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Background The association between growth differentiation factor-15 concentrations and cardiovascular disease has been well described. The study hypothesis was that growth differentiation factor-15 may help cardiac risk stratification in noncardiac surgical patients, in addition to clinical evaluation. Methods The objective of the study was to determine whether preoperative serum growth differentiation factor-15 is associated with the composite primary outcome of myocardial injury after noncardiac surgery and vascular death at 30 days and can improve cardiac risk prediction in noncardiac surgery. This is a prospective cohort study of patients 45 yr or older having major noncardiac surgery. The association between preoperative growth differentiation factor-15 and the primary outcome was determined after adjusting for the Revised Cardiac Risk Index. Preoperative N-terminal-pro hormone brain natriuretic peptide was also added to compare predictive performance with growth differentiation factor-15. Results Between October 27, 2008, and October 30, 2013, a total of 5,238 patients were included who had preoperative growth differentiation factor-15 measured (median, 1,325; interquartile range, 880 to 2,132 pg/ml). The risk of myocardial injury after noncardiac surgery and vascular death was 99 of 1,705 (5.8%) for growth differentiation factor-15 less than 1,000 pg/ml, 161 of 1,332 (12.1%) for growth differentiation factor-15 1,000 to less than 1,500 pg/ml, 302 of 1476 (20.5%) for growth differentiation factor-15 1,500 to less than 3,000 pg/ml, and 247 of 725 (34.1%) for growth differentiation factor-15 concentrations 3,000 pg/ml or greater. Compared to patients who had growth differentiation factor-15 concentrations less than 1,000 pg/ml, the corresponding adjusted hazard ratio for each growth differentiation factor-15 category was 1.93 (95% CI, 1.50 to 2.48), 3.04 (95% CI, 2.41 to 3.84), and 4.8 (95% CI, 3.76 to 6.14), respectively. The addition of growth differentiation factor-15 improved cardiac risk classification by 30.1% (301 per 1,000 patients) compared to Revised Cardiac Risk Index alone. It also provided additional risk classification beyond the combination of preoperative N-terminal-pro hormone brain natriuretic peptide and Revised Cardiac Risk Index (16.1%; 161 per 1,000 patients). Conclusions Growth differentiation factor-15 is strongly associated with 30-day risk of major cardiovascular events and significantly improved cardiac risk prediction in patients undergoing noncardiac surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background Myocardial injury after non-cardiac surgery (MINS), based on measurement of troponin T, is associated with perioperative major adverse cardiovascular events (MACE). We therefore determined the high-sensitivity troponin I (hsTnI) thresholds associated with 30 day MACE after non-cardiac surgery. Methods We performed a nested biobank cohort study of 4553 patients from the Vascular Events in Non-Cardiac Surgery Patients Cohort Evaluation (VISION) Study. We measured hsTnI (ADVIA Centaur® hsTnI assay) on postoperative days 1 to 3 in patients ≥45 years undergoing non-cardiac surgery. An iterative Cox proportional hazard model determined peak postoperative hsTnI thresholds independently associated with MACE (i.e., death, myocardial infarction occurring on postoperative day 4 or after, non-fatal cardiac arrest, or congestive heart failure) within 30 days after surgery. Results MACE occurred in 89/4545 (2.0%) patients. Peak hsTnI values of Conclusion A peak postoperative hsTnI ≥75 ng/L was associated with >5-fold increase in the risk of 30 days MACE compared to levels Clinicaltrials.gov Registration Number: NCT00512109.

Background: The true incidence of abnormal vital signs on post-surgical wards may be seriously underestimated based on nurse obtained conventional measurement. We sought to determine the incidence and severity of postoperative tachycardia, bradycardia and hypoxemia detected by continuous remote automated monitoring (RAM) versus the incidence of these vital sign abnormalities detected during routine nursing care.Methods: We conducted a prospective cohort proof-of-concept study of 121 patients aged ≥45 years recov-ering from orthopedic surgery. Eligible patients were at risk of postoperative myocardial injury and had a planned hospital stay ≥48 hours. Philips’ IntelliVue MX40 wearable RAM technology was used to continu-ously monitor patients’ heart rate and pulse oximetry up to 72 hours following surgery. In addition, study personnel obtained vital signs collected during routine nursing care from participants’ medical charts. Clinically meaningful tachycardia, bradycardia and hypoxemia were defined as heart rates >100, 15 contiguous minutes, respectively.Results: Continuous RAM identified clinically meaningful episodes of tachycardia in 42 of 121 patients [34.7%] versus 7 patients [5.8%] identified by routine nursing care, for an absolute difference 28.9% (95% confidence interval [CI] 20.8, 37.0; p=0.001). RAM also detected bradycardia in 14 of 121 patients [11.6%] versus 6 patients [5.0%] detected by routine care, for an absolute difference 6.6% (95% CI 2.2, 11.0; p=0.07). RAM detected hypoxemia in 25 of 107 patients [23.3%] compared with 1 patient [0.9%] detected through routine monitoring, for an absolute difference of 22.4% (95% CI 14.5, 30.3; p=0.001).Conclusion: Most clinically meaningful episodes of vital signs abnormalities detected by continuous RAM were missed by nurses through conventional periodic monitoring. Continuous RAM technologies have the potential to improve patient outcomes through early identification of physiological abnormalities on surgical wards. RésuméContexte: La fréquence réelle des signes vitaux anormaux dans les unités de soins postopératoires peut être grandement sous-estimée sur la base des mesures classiques obtenues par le personnel infirmier. Nous avons cherché à déterminer la fréquence et la gravité de la tachycardie, de la bradycardie et de l’hypoxémie post-opératoires détectées par une surveillance automatisée à distance (SAD) en continu par rapport à la fréquence de ces anomalies des signes vitaux décelées pendant les soins infirmiers courants.Méthodologie: Nous avons mené une étude prospective de validation de concept auprès de 121 patients âgés de 45 ans ou plus se remettant d’une intervention chirurgicale orthopédique. Les patients admissibles présen-tent un risque de lésion myocardique postopératoire et leur séjour prévu à l’hôpital est d’au moins 48 heures. Le moniteur portable IntelliVue MX40 de Philips issu de la technologie de SAD a été utilisé pour surveiller en continu la fréquence cardiaque et l’oxymétrie de pouls des patients pendant 72 heures après l’interven-tion chirurgicale. En outre, le personnel de l’étude a pu obtenir les mesures des signes vitaux recueillies lors des soins infirmiers courants à partir des dossiers médicaux des participants. La tachycardie, la bradycardie et l’hypoxémie d’importance clinique ont été définies comme étant respectivement une fréquence cardiaque supérieure à 100 pour la tachycardie et inférieure à 55 pour la bradycardie et une saturation pulsée en oxygène (SpO2) inférieure à 90 % pendant plus de 15 minutes consécutives.Résultats: La SAD en continu a relevé des épisodes d’importance clinique de tachycardie chez 42 des 121 patients (34,7 %) comparativement à 7 patients (5,8 %) dans le cas des soins infirmiers courants, soit une différence absolue de 28,9 % (intervalle de confiance [IC] à 95 % de 20,8 à 37,0; P = 0,001). La SAD a égale-ment détecté une bradycardie chez 14 des 121 patients (11,6 %) comparativement à 6 patients (5,0 %) dans le cas des soins courants, soit une différence absolue de 6,6 % (IC à 95 % de 2,2 à 11,0; P = 0,07). La SAD a détecté une hypoxémie chez 25 patients sur 107 (23,3 %) comparativement à 1 patient (0,9 %) dans le cas des soins courants, la différence absolue étant de 22,4 % (IC à 95 % de 14,5 à 30,3; P = 0,001).Conclusion: La plupart des épisodes d’importance clinique d’anomalies des signes vitaux détectés par la SAD en continu ont été manqués par les infirmières lors de la surveillance périodique classique. Les technologies de SAD en continu peuvent améliorer l’évolution de l’état de santé des patients grâce à une détection précoce des anomalies physiologiques dans les services de chirurgie. Methods: We conducted a prospective cohort proof-of-concept study of 121 patients aged ≥45 years recovering from orthopedic surgery. Eligible patients were at risk of postoperative myocardial injury and had a planned hospital stay ≥48 hours. Philips’ IntelliVue MX40 wearable RAM technology was used to continuously monitor patients’ heart rate and pulse oximetry up to 72 hours following surgery. In addition, study personnel obtained vital signs collected during routine nursing care from participants’ medical charts. Clinically meaningful tachycardia, bradycardia and hypoxemia were defined as heart rates >100, 15 contiguous minutes, respectively. Results: Continuous RAM identified clinically meaningful episodes of tachycardia in 42 of 121 patients [34.7%] versus 7 patients [5.8%] identified by routine nursing care, for an absolute difference 28.9% (95% confidence interval [CI] 20.8, 37.0; p=0.001). RAM also detected bradycardia in 14 of 121 patients [11.6%] versus 6 patients [5.0%] detected by routine care, for an absolute difference 6.6% (95% CI 2.2, 11.0; p=0.07). RAM detected hypoxemia in 25 of 107 patients [23.3%] compared with 1 patient [0.9%] detected through routine monitoring, for an absolute difference of 22.4% (95% CI 14.5, 30.3; p=0.001). Conclusion: Most clinically meaningful episodes of vital signs abnormalities detected by continuous RAM were missed by nurses through conventional periodic monitoring. Continuous RAM technologies have the potential to improve patient outcomes through early identification of physiological abnormalities on surgical wards.

