golfinos would say, “you can't spell neurosurgery without n-u-r-s-e.” I encourage you to think about the nurses you work with, in any of the different settings, and know that the wonderful science in these journal pages could not have happened without them. Douglas Kondziolka, MD, MSc Editor-in-Chief, Neurosurgery Publications New York, New York, USA

Reimplantation of the aortic valve in patients with tricuspid aortic valve: the Toronto General Hospital experience.

Aortic valve sparing operations were introduced three decades ago but controversy remains regarding its appropriateness, reproducibility and durability. This article describes the long-term outcomes of patients who had reimplantation of the aortic valve. All patients who had reimplantation of a tricuspid aortic valve at Toronto General Hospital from 1989 through 2019 were selected for this study. Patients were followed prospectively with periodical clinical assessments and imaging of the heart and aorta. Four hundred and four patients were identified. The median age was 48.0 [interquartile range (IQR), 35.0-59.0] years and 310 (76.7%) were men. There were 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome and 33 with acute or chronic aortic dissections. The median follow-up was 11.7 (IQR, 6.8-17.1) years. There were 55 patients alive and without reoperation at 20 years. The cumulative mortality at 20 years was 26.7% [95% confidence interval (CI): 20.6-34.2%], the cumulative incidence of reoperation on the aortic valve was 7.0% (95% CI: 4.0-12.2%) and the development of moderate or severe aortic insufficiency was 11.8% (95% CI: 8.5-16.5%). We could not identify variables associated with reoperation on the aortic valve or with the development of aortic insufficiency. New distal aortic dissections were common in patients with associated genetic syndromes. Reimplantation of the aortic valve in patients with tricuspid aortic valve provides excellent aortic valve function during the first two decades of follow-up. Distal aortic dissections are relatively common in patients with associated genetic syndromes.

Comparing mixed oil to soybean oil lipid emulsion in patients on home parenteral nutrition: a pilot prospective double-blind, crossover, randomized trial

BackgroundHome parenteral nutrition (HPN) can be associated with increased liver enzymes, catheter-related bloodstream infections (CRBSI), and hospitalizations. Mixed oil (MO) versus soybean oil (SO) lipid emulsion reduces risks in hospitalized patients, but there are no randomized double-blinded controlled trials in HPN. Therefore, the primary objective was to test the study’s feasibility such as recruitment and retention in the HPN population and the secondary objective was to assess changes in liver enzymes between MO and SO as well as other clinical and biochemical outcomes.MethodsThis 13-month prospective double-blind crossover randomized pilot trial took place in Toronto, Canada. Participants were HPN patients who were a part of the HPN program at Toronto General Hospital. We recruited patients from the HPN program. HPN patients receiving SO were randomized to either MO or SO, and the study duration was 6 months in each arm (MO or SO) with a 1-month washout period resuming SO. As this is a crossover trial design, the patient is his/her own control. The main outcome measures were descriptions of study feasibility, namely the study recruitment and retention. We also collected biochemical parameters, CRSBI, hospitalization rate, antibiotic use, and mortality. Demographic, nutritional, clinical, and laboratory data were collected at baseline, 3 and 6 months of each arm. The primary analysis population was defined as the per-protocol population who completed the trial including all lipid measurements.ResultsA total of 65 HPN patients were assessed, and 60 met the inclusion criteria for the study. Thirty-five percent (21/60) were randomized using a computer-generated random number sequence generator: 10 participants were randomized to receive SO first while 11 were randomized to receive MO first. At 13 months, 3/10 who received SO first completed the study, whereas 9/11 who received MO first completed the study. This did not meet our a priori criteria for success in recruitment and retention. Between types of lipid emulsions, there were no significant differences in changes in liver enzymes or biochemical and clinical outcomes, despite significant changes in plasma free fatty acid composition reflecting MO or SO.ConclusionsOverall, this pilot trial demonstrated that the use of a prospective double-blind, crossover, randomized trial design was not feasible to conduct in the HPN population because of difficulties in recruiting and retaining patients. In addition, there was no significant impact of MO versus SO lipid emulsion on liver enzymes or most parameters. The lack of significance may be attributed to low sample size from low recruitment and high drop-out rate, short study duration (6 months/arm), and complex care. In a future definitive trial, a multicenter study of longer duration and a larger sample size is recommended, and drop-outs may be reduced by using a parallel study design.Trial registrationClinicalTrials.gov, NCT02796833. Registered on 13 June 2016—retrospectively registered.

