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Background: The effect of the COVID-19 pandemic on the diagnosis and management of lung cancer in Canada is not fully understood. We sought to quantify the provincial volume of diagnostic imaging, thoracic surgeon referrals, time to surgery after referral, and pathologic staging for curative surgery in the context of the pandemic, as well as explore the effect of a pooled patient model, which was implemented to prioritize surgeries for lung cancer and mitigate the effects of the pandemic. Methods: We conducted a retrospective cohort study of patients who underwent diagnostic imaging in Nova Scotia and were subsequently referred to a thoracic surgeon at the province&apos;s only tertiary care centre for surgical management of their primary lung cancer before (Mar. 1, 2019, to Feb. 29, 2020) and during (Mar. 1, 2020, to Feb. 28, 2021) the COVID-19 pandemic. We conducted a survey to capture the patient and surgeon experience with a pooled patient model of managing surgical oncology cases. Results: Compared with the pre-COVID-19 period, the overall volume of chest radiography and chest computed tomography decreased by 30.9% (p < 0.001) and 18.7% (p = 0.002), respectively, in the COVID-19 period. Thoracic surgeon referrals, operative approach, extent of resection, length of hospital stay, and pathologic staging did not significantly differ. Time from referral to surgery was significantly shorter during the COVID-19 period (mean 196.8 d v. 157.9 d, p = 0.04). A pooled patient approach contributed to positive patient satisfaction. Conclusion: The COVID-19 pandemic was associated with reductions in rates of diagnostic imaging and referrals to thoracic surgeons for management of pulmonary cancer. A pooled patient model was used to mitigate the effects of the pandemic on lung cancer management and was positively received by patients. An extended study period is needed to determine the full effect of this redistribution of resources. Contexte : L&apos;effet de la pand mie de COVID-19 sur le diagnostic et la prise en charge du cancer du poumon au Canada n&apos;est pas enti rement compris. Nous avons voulu conna tre le volume provincial d&apos; preuves d&apos;imagerie diagnostique et de demandes de consultation en chirurgie thoracique, de m me que l&apos;intervalle entre les consultations et les chirurgies et le stade de la maladie justiciable d&apos;une chirurgie vis e curative dans le contexte de la pand mie, en plus d&apos;explorer l&apos;effet d&apos;un mod le de cas group s pour tablir l&apos;ordre de priorit des chirurgies pour le cancer du poumon et att nuer les effets de la pand mie. M thodes : Nous avons proc d une tude de cohorte r trospective aupr s des personnes ayant subi des preuves d&apos;imagerie diagnostiques en Nouvelle- cosse et adress es en chirurgie thoracique dans le seul tablissement de soins tertiaires de la province pour une prise en charge chirurgicale de leur n oplasie pulmonaire primitive avant (du 1er mars 2019 au 29 f vrier 2020) et durant (du 1er mars 2020 au 28 f vrier 2021) la pand mie de COVID-19. Nous avons r alis un sondage sur l&apos;exp rience des malades et des chirurgiennes et chirurgiens dans le cadre d&apos;un mod le de cas group s pour la prise en charge chirurgicale en oncologie. R sultats : Comparativement la p riode pr -COVID-19, le volume global des radiographies pulmonaires et des tomodensitom tries thoraciques a diminu de 30,9% (p < 0,001) et de 18,7% (p = 0,002), respectivement, durant la p riode de COVID-19. Les consultations en chirurgie thoracique, l&apos;approche chirurgicale, l&apos;ampleur de la r section, la dur e du s jour hospitalier et la stadification de la maladie n&apos;ont pas diff r significativement. L&apos;intervalle entre les consultations et les chirurgies a t significativement plus bref durant la p riode de COVID-19 (moyenne 196,8 j c. 157,9 j, p = 0,04). Le mod le de priorisation des cas group s a contribu favorablement la satisfaction des malades. Conclusion : La pand mie de COVID-19 a t associ e une r duction des taux d&apos; preuves d&apos;imagerie diagnostique et de demandes de consultation en chirurgie thoracique pour la prise en charge du cancer du poumon. Un mod le de priorisation de cas group s a servi att nuer les effets de la pand mie sur la prise en charge du cancer du poumon et a t accueilli favorablement par les malades. Un volet de prolongation est n cessaire pour mesurer tout l&apos;effet de cette redistribution des ressources., Lung cancer is the leading global cause of cancer-related deaths among both males and females. (1) In Canada, lung cancer has the highest cancer mortality; Nova Scotia has one of [...]