A 40-year-old man with a diagnosis of Sturge–Weber Syndrome (SWS) was admitted to hospital with fever and urosepsis. The sequelae of this condition include seizures, intellectual disability, bilateral glaucoma, hypothyroidism, and diffuse port-wine stain. He was also noted to have several pyogenic granulomas and a large capillary malformation of the lower lip, with associated bleeding risk. Clinical images highlight the diagnostic cues and dermatologic manifestations that are associated with SWS. Management of patients with this condition requires multidisciplinary care of the neurologic, endocrine, and vascular complications of SWS, in addition to extensive psychosocial support. RésuméUn homme de 40 ans ayant reçu un diagnostic de syndrome de Sturge-Weber est admis à l’hôpital en raison d’une pyrexie et d’une urosepsie. Les séquelles de ce syndrome sont l’épilepsie, la déficience intellectuelle, le glaucome bilatéral, l’hypothyroïdie et l’angiome plan diffus. On a également constaté la présence de plusieurs granulomes pyogènes et d’une malformation capillaire importante de la lèvre inférieure qui pose un risque d’hémorragie. Les images cliniques mettent en évidence les indices diagnostiques et les manifestations dermatologiques associés au syndrome de Sturge-Weber. Les patients atteints de cette affection ont besoin d’une prise en charge multidisciplinaire des complications neurologiques, endocriniennes et vasculaires du syndrome de Sturge-Weber, en plus d’un soutien psychosocial important.

This case report describes a 68-year-old male with recurrent multidrug-resistant Salmonella enterica serovar Typhimurium bacteremia acquired during travel abroad. He experienced a recurrence of bacteremia without a clear source and was successfully treated with 10 weeks of intravenous ertapenem. Post hoc genome sequencing revealed an isolate bearing class A, C, and D extended-spectrum β-lactamases (ESBLs). A review of English- and French-language literature since 2000 revealed eight publications that discussed recurrent S. enterica serovar Typhimurium bacteremia. Patients with multidrug-resistant S. enterica serovar Typhimurium should be monitored frequently for recrudescence, even in the absence of risk factors.

Background: Physicians commonly judge whether a myocardial infarction (MI) is type 1 (thrombotic) vs type 2 (supply/demand mismatch) based on clinical information. Little is known about the accuracy of physicians’ clinical judgement in this regard. We aimed to determine the accuracy of physicians’ judgement in the classification of type 1 vs type 2 MI in perioperative and nonoperative settings. Methods: We performed an online survey using cases from the Optical Coherence Tomographic Imaging of Thrombus (OPTIMUS) Study, which investigated the prevalence of a culprit lesion thrombus based on intracoronary optical coherence tomography (OCT) in patients experiencing MI. Four MI cases, 2 perioperative and 2 nonoperative, were selected randomly, stratified by etiology. Physicians were provided with the patient’s medical history, laboratory parameters, and electrocardiograms. Physicians did not have access to intracoronary OCT results. The primary outcome was the accuracy of physicians' judgement of MI etiology, measured as raw agreement between physicians and intracoronary OCT findings. Fleiss’ kappa and Gwet’s AC1 were calculated to correct for chance. Results: The response rate was 57% (308 of 536). Respondents were 62% male; median age was 45 years (standard deviation ± 11); 45% had been in practice for > 15 years. Respondents’ overall accuracy for MI etiology was 60% (95% confidence interval [CI] 57%-63%), including 63% (95% CI 60%-68%) for nonoperative cases, and 56% (95% CI 52%-60%) for perioperative cases. Overall chance-corrected agreement was poor (kappa = 0.05), consistent across specialties and clinical scenarios. Conclusions: Physician accuracy in determining MI etiology based on clinical information is poor. Physicians should consider results from other testing, such as invasive coronary angiography, when determining MI etiology. Résumé: Contexte: Les médecins déterminent généralement s’ils sont en présence d’un infarctus du myocarde (IM) de type 1 (thrombotique) ou de type 2 (demande accrue ou apport réduit en oxygène) sur la base des renseignements cliniques. On en sait cependant très peu au sujet de la justesse du jugement clinique des médecins à cet égard. Nous avons donc cherché à déterminer si les médecins réussissent à distinguer correctement les IM de type 1 et de type 2 dans les contextes périopératoire et non opératoire. Méthodologie: Nous avons mené une enquête en ligne en utilisant les cas de l’étude OPTIMUS (Optical Coherence Tomographic Imaging of Thrombus), qui avait évalué la prévalence des lésions causant un thrombus au moyen de la tomographie par cohérence optique (TCO) endocoronaire chez les patients subissant un IM. Nous avons choisi au hasard quatre cas d’IM stratifiés en fonction de leur cause : deux cas en contexte périopératoire et deux cas en contexte non opératoire. Les médecins avaient accès aux antécédents médicaux, aux résultats des analyses de laboratoire et aux électrocardiogrammes des patients, mais pas aux résultats de la TCO endocoronaire. Le principal paramètre d’évaluation était la justesse du jugement du médecin concernant la cause de l’IM, mesurée en fonction de la concordance approximative entre le jugement du médecin et les observations à la TCO endocoronaire. Les coefficients de concordance kappa de Fleiss et AC1 de Gwet ont servi à corriger pour le hasard. Résultats: Le taux de réponse était de 57 % (308 sur 536). Des participants, 62 % étaient des hommes et 45 % exerçaient depuis plus de 15 ans; l’âge médian était de 45 ans (écart-type : ± 11). La justesse globale avec laquelle les répondants ont déterminé la cause des IM était de 60 % (intervalle de confiance [IC] à 95 % : 57-63 %) : 63 % (IC à 95 % : 60-68 %) dans le cas des IM en contexte non opératoire et 56 % (IC à 95 % : 52-60 %) dans le cas des IM en contexte périopératoire. La concordance globale corrigée pour le hasard était faible (kappa = 0,05) et demeurait constante, sans égard au domaine de spécialité ou au scénario clinique. Conclusions: La justesse du jugement des médecins évaluant la cause d’un IM en fonction des renseignements cliniques est faible. Les médecins devraient envisager de recourir à des tests additionnels, y compris la coronarographie invasive, avant de déterminer la cause d’un IM.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Low 25-hydroxyvitamin D is associated with cardiovascular, renal, and infectious risks. Postsurgical patients are susceptible to similar complications, but whether vitamin D deficiency contributes to postoperative complications remains unclear. We tested whether low preoperative vitamin D is associated with cardiovascular events within 30 days after noncardiac surgery. Methods We evaluated a subset of patients enrolled in the biobank substudy of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were at least 45 yr with at least an overnight hospitalization. Blood was collected preoperatively, and 25-hydroxyvitamin D was measured in stored samples. The primary outcome was the composite of cardiovascular events (death, myocardial injury, nonfatal cardiac arrest, stroke, congestive heart failure) within 30 postoperative days. Secondary outcomes were kidney injury and infectious complications. Results A total of 3,851 participants were eligible for analysis. Preoperative 25-hydroxyvitamin D concentration was 70 ± 30 nmol/l, and 62% of patients were vitamin D deficient. Overall, 26 (0.7%) patients died, 41 (1.1%) had congestive heart failure or nonfatal cardiac arrest, 540 (14%) had myocardial injury, and 15 (0.4%) had strokes. Preoperative vitamin D concentration was not associated with the primary outcome (average relative effect odds ratio [95% CI]: 0.93 [0.85, 1.01] per 10 nmol/l increase in preoperative vitamin D, P = 0.095). However, it was associated with postoperative infection (average relative effect odds ratio [95% CI]: 0.94 [0.90, 0.98] per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.005) and kidney function (estimated mean change in postoperative estimated glomerular filtration rate [95% CI]: 0.29 [0.11, 0.48] ml min-1 1.73 m-2 per 10 nmol/l increase in preoperative vitamin D, P adjusted value = 0.004). Conclusions Preoperative vitamin D was not associated with a composite of postoperative 30-day cardiac outcomes. However, there was a significant association between vitamin D deficiency and a composite of infectious complications and decreased kidney function. While renal effects were not clinically meaningful, the effect of vitamin D supplementation on infectious complications requires further study.

