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Jiayu Yang, Catherine Smith, Anthony Battad
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.201983-f

Jennifer Yin Yee Kwan, May Tsao, Elizabeth A. Barnes
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210307

Richard J. Huntsman, Lauren E. Kelly, Jane Alcorn, Juan Pablo Appendino, Richard E. Bélanger, Bruce Crooks, Yaron Finkelstein, Andrea Gilpin, Evan Lewis, Catherine Litalien, et al.
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.202169

Darren Wan-Teck Lim, Dorothy Hui Lin Ng, Jenny Guek-Hong Low
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210696-f

Abstract:
Une femme de 34 ans s’est présentée pour une consultation externe avec un œdème et un érythème au site d’une cicatrice du vaccin bacille de Calmette–Guérin (BCG) obtenu dans son enfance, 7 jours après avoir reçu sur le bras ipsilatéral sa première dose du vaccin à acide ribonucléique messager (ARN messager) BNT162b2 (Pfizer-BioNTech) contre le SRAS-CoV-2 (figure 1A). Elle a signalé une myalgie et de la fatigue associées au vaccin. Le site d’injection du vaccin BNT162b2 n’était pas enflammé. On a administré la deuxième dose du vaccin sans incident.
Caroline Jeon, Kevin Gough
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.201892-f

Abstract:
Un homme de 60 ans vivant avec le VIH a consulté son médecin de famille pour des problèmes de concentration depuis 3 mois. Au cours des 2 dernières semaines, il a remarqué un érythème étendu et indolore au torse, au dos et aux extrémités (figure 1). Il a été consommateur de méthamphétamine en crystaux, mais pas récemment. Il déclarait avoir eu d’occasionnelles relations sexuelles non protégées avec des hommes et des femmes. Il était difficile de suivre le fil de ses pensées; son débit était rapide, il semblait distrait et formulait des plans grandioses et irréalistes, en contradiction avec sa situation actuelle. Il a perdu son entreprise et son logis. Sa numération des lymphocytes T CD4 était de 159 (488–1711) cellules/μL ou 0,16 (0,49–1,71) × 109/L et sa charge virale du VIH était de 301 108 copies d’ARN/mL.
Kimberley G.S. Thornton, Fiona Mattatall
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210013-f

Abstract:
Les professionnels de la santé devraient discuter régulièrement de fertilité avec les hommes transgenres, surtout ceux qui ont un utérus, sans faire de suppositions sur leurs activités sexuelles ou leurs objectifs génésiques1. Ils devraient parler aux patients qui souhaitent porter un enfant du processus médical et psychosocial auquel ils peuvent s’attendre, depuis la préconception jusqu’à la période postnatale2,3.
Zamir Merali, Armaan K. Malhotra, Michael Balas, Gianni R. Lorello, Alana Flexman, Tara Kiran, Christopher D. Witiw
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210437

Abstract:
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 30 167 physicians who submitted claims to OHIP in 2017, including 17 992 men and 12 175 women. 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.
Mark Keith Hewitt, Jennifer Ann Klowak, Jeffrey M. Pernica, James Leung
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210285

Seema Marwaha
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.211409

Tim Graham
Published: 17 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210794

