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To report the initial safety and effectiveness profile for an anterior shape-changing, modular IOL, Juvene IOL (JIOL), for the treatment of aphakia and presbyopia after removal of the natural crystalline lens due to cataract.2 private practices in Monterrey and Tijuana, Mexico.Exploratory prospective multicenter open-label noncomparative clinical trial.A convenience sample of patients aged 50 to 80 years with planned cataract surgery was recruited to undergo unilateral or bilateral implantation with the JIOL. Patients were required to complete an informed consent and be able to dilate to at least 6.0 mm pharmacologically, be in good overall health, and have no significant eye health history to qualify. Visual acuities, defocus curves, and contrast sensitivity were measured for all patients 12 months postoperatively.51 of 58 eyes completed the 12-month visit. Intraoperative complication rates were extremely low (n = 1; missed base lens tab). The most frequent adverse events (AEs) were prolonged inflammation (N = 6) and cystoid macular edema (N = 4); all AEs were resolved without sequelae by the 12-month visit. The mean monocular logMAR corrected distance visual acuity, distance-corrected intermediate visual acuity, and distance-corrected near visual acuity were 0.01, 0.08, and 0.24, respectively. Defocus testing showed visual acuity20/40 from approximately +1.00 through -2.00 diopters. Binocular implantation (n = 16) provided superior performance over monocular implantation.The JIOL offers a new solution to treat presbyopia, providing clear functional vision performance across a range of distances with an acceptable initial safety profile.

We report the initial six pediatric patients treated with ketamine for benzodiazepine-resistant status epilepticus in an urban, ground-based emergency medical services (EMS) system. Evidence for ketamine as a second-line agent for both adult and pediatric refractory seizure activity in the hospital setting has increased over the past decade. The availability of an inexpensive and familiar second-line prehospital anti-epileptic drug option is extremely desirable. We believe these initial data demonstrate promising seizure control effects without significant respiratory depression, indicating a potential role for ketamine in the EMS treatment of pediatric benzodiazepine-refractory seizures.

Background Treatment of oesophageal cancer is associated with significant morbidity which has an impact on longer term survival. Prehabilitation has been shown to reduce post-operative morbidity and mortality. The aim of this study was to undertake a cost-utility analysis to determine if, based on quality adjusted life-years, prehabilitation should be universally implemented in patients undergoing treatment for oesophageal cancer. Methods Patients with oesophageal cancer who were recruited to a randomised control trial were retrospectively analysed. Three-years follow-up was available for calculating overall survival. Costs were calculated based on network, staging, and treatment algorithms. QALYs were calculated as a matrix cost of treatment, quality of life, and overall survival. Overall survival was calculated from time of diagnosis to death or censorship at three-years follow up. Results Thirty-nine patients were randomised to prehabilitation (n=20, 51%) or standard care (n=19, 49%). The median cost per patient for treatment was £46,770.16 (Inter quartile range (IQR) 41,907.21–58,984.21). The overall cost per patient in the prehabilitation group was lower, £44,382.99 (IQR 42,022.86–54,068.23), when compared with standard care per patient £51,538.07 (IQR41,907.21–68,734.33). The mean survival was 24.7 months in the prehab group compared with 27.7 months in the control group (p=0.523). The cost per-QALY for the prehabilitation group was £24,899.06 compared with £25,781.71 in the standard care group. Conclusions In the setting of a randomised control trial, prehabilitation is clinically effective with observed reductions in total treatment costs and a cheaper cost per QALY.

