Medicine and Health Sciences Commons^™

About Dying And Death: Thanatology's Place In Medical Curriculum, Jill Dombroski

Electronic Thesis and Dissertation Repository

This study explored how healthcare providers engage in advance care planning and end-of-life care conversations. The research explored what shapes their understanding and the extent to which concepts from thanatology they intuitively bring in, explicitly bring in, and maybe fail to recognize. To achieve this, constructivist grounded theory (CGT) methodology guided the design, data collection, analysis, and interpretation of the findings, which allowed for iteration across interviews and analysis with existing theories and data in the literature. The CGT design encouraged further engagement with the literature in an ongoing iterative fashion as well as with the analysis of the data. …

Malperfusion Syndrome In The Setting Of Type A Aortic Dissection, Karama Yaslam Karama Bayamin

Electronic Thesis and Dissertation Repository

Background: Acute Type A aortic dissection (TAAD) patients who experience malperfusion syndrome (MPS) are at the greatest risk of major morbidity and mortality. However, the appropriate timing for open proximal aortic repair in the presence of MPS is still uncertain due to variations in clinical manifestations and diverse treatment approaches.

Methods: We conducted a comprehensive literature review to understand the importance of MPS in the setting of TAAD. Then, we conducted a national survey to understand the perception of cardiovascular surgeons across Canada and their approach for those patients. Furthermore, we performed a retrospective analysis of our local data to …

The Effect Of Kidney Preservation At 10°C With Hemopure And Hydrogen Sulfide Donor, Sodium Thiosulfate, In A Syngeneic Model Of Rat Renal Transplantation, Maria Abou Taka

Electronic Thesis and Dissertation Repository

Kidney transplantation is preferred for patients with end-stage renal disease. The current gold standard for preserving kidneys is static cold storage (SCS) at 4°C in University of Wisconsin (UW) solution. However, SCS contributes to ischemia-reperfusion injury (IRI), which involves cell death and inflammation. Our group showed that SCS of kidneys with hydrogen sulfide donors, like sodium thiosulfate (STS), that reduce tissue injury enhanced kidney survival. Though, there is still a risk of cold renal IRI at 4°C. Recent evidence suggests that preserving organs at 10°C enhanced graft function and survival. Therefore, this thesis will evaluate the effect of 10°C kidney …

Development Of An On-Call Assessment Tool For Competency-Based Surgical Training, Eric C. Mitchell

Electronic Thesis and Dissertation Repository

Introduction: A central tenet of competency-based medical education is formative assessment of trainees. There are no assessments examining resident competence on-call, despite this being a significant component of resident training and characterized by less supervision compared to daytime.

Methods: A national survey was conducted to evaluate the state of assessment in Canadian Plastic and Reconstructive Surgery programs. An on-call assessment tool was developed based on a consensus group and was piloted over six months. Validity of the tool was examined through qualitative and quantitative methods.

Results: There were 63 tools completed across ten residents and seven staff physicians. Tool reliability …

Comparison Of Hip Navigation System Accuracy In Direct Anterior Approach, Jeremy Loh

Electronic Thesis and Dissertation Repository

Introduction

Malposition of the acetabular component has been thought to have an influence on increasing increase the risk instability, impingement, and ultimately revision surgery. Hip navigation technology has been developed to provide the surgeon with real time intraoperative metrics to make critical decisions in implant placement. The goal of this study was to compare the accuracy of acetabular component positioning in direct anterior approach hip replacements using conventional fluoroscopy only technique, fluoroscopic image dependent navigation, and imageless navigation.

Methods

A retrospective data collection and prospective analysis was conducted for this study. After sample size calculations, fifty patients were collected for …

A Long-Term Follow-Up Of The Stability Study: Multicenter Rct Comparing Anterior Cruciate Ligament Reconstruction With And Without Lateral Extra-Articular Tenodesis In Individuals At High Risk Of Graft Failure, Katelyn M. Inch

Electronic Thesis and Dissertation Repository

One hundred and ninety-six patients at the Fowler Kennedy Sport Medicine Clinic (FKSMC) undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) were randomized as part of the multi-center STABILITY study to receive either an isolated ACLR or ACLR with a lateral extra-articular tenodesis (LET). The STABILITY study followed these patients up to two years postoperative, and a long-term follow-up protocol was initiated afterwards. Eighty-two patients from this center were seen at three, five and seven years postoperative as part of a long-term follow-up. Our primary outcome was a composite outcome of instability and graft failure. Secondary outcomes included patient-reported outcome measures …

