RATIONALES: pirometry improves after lung transplant, peaking at 6-18 months. Survival decreases when the highest forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) values fall below 80% predicted, a condition called baseline lung allograft dysfunction (BLAD). OBJECTIVES: To determine if lung function in the first 3 months post-transplant can predict BLAD. METHODS:;We built logistic regression models in a prospective cohort of patients enrolled from December 2017 onward. Of the 207/289 patients who had >= 1 year follow-up, 104 had BLAD while 103 patients achieved FEV1 and FVC > 80% predicted (Normal). The primary predictors of interest included lung function metrics in the first 3 months and clinical variables known to affect graft function. The model developed in the prospective cohort was validated in a retrospective cohort of 1169 patients (631 Normal, 538 BLAD; transplanted 1986-2020) using k-fold cross-validation. RESULTS: The best predictive model was a univariable model with %FEV1 at 3-months (sensitivity: 87% and 84%; specificity: 83% and 81%, prospective and validation models, respectively). The odds ratio was 0.056 (95% CI: 0.024-0.112), indicating that a patient whose 3-month %FEV1 is 1 standard deviation below the cohort mean is 17.8-fold (95% CI: 8.94-41.3) more likely to develop BLAD. CONCLUSION: %FEV1 at 3-months post-transplant is a strong predictor of BLAD. Strategies that maximize 3-month FEV1 could improve survival.

BACKGROUND:Medical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational studies found associations with improved patient safety outcomes, but no randomised controlled studies have been conducted. OBJECTIVE:The primary objective was to determine the impact of medical safety huddles on adverse events. Secondary objectives included the fidelity of huddle implementation and the impact on patient safety culture among physicians. DESIGN:Stepped-wedge cluster randomised trial with four sequences, and each hospital site was a cluster. SETTING:Inpatient oncology, surgery and rehabilitation programmes in four academic hospitals. PARTICIPANTS:Physicians in participating programmes. INTERVENTION:Medical safety huddles were adapted for local context and implemented sequentially based on a computer-generated random sequence every 2 months after a 4-month control period. All sites remained in the intervention phase for at least 9 months. MAIN OUTCOME AND MEASURES:The primary outcome was the rate of adverse events, as determined through blinded chart audits of 912 randomly selected patients. The fidelity of implementation was assessed through the huddle attendance rate, number of safety issues raised in the huddles and number of actions taken in response. Patient safety culture was assessed using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety. RESULTS:The adjusted rate of adverse events (per 1000 patient days) in the postintervention phase was 12% lower compared with preintervention (RR: 0.88; 95% CI: 0.80 to 0.98; p=0.016). The odds of having adverse events posthuddle implementation were 17% lower in the postintervention period compared with preintervention (OR intervention vs control: 0.83; 95% CI: 0.80 to 0.87; p<0.001). The mean huddle attendance rate at each site ranged from 30% to 85%, and the mean number of issues raised per huddle and the mean number of actions taken per huddle ranged from 1.6 to 3.1. The mean (SD) overall patient safety rating increased from 2.3 (0.53) to 2.8 (0.88), p=0.010. The mean per cent (SD) positive score for the composite measures of 'Organisational learning' increased significantly from 35% (26%) to 54% (23%), p=0.00, 'Response to error' 37% (24%) to 52% (22%), p=0.025 and 'Communication about error' 36% (28%) to 64% (42%), p=0.016 after implementation. CONCLUSIONS AND RELEVANCE:Medical safety huddles decreased adverse events and may improve patient safety culture through engaging physicians. TRIAL REGISTRATION NUMBER:NCT05365516.