Michelle Science, Shelly Bolotin, Michael Silverman, Jeya Nadarajah, Bryan Maguire, Rulan S. Parekh, Allison McGeer, Kevin L. Schwartz, Laura Alexander, Upton Allen, et al.
Published: 12 October 2021
Abstract:
Background: Health care workers have a critical role in the pandemic response to COVID-19 and may be at increased risk of infection. The objective of this study was to assess the seroprevalence of SARS-CoV-2 immunoglobulin G (IgG) antibodies among health care workers during and after the first wave of the pandemic. Methods: We conducted a prospective multicentre cohort study involving health care workers in Ontario, Canada, to detect IgG antibodies against SARS-CoV-2. Blood samples and self-reported questionnaires were obtained at enrolment, at 6 weeks and at 12 weeks. A community hospital, tertiary care pediatric hospital and a combined adult–pediatric academic health centre enrolled participants from Apr. 1 to Nov. 13, 2020. Predictors of seropositivity were evaluated using a multivariable logistic regression, adjusted for clustering by hospital site. Results: Among the 1062 health care workers participating, the median age was 40 years, and 834 (78.5%) were female. Overall, 57 (5.4%) were seropositive at any time point (2.5% when participants with prior infection confirmed by polymerase chain reaction testing were excluded). Seroprevalence was higher among those who had a known unprotected exposure to a patient with COVID-19 (p< 0.001) and those who had been contacted by public health because of a nonhospital exposure (p = 0.003). Providing direct care to patients with COVID-19 or working on a unit with a COVID-19 outbreak was not associated with higher seroprevalence. In multivariable logistic regression, presence of symptomatic contacts in the household was the strongest predictor of seropositivity (adjusted odds ratio 7.15, 95% confidence interval 5.42–9.41). Interpretation: Health care workers exposed to household risk factors were more likely to be seropositive than those not exposed, highlighting the need to emphasize the importance of public health measures both inside and outside of the hospital.
Marcel Tomaszewski, David Sanders, Robert Enns, Laura Gentile, Scott Cowie, Carla Nash, Denis Petrunia, Paul Mullins, Jeremy Hamm, Nazanin Azari-Razm, et al.
Published: 12 October 2021
Abstract:
Background: The risks associated with colonoscopy performed through the British Columbia Colon Screening Program (BCCSP) are not known. We aimed to determine the rate of colonoscopy-related serious adverse events within this program. Methods: For this prospective observational study, we used the BCCSP database to identify participants 50 to 74 years of age who had a positive result on fecal immunochemical testing (FIT) between Nov. 15, 2013, and Dec. 31, 2017, followed by colonoscopy. Unplanned medical events were recorded at the time of colonoscopy and 14 days later. We reviewed the unplanned events and defined them as serious adverse events if they resulted in death, hospital admission or intervention; we also classified them as probably, possibly or unlikely related to the colonoscopy. The primary outcome was the overall rate of serious adverse events; the secondary outcomes were 14-day post-colonoscopy rates of perforation, bleeding and death. Results: During the study period, a total of 96 192 colonoscopies were performed by 308 physicians at 50 sites. The median age of patients was 62 (10th–90th percentile 52–71) years, and 56% were male. Of these, 78 831 patients were contacted after the colonoscopy. Serious adverse events were deemed to have occurred in 350 colonoscopies (44 per 10 000, 95% confidence interval [CI] 39–50 per 10 000), with a number needed to harm of 225. Of the 332 (94.9%) serious adverse events that were probably or possibly related to colonoscopy, perforation occurred in 6 (95% CI 5–8) per 10 000 colonoscopies, bleeding in 26 (95% CI 22–30) per 10 000 colonoscopies and death in 3 (95% CI 1–10) per 100 000 colonoscopies. Interpretation: The rate of serious adverse events associated with colonoscopy in the BCCSP was in keeping with previous publications and met accepted benchmarks. The findings of this study inform stakeholders of the risks associated with colonoscopy in an FIT-based colon screening program.
Keerat Grewal, Clare L. Atzema, Peter C. Austin, Kerstin de Wit, Sunjay Sharma, Nicole Mittmann, Bjug Borgundvaag, Shelley L. McLeod
Published: 11 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210811

Abstract:
Background: Intracranial hemorrhage (ICH) after head injury is a concern among older adult patients on anticoagulation. We evaluated the risk of ICH after an emergency department visit for head injury among patients 65 years and older taking warfarin or a direct oral anticoagulant (DOAC) compared with patients not taking anticoagulants. We also evaluated risk of 30-day mortality and neurosurgical intervention among patients with ICH. Methods: In this retrospective cohort study, we used population-based data of patients 65 years and older seen in an Ontario emergency department with a head injury. We matched patients on the propensity score to create 3 pairwise-matched cohorts based on anticoagulation status (warfarin v. DOAC, warfarin v. no anticoagulant, DOAC v. no anticoagulant). For each cohort, we calculated the relative risk of ICH at the index emergency department visit and 30-day mortality. We also calculated the hazard of neurosurgical intervention among patients with ICH. Results: We identified 77 834 patients with head injury, including 64 917 (83.4%) who were not on anticoagulation, 9214 (11.8%) who were on DOACs and 3703 (4.8%) who were on warfarin. Of these, 5.9% of patients had ICH at the index emergency department visit. Patients on warfarin had an increased risk of ICH compared with matched patients on DOACs (relative risk [RR] 1.43, 95% confidence interval [CI] 1.20–1.69) and patients not on anticoagulation (RR 1.36, 95% CI 1.15–1.61). We did not observe a difference in ICH between patients on DOACs compared with matched patients not on anticoagulation. In patients with ICH, 30-day mortality did not differ by anticoagulation status or type. Patients on warfarin had an increased hazard of neurosurgery compared with patients not on anticoagulation. Interpretation: Patients on warfarin seen in the emergency department with a head injury had higher relative risks of ICH than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of ICH for patients on a DOAC was not significantly different compared with no anticoagulation. Further research should confirm that older adults using warfarin are the only group at higher risk of ICH after head injury.
Joel W. Howlett, Matthew Hearn, Cameron Bakala
Published: 11 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.202803-f