Total Hip Arthroplasty In Young Patients, Aaron G. Chen

Electronic Thesis and Dissertation Repository

Total hip arthroplasty (THA) is the gold standard in treatment of hip arthritis yet is often avoided in young patients due to concerns of inferior survivorship. We aim to explore the role of THA in young patients and assess whether these historical concerns are valid in contemporary THA by presenting the results of: (1) a systematic review and meta-analysis of the current literature, (2) a retrospective database review, and (3) a retrospective population-based study. We found excellent long-term survivorship with modern THA in young patients, demonstrating greater than 90% revision-free survival up to 15 years. Factors that may increase risk …

The Molecular Landscape Of Early-Stage Breast Cancer With Lymph Node Metastasis, Farhad Ghasemi

Electronic Thesis and Dissertation Repository

Axillary lymph nodes (ALNs) are the primary site of metastasis in breast cancer, and their involvement has implications in disease staging, prognostication, and treatment decisions. A non-invasive modality of assessing the risk of ALN metastasis can improve care in patients with early-stage breast cancer by omitting the morbidity and costs associated with axillary surgery.

This thesis explores the molecular landscape of early-stage breast cancers with ALN metastasis and shows the potential of tumour molecular signatures in predicting ALN involvement. After a systematic review of the literature, we use data from The Cancer Genome Atlas (TCGA) to develop molecular signatures correlated …

Feasibility And Clinical Value Of 3-Dimensional Myocardial Deformation Analysis By Computed Tomography In Transcatheter Aortic Valve Replacement Patients, Mohamad Rabbani

Electronic Thesis and Dissertation Repository

Purpose: Multi-phase computed tomography angiography (CTA) for the pre-procedural planning of TAVR presents a unique opportunity to assess 3D myocardial biomechanics. This study aimed to assess the feasibility and predictive utility of 3D myocardial deformation analysis (3D-MDA) based principal strain to predict heart failure or death following TAVR using pre-procedural, multi-phase computed tomography angiography (CTA) datasets.

Methods: Two hundred and five patients undergoing pre-TAVR multi-phase gated CTA followed by successful TAVR were retrospectively identified. Whole heart 3D mesh chamber models were generated followed by 3D-MDA of the left ventricle (LV) to determine global LV minimum principal strain (minPS) for endocardial, …

Spin And Distortion In Surgical Trials, Andrea Mataruga

Electronic Thesis and Dissertation Repository

Research problem: Randomized controlled trials (RCTs) are essential; however, their validity can be threatened through distortion or spin. This study quantifies publication bias and distorted outcome reporting.

Methodology: All surgical RCTs registered on ClinicalTrials.gov from 1997-2017 were identified and a sample was obtained through random and intentional selection. Failure to publish (proportion of studies that remain unpublished), outcome distortion (changing intended outcomes), and spin (distorted presentation) were explored. Comparisons were made for positive versus negative studies and for high-income (HICs) versus low-middle income countries (LMICs).

Results: In total, 13,761 RCTs were registered (median enrollment size = 96, 94% from …

4dct Analysis Of In-Vivo Carpal Kinematics During Fem, Manisha R. Mistry

Electronic Thesis and Dissertation Repository

A consensus, detailed understanding of carpal kinematics remains elusive. 4-dimensional CT (4DCT) is a validated modality capable of accurately studying in-vivokinematic motion. The objective of this work is to quantify normal, in-vivo kinematic motion of the carpus through a flexion-extension arc of motion using 4DCT. Ten healthy, un-injured volunteers underwent a 4DCT scanning protocol through a complete arc of flexion-extension motion. Kinematic changes in motion were quantified using helical axis motion data for each carpal bone. Helical axes were compared between bones and statistical analysis performed using repeated-measures ANOVA to identify difference in kinematic motion between bones (p<0.05). The carpus can be divided into four main kinematic blocks: the distal carpal block, the proximal carpal block and individual scaphoid and trapezial blocks. This work supports an additional segmentation of the trapezium from the distal carpal row, which suggests some modulation between the scaphoid and distal carpal row.

Addressing Bias In Non-Experimental Studies Assessing Treatment Outcomes In Prostate Cancer, David E. Guy

Electronic Thesis and Dissertation Repository

We evaluated the ability of matching techniques to balance baseline characteristics between treatment groups using non-experimental data. We identified a set of balance diagnostics that assessed key differences in baseline covariates with potential for confounding. These diagnostics were used in a novel systematic approach to developing and evaluating models for use in propensity score matching that optimized balance and data retention. We then compared the performance of propensity score and coarsened exact matching strategies in optimizing balance and data retention, using non-experimental data from a pan-Canadian prostate cancer database. Both matching techniques balanced baseline covariates adequately and retained approximately 70% …