BACKGROUND Perioperative bleeding is common in patients undergoing noncardiac surgery. Tranexamic acid is an antifibrinolytic drug that may safely decrease such bleeding. METHODS We conducted a trial involving patients undergoing noncardiac surgery. Patients were randomly assigned to receive tranexamic acid (1-g intravenous bolus) or placebo at the start and end of surgery (reported here) and, with the use of a partial factorial design, a hypotension-avoidance or hypertension-avoidance strategy (not reported here). The primary efficacy outcome was life-threatening bleeding, major bleeding, or bleeding into a critical organ (composite bleeding outcome) at 30 days. The pri- mary safety outcome was myocardial injury after noncardiac surgery, nonhemor- rhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism (composite cardiovascular outcome) at 30 days. To establish the noninferiority of tranexamic acid to placebo for the composite cardiovascular out- come, the upper boundary of the one-sided 97.5% confidence interval for the hazard ratio had to be below 1.125, and the one-sided P value had to be less than 0.025. RESULTS A total of 9535 patients underwent randomization. A composite bleeding outcome event occurred in 433 of 4757 patients (9.1%) in the tranexamic acid group and in 561 of 4778 patients (11.7%) in the placebo group (hazard ratio, 0.76; 95% confi- dence interval [CI], 0.67 to 0.87; absolute difference, −2.6 percentage points; 95% CI, −3.8 to −1.4; two-sided P

To the Editor: Acute kidney injury (AKI) is a lesser-known complication of hip fracture that may come about owing to decreased kidney perfusion and heightened inflammation from trauma, pain, bleeding, and fasting. Approximately 15%-20% of patients undergoing surgery for a hip fracture develop AKI, with 0.5%-1.8% receiving dialysis. [...]

Introduction COVID-19 is an international public health crisis with more than 132 million infections worldwide. Beyond acute infection, emerging data indicate patients diagnosed with COVID-19 may experience persistent sequelae similar to survivors of sepsis or acute respiratory syndromes, including mobility limitations and fatigue. However, there is limited evidence on the trajectory of functional recovery in those hospitalised with COVID-19. The primary aim of the Coronavirus Registry Functional Recovery (COREG-FR) study is to understand the trajectory of functional recovery among individuals hospitalised for COVID-19 over the medium (up to 6 months) and longer term (6–12 months) that will guide clinical care and optimal management of serious COVID-19 illness and recovery. Methods and analysis COREG-FR is a multicentre longitudinal cohort study. We will enrol a minimum of 211 adults age 18 years and older with COVID-19 from five hospitals. Participants will be followed from admission to hospital as an inpatient, to hospital discharge, and at 3-month, 6-month, 9-month and up to 12-month post-hospital discharge. We will conduct telephone interviews at ward admission and discharge, and telephone interviews plus in-person assessments of physical function and lung function at all remaining follow-ups. Our primary outcome is the Activity Measure for Post-Acute Care mobility scale measured at all time points. We will conduct linear mixed effects regression analyses to explore determinants of functional outcomes after COVID-19 illness. Subgroup analyses based on age (≤65 vs >65 years), frailty status (Clinical Frailty Scale score ≤4 vs >5) and variants of concern will be conducted. Ethics and dissemination COREG-FR has been approved by Research Ethics Boards at participating sites. We will disseminate this work through peer-reviewed manuscripts, presentations at national and international meetings and through the established COREG website (www.coregontario.ca). COREG-FR is designed as a data platform for future studies evaluating COVID-19 recovery. Trial registration number NCT04602260; Pre-results.

Pituitary apoplexy (PA) is an acute and potentially vision-threatening clinical condition caused by hemorrhage or infarction of the pituitary gland. PA usually occurs in a pre-existing pituitary tumor. Severe headache is almost universal and is often accompanied by hormonal deficiencies that require immediate empiric treatment. Magnetic resonance imaging is the recommended diagnostic imaging modality. Patients without acute neurological decline can be managed conservatively. RésuméL’apoplexie hypophysaire est un état clinique aigu pouvant faire perdre la vue qui est causée par une hémorragie ou un infarctus de l’hypophyse. Elle survient généralement en présence d’une tumeur hypophysaire préexistante. Un mal de tête intense apparaît dans pratiquement tous les cas, accompagné souvent d’insuffisances hormonales qui nécessitent un traitement empirique immédiat. L’imagerie par résonance magnétique est la modalité d’imagerie diagnostique recommandée. Les patients ne présentant aucune détérioration neurologique aiguë peuvent être pris en charge de manière conservatrice.

INTRODUCTION Health care professionals rely on annual general meetings (AGMs) to obtain up-to-date information and practice guidelines relevant to their specialty. The majority of such information at meetings is presented through abstract sessions. However, the quality of the evidence presented during such abstract sessions is unclear. Standardized measures were applied to assess the quality of evidence of abstracts presented at the Canadian Society of Nephrology AGM over a 5-year period. METHODS Two authors independently reviewed all CSN AGM abstracts presented from 2012 to 2016. Using a schema published in 2011 by the Oxford Centre for Evidence-Based Medicine (OCEBM), each abstract was subsequently ranked based on the quality of evidence. Schema categories ranged from level I, representing the highest evidence quality, to level V, representing the lowest. The number of authors and the authors' institution affiliations were also collected from the abstracts, where available, or if affiliations were unclear, an internet search of the author was performed. RESULTS Six hundred forty-two articles were screened. In total, 70% (n = 450) met the inclusion criteria. When assessed, 15% of articles were level I (highest quality), 17% level II, 53% level III, 12% level IV, and 3% level V (lowest quality). A Jonckheere-Terpstra test demonstrated a significant trend of increasing quality of evidence (P < .05) and collaboration (P < .005) over the 5-year study period. There was a significant correlation between level of evidence and collaboration across years reviewed in the study, rs(98) = -0.226, P < .001. DISCUSSION The results indicate a consistent increase in quality of evidence and collaborative submissions over time. To the authors' knowledge, this is the first assessment and analysis of AGM presentation quality within internal medicine and its subspecialties. Documenting and monitoring changes in the quality of evidence with a standardized framework may offer valuable insight pertaining to the medical field and the research community.

Background After nonelective (i.e., semiurgent, urgent and emergent) surgeries, patients discharged from hospitals are at risk of readmissions, emergency department visits or death. During the coronavirus disease 2019 (COVID-19) pandemic, we are undertaking the Post Discharge after Surgery Virtual Care with Remote Automated Monitoring Technology (PVC-RAM) trial to determine if virtual care with remote automated monitoring (RAM) compared with standard care will increase the number of days adult patients remain alive at home after being discharged following nonelective surgery. Methods We are conducting a randomized controlled trial in which 900 adults who are being discharged after nonelective surgery from 8 Canadian hospitals are randomly assigned to receive virtual care with RAM or standard care. Outcome adjudicators are masked to group allocations. Patients in the experimental group learn how to use the study's tablet computer and RAM technology, which will measure their vital signs. For 30 days, patients take daily biophysical measurements and complete a recovery survey. Patients interact with nurses via the cellular modem-enabled tablet, who escalate care to preassigned and available physicians if RAM measurements exceed predetermined thresholds, patients report symptoms, a medication error is identified or the nurses have concerns they cannot resolve. The primary outcome is number of days alive at home during the 30 days after randomization. Interpretation This trial will inform management of patients after discharge following surgery in the COVID-19 pandemic and offer insights for management of patients who undergo nonelective surgery in a nonpandemic setting. Knowledge dissemination will be supported through an online multimedia resource centre, policy briefs, presentations, peer-reviewed journal publications and media engagement. Trial registration ClinicalTrials.gov, no. NCT04344665.

The pursuit of more efficient patient-friendly health systems and reductions in tertiary health services use has seen enormous growth in the application and study of remote patient monitoring systems for cardiovascular patient care. While there are many consumer-grade products available to monitor patient wellness, the regulation of these technologies varies considerably, with most products having little to no evaluation data. As the science and practice of virtual care continues to evolve, clinicians and researchers can benefit from an understanding of more comprehensive solutions, capable of monitoring three or more biophysical parameters (e.g., oxygen saturation, heart rate) continuously and simultaneously. These devices, herein referred to as continuous multiparameter remote automated monitoring (CM-RAM) devices, have the potential to revolutionize virtual patient care. Through seamless integration of multiple biophysical signals, CM-RAM technologies can allow for the acquisition of high-volume big data for the development of algorithms to facilitate early detection of negative changes in patient health status and timely clinician response. In this article, we review key principles, architecture, and components of CM-RAM technologies. Work to date in this field and related implications are also presented, including strategic priorities for advancing the science and practice of CM-RAM.

Objectives Annual general meetings (AGMs) are often seen and promoted as great sources of contemporary information for the modern health-care professional. The quality of research evidence presented at these conferences, however, remains unclear. This paper evaluates the level of evidence (LoE) of research presented at the 2015 to 2019 AGMs of Diabetes Canada (DC). Methods Using the framework we first published to evaluate the LoE presented at the Canadian Society of Nephrology (CSN) AGMs, 2 authors independently assigned eligible abstracts a study type and grade. Research assistants separately recorded corresponding author and city affiliations. Results Of 832 published abstracts, 68% (N=568) met the inclusion criteria. These abstracts were classified as follows: 12% Level I (highest quality); 30% Level II; 36% Level III; 14% Level IV and 8% Level V (lowest quality). The LoE remained consistent over the 5-year study period, as observed by the Jonckheere–Terpstra test (p=0.754). The LoE of DC AGMs was similar to that of CSN AGMs (p=0.125). The number of authors was positively associated with improved LoE (p Conclusions Based on our novel auditing methodology, the LoE of DC AGMs is on par with other analyzed national AGMs. Adoption of this metric for all AGMs would aid in identifying unfavourable trends and alert planning and abstract selection committees of trends in LoE. Such studies will increase transparency for stakeholders and facilitate quality improvement initiatives.

