CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne最新文献

{"title":"Antithrombotiques chez les patients atteints de COVID-19.","authors":"Faizan Khan, Tobias Tritschler, Ryan Zarychanski","doi":"10.1503/cmaj.220189-f","DOIUrl":"https://doi.org/10.1503/cmaj.220189-f","url":null,"abstract":"","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E1074-E1075"},"PeriodicalIF":14.6,"publicationDate":"2022-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/00/3f/194e1074.PMC9365430.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40593148","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Fixed drug eruption.","authors":"Yu-Ju Chou, Hua-Ching Chang","doi":"10.1503/cmaj.220049","DOIUrl":"https://doi.org/10.1503/cmaj.220049","url":null,"abstract":"CMAJ | August 2, 2022 | Volume 194 | Issue 29 © 2022 CMA Impact Inc. or its licensors A 31-year-old woman presented to the dermatology department with an asymptomatic erythematous patch on the dorsum of her right foot (Figure 1A). She had taken 1 dose of doxycycline (100 mg) the previous day as empirical treatment after picosecond laser treatment for acne scars. She had had a similar episode the previous year on the same site, after taking the same dose of doxycycline after laser treatment (Figure 1B). She had no notable medical history, and no other local or systemic symptoms, including fever. The erythematous patch was well demarcated, with a central dusky zone. There was no tenderness, heat or discharge. We diagnosed a fixed drug eruption and prescribed clobetasol propionate. After 1 week of treatment, the lesion had resolved. Although patch testing was negative, an oral rechallenge with 100 mg doxycycline was positive. Fixed drug eruptions are common,1,2 and constitute 14%–22% of cutaneous drug reactions among children.3 They are type IV hypersensitivity reactions that appear within 1 week after initial drug exposure, but may occur within minutes upon re-exposure.1,2 Fixed drug eruptions are characterized by well-circumscribed, round or oval, erythematous patches, plaques or, less frequently, bullae with a dusky-grey centre. They occur most commonly after exposure to acetaminophen, nonsteroidal anti-inflammatory drugs, anticonvulsants and antibiotics.1,2 The lips, the anogenital area and previous trauma areas are the most common sites.2 The diagnosis is clinical, but skin biopsy, topical patch test, lymphocyte transformation test or systemic rechallenge may help identify the causative drug.1,2 Differential diagnoses include erythema multiforme, contact dermatitis, cellulitis and herpes simplex infection.2 Systemic antihistamines and topical corticosteroids may be required for symptomatic relief.1 The condition is usually self-limiting; however, hyperpigmentation may remain.2 Patients should avoid re-exposure to the causative drug; local recurrence commonly occurs, although extensive lesional blistering has been reported.","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E1036"},"PeriodicalIF":14.6,"publicationDate":"2022-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/30/db/194e1036.PMC9481251.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40578519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Revisiting the concept of urgency in surgical prioritization and addressing backlogs in elective surgery provision.","authors":"Kayla Wiebe, Simon Kelley, Roxanne E Kirsch","doi":"10.1503/cmaj.220420","DOIUrl":"https://doi.org/10.1503/cmaj.220420","url":null,"abstract":"© 2022 CMA Impact Inc. or its licensors CMAJ | August 2, 2022 | Volume 194 | Issue 29 E1037 In Canada’s health care systems, urgency has long been the first consideration in patient prioritization. In the context of allocat­ ing surgical resources, urgent procedures are prioritized over elective (scheduled) ones.1 However, prioritizing urgency, par­ ticularly in times of resource constraints, leads to a problem of 2 wait lists: a growing wait list of urgent cases and a much larger wait list of scheduled cases that frequently become delayed past their appropriate wait times, leading to adverse patient out­ comes. We discuss this problem, which we refer to as the urgency dilemma, as well as some potential solutions. Two types of surgical cases are negatively affected by a nar­ row understanding of urgency. The first type is the scheduled case that will eventually become urgent, where the consequence of a delay in timely surgery is that the patient’s outcome is worse than it would have been had they been treated earlier. As delays worsen, an increasing number of patients with scheduled surger­ ies progress to requiring urgent surgery. A 2022 cohort study sug­ gested that delays in cancer detection will leave higher propor­ tions of cancers “unresectable or incurable at presentation.”2 It is “a matter of time before elective cancer surgery