查看更多>>摘要：We laud the authors of a recent CMAJ article for their usable framework for the development and adoption of machine-learned solutions1 and propose that this will be useful to guide the use of machine learning in paramedicine. Paramedic clinical decision-making is well positioned to benefit from machine learning, given the prevalence of large paramedic data repositories in Canada. These data repositories are not just large, but are rich in structured patient data features (i.e., clinical, nonclinical, administrative), such as primary complaint, medications, detailed physical assessments, vital signs (including cardiac monitoring), physiologic scores, paramedic interventions and time stamps to encode a sequence of events. These are ideal conditions to construct accurate prediction models. Given that paramedics need to make accurate clinical decisions when patient presentations are complex, machine learning algorithms could inform point-of-care treatment and more appropriate transport destinations besides emergency departments (EDs). To test the accuracy of machine learning algorithms in predicting future patient outcomes while in the prehospital field, the integration of paramedic and hospital ED data is required. Assembling and housing integrated data are barriers, but could be overcome if paramedic services partner with data scientists and data centres.
查看更多>>摘要：In their editorial published in CMAJ, Drs. Stall, Tardif and Sinha presciently highlighted that the $50 million in federal funding over 5 years will likely be inadequate to achieve the stated goals of Canada’s first national dementia strategy. This has proven true at the front lines of clinical care. As a clinician providing hospital care for people with dementia, I have been unable to detect any meaningful improvements — rather, things are getting worse, especially in acute care. Analyses by the Canadian Institute for Health Information (CIHI) show that when older adults living with dementia are admitted to hospital, they are 50% more likely to experience hospital harm and have twice the length of stay of people without dementia. Although dementia once accounted for one-third of alternate level of care (ALC) days, CIHI estimates that this impact has grown and dementia now accounts for almost half of ALC days.
查看更多>>摘要：More than 5 of every 1000 people in Canada will receive a new diagnosis of heart failure this year. Many more will have respiratory symptoms that will prompt the ordering of chest radiography. In a related research article, Torres and colleagues challenged an established rule-of-thumb of chest radiography, namely that a cardiac silhouette wider than half of the chest diameter represents cardiomegaly, which is suggestive of underlying heart failure. They compared cardiothoracic ratio measurements on chest radiographs with the gold standard of assessing cardiac enlargement with magnetic resonance imaging (MRI),3 and showed that the positive and negative likelihood ratios (LR) of the cardiothoracic ratio are unhelpful in either confirming or refuting cardiomegaly at any cutpoint. The absolute size of the cardiac silhouette was more useful, with a maximum heart diameter greater than 19 cm for men and greater than 13 cm for women associated with clinically useful LRs for predicting cardiac enlargement.
查看更多>>摘要：In Canada, commercial data brokers are currently able to use deidentified patient data from pharmacies, private drug insurers, the federal government and medical clinics without patient consent. They are able to do this because of a lack of privacy protections for deidentified data. A proposed federal privacy bill, the Consumer Privacy Protection Act (Bill C-11) would have halted disclosure of deidentified data to commercial entities, although the bill left some important issues unresolved. However, the bill died when parliament was dissolved in August 2021. Updated legislation should be strengthened to protect patient data and support appropriate uses. We discuss how deidentified patient data are currently being used, potential harms of their use, views of patients and the public about the use of their deidentified data and how legislation can be strengthened to better protect people in Canada.
查看更多>>摘要：Physicians often hesitate to prescribe β-blocker therapy for patients who actively use stimulants, even for indications such as heart failure with reduced ejection fraction and tachyarrhythmias, worrying that potentially harmful interactions will outweigh well-established benefits. The American Heart Association guidelines for the management of non-ST elevation myocardial infarction (NSTEMI), published in 2014, advise against using β-blockers in acute myocardial infarction with signs of acute stimulant intoxication, unless patients are also receiving a coronary vasodilator. Outside of acute stimulant intoxication, however, these guidelines state that patients presenting with NSTEMI and recent stimulant use should receive the same care as patients who do not use stimulants. A Canadian guideline on heart failure makes no specific recommendations for or against the use of β-blockers in patients who use stimulants. We argue that in the absence of guidance to the contrary, doctors should reconsider their tendency to withhold β-blockers from patients who use stimulants.
