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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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    Bones like porcelain, soul like a sage

    Jocelyn Chase
    3页
    查看更多>>摘要：I met Ms. T on a busy day, the last patient on my rounds in the late afternoon. My feet were dragging, my spirits lagging, stomach hungry and patience short. I resigned myself to the infection control alert at the door. Earlier that day, a patient in the four-person room had tested positive for SARS-CoV-2 infection, and now Ms. T and her two remaining roommates were prisoners to infection control. I donned the stifling N95 mask, face shield and gown, immediately hot and irritable. On meeting Ms. T, I could see that, at 86 years old, she was sharp of mind but frail of body, weighing only 80 pounds, less than 1 pound for every year of her life. “How is your pain today, Ms. T?” I asked, hoping that it was better so I could finish up and head home, to cook dinner and do homework with my two young children. “Terrible!” she said. “That gabapentin makes my mouth so dry and my head too fuzzy. I told the nurse to take it away.” Frustration welled in me, as it sometimes does when patients don’t conform to my expectations and I am feeling depleted by a long day. “Why can’t she just get better?” I thought. She had been admitted almost 2 weeks ago and, although she could walk gingerly to the bathroom, her left-sided sciatica and hip arthritis were bad and she couldn’t go home.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Is one-way masking enough?

    Lauren Vogel
    1页
    查看更多>>摘要：Face masks work best to prevent the spread of SARS-CoV-2 when everyone wears one. But experts say it is still worth wearing a mask to protect yourself, even if no one else does. While public health messaging has tended to emphasize the importance of wearing a mask to protect others, numerous studies have demonstrated that the right mask protects the wearer, too. “We have collectively done a poor job at communicating the strong efficacy of N95 respirators,” according to Lisa Brosseau, a bioaerosol scientist and industrial hygienist at the University of Minnesota’s Center for Infectious Disease Research and Policy. Recent data from the United States shows that people who always wore a face mask in indoor public settings were less likely to test positive for SARS-CoV-2 than those who never wore a mask. Better quality masks offered greater protection. Wearing an N95 or KN95 respirator lowered the odds of infection by 83%, whereas wearing a surgical mask or cloth mask lowered the odds by 66% and 56%, respectively.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Acute confusion in a 55-year-old man with endstage renal disease

    Nisha AndanyAaron IzenbergBourne AugusteSheliza Halani...
    4页
    查看更多>>摘要：A 55-year-old man with end-stage renal disease secondary to diabetes presented to hospital with a 1-day history of confusion and word-finding difficulties. His medical history included diabetic nephropathy, anemia secondary to renal disease, gout, dyslipidemia, hypertension (baseline blood pressure 150/90 mm Hg) and depression. His regular medications were perindopril, amlodipine, lanthanum carbonate, allopurinol, linagliptin, rosuva-statin, citalopram, insulin and erythropoietin. He had been receiving continuous cycling peritoneal dialysis for 7 months, with no recent changes. Three weeks earlier, the patient had developed an erythematous and clustered, painless rash on his back and scalp, which was not in a dermatomal distribution. Three days before his hospital visit, his family physician had prescribed oral valacyclovir 1g three times daily for presumed zoster infection. He had taken 4 doses of valacyclo-vir by the time he presented to hospital.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Postoperative outcomes for Nunavut Inuit at a Canadian quaternary care centre: a retrospective cohort study

    Jenny Hoang-NguyenJustine O’SheaCaitlin ChampionChelsey Sheffield...
    8页
    查看更多>>摘要：Background: Structural aspects of health care systems, such as limited access to specialized surgical and perioperative care, can negatively affect the outcomes and resource use of patients undergoing elective and emergency surgical procedures. The aim of this study was to compare postoperative outcomes of Nunavut Inuit and non-Inuit patients at a Canadian quaternary care centre. Methods: We conducted a retrospective cohort study involving adult (age > 18 yr) patients undergoing inpatient surgery from 2011 to 2018 at The Ottawa Hospital, the quaternary referral hospital for the Qikiqtaaluk Region of Nunavut. The study was designed and conducted in collaboration with Nunavut Tunngavik Incorporated. The primary outcome was a composite of in-hospital death or complications. Secondary outcomes included postoperative length of stay in hospital, adverse discharge disposition, readmissions within 30 days and total hospitalization costs. Results: A total of 98701 episodes of inpatient surgical care occurred among patients aged 18 to 104 years; 928 (0.9%) of these involved Nunavut Inuit, and 97773 involved non-Inuit patients. Death or postoperative complication occurred more often among Nunavut Inuit than non-Inuit patients (159 [17.2%] v. 15691 [16.1%]), which was significantly different after adjustment for age, sex, surgical specialty, risk and urgency (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.03-1.51). This association was most pronounced in cases of cancer (OR 1.63, 95% CI 1.03-2.58) and elective surgery (OR 1.58, 95% CI 1.20-2.10). Adjusted rates of readmission, adverse discharge disposition, length of stay and total costs were significantly higher for Nunavut Inuit. Interpretation: Nunavut Inuit had a 25% relative increase in their odds of morbidity and death after surgery at a major quaternary care hospital in Canada compared with non-Inuit patients, while also having higher rates of other adverse outcomes and resource use. An examination of perioperative systems involving patients, Inuit leadership, health care providers and governments is required to address these differences in health outcomes.
      原文链接:
    • NSTL