becomes urgent,”3 adding further burden to a resource­constrained sys­ tem.4 The problem becomes deciding where urgency begins such that health care resources can be appropriately allocated. The second type of case is the one that will never escalate to an urgent classification. Here, the consequences of delay will not be loss of life or limb, but rather persistent and seriously compro­ mised quality of life for the patient, in domains that may include development, mobility, fertility or mental health. Delays may increase the complexity of a surgery or lead to higher risks of complications or poor postoperative outcomes.5–7 Moreover, pediatric patients who require time­sensitive surgeries to co incide with critical developmental milestones may have life­ long consequences of delayed surgery. The surgical wait list problem has prompted calls from health care leaders to redesign how we deliver surgical care in Can­ ada.8–10 Given the urgency dilemma we have described, we pro­ pose a multistep plan to improve access for scheduled surgeries while not abandoning urgent cases in the process. The first step is to reframe what “urgency” and “scheduled” mean in surgery. Urgency is relative, and scheduled surgeries are not optional. “Urgent” and “scheduled” designations are not 2 discrete classifications of surgical importance; rather, they are 2 different and movable points on the same dynamic continuum of time­sensitive care. Reconceptualizing this continuum would allow and encourage health care systems to explicitly preserve room for scheduled cases. Urgent cases that can wait until the end of their urgency window should ","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E1037-E1039"},"PeriodicalIF":14.6,"publicationDate":"2022-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/35/5c/194e1037.PMC9481254.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40578517","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Occupational hypersensitivity pneumonitis after polyurethane adhesive exposure.","authors":"Arbaaz Patel,&nbsp;Aasim Hasany,&nbsp;Susan M Tarlo","doi":"10.1503/cmaj.220052","DOIUrl":"https://doi.org/10.1503/cmaj.220052","url":null,"abstract":"CMAJ | August 2, 2022 | Volume 194 | Issue 29 E1027 A 47-year-old woman presented to hospital with a 3-month history of dry cough, wheeze, dyspnea and intermittent fever. She had been briefly admitted 2 months earlier to treat a presumed lower respiratory tract infection or bronchitis; she had been prescribed inhalers (salbutamol, ipratropium) and antibiotics (ceftriaxone and azithromycin initially and then amoxicillin–clavulanic acid). The patient had smoked 7 cigarettes per day for 12 years, but had stopped smoking 3 months earlier. She was not on any regular medications and her medical history was notable only for obstructive sleep apnea, which was treated with continuous positive airway pressure. She had no history of asthma, no pets and no exposures to hot tubs, birds or moulds at home. She had recently started working at a horticultural company where she made plug sets for plants, in which soil, adhesives, oil and water were combined to create stable moulds for seedlings. The patient’s chest radiograph was normal on presentation and unchanged from her previous admission 2 months earlier. She was referred to the inpatient respirology service. When assessed, her respiratory rate was 22 breaths/min, oxygen saturation was 96% on room air, temperature was 35.9°C, heart rate was 104 beats/min and blood pressure was 129/86 mm Hg. She had wheezes bilaterally and normal heart sounds. On examination, she had no evidence of finger clubbing, leg edema, rashes or features to suggest a connective tissue disorder. The emergency department physician ordered a computed tomography (CT) scan of the chest with contrast (pulmonary embolus protocol) to rule out pulmonary embolism. Figure 1 is a representative chest CT image from the time of hospital admission, showing diffuse centrilobular ground glass nodules in both lungs without any zonal predominance. There were no pulmonary emboli. The patient had substantial leukocytosis with neutrophilia (leukocytes 15.6 [normal 4.0–11.0] × 109/L, neutrophils 12.0 [normal 2.0–7.5] × 109/L), a normal eosinophil count (0.2 [normal 0.0–0.5] × 109/L) and an elevated C-reactive protein (49 [normal < 8 mg/L). Because interstitial lung disease was suspected, rheumatoid factor, antinuclear antibody, and cytoplasmic and perinuclear antineutrophil cytoplasmic antibody levels were ordered and were all negative. Brain natriuretic peptide and troponin levels, ordered by an emergency department physician, were within normal limits on both visits to hospital. Spirometry showed proportionate reduction in forced expiratory volume at 1 second (FEV1) and forced vital capacity (FVC), with no evidence of obstruction. Her FVC was 2.13 L (59% predicted), her FEV1 was 1.54 L (53% predicted) and her FEV1:FVC ratio was 72.3%. A bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was performed. The fluid from bronchoalveolar Practice | Cases CPD","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E1027-E1030"},"PeriodicalIF":14.6,"publicationDate":"2022-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/cf/ec/194e1027.PMC9481262.