Charlotte CrosbieAllan McDougallHarpreet PangliRiyad B. Abu-Laban...
1页
查看更多>>摘要：Background: An understanding of regulatory complaints against resident physicians is important for practice improvement. We describe regulatory college complaints against resident physicians using data from the Canadian Medical Protective Association (CMPA). Methods: We conducted a retrospective analysis of college complaint cases involving resident doctors closed by the CMPA, a mutual medicolegal defence organization for more than 100000 physicians, representing an estimated 95% of Canadian physicians. Eligible cases were those closed between 2008 and 2017 (for time trends) or between 2013 and 2017 (for descriptive analyses). To explore the characteristics of college cases, we extracted the reason for complaint, the case outcome, whether the complaint involved a procedure, and whether the complaint stemmed from a single episode or multiple episodes of care. We also conducted a 10-year trend analysis of cases closed from 2008 to 2017, comparing cases involving resident doctors with cases involving only nonresident physicians. Results: Our analysis included 142 cases that involved 145 patients. Over the 10-year period, college complaints involving residents increased significantly (p = 0.003) from 5.4 per 1000 residents in 2008 to 7.9 per 1000 in 2017 (see figure). While college complaints increased for both resident and nonresident physicians over the study period, the increase in complaints involving residents was significantly lower than the increase across all nonresident CMPA members (p < 0.001). For cases from the descriptive analysis (2013-2017), the top complaint was deficient patient assessment (69/142, 48.6%). Some patients (22/145, 15.2%) experienced severe outcomes. Most cases (135/142, 97.9%) did not result in severe physician sanctions. Our classification of complaints found 106 of 163 (65.0%) involved clinical problems, 95 of 163 (58.3%) relationship problems (e.g., communication) and 67 of 163 (41.1%) professionalism problems. In college decisions, 36 of 163 (22.1%) had a classification of clinical problem, 66 of 163 (40.5%) a patient-physician relationship problem and 63 of 163 (38.7%) a professionalism problem. In 63 of 163 (38.7%) college decisions, the college had no criticism. Interpretation: Problems with communication and professionalism feature prominently in resident college complaints, and we note the potential for mismatch between patient and health care provider perceptions of care. These results may direct medical education to areas of potential practice improvement.
查看更多>>摘要：Background: As the leading cause of emergency department visits in Canada, pain disproportionately affects socioeconomically disadvantaged populations. We examine the association between household food insecurity and individuals’ pain-driven emergency department visits. Methods: We designed a cross-sectional study linking the Canadian Community Health Survey 2005-2017 to the National Ambulatory Care Reporting System 2003-2017. Food insecurity was measured using a validated questionnaire. We excluded individuals with missing food insecurity status, individuals younger than 12 years and jurisdiction-years with partial emergency department records. We assessed emergency department visits driven by pain at different sites (migraine, other headaches, chestthroat pain, abdomen-pelvis pain, dorsalgia, joint pain, limb pain, other pain) and their characteristics (frequency, cause, acuity and time of emergency department visit) in Ontario and Alberta. We adjusted for sociodemographic characteristics, lifestyle and prior non-pain-driven emergency department visits in the models. Results: The sample contained 212300 individuals aged 12 years and older. Compared with food-secure individuals, marginally, moderately and severely food-insecure people had 1.42 (95% confidence interval [Cl] 1.20-1.68), 1.64 (95% Cl 1.37-1.96) and 1.99 (95% Cl 1.61-2.46) times higher adjusted incidence rates of pain-driven emergency department visits, respectively. The association was similar across sexes and significant among adults but not adolescents (see figure). Food insecurity was further associated with site-specific pain, with severely food-insecure individuals having significantly higher pain incidence than food-secure individuals. Severe food insecurity predicted more frequent, multicause, high-acuity and after-hours emergency department visits. Interpretation: Household food insecurity status is significantly associated with pain-driven emergency department visits in the Canadian population. Policies targeting food insecurity may reduce pain and emergency department utilization.
Mohammad AlkhalilMicha? KuzemczakAlan BellSol Stern...
