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Several letters to the editor are presented in response to the article "The need for an Institute of Continuing Health Education," by Paul Hébert in the 2008 issue.

Objective: To compare a restrictive versus a liberal transfusion strategy in patients with moderate to severe closed head injury following multiple trauma in 13 Canadian intensive care units (ICUs).Methods: This is a subgroup analysis of a multicenter randomized controlled clinical trial involving sixty-seven critically ill patients from the Transfusion Requirements in the Critical Care trial who sustained a closed head injury. Patients had a hemoglobin concentration less than 9.0 g/dL within 72 hours of admission to the ICU. Patients were randomized to a restrictive allogeneic red blood cell transfusion strategy (hemoglobin 7.0 g/dL and maintained between 7.0 and 9.0 g/dL) or a liberal strategy (hemoglobin 10.0 g/dL and maintained between 10.0 and 12.0 g/dL).Results: Baseline characteristics in the restrictive ( n = 29) and the liberal ( n = 38) transfusion groups were comparable. Average hemoglobin concentrations and red blood cell units transfused per patient were significantly lower in the restrictive compared to the liberal group. The 30-day all-cause mortality rates in the restrictive group were 17% as compared to 13% in the liberal group (risk difference 4.1 with 95% confidence interval [CI], 13.4 to 21.5, p = 0.64). Presence of multiple organ dysfunction (12.1 +/- 6.4 versus 10.6 +/- 6.3, p = 0.35) and changes in multiple organ dysfunction from baseline scores adjusted for death (4.5 +/- 6.2 versus 3.4 +/- 6.2, p = 0.49) were similar between the restrictive and liberal transfusion groups, respectively. Median length of stay in ICU (10 days, interquartile range 5 to 21 days versus 8 days, interquartile range 5 to 11 days, p = 0.26) and hospital (27 days, interquartile range 14 to 39 days versus 30.5 days, interquartile range 17 to 47 days, p = 0.72) were similar between the restrictive and liberal transfusion groups.Conclusions: We were unable to detect significant improvements in mortality with a liberal as compared to restrictive transfusion strategy in critically ill trauma victims with moderate to severe head injury. [ABSTRACT FROM AUTHOR]

This study examined themes relevant to health-related quality of life as identified by patients undergoing major surgery and by health care providers. Semi-structured interviews were conducted with 52 patients undergoing major abdominal, cardiac, orthopedic, thoracic, or vascular surgical procedures and 33 health professionals from various disciplines. A total of 58 themes were identified by content analysis. These themes were categorized into 6 domains. These were: physical well-being (14 themes), emotional well-being (13 themes), concern about quality of care (12 themes), social well-being (12 themes), cognitive preparation (4 themes), and spiritual well-being (3 themes). In general, we found that most aspects of health-related quality of life were common across various major surgical procedures and between patients and health care providers. However, when we examined the coverage of these themes in seven commonly-used health-related quality of life instruments, we found that many of the most frequently mentioned themes were not assessed with the available measures. A new evaluative instrument tailored to patients undergoing major surgery may therefore be warranted. [ABSTRACT FROM AUTHOR]

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Background Methods Results Conclusions Geriatric Emergency Department (ED) Guidelines recommend optimizing transitions of care for older patients with complex needs. In this study, we investigated referral patterns to interprofessional services, including occupational therapy, physiotherapy, dietician, social work, home care, and specialized geriatric services, among older adults presenting to the ED with high‐risk characteristics.We recruited community‐dwelling older adults presenting to 10 EDs across Ontario, Quebec, and Newfoundland, Canada, from April 2017 to July 2018. To observe processes of care in the ED, we deployed a two‐stage high‐risk case‐finding and focused comprehensive assessment process based on the interRAI ED‐Screener and ED Contact Assessment to identify and characterize older adults at high risk. We analyzed the secondary data using descriptive statistics and logistic regression.We screened 5265 individuals with the ED Screener, further assessed 1479 with the ED Contact Assessment, and analyzed data from a subset of 1055 community‐dwelling older adults assessed with the ED Contact Assessment. Participants in our study sample had a mean age of 83 years, 58% were female, and many had a complex burden of cognitive and functional impairment and social needs. Over half of this high‐needs sample were referred to general home care services (62.7%), occupational therapy (59.3%), and physiotherapy services (55.2%), while 16% were referred to specialized geriatric services. We also found a significant positive association between interprofessional referrals and the Assessment Urgency Algorithm and Institutional Risk Scale. The most important determinants of referral to interprofessional services were hospital province, functional, clinical, and social burden and support measures.The referral patterns identified suggest that patient needs and risk intensity did not always guide referral patterns in the Canadian EDs investigated. We suggest that EDs critically examine the appropriateness of their documentation and referral systems for supporting person‐centered care provision. [ABSTRACT FROM AUTHOR]

This article discusses a study that reviews physiologic evidence regarding an optimum hemoglobin concentration in anemic patients or in patients with specific diseases. From the brief review of physiologic principles and the strong consensus in the literature, it is evident that cardiac function must be a central consideration in decisions about transfusion in anemia, because of the critical role it plays in assuring adequate O2 supply to all vital tissues.