Ginette Moores, Rohan D’Souza, Esther Bui
Published: 11 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210065-f

Abstract:
L’utilisation d’anticonvulsivants s’est répandue; en effet, 90 % des patientes en prennent pour traiter une maladie psychiatrique ou des douleurs1. L’exposition in utero à ces agents est associée à un risque de malformations congénitales majeures de 2 à 5 fois plus grand qui varie d’un médicament à l’autre. Le risque est moindre (2 %–3 %) avec la lamotrigine, le lévétiracétam et l’oxcarbazépine et plus élevé avec le valproate (5 %–15 %), surtout lorsqu’il est pris avec d’autres anticonvulsivants2.
Miriam Kimpton, Srishti Kumar, Philip S. Wells, Doug Coyle, Marc Carrier, Kednapa Thavorn
Published: 11 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210523

Abstract:
Background: Apixaban (2.5 mg) taken twice daily has been shown to substantially reduce the risk of venous thromboembolism (VTE) compared with placebo for the primary thromboprophylaxis of ambulatory patients with cancer who are starting chemotherapy and are at intermediate-to-high risk of VTE. We aimed to compare the health system costs and health benefits associated with primary thromboprophylaxis using apixaban with those associated with the current standard of care (where no primary thromboprophylaxis is given), from the perspective of Canada’s publicly funded health care system in this subpopulation of patients with cancer over a lifetime horizon. Methods: We performed a cost–utility analysis to estimate the incremental cost per quality-adjusted life-year (QALY) gained with primary thromboprophylaxis using apixaban. We obtained baseline event rates and the efficacy of apixaban from the Apixaban for the Prevention of Venous Thromboembolism in High-Risk Ambulatory Cancer Patients (AVERT) trial on apixaban prophylaxis. We estimated relative risk for bleeding, risk of complications associated with VTE treatment, mortality rates, costs and utilities from other published sources. Results: Over a lifetime horizon, apixaban resulted in lower costs to the health system (Can$7902.98 v. Can$14 875.82) and an improvement in QALYs (9.089 v. 9.006). The key driver of cost–effectiveness results was the relative risk of VTE as a result of apixaban. Results from the probabilistic analysis showed that at a willingness to pay of Can$50 000 per QALY, the strategy with the highest probability of being most cost-effective was apixaban, with a probability of 99.87%. Interpretation: We found that apixaban is a cost-saving option for the primary thromboprophylaxis of ambulatory patients with cancer who are starting chemotherapy and are at intermediate-to-high risk of VTE.
Kristyna Cleminson, Mary Lou Baxter
Published: 11 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210448

Sabrina H.M. Yeung, Lianne E. Rotin, Kevin Singh, Robert Wu, Matthew B. Stanbrook
Published: 11 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210439

