Victoria General Hospital Research Articles

Evaluation of a Fully Digital, In-House Virtual Surgical Planning Workflow for Bimaxillary Orthognathic Surgery

The advantages of virtual surgical planning (VSP) for orthognathic surgery are clear. Previous studies have evaluated in-house VSP; however, few fully digital, in-house protocols for orthognathic surgery have been studied. The purpose of this study was to evaluate the difference between the virtual surgical plan and actual surgical outcome for orthognathic surgery using a fully digital, in-house VSP workflow. This is a prospective cohort study from September 2020 to November 2022 of patients at the Victoria General Hospital in Halifax, NS, Canada who underwent bimaxillary orthognathic surgery. Patients were excluded if they had previously undergone orthognathic surgery or were diagnosed with a craniofacial syndrome. The primary outcome variables were the mean 3-dimensional (3D) (Euclidean) distance error, as well as mean error and mean absolute error in the transverse (x axis), vertical (y axis), and anterior-posterior (z axis) dimensions. Covariates included age, sex, and surgical sequence (mandible-first or maxilla-first). The primary outcome was tested using Z and t critical value confidence intervals. The P value was set at .05. The 3D distance error for mandible-first and maxilla-first groups was compared using a 2-sample t-test as well as analysis of variance. The study sample included 52 subjects (24 males and 28 females) with a mean age of 27.7 (± 12.1) years. Forty three subjects underwent mandible-first surgery and 9 maxilla-first surgery. The mean absolute distance error was largest in the anterior-posterior dimension for all landmarks (except posterior nasal spine, left condyle, and gonion) and exceeded the threshold for clinical acceptability (2mm) in 16 of 23 landmarks. Additionally, mean distance error in the anterior-posterior dimension was negative for all landmarks, indicating deficient movement in that direction. The effect of surgical sequence on 3D distance error was not statistically significant (P=.37). In general, the largest contributor to mean 3D distance error was deficient movement in the anterior-posterior direction. Otherwise, mean absolute distance error in the vertical and transverse dimensions was clinically acceptable (< 2mm). These findings were felt to be valuable for treatment planning purposes when using a fully digital, in-house VSP workflow.

INvestigation of the impact of a Pharmacist in a Hospital At Home Care Team (IN PHACT).

In November 2020, Island Health, with the support of the British Columbia Ministry of Health, introduced the Hospital at Home (HaH) care model at Victoria General Hospital in Victoria, British Columbia. Given the acuity of the patients anticipated to receive care through this model, questions arose regarding how the delivery of clinical pharmacy services on which inpatients rely on could be included. With limited supporting evidence for the inclusion of a clinical pharmacist, Island Health launched the HaH program with 2 clinical pharmacists who provide services 7 days a week during daytime hours. The aim of this study is to assess the impact of the HaH pharmacist on patient care, from the perspective of the pharmacists serving in this role, patients, caregivers and program stakeholders. This prospective, observational mixed-methods study was conducted from December 2021 to March 2022. Data collection involved the HaH pharmacist documenting daily clinical activities and resolving drug therapy problems, patients and caregivers completing a 4-question postdischarge phone survey and program stakeholders completing a 9-question online survey and an optional 7-question interview. It was found that one of the most significant roles the pharmacist plays is in identifying indications for medication therapy and making recommendations to initiate therapy where there is an absence. There was high congruence between patient, caregiver and stakeholder perceptions that the HaH pharmacist positively affects patient care within the Island Health model. This study provides support for the integration of a dedicated clinical pharmacist in the HaH care model.