Prognostic echocardiographic findings in patients supported with venoarterial extracorporeal membrane oxygenation for cardiogenic shock.

Echocardiography is critical in the management of patients supported with veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study aimed to identify the incidence of critical echocardiographic findings and determine their prognostic significance. All available echocardiograms, hemodynamic variables and outcomes of patients with CS supported with V-A in the period of 2011-2018 at the Toronto General Hospital were retrospectively reviewed. Critical echocardiographic findings were defined as minimal to no left ventricular (LV) ejection, the presence of intra-cardiac clot, significant pericardial effusion and malpositioning of ECMO cannulae. 130 patients were included in this study with in-hospital mortality of 58.5%. Critical findings were most often seen in the first echocardiogram (42/121; 35%). The incidence of critical findings in the first echocardiogram was minimal to no LV ejection in 28 patients (23%), intracardiac thromboses in 8 patients (6.6%), tamponade in 5 patients (4%) and malpositioned cannulae in 1 patient (0.8%). Presence of a critical finding in the first study was associated with an odds ratio for in-hospital mortality of 2.32 (95% CI 1.01-5.06, P = 0.011). The initial echocardiogram was most likely to demonstrate a critical finding of which the most common was minimal to no LV ejection. Critical echocardiographic findings carried prognostic significance for in-hospital mortality.

Association Between the Presence of Metabolic Comorbidities and Liver-Related Events in Patients With Chronic Hepatitis B

Patients with chronic hepatitis B (CHB) are at increased risk of hepatocellular carcinoma (HCC) and (liver-related) mortality. In addition to hepatitis B related factors, metabolic comorbidities may contribute to the progression of fibrosis. Therefore, we studied the association between metabolic comorbidities and adverse clinical outcomes in patients with CHB. We conducted a retrospective cohort study of CHB patients attending the Erasmus MC, the Netherlands and CHB patients who underwent liver biopsy in the Toronto General Hospital, Canada. Presence of metabolic comorbidities (i.e. overweight, diabetes mellitus, hypertension and dyslipidemia) was assessed based on chart review. The primary endpoint was liver-related events, defined as the first composite of HCC, liver transplantation or liver-related mortality. We analyzed 1850 patients of which 926 (50.1%) patients were overweight, 161 (8.7%) had hypertension, 116 (6.3%) had dyslipidemia and 82 (4.4%) had diabetes. During a median follow-up of 7.3 years (IQR 2.9-11.5) a total of 111 first events were recorded. Hypertension (hazard ratio [HR] 8.3, 95%CI 5.5-12.7), diabetes (HR 5.4, 95%CI 3.2-9.1), dyslipidemia (HR 2.8, 95%CI 1.6-4.8) and overweight (HR 1.7, 95%CI 1.1-2.5) were associated with increased risk for liver-related events. Presence of multiple comorbidities further increased the risk. Findings were consistent for patients with and without cirrhosis, among non-cirrhotic HBeAg-negative patients with HBV DNA <2,000 IU/mL and in multivariable analysis adjusting for age, sex, ethnicity, HBeAg status, HBV DNA, use of antiviral therapy and presence of cirrhosis. Metabolic comorbidities in CHB patients are associated with increased risk for liver-related events, with the highest risk observed in patients with multiple comorbidities. Findings were consistent in various clinically relevant subgroups underscoring the need for thorough metabolic assessment in patients with CHB.