Trauma 2021Perceptions of a trauma team regarding in situ simulationEpidemiology of submersion injuries in Canadian children and adolescents: 1990–2018A survey of medical and administrative directors on REBOA use in Canadian trauma centresCut to the chase: comparing cutting tools in the exposure of simulated trauma patientsPediatric major trauma. Anaesthesia education: airway, breathing, coffee and cases 2020–2021Geriatric trauma care at a level 1 trauma centre: Are we following best practice?Was the introduction of a provincially standardized consensus statement for postintubation analgesia and sedation associated with increased use of associated pharmacological therapies in New Brunswick?Are there important variations in the care of adult trauma patients with isolated, nonoperative subdural hematomas between those admitted to a neurosurgical centre and those admitted to a non-neurosurgical centre for their entire inpatient stay?Flattening the curve on the negative psychosocial impact of trauma on the family of acute care trauma survivors: a quantitative studyDoes ACLS belong in ATLS? Seeking evidence during resuscitative thoracotomyAutologous omental harvest for microvascular free flap reconstruction of a severe traumatic scalp degloving injury: a case reportDerivation and validation of actionable quality indicators targeting reductions in complications for injury admissionsASA dosing practices in the management of blunt cerebrovascular injury: a retrospective reviewA retrospective analysis of bicycle lane collisions in Vancouver, British Columbia, from 2012 to 2017Evaluating the Screening, Brief Intervention and Referral to Treatment (SBIRT) process at Vancouver General HospitalAlcohol use and trauma in Alberta after COVID-19 lockdown: overrepresentation and undertreatment are opportunities for improvementMental health and addiction diagnoses are linked to increased violent injuries and gaps in provision of resources during the COVID-19 pandemicPain management strategies after orthopedic trauma in a level 1 trauma centre: a descriptive study with a view of optimizing practicesStudy to Actively Warm Trauma Patients (STAY WARM): a feasibility pilot evaluationPrehospital trauma care in civilian and military settings including cold environments: a systematic review and knowledge gap analysisAntibiotic administration in open fractures: adherence to guidelines at a Canadian trauma centreAre we meeting massive transfusion protocol activation and blood product delivery times in trauma patients? A retrospective review from 2014 to 2018Unplanned returns to the operating room: a quality improvement initiative at a level 1 trauma centreStopping the bleed: the history and rebirth of Canadian freeze-dried plasmaThe state of the evidence for emergency medical services (EMS) care of prehospital severe traumatic brain injury: an analysis of appraised research from the Prehospital Evidence-based Practice programA mixed methods study of a...
Olga Bednarek, Mike O’Leary, Sean Hurley, Caleb Cummings, Ruth Bird, Sidney Frattini, Stacey McEachern, Susan Benjamin, Asha Pereira, William Brigode, et al.
Published: 4 October 2021
Canadian Journal of Surgery, Volume 64; https://doi.org/10.1503/cjs.014121

David N. Fisman, Ashleigh R. Tuite
Published: 4 October 2021
Canadian Medical Association Journal; https://doi.org/10.1503/cmaj.211248

Abstract:
Background: Between February and June 2021, the initial wild-type strains of SARS-CoV-2 were supplanted in Ontario, Canada, by new variants of concern (VOCs), first those with the N501Y mutation (i.e., Alpha/B1.1.17, Beta/B.1.351 and Gamma/P.1 variants) and then the Delta/B.1.617 variant. The increased transmissibility of these VOCs has been documented, but knowledge about their virulence is limited. We used Ontario’s COVID-19 case data to evaluate the virulence of these VOCs compared with non-VOC SARS-CoV-2 strains, as measured by risk of hospitalization, intensive care unit (ICU) admission and death. Methods: We created a retrospective cohort of people in Ontario who tested positive for SARS-CoV-2 and were screened for VOCs, with dates of test report between Feb. 7 and June 27, 2021. We constructed mixed-effect logistic regression models with hospitalization, ICU admission and death as outcome variables. We adjusted models for age, sex, time, vaccination status, comorbid­ities and pregnancy status. We included health units as random intercepts. Results: Our cohort included 212 326 people. Compared with non-VOC SARS-CoV-2 strains, the adjusted elevation in risk associated with N501Y-positive variants was 52% (95% confidence interval [CI] 42%–63%) for hospitalization, 89% (95% CI 67%–117%) for ICU admission and 51% (95% CI 30%–78%) for death. Increased risk with the Delta variant was more pronounced at 108% (95% CI 78%–140%) for hospitalization, 235% (95% CI 160%–331%) for ICU admission and 133% (95% CI 54%–231%) for death. Interpretation: The increasing virulence of SARS-CoV-2 VOCs will lead to a considerably larger, and more deadly, pandemic than would have occurred in the absence of the emergence of VOCs.
Guifeng Chen, Zhongjie Li, Guodong Ding
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.202663-f

