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Canadian Medical Association Journal
Canadian Medical Association
Canadian Medical Association Journal

Canadian Medical Association

0820-3946

Canadian Medical Association Journal/Journal Canadian Medical Association JournalAHCISCIISTP
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    Biased data lead to biased algorithms

    Anamaria Richardson
    1页
    查看更多>>摘要：Although machine learning and use of machine-learned models are a technology that will revolutionize medicine and provide more opportunities to improve health outcomes, I was disappointed that none of the articles in the recent CMAJ series on the subject discussed what is known to be a major, and topical, issue with algorithms and machine learning — that they replicate social biases that exist in the systems they are supporting. If biased data are used, then biased algorithms follow. Populations that are over-or underrepresented in data will experience the continued marginalization and failure of machine learning.
      原文链接:
    • NSTL

    Low-dose ketamine in the prehospital setting

    Alvin YuhalogarasanChris BarclayP. Richard Verbeek
    1页
    查看更多>>摘要：We read the recent CMAJ article on ketamine for the treatment of acute pain by Silverstein and colleagues with great interest. They note that low-dose ketamine is an effective analgesic in several clinical settings, including anesthesiology, critical care, pain management and emergency medicine. We wish to bring attention to emerging literature that effective and safe administration of low-dose ketamine can be provided to adult and pediatric patients by paramedics in the prehospital setting. Importantly, a joint position statement supporting the prehospital use of ketamine as an analgesic in acute trauma patients has recently been published by several American organizations, including the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians and the National Association of Emergency Medical Services Physicians.
      原文链接:
    • NSTL

    Replacing high-stakes summative examinations with graduated medical licensure in Canada

    Brent ThomaSra MonteiroAlim PardhanHeather Waters...
    3页
    查看更多>>摘要：The COVID-19 pandemic has disrupted the medical assessment system in Canada. Examinations delivered by The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) were delayed, cancelled or adapted. As these examinations are required for independent practice, this had a negative impact on trainees, supervisors and patients during a time of great stress within our health care system. Although disruptive, these challenges provided an opportunity for change by unfreezing the historical approach to medical licensure in Canada — an approach that can be characterized as arduous, expensive, logistically challenging, poorly aligned with clinical practice and potentially biased.
      原文链接:
    • NSTL

    Learning from a social experiment in consent for deceased organ donation

    Sam D. Shemie
    3页
    查看更多>>摘要：The organ donation and transplantation system in Canada is currently transforming from a fragmented system with stagnant performance to a collaborative system with sustained incremental improvement (www.cihi.ca/en/e-statistics-on-organ -transplants-waiting-lists-and-donors). A potential donor intersects with the health care system in a predictable trajectory, from prehospital care to emergency department to intensive care unit to operating room. The transition from attempts to save a life, to acceptance of inevitable death, to organ donation is a complex, fragile and emotionally challenging, albeit predictable, process for both families and health care providers. Optimization of each step is required to improve the system. Provincial organ donation organizations carry the operational workload of managing the donation process and connecting with transplant recipients. In a related research article, Singh and colleagues evaluated factors that influence consent for organ donation in Ontario, a province that has implemented many of the fundamentals of system improvement to increase deceased organ donation. The authors' findings answer some questions, but raise others in light of recent policy changes in Nova Scotia.
      原文链接:
    • NSTL

    Factors associated with consent for organ donation: a retrospective population-based study

    Jeffrey M. SinghIan M. BallMichael HartwickEli Malus...
    1页
    查看更多>>摘要：Background: Optimizing the approach to and consent of potential organ donors maximizes patient autonomy and the availability of organs for transplants. We set out to identify modifiable factors associated with donation consent. Methods: We conducted a retrospective cohort study of consecutive adults (≥ 18 yr) referred for organ donation in Ontario between April 2013 and June 2019. We analyzed patient clinical data and demographics, data on substitute decision-makers and characteristics of the donation consent approach. Study outcomes were consent for organ donation and approach rate. We evaluated independent associations between consent and approach- and system-level factors. Results: We identified 34 837 referrals for organ donation, of which 6548 (18.8%) substitute decision-makers were approached for consent. Of these, 3927 (60.0% of approaches) consented for organ donation and 1883 (48.0% of consents) patients proceeded to be organ donors. The most common reason substitute decision-makers were not approached for consent in a case with donation potential was a late referral by the health care team (45.2%). Modifiable factors independently associated with consent included a telephone approach for consent (adjusted odds ratio [OR] 0.46, 95% confidence interval [Cl] 0.35-0.58) and a collaborative approach by a physician and donation coordinator (adjusted OR 1.26, 95% Cl 1.01-1.59) (see table). Interpretation: Consent for organ donation was associated with several modifiable factors. Organizations should target interventions to ensure timely referrals to organ donation organizations, increase in-person consent approaches and increase physician participation in the approach process.
      原文链接:
    • NSTL

    Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada

    Louise Y.SunAnna ChuDerrick Y. TarnXuesong Wang...
    1页
    查看更多>>摘要：Background: Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG+AVR. Methods: We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020). Results: The derivation cohorts included 13435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG (see table), 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts. Interpretation: Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.
      原文链接:
    • NSTL

    SARS-CoV-2 seroprevalence in health care workers from 10 hospitals in Quebec, Canada: a cross-sectional study

    Nicholas BrousseauLaurianne MorinManale Ouakki
    1页
    查看更多>>摘要：Background: The COVID-19 pandemic has disproportionately affected health care workers. We sought to estimate SARS-CoV-2 seroprevalence among hospital health care workers in Quebec, Canada, after the first wave of the pandemic and to explore factors associated with SARS-CoV-2 seropositivity. Methods: Between July 6 and Sept 24,2020, we enrolled health care workers from 10 hospitals, including 8 from a region with a high incidence of COVID-19 (the Montreal area) and 2 from low-incidence regions of Quebec. Eligible health care workers were physicians, nurses, orderlies and cleaning staff working in 4 types of care units (emergency department, intensive care unit, COVID-19 inpatient unit and non-COVID-19 inpatient unit). Participants completed a questionnaire and underwent SARS-CoV-2 serology testing. We identified factors independently associated with higher seroprevalence. Results: Among 2056 enrolled health care workers, 241 (11.7%) had positive SARS-CoV-2 serology. Of these, 171 (71.0%) had been previously diagnosed with COVID-19. Seroprevalence varied among hospitals, from 2.4% to 3.7% in low-incidence regions to 17.9% to 32.0% in hospitals with outbreaks involving 5 or more health care workers (see figure). Higher seroprevalence was associated with working in a hospital where outbreaks occurred (adjusted prevalence ratio 4.16,95% confidence interval [Cl] 2.63-6.57), being a nurse or nursing assistant (adjusted prevalence ratio 1.34, 95% Cl 1.03-1.74) or an orderly (adjusted prevalence ratio 1.49, 95% Cl 1.12-1.97), and Black or Hispanic ethnicity (adjusted prevalence ratio 1.41, 95% Cl 1.13-1.76). Lower seroprevalence was associated with working in the intensive care unit (adjusted prevalence ratio 0.47, 95% Cl 0.30-0.71) or the emergency department (adjusted prevalence ratio 0.61, 95% Cl 0.39-0.98). Interpretation: Health care workers in Quebec hospitals were at high risk of SARS-CoV-2 infection, particularly in outbreak settings. More work is needed to better understand SARS-CoV-2 transmission dynamics in health care settings.
      原文链接:
    • NSTL

    Outcomes in patients with and without disability admitted to hospital with COVID-19: a retrospective cohort study