The YEARS criteria combine D-dimer testing and clinical features (hemoptysis, signs of deep vein thrombosis, and pulmonary embolism as the most likely diagnosis) to risk stratify patients with symptoms of pulmonary embolism who may undergo CT pulmonary angiography in the emergency department (ED). Electronic clinical decision support can optimize CT pulmonary angiography utilization in EDs, yet its effectiveness with the YEARS criteria remains unstudied. Our goal is to increase the percentage of CT pulmonary angiograms performed with a D-dimer by 10

Objectives: To evaluate the quality of operative reports for endometriosis surgeries performed by fellowship-trained, high-volume endometriosis surgeons. Methods: In this retrospective review, 5 consecutive deidentified surgical reports per surgeon were evaluated by 2 reviewers. Each dictation was assigned a quality score (between 0 and 28), based on the number of components from the American Association of Gynecologic Laparoscopists (AAGL) classification system that were documented. The primary outcome was the proportion of reports for which the endometriosis AAGL 2021 stage could be assigned. Secondary outcomes included median dictation quality scores, proportion of dictations for fertility-preserving cases where the Endometriosis Fertility Index score could be assigned, individual quality score components, and quality score variation between surgeons, institutions, and reporting methods. Results: Overall, 82 operative reports were reviewed from 16 surgeons across 7 sites in Ontario. The AAGL stage could be assigned in 48/82 (59%) of cases, and the Endometriosis Fertility Index score could be assigned in 31/45 of fertility-preserving cases (69%). The median quality score was 57% (range 18%-86%). Only 13% of operative reports included comments on residual disease. Quality score consistency between reports was poor for a given surgeon (intraclass correlation coefficient 0.22; 95% CI 0.03-0.49). Quality scores differed significantly between surgeons (c2 = 30.6, df = 16, P = 0.015) and institutions (c2 = 19.59, df = 7, P = 0.007). Operative report quality score did not differ based on completion by trainee or staff, template use, or whether the report was completed by telephone or typed. Conclusions: There is significant variability and inconsistency in endometriosis surgery documentation. There is a need to standardize surgical documentation for endometriosis surgeries, enhancing communication and ultimately patient care.

OBJECTIVE:To evaluate the effect of hormonal suppression of endometriosis on the size of endometriotic ovarian cysts. DATA SOURCES:The authors searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov from January 2012 to December 2022. METHODS OF STUDY SELECTION:We included studies of premenopausal women undergoing hormonal treatment of endometriosis for ≥3 months. The authors excluded studies involving surgical intervention in the follow-up period and those using hormones to prevent endometrioma recurrence after endometriosis surgery. Risk of bias was assessed with the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. The protocol was registered in PROSPERO (CRD42022385612). TABULATION, INTEGRATION, AND RESULTS:The primary outcome was the mean change in endometrioma volume, expressed as a percentage, from baseline to at least 6 months. Secondary outcomes were the change in volume at 3 months and analyses by class of hormonal therapy. The authors included 16 studies (15 cohort studies, 1 randomized controlled trial) of 888 patients treated with dienogest (7 studies), other progestins (4), combined hormonal contraceptives (2), and other suppressive therapy (3). Globally, the decrease in endometrioma volume became statistically significant at 6 months with a mean reduction of 55% (95% confidence interval, -40 to -71; 18 treatment groups; 730 patients; p <.001; I2 = 96%). The reduction was the greatest with dienogest and norethindrone acetate plus letrozole, followed by relugolix and leuprolide acetate. The volume reduction was not statistically significant with combined hormonal contraceptives or other progestins. There was high heterogeneity, and studies were at risk of selection bias. CONCLUSION:Hormonal suppression can substantially reduce endometrioma size, but there is uncertainty in the exact reduction patients may experience.