The purpose of this study was to examine sex-based trends in incidence of elective abdominal aortic aneurysm (AAA), ruptured AAA, ruptured AAA repair and AAA-related mortality.A retrospective analysis of patients presenting with AAA from 2005-2015 was conducted. Rates of elective AAA repair, ruptured AAA, ruptured AAA repair, and mortality were obtained from linking provincial administrative data using medical services insurance billing number. The age-adjusted incidence of elective AAA repair, overall rate of ruptured AAA, ruptured AAA repair, and AAA-related mortality was calculated for each sex based on Canadian census estimates, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends in incidence over time.1986 elective AAA repairs were identified, of which 1098 were repaired open and 898 endovascular AAA repair (EVAR). 570 ruptured AAAs were identified, of which 295 (52%) were repaired: 259 open and 36 EVAR. The proportion of ruptured AAA that was repaired did not change over time (p=0.54). The proportion repairs performed using EVAR increased significantly in both elective (p0.001) and rupture repairs (p0.001). During the study period, 662 patients died of AAA-associated mortality. The average incidence of elective AAA repair in men was 29.3 (95% CI: 27.8 to 30.8) per 100,000 and decreased over time (p=0.04), whereas the average incidence in women was 9.2 [8.3 to 10.0] and stable (p=0.07). The incidence of open elective AAA repair was 10.5 [9.9-11.1] with a decreasing trend over time (p0.001) and EVAR was 9.0 (8.5-9.6) with an increasing trend over time (p0.001). A decreasing trend of overall ruptured AAA (5.4 [5.0-5.9], p0.001), ruptured AAA repair (2.9 [2.5-3.2], p=0.02), and of AAA-related mortality (6.2 [5.8-6.8], p0.001) was found, with consistent trends in both sexes. The incidence of open ruptured AAA repair decreased over time (p=0.001) whereas the incidence of ruptured EVAR remained stable (p=0.23).The incidence of elective AAA repair is decreasing in males but not females, whereas the incidence of rupture has decreased in both sexes. This has translated into reduced incidence of AAA-related mortality. Increased adoption of EVAR for ruptured AAA should continue these trends.

To perform a province-wide evaluation of adult major traumas and determine the proportion of patients who met clinical and/or anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA). This is a retrospective analysis of all major trauma patients (age > 16) presenting to the sole adult level 1 trauma centre in Nova Scotia over a 5-year period (2012–2017). Data were collected from the Nova Scotia Trauma Registry and medical charts. We identified potential REBOA candidates using either: (1) clinical criteria (primary survey, Focused Assessment with Sonography for Trauma, pelvic/chest X-ray); or (2) anatomical criteria (ICD-10-CA codes). Potential candidates with persistent hypotension were considered true REBOA candidates. Overall 2885 patients were included in the analysis, of whom 248 (8.6%) patients were in shock (including 106 transfer patients) and had their charts reviewed. A total of 137 patients met clinical criteria for REBOA; 44 (1.5%) had persistent hypotension 10–20 min into resuscitation and were considered true REBOA candidates. There were 59 patients who met anatomical criteria for REBOA, of whom 15 (0.5%) patients had persistent hypotension and were true REBOA candidates. The 15 REBOA candidates based on anatomical criteria also met clinical criteria for REBOA. In this registry-based retrospective analysis, 1.5% of adult major trauma patients Nova Scotia were REBOA candidates based on resuscitative clinical presentation, while 0.5% were candidates based on post hoc anatomical injury patterns. Our findings suggest that using clinical findings and bedside imaging modalities as criteria may overestimate the number of candidates for REBOA.

