Sean A. Kennedy

Effects of induced monocular blur versus anisometropic amblyopia on saccades, reaching, and eye-hand coordination.

PURPOSE We previously showed that anisometropic amblyopia affects the programming and execution of saccades and reaching movements. In our current study, we investigated whether these amblyopia-related changes simply are due to a reduction in visual acuity alone by inducing artificial blur in one eye in visually-normal participants. METHODS Twelve visually-normal participants performed saccades and reach-to-touch movements to targets presented on a computer screen during binocular and monocular viewing. A contact lens was used to blur the vision of one eye to a mean acuity level of 20/50. Saccades and reaching kinematics were compared before blur, immediately after blur, and 5 hours after blur was induced. The 5 hours after blur kinematic data from visually-normal participants also were compared to those from 12 patients with anisometropic amblyopia who had comparable acuity in the amblyopic eye. RESULTS Primary saccades (latency, amplitude, peak velocity), reaching movements (reaction time, movement time, peak acceleration, duration of the acceleration phase), and eye-hand coordination (saccade-to-reach planning interval, saccade-to-reach peak velocity interval) were not affected by induced monocular blur in visually-normal participants, either immediately or 5 hours after blur. Compared to visually-normal participants after 5 hours of blur, patients with anisometropic amblyopia had significantly longer and more variable saccade latency during amblyopic eye viewing, lower peak acceleration, and a longer acceleration phase during reaching, and a different temporal pattern of eye-hand coordination. CONCLUSIONS Artificially-induced monocular blur in visually-normal participants did not affect saccades, reaching movements, and eye-hand coordination during a simple reach-to-touch task even after a period of blur exposure. In contrast, patients with anisometropic amblyopia demonstrated significantly different kinematics while performing the same task. These results indicate that loss of visual acuity alone cannot explain the kinematic changes seen in patients with mild anisometropic amblyopia.

Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies

Background: Persistent pain after breast cancer surgery affects up to 60% of patients. Early identification of those at higher risk could help inform optimal management. We conducted a systematic review and meta-analysis of observational studies to explore factors associated with persistent pain among women who have undergone surgery for breast cancer. Methods: We searched the MEDLINE, Embase, CINAHL and PsycINFO databases from inception to Mar. 12, 2015, to identify cohort or case–control studies that explored the association between risk factors and persistent pain (lasting ≥ 2 mo) after breast cancer surgery. We pooled estimates of association using random-effects models, when possible, for all independent variables reported by more than 1 study. We reported relative measures of association as pooled odds ratios (ORs) and absolute measures of association as the absolute risk increase. Results: Thirty studies, involving a total of 19 813 patients, reported the association of 77 independent variables with persistent pain. High-quality evidence showed increased odds of persistent pain with younger age (OR for every 10-yr decrement 1.36, 95% confidence interval [CI] 1.24–1.48), radiotherapy (OR 1.35, 95% CI 1.16–1.57), axillary lymph node dissection (OR 2.41, 95% CI 1.73–3.35) and greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI 1.03–1.30). Moderate-quality evidence suggested an association with the presence of preoperative pain (OR 1.29, 95% CI 1.01–1.64). Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these ORs ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection). High-quality evidence showed no association with body mass index, type of breast surgery, chemotherapy or endocrine therapy. Interpretation: Development of persistent pain after breast cancer surgery was associated with younger age, radiotherapy, axillary lymph node dissection, greater acute postoperative pain and preoperative pain. Axillary lymph node dissection provides the only high-yield target for a modifiable risk factor to prevent the development of persistent pain after breast cancer surgery.

