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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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    Infertility treatment and postpartum mental illness: a populationbased cohort study

    Jessica PudwellMaya DjerbouaDeshayne B. FellOlga Basso...
    9页
    查看更多>>摘要：Background: Subfertility and infertility treatment can be stressful experiences, but it is unknown whether each predisposes to postpartum mental illness. We sought to evaluate associations between subfertility or infertility treatment and postpartum mental illness. Methods: We conducted a population-based cohort study of individuals without pre-existing mental illness who gave birth in Ontario, Canada, from 2006 to 2014, stratified by fertility exposure: subfertility without infertility treatment; noninvasive infertility treatment (intrauterine insemination); invasive infertility treatment (in vitro fertilization); and no reproductive assistance. The primary outcome was mental illness occurring 365 days or sooner after birth (defined as > 2 outpatient visits, an emergency department visit or a hospital admission with a mood, anxiety, psychotic, or substance use disorder, self-harm event or other mental illness). We used multivariable Poisson regression with robust error variance to assess associations between fertility exposure and postpartum mental illness. Results: The study cohort comprised 786 064 births (mean age 30.42 yr, standard deviation 5.30 yr), including 78 283 with subfertility without treatment, 9178 with noninvasive infertility treatment, 9633 with invasive infertility treatment and 688 970 without reproductive assistance. Postpartum mental illness occurred in 60.8 per 1000 births among individuals without reproductive assistance. Relative to individuals without reproductive assistance, those with subfertility had a higher adjusted relative risk of postpartum mental illness (1.14, 95% confidence interval 1.10-1.17), which was similar in noninvasive and invasive infertility treatment groups. Interpretation: Subfertility or infertility treatment conferred a slightly higher risk of postpartum mental illness compared with no reproductive assistance. Further research should elucidate whether the stress of infertility, its treatment or physician selection contributes to this association.
      原文链接:
    • NSTL

    Antenatal corticosteroid administration and attention-deficit/hyperactivity disorder in childhood: a regression discontinuity study

    M. Ama SkollPeter SochaMyriam SrourJoseph Y. Ting...
    7页
    查看更多>>摘要：Background: Antenatal corticosteroids reduce respiratory morbidity in preterm infants, but their use during late preterm gestation (34-36 weeks) is limited because their safety for longer-term child neurodevelopment is unclear. We sought to determine if fetuses with higher probability of exposure to antenatal corticosteroids had increased rates of prescriptions for attention-deficit/hyperactivity disorder (ADHD) medication in childhood, using a quasiexperimental design that better controls for confounding than existing observational studies. Methods: We identified 16358 children whose birthing parents were admitted for delivery between 31 + 0 (31 weeks, 0 days) and 36 + 6 weeks’ gestation in 2000-2013, using a perinatal data registry from British Columbia, Canada, and linked their records with population-based child ADHD medication data (2000-2018). We used a regression discontinuity design to capitalize on the fact that pregnancies presenting for delivery immediately before and immediately after the clinical cut-off for antenatal corticosteroid administration of 34 + 0 weeks’ gestation have very different levels of exposure to corticosteroids, but are otherwise similar with respect to confounders. Results: Over a median follow-up period of 9 years, 892 (5.5%) children had 1 or more dispensations of ADHD medication. Children whose birthing parents were admitted for delivery just before the corticosteroid clinical cut-off of 34 + 0 weeks’ gestation did not appear to be more likely to be prescribed ADHD medication than those admitted just after the cut-off (rate ratio 1.1, 95% confidence interval [CI] 0.8 to 1.6; 1.3 excess cases per 100 children, 95% CI -2.5 to 5.7). Interpretation: We found little evidence that children with higher probability of exposure to antenatal corticosteroids have higher rates of ADHD prescriptions in childhood, supporting the safety of antenatal corticosteroids for this neurodevelopmental outcome.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Canada’s research community divided over proposed prescription to ease ethics approval woes

    2页
    查看更多>>摘要：Researchers have long complained that ethics approval processes for studies involving multiple institutions are timeconsuming, overly complicated, and often redundant. Historically, research ethics boards (REBs) at each participating hospital or university would conduct their own reviews of proposed studies — duplicating and sometimes conflicting with each other’s processes and verdicts. Canada’s Interagency Advisory Panel on Research Ethics is proposing to dramatically simplify that process by mandating that all applications for multisite, minimal risk studies undergo an initial review by a single REB of record whose verdict and rationale would then be circulated to other participating sites for their review and approval. During consultations on the proposal, some researchers welcomed the change as necessary and long overdue. According to Hilary Bergsieker, chair of the University of Waterloo Human Research Ethics Board, the proposal could result in “substantial savings in time for researchers” and reduce conflicts arising from “minor local differences” in the interpretation of ethics policies. For example, she noted that the University of Waterloo requires a notice of ethics clearance on all study recruitment materials, but the University of British Columbia strongly discourages such statements as being potentially coercive.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Excess mortality, COVID-19 and health care systems in Canada