Abstract:
Un garçon de 10 ans a été dirigé vers le département de pédiatrie pour douleur et œdème croissants au coude droit depuis une dizaine de jours et une faible fièvre intermittente. Il n’avait aucun autre symptôme constitutionnel, tel que perte de poids, diaphorèse nocturne ou malaise, et ses symptômes ne s’étaient pas améliorés à la suite d’une antibiothérapie orale par cefprozil (15 mg/kg/j, 2 fois par jour pendant 6 jours). L’enfant a déclaré avoir été mordu à l’index droit par un chat errant 4 semaines auparavant et présentait une lésion résiduelle de 0,5 cm. Ses ganglions lymphatiques supra-et épitrochléaires étaient hypertrophiés et sensibles, et il avait des ganglions plus petits, mais sensibles à l’aisselle ipsilatérale. Nous n’avons pas observé d’hépatosplénomégalie ni d’autres lymphadénopathies. Des échographies de la partie supérieure du bras et de l’aisselle droite ont montré des masses hyperémiques solides, échogènes et bien délimitées, avec des pédicules vasculaires proéminents typiques des ganglions lymphatiques hypertrophiés (figure 1 et annexe 1, accessible en anglais au www.cmaj.ca/lookup/doi/10.1503/cmaj.202663/tab-related-content). Les résultats des analyses sérologiques visant le virus Epstein–Barr, le cytomégalovirus, les adénovirus, les mycoplasma, la toxoplasmose, la syphilis et le VIH se sont révélés négatifs. L’analyse par séquençage métagénomique de nouvelle génération à partir d’un échantillon de sang entier a montré la présence d’une infection à Bartonella henselae. Le patient ne tolérant pas l’azithromycine orale, nous l’avons traité au moyen d’azithromycine intraveineuse (10 mg/kg/j, 1 fois par jour) pendant 7 jours. Sa fièvre s’est rapidement résorbée et ses ganglions lymphatiques ont graduellement diminué de volume. L’enfant est resté bien et n’a signalé aucun autre symptôme lors des suivis périodiques.
Olivia Geen, Bram Rochwerg, Xuyi Mimi Wang
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210652

A. Kinga Malinowski, Ally Murji
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210007-f

Abstract:
La carence en fer prénatale s’observe chez plus de 30 % des personnes enceintes au Canada1; elle a été associée à un faible poids à la naissance, à une petite taille par rapport à l’âge gestationnel, à la prématurité, au besoin de transfusions pour la mère, à l’hémorragie post-partum2,3 et à des effets neurocognitifs à long terme chez l’enfant4.
Anne Pham-Huy, Karina A. Top, Cora Constantinescu, Cynthia H. Seow, Darine El-Chaâr
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.202391-f

Evan Tang, Kinwah Fung, An-Wen Chan
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210595

Abstract:
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 population-based 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 [CI] 1.7 to 2.1 from 2003 to 2017). 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% CI 6.4 to 11.4 in males; 8.0%, 95% CI 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.
Irene López Riquelme, Elisabeth Gómez Moyano
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210310

Gabriel Crevier-Sorbo, Aura Cernii, Andrei Cepoi
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210551

George Mundy-Baird, Angelos Kyriacou, Akheel A. Syed
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.202787-f