Ruptured abdominal aortic aneurysms (RAAAs) are surgical emergencies that require immediate and expert treatment. It has been unclear whether presentation during evenings and weekends, when "on call" teams are primarily responsible for patient care, is associated with worse outcomes. Our objective was to evaluate the outcomes of patients presenting with RAAAs after-hours vs during the workday.A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients who had presented to the hospital with RAAAs during the workday (Monday through Friday, 6 am to 6 pm) were compared with those who had presented after-hours (6 pm to 6 am during the week and on weekends). The baseline and operative characteristics were identified for all patients through the available databases and a review of the medical records. Mortality before surgery, 30-day mortality, and operative mortality were compared between groups using multivariable logistic regression, adjusting for factors clinically significant on univariable analysis.A total of 390 patients with RAAAs were identified from 2005 to 2015, of whom 205 (53%) had presented during the workday and 185 (47%) after-hours. The overall chance of survival (OCS) was 45% overall, 49% if admitted to hospital, and 64% if surgery had been performed. During the workday, the OCS was 43% overall, 48% if admitted to hospital, and 67% if surgery had been performed. After-hours, the OCS was 46% overall, 49% if admitted to hospital, and 61% if surgery had been performed. Mortality before surgery was increased for patients who had presented to the hospital during the workday compared with after-hours (36% vs 26%; P = .04). The 30-day mortality (57% vs 54%; P = .62), rates of operative management (63% vs 72%; P = .06), and operative mortality (33% vs 39%; P = .33) were similar between the workday and after-hours groups (57% vs 54%; P = .06). After adjusting for significant clinical variables, the patients who had presented with RAAAs after-hours had had a similar odds of dying before surgery (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.41-1.03), operative management (OR, 1.47; 95% CI, 0.93-2.31), 30-day mortality (OR, 0.98; 95% CI, 0.63-1.51), and operative mortality (OR, 1.33; 95% CI, 0.78-2.26). In the subgroup of patients presenting to a hospital with endovascular capabilities, patients presenting after-hours had had similar odds of 30-day mortality (OR, 1.07; 95% CI, 0.57-2.02), and operative mortality (OR, 1.14; 95% CI, 0.58-2.23).We found that patients presenting to the hospital with RAAAs after-hours did not have increased adjusted odds of mortality before surgery, operative management, 30-day mortality, or operative mortality.

Aim Oesophageal perforation is a relatively rare surgical condition associated with a high mortality risk. Currently there is no clear consensus on a superior approach to treating this condition, and the rarity of oesophageal perforation has led to a great variability in treatment between centres. This study aims to report the experiences of a tertiary referral centre over 12 years. Methods We collected data on patients presenting with oesophageal perforation at a tertiary referral centre from 2009–2021 (n=83). Demographics, presenting symptoms, length of stay and complications were collected retrospectively using the electronic patient record. Results The most common cause of perforation in our dataset was Boerhaave's (50.6%), followed by Iatrogenic (37.4%); other causes included trauma, malignancy and foreign body ingestion. Typical signs/symptoms included chest pain (54.2%), vomiting (48.2%), and pleural effusion (42.2%). For all aetiologies, operative intervention was required in 49.4% of patients. Patients presenting with Boerhaave's were more likely to be treated surgically (73.8%). Of these, thoracotomy/laparotomy with t-tube repair was the most common procedure performed (59.5%). The 30 day and 90 day mortality rates were 16.9% and 21.6% respectively. The median length of hospital stay was 40 days. Conclusion Here we show the experience from a high intake tertiary referral centre over 12 years. Our data confirms the severity of oesophageal perforation and its association with prolonged hospital stay and mortality. Further collaboration with other centres is needed to understand more about this condition.

Aim Oesophageal perforation is a challenging condition associated with high mortality and morbidity. There is a lack of consensus regarding the optimal treatment strategy, when and whom to operate on. The aim of this study is to identify the optimal morbidity and mortality risk prediction tool for patients with oesophageal perforation. Methods We compared and validated commonly used risk prediction models, including the Pittsburgh Severity Score (PSS), the National Emergency Laparotomy Audit score (NELA score), the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM), and the Surgical Outcome Risk Tool (SORT) using a dataset of 83 patients ranging from 2009 to 2021. The ability to predict morbidity was assessed using the comprehensive complication index (CCI). The CCI was calculated for both operative and non-operative cohorts. Results Of the scores assessed, NELA showed the most robust predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.812, 0.8602, 0.8302, respectively). The PSS also showed significant predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.792, 0.856, 0.813 respectively). Furthermore, NELA had the strongest correlation between score and CCI (rs 0.644 p Conclusion Despite not being validated for oesophageal pathology, NELA appears to be the optimum scoring model to predict mortality and morbidity for this patient population. This is the first study to compare the efficacy of different risk prediction models in oesophageal perforations and could be used to inform shared decision making and peri-operative outcomes. Further large-scale validation of risk prediction tools is required to corroborate these findings.