    Kimberlyn McGrail
    5页
    查看更多>>摘要：During the first year of the COVID-19 pandemic through early 2021, international comparisons showed a wide variation in patterns of mortality across countries.1 Although some countries saw no change in mortality or even fewer deaths than expected, others saw marked increases, such as a 19% increase in Italy, 18% in the United Kingdom and 22% in the United States.1 In Canada, a 5% increase was reported during this early pandemic period.1 A report from the Public Health Agency of Canada suggested differential mortality rates among older adults across Canada’s provinces in 2020.2 An analysis of data from the first few months of the pandemic showed a twofold variation in excess mortality rates across regions of England and Wales,3 whereby excess mortality refers to the degree to which observed deaths exceed expected deaths (based on modelling of previous years of age-specific mortality).4,5 Excess mortality is a useful indicator of the populationwide effects of the COVID-19 pandemic. Given the observed variation across and within other countries, variation across provinces and territories in Canada is likely. This analysis uses publicly available data to explore excess mortality related to COVID-19 in the Canadian provinces from the start of the pandemic in March 2020 through October 2021 to shed light on the population-wide effects of the pandemic and variations across the country.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Rosella C

    1页
    查看更多>>摘要：My health deteriorated over a period of 6 years. My symptoms escalated from easy bruising, hair loss, high blood pressure, skin thinning and flushed skin to rapid weight gain in my midsection, a puffy face, fatigue and severe joint pain. I had become unrecognizable. I was diagnosed with resistant hypertension and started medications for the first time. I was referred to several specialists by my family doctor — a cardiologist for my blood pressure, a dermatologist for the bruising and thin skin, even an allergist. One day, I tripped over some shoes, fractured a bone in my foot and ended up at the hospital. I followed the recommended directions, but I think the fracture never fully healed. I told both my orthopedic surgeon and family doctor that I thought there was a greater problem, but my concerns were quickly dismissed. I scheduled another appointment with my family doctor soon after for a blood test. I walked in with crutches and extensive bruising that had become impossible to hide. I left with only a higher dose of medication for my blood pressure. Growing frustrated, I paid out of pocket for a naturopathic doctor who listened to my whole story, not just small parts of it. She conducted several blood tests and high cortisol levels were identified, but she didn’t tell me what my diagnosis was or how to treat it. It wasn’t until after my 50th birthday, when we had a small outdoor pandemic gathering, that a friend called to ask if I had Cushing disease. His sister had it, and he thought my face and body had changed dramatically, similar to hers. This was the first time I, or my family, was made aware of Cushing disease as a diagnosis.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Prescribed opioid analgesics in early pregnancy and the risk of congenital anomalies: a population-based cohort study

    Alexa C. BowieMartha M. WerlerMaria P. VelezWenbin Li...
    11页
    查看更多>>摘要：Background: Recent data suggest an increased risk of congenital anomalies with prenatal exposure to opioid analgesics. We sought to further quantify the risk of anomalies after opioid analgesic exposure during the first trimester in a population-based cohort study. Methods: Using administrative health data from Ontario, we followed 599579 gestational parent-infant pairs from singleton pregnancies without opioid use disorder. We identified opioid analgesics dispensed in the first trimester and congenital anomalies diagnosed during the first year of life. We estimated propensity score-adjusted risk ratios (RRs) between first trimester exposure (any opioid analgesic and specific agents) and congenital anomalies (any anomaly, organ system anomalies, major or minor anomalies and specific anomalies). Results: The prevalence of congenital anomalies was 2.8% in exposed infants and 2.0% in unexposed infants. Relative to unexposed infants, we observed elevated risks among those who were exposed for some anomaly groups, including gastrointestinal anomalies (any opioid analgesic: adjusted RR 1.46, 95% confidence interval [CI] 1.15-1.85; codeine: adjusted RR 1.53, 95% CI 1.12-2.09; tramadol: adjusted RR 2.69, 95% CI 1.34-5.38) and several specific anomalies, including ankyloglossia (any opioid: adjusted RR 1.88, 95% CI 1.30-2.72; codeine: adjusted RR 2.14, 95% CI 1.35-3.40). These findings persisted in sensitivity analyses. Interpretation: Although the absolute risk of congenital anomalies was low, our findings add to accumulating data that suggest a small increased risk of some organ system anomalies and specific anomalies with first trimester exposure to opioid analgesics. These findings further quantify the potential risks associated with prenatal exposure to opioid analgesics to inform treatment choices for pain in pregnancy.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Perspectives of a patient and a physiatrist on neuralgic amyotrophy