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

Objective To determine if virtual care with remote automated monitoring (RAM) technology versus standard care increases days alive at home among adults discharged after non-elective surgery during the covid-19 pandemic. Design Multicentre randomised controlled trial. Setting 8 acute care hospitals in Canada. Participants 905 adults (≥40 years) who resided in areas with mobile phone coverage and were to be discharged from hospital after non-elective surgery were randomised either to virtual care and RAM (n=451) or to standard care (n=454). 903 participants (99.8%) completed the 31 day follow-up. Intervention Participants in the experimental group received a tablet computer and RAM technology that measured blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and body weight. For 30 days the participants took daily biophysical measurements and photographs of their wound and interacted with nurses virtually. Participants in the standard care group received post-hospital discharge management according to the centre’s usual care. Patients, healthcare providers, and data collectors were aware of patients’ group allocations. Outcome adjudicators were blinded to group allocation. Main outcome measures The primary outcome was days alive at home during 31 days of follow-up. The 12 secondary outcomes included acute hospital care, detection and correction of drug errors, and pain at 7, 15, and 30 days after randomisation. Results All 905 participants (mean age 63.1 years) were analysed in the groups to which they were randomised. Days alive at home during 31 days of follow-up were 29.7 in the virtual care group and 29.5 in the standard care group: relative risk 1.01 (95% confidence interval 0.99 to 1.02); absolute difference 0.2% (95% confidence interval −0.5% to 0.9%). 99 participants (22.0%) in the virtual care group and 124 (27.3%) in the standard care group required acute hospital care: relative risk 0.80 (0.64 to 1.01); absolute difference 5.3% (−0.3% to 10.9%). More participants in the virtual care group than standard care group had a drug error detected (134 (29.7%) v 25 (5.5%); absolute difference 24.2%, 19.5% to 28.9%) and a drug error corrected (absolute difference 24.4%, 19.9% to 28.9%). Fewer participants in the virtual care group than standard care group reported pain at 7, 15, and 30 days after randomisation: absolute differences 13.9% (7.4% to 20.4%), 11.9% (5.1% to 18.7%), and 9.6% (2.9% to 16.3%), respectively. Beneficial effects proved substantially larger in centres with a higher rate of care escalation. Conclusion Virtual care with RAM shows promise in improving outcomes important to patients and to optimal health system function. Trial registration ClinicalTrials.gov NCT04344665 .

Introduction Evidence of the benefit of distributed instruction and interleaved practice comes from studies using simple materials (e. g. word pairs). Furthermore, there is currently no evidence of the combined impact of these strategies in undergraduate medical education. The present study evaluated the impact of varying both instruction and practice schedules for the acquisition of ECG interpretation skills. Methods We conducted a 2 × 2 factorial study with two levels of instruction (massed and distributed) and two levels of practice (interleaved and blocked). A three-module introductory course in ECG interpretation was delivered to 80 first year medical undergraduate students. Students were assigned to one of four Instruction-Practice conditions: Massed-Interleaved, Massed-Blocked, Distributed-Interleaved and Distributed-Blocked. Learning was evaluated by a multiple choice quiz at the end of each module and a final multiple choice quiz at the end of the course. Results End of module mean scores showed that distributed instruction was consistently superior to massed instruction (52% vs 42%, p < 0.01). However, there was no effect of practice and no interaction between teaching and practice methods. The delayed final test scores revealed an advantage for blocked over mixed practice (34% vs 24%, p < 0.05) and distributed over massed instruction (34% vs 24%, p < 0.05). Discussion These results suggest that these popular strategies may have varying effects with complex learning materials. Further research is required to understand how these strategies affect the learning of simple and very complex skills. Electronic supplementary material The online version of this article (doi: 10.1007/s40037-017-0365-x) contains supplementary material, which is available to authorized users.

Background The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown. Methods In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes. Results Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery. Conclusions Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

The colon cutoff sign is a radiographic sign often associated with a diagnosis of acute pancreatitis. The patient highlighted in this case presented with nausea, vomiting, and abdominal discomfort and was referred with a diagnosis of viral gastroenteritis. The abdominal radiograph demonstrated the colon cutoff sign, but all other biochemical and imaging modalities were within normal limits. This case highlights the importance of relying on the entire clinical assessment when diagnosing pathology. Resume Le signe de coupure du côlon est un signe radiographique souvent associé à un diagnostic de pancréatite aiguë. Le patient mis en évidence dans ce cas présentait des nausées, des vomissements et une gêne abdominale et a été orienté vers un service de gastro-entérite virale. La radiographie abdominale a montré le signe de coupure du côlon, mais toutes les autres modalités biochimiques et d'imagerie étaient dans les limites normales. Ce cas souligne l'importance de s'appuyer sur l'ensemble de l'évaluation clinique pour diagnostiquer la pathologie.

Background Cancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses. Methods This was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important). Results Between July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37%). The most important barriers to GoC discussions were patient and family factors. They included family members’ difficulty accepting poor prognoses (mean score 5.9, 95% CI [5.7, 6.2]), lack of family agreement in the goals of care (mean score 5.8, 95% CI [5.5, 6.1]), difficulty understanding the limitations of life-sustaining treatments (mean score 5.8, 95% CI [5.6, 6.1]), lack of patients’ capacity to make goals of care decisions (mean score 5.7, 95% CI [5.5, 6.0]), and language barriers (mean score 5.7, 95% CI [5.4, 5.9]). Participants viewed system factors and healthcare provider factors as less important barriers. Conclusions Oncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions. Electronic supplementary material The online version of this article (10.1186/s12885-019-5333-x) contains supplementary material, which is available to authorized users.

IntroductionAnnually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%–10% at 30 days and 10%–20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial—HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications.Methods and analysisHIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients.Ethics and disseminationAll centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources.Trial registration numberNCT02027896; Pre-results.

Perioperative Medicine Special Issue / Numéro spécial sur la médecine périopératoire

Background The PeriOperative ISchemia Evaluation-2 (POISE-2) trial compared aspirin with placebo after noncardiac surgery. Methods The authors randomly assigned 10,010 patients undergoing noncardiac surgery to receive 200 mg aspirin or placebo 2 to 4 h before surgery and then 100 mg aspirin daily or placebo daily for up to 30 days after surgery. Herein, the authors report the effect of aspirin on venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, as well as an updated pooled analysis of randomized trials of antiplatelet therapy for VTE prevention in noncardiac surgery patients. Results Six thousand five hundred forty-eight patients (65.4%) received anticoagulant prophylaxis. VTE occurred in 53 patients (1.1%) allocated to aspirin and in 60 patients (1.2%) allocated to placebo (hazard ratio, 0.89; 95% CI, 0.61 to 1.28). Major or life-threatening bleeding occurred in 312 patients (6.3%) allocated to aspirin and in 256 patients (5.1%) allocated to placebo (hazard ratio, 1.22; 95% CI, 1.04 to 1.44). Concomitant use of anticoagulant prophylaxis did not modify the effect of aspirin on VTE or bleeding. Pooled analysis of the POISE-2 and Pulmonary Embolism Prevention trials demonstrated that symptomatic VTE occurred in 173 (1.3%) of 13,724 patients allocated to aspirin and in 246 (1.8%) of 13,730 patients allocated to placebo (odds ratio, 0.71; 95% CI, 0.56 to 0.89; heterogeneity P = 0.27; I2 = 17%); the impact of aspirin was very similar in those who did and did not receive pharmacologic prophylaxis. Pooled estimates for symptomatic VTE were similar to the pooled estimates for any deep vein thrombosis and pulmonary embolism from the POISE-2 trial, Pulmonary Embolism Prevention trial, and the Antiplatelet Trialists’ Collaboration meta-analysis. Conclusions Aspirin in the POISE-2 trial did not reduce VTE, but two thirds of patients received anticoagulant prophylaxis, there were few VTE events, and results were consistent with a wide range of aspirin effects. A pooled analysis of the randomized trials demonstrates evidence for the efficacy of aspirin for VTE prevention in hospitalized surgical patients.