Aim Oesophageal perforation is a rare surgical condition with high mortality. Boerhaave's syndrome (BS) may be associated with worse outcomes due to the degree of mediastinal contamination when compared to ‘clean’ iatrogenic perforations. This study aims to assess the differences in treatment and outcome between these two groups. Methods Data was collected from a tertiary centre from 2009–2021 (n=73, 42 BS, 31 Iatrogenic). Data was collected retrospectively using the electronic patient record. Complications were quantified using the comprehensive complication index (CCI). Univariate analysis was used to determine statistical significance. Results BS had a higher 30-day mortality compared to iatrogenic perforations (21.4% vs 3.2% p=0.025), however this was no longer significant at 90 days and 1 year (21.4% vs 16.1% p=0.57, 21.4% vs 19.4% p=0.83). Iatrogenic perforations were more likely to be managed non-operatively (73.8% vs 25.8% p Conclusion Whilst CCI and 30-day mortality was higher in Boerhaave's there was no difference in 90-day and 1 year mortality suggesting that long-term survival is not dictated by aetiology of the perforation. Most of the iatrogenic perforation were managed non-operatively which raises the question whether iatrogenic perforation should be managed more aggressively.

Centralization of vascular surgery care for Ruptured Abdominal Aortic Aneurysms (RAAAs) to high volume tertiary centers may hinder access to timely surgical intervention for patients in remote areas. The objective of this study was to determine the association between distance from vascular care and mortality from RAAA in the province of Nova Scotia, Canada.A retrospective cohort study of all RAAAs in Nova Scotia between 2005 and 2015 was performed through linkage of administrative databases. Patients were divided into groups by estimated travel time from their place of residence to the tertiary center (1 hour and ≥1 hour) using geographic information software. Baseline and operative characteristics were identified for all patients through available databases and completed through chart review. Mortality at home, during transfer to the vascular center and overall 30-day mortality were compared between groups using t-test and chi-squared test, as appropriate. Multivariable logistic regression analysis was used to calculate the independent effect of travel time on survival outcomes.A total of 567 patients with RAAA were identified from 2005-2015, of which 250 (44%) resided1 hour travel time to the tertiary center and 317 (56%) resided ≥1 hour. On multivariable analysis, travel time ≥1 hour from vascular care was an independent predictor of mortality at home (OR 1.68, 95% CI 1.07-2.63, p=0.02), mortality prior to operation (OR 2.64, 95% CI 1.81-3.83, p0.001), and overall 30-day mortality (OR 1.61, 95% CI 1.10-2.37, p=0.02). In patients who received an operation (n=294), there was no association between increased travel time and mortality (OR 1.02, 95% CI 0.60-1.73, p=0.94).Travel time ≥1 hour to the tertiary center is associated with significantly higher mortality from ruptured AAA. However, there was no difference in overall chance of survival between groups for patients that underwent AAA repair. Therefore, strategies to facilitate early detection and timely transfer to a vascular surgery center may improve outcomes for patients with RAAA.