A systematic survey of the methods literature on the reporting quality and optimal methods of handling participants with missing outcome data for continuous outcomes in randomized controlled trials

OBJECTIVE To conduct (1) a systematic survey of the reporting quality of simulation studies dealing with how to handle missing participant data (MPD) in randomized control trials and (2) summarize the findings of these studies. STUDY DESIGN AND SETTING We included simulation studies comparing statistical methods dealing with continuous MPD in randomized controlled trials addressing bias, precision, coverage, accuracy, power, type-I error, and overall ranking. For the reporting of simulation studies, we adapted previously developed criteria for reporting quality and applied them to eligible studies. RESULTS Of 16,446 identified citations, the 60 eligible generally had important limitations in reporting, particularly in reporting simulation procedures. Of the 60 studies, 47 addressed ignorable and 32 addressed nonignorable data. For ignorable missing data, mixed model was most frequently the best on overall ranking (9 times best, 34.6% of times tested) and bias (10, 55.6%). Multiple imputation was also performed well. For nonignorable data, mixed model was most frequently the best on overall ranking (7, 46.7%) and bias (8, 57.1%). Mixed model performance varied on other criteria. Last observation carried forward (LOCF) was very seldom the best performing, and for nonignorable MPD frequently the worst. CONCLUSION Simulation studies addressing methods to deal with MPD suffered from serious limitations. The mixed model approach was superior to other methods in terms of overall performance and bias. LOCF performed worst.Please cite this article as: Zhang Y, Alyass A, Vanniyasingam T, Sadeghirad B, Flórez ID, Pichika SC, Kennedy SA, Abdulkarimova U, Zhang Y, Iljon T, Morgano GP, Colunga Lozano LE, Aloweni FAB, Lopes LC, Yepes-Nuñez JJ, Fei Y, Wang L, Kahale LA, Meyre D, Akl EA, Thabane L, Guyatt G, Reporting quality and optimal methods of handling participants with missing outcome data for continuous outcomes in randomized controlled trials: a systematic survey of the methods literature, Journal of Clinical Epidemiology (2017), doi: 10.1016/j.jclinepi.2017.05.016.

Predictors of Unemployment After Breast Cancer Surgery: A Systematic Review and Meta-Analysis of Observational Studies

Purpose Breast cancer surgery is associated with unemployment. Identifying high-risk patients could help inform strategies to promote return to work. We systematically reviewed observational studies to explore factors associated with unemployment after breast cancer surgery. Methods We searched MEDLINE, EMBASE, CINAHL, and PsycINFO to identify studies that explored risk factors for unemployment after breast cancer surgery. When possible, we pooled estimates of association for all independent variables reported by more than one study. Results Twenty-six studies (46,927 patients) reported the association of 127 variables with unemployment after breast cancer surgery. Access to universal health care was associated with higher rates of unemployment (26.6% v 15.4%; test of interaction P = .05). High-quality evidence showed that unemployment after breast cancer surgery was associated with high psychological job demands (odds ratio [OR], 4.26; 95% CI, 2.27 to 7.97), childlessness (OR, 1.30; 95% CI, 1.11 to 1.53), lower education level (OR, 1.15; 95% CI, 1.05 to 1.25), lower income level (OR, 1.46; 95% CI, 1.24 to 1.73), cancer stage II, III or IV (OR, 1.43; 95% CI, 1.13 to 1.82), and mastectomy versus breast-conserving surgery (OR, 1.18; 95% CI, 1.07 to 1.30). Moderate-quality evidence suggested an association with high physical job demands (OR, 2.11; 95%CI, 1.52 to 2.93), African-American ethnicity (OR, 1.89; 95% CI, 1.21 to 2.96), and receipt of chemotherapy (OR, 1.95; 95% CI, 1.36 to 2.79). High-quality evidence demonstrated no significant association with part-time hours, blue-collar work, tumor size, positive lymph nodes, or receipt of radiotherapy or endocrine therapy; moderate-quality evidence suggested no association with age, marital status, or axillary lymph node dissection. Conclusion Addressing high physical and psychological job demands may be important in reducing unemployment after breast cancer surgery.