A67 RISK FACTORS ASSOCIATED WITH CRITICAL CARE AFTER INPATIENT GASTROINTESTINAL ENDOSCOPY: A 5-YEAR TERTIARY HOSPITAL STUDY

Abstract Background A subset of hospitalized patients will require critical care after their gastrointestinal endoscopy (GIE) and predicting which patients are at high risk of requiring critical care remains an important challenge. Purpose To identify protective and aggravating clinical risk factors associated with critical care involvement within 7 days of inpatient GIE in adults and to develop a tool that could assist in risk-stratifying patients at high risk of requiring critical care post-endoscopy. Method This was a single-centre retrospective case-control study of adult patients who underwent inpatient GIE while admitted to ward-level care at Toronto General Hospital from years 2015 to 2019. Cases were defined by inpatients who required critical care response team and/or critical care admission within 7 days of GIE, compared to control patients who did not require critical care throughout admission. Chart review and linked secondary sources were used with defined inclusion and exclusion criteria. Both univariate and multivariate analyses were performed comparing patient baseline, clinical history (including cardiovascular, respiratory, other co-morbidities) and endoscopy characteristics. Result(s) We identified a total of 275 patients with 302 endoscopies as cases and 2069 patient controls who satisfied inclusion criteria. Critical care involvement was most commonly due to cardiovascular-related complications (n=175, 58%) followed by respiratory complications (n=117, 39%). Amongst cases, death occurred in 9 (3%), 25 (9%) and 67 (22%) within 72 hours, 7 days and 30 days respectively post endoscopy. The strongest associations with critical care involvement within 7 days after GIE included a history of discharge from critical care (OR 2.29 CI 1.70-3.04) and/or recent mechanical ventilatory support (OR 2.27 CI 1.30-3.91) in the 30 days prior to endoscopy, having several co-morbidities involving major organ systems (elevated troponin OR 3.20 CI 2.26-4.52, cirrhosis OR 2.5 CI 1.80-3.46, renal dysfunction 2.09 CI 1.57-2.78) and patients admitted under surgical (OR 3.82 CI 2.54-5.71) or transplant services (OR 4.63 CI 2.94-7.26). The majority of adverse events among cases were not found to be complications directly related to GIE (64% unlikely, 20% possible, 9% probable, 7% definite). Patients with a history of pulmonary hypertension (OR 5.68 CI 0.53-60.70) and ASA score III/IV (OR 3.28 CI 1.01-10.73) had the highest odds of probable or definite endoscopy-related adverse events. Conclusion(s) This study is the largest to date to examine risk factors associated with critical care requirements post GIE in the tertiary care inpatient setting. The risk factors we have identified can be used to create a tool to determine which inpatients may benefit from anesthesia consultation and support during their endoscopic procedure. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

A42 LIVE DONOR LIVER TRANSPLANTATION IN PRIMARY SCLEROSING CHOLANGITIS: AN INDICATOR OF AN ORGAN ALLOCATION SYSTEM NOT ADDRESSING PATIENT NEED

Abstract Background Liver transplantation is frequently lifesaving for people living with primary sclerosing cholangitis (PSC). However, patients are waitlisted for liver transplant (LT) according to the MELD-Na score, which may not accurately reflect the burden of living with PSC. Purpose We sought to describe and analyze the clinical trajectory for patients with PSC referred for LT, in a mixed deceased donor/live donor transplant programme. Method This was a retrospective cohort study from November 2012 to December 2019 including all patients with PSC referred for assessment at the University Health Network Liver Transplant Clinic. Patients who required multiorgan transplant or re-transplantation were excluded. Liver symptoms, hepatobiliary malignancy, MELD-Na progression, and death were abstracted from chart review. Competing Risk analysis was used for timing of LT, transplant type, and death. Result(s) Of 172 PSC patients assessed, 144 (84%) were listed, of whom 106/144 (74%) were transplanted. Mean age was 47.6 years and 66% were male. During follow-up through to 2021, 23/144 (16%) were removed from the waitlist due to infection, clinical deterioration, liver-related mortality or new cancer; 3 had clinical improvement. At the time of listing, 118/144 (81.95%) had a potential Living Donor (pLD) of whom 94 were transplanted: 64 live donor and 30 deceased donor. Patients with pLD had 79% lower mortality (p&amp;lt;0.001), and higher rates of transplantation (80% vs 46%). Exception points were granted to 13/172 (7.5%) patients. Conclusion(s) In a high-volume North American liver transplant centre, most patients with PSC assessed for transplant were listed and subsequently transplanted. However, this was a consequence of patients engaging in live donor transplantation. Our findings support the concern from patients with PSC that MELD-Na allocation does not adequately address their needs. Please acknowledge all funding agencies by checking the applicable boxes below CIHR, Other Please indicate your source of funding; This study was supported by PSC Partners Canada, Canadian Institutes of Health Research (CIHR), Toronto General and Western Hospital Foundation. Disclosure of Interest None Declared