STUDY OF CORRELATION OF FOETAL BRAIN WEIGHT TO FOETAL TOTAL BODY WEIGHT TO ASSESS THE DEVELOPMENT OF BRAIN

Background: Owing to the present-day usage of advanced development of ultrasonographic technique with high resolution scanning, one is able to identify, analyse and report the congenital abnormalities of rd developing foetuses in their intrauterine life with great specicity. As the development of neural tube begins very early as 3 week of intrauterine period, a clinician is able to detect neural tube defects at a very early stage. The normal growth of the brain during the intrauterine period can be estimated by assessing the ratio of foetal brain weight to the total body weight of the foetus by measuring the various parameters of the foetuses. The weight of the foetal brain varies in various conditions like congenital heart defects, intrauterine growth retardation, microcephaly, neural tube defects associated with folic acid deciency and due to various teratogenic factors. So, studying the ratio of foetal brain to total body weight is useful tool to diagnose various conditions. Methodology: A total of about 100 foetuses of different gestational ages were collected from the Gynaecology and Obstetrics department in King George Hospital and Victoria General Hospital, Visakhapatnam. It was ensured that the foetuses are properly embalmed as soon as they are procured and foetal height, weight and other important parameters required for the study were taken. Results: The ratios were calculated for gestational ages from 13 to 40 weeks. The ratio for brain declined very slowly throughout the period examined. An observation of practical importance of the brain weight/bodyweight ratios was virtually constant after 30 weeks of gestation. Conclusion: In this study foetal body weight is compared with the brain weight to correlate the subsequent brain development according to the weight of the foetus. By this study we can understand the foetal brain growth and compare results attained with the readings of foetal brain vol / weights got by non-invasive techniques like ultrasound, MRI scanning and identify the affected brain development in various conditions like congenital heart defects, intrauterine growth retardation, syndromes with associated microcephaly, zika virus infections and genetic anomalies etc

P.070 Introducing Stroke Endovascular Thrombectomy Into A Smaller Canadian Site, Is It Safe?

Background: Success of Endovascular Thrombectomy (EVT) requires ultra-fast access to specialized neuro imaging, neurological assessment and an angio suite with interventional radiologists. Prior access was via transport to Vancouver and outcomes were poor, with a high rate of disability or death. This appeared primarily due to long delays. Methods: Quality control process, in parallel to the introduction of a new intervention, EVT, to Vancouver Island, to determine if this intervention could be delivered with reasonable safety and good outcomes. Patients receiving EVT from May, 2016 until Sep, 2019 are included, with 90-day outcomes. Data was collected by stroke nurses. Results: The proportion of patients having a good outcome was comparable to that of the major clinical trial involving Canadian academic centres. The proportion sustaining a poor outcome was comparable to the control group in that trial population (who still received tPA treatment where possible). This was despite a median age 4.5 years greater than in that trial. Conclusions: EVT required coordination of multiple services. Victoria General Hospital performance in terms of speed to treatment was slower than in the published trials. This is a factor in determining outcome and is therefore an important quality improvement target moving forward.

A136 LIVING ON THE EDGE: EUS-DIRECTED TRANSGASTRIC ERCP (EDGE) IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS ANATOMY

Abstract Background Roux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EUS-directed transgastric ERCP (EDGE), is an entirely endoscopic approach which involves accessing the excluded stomach to facilitate conventional ERCP. Objectives To describe the results of EDGE procedures performed in two centres in British Columbia. Aims To describe the results of EDGE procedures performed in two centres in British Columbia. Methods Data were collected from five patient cases who had undergone an EDGE procedure at Victoria General Hospital (4) or Vancouver General Hospital (1) in British Columbia from 2019 to 2020. All patients had a history of RYGB bariatric surgery. In each of the procedures, a 20 mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS-guidance to allow access from the gastric remnant or proximal jejunum to the excluded stomach. Subsequently, during a separate procedure 4 to 28 days later, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was removed 0 to 38 days later and replaced with a double pigtail stent to facilitate controlled closure of the gastro-jejunal or gastro-gastric fistula. Results Of the five cases included in the case series, 4 patients underwent EDGE for treatment of choledocholithiasis and one patient underwent the procedure for gallstone pancreatitis. The technical success rate of the EDGE procedure in the five cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all of the cases. There were no adverse events related to the EDGE procedure in these five cases. Conclusions The results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery. Funding Agencies None

Endoscopic tympanic neurectomy for otic neuralgia—a case series

Otic neuralgia (ON) is a diagnostic and therapeutic challenge. ON is often attributed to either direct or referred pain from other structures. The tympanic nerve is the major contributor to sensory supply of the middle ear mucosa. A tympanic neurectomy has previously been described for the management of ON with promising results. This work aims to describe an endoscopic approach to the tympanic neurectomy and assess results in a case series of 8 patients. A multi-center retrospective review was conducted searching for cases of endoscopic tympanic neurectomies performed for ON; the sites included Royal North Shore Hospital; Sydney, Macquarie University Hospital, Sydney and the Victoria General Hospital, Dalhousie University, Halifax. From May 2014 to December 2016 there were a total of eight endoscopic tympanic neurectomies performed for ON. The mean age at presentation was 46.4 years (range, 29–75 years), there were 7 females and 1 male. All patients were pain free after an average of 2.1 months (range, immediate relief to 5 months) with one case of recurrent ON noted that resolved after further treatment. Tympanic neurectomy offers a therapeutic option for ON once alternative causes have been excluded. The endoscope allows improved visualization allowing for a more precise and complete neurectomy.