Abstract:
Une femme de 41 ans a consulté à l’hôpital pour un œdème et de la douleur à la portion antérieure du cou, aggravés par la déglutition, après une maladie des voies respiratoires supérieures fébrile d’une durée d’une semaine. Elle présentait un goitre extrêmement sensible et un léger tremblement des mains. Sa température était de 37,1 °C, sa fréquence cardiaque, de 92–122 battements/minute et sa tension artérielle, de 116/68 mm Hg. Son taux de thyréostimuline était indétectable à < 0,01 mU/L (valeurs normales 0,35–5,50), et ses taux de thyroxine libre (59,0 pmol/L; valeurs normales 10,0–20,0) et de triiodothyronine libre (27,4 pmol/L; valeurs normales 3,5–6,5) étaient élevés. Son taux de protéine C-réactive et sa vitesse de sédimentation érythrocytaire étaient élevés (annexe 1, accessible en anglais au www.cmaj.ca/lookup/doi/10.1503/cmaj.202787/tab-related-content). Les urgentologues ont écarté la thyroïdite suppurée et l’abcès thyroïdien avec une tomodensitométrie (TDM) qui a montré une hypertrophie de la thyroïde (figure 1). L’endocrinologue a diagnostiqué une thyroïdite subaiguë et a prescrit un court traitement de prednisolone orale, d’ibuprofène et de propranolol; la douleur et la taille du goitre de la patiente ont diminué en l’espace de 24 heures. Après son congé hospitalier, ses symptômes sont rentrés dans l’ordre sans autre intervention, après quoi elle a eu une période d’hypothyroxinémie asymptomatique, puis un retour à l’euthyroïdie (annexe 1).
Alexander Kumachev, David W. Frost
Published: 3 October 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210359

Abstract:
Clinicians obtain ferritin levels when they suspect iron deficiency or overload; they may also obtain ferritin levels during the work-up of some hematologic or autoimmune conditions.1–4 Levels may be elevated in many chronic conditions (Box 1) or during acute illness, which can confound interpretation.2 Levels that return to normal after resolution of illness do not require further investigation.
Katie Oxford, Greg Walsh, Jonathan Bungay, Stephen Quigley, Adam Dubrowski
Published: 27 September 2021
Canadian Journal of Surgery, Volume 64; https://doi.org/10.1503/cjs.018719

Abstract:
Background It is critical that junior residents be given opportunities to practise bowel anastomosis before performing the procedure in patients. Three-dimensional (3D) printing is an affordable way to provide realistic, reusable intestinal simulators. The aim of this study was to test the face and content validity of a 3D-printed simulator for bowel anastomosis. Methods The bowel anastomosis simulator was designed and assembled with the use of desktop 3D printers and silicone solutions. The production cost ranges from $2.67 to $131, depending on which aspects of the model one prefers to include. We incorporated input from a general surgeon regarding design modifications to improve the realism of the model. Nine experts in general surgery (6 staff surgeons and 3 senior residents) were asked to perform an anastomosis with the model and then complete 2 surveys regarding face and content validity. Items were rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). Results The overall average score for product quality was 3.58, indicating good face validity. The average score for realism (e.g., flexibility and texture of the model) was 3.77. The simulator was rated as being useful for training, with an overall average score of 3.98. In general, the participants agreed that the simulator would be a valuable addition to current simulation-based medical education (average score 4.11). They commented that the model would be improved by adding extra layers to simulate mucosa. Conclusion Experts found the 3D-printed bowel anastomosis simulator to be an appropriate tool for the education of surgical residents, based on the model’s texture, appearance and ability to undergo an anastomosis. This model provides an affordable way for surgical residents to learn bowel anastomosis. Future research will focus on proving educational efficacy, effectiveness and transfer that can be adapted for laparoscopic anastomosis training, hand-sewing and stapling procedures. Contexte Il est crucial que les résidents juniors aient l’occasion de s’exercer à l’anastomose intestinale avant d’intervenir sur des patients. L’impression en 3 dimensions (3D) est une façon abordable de produire des simulateurs intestinaux réalistes et réutilisables. Le but de cette étude était de vérifier la validité apparente et de contenu des simulateurs obtenus par impression 3D pour l’anastomose intestinale. Méthodes Le simulateur d’anastomose intestinale est conçu et assemblé avec des imprimantes de bureau 3D et des solutions de silicone. Le coût de fabrication varie de 2,67 $ à 131 $, selon le nombre de composants désiré. Suite aux commentaires d’un chirurgien général nous avons modifié le modèle afin de le rendre plus réaliste. Nous avons demandé à 9 experts en chirurgie générale (6 chirurgiens en poste et 3 résidents séniors) d’effectuer une anastomose sur le modèle, puis de répondre à 2 questionnaires sur sa validité apparente et de contenu. Les questions étaient notées sur une échelle de Likert en 5 points, allant de 1 (« en désaccord total ») à 5 (« tout à fait d’accord »). Résultats Le score moyen global pour la qualité du produit a été de 3,58, soit une bonne validité apparente. Le score moyen pour le réalisme (p. ex., flexibilité et texture du modèle) a été de 3,77. Le simulateur a été jugé utile pour la formation, avec un score moyen global de 3,98. En général, les participants ont convenu que le simulateur serait un ajout précieux à la formation actuelle par simulation (score moyen 4,11). Ils ont formulé un commentaire à l’effet que le modèle gagnerait à comporter des couches supplémentaires pour simuler la muqueuse. Conclusion Les experts ont jugé que le simulateur d’anastomose intestinale 3D constitue un outil approprié pour la formation des résidents en chirurgie, du point de vue de la texture et de l’aspect du modèle et de la capacité de pratiquer l’anastomose. Ce modèle constitue une façon abordable d’apprendre comment effectuer une anastomose intestinale pour les résidents en chirurgie. La recherche à venir portera sur la détermination de son efficacité didactique, son efficacité et de son applicabilité à l’enseignement de la technique d’anastomose laparoscopique, de la suture à la main et des techniques d’agrafage.
David Isa, David Pace
Published: 27 September 2021
Canadian Journal of Surgery, Volume 64; https://doi.org/10.1503/cjs.004619