This article presents an evaluation of published guidelines and therapeutic recommendations for the transfusion of allogeneic red blood cells and plasma. In this review of published clinical practice guidelines it is noted that most of the guidelines were weak in terms of the methods they used, compared with current norms. The concept of an arbitrary transfusion trigger for allogeneic red blood cell transfusions or standard protocols for plasma use was refuted by most guidelines, instead most advocated an assessment of clinical need or use of clinical judgment.

This article discusses a study that reviews published materials describing practice variation in the transfusion of allogeneic red blood cells. A significant variation in allogeneic red blood cells transfusion practice has been reported in a number of studies and a variety of patient populations. Despite rids, few studies attempt to explain or minimize excessive practice variation. Randomized clinical trials should be conducted to determine best transfusion practice in a variety of clinical settings. Prospective cohort studies are also needed to describe transfusion practice.

The author comments on the restrictive approach to blood transfusion with a threshold of seven grams per deciliter as the recommended standard of care. The difference in mortality, pulmonary edema and organ failure rates between restrictive and liberal transfusion is discussed. It compares the Protocolized Care for Early Septic Shock (ProCESS) and the Australasian Resuscitation in Sepsis Evaluation (ARISE) trials. Best practices recommended under the Surviving Sepsis Campaign are highlighted.

The authors reply to Chapalain and Aubron's fragility index analysis and Khan, Spertus, and Chan's Bayesian analysis, which both supplement the primary results of the Myocardial Ischemia and Transfusion trial. Their Bayesian analysis demonstrates a higher probability of harm from a restrictive transfusion strategy, endorsing the adoption of a liberal strategy in acute myocardial infarction and anemia patients, although acknowledging the tradeoff involved in increasing blood usage.

Several letters to the editor are presented in response to articles in previous issues including the health care systems in Gaza, the reaction of the medical media on the destructive attacks of the Israeli state to the people and the exposure of the humanitarian disaster in the country.

The article focuses on the launch of "Open Medicine," an online-only general medical journal. It notes the benefits of the medical journal to Canadian researchers in terms of scientific productivity. It describes the journal as open-access, which creates opportunities for knowledge dissemination that are not provided by traditional publishing models. The advantages of open-access journals compared with the traditional periodicals are also discussed.

Introduction: Social prescribing offers a formal pathway of connecting patients in the health system with sources of support within the community to help improve their health and well‐being. Since its launch in March 2022, the Canadian Institute for Social Prescribing has acted as a collective impact network to identify, connect and build upon established social prescribing initiatives using a co‐design methodology. The institute received input from a participant advisory council, co‐design partners and several communities of interest groups. This study aimed to describe the perceptions of the Canadian Institute for Social Prescribing's role in advancing social prescribing using a co‐design approach and the barriers and facilitators to implementing social prescribing in Canada. Methods: We used a qualitative descriptive study design, document analysis, participant observation and semi‐structured individual interviews (n = 7) with members of the Canadian Institute for Social Prescribing co‐design group and the institute's leadership. We also analysed documents, field notes and transcripts using codebook thematic analysis. Results: Four themes were developed representing the facilitators of implementing the Canadian Institute for Social Prescribing to support social prescribing: Creating relational mechanisms (i.e., partnerships and connections), Bringing awareness to social prescribing and contributing to the evidence (i.e., values and beliefs), Addressing systemic conditions (i.e., having a common language for social prescribing and organizing the community health sector) and Enabling funding and policy to drive social prescribing initiatives (i.e., shifting evidence into policy and securing sustainable funding). Conclusion: Participants' reflections on the co‐design process demonstrated that the Canadian Institute for Social Prescribing development provided networking opportunities and shared resources relevant to social prescribing. Co‐design efforts also fostered relational and informational support, which laid the necessary groundwork in Canada to overcome the complex interplay between the macro‐ and micro‐level settings in which social prescribing is practiced. Patient or Public Contribution: The interviews and observations involved participants with lived experience of delivering, receiving or advocating for social prescribing. [ABSTRACT FROM AUTHOR]

The article discusses the MINT trial, which examined the impact of restrictive versus liberal transfusion strategies on patients with acute myocardial infarction and anemia. The trial involved 3504 patients and found that overall mortality did not differ significantly between the two strategies at 6 months. However, the restrictive strategy was associated with a higher risk of cardiac death within the first 30 days, potentially due to worsened myocardial ischemia. The study had limitations in terms of cause of death classification and trial design but provided valuable insights into transfusion strategies for this patient population. [Extracted from the article]

The article focuses on red blood transfusion methods and analyzes two different approaches for the process including lower and higher hemoglobin threshold to minimize the use of red blood cells and reverting any adverse clinical outcomes. It informs that a new research evidence for hematocrit criterion is founded through a study conducted on 600o patients and includes 19 randomized controlled trials. A chart depicting the association if higher and lower levels of hemoglobin threshold in patients with anemia are presented.