Objective The objective of this study was to evaluate the safety and effectiveness of single ProGlide use per bilateral access site for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. Methods A retrospective cohort study was performed for all elective percutaneous EVARs from November 2015 to December 2017 at the QEII Health Sciences Centre (Halifax, Nova Scotia, Canada). Exposure of interest was number of ProGlides used per access site, dichotomized into bilateral single ProGlide closure vs nonsingle ProGlide closure on at least one femoral arteriotomy. Outcomes included Valve Academic Research Consortium (VARC)-2 and Bleeding Academic Research Consortium (BARC) criteria. Groups were compared with Fisher exact test, analysis of variance, or Wilcoxon rank sum, as appropriate. Logistic regression was used to compare the effect of single ProGlide use on VARC-2 and BARC criteria. Results A total of 131 cases were included, of which 116 had bilateral single ProGlide use for access closure. Baseline characteristics including comorbidities and smoking status were compared between groups. Groups were similar for all characteristics except smoking status, with an increased proportion of former smokers in the nonsingle ProGlide group. There were 119 (90.8%) patients who had single ProGlide use on the right femoral artery and 121 (92.4%) on the left; 16 (12.2%) patients had ProGlide deployment issues. Median maximal right and left femoral sheath diameters were 16F (interquartile range [IQR], 16F-18F) and 14F (IQR, 14F-16F), respectively. Median length of stay was 1 day (IQR, 1-1 day). VARC-2 criteria occurred in 8 of 131 (6.11%) patients, 6 of 116 (5.17%) with bilateral single ProGlides and 2 of 15 (13.3%) with nonsingle ProGlides. BARC criteria occurred in 6 of 131 (4.58%) patients, 5 of 116 (4.31%) with bilateral single ProGlides and 1 of 15 (6.67%) with nonsingle ProGlides. Single ProGlide use was not associated with a difference in VARC-2 (odds ratio, 0.35; 95% confidence interval, 0.64-1.94) or BARC (odds ratio, 0.63; 95% confidence interval, 0.07-6.79) criteria. No patients developed pseudoaneurysms or required repeated intervention for bleeding. Conclusions Single ProGlide use per vascular access site in patients undergoing EVAR is a safe and effective method for access closure with sheath diameters up to and including 16F.

This article contributes to this discussion in three ways. First, it undertakes the first academic case study of the Loulo mine in Mali. Utilizing a variety of sources, including United States Securities and Exchange Commission (SEC) Filings, Canadian National Instrument 43-101 filings relating to Mineral Disclosure in Canada, annual and quarterly company reports, non-governmental organization (NGO) and human rights reports, and other secondary literature, this article presents a broad overview of the Loulo mine. In doing so, it challenges the corporate narrative that the Loulo mine has been a laudable contributor to sustainable development in Mali. This article contributes to this discussion in three ways. First, it undertakes the first academic case study of the Loulo mine in Mali. Utilizing a variety of sources, including United States Securities and Exchange Commission (SEC) Filings, Canadian National Instrument 43-101 filings relating to Mineral Disclosure in Canada, annual and quarterly company reports, non-governmental organization (NGO) and human rights reports, and other secondary literature, this article presents a broad overview of the Loulo mine. In doing so, it challenges the corporate narrative that the Loulo mine has been a laudable contributor to sustainable development in Mali.

Background Oesophageal perforation is a challenging surgical condition associated with high mortality and morbidity. There is a lack of consensus regarding the optimal treatment strategy, when and whom to operate on. Treatment options include primary repair, t-tube repair, emergency oesophagectomy, endoscopic therapy, and palliation. Whilst many risk prediction models exist, the only specific score to predict mortality in oesophageal perforations is the Pittsburgh Severity Score (PSS). However, there is limited evidence on its validity and even less literature to predict short and long-term morbidity in these patients. Methods We compared and validated commonly used risk prediction models, including the PSS, the National Emergency Laparotomy Audit score (NELA score), the Portsmouth Physiological and Operatic Severity Score for the enumeration of Mortality (P-POSSUM), and the Surgical Outcome Risk Tool (SORT) using a dataset of 83 patients ranging from 2009 to 2021. The power to predict mortality and morbidity was assessed using the comprehensive complication index (CCI). The CCI was calculated using complications for both operative and non-operative cohorts. Results Of the scores assessed, NELA showed the most robust predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.812, 0.8602, 0.8302, respectively). The PSS also showed significant predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.792, 0.856, 0.813 respectively). Furthermore, NELA had the strongest correlation between score and CCI (rs 0.644 p Conclusions Despite not being validated for oesophageal pathology, NELA appears to be the optimum scoring model to predict mortality and morbidity for this patient population. This is the first study to compare the efficacy of different risk prediction models in oesophageal perforations and could be used to inform shared decision making and peri-operative outcomes. Further large-scale validation of risk prediction tools is required to corroborate these findings.