    Housing conditions and respiratory morbidity in Indigenous children in remote communities in Northwestern Ontario, Canada

    Thomas KovesiJ. David MillerGary MallachAriel Root...
    9页
    查看更多>>摘要：Background: Rates of lower respiratory tract infection (LRTI) among First Nations (FN) children living in Canada are elevated. We aimed to quantify indoor environmental quality (IEQ) in the homes of FN children in isolated communities and evaluate any associations with respiratory morbidity. Methods: We performed a crosssectional evaluation of 98 FN children (81 with complete data) aged 3 years or younger, living in 4 FN communities in the Sioux Lookout region of Northern Ontario. We performed medical chart reviews and administered questionnaires. We performed a housing inspection, including quantifying the interior surface area of mould (SAM). We monitored air quality for 5 days in each home and quantified the contaminant loading of settled floor dust, including endotoxin. We analyzed associations between IEQ variables and respiratory conditions using univariable and multivariable analyses. Results: Participants had a mean age of 1.6 years and 21% had been admitted to hospital for respiratory infections before age 2 years. Houses were generally crowded (mean occupancy 6.6 [standard deviation 2.6, range 3-17] people per house). Serious housing concerns were frequent, including a lack of functioning controlled ventilation. The mean SAM in the occupied space was 0.2 m2. In multivariable modelling, there was evidence of an association of LRTI with log endotoxin (p = 0.07) and age (p = 0.02), and for upper respiratory tract infections, with SAM (p = 0.07) and age (p = 0.03). Wheeze with colds was associated with log endotoxin (p = 0.03) and age (p = 0.04). Interpretation: We observed poor housing conditions and an association between endotoxin and wheezing in young FN children living in Northern Ontario.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Necrosis secondary to cold agglutinin disease

    Hiroaki NakagawaChiaki KatoYasushi Miyata
    1页
    查看更多>>摘要：An 80-year-old man presented to our clinic with a 7-month history of purple discoloration, numbness and pain of the left third and fourth digits (Figure 1A). His other hand and his feet were unaffected. The discoloration was exacerbated by cold exposure but did not return to normal colour or show paroxysmal pallor, ruling out Raynaud phenomenon. He had a history of well-controlled diabetes, was not hypertensive and did not smoke. His body mass index was 19.7. Laboratory investigations were as follows: hemoglobin 10.6 (normal 13.5-17.6) g/dL, reticulocyte count 6.4% (normal 0.6%-2.0%), indirect bilirubin 1.2 (normal 0.2-0.9) mg/dL, lactate dehydrogenase 514 (normal 106-211) IU/L, reduced haptoglobin, elevated immunoglobulin M (IgM) 526 (normal 33-190) mg/dL, hemagglutination on blood smear (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/ cmaj.211570/tab-related-content) and normal leukocyte count. A direct Coombs test was anti-C3 positive and cold agglutinin titre was 1:8192 (normal < 64) at 4°C. Screening for infectious mononucleosis, Mycoplasma pneumoniae, syphilis, antinuclear antibodies, autoantibodies and cryoglobulin was negative. Whole-body computed tomography was normal. We diagnosed cold agglutinin disease and referred the patient to hematology. Seven days later, his left fourth fingertip appeared necrotic (Figure 1B). Because neither revascularization nor surgery was indicated, the patient was instructed to avoid exposure to cold and keep warm, and the finger healed. At 12-months’ follow-up, having avoided cold exposures only, he had no new lesions or progression of anemia.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Should physicians rethink travel to conferences?