Background Allied health care professionals can contribute meaningfully to goals-of-care discussions with seriously ill hospitalized patients and their families. We sought to explore the perspective of hospital-based allied health care professionals on their role in goals-of-care discussions and to identify barriers to their participation. Methods We surveyed allied health care professionals (social workers, physiotherapists, occupational therapists, registered dietitians, speech-language pathologists and pharmacists) on internal medicine, hematology-oncology, medical oncology and radiation oncology wards at 2 tertiary care hospitals in Hamilton, Ontario, from April 2013 to May 2014. We modified a validated questionnaire originally designed to assess barriers to discussing goals of care from the perspective of nurses, residents and staff physicians on hospital medical wards. Respondents rated the questionnaire items on a 7-point Likert scale. Results Of the 47 allied health care professionals invited, 32 (68%) participated: 9 physiotherapists, 7 social workers, 6 occupational therapists, 4 registered dietitians, 3 pharmacists and 2 speech-language pathologists; in 1 case, the profession was unknown. The greatest perceived barriers to engaging in goals-of-care discussions were lack of patient decision-making capacity (mean rating 5.9 [standard error (SE) 0.3]), lack of awareness of patients' previous discussions with other team members (mean rating 5.7 [SE 0.3]) and family members' difficulty accepting a poor prognosis (mean rating 5.6 [SE 0.2]). Although the respondents felt it was most acceptable for staff physicians, residents and advanced practice nurses to exchange information and reach a final decision during goals-of-care discussions, they felt it was acceptable for a broader range of allied health care professionals to initiate discussions (mean rating 4.7-5.8) and to act as decision coaches (clarifying values, weighing options) with patients and families (mean rating 5.3-6.1). Interpretation Allied health care professionals are willing to initiate goals-of-care discussions and to act as a decision coach with seriously ill hospitalized patients and their families. By improving interprofessional collaboration, we can engage the entire health care team in this process.

Summary Background Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. Methods In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. Findings Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55–0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55–1·53; p=0·76). Interpretation Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication. Funding Boehringer Ingelheim and Canadian Institutes of Health Research.

Background: Choosing Wisely Canada (CWC), an initiative to reduce low-value care, launched in April 2014. However, it remains unclear to what extent physicians are aware of the initiative and specific recommendations. The objective of this study was to assess physician awareness of the CWC campaign and recommendations, in addition to assessment of attitudes and perspectives on low-value medical care.Methods: This study was conducted as a survey of faculty physicians and residents of McMaster University. Electronic surveys were sent to all faculty physicians and residents within specialties with CWC recommendations. Responses were analyzed to determine awareness of CWC recommendations, defined as awareness of ≥3 recommendations targeted to a respondent’s respective specialty.Results: A total of 361 respondents were included in the analysis (response rate = 33%). Eighty-eight percent of respondents were aware of the CWC campaign. Only 30.1% (95% CI 23.5–36.7%) of respondents were able to correctly describe ≥3 of the recommendations targeted to their respective specialty, with a mean of 1.6 (95% CI 1.4–1.9) recommendations correctly identified per respondent. Most recommendations (70.9%) were reported as already being part of a respondents’ practice prior to release of the CWC recommendations. Interpretation: Despite general awareness of the CWC campaign, more than two thirds of physicians cannot describe most recommendations targeted to their own specialty. Nonetheless, many of these physicians report already practicing in compliance with these recommendations. Future studies are required to identify methods to improve communication, to track compliance with current CWC recommendations, and to determine areas of care that would most benefit from additional recommendations. Choosing Wisely Canada (CWC), an initiative to reduce low-value and unnecessary medical care, launched in April 2014.1 Modeled after the Choosing Wisely campaign in the US,2 CWC seeks to engage clinicians and patients in conversation about unnecessary tests and treatments. The campaign centres on “top five” lists developed by medical specialty societies of items within their respective specialties deemed to be of low-value, lacking benefit, or potentially harmful.3 CWC recommendation lists were intended to be physician-led, patient-focused, evidence-based, multi-professional, and transparent,4 with each group formulating their own list using these guiding principles.The Institute of Medicine estimates that approximately 30% of health care in the US adds no value to patient care.5 Additionally, a large majority of physicians have recognized over-testing as an issue, and 72% of those surveyed acknowledge ordering at least one unnecessary test or treatment each week.6 Common reasons cited for doing so included concerns for malpractice, safety, and patient preference.Specific list recommendations have been rolled out by national specialty societies and in local campaigns in hospitals across Canada. Further, Canadian medical schools are beginning to incorporate the campaign into the undergraduate curriculum through the Students and Trainees Advocating for Resource Stewardship campaign, and resource stewardship has been added to the CanMEDS ‘Leader’ competency.7,8 However, early research out of the US suggests that its now 3-year-old campaign has had variable success, with little effect on national physician practice. Analysis of 7 low-value services found only a very modest improvement in practice in two specific Choosing Wisely recommendations.9 Of the remaining five, three demonstrated no change in practice, and two revealed changes contradictory to the recommendation.As the campaign has passed the 3-year mark in Canada, it is not yet known what effect it has had on physician practice. Furthermore, it remains unclear to what extent physicians, including trainees, have been aware of the initiative, and whether they are aware of specific recommendations relevant to their own specialty. The objective of this study was to assess physician awareness of the CWC campaign, both in terms of general awareness and of specialty-specific recommendations, in addition to assessment of attitudes and perspectives on low-value medical care.MethodsDesign and PopulationThe study was conducted as a survey among physician residents and faculty at McMaster University in Hamilton, Ontario. The project was exempted from full review by the Hamilton Integrated Research Ethics Board.The survey was sent to all residents and faculty within specialties that had existing CWC recommendations at the time of survey dissemination. Email lists of residents and faculty physicians were provided to us from individual programs. Emails were initially sent in March 2016, with reminder emails sent out monthly for two subsequent months. The survey remained open from March to June 2016. Respondents were excluded from survey analysis if their primary specialty lacked CWC recommendations, or if they self-reported that less than 10% of their work was devoted to clinical duties.ContentThe survey questions were created to collect data on respondent demographics, awareness of CWC recommendations, and to assess attitudes and perspectives of respondents on low-value medical care. Questions were devised via discussion among content experts, and in conjunction with previously unpublished surveys that assessed similar themes. After initial completion, the survey was pilot tested among ten residents and faculty physicians, and subsequent changes were made to improve on its readability, avoid misinterpretation of specific questions, and improve response options.The primary outcome of the survey was the proportion of respondents with awareness of at least three of the CWC recommendations targeted to their respective specialty. If a respondent answered positively to awareness of the CWC campaign, they were asked to describe up to five of the recommendations in their own words, including for each recommendation the (1) target population, (2) test, procedure, and/or intervention, and (3) clinical context (when applicable). Responses were categorized as correctly aware of the recommendation if they included all of (1), (2), and (3, when applicable). Two independent adjudicators assessed responses; if disagreement occurred following a consensus step, the response was assessed by a third adjudicator.Data AnalysisSurvey data was analyzed using descriptive statistics. Primary outcome data was presented using confidence interval on a proportion.ResultsDemographicsThe survey was sent to 1361 physicians, with 446 individuals (201 faculty physicians, 245 residents) responding to the survey (response rate = 33%). Of these, 85 were excluded for various reasons (47 for incomplete surveys, 26 for primary specialty without CWC recommendations, and 12 for self-reporting less than 10% of their work as devoted to clinical duties). A total of 361 responses, representing 22 specialties, were included in the final analysis (Table 1). The mean age of respondents was 37.6 (SD ±12.0). The largest proportion of responses came from Family Medicine (25%), Internal Medicine (20%), Emergency Medicine (10%), and Anesthesia (8%).Table 1. Demographics of survey respondents Awareness of the Campaign and its RecommendationsA total of 316 respondents (88%) were aware of the CWC campaign (Table 2). Respondents reported awareness via word of mouth (26%), medical publications, (21%), conferences (16%), and hospital communications (10%). Of these, 185 (59%) reported awareness of their own specialty’s recommendations. Only 56 respondents (30.1%, 95% CI 23.5–36.7%) were able to correctly identify ≥3 of these recommendations. Respondents correctly identified an average of 1.6 (95% CI 1.4–1.9) recommendations (1.7, 95% CI 1.3–2.1 vs. 1.5, 95% CI 1.2–1.8, for faculty physicians versus residents, respectively). The frequency of specific recommendations correctly identified by respondents is presented in Table 2.Table 2. Awareness of the Choosing Wisely Canada Campaign Perspectives on Specific CWC RecommendationsRespondents were presented with the specific CWC recommendations targeted to their specialty, and asked to respond to the recommendations’ influence on their practice (Table 3). A total of 2,425 recommendations were presented to the 361 respondents. Respondents noted that the individual recommendations were likely to change their practice in 18.5% of cases. In only 10.6% of cases did the respondent note that the recommendation would not change their practice. The remaining 70.9% of cases stated that the recommendation was already their practice prior to release of the CWC recommendations. Table 3. Perspectives on Specific Choosing Wisely Canada Recommendations Views on Low-Value Medical ServicesRespondent attitudes and perspectives on low-value medical services are presented in Figure 1. A majority of respondents either agreed or strongly agreed that they have a responsibility to decrease use of inappropriate health care services (95%, 95% CI 93–97%), and that many patients would benefit from implementation of recommendations to decrease use of these services (82%, 95% CI 78–86%). Respondents mostly disagreed or strongly disagreed with the notion that patients have sufficient information to make informed decisions about inappropriate use of services (54%, 95% CI 49–59%). Most respondents either agreed or strongly agreed that cost to society is an important factor in decision-making around interventions (65%, 95% CI 60–70%), though many disagreed or strongly disagreed that they were aware of the costs of these tests and/or treatments (30%, 95% CI 25–35%). Figure 1. Views on low-value medical services (n = 347 ) Respondents were additionally asked to rank four barriers to implementing recommendations to decrease use of inappropriate services (Figure 2). Most respondents (38%, 95% CI 33–43%) ranked concern regarding medico-legal risk as the number one barrier, with patient requests for tests and treatments closely following (33%, 95% CI 28–38%). Lack of time to assess whether an individual would or would not benefit from a service was ranked first by 25% (95% CI 20–30%) of respondents. Only 4% (95% CI 2–6%) of respondents ranked payment policies that reward ordering more services as the top barrier. Figure 2. Barriers to implementing recommendations (n = 347). DiscussionAs far as we are aware, this is the first survey to assess physician awareness of the CWC campaign. Our results indicate that while most physicians have a general awareness of the campaign, few are able to describe most of the specific recommendations targeted to their own specialty. Only 30.1% of respondents could appropriately describe three or more recommendations, and over half of respondents were able to describe only one, or couldn’t describe any, of the recommendations. In addition, respondents’ views were largely supportive of reducing low-value medical care, with physicians acknowledging both responsibility and a patient-benefit to reducing use of inappropriate services.Our results suggest, however, several possible barriers to the campaign having an impact on practice. For one, the lack of awareness may indicate that there has been inadequate communication of specific recommendations. Previous work in the United States has found that physicians aware of the Choosing Wisely campaign view it as a legitimate source of guidance, and report that it has empowered them to reduce the use of unnecessary tests and procedures.10 Accordingly, a lack of awareness would likely be a significant impediment in attempts to reduce resource utilization of low-value medical care. However, our findings additionally demonstrate that respondents report practicing in compliance with 70.9% of recommendations prior to release of the CWC campaign.While it is possible that there is a discrepancy between physicians’ reported and actual practice, these findings are in keeping with other studies suggesting that certain recommendations had high rates of baseline adherence prior to publication of the campaign. A study from the United States identified very low baseline rates of preoperative stress testing before low-risk surgeries,11 while another identified infrequent rates of Pap testing among women under 21 years of age and sinusitis imaging for acute mild-to-moderate sinusitis or uncomplicated acute rhinitis.9 These findings were all in accordance with published Choosing Wisely recommendations, suggesting that some recommendations were not targeting high-yield areas of low-value care. However, while a recent Canadian study by Kirkham and colleagues assessing preoperative testing prior to low-risk surgical procedures within Ontario hospitals demonstrated low baseline utilization of certain tests (e.g., echocardiography, stress tests), it did show widely variable utilization of other tests (e.g., electrocardiogram) among institutions.12 This may indicate that further communication of the CWC recommendations may have greater impact within institutions with lower rates of baseline compliance. Additionally, measurements of baseline utilization prior to release of further recommendations may help identify areas of greatest potential impact.Our study additionally demonstrated other areas in which further interventions could potentially impact rates of utilization of low-value care. Many of our respondents believed that patients drive inappropriate services more often than physicians, but that patients largely lack the information to make these informed decisions. Strengthening communication of the campaign to the general public, while targeting specific high-yield areas of patient utilization, may help further reduce use of certain services. Furthermore, though a majority of respondents identified cost to society as an important factor in the decision to use or not use an intervention, less than half of respondents reported awareness of the cost of tests and treatments they prescribe. Numerous other studies have found deficits in both self-reported and actual awareness of the costs of medical care in the US.10,13 Surveys of Canadian physicians have demonstrated very poor cost awareness among both family physicians and residents.14,15 While enhancing knowledge of low-value areas of care is the primary goal of campaigns such as CWC, it is possible that physician education on the costs of tests and treatments would lead to further improvements in resource utilization. Finally, evidence suggests that physicians who value cost consciousness are more likely to avoid the use of low-value services, while greater knowledge of guidelines alone is not associated with reduced use of low-value services.16 Accordingly, efforts may be further focused on enhancing a sense of cost consciousness among trainees and physicians.LimitationsOur survey does possess several limitations. Firstly, our response rate was only 33%; thus, it remains possible that our sample was not fully representative of the target population, and we cannot rule out a selection bias favouring respondents more familiar with the CWC campaign. Secondly, we restricted our population to physicians associated with McMaster University. We cannot extrapolate these findings to physicians associated with other universities or physicians in non-academic settings, especially given the fact that local CWC communication initiatives have been occurring to variable extents across the country. Thirdly, we were unable to avoid the possibility that respondents were able to search for their specialty-specific recommendations while completing the survey. However, we have no reason to believe respondents would have any incentive to do so. Lastly, we were unable to account for physicians who identify with more than one medical specialty.ConclusionsDespite general awareness of the CWC campaign, most physicians cannot describe recommendations targeted to their own specialty. Nonetheless, many of these physicians report already practicing in compliance with these recommendations. Multiple barriers to implementing change were identified, including the potential of recommendations targeting lower-yield areas of care, patient requests for tests and treatment, physician awareness of cost, and concern regarding medico-legal risk. Future studies are required to explore awareness of the campaign in other academic and community sites across the country. Additionally, future efforts should be directed towards identifying methods of improving communication of current CWC recommendations, including the potential for targeting both specific recommendations and institutions with low baseline compliance, and to determine areas of care that would most benefit from additional recommendations.