11页
查看更多>>摘要：After an acute coronary syndrome, as many as 1 in 5 patients will have a second ischemic event within 5 years. Residual risk is related to several factors that may be mitigated by pharmacologic and nonpharmacologic interventions. Antiplatelet therapy is a cornerstone in the management of acute coronary syndrome. Acetylsalicylic acid (ASA) — a cyclooxygenase-1 inhibitor — was introduced as an effective treatment for myocardial infarction almost 5 decades ago and remains the most widely used antiplatelet therapy. Although ASA is effective in reducing mortality rates, combining ASA with a second antiplatelet agent, a P2Y12 receptor inhibitor (known as dual antiplatelet therapy [DART]) provides additional benefit and is now the preferred initial strategy for acute coronary syndromes over ASA alone. We review emerging evidence regarding the use of antiplatelet therapy in acute coronary syndromes, as well as updates to the Canadian and European Society of Cardiology guidelines that highlight adjustments in the choice and duration of antiplatelet therapy, in addition to ASA (Box 1). We particularly focus on strategies to reduce bleeding risk after percutaneous coronary intervention (PCI).
Gregory CostainRonald D. CohnStephen W. SchererChristian R. Marshall...
4页
查看更多>>摘要：Genetic testing of patient constitutional DNA (i.e., their genome) is increasingly performed in medical practice. Sequencing an entire human genome (about 3.2 billion nucleotides) is now possible to complete in days to weeks, and at a similar cost to some advanced imaging tests or to a brief admission to hospital. Genome sequencing is being integrated into health care systems internationally, most notably in the United Kingdom. Starting in 2021, genome sequencing is being performed as a clinical genetic test in Ontario, Canada. What is genome sequencing? Genome sequencing (or whole genome sequencing) is a comprehensive test capable of detecting nearly all DNA variation in a genome. Sequencing can diagnose most of the > 6000 conditions listed in the Online Mendelian Inheritance in Man database (www.omim.org) for which the genetic basis is currently understood. These include cystic fibrosis, Duchenne muscular dystrophy, familial hypercholesterolemia, hemophilia A, Lynch syndrome, Marfan syndrome and multiple endocrine neoplasia. Most diagnoses are individually rare (i.e., < 1 in 2000 live births) or ultra-rare (i.e., < 100 people reported in the medical literature), and thus less likely to be suspected a priori (e.g., Kabuki syndrome; Figure 1). Patients may present with unusual constellations of features, or with common diseases like autism spectrum disorder, cardiomyopathy, congenital heart disease, epilepsy, cancer, schizophrenia or dementia, although this list is not comprehensive.
Jordan MahAnthony LieuEmma HolmesStephen Vaughan...
6页
查看更多>>摘要：A 71-year-old man presented to the emergency department with a 4-month history of weight loss, anorexia and constipation, and a 2-week history of abdominal pain. He had biopsy-proven immunoglobulin G4 (lgG4)-related disease involving the pancreas and kidneys with 2 episodes of Gramnegative bacteremia over the past 3 years. The first episode was attributed to cholangitis and the second to a suspected obstructive pancreatic cancer. For these reasons, he underwent a cholecystectomy and Roux-en-Y hepaticojejunostomy; no cancer was found. During the previous 3 years, he had received multiple courses of immunosuppressive medications for flares of lgG4-related disease, including rituximab, mycophenolate mofetil and many courses of high-dose steroids (Figure 1). About 1 month before presentation, he had been started on high-dose steroids to treat a flare of lgG4-related disease causing acute kidney injury. He had immigrated from China 40 years earlier and had not travelled recently.
查看更多>>摘要：1 Multiple myeloma is the second most common malignant hematologic disease in Canada The incidence of multiple myeloma in Canada is 55 per 1000000 people, and the prevalence is increasing.1 Novel therapies, such as immunomodulatory drugs and proteasome inhibitors, have increased progression-free 5-year survival from 29% in 1997 to 68% in 2014 among patients who have received autologous stem cell transplantation. 2 All patients with multiple myeloma should be referred early for assessment of transplant eligibility Eligibility for therapy, including autologous stem cell transplant, is determined not only by age and renal function, but also by comorbidities and functional status.3 All-cause mortality rates 100 days post-transplantation are similar for younger (40-60 yr) compared with older (≥ 60 yr) patients (1% v. 2%). 3 Bisphosphonates are recommended for all patients with multiple myeloma, regardless of evidence of bone disease Zoledronic acid and pamidronate prevent osteopenia, lytic disease and fractures. Dosing and frequency depend on indications and risk factors.4 Use of more potent intravenous bisphosphonates, however, increases the risk of osteonecrosis of the jaw; regular dental assessments can reduce associated risks.