    Erin C. Will
    1页
    查看更多>>摘要：2021 was a year like no other as the planet experienced an unrelenting series of climate-related disasters. The widespread nature and severity of these disasters, from a deep freeze in Texas that left 4.5 million people without power, to the heat dome that suffocated western Canada and killed 595 people in British Columbia, to the wildfires in Turkey that destroyed 1700 km2 of forest, to the atmospheric river that devastated the BC Interior and forced almost 20 000 people to flee their homes, were unignorable reminders of the future disasters we will face if we do not do all that we can to mitigate climate change. The Intergovernmental Panel on Climate Change has indicated that the planet is in a “code red” situation and change must occur now if we are to prevent unthinkable devastation. As physicians, we bear a special responsibility to be leaders and role models in taking action against climate change and changing our lifestyles in ways that embody this responsibility. One such action can be reducing unnecessary air travel. Flight is often cited as a disproportionate cause of climate change because of the additive effects of fossil fuel consumption with the subsequent greenhouse gas emissions and the water vapour in contrails that help to trap heat near the earth’s surface.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Extending the impact of CMAJ

    Kirsten Patrick
    2页
    查看更多>>摘要：This is my first editorial as editor-in-chief, after serving for almost a year as interim in the role. As the first woman editor-in-chief in the CMAJ’s 111-year history, although not the first to be tapped to steer the journal in an interim capacity, I represent change. In 2022, under-resourced and inadequate health systems in Canada face the ongoing COVID-19 pandemic, alongside a worsening health workforce crisis and increasing health effects of global and local social determinants of health that worsen existing inequities. How can CMAJ be part of addressing these challenges? How can the journal help facilitate much needed change? My vision for CMAJ during my tenure as editor-in-chief is informed by my extensive experience working as a medical editor; my varied experience as a clinician, a researcher, an immigrant, and a patient in 3 very different health systems; and my understanding that collaborative, open-minded and kind leadership is what is needed now to address the serious threats to health that we face globally and in Canada.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Corneal foreign bodies

    Athithan AmbikkumarBryan ArthursChristian El-Hadad
    1页
    查看更多>>摘要：1 Clinical evaluation of corneal foreign bodies includes lid eversion and fluorescein staining Ocular trauma accounts for 8% of emergency department visits; of these, 31% involve corneal foreign bodies. A focused history includes presenting symptoms, type of foreign body, penetrability, entry velocity, duration since injury, concurrent contact lens usage and ocular history.1 Evaluation includes assessment of visual acuity, pupillary response and extraocular movements, and fluorescein staining. Vertical scratch marks that stain with fluorescein suggest a foreign body under the upper lid. In this case, the upper lid should be fully everted during examination. A Wood lamp has low sensitivity (52%) for fluorescein uptake compared with a slit lamp. Patients who continue to be symptomatic 24 hours after a negative Wood lamp examination should be re-examined in the emergency department or clinic. 2 Clinicians should screen for penetrating injuries of the globe It is important to rule out open-globe injuries, as these complicate some presentations of corneal foreign bodies. A penetrated globe can be iden-tified if a green streak flows out from a fluorescein-soaked foreign body; however, the streak may be absent when penetrating injuries are selfsealing. If an intraocular foreign body is suspected, orbital computed tomography should be performed. Penetrating injuries require urgent referral to an ophthalmologist without displacing the foreign body.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Dermatitis after exposure to Lymantria dispar dispar

    David O. CroitoruStephanie G. Brooks MAKucy Pon
    1页
    查看更多>>摘要：In early June 2021, a 60-year-old man presented to our emergency department with 4 days of progressive facial swelling and pruritic rash that was not responsive to valacyclovir (Figure 1). Slit-lamp examination did not suggest herpes zoster or ophthalmia nodosa. Sixteen hours before onset, he had been removing and shaking a burlap trap, placed because of a local infestation of Lymantria dispar dispar moths. He reported no previous reactions to latex, atopy nor prior contact with this moth species, but reported annual infestations of L. dispar dispar on his property since 2019. We treated the patient with prednisone (20 mg once a day for 7 days), and his lesions resolved in 3 weeks. Two weeks later, he developed a similar eruption 1 day after weeding under a maple tree infested with L. dispar dispar. This cleared after another 2 weeks of prednisone, which was then tapered, with no recurrence.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc