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One solution to hallway medicine: outpatient hip-replacements

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Kaori Noguchi recalls being taken aback when her surgeon’s office called to book her hip replacement surgery.

She was told she could have the operation as an outpatient, meaning she would be in and out of hospital the same day.

Thirty years ago, this procedure would have required a hospital stay of up to seven days, and more recently it’s taken an average of three days.

“Initially I was a bit freaked out,” Noguchi said, explaining that she was concerned she would be in too much pain and not mobile enough to leave the hospital so soon.

But on Monday she did just that. The 47-year-old Toronto resident left Women’s College Hospital just after 4 p.m. — only four hours after being wheeled out of the operating room and eight hours after arriving at the hospital.

Women’s College is the only fully ambulatory hospital in Ontario, meaning it has no overnight beds. It describes itself as “a hospital designed to keep people out of hospital.”

Part of its mission is to help improve the broader health system. One way it’s trying to do that is by spreading the word about the advantages of ambulatory, or outpatient, surgery.

Surgeon-in-chief Dr. David Urbach said doing more joint-replacements this way could take significant pressure off the entire hospital system.

“This approach, applied throughout the province, has the potential to save a huge amount of money and free up many beds in the Ontario hospital system,” he said.

According to data from the hospital, approximately 50,000 hip and knee replacements are done annually in Ontario. The average hospital stay is three days.

Health reporter Theresa Boyle shares her experience witnessing a hip surgery | Story Behind the Story

If 50 per cent were done on an outpatient basis, that would free up 75,000 days of hospital beds annually. That would be the equivalent of opening up a new 200-bed hospital.

10:30 A.M. Kaori Noguchi's leg is held up while the medical team prepare for surgery.
10:30 A.M. Kaori Noguchi’s leg is held up while the medical team prepare for surgery.  (Steve Russell)

The savings would amount to more than $100 million annually.

“What we are advocating is to transform up to half of all total joint operations into same-day discharge ambulatory procedures, without patients entering a hospital ward at all,” Urbach said.

Women’s College rolled out a similar program for knee replacements earlier this year.

Anthony Dale, president of the Ontario Hospital Association, said solutions like this are needed to address hospital overcrowding.

“This work at Women’s College Hospital is a great example of the kind of innovation that’s needed to end hallway health care,” he said, referring to the phenomenon of hospitals being so crowded that patients are cared for in corridors.

11:48 A.M. Anesthesia assistant Angela Chan begins to wake patient Kaori Noguchi after the surgery.
11:48 A.M. Anesthesia assistant Angela Chan begins to wake patient Kaori Noguchi after the surgery.  (Steve Russell)

Though Women’s College is not the first hospital in Ontario to do ambulatory hip-replacements, this kind of surgery is “not widespread at all,” Dale noted. “The fact you can have it done in a single day … that’s pretty powerful.”

Urbach estimates fewer than 100 total joint replacements, without overnight hospital admissions, were done in the province prior to this year.

Ambulatory hip-replacement surgery was pioneered in Chicago in the early 2000s, explained Dr. John Antoniou, president of the Canadian Orthopaedic Association, adding today it is done with much more regularity south of the border.

He acknowledged some patients might be uncomfortable with the idea of leaving the hospital so soon and said initiatives such as the one at Women’s College “help make it more socially acceptable.”

Noguchi said she came around to being OK with the idea of ambulatory surgery after her doctors explained how it worked and shared with her media stories about others getting it.

She is the fourth patient at Women’s College to undergo outpatient hip replacement surgery in the last month.

Noguchi has hip dysplasia, a condition that has resulted in painful arthritis and causes her to limp.

11:04 A.M. Surgeons Dr. Paul Kuzyk uses a tool to prepare the hip socket as Dr. Oleg Safir, right, looks on.
11:04 A.M. Surgeons Dr. Paul Kuzyk uses a tool to prepare the hip socket as Dr. Oleg Safir, right, looks on.  (Steve Russell)

In recent years, the pain has become so bad it interrupts her sleep. It has also forced her to switch to a desk job in her field of event and catering management. It hurts when she is on her feet for too long.

The way the actual surgery is done is no different for outpatients than for those with longer hospital stays. What is different is the anesthesia and aftercare.

“What we have done is develop a virtual care pathway that makes same-day total joint replacement routine for many patients,” Urbach explained.

Ultra short-acting spinal and regional anesthesia is used instead of general anesthesia. That shortens recovery time and allows patients to walk comfortably immediately after surgery.

“We add additional resources to replicate the in-hospital post-op care experience,” Urbach added.

Surgeon Dr. Paul Kuzyk prepares to move the adductor muscle.
Surgeon Dr. Paul Kuzyk prepares to move the adductor muscle.  (Steve Russell)

That includes a virtual care app, developed by the hospital, which allows patients to keep in touch with their care teams.

“The app replicates the experience you would have as a surgeon seeing your patient in hospital. You can look at them face to face, you can answer questions, you can see if they are in pain, you can see how they are doing,” he said.