Cognitive biases, or systematic errors in cognition, are important contributors to diagnostic error in medicine. In our review, we explore the psychological underpinnings of cognitive bias and highlight several common biases using clinical cases. We conclude by reviewing strategies to improve diagnostic accuracy and by discussing controversies and future research directions.RésuméLes préjugés cognitifs, ou les erreurs systématiques dans la cognition, sont des contributeurs importants à l'erreur diagnostique dans la médecine. Dans notre examen, nous explorons les fondements psychologiques du biais cognitif et soulignons plusieurs préjugés communs en utilisant des cas cliniques. Nous concluons en examinant les stratégies visant à améliorer la précision diagnostique et en discutant des controverses et des futures orientations de recherche.Research in the field of behavioural psychology and its application to medicine has been ongoing for several decades in an effort to better understand clinical decision making.1 Cognitive biases (systematic errors in cognition) are increasingly recognized in behavioural economics2 and more recently have been shown to affect medical decision making.3 Over 100 such cognitive biases have been identified and several dozen are postulated to play a major role in diagnostic error.4 Cognitive errors can take many forms and in one study contributed to as many as 74% of diagnostic errors by internists. 5 Most of these errors were due to “faulty synthesis” of information, including premature diagnostic closure and failed use of heuristics.5 Inadequate medical knowledge, on the other hand, was rare and mostly identified in cases concerning rare conditions. 5 Professional organizations such as the Royal College of Physicians and Surgeons of Canada and the Canadian Medical Protective Association have since been working to raise awareness of cognitive bias in clinical practice.6In our review, we explore the role of cognitive bias in diagnostic error through the use of clinical cases. We also review the literature on de-biasing strategies and comment on limitations and future directions of research.The Dual Process TheoryA prevailing theory to explain the existence of cognitive bias is the dual process theory, which asserts that two cognitive systems are used in decision making, herein called System 1 and System 2 (Table 1). 2,7System 1 can be thought of as our intuitive mode of thinking. It generates hypotheses rapidly, operates beneath our perceptible consciousness and makes judgments that are highly dependent on contextual clues. System 1 is characterized by heuristics (short cuts, or “rules of thumb”) and is an important component of clinical judgment or expertise. In contrast, System 2 is slow, deliberate, analytical and more demanding on cognition. It applies rules that are acquired through learning and it can play a “monitoring role” over System 1, and thus overrides heuristics when their use is inappropriate. The dual process theory implies that errors result when inappropriate judgments generated by System 1 fail to be recognized and corrected by System 2. Maintaining constant vigilance over System 1 would be both impractical and time consuming for routine decisions and would diminish the value of intuition. It follows that a more practical way of improving reasoning is to identify the most common biases of System 1 and to recognize situations when mistakes are most likely to occur.2Alternative Theories of CognitionVariations of dual process theory have further refined our understanding of medical decision making. Fuzzy trace theory, for example, proposes that individuals process information through parallel gist and verbatim representations.8 The “gist” is analogous to System 1 and represents the bottom-line “meaning” of information. This representation is subject to an individual’s worldview, emotions and experiences. In contrast, verbatim representations are precise, literal and analogous to System 2. Fuzzy trace theory is particularly useful in explaining how patients might interpret health information. Proponents of this theory contend that in order for information to lead to meaningful behavioural change, physicians must appeal to both gist and verbatim representations when communicating with patients.8 Other models, such as dynamic graded continuum theory, do away with the dichotomy of System 1 and System 2 and instead represent implicit, automatic and explicit cognitive processes on a continuous scale.9 These single system models are useful to compare against dual process theory but have not replaced it as a well-established framework for understanding and mitigating cognitive bias in clinical decision making.7Case 1: A 55-Year-Old Male with Retrosternal Chest PainA 55year-old non-smoking male was assessed in a busy Emergency Department (ED) for retrosternal chest pain. Past medical history is significant for osteoarthritis for which he takes naproxen. On review of his history, the patient has had multiple visits for retrosternal chest pain in the previous two months. At each encounter, he was discharged home after a negative cardiac workup.Vital signs in the ED were within normal limits except for sinus tachycardia at 112 beats per minute. On exam, the patient was visibly distressed. Cardiac and respiratory exams were normal. There was mild tenderness in the epigastrium. Basic blood-work revealed leukocytosis (16.0 × 109/L), a mildly elevated high sensitivity cardiac troponin, and no other abnormalities. An ECG revealed T wave flattening in leads V3-V4.The patient was referred to the internal medicine service with a diagnosis of non-ST-elevation myocardial infarction and treated with aspirin, clopidogrel, and fondaparinux. Several hours later, the patient became more agitated and complained of worsening retrosternal and epigastric pain. On re-examination, heart rate had increased to 139 beats per minute, blood pressure dropped to 77/60 and he had a rigid abdomen. Abdominal radiography revealed free air under the right hemi-diaphragm and the patient was rushed to the operating room where a perforated gastric ulcer was detected and repaired. The case above illustrates numerous cognitive biases, including:1. Premature diagnostic closure: the tendency to accept a diagnosis before it is fully verified.42. Anchoring: the tendency to over-emphasize features in the patient’s initial presentation and failing to adjust the clinical impression after learning new information.43. Confirmation bias: the tendency to look for confirming evidence to support a diagnosis, rather than to look for (or explain) evidence which puts the diagnosis in question.4In this case, the physician based the diagnosis of myocardial infarction primarily on symptoms of chest pain and an elevated cardiac troponin. However, several other objective findings were present and when taken together, suggested a diagnosis other than myocardial infarction. These included a tender epigastrium, leukocytosis, and resting sinus tachycardia. These symptoms/signs were not explicitly explained or investigated before a treatment decision was made. Premature diagnostic closure is one of the most common cognitive biases underlying medical errors5 and it affects clinicians at all levels of training.10 It is multifactorial in origin5 and is especially common in the face of other cognitive biases such as anchoring and confirmation bias.The physician in this case “anchored” to a diagnosis of cardiac chest pain given the patient’s previous ED visit history and his/her best intentions of ruling out a “worst case scenario.” Anchoring can be especially powerful in the face of abnormal screening investigations that have been reviewed even before the physician has acquired a history or performed a physical examination. If the physician had reviewed the screening investigations before seeing the patient, he/she might have narrowed the differential diagnosis prematurely, failed to gather all the relevant information and failed to adjust the clinical impression based on new information.The physician demonstrated confirmation bias by failing to explain the abnormalities that put the diagnosis of myocardial infarction in question (e.g. tender epigastrium, leukocytosis). Confirmation bias arises from an attempt to avoid cognitive dissonance, a distressing psychological conflict which occurs when inconsistent beliefs or theories are held simultaneously.11 In one study evaluating clinical decision making amongst 75 psychiatrists and 75 medical students,12 13% of psychiatrists and 25% of medical students demonstrated confirmation bias when searching for information after having made a preliminary diagnosis. In this study, confirmation bias resulted in more frequent diagnostic errors and predictably impacted subsequent treatment decisions.An appropriate consideration of all diagnostic possibilities is the first step in avoiding diagnostic error. While acquiring information, physicians should step back and consolidate new data with the working diagnosis, as failure to do so can result in confirmation bias.13 All abnormal findings and tests, especially if considered clinically relevant should be explained by the most probable diagnosis. An alternate diagnosis or the possibility of more than one diagnosis should be considered when an abnormal finding or test cannot reasonably be explained by the working diagnosis.Tschen et al observed a team of physicians working through a simulated scenario which had diagnostic ambiguity.14 Two approaches were found to be effective in reducing the effect of confirmation bias: explicit reasoning and talking to the room. Explicit reasoning involves making causal inferences when interpreting and communicating information. Talking to the room is a process whereby diagnostic reasoning is explained in an unstructured way to a team member or colleague in the room. This allows the clinician the opportunity to elaborate on their thoughts and observers to point out errors or suggest alternate diagnoses in a shared mental model.Case 2: A 30-Yearold Male with Confusion and SeizuresA 30-year-old homeless male is found confused on the street by paramedics and brought to the