Little hospital on the South Common: A history of the Victoria General Hospital

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Intraoperative glycaemic control

Although there is strong evidence that supports the appropriate control of intraoperative glycaemic levels, there is little literature we are aware of that assesses how well perioperative physicians manage it. This project describes an audit of intraoperative glycaemic control at Victoria General Hospital in Victoria, British Columbia, Canada. There were 51 surgical patients included in the audit that took place over 19 days. The results showed that 25.5% of patients included in the audit had a blood glucose level outside the ideal range. Due to the association between poor glycaemic control and increased morbidity and mortality, we found this percentage left considerable room for improvement. We make several recommendations, including the introduction of an evidence-based protocol that guides anaesthetists when to measure and, if clinically indicated, correct intraoperative glycaemic levels.

LO011: Identification of mild acute cerebrovascular syndrome (ACVS) in the emergency department: validation of an ACVS clinical classifier to help distinguish mimics

Introduction: National guidelines (NICE, AHA) for management of Acute Cerebrovascular Syndrome (ACVS) in the Emergency Department (ED) recommend the use of ABCD2 score to risk stratify patients despite its poor specificity and low diagnostic accuracy. The SpecTRA project previously developed a clinical classifier for ACVS vs. Mimic derived from historical clinical data collected during a 5-year period at an outpatient stroke clinic (Victoria, BC). Here we present a prospective evaluation of the performance of our clinical classifier on prospectively collected ED patient data compared to the industry-standard ABCD2. Methods: The prospective cohort consisted of ED patients (N=555, Male=54%, Mean (SD) Age=68.7(15.5), ACVS=70%) enrolled between Jan 2014 and May 2015 at Victoria General Hospital (BC) and Foothills Medical Centre (Calgary, AB). ABCD2 and clinical classifier scores were calculated from clinical data from the ED. We compared the performance of the two classifiers using DeLong’s test of Dependent Receiver Operating Curves (ROC). In keeping with national guidelines, we used a score of 4 or more to assess sensitivity, specificity and accuracy (sens/spec and acc) of the ABCD2; for our clinical classifier, we used the cut point previously determined to maximize agreement between predictions and true class labels in the historical data. Results: Our new clinical classifier significantly outperformed the ABCD2 (z=2.44, p=0.015) with an AUC of 0.72, (95% CI: 0.68, 0.77) vs. 0.66 (0.61, 0.71). In terms of sens/spec and acc, our classifier achieved 0.78/0.55 with acc 71% compared to 0.75/0.46 with acc 66% for the ABCD2 (using the previously specified cut points). Conclusion: Our ACVS clinical classifier showed better performance than the ABCD2 score on a prospective sample of ED patients. The improved specificity of the clinical classifier relative to existing prognostic tools would reduce the number of non-ACVS patients referred for early treatment as well as conserve medical resources. Our ongoing multi-site study will evaluate the utility of the ACVS classifier embedded in a logic-enabled e-fillable form. This form will also provide risk-based thresholds guiding timely ordering of CTA as well as links to clinical treatment guidelines. Longer-term, the e-form and classifiers will be further enhanced to include plasma-based protein biomarker data.

Assessing the Effects of Participant Preference and Demographics in the Usage of Web-based Survey Questionnaires by Women Attending Screening Mammography in British Columbia.