Abstract Objectives To understand how a heart failure diagnosis and admission health instability predict health transitions and outcomes among newly admitted nursing home residents. Design Retrospective cohort study of linked administrative data, including the Continuing Care Report System MDS 2.0 for nursing homes, the Discharge Abstract Database for hospitalized patients, and National Ambulatory Care Reporting System to track emergency department visits. Setting and participants Older adults, aged 65 years and above, admitted to nursing homes in Ontario, Alberta, and British Columbia, Canada, from 2010 to 2016. Measures Mortality and hospitalization were plotted over 1 year. Multistate Markov models were used to estimate adjusted odds ratios (ORs) for transitions to different states of health in stability, hospitalization, and death, stratified by heart failure diagnosis and by interRAI Changes in Health and End-stage disease Signs and Symptoms (CHESS) score, at 90 days following admission to a nursing home. Results The final sample included 143,067 residents. Adverse events were most common in the first 90 days. A diagnosis of heart failure predicted worsening health instability, hospitalizations, and mortality. The effect of heart failure on hospitalizations and death was strongest for low baseline health instability (CHESS = 0; OR 1.63, 95% confidence interval (CI) 1.58-1.68, and OR 1.71, 95% CI 1.57-1.86, respectively), versus moderate instability (CHESS = 1-2; OR 1.36, 95% CI 1.32-1.39, and OR 1.48, 95% CI 1.41-1.55), versus high instability (CHESS = 3; OR 1.12, 95% CI 1.03-1.23, and OR 1.21, 95% CI 1.11-1.32). The magnitude of the impact of a heart failure diagnosis was greatest for lower baseline health instability. Residents with the highest degree of health instability were also most likely to die in hospital. Conclusions and implications A diagnosis of heart failure and health instability provide complementary information to predict transfers, deaths, and adverse outcomes. Clearly identifying these at-risk patients may be useful in targeting interventions in nursing homes. [ABSTRACT FROM AUTHOR]

The authors reflect on the significance of early detection and care of eye diseases in Canada. They state that while loss of vision from all kinds of eye diseases may not lead to mortality, it can be responsible for the profound loss of quality of life. The authors claim that getting the scientific basis right and providing better integrated eye care services for screening will lead toward a clearer path ahead.

The authors reflect on the failure of the pharmaceutical industry to submit evidence supporting safe pediatric doses and dosing intervals to Health Canada. The authors state that according to the "Compendium of Pharmaceuticals and Specialties" (CPS), there is insufficient evidence to support the use of Celebrex in juvenile idiopathic arthritis. They suggest that Canadian children can be protected by asking politicians to enact legislation similar to the U.S. Pediatric Research Equity Act.

In this article the author discusses the importance of drug monitoring regarding the off-label use of recombitant factor VIIa. According to the author, VIIa was first licensed in 1996 for the treatment and prevention of bleeding connected to surgery for people with hemophilia. He adds that drug monitoring can be done by having a better collaboration between the payer and the insurer and having health professionals participate in evidence-based evaluation of new drugs.

The author reflects on the move of the Canadian government to change its policy on tobacco warning labels and focus on fighting contrabands that leads to a rapid increase of smokers in the country. He argues that warning labels are important to remind smokers about the danger of smoking and would help to curb smoking-related illness and death. He points out that the there is no apparent reason why opposing contraband should hinder the government from keeping with new warning labels.

The authors talk about the development of an electronic uniform disclosure form by the International Committee of Medical Journal Editors (ICMJE). They express their gratitude to authors, editors and other interested parties who commented on the form and contributed on its implementation. They suggest to use the revised ICMJE form which will relieve the confusion that exists when multiple journals use different reporting formats as well as ease the burden on the biomedical research community.

The article reflects on the uniform format for disclosure of financial associations of authors of articles published in biomedical journals like International Committee of Medical Journal Editors (ICMJE) journals. The form now posted on the ICMJE Web site includes instructions to help authors provide the information and a sample completed form is also available.

The authors reflect on the right of every child to have a better place to live on. They recommend that Canada must prioritize searching permanent homes for children and youth in the care of child welfare agencies for full development of their personalities. They are critical about the highest percentage of children and youth in contact with the justice system compared to those who are adopted from care. They believe that to drive change, people in the country must open their homes for children.

The authors discusses the disclosure of financial associations of authors of articles published in biomedical journals. The disclosure is said to help the reader to understand the relationship between the authors and entities that may have an interest in the article. The authors introduce a disclosure form adopted by journals that are members of the International Committee of Medical Journal Editors (ICMJE) and encourage other journals to adopt the format. They believe that adopting the format will make the disclosure process easier and less confusing.