Abstract:
Background Aboriginal people have higher prevalence rates of diabetes than non-Aboriginal people in the same geographic locations, and diabetic foot ulcer (DFU) complication rates are also presumed to be higher. The aim of this systematic review and meta-analysis was to compare DFU outcomes in Aboriginal and non-Aboriginal populations. Methods We searched PubMed, Embase, CINAHL and the Cochrane Library from inception to October 2018. Inclusion criteria were all types of studies comparing the outcomes of Aboriginal and non-Aboriginal patients with DFU, and studies from Canada, the United States, Australia and New Zealand. Exclusion criteria were patient age younger than 18 years, and studies in any language other than English. The primary outcome was the major amputation rate. We assessed the risk of bias using the ROBINS-I (Risk Of Bias In Non-randomized Studies – of Interventions) tool. Effect measures were reported as odds ratio (OR) with 95% confidence interval (CI). Results Six cohort studies with a total of 244 792 patients (2609 Aboriginal, 242 183 non-Aboriginal) with DFUs were included. The Aboriginal population was found to have a higher rate of major amputation than the non-Aboriginal population (OR 1.85, 95% CI 1.04–3.31). Four studies were deemed to have moderate risk of bias, and 2 were deemed to have serious risk of bias. Conclusion Our analysis of the available studies supports the conclusion that DFU outcomes, particularly the major amputation rate, are worse in Aboriginal populations than in non-Aboriginal populations in the same geographic locations. Rurality was not uniformly accounted for in all included studies, which may affect how these outcome differences are interpreted. The effect of rurality may be closely intertwined with ethnicity, resulting in worse outcomes. Contexte Le taux de prévalence du diabète chez les Autochtones dépasse celui chez les Allochtones des mêmes régions géographiques. On présume qu’il en va de même pour le taux de complications d’un ulcère du pied diabétique (UPD). Le but de cette revue systématique et de cette méta-analyse était de comparer les issues d’UPD dans les populations autochtones et allochtones. Méthodes Nous avons interrogé PubMed, Embase, CINAHL et la Bibliothèque Cochrane, de leur création jusqu’à octobre 2018. Les critères d’inclusion étaient tous les types d’études comparant les résultats de patients autochtones et allochtones atteints d’UPD, et la réalisation au Canada, aux États-Unis, en Australie ou en Nouvelle-Zélande. Les patients de moins de 18 ans et les études dans une langue autre que l’anglais ont été exclus. L’issue primaire était le taux d’amputation majeure. Nous avons évalué le risque de biais à l’aide de l’outil ROBINS-I (Risk Of Bias In Non-randomized Studies – of Interventions). Les mesures de l’effet sont données sous forme de rapport de cotes (RC) avec intervalle de confiance (IC) de 95 %. Résultats Nous avons inclus 6 études de cohortes totalisant 244 792 patients atteints d’UPD (2609 Autochtones et 242 183 Allochtones). La population autochtone présentait un taux d’amputation majeure plus élevé que celle allochtone (RC 1,85; IC de 95 % 1,04–3,31). Le risque de biais était jugé modéré pour 4 études et important pour les 2 autres. Conclusion Notre analyse des études disponibles confirme l’hypothèse voulant que les issues d’UPD, en particulier le taux d’amputation majeure, soient pires chez les Autochtones que chez les Allochtones d’une même région. La prise en compte de la ruralité variait entre les études, ce qui pourrait fausser l’interprétation des disparités. Il est possible que l’incidence de la ruralité soit plus étroitement liée à l’ethnicité, causant ainsi une hausse des issues défavorables.
Danyal Ladha, Karima Khamisa, Steven Promislow
Published: 26 September 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.202620-f