Background Longitudinal data on the detectability of monkeypox virus (MPXV) genetic material in different specimen types are scarce. Methods We describe MPXV-specific polymerase chain reaction (PCR) results from adults with confirmed mpox infection from Toronto, Canada, including a cohort undergoing weekly collection of specimens from multiple anatomic sites until 1 week after skin lesions had fully healed. We quantified the time from symptom onset to resolution of detectable viral DNA (computed tomography [Ct] >= 35) by modeling exponential decay in Ct value as a function of illness day for each site, censoring at the time of tecovirimat initiation. Results Among 64 men who have sex with men, the median (interquartile range [IQR]) age was 39 (32.75-45.25) years, and 49% had HIV. Twenty received tecovirimat. Viral DNA was detectable (Ct < 35) at baseline in 74% of genital/buttock/perianal skin swabs, 56% of other skin swabs, 44% of rectal swabs, 37% of throat swabs, 27% of urine, 26% of nasopharyngeal swabs, and 8% of semen samples. The median time to resolution of detectable DNA (IQR) was longest for genital/buttock/perianal skin and other skin swabs at 30.0 (23.0-47.9) and 22.4 (16.6-29.4) days, respectively, and shortest for nasopharyngeal swabs and semen at 0 (0-12.1) and 0 (0-0) days, respectively. We did not observe an effect of tecovirimat on the rate of decay in viral DNA detectability in any specimen type (all P > .05). Conclusions MPXV DNA detectability varies by specimen type and persists for over 3-4 weeks in skin specimens. The rate of decay did not differ by tecovirimat use in this nonrandomized study.

IntroductionTotal knee arthroplasty is associated with significant postoperative pain. Continuous adductor canal blocks via an inserted adductor canal catheter are effective analgesia interventions with the advantage of decreasing quadriceps weakness and the potential of extending the analgesic effect. The classical adductor canal catheter insertion technique may have a high likelihood of catheter dislodgement out of the canal. The interfascial plane between the sartorius muscle and femoral artery (ISAFE) approach has the potential of decreasing the adductor canal catheter migration. The purpose of this study was to evaluate the incidence of catheter dislodgment to outside the adductor canal, for ISAFE and classical approaches. We hypothesized that ISAFE approach would result in a lower dislodgment rate.MethodsNinety-seven patients for unilateral total knee arthroplasty were included and randomized to either ISAFE intervention group or conventional group. The primary outcome was the incidence of adductor canal catheter dislodged to outside the adductor canal, on ultrasound evaluation, 24 hours after the surgery. Secondary outcomes were pain scores, opioid consumption and continuous adductor canal block related complications for the first 48 hours after surgery.ResultsThe catheters placed using ISAFE approach had a lower rate of dislodgement in comparison to the control group (18.6% vs 44.9%, respectively, p=0.01), at 24 hours after surgery; and lower pain scores for rest, on the first two postoperative days.ConclusionsISAFE group had a significantly lower rate of dislodgement at 24 hours. The continuous adductor canal block analgesic benefit for knee arthroplasty depends on the position of the tip of the catheter inside the adductor canal.

ObjectiveThe primary objective was to evaluate the prevalence of undiagnosed iron deficiency in patients with endometriosis.MethodsWe performed a multi-center, cross-sectional study at two tertiary care hospitals. We included 251 non-pregnant women (18-50 years old) presenting with a clinical or surgical diagnosis of symptomatic endometriosis. Patients who consented to the study underwent screening bloodwork (including complete blood count, ferritin, and transferrin saturation) and completed the study survey assessing demographics, medical and surgical history, and validated questionnaires to assess iron deficiency and endometriosis symptoms.ResultsThe prevalence of iron deficiency in our endometriosis cohort was 53.4% (134/251), and the prevalence of iron deficiency anemia was 13.5% (34/251). Patients with iron deficiency were more likely to have heavy menstrual bleeding (HMB) compared with patients without iron deficiency (66/133, 49.6% vs. 40/115, 34.8%, p = 0.022). Nonetheless, 58% (142/251) of our study population did not endorse HMB. Despite absence of HMB, 47% (67/142) of these patients were iron-deficient. Transferrin saturation was diagnostic for iron deficiency in 63 of 176 patients (35.7%) who had a normal ferritin (>= 30 ng/mL). Patients with iron deficiency had a significantly lower adjusted median Functional Assessment of Chronic Illness Therapy Fatigue Subscale score compared with those without iron deficiency (26.3. vs. 29.8, p = 0.025).ConclusionThis study highlights the high prevalence of iron deficiency, which remains undiagnosed in over half of patients with endometriosis presenting to a gynecologist. Future research should focus on assessing the effectiveness of iron therapy in improving symptoms and overall well-being in this population.