Incidence and clinical predictors of early and late complications of implantable cardioverter-defibrillators in adults with congenital heart disease.

The Implantable cardioverter-defibrillator (ICD) has been proven to improve survival in adults with congenital heart disease (ACHD), however it is associated with a high rate of complications. We aimed to quantify the incidence of early (≤3 months) and late (>3 months) complications (EC, LC) in ACHD patients implanted with an ICD and identify their clinical predictors. We retrospectively reviewed 207 patients who had ICD follow-up at Toronto General Hospital between 1996 and 2019. Most common diagnoses were Tetralogy of Fallot (32.4%), dextro-transposition of the great arteries (17.9%), congenital corrected transposition of the great arteries (13%). No intraprocedural complications were observed. Median follow up was 3.4 years (0.1-23). 24 patients (12%) developed EC (4 hematomas, 20 lead dislodgments). A total of 56 LC occurred (46% lead failure, 21% infection, 11% prophylactic lead extraction, 9% neurologic pain, 9% erosion, 4% other) with an incidence rate of LC of 18% per 5 person-years. Anatomic complexity (odds ratio 2.9,p=0.02) and CRTD implant(OR 2.5,p=0.04) were associated with EC. Survival free from LC was 92%, 86%, 65% respectively after 1,5 and 10 years. Presence of legacy leads (hazard ratio 2.9,p=0.006) and subpulmonary ejection fraction (5% increase, HR 1.35,p=0.031) were associated with LC. ACHD patients at risk of SCD continue to benefit from newer device technology. However, these patients-particularly those with greater anatomic and device complexity-remain at increased risk of developing complications over their lifetime. Given the life expectancy of this population, careful consideration needs to be given when a device for primary prevention is being contemplated.

Lymphopenia at the time of transplant is associated with short-term mortality after deceased donor liver transplantation

Absolute lymphocyte count (ALC) is considered a surrogate marker for nutritional status and immunocompetence. We investigated the association between ALC and post-liver transplant outcomes in patients who received a deceased donor liver transplant (DDLT). Patients were categorized by ALC at liver transplant: low (<500/μL), mid (500-1000/μL), and high ALC (>1000/μL). Our main analysis used retrospective data (2013-2018) for DDLT recipients from Henry Ford Hospital (United States); the results were further validated using data from the Toronto General Hospital (Canada). Among 449 DDLT recipients, the low ALC group demonstrated higher 180-day mortality than mid and high ALC groups (83.1% vs 95.8% and 97.4%, respectively; low vs mid: P = .001; low vs high: P < .001). A larger proportion of patients with low ALC died of sepsis compared with the combined mid/high groups (9.1% vs 0.8%; P < .001). In multivariable analysis, pretransplant ALC was associated with 180-day mortality (hazard ratio, 0.20; P = .004). Patients with low ALC had higher rates of bacteremia (22.7% vs 8.1%; P < .001) and cytomegaloviremia (15.2% vs 6.8%; P = .03) than patients with mid/high ALC. Low ALC pretransplant through postoperative day 30 was associated with 180-day mortality among patients who received rabbit antithymocyte globulin induction (P = .001). Pretransplant lymphopenia is associated with short-term mortality and a higher incidence of posttransplant infections in DDLT patients.