Pleurodesis Using Hypertonic Glucose Administration To Treat Post-Operative Air Leaks Following Lung Resection Surgery (Plug): Phase I Trial, Mehdi Qiabi

Electronic Thesis and Dissertation Repository

Introduction: Pulmonary air leaks from unhealed lung tissue are one of the most common complications after lung surgery. This adverse event leads to a delay in chest tube removal, prolonged pain, increased infections, prolonged hospital stay, and increased costs to the health care system. Objective: To define the most appropriate safe dose of dextrose 50% (D50) to seal air leaks in patients that have undergone lung resection surgery. Primary outcome was the occurrence of any adverse event. Methods: Prospective, single-arm, single-center, rule-based escalation traditional 3+3 design phase I trial where patients with an active air leak on …

Surgical Residency Workload, Perceptions And Educational Value: Implications For Competency- Based Medical Education, Eric Walser

Electronic Thesis and Dissertation Repository

Introduction: Surgical training has transitioned to competency-based medical education. There is incomplete understanding of current resident workload and how workload is perceived by trainees and faculty.

Methods: A prospective time-motion study was conducted in a Canadian general surgery training program. A web-based survey was used to compare observational data with faculty and learner perceptions of actual and ideal resident workloads and the educational value of workload components.

Results: 54 clinical periods were assessed (662.8 hours, 6375 individual events). 39.7% of time was spent on direct patient care, 33.2% on indirect patient care and 7.5% on education, including

Conclusion: Curriculum changes …

In Vitro Analyses Of The Contributions Of The Hip Capsule To Joint Biomechanics, Emma Donnelly

Electronic Thesis and Dissertation Repository

Optimal management of the hip capsule during arthroscopic surgery has not been established. The impact of incisions made to the capsule during minimally invasive procedures on joint biomechanics, and whether repair provides any benefit, continue to be debated. The effectiveness of capsular repair to restore native kinematics may be insufficient. Therefore, a better understanding of joint behavior during various capsule conditions is needed. A new robotic system was used to analyze the effect of progressive capsulotomy incision and repairs on the behavior of a normal hip within range of motion (ROM) limits with respect to the intact joint. Complete repairs …

Assessment Of Landing Biomechanics And Rehabilitation After Anterior Cruciate Ligament Reconstruction, Sheila S. Gagnon

Electronic Thesis and Dissertation Repository

Aberrant landing biomechanics increase the risk of anterior cruciate ligament (ACL) injury and are a focus of rehabilitation after ACL reconstruction. The purpose of the present thesis was to develop and evaluate methods of assessing landing mechanics and investigate the effects of different rehabilitation strategies after ACL reconstruction. Three studies were conducted. The first study used a Delphi process to develop the content of a Clinician-Rated Drop Vertical Jump Scale to evaluate jump landing mechanics during rehabilitation after ACL reconstruction. Twenty experts participated in four rounds of questioning, resulting in 92% agreement for knee valgus collapse, lateral trunk lean, insufficient …

The Examination Of Expectations In Day-Surgery Patients And The Development Of A Patient Satisfaction Questionnaire For Day-Surgery Patients, Tishara M. Wijayanayaka

Electronic Thesis and Dissertation Repository

Patient satisfaction has become a growing area of study within health care. Existing hospital- wide satisfaction tools don’t provide the specificity that various departments require to truly get a sense of where they stand in terms of patient satisfaction. Further, many of these tools fail to consider an important component associated with satisfaction, patient expectations. Currently, there is no patient satisfaction tool specific to adult day-surgery patients that has been developed through a careful exploration of patient expectations. In this qualitative study, we conducted a series of semi-structured interviews on patients undergoing outpatient surgery to explore expectations. We performed a …

Ultrasound-Guided Resuscitation In Open Aortic Surgery - The Aortus Trial, John H. Landau

Electronic Thesis and Dissertation Repository

Introduction: Major abdominal aortic surgery requires significant fluid resuscitation in the post-operative phase. Patients are at significant risk of perioperative morbidity and mortality which can be affected by the approach to post-operative fluid resuscitation. Point of care ultrasonography (POCUS) has evolved as a tool to perform whole-body assessments at the bedside to augment the physical exam and guide the resuscitation of the critically ill. This study will aim to explore the value of rigorous goal-directed resuscitation in aortic surgery using point of care ultrasonography (POCUS).

Methods: In an open-label, randomized, feasibility trial we enrolled 17 patients to receive resuscitation guided …

Navigation And Patient Specific Instrumentation In Shoulder Arthroplasty, Joseph Cavanagh

Electronic Thesis and Dissertation Repository

The humeral head osteotomy influences shoulder arthroplasty component height, version and neck shaft angle and therefore outcomes. The purpose of this study is to develop and utilize navigation to execute the osteotomy.