BackgroundIncreased usage of Internet applications has allowed for the collection of patient reported outcomes (PROs) and other health data through Web-based communication and questionnaires. While these Web platforms allow for increased speed and scope of communication delivery, there are certain limitations associated with this technology, as survey mode preferences vary across demographic groups.ObjectiveTo investigate the impact of demographic factors and participant preferences on the use of a Web-based questionnaire in comparison with more traditional methods (mail and phone) for women participating in screening mammography in British Columbia, Canada.MethodsA sample of women attending the Screening Mammography Program of British Columbia (SMPBC) participated in a breast cancer risk assessment project. The study questionnaire was administered through one of three modes (ie, telephone, mail, or website platform). Survey mode preferences and actual methods of response were analyzed for participants recruited from Victoria General Hospital. Both univariate and multivariate analyses were used to investigate the association of demographic factors (ie, age, education level, and ethnicity) with certain survey response types.ResultsA total of 1192 women successfully completed the study questionnaire at Victoria General Hospital. Mail was stated as the most preferred survey mode (509/1192, 42.70%), followed by website platform (422/1192, 35.40%), and telephone (147/1192, 12.33%). Over 80% (955/1192) of participants completed the questionnaire in the mode previously specified as their most preferred; mail was the most common method of response (688/1192, 57.72%). Mail was also the most preferred type of questionnaire response method when participants responded in a mode other than their original preference. The average age of participants who responded via the Web-based platform (age 52.9, 95% confidence interval [CI] 52.1-53.7) was significantly lower than those who used mail and telephone methods (age 55.9, 95% CI 55.2-56.5; P<.001); each decade of increased age was associated with a 0.97-fold decrease in the odds of using the website platform (P<.001). Web-based participation was more likely for those who completed higher levels of education; each interval increase leading to a 1.83 increase in the odds of website platform usage (P<.001). Ethnicity was not shown to play a role in participant preference for the website platform (P=.96).ConclusionsIt is beneficial to consider participant survey mode preference when planning to collect PROs and other patient health data. Younger participants and those of higher education level were more likely to use the website platform questionnaire; Web-based participation failed to vary across ethnic group. Because mail questionnaires were still the most preferred survey mode, it will be important to employ strategies, such as user-friendly design and Web-based support, to ensure that the patient feedback being collected is representative of the population being served.

Restricted: Increasing Access to the Reference Collection

&lt;strong&gt;Abstract: Introduction:&lt;/strong&gt; The objective of this project was to determine whether or not a hospital library reference collection is still necessary or justified. Two academic hospital libraries moved all reference books to the general collection to see whether increased access to these materials would increase their use. &lt;strong&gt;Description:&lt;/strong&gt; All reference books were updated to circulating status and shelved in the circulating collection. As these items were used, statistics were gathered in the integrated library system (ALMA). Statistics were gathered from August 2014 to January 2015. Circulation statistics for equivalent periods prior to and during the project were compared to determine whether changing access to the collection increased use. &lt;strong&gt;Outcomes:&lt;/strong&gt; Uses of the reference collection items doubled at Seven Oaks General Hospital (SOGH) and more than tripled at Victoria General Hospital (VGH). The percentage of reference titles used tripled at SOGH and doubled at VGH. &lt;strong&gt;Discussion:&lt;/strong&gt; The change to circulating status significantly increased access to and use of the reference collection. This borrowing policy change for the reference collection will be recommended to the other hospital libraries within the University of Manitoba.

Mining clinical text for stroke prediction

One of the main problems in treating stroke patients is accurate and timely triage and assessment. Not all stroke events have direct severe consequences. Full strokes are often preceded by transient ischemic attacks (TIA) or mini strokes, which exhibit signs and symptoms similar to less concerning health events, e.g., migraines. In this paper, natural language techniques are presented to process a large collection of medical narrative descriptions extracting features that can be subsequently used for automatic classification using Data Mining algorithms. We reviewed 5658 cases and analyzed the chief complaint and history of the patient illness reported at stroke rapid assessment unit (SRAU) at Victoria General Hospital (VGH). Data were collected by neurologists and stroke nurses between years 2008 and 2013. Based on a clinician-supplied list of important sign and symptom terms, we translated narrative medical text into well-codified sentences achieving an impressive agreement with a human expert. Afterwards, Data Mining algorithms were applied on codified data and obtaining not only prediction models, but also important weights for the codified terms. An extensive experimental evaluation of several classifiers is provided based on past data to predict new cases. Notably, we achieved a sensitivity of about 84 % and specificity of 64 % using support vector machines (SVM). The top terms identified by data mining algorithms were responsible for most of the prediction quality; therefore, they can be used to build a questionnaire-like, online application that can be employed as a first-line screening in triage for detecting stroke/TIA or mimic and help triage decide for the next step of treatment or discharge the patient.