Models for Evidence Generation During the COVID-19 Pandemic: New Opportunities for Clinical Trials in Cardiovascular Medicine

HomeCirculationVol. 147, No. 3Models for Evidence Generation During the COVID-19 Pandemic: New Opportunities for Clinical Trials in Cardiovascular Medicine No AccessArticle CommentaryRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessArticle CommentaryRequest AccessFull TextModels for Evidence Generation During the COVID-19 Pandemic: New Opportunities for Clinical Trials in Cardiovascular Medicine Patrick R. Lawler, MD, MPH Patrick R. LawlerPatrick R. Lawler Correspondence to: Patrick R. Lawler, MD, MPH, Peter Munk Cardiac Center, Toronto General Hospital, RFE3-410, 190 Elizabeth St, Toronto, ON, Canada M5G 2C4. Email: E-mail Address: [email protected] https://orcid.org/0000-0001-5155-5071 Peter Munk Cardiac Centre, Toronto General Hospital; and Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada. Search for more papers by this author Originally published17 Jan 2023https://doi.org/10.1161/CIRCULATIONAHA.122.061231Circulation. 2023;147:187–189FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at www.ahajournals.org/journal/circFor Sources of Funding and Disclosures, see page 189.Correspondence to: Patrick R. Lawler, MD, MPH, Peter Munk Cardiac Center, Toronto General Hospital, RFE3-410, 190 Elizabeth St, Toronto, ON, Canada M5G 2C4. Email: patrick.[email protected]ca

Comparison of modes of failure and clinical outcomes between explanted porcine and bovine pericardial bioprosthetic valves

ObjectiveTo compare pathological and hemodynamic modes of failure and operative outcomes between explanted porcine and bovine pericardial bioprosthetic valves. MethodsPatients who underwent explantation of their bioprosthetic valves at Toronto General Hospital from 2007 to 2019 were identified. Retrospective chart review was conducted to attain demographic information, operative outcomes, and echocardiography and pathology reports. ResultsA total of 278 patients underwent explantation of their porcine (n=183) or bovine pericardial (n=95) valves. A greater proportion of the porcine group had severe regurgitation, compared to the bovine group (45.3% vs. 19.8%, p<.001). Porcine valves had higher rates of cusp flail (19.4% vs. 3.3%, p<.001). The rates of moderate or worse stenosis were higher among bovine pericardial valves (37.9% vs. 15.8%, p<.001). On pathologic examination, the porcine valves exhibited more cusp tears (67.6% vs. 50.5%, p=.006), while higher incidences of calcification were found in the bovine group (p<.001). Rate of stroke was higher during the explantation procedure of the bovine valves (5.3% vs. 0.5%, p=.040). ConclusionsThe primary mode of failure was regurgitation in porcine valves due to cusp tears and stenosis in bovine valves due to calcification. Establishing a clear understanding of failure modes based on valve material may improve design and guide valve selection at the time of surgery.

The Beginning of the American Thyroid Association Centennial Year

The Beginning of the American Thyroid Association Centennial Year

Medical Assistance in Dying (MAiD) as a Source of Liver Grafts: Honouring the Ultimate Gift.

To report the clinical outcomes of liver transplants from donors after medical assistance in dying (MAiD) versus donors after cardiac death (DCD) and deceased brain death (DBD). In North America, the number of patients needing liver transplants exceeds the number of available donors. In 2016, MAiD was legalized in Canada. All patients undergoing deceased donor liver transplantation at Toronto General Hospital between 2016 and 2021 were included in the study. Recipient perioperative and postoperative variables and donor physiological variables were compared among 3 groups. Eight hundred seven patients underwent deceased donor liver transplantation during the study period, including DBD (n=719; 89%), DCD (n=77; 9.5%), and MAiD (n=11; 1.4%). The overall incidence of biliary complications was 6.9% (n=56), the most common being strictures (n=55;6.8%), highest among the MAiD recipients [5.8% (DBD) vs. 14.2% (DCD) vs. 18.2% (MAiD); P =0.008]. There was no significant difference in 1 year (98.4% vs. 96.4% vs. 100%) and 3-year (89.3% vs. 88.7% vs. 100%) ( P =0.56) patient survival among the 3 groups. The 1- and 3- year graft survival rates were comparable (96.2% vs. 95.2% vs. 100% and 92.5% vs. 91% vs. 100%; P =0.37). With expected physiological hemodynamic challenges among MAiD and DCD compared with DBD donors, a higher rate of biliary complications was observed in MAiD donors, with no significant difference noted in short-and long-term graft outcomes among the 3 groups. While ethical challenges persist, good initial results suggest that MAiD donors can be safely used in liver transplantation, with results comparable with other established forms of donation.