ED for assessment. Empty bottles of alcohol were noted at the scene. The CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol is initiated and he is given several doses of lorazepam to minimal effect. Several hours after the patient is admitted, a resident on-call is paged for elevated CIWA scores on the basis of diaphoresis and agitation. Several additional doses of lorazepam are ordered which fail to completely resolve the symptoms. Gradually, the patient becomes more obtunded. The on-call resident orders a capillary blood glucose and it measures 1.1 mmol/L. Intravenous D50W is promptly administered, the blood glucose normalizes and the patient’s level of consciousness improves.The case above illustrates the following biases:1. Availability bias: the tendency to weigh a diagnosis as being more likely if it comes to mind more readily.42. Diagnostic momentum: the tendency for labels to “stick” to patients and become more definite with time.4Although the symptoms of diaphoresis and agitation are not specific to alcohol withdrawal, this diagnosis was deemed most likely based on how readily it came to mind, the empty alcohol bottles at the scene, and potentially on the patient’s demographics. The unproven diagnosis of alcohol withdrawal “stuck” with the patient despite minimal improvement after a therapeutic trial of benzodiazepines.Availability bias has been shown to affect internal medicine residents. In one single-centre study,15 18 first-year and 18 second-year residents were exposed to case descriptions with associated diagnoses as part of an exercise. They were then asked to diagnose a series of new cases, some of which appeared similar to those they had previously encountered but with pertinent differences that made an alternate diagnosis more likely. Second year residents had lower diagnostic accuracy on these similar-appearing cases; a result consistent with availability bias. First year residents were less prone to this bias because of their limited clinical experience. Most importantly, subsequent reflective diagnostic reasoning countered the bias and improved accuracy.General Strategies to Avoid Cognitive BiasInterventions aimed at mitigating diagnostic error due to cognitive bias take several approaches.1. Improving clinical reasoning2. Reducing cognitive burden3. Improving knowledge and experienceDespite a large number of proposed interventions, there is a lack of empirical evidence supporting the efficacy of many de-biasing strategies. 16 What follows is a brief review of the current evidence.Improving Clinical ReasoningSeveral “de-biasing” strategies have been proposed to improve clinical reasoning. De-biasing strategies assume that System 1 processes are more prone to bias due to their heavy reliance on heuristics and therefore the solution is to activate System 2 at critical points in decision making. De-biasing occurs in several stages: at first an individual is educated about the presence of a cognitive bias, they then employ strategies to eliminate that bias and finally they maintain those strategies in the long term.17Metacognition, or “thinking about thinking,” involves reflecting on one’s own diagnostic reasoning. Internal reflection along with awareness of potential biases should allow the clinician to identify faulty reasoning. However, the evidence underlying reflective practice is mixed.16 Several studies have tried to encourage reflective practice and System 2 processes by instructing participants to proceed slowly through their reasoning18 or by giving participants the opportunity to review their diagnoses.19 These studies have found minimal or no impact on reducing the rate of diagnostic error. On the other hand, some studies have shown improved diagnostic accuracy when physicians are asked to explicitly state their differential diagnoses along with features that are consistent or inconsistent with each diagnosis.20 These results suggest that if reflective practice is to be effective, it must involve a thorough review of the differential diagnosis as opposed to simply taking additional time.Reducing Cognitive BurdenTools that reduce the cognitive burden placed on physicians may reduce the frequency of diagnostic errors. One suggestion has been to incorporate the use of checklists in the diagnostic process. These checklists would be matched to common presenting symptoms and include a list of possible diagnoses. One randomized controlled trial failed to show a statistically significant reduction in the diagnostic error rate with the use of checklists, except in a small subgroup of patients treated in the ED. 21 These findings challenge the results of two other studies that found checklists to be effective in improving scrutiny22 and diagnostic accuracy23 when interpreting electrocardiograms. More advanced forms of clinician decision support systems have also been studied.24 Software programs such as DXplain generate a list of potential diagnoses based on a patient’s chief complaint. In one study, when the software provided physicians a list of possible diagnoses before evaluating patients, diagnoses were 1.31 times more likely to be correct. 25 The use of diagnostic support tools may grow in the future as they are integrated into electronic medical record systems.Improving Knowledge and ExperienceA combination of experience, knowledge and feedback are integral in developing a clinician’s intuition to produce the best hypotheses. Experience without feedback can lead to overconfidence, which itself is a cognitive bias. The evidence supporting feedback is strong. Fridriksson et al showed a significant reduction in diagnostic error when referring doctors were provided feedback on the identification of subarachnoid hemorrhage.26 A systematic review of 118 randomized trials concluded that feedback was effective in improving professional practice.27 The specific characteristics of the best feedback were elusive. In general, however, feedback was thought to be most effective when it was explicit and delivered close to the time of decision making. ConclusionsIn our review, we explore clinical decision making through the lens of dual-process theory. However, multiple different dual-processing models are still being explored and fundamental questions are still under debate. For example, some experts believe that instead of focusing on de-biasing strategies, the key to improving intuitive (System 1) processes is simply to acquire more formal and experiential knowledge.19 Other unanswered questions include: the impact and magnitude of cognitive bias in actual clinical practice, which biases are most prevalent in each medical specialty and which strategies are the most effective in mitigating bias. Further study is also needed to assess the impact of novel educational methods, such as case-based and simulation-based learning, which are promising venues where trainees may identify and correct cognitive biases in a directly observed setting. References 1. Norman G. Research in clinical reasoning: past history and current trends. Med Educ 2005;39:418–27.2. Kahneman D. Thinking, fast and slow. Farrar, Straus and Giroux; 2011.3. Croskerry P. From mindless to mindful practice — cognitive bias and clinical decision making. N Engl J Med 2013;368:2445–8.4. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine 2003;78:775–80.5. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–9.6. Parush A, Campbell C, Hunter A, et al. Situational awareness and patient safety - a short primer. Ottawa ON: The Royal College of Physicians and Surgeons of Canada; 2011.7. Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online 2011;16.8. Reyna VF. A theory of medical decision making and health: fuzzy trace theory. Med Decis 2008;28:850–65.9. Osman M. An evaluation of dual-process theories of reasoning. Psychonom Bull review 2004;11:988–1010.10. Dubeau CE, Voytovich AE, Rippey RM. Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect. Med Dec Mak 1986;6:169–73.11. Nickerson RS. Confirmation bias: A ubiquitous phenomenon in many guises. Rev Gen Psychol 1998;2:175.12. Mendel R, Traut-Mattausch E, Jonas E, et al. Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses. Psychol Med 2011;41:2651–9.13. Pines JM. Profiles in patient safety: confirmation bias in emergency medicine. Acad Emerg Med 2006;13:90–4.14. Tschan F, Semmer NK, Gurtner A, et al. Explicit reasoning, confirmation bias, and illusory transactive memory: a simulation study of group medical decision making. Small Group Res 2009;40:271–300.15. Mamede S, van Gog T, van den Berge K, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA 2010;304:1198–203.16. Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Safe 2012;21:535–57.17. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013.18. Norman G, Sherbino J, Dore K, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med 2014;89:277–84.19. Monteiro SD, Sherbino J, Patel A, Mazzetti I, Norman GR, Howey E. Reflecting on diagnostic errors: taking a second look is not enough. J Gen Intern Med 2015;30:1270–4.20. Bass A, Geddes C, Wright B, Coderre S, Rikers R, McLaughlin K. Experienced physicians benefit from analyzing initial diagnostic hypotheses. Can Med Educ J 2013;4:e7–e15.21. Ely JW, Graber MA. Checklists to prevent diagnostic errors: a pilot randomized controlled trial. Diagnosis 2015;2.22. Sibbald M, de Bruin ABH, Yu E, van Merrienboer JJG. Why verifying diagnostic decisions with a checklist can help: insights from eye tracking. Adv Health Sci Educ Theory Pract 2015;20:1053–60.23. Sibbald M, de Bruin ABH, van Merrienboer JJG. Checklists improve experts' diagnostic decisions. Med Educ 2013;47:301–8.24. Garg AX, Adhikari NKJ, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293:1223–38.25. Kostopoulou O, Rosen A, Round T, et al. Early diagnostic suggestions improve accuracy of GPs: a randomised controlled trial using computer-simulated patients. Br J Gen Pract 2015;65:e49–54.26. Fridriksson S, Hillman J, Landtblom AM, Boive J. Education of referring doctors about sudden onset headache in subarachnoid hemorrhage. A prospective study. Acta Neurol Scand 2001;103:238–42.27. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care 2006;15:433–6.