BACKGROUND:Exposure to air pollution post-lung transplant has been shown to decrease graft and patient survival. This study examines the impact of air pollution exposure in the first 3 months post-transplant on baseline (i.e., highest) forced expiratory volume in 1 second (FEV1) achieved and development of chronic lung allograft dysfunction (CLAD). METHODS:Double-lung transplant recipients (n = 82) were prospectively enrolled for comprehensive indoor and personal environmental monitoring at 6- and 12-week post transplant and followed for >4 years. Associations between clinical and exposure variables were investigated using an exposomics approach followed by analysis with a Cox proportional hazards model. Multivariable analyses were used to examine the impact of air pollution on baseline % predicted FEV1 (defined as the average of the 2 highest values post transplant) and risk of CLAD. RESULTS:Multivariable analysis revealed a significant inverse relationship between personal black carbon (BC) levels and baseline % FEV1. The multivariable model indicated that patients with higher-than-median exposure to BC (>350 ng/m3) attained a baseline % FEV1 that was 8.8% lower than those with lower-than-median BC exposure (p = 0.019). Cox proportional hazards model analysis revealed that patients with high personal BC exposure had a 2.4 times higher hazard risk for CLAD than patients with low BC exposure (p = 0.045). CONCLUSIONS:Higher personal BC levels during the first 3 months post-transplant decrease baseline FEV1 and double the risk of CLAD. Strategies to reduce BC exposure early following a lung transplant may help improve lung function and long-term outcomes.

Hysterectomies are the most commonly performed non-obstetric abdominal surgery worldwide with over 41,000 performed in Canada annually(1). One in five patients undergoing elective benign hysterectomy is anemic (hemoglobin level <120 g/L)(2). Preoperative anemia is a hysterectomy quality metric consistently associated with increased perioperative morbidity and mortality(2). Clinical practice guidelines recommend correction of anemia prior to elective gynecologic surgery(3). Although anemia is a known risk factor for adverse perioperative outcomes, its financial burden on the healthcare system is unclear.

Introduction: Variable transplant-related knowledge may contribute to inequitable access to living donor kidney transplant (LDKT). We compared transplant-related knowledge between African, Caribbean, and Black (ACB) versus White Canadian patients with kidney failure using the Knowledge Assessment of Renal Transplantation (KART) questionnaire. Methods: This was a cross-sectional cohort study. Data were collected from a cross-sectional convenience sample of adults with kidney failure in Toronto. Participants also answered an exploratory question about their distrust in the kidney allocation system. Clinical characteristics were abstracted from medical records. The potential contribution of distrust to differences in transplant knowledge was assessed in mediation analysis. Results: Among 577 participants (mean [SD] age 57 [14] years, 63% male), 25% were ACB, and 43% were White Canadians. 45% of ACB versus 26% of White participants scored in the lowest tertile of the KART score. The relative risk ratio to be in the lowest tertile for ACB compared to White participants was 2.22 (95% confidence interval [CI]: 1.11, 4.43) after multivariable adjustment. About half of the difference in the knowledge score between ACB versus White patients was mediated by distrust in the kidney allocation system. Conclusion: Participants with kidney failure from ACB communities have less transplant-related knowledge compared to White participants. Distrust is potentially contributing to this difference.

Purpose Thoracic epidural analgesia (TEA) is a well stablished technique for pain management in major thoracic and abdominal surgeries; however, it has considerable failure rates. Local anesthetic (LA) administration and subsequent assessment of sensory block through physical examination (e.g., decreased temperature perception determined via an LA temperature dissociation test [LATDT]) has been the historical standard for evaluation of thoracic epidural placement. Nevertheless, newer methods to objectively evaluate successful placement have recently been developed, e.g., the epidural electrical stimulation test (EEST) and epidural pressure waveform analysis (EWA). The purpose of this study was to evaluate the effectiveness of preoperative TEA catheter testing (LATDT, EEST, and EWA) on reducing TEA failure. Methods After obtaining an institutional research ethics board approval for a retrospective study, we conducted a single-institution retrospective review on all TEAs performed between January 2016 and December 2021. Patients were assigned to one of four groups based on the performed test method to verify the placement of the TEA catheter: no test, LATDT, EEST, and EWA. A TEA was deemed successful if it provided bilateral dermatomal sensory block to ice test in the postoperative period, and was used for patient analgesia for at least 24 hr. Results One thousand two hundred and forty-one patients submitted to preoperative TEA were included. Twenty-eight patients were excluded. Tested and untested epidurals had failure rates of 3.8% (95% confidence interval [CI], 1.8 to 6.2) and 11.5% (95% CI, 5.2 to 17.1), respectively ( P < 0.001). Conclusion Objective preoperative testing after placement of thoracic epidurals was associated with a reduction in failure rates.