Joel G. RayJon BarrettHoward BergerMichael Geary...
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查看更多>>摘要：Background: People whose singleton pregnancy is affected by hypertensive disorders of pregnancy (HDP) are at risk of future cardiovascular disease. It is unclear, however, whether this association can be extrapolated to twin pregnancies. We aimed to compare the association between HDP and future cardiovascular disease after twin and singleton pregnancies. Methods: We conducted a populationbased retrospective cohort study that included nulliparous people in Ontario, Canada, 1992-2017. We compared the future risk of cardiovascular disease among pregnant people from the following 4 groups: those who delivered a singleton without HDP (referent) and with HDP, and those who delivered twins either with or without HDP. Results: The populations of the 4 groups were as follows: 1431651 pregnant people in the singleton birth without HDP group; 98631 singleton birth with HDP; 21046 twin birth without HDP; and 4283 twin birth with HDP. The median duration of follow-up was 13 (interquartile range 7-20) years. The incidence rate of cardiovascular disease was lowest among those with a singleton or twin birth without HDP (0.72 and 0.74 per 1000 person-years, respectively). Compared with people with a singleton birth without HDP, the risk of cardiovascular disease was highest among those with a singleton birth and HDP (1.47 per 1000 person-years; adjusted hazard ratio [HR] 1.81 [95% confidence interval (Cl) 1.72-1.90]), followed by people with a twin pregnancy and HDP (1.07 per 1000 person-years; adjusted HR 1.36 [95% Cl 1.04-1.77]) (see figure). The risk of the primary outcome after a twin pregnancy with HDP was lower than that after a singleton pregnancy with HDP (adjusted HR 0.74 [95% Cl 0.57-0.97]), when compared directly. Interpretation: In a twin pregnancy, HDP are weaker risk factors for postpartum cardiovascular disease than in a singleton pregnancy.
查看更多>>摘要：Background: Keratinocyte carcinoma is the most common malignant disease, but it is not captured in major registries. We aimed to describe differences by sex in the incidence and mortality rates of keratinocyte carcinoma in Ontario, Canada. Methods: We conducted a populationbased retrospective study of adults residing in Ontario between Jan. 1,1998, and Dec. 31, 2017, using linked health administrative databases. We identified the first diagnosis of keratinocyte carcinoma using a validated algorithm of health insurance claims, and deaths related to keratinocyte carcinoma from death certificates. We calculated the incidence and mortality rates of keratinocyte carcinoma, stratified by sex, age and income quintile. We evaluated trends using the average annual percentage change (AAPC) based on joinpoint regression. Results: After decreasing from 1998 to 2003, the incidence rate of keratinocyte carcinoma increased by 30% to 369 per 100 000 males and 345 per 100 000 females in 2017 (AAPC 1.9%, 95% confidence interval [Cl] 1.7 to 2.1 from 2003 to 2017) (see figure). The incidence rate was higher in females younger than 55 years, but higher in males aged 55 years or older. Between 2008 and 2017, the incidence rate rose faster in females than males aged 45-54 years (AAPC 1.2% v. 0.5%, p = 0.01) and 55-64 years (1.2% v. 0.1%, p < 0.01). The incidence was higher in males than females in the higher income quintiles. Between 1998 and 2017, the mortality rate of keratinocyte carcinoma was 1.8 times higher in males than females, on average, and rose 4.8-fold overall (AAPC 8.9%, 95% Cl 6.4 to 11.4 in males; 8.0%, 95% Cl 5.3-10.8 in females). Interpretation: The population burden of keratinocyte carcinoma is growing, and the incidence and mortality rates rose disproportionately among certain sex- and age-specific groups. This warrants further investigation into causal factors and renewed preventive public health measures.
Zamir MeraliArmaan K. MalhotraMichael BalasGianni R. Lorello...