查看更多>>摘要：1 Routine care for transgender men should include discussions of fertility goals Fertility planning for all transgender men, particularly those with a uterus, should be discussed at regular intervals without assumption of type of sexual activity or fertility goals.1 For patients aiming for pregnancy, clinicians should discuss both medical and psychosocial expectations from preconception to postpartum. 2 Testosterone is not a form of contraception, even in patients who are amenorrheic Transgender men with a uterus are at risk of unplanned pregnancy. Limited literature suggests similarly high rates of unplanned pregnancies in this population as in ciswomen and similar uptake of all contraceptive options, from barrier methods to hormonal contraceptives.1 Oral contraceptives may be used concurrently with androgenic hormone therapy. 3 Preconception counselling in transgender men must include discussion around continuation of testosterone therapy Testosterone has teratogenic effects; specifically it can cause abnormal urogenital development in a female fetus. Therefore, testosterone should not be used while attempting conception or during pregnancy.
查看更多>>摘要：An 81-year-old woman presented to the emergency department with a 2-week history of malaise, fever and anorexia, with oral pain and odynophagia. Her medical history was remarkable only for type 2 diabetes mellitus. She was not taking any immunosuppressive agents. Her body temperature was 37.7°C, and other vital signs were normal. Physical examination showed multiple yellowish-white, pseudomembranous lesions on the patient’s tongue (Figure 1A). The rest of the physical examination was unremarkable. Esophagogastroduodenoscopy showed multiple shallow ulcers with a white coating (Figure 1B and Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/ cmaj.210352/tab-related-content). Glossal and esophageal biopsies showed multinucleated cells with moulded, groundglass nuclei (Appendix 2, available at www.cmaj.ca/lookup/doi/10.1503/cmaj ,210352/tab-related-content). Results from polymerase chain reaction and immunohistochemical staining of the specimens were positive for herpes simplex virus type 1 (HSV-1), and we diagnosed herpetic glossitis and esophagitis. We did not find any evidence of malignant disease on a whole body computed tomography scan and upper and lower endoscopy. The patient’s HIV test result was negative and her hemoglobin A1c was 7.2%. We treated her with a 7-day course of acyclovir, intravenously because of her odynophagia, and the oral and esophageal lesions completely resolved.
查看更多>>摘要：Quebec’s recent move to tax people who refuse COVID-19 vaccinations reopened debate about the merits of such penalties. Premier Fran?ois Legault said that choosing to remain unvaccinated has consequences for the health care system and not all Quebecers should foot the bill. Roughly one in 10 adults in Quebec remain unvaccinated, yet they account for an outsized share of COVID-19 hospitalizations and about half of all intensive care patients. With hospitals postponing surgeries and some 20 000 health workers sick with COVID-19, fining those who refuse vaccinations becomes “a question of fairness,” Legault said. The new “health contribution” will apply only to unvaccinated adults without medical exemptions. The government is still working out the details, but Legault said the levy would be “significant” and higher than $100. Do penalties boost vaccination rates? Some experts argue that increasing penalties for unvaccinated people may further entrench those opposed to vaccination. Others say that governments should focus on building trust in vaccines and offer rewards for getting the shots instead.
查看更多>>摘要：The COVID-19 pandemic has been a catalyst for more accessible abortion care in Canada, even as other countries report increasing barriers to the service. Until recently, most people seeking abortions in Canada had to travel to clinics or hospitals — and sometimes out of the province or country — leading to major gaps in access. The approval in 2015 of the abortion pill, mifepristone, raised hopes that some of these gaps could be closed, but it was another two years before people could take the medication at home. Making mifepristone available as a normal prescription increased the proportion of medical abortions in Canada from roughly 2% to 31% without any change in complications or the overall abortion rate. But according to a study of more than 300 Canadian abortion providers published in Family Practice, fewer than one in five had any experience providing medical abortions by telemedicine before the pandemic. By January 2021, however, nearly nine in 10 reported providing some or all aspects of abortion care virtually — from counselling and prescribing to follow up and emergency care.
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