BACKGROUND:Emergency department (ED) utilization is a significant concern in many countries, but few population-based studies have compared ED use. Our objective was to compare ED utilization in New York (United States), Ontario (Canada), and New Zealand (NZ).METHODS:A retrospective cross-sectional analysis of all ED visits between January 1, 2016, and September 30, 2017, for adults ≥18 years using data from the State Emergency Department and Inpatient Databases (New York), the National Ambulatory Care Reporting System and Discharge Abstract Data (Ontario), and the National Non-Admitted Patient Collection and the National Minimum Data Set (New Zealand). Outcomes included age- and sex-standardized per-capita ED utilization (overall and stratified by neighborhood income), ED disposition, and ED revisit and hospitalization within 30 days of ED discharge.RESULTS:There were 10,998,371 ED visits in New York, 8,754,751 in Ontario, and 1,547,801 in New Zealand. Patients were older in Ontario (mean age 51.1 years) compared to New Zealand (50.3) and New York (48.7). Annual sex- and age-standardized per-capita ED utilization was higher in Ontario than New York or New Zealand (443.2 vs. 404.0 or 248.4 visits per 1000 population/year, respectively). In all countries, ED utilization was highest for residents of the lowest income quintile neighborhoods. The proportion of ED visits resulting in hospitalization was higher in New Zealand (34.5%) compared to New York (20.8%) and Ontario (12.8%). Thirty-day ED revisits were higher in Ontario (27.0%) than New Zealand (18.6%) or New York (21.4%).CONCLUSIONS:Patterns of ED utilization differed widely across three high-income countries. These differences highlight the varying approaches that our countries take with respect to urgent visits, suggest opportunities for shared learning through international comparisons, and raise important questions about optimal approaches for all countries.

Per the BJOG Author Guidelines, a Research Letter should not include an abstract or subheadings.

Income disparities may affect patients’ care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited. To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities. Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial. Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals. The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted. Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0–3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health. There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

Preoperative anaemia (haemoglobin <12 g/dL) is a risk factor for adverse perioperative outcomes following gynaecological surgery, including an increased risk of blood transfusions, surgical site infections, prolonged hospital stay and hospital readmission.1 Clinical practice guidelines have also identified preoperative anaemia as a quality metric impacting patient safety.2,3 It is imperative that institutions continuously assess performance around this quality indicator and use findings to inform and target quality improvement initiatives. Our objective was to evaluate predictors of anaemia prior to elective hysterectomy for benign indications and identify the presence, if any, of hospitaland surgeonlevel performance variation (Figure 1). We conducted a multicentre, retrospective review of all patients undergoing elective hysterectomy at nine Canadian hospitals (six academic, three community) between July 2016 and December 2020. Patients with a preoperative diagnosis of malignancy or pregnancyrelated complications were excluded. The primary outcome, preoperative anaemia, was defined as a haemoglobin level <12 g/dL nearest to surgery and within 3 months of the procedure. Patient, case and surgeon characteristics for patients with and without anaemia were reported descriptively and bivariate comparisons between the groups were completed. After controlling for surgical complexity factors (e.g. hysterectomy route, uterine weight, presence of endometriosis and/or adhesions, concurrent surgical procedures, and blood loss), linear mixed effects regression was used to assess associations between anaemia status and several prespecified patient (e.g. age, body mass index, previous surgeries, diagnosis at time of surgery), case (e.g. route of hysterectomy, intraoperative findings, uterine weight, concurrent surgical procedures, estimated blood loss) and surgeon variables (e.g. hysterectomy volume, level of training, years in practice, setting of practice – academic or community). For each variable, we reported an adjusted odds ratio (aOR), 95% confidence interval (CI) and Wald test pvalue. To quantify hospitaland surgeonlevel heterogeneity, a median odds ratio (p < s) was calculated for each set of random effects.4 A total of 4557 hysterectomies performed by 113 surgeons at nine hospitals were included, of which 909 patients (19.9%) were found preoperatively to be anaemic. The following factors were significantly associated with preoperative anaemia: a diagnosis of abnormal uterine bleeding (aOR 1.48, 95% CI 1.20– 1.81, p < 0.001); uterine weight in the two uppermost quartiles compared with the first quartile (aOR 2.41, 95% CI 1.71– 3.38, p < 0.001 and aOR 3.52, 95% CI 2.34– 4.50, p < 0.001, respectively); surgeon length of practice >11 years (aOR 1.66, 95% CI 1.29– 2.12, p < 0.001); and community hospital (aOR 2.05, 95% CI 1.44– 2.93, p < 0.001). Additionally, there was considerable variability in preoperative anaemia rates among hospitals (MOR 1.54) and surgeons (MOR 1.29). Specifically, a patient had a 54% higher chance of preoperative anaemia at one randomly selected hospital than at another; and a 29% higher chance of being anaemic if cared for by one surgeon than by another. In this multicentre study of over 4500 hysterectomies, one in five patients were anaemic at the time of their elective procedure. Patients with abnormal uterine bleeding and larger uteri were most likely to have preoperative anaemia, as were patients who had surgery at community sites and/or with surgeons in practice the longest. There was also considerable Accepted: 14 December 2022 | Published Online 15 February 2023

Introduction The aim of our study was to assess the initial impact of COVID-19 on total publicly-funded direct healthcare costs and health services use in two Canadian provinces, Ontario and British Columbia (BC). Methods This retrospective repeated cross-sectional study used population-based administrative datasets, linked within each province, from January 1, 2018 to December 27, 2020. Interrupted time series analysis was used to estimate changes in the level and trends of weekly resource use and costs, with March 16-22, 2020 as the first pandemic week. Also, in each week of 2020, we identified cases with their first positive SARS-CoV-2 test and estimated their healthcare costs until death or December 27, 2020. Results The resources with the largest level declines (95% confidence interval) in use in the first pandemic week compared to the previous week were physician services [Ontario: -43% (-49%,-37%); BC: -24% (-30%,-19%) (both p<0.001)] and emergency department visits [Ontario: -41% (-47%,-35%); BC: -29% (-35%,-23%) (both p<0.001)]. Hospital admissions declined by 27% (-32%,-23%) in Ontario and 21% (-26%,-16%) in BC (both p<0.001). Resource use subsequently rose but did not return to pre-pandemic levels. Only home care and dialysis clinic visits did not significantly decrease compared to pre-pandemic. Costs for COVID-19 cases represented 1.3% and 0.7% of total direct healthcare costs in 2020 in Ontario and BC, respectively. Conclusions Reduced utilization of healthcare services in the overall population outweighed utilization by COVID-19 patients in 2020. Meeting the needs of all patients across all services is essential to maintain resilient healthcare systems.