    Hilary K. BrownSudipta SahaTimothy C.Y.ChanAngela M. Cheung...
    1页
    查看更多>>摘要：Background: Disability-related considerations have largely been absent from the COVID-19 response, despite evidence that people with disabilities are at elevated risk for acquiring COVID-19. We evaluated clinical outcomes in patients who were admitted to hospital with COVID-19 with a disability compared with patients without a disability. Methods: We conducted a retrospective cohort study that included adults with COVID-19 who were admitted to hospital and discharged between Jan. 1,2020, and Nov. 30, 2020, at 7 hospitals in Ontario, Canada. We compared in-hospital death, admission to the intensive care unit (ICU), hospital length of stay and unplanned 30-day readmission among patients with and without a physical disability, hearing or vision impairment, traumatic brain injury, or intellectual or developmental disability, overall and stratified by age (≤64 and ≥ 65 yr) using multivariable regression, controlling for sex, residence in a long-term care facility and comorbidity. Results: Among 1279 admissions to hospital for COVID-19, 22.3% had a disability. We found that patients with a disability were more likely to die than those without a disability (28.1% v. 17.6%), had longer hospital stays (median 13.9 v. 7.8 d) and more readmissions (17.6% v. 7.9%), but had lower ICU admission rates (22.5% v. 28.3%). After adjustment, there were no statistically significant differences between those with and without disabilities for in-hospital death or admission to ICU. After adjustment, patients with a disability had longer hospital stays (rate ratio 1.36, 95% confidence interval [Cl] 1.19-1.56) and greater risk of readmission (relative risk 1.77, 95% Cl 1.14-2.75) (see figure). In age-stratified analyses, we observed longer hospital stays among patients with a disability than in those without, in both younger and older subgroups; readmission risk was driven by younger patients with a disability. Interpretation: Patients with a disability who were admitted to hospital with COVID-19 had longer stays and elevated readmission risk than those without disabilities. Disability-related needs should be addressed to support these patients in hospital and after discharge.
      原文链接:
    • NSTL

    Cannabis-related emergency department visits by youths and their outcomes in Ontario: a trend analysis

    Melanie BechardPaula CloutierIsac LimaMina Salamatmanesh...
    1页
    查看更多>>摘要：Background: Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex. Methods: Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13,14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for cannabis poisoning and mental disorders due to cannabinoids. We categorized presentations as "less severe" versus "more severe" using scores assigned by nurses at triage. Results: We examined 14697778 emergency department visits. Cannabis-related visits increased from 3.8 per 10000 youths (95% confidence interval [Cl] 3.5-4.0) in 2003 to 17.9 (95% Cl 17.4-18.4) in 2017, a 4.8-fold increase (95% Cl 4.4-5.1) (see figure). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios > 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10000 (95% Cl 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% Cl 20.9-22.9) among those aged 14-18 years, and 0.8 per 10000 (95% Cl 0.5-1.0) among those aged 10-13 years. In 2017,88.2% (95% Cl 87.3%-89.0%) of cannabis-related visits and 58.1% (95% Cl 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe" (rate ratio 1.52, 95% Cl 1.50-1.53). Similarly, in 2017, 19.0% (95% Cl 18.0%-20.1%) of cannabis-related visits and 5.8% (95% Cl 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3,95% Cl 3.1-3.5). Interpretation: Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.
      原文链接:
    • NSTL

    Pregnant people's responses to the COVID-19 pandemic: a mixed-methods, descriptive study

    Hamideh BayrampourSukhpreet K. TamanaAmelie Boutin
    1页
    查看更多>>摘要：Background: Given the extent of the COVID-19 pandemic and uncertainty around the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population. Methods: This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We conducted the study between Mar. 20 and May 31,2020, in British Columbia, Canada. Any pregnant person at any gestational age living in BC was eligible to participate. We collected quantitative data using online survey tools, including the Edinburgh Postnatal Depression Scale (EPDS) and the 7-item Generalized Anxiety Disorder questionnaire (GAD-7). We collected qualitative data using open-ended questions to explore people's thoughts, feelings and experiences during the pandemic. Participants were recruited using study posters distributed via prenatal care clinics and classes, LifeLabs and social media across the province. We used thematic and descriptive analyses to analyze the data, and we integrated the qualitative and quantitative findings at the interpretation level. Results: The study sample included 96 participants with mean (± standard deviation) maternal and gestational ages of 32 ± 3.92 years and 22.73 ± 8.93 weeks, respectively. Most (93%; n = 89) identified as female. Of the participants, 54% (n = 50) and 35% (n = 34) reported anxiety and depressive symptoms, as measured by the GAD-7 and EPDS, respectively. Overarching themes that emerged from the qualitative data included uncertainty about birth plans and setting, added burden to existing health and social disparities, perceived or projected lack of support or limited support, concerns about early development, and struggle over managing multiple demands. Perceived maternity care needs included mental health support, maintaining prenatal care, frequent and proactive check-ins to build rapport, and recommendations specific to the pandemic (see table). Interpretation: We found that the impact of the COVID-19 pandemic on the pregnant population has been substantial. The findings of this mixed-methods study can be used to help plan informed and evidence-based health care interventions to mitigate adverse effects and support mothers and families.
      原文链接:
    • NSTL