Bridging Protocol for Surgical Patients: One Clinic's Experience Facilitating a Safe Anticoagulation Intervention.

Surgical candidates often present with complex medical histories that necessitate an individualized approach to care to minimize surgical and anesthetic risk. Patients on warfarin require exceptionally careful clinical assessment, consideration, and consistency to reduce the risk of perioperative thromboembolism and bleeding complications. In response to this need, Victoria General Hospital in Winnipeg, Manitoba, Canada developed a bridging protocol based on evidence-based guidelines and a checklist tool to incorporate and communicate the necessary tasks among the interprofessional team. The purpose of this initiative was to create a patient-focused process to assist those at risk for a thromboembolic event to navigate through a clear, consistent, and collaborative surgical experience whenever cessation and resumption of warfarin administration was required.

Kevin Delgado Barron, MD (1929–2013)

Dr. Kevin Delgado Barron died on October 28, 2013, at his home in Loudonville, New York, in the company of his family. He was 84. Dr. Barron was born in St. John's, Newfoundland, British Dominion, Canada, in 1929, third son of John A. Barron and Mercedes Delgado. He attended medical school at Dalhousie Medical School in Halifax, Nova Scotia, Canada. After concluding his internal medicine clerkship at Victoria General Hospital in Halifax and Queen Mary VA Hospital, Montreal, Canada, and a brief stint in 1952 as ship's doctor on coastal steamer the SS Kyle , he completed his neurology residency at Montefiore Hospital, New York, followed by a fellowship in neuropathology. Subsequent academic appointments included instructor at the Neurological Institute at Columbia University Medical Center, New York; associate in neurology, psychiatry, and pathology at Northwestern University Medical School, Chicago; and section chief of neurology service and director of the electron microscope laboratory and the neuropathology research service at the VA Hospital, Hines, Illinois.

Estimation of additional MRI resources needed in British Columbia for screening high-risk women for breast cancer.

51 Background: Screening women at high risk with MRI has been shown to detect breast cancer at an early stage. Therefore, MRI screening has been recommended in the UK and USA for women who are at a high risk of developing breast cancer. However, there is no information available in the province of British Columbia (BC) about the number of women who have a high risk of developing breast cancer. Therefore, we carried out a study to estimate the breast cancer risk distribution in three sample populations in BC using Tyrer-Cuzick (TC) risk prediction model so that additional resource requirement for MRI breast screening can be calculated. Methods: A survey questionnaire was designed based on the TC model, which includes family history, hormonal factors, and benign breast disease. Additional questions also include factors that are used in other models (Gail, Claus, and BCRAPRO) as well as factors that may be included in the future. Women were recruited by staff and volunteers at three screening mammography clinics: Kelowna, Victoria General Hospital, and BC Women’s Health Centre in Vancouver. The survey was available to women to complete on the web, by phone, or on paper. An online database was constructed to store and query the data. The 10-year risk of developing breast cancer for each woman was calculated using the Tyrer-Cuzick IBIS Risk Evaluator software and the risk distribution of the survey population was analyzed. Results: Data from 3,200 women recruited from three sites, gives a risk distribution showing 2.6% are at high risk of developing breast cancer, 31.2% are at moderate risk, and 66.2% are at low risk. Based on NICE guidelines (UK), high risk is defined as having a 10-year risk of greater than 8%, moderate risk as 3-8%, and low risk as less than 3%. Extrapolating this to the approximately 500,000 women who are eligible to attend for screening mammography in BC, 13,000 women are considered at high risk. Conclusions: Our results indicate that 2.6% of women ages 40-79 attending screening mammography in BC may have a very high risk of developing breast cancer based on personal and family history. Based on a 14-hour work day, three additional MRI scanners would be required to implement MRI screening for these high-risk women in BC.

Editorial introductions

Editorial introductions

Editorial introductions

Editorial introductions

Building a Better Preoperative Assessment Clinic

In every surgical patient's journey, a well-run preoperative assessment clinic (PAC) is an essential first step in ensuring excellence in quality and patient safety. In 2007, the PAC at Victoria General Hospital, a busy community hospital, averaging more than 7,000 surgical procedures per year, struggled to support the volume of surgical patients. Processes were ill defined, staffing levels were suboptimal, and the physical space was inadequate. This hospital is one of seven acute care hospitals that provide surgical services within the city, under the umbrella of a regional health authority, and is the largest of 11 regional health authorities within the province. With support of the PAC team and administration, a commitment was made to embark on improvements with limited financial resources and space available. After implementing the proposed changes and evaluating the data, the evidence indicates that several small changes can make significant overall improvements in providing superior patient care, more efficient processes, and healthier work environments.

George Karpati, MD, FAAN (1934–2009)

Dr. George Karpati died suddenly on February 7 while at the zenith of a career as a clinical myologist and neuroscientist that spanned over 40 years. Born in Hungary, George earned his medical degree from Dalhousie University in Halifax, Nova Scotia. He spent his entire academic career on the neurology faculty of McGill University and at the Montreal Neurological Institute (MNI). After medical school he had clinical training at the Victoria General Hospital in Montreal, the MNI, and the Henry Ford Hospital. He trained in Research Neuromuscular Histochemistry with W. King Engel at the National Institutes of Health. George Karpati combined the skills of a clinical neurologist, …

Effects of G-CSF vs. No G-CSF on Outcomes Post-Autologous Stem Cell Transplant - A Two-Centre Retrospective Study.

INTRODUCTION In management of patients post-autologous stem cell transplant (ASCT), there continues to be controversy regarding the benefit of granulocyte-colony stimulating factor (GCSF) given post-autologous stem cell transplantation on length of time to engraftment and rates of febrile neutropenia. We conducted a chart review on all patients who received autologous stem cell transplants with follow-up at two tertiary care centres, the Health Sciences Centre in St. John's, Newfoundland, and Victoria General Hospital in Halifax, Nova Scotia from February 2001 to February 2006.METHODS Comparison was made between two groups, either receiving (Group A) or not receiving (Group B) planned GCSF (starting 5 days post ASCT) for engraftment purposes. Patients who were not intended to receive GCSF but later received it due to delayed engraftment or febrile neutropenia remained in the non-intervention arm for analysis. Patients were excluded who had CD34+ infusion doses of < 2.5 cells x 106/kg body weight as all these patients received planned GCSF to promote engraftment at both centers. Also, we excluded patients who were transferred from the treatment center (Halifax or St. John's) to their referring center for post transplant care prior to engraftment as follow up data would not be available for these cases. Primary outcomes included time to neutrophil engraftment and days to hospital discharge. Secondary outcomes included episodes of febrile neutropenia, number of packed red cell and platelet transfusions, days to platelet engraftment and transplant related mortality. Comparison between groups of episodes of febrile neutropenia was performed using Fisher's exact test and all other variables were analyzed using the unpaired t-test.RESULTS 215 patients were included, having received autologous stem cell transplants at the above centres from February 2001 to February 2006. There were no significant differences between the two groups in age, sex, or diagnoses. More patients in Group B received etoposide/melphalan conditioning whereas there were more treated with BEAM in group A. Mobilizing regimens also differed significantly, with more patients in the group B receiving GCSF alone. Median time to neutrophil engraftment differed between group A and group B (11 vs. 14 days respectively, p<0.0001). There was a higher incidence of febrile neutropenia in patients in group B (89%) compared with group A (76%, p<0.01). However, there was no significant difference between days to hospital discharge, platelet and packed red cell transfusions, or transplant related mortality. One distinct weakness of the study was in evaluating the duration of hospital stay as this was determined by date of final discharge post transplant and did not take into account delayed admissions or periods of discharge between recurrent admissions for transplant-related issues.CONCLUSION We observed a significant difference between the rate of febrile neutropenia and duration to neutrophil engraftment in those routinely receiving GCSF as part of post-transplant care vs. those who receive it either not at all or only for delayed engraftment. However, the clinical significance of these findings is unclear, particularly as the time to hospital discharge and the transfusion requirement was the same between the groups. Nonetheless, these results indicate a need for further study in this area, and suggest that more dedicated research into cost-effectiveness of the intervention may be useful.