3D printed models were used to develop a navigation technique, and then to execute planned osteotomies. Free hand, fixed angle guide, patient specific guides, and real time navigation osteotomies were completed. The height, neck shaft angle and version were recorded. Also collected, were the planes of the guides once they were placed.

Navigation had significantly less error from the planned osteotomy in neck shaft angle versus all other …

Quadriceps Muscle Layer Thickness In Kidney Transplant Recipients: A Potential Measure Of Frailty And Sarcopenia, Max A. Levine

Electronic Thesis and Dissertation Repository

Introduction: Frailty and sarcopenia are related concepts that can impact outcomes after kidney transplantation. Measures of these two entities and new/emerging metrics of sarcopenia remain to be validated.

Methods: In a prospective cohort study, kidney and kidney-pancreas transplant recipients were assessed at the time of transplant with the Physical Frailty Phenotype, bioimpedance analysis, quadriceps muscle layer thickness (QMLT), and CT. The impact on length of stay (LOS), prediction of frailty/sarcopenia, and relative concordance of metrics were analyzed.

Results: Low QMLT, a putative surrogate of sarcopenia/frailty, was more frequently associated with longer LOS (>14 days) after transplant. Additionally, QMLT was …

The Of Application Of 3d-Printing To Lumbar Spine Surgery, Andrew J. Kanawati

Electronic Thesis and Dissertation Repository

Rapid prototyping refers to the manufacturing process in which a three-dimensional (3D) digital model can be transformed into a physical model by layering material in the shape of successive cross sections atop of previously layers. Rapid prototyping has been increasing in popularity in the field of medicine and surgery due to the ability to personalize various aspects of patient care. The thesis will explore the use of rapid prototyping in lumbar spine surgery, aim to quantify the accuracy of medical imaging when relating to imaged structures and their corresponding models produced by rapid prototyping, and determine if complex patient-specific guides …

Feasibility Of Post-Operative Mobile Health Monitoring Among Colorectal Surgery Patients, Tanya Kuper

Electronic Thesis and Dissertation Repository

Post-operative readmission following colorectal surgery is a common and costly occurrence. Remote health monitoring via mobile applications has the potential to reduce post-operative readmissions by early identification of complications. This intervention depends on patient acceptance and compliance with available technology. The feasibility of home monitoring using automated daily surveys and wound photo uploads, delivered via a mobile health application, was tested in the immediate post-operative period after colorectal surgery. Patient compliance, the association between generated alerts and readmissions, and patient satisfaction were measured. Patient satisfaction was high; 80.5% of patients reported that they felt safer going home knowing that they …

The Standardization Of Outpatient Procedure (Stop) Narcotics: A Prospective Non-Inferiority Study To Reduce Opioid Use In Outpatient General Surgical Procedures, Luke B. Hartford

Electronic Thesis and Dissertation Repository

Surgeons play a significant role in the opioid crisis. A standardized, multipronged analgesia protocol was implemented with the objective of providing adequate analgesia while reducing opioids after outpatient breast and anorectal surgery.

A prospective, pre- and post-intervention study was designed to demonstrate non-inferiority for patient-reported post-operative pain. The intervention included patient and provider education, and multimodal perioperative analgesic strategies including opioid rescue prescriptions.

We evaluated 266 procedures. After implementation of the STOP Narcotics protocol, average post-operative pain scores in the post-intervention groups was non-inferior compared to the pre-intervention groups [(2.0 vs 2.1/10, p = 0.40, breast procedures) and (2.8 vs …

Academic Center Tiered Operating Room Strategy (Action): Comparing A High Efficiency Or To The Conventional Or, Moaz Bin Yunus Chohan

Electronic Thesis and Dissertation Repository

Canadian healthcare system is under immense economic pressure. In an attempt to resolve the problem, outpatient surgical services were offered to patients presenting with orthopaedic surgical complaints. An observational cohort study was carried out, comparing the conventional surgical setup to the newly designed high-efficiency setup that provided similar care, with a significantly lower operating cost. A total of 200 patients were enrolled in the study. Standardized and unstandardized questionnaires were used to evaluate pre-operative and post-operative patient data that reflected quality of life outcomes. Data was collected at enrolment and during post-operative follow-ups of up to 6 months. Results indicate …

Interpreting Patient Reported Outcomes In Orthopaedic Surgery: A Systematic Review, Shgufta Docter, Zina Fathalla, Michael Lukacs, Michaela Khan, Morgan Jennings, Shu-Hsuan Liu, Dong Zi, Dianne Bryant

Western Research Forum

Background: Reporting methods of patient reported outcome measures (PROMs) vary in orthopaedic surgery literature. While most studies report statistical significance, the interpretation of results would be improved if authors reported confidence intervals (CIs), the minimally clinically important difference (MCID), and number needed to treat (NNT).