Society of Interventional Radiology Position Statement: Staffing Guidelines for the Interventional Radiology Suite

INTRODUCTION Although the risk of adverse events from image-guided and interventional radiologic procedures is low, adverse events do occur, and there is evidence that inadequate resources and staffing can be associated with poorer outcomes (1–4). There is a paucity of guidelines on the necessary components of a successful IR program (5). The intent of the present document is to provide reference guidelines for the requirements for safe operation of IR suites in terms of appropriate staffing from patient intake to discharge (including pre-, peri-, and postprocedure requirements). In centers with a greater proportion of higher-complexity cases and/or patients at higher risk (eg, American Society of Anesthesiologists [ASA] status 3/4), there may be a need for additional staffing resources.

New and experimental approaches to back pain

For references, please see Appendix 1, available at [www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.130640/-/DC1][1] A definitive cause cannot be determined in most patients with back pain, and most instances of back pain will resolve without treatment. The most common identifiable causes of persistent

Perioperative psychotherapy for persistent post-surgical pain and physical impairment: a meta-analysis of randomised trials

Background: Persistent post‐surgical pain affects 10–80% of individuals after common operations, and is more common among patients with psychological factors such as depression, anxiety, or catastrophising. Methods: We conducted a systematic review and meta‐analysis of randomised, controlled trials to evaluate the efficacy of perioperative psychotherapy for persistent post‐surgical pain and physical impairment. Paired independent reviewers identified studies, extracted data, and assessed risk of bias. The Grading of Recommendations, Assessment, Development and Evaluation system was used to assess the quality of evidence. Results: Our search of five electronic databases, up to September 1, 2016, found 15 trials (2220 patients) that were eligible for review. For both persistent post‐surgical pain and physical impairment, perioperative education was ineffective, while active psychotherapy suggested a benefit (test of interaction P=0.01 for both outcomes). Moderate quality evidence showed that active perioperative psychotherapy (cognitive‐behaviour therapy, relaxation therapy, or both) significantly reduced persistent post‐surgical pain [weighted mean difference (WMD) −1.06 cm on a 10 cm visual analogue scale for pain, 95% confidence interval (CI) −1.56 to −0.55 cm; risk difference (RD) for achieving no more than mild pain (≤3 cm) 14%, 95% CI 8–21%] and physical impairment [WMD −9.87% on the 0–100% Oswestry Disability Index, 95% CI −13.42 to −6.32%, RD for achieving no more than mild disability (≤20%) 21%, 95% CI 13–29%]. Conclusions: Perioperative cognitive behavioural therapy and relaxation therapy are effective for reducing persistent pain and physical impairment after surgery. Future studies should explore targeted psychotherapy for surgical patients at higher risk for poor outcome. Clinical trial registration: PROSPERO CRD42016047335.

Meta-Analysis of Local Endovascular Therapy for Acute Ischemic Stroke

A meta-analysis was performed to assess randomized controlled trials comparing local endovascular therapy (with and without intravenous thrombolysis) versus standard care (intravenous thrombolysis alone when appropriate) for acute ischemic stroke. Local endovascular therapy showed a significant improvement in functional independence versus standard care (odds ratio, 1.779; 95% confidence interval, 1.262-2.507; P < .001). This benefit strengthened further on subgroup analyses of trials in which a majority of cases used stent retrievers, trials with intravenous thrombolysis use in both arms when appropriate, and trials that required preprocedural imaging of all patients. There were no significant differences between arms in terms of mortality, hemicraniectomy, intracranial hemorrhage, and cerebral edema rates (P > .05). In conclusion, in the treatment of acute ischemic stroke, local endovascular therapy leads to improved functional independence compared with standard care.

Pocketbook versus patient

We read with interest the systematic review by Jenkins and colleagues.[1][1] Yes, imaging is sometimes overused and is a substantial financial cost for our publicly funded health care system.[2][2],[3][3] However, we question the utility of assessing interventions by measuring reductions in imaging

A 28-year-old man with acute chest pain

A 28-year-old man presents to the emergency department with a five-hour history of retrosternal chest pain radiating to his left arm. He reports that the pain is worse on inspiration and eases when he leans forward. His past medical history is unremarkable. The patient denies recent use of