As well, remote monitoring devices are used, including step counters.

“Many patients probably have enhanced exposure to their care team,” Urbach said. “Doctors and nurses can connect with them using mobile devices instead of rushing to see them in hospital wards.”

Dr. Paul Kuzyk, one of two orthopedic surgeons who operated on Noguchi, explained that not all patients who need hip replacements are candidates for day surgery. It works best on those who are otherwise healthy, highly motivated and have loved ones at home to help them recover.

2:30 P.M. Patient Kaori Noguchi walks with physiotherapist Hari Nair.
2:30 P.M. Patient Kaori Noguchi walks with physiotherapist Hari Nair.  (Steve Russell)

The surgery itself took less than two hours. Noguchi was out of it for the most part, awakening only briefly to the noise generated by orthopedic surgery tools.

She was oblivious to what was happening below the surgical drape and assured the anesthesia assistant she was comfortable.

After Kuzyk removed the femoral head — the “ball” part of the ball-and-socket hip joint — he pointed out where it had been damaged by arthritis. Cartilage was visibly worn away from the surface.

Kuzyk and fellow surgeon, Dr. Oleg Safir, replaced Noguchi’s hip with ceramic, plastic and titanium parts. Their work was physically demanding.

11:23 A.M. The ceramic ball is ready to be placed onto the metal femoral stem.
11:23 A.M. The ceramic ball is ready to be placed onto the metal femoral stem.  (Steve Russell)

Safir explained stays were longer in the past because hospitals wanted to ensure patients did not suffer from post-surgical complications.

As stays have shortened, complication rates have been closely monitored. They have not increased, Safir said.

Urbach said outcomes are excellent and patients recover just as well with ambulatory surgery.

“Being able to discharge a patient on the day of surgery means the patient has to be completely comfortable, mobile, stable and confident,” he said. “We ensure patients feel so good after surgery that they are not afraid of going home.”

Patients benefit by recovering in the comfort and familiarity of their own homes, Urbach noted. Shorter stays reduce the risk of picking up a hospital-acquired infection or developing hospital-acquired delirium, he added.

Less than three hours after her surgery, Noguchi was on her feet. She tested out her new hip, walking down the hospital corridor with the aid of a walker.

Physiotherapist Hari Nair then guided her as she climbed a staircase, using a cane.

Noguchi said she was in no discomfort. She was on painkillers and given a prescription so she could continue taking them at home.

“It’s pretty amazing how they can do this operation as and in-and-out surgery,” she exclaimed. “I’m feeling good. I’m ready to go.”

Theresa Boyle is a Toronto-based reporter covering health. Follow her on Twitter: @theresaboyle

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Anglais

Nostalgia and much more with Starburst XXXtreme

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Get a taste of adventure with Starburst XXXtreme based on the legendary NetEnt Game. The nostalgic themes are sure to capture fans of the classic version as they get treated to higher intensity, better visuals, and features. The most significant element of the game is its volatility. Patience will not be an essential virtue considering the insane gameplay, and there is a lot of win potential involved. It retains the original makeup of the previous game while adding a healthy dose of adrenaline. 

Starburst Visuals and Symbols

The game is definitely more conspicuous than before. The setting happens over a 5-reel, 3-row game grid with nine fixed win lines, which function if a succession from the left to the right reel is present. Only those players that that attain the highest win per bet line are paid. From a visual standpoint, the Starburst XXXtreme slots illustrates lightning effects behind the reels, which is not surprising as it is inherited from the original version. Available themes include Classic, Jewels, and Space. The game is also available in both desktop and mobile versions, which is advantageous for players considering the global pandemic. According to Techguide, American gamers are increasingly having more engaging gaming experiences to socialize to fill the gap of in-person interaction. Starburst XXXtreme allows them to fill the social void at a time when there is so much time to be had indoors. 

Starburst XXXTreme Features

Players get to alternate on three features which are Starburst Wilds, XXXtreme Spins, and Random Wilds. The first appears on reels 2,3, or 4. When these land, they expand to cover all positions while also calculating the wins. They are also locked for a respin. If a new one hits, it also becomes locked while awarding another respin. Starburst XXXtreme offers a choice between two scenarios for a higher stake. In one scenario with a ten times stake, the Starburst Wild is set on random on reels 2,3, or 4, and a multiplier starts the respin. The second scenario, which has a 95 times stake, starts with two guaranteed starburst wilds on reels 2,3, or 4. it also plays out using respin game sequence and features. The game also increases the potential with the Random Wilds feature to add Starburst Wilds to a vacant reel at the end of a spin. Every Starburst Wild gives a random multiplier with potential wins of x2, x3, x5, x10, x25, x50, x100, or even x150.

The new feature is sure to be a big hit with the gaming market as online gambling has shown significant growth during the lockdown. AdAge indicates the current casino customer base is an estimated one in five Americans, so Starburst XXXtreme’s additional features will achieve considerable popularity. 