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查看更多>>摘要：Background: Differences in physician income by gender have been described in numerous jurisdictions, but few studies have looked at a Canadian cohort with adjustment for confounders. In this study, we aimed to understand differences in fee-for-service payments to men and women physicians in Ontario. Methods: We conducted a cross-sectional analysis of all Ontario physicians who submitted claims to the Ontario Health Insurance Plan (OHIP) in 2017. For each physician, we gathered demographic information from the College of Physicians and Surgeons of Ontario registry. We compared differences in physician claims between men and women in the entire cohort and within each specialty using multivariable linear regressions, controlling for length of practice, specialty and practice location. Results: We identified a cohort of 30167 physicians who submitted claims to OHIP in 2017, including 17 992 men and 12175 women (see figure). When controlling for confounding variables in a linear mixed-effects regression model, annual physician claims were $93 930 (95% confidence interval $88 434 to $99 431) higher for men than for women. Women claimed 74% as much as men when adjusting for covariates. This discrepancy was present in nearly all specialty categories. Men claimed more than women throughout their careers, with the greatest gap 10-15 years into practice. Interpretation: We found a gender gap in fee-for-service claims in Ontario, with women claiming less than men overall and in nearly every specialty. Further work is required to understand the root causes of the gender pay gap.
查看更多>>摘要：Background: Active screening for tuberculosis (TB) involves systematic detection of previously undiagnosed TB disease or latent TB infection (LTBI). It may be an important step toward elimination of TB among Inuit in Canada. We aimed to evaluate the cost-effectiveness of community-wide active screening for TB infection and disease in 2 Inuit communities in Nunavik. Methods: We incorporated screening data from the 2 communities into a decision analysis model. We predicted TB-related health outcomes over a 20-year time frame, beginning in 2019. We assessed the cost-effectiveness of active screening in the presence of varying outbreak frequency and intensity. We also considered scenarios involving variation in timing, impact and uptake of screening programs. Results: Given a single large outbreak in 2019, we estimated that 1 round of active screening reduced TB disease by 13% (95% uncertainty range -3% to 27%) and was cost saving compared with no screening, over 20 years. In the presence of simulated large outbreaks every 3 years thereafter, a single round of active screening was cost saving, as was biennial active screening. Compared with a single round, we also determined that biennial active screening reduced TB disease by 59% (95% uncertainty range 52% to 63%) (see table) and was estimated to cost Can$6430 (95% uncertainty range -$29131 to $13 658 in 2019 Can$) per additional active TB case prevented. With smaller outbreaks or improved rates of treatment initiation and completion for people with LTBI, we determined that biennial active screening remained reasonably cost-effective compared with no active screening. Interpretation: Active screening is a potentially cost-saving approach to reducing disease burden in Inuit communities that have frequent TB outbreaks.
Felipe Soares TorresDiego A. EiferFelipe Sanchez TimesElsie T. Nguyen...
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查看更多>>摘要：Background: The cardiothoracic ratio (CTR) is commonly assessed on chest radiography for detection of cardiac chamber enlargement, but the traditional cutpoint of 0.5 has low specificity. We sought to evaluate the diagnostic accuracy of new measurement techniques for the detection of cardiac enlargement on chest radiographs. Methods: We obtained retrospective cross-sectional data on consecutive patients who underwent both chest radiography and cardiac magnetic resonance imaging (MRI) within a 14-day interval between 2006 and 2016 at a large academic hospital network. We established the presence of cardiac chamber enlargement using cardiac MRI as the reference standard. We evaluated the diagnostic performance of different techniques for measuring heart size and CTR on frontal chest radiographs. Results: Of 152 patients included, 81 (53%) were men and the mean age was 52 years. Maximum heart diameter had the highest area under the receiver operating characteristic curve for detection of cardiac enlargement (0.827, 95% confidence interval 0.760-0.894). In the subgroup of posteroanterior chest radiography studies (n = 101), a CTR cutpoint of 0.50 had only moderate sensitivity (72%) and specificity (72%). In men, a maximum heart diameter cutpoint of 15 cm had a sensitivity of 86% and a negative likelihood ratio of 0.24, and a cutpoint of 19 cm had a specificity of 100% and a positive likelihood ratio of infinity. In women, a maximum heart diameter cutpoint of 13 cm had a sensitivity of 91% and a negative likelihood ratio of 0.15, and a cutpoint of 17 cm had a specificity of 91% and a positive likelihood ratio of 3.5 (see table). Interpretation: A traditional CTR cut-point of 0.5 has limited diagnostic value. Simple heart diameter measurements have higher diagnostic performance measures than CTR.
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