Prevention and Management of Chronic Postsurgical Pain and Persistent Opioid Use Following Solid Organ Transplantation: Experiences From the Toronto General Hospital Transitional Pain Service.

With >700 transplant surgeries performed each year, Toronto General Hospital (TGH) is currently one of the largest adult transplant centers in North America. There is a lack of literature regarding both the identification and management of chronic postsurgical pain (CPSP) after organ transplantation. Since 2014, the TGH Transitional Pain Service (TPS) has helped manage patients who developed CPSP after solid organ transplantation (SOT), including heart, lung, liver, and renal transplants. In this retrospective cohort study, we describe the association between opioid consumption, psychological characteristics of pain, and demographic characteristics of 140 SOT patients who participated in the multidisciplinary treatment at the TGH TPS, incorporating psychology and physiotherapy as key parts of our multimodal pain management regimen. Treatment by the multidisciplinary TPS team was associated with significant improvement in pain severity and a reduction in opioid consumption. Given the risk of CPSP after SOT, robust follow-up and management by a multidisciplinary team should be considered to prevent CPSP, help guide opioid weaning, and provide psychological support to these patients to improve their recovery trajectory and quality of life postoperatively.

Design of a Patient Voice App Experience for Heart Failure Management: Usability Study.

The use of digital therapeutics (DTx) in the prevention and management of medical conditions has increased through the years, with an estimated 44 million people using one as part of their treatment plan in 2021, nearly double the number from the previous year. DTx are commonly accessed through smartphone apps, but offering these treatments through additional platforms can improve the accessibility of these interventions. Voice apps are an emerging technology in the digital health field; not only do they have the potential to improve DTx adherence, but they can also create a better user experience for some user groups. This research aimed to identify the acceptability and feasibility of offering a voice app for a chronic disease self-management program. The objective of this project was to design, develop, and evaluate a voice app of an already-existing smartphone-based heart failure self-management program, Medly, to be used as a case study. A voice app version of Medly was designed and developed through a user-centered design process. We conducted a usability study and semistructured interviews with patients with heart failure (N=8) at the Peter Munk Cardiac Clinic in Toronto General Hospital to better understand the user experience. A Medly voice app prototype was built using a software development kit in tandem with a cloud computing platform and was verified and validated before the usability study. Data collection and analysis were guided by a mixed methods triangulation convergence design. Common themes were identified in the results of the usability study, which involved 8 participants with heart failure. Almost all participants (7/8, 88%) were satisfied with the voice app and felt confident using it, although half of the participants (4/8, 50%) were unsure about using it in the future. Six main themes were identified: changes in physical behavior, preference between voice app and smartphone, importance of music during voice app interaction, lack of privacy concerns, desired reassurances during voice app interaction, and helpful aids during voice app interaction. These findings were triangulated with the quantitative data, and it concluded that the main area for improvement was related to the ease of use; design changes were then implemented to better improve the user experience. This work offered preliminary insight into the acceptability and feasibility of a Medly voice app. Given the recent emergence of voice apps in health care, we believe that this research offered invaluable insight into successfully deploying DTx for chronic disease self-management using this technology.

Feasibility of video-based joint hypermobility assessment in individuals with suspected Ehlers-Danlos syndromes/generalised hypermobility spectrum disorders: a single-site observational study protocol

IntroductionEhlers-Danlos syndromes (EDS)/generalised hypermobility spectrum disorders (G-HSD) affect the connective tissue of the body and present with a heterogeneous set of symptoms that pose a challenge for diagnosis. One of...