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40578520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Correction to \"Canada's response to the initial 2 years of the COVID-19 pandemic: a comparison with peer countries\".","authors":"","doi":"10.1503/cmaj.221048","DOIUrl":"https://doi.org/10.1503/cmaj.221048","url":null,"abstract":"","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E1042"},"PeriodicalIF":14.6,"publicationDate":"2022-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9481261/pdf/194e1042.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40578521","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Do ask, but don't screen: identifying peripartum depression in primary care.","authors":"Kirsten Patrick","doi":"10.1503/cmaj.221020","DOIUrl":"https://doi.org/10.1503/cmaj.221020","url":null,"abstract":"E994 CMAJ | July 25, 2022 | Volume 194 | Issue 28 © 2022 CMA Impact Inc. or its licensors In updated guidance, the Canadian Task Force on Preventive Health Care has again recommended that physicians in Canada should not routinely screen people without a personal history of mental disorder for depression in pregnancy and the postpartum period using dedicated instruments.1 The key message is “Do ask, but don’t screen.” High-quality evidence to support the clinical effectiveness of instrument-based depression screening in the peripartum period in a primary care setting is exceedingly limited. The guideline authors emphasize, however, that asking about mental wellbeing during this period is important and should remain part of standard antenatal and postnatal care, and that people who show symptoms and signs of depression should receive appropriate diagnostic and follow-up care. The task force conducted a comprehensive search for studies that compared instrument-based depression screening in pregnant and postpartum people in primary care settings and measured important clinical and developmental outcomes for either parent or offspring. They found only 1 randomized trial of moderate size eligible to inform the current guideline. That, in itself, is telling. Screening for depression in the peripartum is recommended by guidelines from many other bodies, and such screening — using instruments such as the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire (PHQ)-2 or PHQ-9 — continues in many jurisdictions across Canada.1 A recent systematic review and individual patient data meta-analysis seeking to establish the accuracy of the EPDS in identifying people with depression found 121 studies from across the world that had compared the EPDS with a diagnostic interview.2 Yet, studies looking at whether such screening is either clinically effective or harmful are essentially lacking. Consolidated principles for screening hold that screening tests or programs should fulfill criteria in 3 domains: conditionrelated, test-related and system-related.3 The condition being screened for should be common, the test should be valid and postscreening steps for definitive diagnosis and appropriate care should be clear, with adequate infrastructure to support the screening program. Any program of screening should be ethically acceptable, cost effective and explicitly linked to program planning, monitoring, evaluating and reporting.3 Depression of any severity in pregnancy and the postpartum period is relatively common, with some variation across populations.4 The authors of the related guideline thoroughly explain the serious potential consequences of untreated peripartum depression for both the depressed parent and their offspring, identified by good observational studies.1 Commonly used screening instruments have been shown to be reasonably good at detecting and ruling out depression.2 However, the systematic review that underpinned the new guideline ","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E994-E995"},"PeriodicalIF":14.6,"publicationDate":"2022-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/af/f4/194e994.PMC9328467.