    Andreas Laupacis
    2页
    查看更多>>摘要：A patient’s perspective The pain in both shoulders started around midnight and got worse as the night went on. It felt like someone was stabbing me. No matter what position I was in, I couldn’t sleep. In the morning, I went to work. The pain was bearable, but when I picked up something a little bit heavy, it felt like somebody was trying to pull my arm out of the socket. At that point, I realized, “Okay, this isn’t just aches and pains.” At the first hospital, they didn’t really know what was wrong with me. The doctor was thinking maybe shingles. They gave me some steroids and Tylenol 3s and sent me home. The pain got worse throughout the day. Again, I couldn’t sleep. In the morning, I called my family doctor. Because of COVID-19 restrictions, he just right lower forearm. I couldn’t lift anything. My fingers and thumb felt paralyzed. I’ve always had a good grip, but I just had nothing there. That was scary. I ended up quitting my job in a stockyard because I couldn’t do it. I became selfemployed. I had no insurance, so I was worrying about money. I wanted someone to tell me what was wrong. The specialist thought I had something called Parsonage-Turner syndrome. He said this thing could heal itself, or it might not, but it’s a long process. And I was just like, “Well ... ?” A few months later, he did a nerve test and realized the nerves weren’t connected in my arm.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Final consent, advance consent and alleviating suffering in frail adults requesting MAiD

    Jill OliverAngel PetropanagosPaula Chidwick
    1页
    查看更多>>摘要：We thank Engelhart and colleagues1 for bringing forward an important topic in their article published in CMAJ. The association between frailty and eligibility for medical assistance in dying (MAiD) requires attention, as the authors state, especially in light of changes to the Criminal Code of Canada, brought about by Bill C72 receiving Royal Assent in March 2021. We wish to highlight 2 important points of clarification. First, the authors state, “Bill C-7 also permits MAiD through an advanced directive if eligibility was determined when the person was capable.”1 The Criminal Code3 does not actually allow for an advance directive for MAiD; rather, it allows for a waiver of final consent and advance consent. The former is permitted only for eligible persons whose natural death is reasonably foreseeable, and must be accompanied by a written arrangement with the provider identifying a specific date for provision, among other requirements. This act of waiving final consent is later referred to as “advance consent” in the Code. In addition, the Code allows for advance consent in cases of failed selfadministration of MAiD medications.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    Treating acetaminophen overdose

    Mark C. YaremaDavid N. JuurlinkMarco L.A. Sivilotti
    1页
    查看更多>>摘要：1 Acetaminophen overdose remains common A billion doses of acetaminophen are taken safely each year, but 10 000 people in Canada overdose on this medication annually. About one-third are hospitalized for treatment with the antidote, acetylcysteine, and 1%-2% die. Most fatalities result from delayed presentation after deliberate overdose, or from excessive dosing for fever or pain over several days. Clinicians should treat overdoses empirically with acetylcysteine, unless clearly unnecessary Because the efficacy of acetylcysteine is highly time-dependent, it can be started for any acetaminophen overdose. For acute overdoses that occurred at a reliably known time, acetylcysteine is not needed provided that the patient’s peak acetaminophen concentration is below the Rumack-Matthew nomogram treatment line. Death from acetaminophen-induced liver failure is rare if acetylcysteine is started promptly. Dosed correctly, adverse reactions are rarely life-threatening. 3 Acetylcysteine should be continued until the patient meets stopping criteria based on individualized serial testing Although original treatment protocols stipulated a fixed treatment duration (e.g., 20 h), medical toxicologists now recommend a patient-tailored approach to reduce both over- and undertreatment. Serial testing permits more accurate risk stratification and often shortens treatment. Acetylcysteine can be safely stopped when the patient’s acetaminophen concentration is undetectable, liver function tests are improving, and the patient is not encephalopathic (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.210703/tab -related-content). Acetaminophen concentrations should fall tenfold every 12 hours if absorption is complete and liver function is normal.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc

    First Nations status and emergency department triage scores in Alberta: a retrospective cohort study

    Patrick McLaneCheryl BarnabeLeslee MackeyLea Bill...
    9页
    查看更多>>摘要：Background: Previous studies have found that race is associated with emergency department triage scores, raising concerns about potential health care inequity. As part of a project on quality of care for First Nations people in Alberta, we sought to understand the relation between First Nations status and triage scores. Methods: We conducted a populationbased retrospective cohort study of health administrative data from April 2012 to March 2017 to evaluate acuity of triage scores, categorized as a binary outcome of higher or lower acuity score. We developed multivariable multilevel logistic mixed-effects regression models using the levels of emergency department visit, patient (for patients with multiple visits) and facility. We further evaluated the triage of visits related to 5 disease categories and 5 specific diagnoses to better compare triage outcomes of First Nations and non-First Nations patients. Results: First Nations status was associated with lower odds of receiving higher acuity triage scores (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.92-0.94) compared with non-First Nations patients in adjusted models. First Nations patients had lower odds of acute triage for all 5 disease categories and for 3 of 5 diagnoses, including long bone fractures (OR 0.82, 95% CI 0.760.88), acute upper respiratory infection (OR 0.90, 95% CI 0.84-0.98) and anxiety disorder (OR 0.67, 95% CI 0.60-0.74). Interpretation: First Nations status was associated with lower odds of higher acuity triage scores across a number of conditions and diagnoses. This may reflect systemic racism, stereotyping and potentially other factors that affected triage assessments.
      原文链接:
    • NSTL
    • Cma-Canadian Medical Assoc