Background:Chronic lung allograft dysfunction (CLAD) is the major cause of death post-lung transplantation, with acute cellular rejection (ACR) being the biggest contributing risk factor. Although patients are routinely monitored with spirometry, FEV1 is stable or improving in most ACR episodes. In contrast, oscillometry is highly sensitive to respiratory mechanics and shown to track graft injury associated with ACR and its improvement following treatment. We hypothesize that intra-subject variability in oscillometry measurements correlates with ACR and risk of CLAD.Methods:Of 289 bilateral lung recipients enrolled for oscillometry prior to laboratory-based spirometry between December 2017 and March 2020, 230 had ≥ 3 months and 175 had ≥ 6 months of follow-up. While 37 patients developed CLAD, only 29 had oscillometry at time of CLAD onset and were included for analysis. These 29 CLAD patients were time-matched with 129 CLAD-free recipients. We performed multivariable regression to investigate the associations between variance in spirometry/oscillometry and the A-score, a cumulative index of ACR, as our predictor of primary interest. Conditional logistic regression models were built to investigate associations with CLAD.Results:Multivariable regression showed that the A-score was positively associated with the variance in oscillometry measurements. Conditional logistic regression models revealed that higher variance in the oscillometry metrics of ventilatory inhomogeneity, X5, AX, and R5-19, was independently associated with increased risk of CLAD (p < 0.05); no association was found for variance in %predicted FEV1.Conclusion:Oscillometry tracks graft injury and recovery post-transplant. Monitoring with oscillometry could facilitate earlier identification of graft injury, prompting investigation to identify treatable causes and decrease the risk of CLAD.

Background Approximately 20% of patients who are discharged from hospital for an acute exacerbation of COPD (AECOPD) are readmitted within 30 days. To reduce this, it is important both to identify all individuals admitted with AECOPD and to predict those who are at higher risk for readmission. Objectives To develop two clinical prediction models using data available in electronic medical records: 1) identifying patients admitted with AECOPD and 2) predicting 30-day readmission in patients discharged after AECOPD. Methods Two datasets were created using all admissions to General Internal Medicine from 2012 to 2018 at two hospitals: one cohort to identify AECOPD and a second cohort to predict 30-day readmissions. We fit and internally validated models with four algorithms. Results Of the 64,609 admissions, 3,620 (5.6%) were diagnosed with an AECOPD. Of those discharged, 518 (15.4%) had a readmission to hospital within 30 days. For identification of patients with a diagnosis of an AECOPD, the top-performing models were LASSO and a four-variable regression model that consisted of specific medications ordered within the first 72 hours of admission. For 30-day readmission prediction, a two-variable regression model was the top performing model consisting of number of COPD admissions in the previous year and the number of non-COPD admissions in the previous year. Conclusion We generated clinical prediction models to identify AECOPDs during hospitalization and to predict 30-day readmissions after an acute exacerbation from a dataset derived from available EMR data. Further work is needed to improve and externally validate these models.

Objectives: To increase peripheral nerve block (PNB) administration for ankle fracture surgeries (AFSs) at our institution to above 50% by January 1st, 2021. Design: Longitudinal, single-center quality improvement study conducted at a high-volume tertiary care center. Patients: All patients undergoing isolated AFS for unimalleolar, bimalleolar, or trimalleolar ankle fracture from July 2017 to April 2021 were included in this study. Intervention: Interventions implemented to minimize barriers for PNB administration included recruitment and training of expert anesthesiologists in regional anesthesia, procurement of ultrasound machines, implementation of a dedicated block room, and creation of a pamphlet for patients describing multimodal analgesia. Main Outcome Measurement: The primary outcome was the percentage of patients receiving PNB for AFS. Secondary outcomes included hospital length-of-stay, postanesthesia care unit (PACU) and 24-hour postoperative opioid consumption (mean oral morphine equivalent [OME]), proportion of patients not requiring opioid analgesic in PACU, and PACU and 24-hour postoperative nausea/vomiting requiring antiemetic. Results: The PNB and non-PNB groups included 78 and 157 patients, respectively. PNB administration increased from <5% to 53% after implementation of the improvement bundle. Mean PACU and 24-hour opioid analgesic consumption was lower in the PNB group (PACU OME 38.96 mg vs. 55.42 mg, P = 0.001; 24-hour OME 50.83 mg vs. 65.69 mg, P = 0.008). A greater proportion of patients in the PNB group did not require PACU opioids (62.8% vs. 27.4%, P < 0.001). Conclusions: By performing a root cause analysis and implementing a multidisciplinary, patient-centered improvement bundle, we increased PNB administration for AFSs, resulting in reduced postoperative opioid analgesia consumption. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.