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40539144","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Antiviral treatment for COVID-19: ensuring evidence is applicable to current circumstances.","authors":"Corinne M Hohl,&nbsp;Andrew D McRae","doi":"10.1503/cmaj.221012","DOIUrl":"https://doi.org/10.1503/cmaj.221012","url":null,"abstract":"E996 CMAJ | July 25, 2022 | Volume 194 | Issue 28 © 2022 CMA Impact Inc. or its licensors In related research, Pitre and colleagues1 present the findings of a network meta-analysis that sought to establish the relative efficacy of oral antiviral therapies in reducing the risk of hospital admission or death in patients with mild-to-moderate COVID-19. This is an important patient population to enroll in randomized trials, as most patients with COVID-19 have mild disease and are treated as outpatients. The authors conclude that there is compelling evidence supporting the efficacy of nirmatrelvir–ritonavir and molnupiravir in reducing the risk death or hospital admission. The challenge lies in applying the findings to current patients with COVID-19. The largest trial on nirmatrelvir–ritonavir, EPIC-HR, which was included in the network meta-analysis, enrolled unvaccinated participants who were infected with the Delta variant and had no evidence of previous SARS-CoV-2 infection.2 Yet, currently, 83% of eligible people in Canada have received 2 doses of SARS-CoV-2 vaccine, which confers a high degree of protection against the same outcomes as these therapies have been shown to prevent.3–5 Many people who acquire SARS-CoV-2 now have had a previous infection, and most recent cases have been infected with Omicron subvariants, which are less virulent than Delta.6 Nirmatrelvir–ritonavir is likely less effective in the real-world setting than suggested by the findings of the related network metaanalysis. Indeed, the manufacturer of nirmtrelvir–ritonavir recently terminated a trial that included vaccinated patients who were enrolled during the Omicron wave after an interim analysis found no statistically significant reduction in hospital admissions or deaths.7 A recent observational study examining the effectiveness of nirmatrelvir–ritonavir among vaccinated patients infected with Omicron and without evidence of previous infection concluded that it was effective in reducing severe COVID-19; however, estimates of its effectiveness in preventing severe COVID-19 or death was lower than was observed in the EPIC-HR trial.8 Indeed, the study suggested that vaccination alone was as or more effective than nirmatrelvir–ritonavir, and that the effectiveness of nirmatrelvir–ritonavir did not vary by vaccination status.8 Applying available evidence to clinical and policy decisions as the virus and population characteristics evolve is challenging. This is reflected in current Canadian guidelines for the use of novel antiviral drugs, which vary by province in terms of the age groups and comorbidities that define “high risk” to determine eligibility for publicly funded oral antiviral therapy. These therapeutic decisions would benefit from additional evidence from randomized controlled trials (RCTs), but this evidence is unlikely to emerge soon. In a search of clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform and the Cochrane C","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E996-E997"},"PeriodicalIF":14.6,"publicationDate":"2022-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d4/c8/194e996.PMC9328461.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40539146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Supporting patient choice at end of life.","authors":"Norman Nasser,&nbsp;Nadia J Pruett,&nbsp;Jason Sawyer,&nbsp;Amy E Nolen","doi":"10.1503/cmaj.220338","DOIUrl":"https://doi.org/10.1503/cmaj.220338","url":null,"abstract":"","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E990-E992"},"PeriodicalIF":14.6,"publicationDate":"2022-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/02/0a/194e990.PMC9328458.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40539143","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Erythromelalgia presenting with body pain.","authors":"Kosuke Ishizuka,&nbsp;Daiki Yokokawa,&nbsp;Masatomi Ikusaka","doi":"10.1503/cmaj.211677","DOIUrl":"https://doi.org/10.1503/cmaj.211677","url":null,"abstract":"","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E993"},"PeriodicalIF":14.6,"publicationDate":"2022-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d6/b3/194e993.PMC9328460.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40539141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Weak SARS-CoV-2 vaccine booster campaign resurrects specter of health care hesistancy.","authors":"Diana Duong,&nbsp;Lauren Vogel","doi":"10.1503/cmaj.1096008","DOIUrl":"https://doi.org/10.1503/cmaj.1096008","url":null,"abstract":"","PeriodicalId":520595,"journal":{"name":"CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne","volume":" ","pages":"E998-E999"},"PeriodicalIF":14.6,"publicationDate":"2022-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/4f/57/194e998.PMC9328466.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40539145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}