Abstract:
Un homme de 77 ans atteint de démence vasculaire s’est présenté au service des urgences pour de la dyspnée. Ses antécédents médicaux comprenaient une sténose mitrale rhumatismale et un remplacement de valve mitrale avec prothèse mécanique en 2001. À l’examen, le patient était afébrile et euvolémique; il présentait un ictère. À l’auscultation, un nouveau souffle holosystolique était audible, en particulier à l’apex. Les analyses de laboratoire ont révélé un faible taux d’hémoglobine (89 g/L [plage normale 125–170]), un volume globulaire moyen (98,9 fl [plage normale 80–100]), une numération plaquettaire normale, un taux d’haptoglobine indétectable, et une élévation de la lacticodeshydrogénase (1603 U/L [plage normale 99–167]), de la bilirubine (totale: 45 μmol/L [normale < 15]; directe: 19 μmol/L [normale < 5]) et de la numération réticulocytaire (42,9 % [plage normale 1,5 %–15 %]). Le test direct à l’antiglobuline (TDA) (anciennement test de Coombs direct) était négatif. Nous avons observé de nombreux schizocytes au frottis sanguin (figure 1). Un échocardiogramme transthoracique a montré une déhiscence postérieure de la valve prothétique, accompagnée d’une régurgitation paravalvulaire mitrale substantielle absente lors de l’échocardiogramme effectué 5 mois auparavant (annexe 1, accessible en anglais au www.cmaj.ca/lookup/doi/10.1503/cmaj.202620/tab-related-content). La fraction d’éjection du ventricule gauche était de 50 % à 55 %. Les hémocultures négatives, couplées à l’absence de fièvre ou d’autres indices infectieux, rendaient l’endocardite improbable. Le patient a reçu un diagnostic d’anémie hémolytique macroangiopathique causée par la déhiscence de la valve prothétique. Il a été traité de façon conservatrice étant donné son mauvais état fonctionnel de base.
Jonathan C. Yeung, Marcelo Cypel, Cecilia Chaparro, Shaf Keshavjee
Published: 26 September 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.211143

Jane Kobylianskii, Emily Austin, Wayne L. Gold, Peter E. Wu
Published: 26 September 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210725-f

Amy R. Zipursky, Savithiri Ratnapalan
Published: 26 September 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210572

Abstract:
Between 1999 and 2019, the United States National Poison Data System reported a 66.7% increase in yearly ingestion of button batteries (6.98 to 10.46 per million population) and a 10-fold increase in complications (0.77% [n = 76] to 7.53% [n = 551]).1 Button batteries can cause substantial tissue damage within 2 hours of ingestion.2
Hannah Feiner, Sunit Das, Suzanne Turner, Kaitie Turchin
Published: 19 September 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.210901

Margot A. Rosenthal, Sarah K. McQuillan
Published: 19 September 2021
Canadian Medical Association Journal, Volume 193; https://doi.org/10.1503/cmaj.202413-f

Abstract:
Au Canada, les naissances vivantes chez les mères de moins de 19 ans représentaient 5,3 % des cas en 2000, 4 % des cas en 2010 et 1,7 % des cas en 20191. Cependant, plus de 80 % des grossesses de mères adolescentes sont non planifiées et plusieurs sont interrompues2. La Société canadienne de pédiatrie recommande un accès rapide aux méthodes de contraception et des ordonnances à renouvellement annuel afin de diminuer l’incidence des grossesses non planifiées et d’augmenter le taux de poursuite de la contraception3.
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