OBJECTIVE Rheumatoid arthritis (RA) portends significant cardiovascular morbidity and mortality. We therefore determined how often rheumatologists screened for and managed cardiovascular risk factors in RA patients, and the barriers to doing so. METHODS We examined 300 patient charts from 10 university-affiliated rheumatology practices, to ascertain if they had been screened, treated and/or referred over a 3-year period. We subsequently distributed a national survey to Canadian rheumatologists to elucidate challenges in performing optimal cardiovascular risk modification. RESULTS Most patients were screened for hypertension. Forty-one per cent were found to be hypertensive; however, the majority of these patients were neither treated nor referred to another provider for management. A small minority of patients were screened for diabetes and/or hyperlipidaemia, and these were usually not addressed if abnormal. Men were referred more frequently than women. Consistent with these findings, the majority of rheumatologists from the national survey felt that they did not manage cardiovascular risk adequately; 79.4% cited a lack of time as a major barrier, and 82.5% felt that it should be managed by the primary care provider. CONCLUSION There is marked underdiagnosis and undertreatment of cardiac risk in RA. Several major barriers exist, including lack of time. Most rheumatologists feel that this aspect of care is the responsibility of primary care physicians.

Background Medication reconciliation (MedRec) has been a mandated or recommended activity in Canada, the USA and the UK for nearly 10 years. Accreditation bodies in North America will soon require MedRec for every admission, transfer and discharge of every patient. Studies of MedRec have revealed unintentional discrepancies in prescriptions but no clear evidence that clinically important outcomes are improved, leading to widely variable practices. Our objective was to apply process mapping methodology to MedRec to clarify current processes and resource usage, identify potential efficiencies and gaps in care, and make recommendations for improvement in the light of current literature evidence of effectiveness. Methods Process engineers observed and recorded all MedRec activities at 3 academic teaching hospitals, from initial emergency department triage to patient discharge, for general internal medicine patients. Process maps were validated with frontline staff, then with the study team, managers and patient safety leads to summarise current problems and discuss solutions. Results Across all of the 3 hospitals, 5 general problem themes were identified: lack of use of all available medication sources, duplication of effort creating inefficiency, lack of timeliness of completion of the Best Possible Medication History, lack of standardisation of the MedRec process, and suboptimal communication of MedRec issues between physicians, pharmacists and nurses. Discussion MedRec as practised in this environment requires improvements in quality, timeliness, consistency and dissemination. Further research exploring efficient use of resources, in terms of personnel and costs, is required.

Background: Previous studies have demonstrated higher referral rates for invasive procedures among patients admitted with acute coronary syndromes (ACS) to hospitals with catheterization facilities compared to those without. Studies have also reported underuse of evidence-based medical therapies and cardiac rehabilitation programs post myocardial infarction. We evaluated referral patterns for cardiac catheterization and use of secondary prevention strategies in current practice. Methods: We conducted a retrospective study of 397 patients with non-ST segment elevation ACS, comparing angiography referrals at a hospital with on-site catheterization facilities (Site A, n = 194) versus a hospital without (Site B, n = 203). We also recorded the use of secondary prevention strategies including discharge medications, referrals to smoking cessation programs and cardiac rehabilitation. Results: There was no significant effect of on-site angiography on the decision to manage patients invasively (adjusted OR for on-site angiography 1.49 95% CI 0.92-2.44, p = .11), or wait times for cardiac catheterization (Site A 1.9 days vs. Site B 2.2 days, difference −0.3 days, 95% CI −0.83 to 0.55, p = .70). However, at the time of hospital discharge, less than 70% of patients were prescribed dual antiplatelet therapy and only 13% of patients were referred for cardiac rehabilitation. Conclusion: These observations suggest that in contemporary practice in a Southern Ontario community, the availability of on-site percutaneous coronary intervention does not influence referral rates or wait times for cardiac catheterization. However we did observe significant underuse of cardiac rehabilitation programs and certain medical therapies. This suggests that despite improvements in access to invasive procedures, there remain important gaps in secondary prevention of coronary artery disease, which represent opportunities to improve quality of care in these patients.

Hepatic encephalopathy (HE) is a common complication of cirrhosis of the liver. It is also extremely debilitating, with an untreated 3-year survival of only 23 %. While the exact pathophysiology of HE has yet to be elucidated, a number of contributing factors have been described. Abnormal levels and altered metabolism of ammonia play a central role. Recently, inflammation has also been identified as a contributor to HE. Improved understanding of the pathophysiology of HE is crucial, as current therapy centers on reduction of the body's ammonia load. Lactulose is the first-line therapy for HE, with some antibiotics recently showing promise for improved outcomes in patients with HE. The role of anti-inflammatory therapies has yet to be evaluated.

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.