Quantifying the impact of equity, diversity, and inclusion in electrophysiology: Training the first female electrophysiologists from Jamaica and Saint Lucia.

Delivery of electrophysiology (EP) care in developing nations and underserviced populations faces many hurdles, including the lack of local expertise and knowledge creation. The West Indies has experienced a paucity of local EP expertise. The University of Toronto has undertaken a unique collaborative educational effort with the University of the West Indies. We describe the effects of equity, diversity, and inclusion (EDI) in EP training at Toronto General Hospital in Canada by quantifying the impact of training the first female electrophysiologists to practice in Jamaica and Saint Lucia. Data from the ministries of health in Jamaica and Saint Lucia were reviewed. The number of arrhythmia clinic patients seen, EP studies and ablations performed, pacemaker clinic patients seen, and implantable devices, permanent pacemakers (PPMs), and implantable cardioverter-defibrillators (ICDs) implanted were assessed. One hundred one arrhythmia consults were seen by the new electrophysiologist in Jamaica after her return from training in 2020. She has since performed 19 EP studies/catheter ablations at a newly established ablation laboratory. Three cases of left ventricular (LV) dysfunction due to tachy-cardiomyopathy were treated successfully with catheter ablation with immense improvement in LV ejection fraction. Thirteen PPMs, 1 ICD, and 3 LV leads were implanted, after which no early complications were identified. In Saint Lucia, where there is no dedicated electrophysiology laboratory, 2 patients who required catheter ablation for tachycardia-mediated LV dysfunction were identified by the electrophysiologist since her return to the island in 2018. The patients were appropriately referred, resulting in restoration of normal LV function. Six PPMs also were implanted in Saint Lucia. Knowledge translation has been limited by the lack of accessibility to the required devices, catheters, and specialized equipment and accessories, mainly because of their costs. Training the first female electrophysiologists from Jamaica and Saint Lucia led to a quantifiable impact on EP care in both of these Caribbean countries. EDI strategies in EP training programs provide much needed benefits to developing nations, but more support is needed to allow new electrophysiologists to fully utilize their EP training to care for underserviced populations.

The Heartbeat of Innovation: A History of Cardiac Surgery at the Toronto General Hospital. Edward Shorter, Hugh E. Scully, and Bernard S. Goldman.

<i>The Heartbeat of Innovation: A History of Cardiac Surgery at the Toronto General Hospital</i>. Edward Shorter, Hugh E. Scully, and Bernard S. Goldman.

COVID-19 vaccines: a geographic, social and policy view of vaccination efforts in Ontario, Canada

Abstract In recent months, more studies are emerging regarding how various nations and regions fared during the initial two years of the COVID-19 pandemic. Canada is cited as an example of a country that had performed reasonably well versus other countries with comparable infrastructures and health care systems (Razek et al., 2022). The reason is largely attributed to a combination of several public health measures coupled with widespread vaccination uptake, as a result of a country-wide vaccination campaign. This paper is based on a keynote talk given at the Autumn 2021 CJRES Annual Conference, by Dr. Isaac I. Bogoch. Dr Bogoch is an Associate Professor in the Department of Medicine at the University of Toronto, and an Infectious Diseases Consultant in the Division of Infectious Diseases at the Toronto General Hospital. Dr. Bogoch was a member of Ontario’s Vaccine Distribution Taskforce, which helped guide vaccine policy during the initial rollout of COVID-19 vaccines between December 2020 through August 2021. Dr. Bogoch explains the unique vaccine policy in the Province of Ontario and in particular the social innovation around prioritising the most vulnerable and disadvantaged neighbourhoods first, thus leading to an important intra-regional social policy view of vaccine efforts on the path beyond the ‘emergency phase’ of the COVID-19 pandemic. What is clearly obvious from his presentation is the heightened role of urban geography tools and techniques and intra-regional policy in vaccine equity efforts. Policy lessons learned in Ontario may help us sort out future urban, social, economic, epidemiologic and public health challenges and their sometimes-complex intersections in regions, economy and society. The following is an edited transcript from Dr. Bogoch’s talk.