What We Think About The Game

The gambling market has continued to diversify post-pandemic, so it is one of the most opportune times to release an online casino-based game. Thankfully Starburst XXXtreme features eye-catching visuals, including the jewels and space themes. These attract audience participation and make the gameplay inviting. The game also has a nostalgic edge. The previous NetEnt iteration featured similar visuals and gameplay, so the audience has some familiarity with it. The producers have revamped this version by tweaking the features to improve the volatility and engagement. 

That is characterized by the potential win cap of 200,000 times the bet. Starburst XXXtreme does not just give betting alternatives for players that want to go big. The increase of multipliers also provides a great experience. If the respins in the previous version were great, knowing that multipliers can go hundreds of times overtakes the game to a new level. 

Players should get excited about this offering. All of the features can be triggered within a single spin. Whether one plays the standard game or takes the XXXtreme spin route, it is possible to activate all of the features. Of course, the potential 200,000 times potential is a huge carrot. However, the bet size is probably going to be restricted and vary depending on the casino. It is also worth pointing out that a malfunction during the gameplay will void all of the payouts and progress. Overall, the game itself has been designed to provide a capped win of 200,000 times the original bet. 

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Anglais

‘We’re back’: Montreal festival promoters happy to return but looking to next year

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In downtown Montreal, it’s festival season.

In the city’s entertainment district, a musical act was conducting a sound check on stage Friday evening — the second day of the French-language version of the renowned Just For Laughs comedy festival. Tickets for many of the festival’s free outdoor shows — limited by COVID-19 regulations — were sold out.

Two blocks away, more than 100 people were watching an acoustic performance by the Isaac Neto Trio — part of the last weekend of the Festival International Nuits d’Afrique, a celebration of music from the African continent and the African diaspora.

With COVID-19 restrictions continuing to limit capacity, festival organizers say they’re glad to be back but looking forward to next year when they hope border restrictions and capacity limits won’t affect their plans.

Charles Décarie, Just For Laughs’ CEO and president, said this is a “transition year.”

“Even though we have major constraints from the public health group in Montreal, we’ve managed to design a festival that can navigate through those constraints,” Décarie said.

The French-language Juste pour rire festival began on July 15 and is followed by the English-language festival until July 31.

When planning began in February and March, Décarie said, organizers came up with a variety of scenarios for different crowd sizes, ranging from no spectators to 50 per cent of usual capacity.

“You’ve got to build scenarios,” he said. “You do have to plan a little bit more than usual because you have to have alternatives.”

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Anglais

MELS new major movie studio to be built in Montreal

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MONTREAL — MELS Studios will build a new film studio in Montreal, filling some of the gap in supply to meet the demand of Hollywood productions.

MELS president Martin Carrier said on Friday that MELS 4 studio construction will begin « as soon as possible », either in the fall or winter of next year. The studio could host productions as early as spring 2023.

The total investment for the project is $76 million, with the Quebec government contributing a $25 million loan. The project will create 110 jobs, according to the company.

The TVA Group subsidiary’s project will enable it to stand out « even more » internationally, according to Quebecor president and CEO Pierre Karl Péladeau. In the past, MELS Studios has hosted several major productions, including chapters of the X-Men franchise. The next Transformers movie is shooting this summer in Montreal.

Péladeau insisted that local cultural productions would also benefit from the new facility, adding that the studio ensures foreign revenues and to showcase talent and maintain an industry of Quebec producers.

STUDIO SHORTAGE

The film industry is cramped in Montreal.

According to a report published last May by the Bureau du cinéma et de la télévision du Québec (BCTQ), there is a shortage of nearly 400,000 square feet of studio space.

With the addition of MELS 4, which will be 160,000 square feet, the company is filling part of the gap.

Carrier admitted that he has had to turn down contracts because of the lack of space, representing missed opportunities of « tens of millions of dollars, not only for MELS, but also for the Quebec economy. »

« Montreal’s expertise is in high demand, » said Montreal Mayor Valérie Plante, who was present at the announcement.

She said she received great testimonials from « Netflix, Disney, HBO and company » during an economic mission to Los Angeles in 2019.

« What stands out is that they love Montreal because of its expertise, knowledge and beauty. We need more space, like MELS 4, » she said.

There is still not enough capacity in Quebec, acknowledged Minister of Finance, the Economy and Innovation Eric Girard.

« It is certain that the government is concerned about fairness and balance, so if other requests come in, we will study them with the same seriousness as we have studied this one, » he said.

Grandé Studios is the second-largest player in the industry. Last May, the company said it had expansion plans that should begin in 2022. Investissement Québec and Bell are minority shareholders in the company.

For its part, MELS will have 400,000 square feet of production space once MELS 4 is completed. The company employs 450 people in Quebec and offers a range of services including studio and equipment rentals, image and sound postproduction, visual effects and a virtual production platform.

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