Objective: To assess the quality and interpretability of reporting the results of PROMs. To evaluate reporting, we will assess the proportion of studies that reported (1) 95% CIs, (2) MCID, and (3) NNT. To evaluate interpretation, we will assess the proportion of studies that discussed results using the MCID or the effect sizes and how …

Ultra-High Field Magnetic Resonance Imaging For Stereotactic Neurosurgery, Jonathan Lau

Electronic Thesis and Dissertation Repository

Stereotactic neurosurgery is a subspecialty within neurosurgery concerned with accurate targeting of brain structures. Deep brain stimulation (DBS) is a specific type of stereotaxy in which electrodes are implanted in deep brain structures. It has proven therapeutic efficacy in Parkinson’s disease and Essential Tremor, but with an expanding number of indications under evaluation including Alzheimer’s disease, depression, epilepsy, and obesity, many more Canadians with chronic health conditions may benefit. Accurate surgical targeting is crucial with millimeter deviations resulting in unwanted side effects including muscle contractions, or worse, vessel injury. Lack of adequate visualization of surgical targets with conventional lower field …

Aggregate Morbidity And Mortality Of Defunctioning Loop Ileostomy Fro Formation To Closure: A Large Population Retrospective Cohort Analysis, Mei Yang

Electronic Thesis and Dissertation Repository

There is evidence that defunctioning loop ileostomies (DLIs) are associated with decreased risk of clinically significant anastomotic leaks, but at what cost? This population-based retrospective cohort study used administrative data to investigate differences in outcomes between patients undergoing low anterior resection with and without DLIs. We included all adult patients undergoing low anterior resection from 2002 to 2014 and identified outcomes within 30-days to 2-year of the index surgery. Outcomes included hospital readmission, reoperation, major complications, mortality, bleeding, and ileostomy reversal. DLIs were associated with significantly worse outcomes after low anterior resection, including increased risk of major complication, acute kidney …

Cost Effectiveness Of Bilateral Prophylactic Mastectomy With And Without Different Breast Reconstruction Techniques Versus Screening In Women With High Risk Of Breast Cancer In The Canadian Province Of Ontario, Badria Aljohani

Electronic Thesis and Dissertation Repository

We aimed to investigate the cost-effectiveness of bilateral prophylactic mastectomy (BPM) with and without different reconstruction for the purpose of determining which strategies represent value for money. We developed a decision analytic model to project the lifetime clinical and economic consequences of different strategies. The decision model was parameterized using 10-year follow up and cost data from Ontario administrative health databases and Ontario Cancer registry. Compared to the organized screening-based strategy, surgical strategies ranged from being more effective and cost-saving and up to being associated with an incremental cost effectiveness ratio (ICER) of $63,010 per quality-adjusted life year (QALY) gained, …

Oncoplastic Surgery: Is It Time To Change? From Innovation To Adoption Using Mentorship Program, Eman Khayat

Electronic Thesis and Dissertation Repository

Oncoplastic surgery is considered the standard of care for breast cancer therapy in numerous Western World countries, particularly in Europe. Despite the advancement of knowledge, Canada still lags in adoption of oncoplasty into the standard surgical practice. In our study, a mentorship program was used to introduce oncoplastic surgery to practicing breast surgeons at LHSC. The change in perception and adoption of oncoplastic surgery were evaluated using semi-structured interviews, before and after the intervention, by qualitative thematic analysis method. Mentorship program was validated as a superior method of learning new surgical techniques by practicing surgeons, demonstrating acceptance of different levels …

Perioperative Gait Analysis After Total Hip Arthroplasty: Does Outpatient Surgery Compromise Patient Outcomes?, Bryn O. Zomar, Susan W. Hunter, Dianne Bryant, Brent A. Lanting, James L. Howard

Western Research Forum

Background: There has been a continuing trend towards decreasing the length of hospital stay for patients undergoing total hip arthroplasty (THA). Outpatient procedures, discharging patients on the same day as surgery, have now become possible yet little research has been done to examine the impact this might have on patients during early recovery. We aimed to investigate the impact of discharge time on gait and patient-reported outcomes in the early post-operative period.

Methods: We measured gait velocity, stride length, single-limb support and single-limb support symmetry preoperatively, at discharge from the hospital, and two-, six- and 12-weeks postoperatively. Participants also completed …