Background: Patients with knee osteoarthritis (OA) in northwestern Ontario are referred by their primary care provider (PCP) to a centralized assessment clinic for evaluation by an advanced practice physiotherapist (APP) to determine if they will require surgical management. However, many patients are found to not require surgical management, resulting in delays for patients who do. A decision-support tool was developed to address this issue and to guide treatment options by determining the need for surgical or nonsurgical approaches. Methods: We used a proof-of-concept method to assess the use of the decision-support tool in northwestern Ontario. Data from 100 consecutive patients assessed for knee OA management were collected from the Thunder Bay centralized assessment clinic. Two levels of agreement analyses (calculated using Cohen K statistic) were performed, between the APP assessment decision (surgical or nonsurgical) and the decision-support tool recommendation, and between the surgeon's decision (surgical or nonsurgical) and the decision-support tool recommendation. Results: We found a near-perfect agreement ([kappa] = 0.870, n = 65) between the APP decision and the decision-support tool recommendation, when controlled for patient preference. There was a substantial level of agreement ([kappa] = 0.618, n = 72) between the decision-support tool recommendation and the surgeon's decision. Conclusion: The decision-support tool recommendation showed considerable agreement with the decisions of the APP and surgeon indicating that it could be a valuable tool to guide PCPs caring for patients with knee OA. The applicability of a decision-support tool in northwestern Ontario displayed promising results, but further research is needed to examine the feasibility in a primary care setting. Contexte: Dans le nord-ouest de l'Ontario, les personnes atteintes d'arthrose du genou sont orientées par leur prestataire de soins de santé primaires vers une clinique d'évaluation centralisée pour qu'un ou une physiothérapeute en pratique avancée détermine le besoin d'avoir recours à une chirurgie. Toutefois, un tel traitement n'est finalement pas nécessaire pour de nombreuses personnes, ce qui entraîne des retards pour ceux et celles qui en ont besoin. Nous avons élaboré un outil d'aide à la prise de décisions cliniques afin de résoudre cet enjeu et d'orienter les options thérapeutiques en déterminant le besoin pour des traitements chirurgicaux ou non chirurgicaux. Méthodes: Nous avons employé une méthode de validation de principe dans le but d'évaluer l'utilisation de l'outil d'aide à la prise de décisions dans le nord-ouest de l'Ontario. Nous avons colligé les données de 100 patientes et patients consécutifs évalués pour la prise en charge d'une arthrose du genou à la clinique d'évaluation centralisée de Thunder Bay. Nous avons réalisé 2 niveaux d'analyse d'accord (calculée à l'aide de la méthode statistique du K de Cohen) : entre la décision fondée sur l'évaluation du ou de la physiothérapeute en pratique avancée (traitement chirurgical et non chirurgical) et la recommandation de l'outil d'aide à la prise de décisions, ainsi qu'entre la décision du chirurgien ou de la chirurgienne (traitement chirurgical ou non chirurgical) et celle de l'outil d'aide à la prise de décisions. Résultats: Nous avons observé un accord quasi parfait ([kappa] = 0,870, n = 65) entre la décision du ou de la physiothérapeute en pratique avancée et la recommandation de l'outil d'aide à la prise de décisions lorsqu'on tient compte des préférences du patient ou de la patiente. Nous avons constaté un accord important ([kappa] = 0,618, n = 72) entre la recommandation de l'outil d'aide à la prise de décisions et la décision du chirurgien ou de la chirurgienne. Conclusion : Les recommandations offertes par l'outil d'aide à la prise de décisions ont démontré un accord remarquable entre les décisions prises par le ou la physiothérapeute en pratique avancée et le chirurgien ou la chirurgienne, ce qui permet de croire qu'il s'agit d'un outil précieux pour guider les prestataires de soins de santé primaires auprès des personnes atteintes d'arthrose du genou. La pertinence du déploiement de l'outil d'aide à la prise de décisions dans le nord-ouest de l'Ontario a montré des résultats prometteurs, mais de plus amples travaux de recherche sont nécessaires afin d'en examiner la faisabilité dans le contexte des soins de santé primaires., Access to timely and appropriate health care is a challenge in northwestern Ontario (1) where the lack of adequate care in rural areas stems from several factors, including health care [...]

Background: Injury severity scales have traditionally been used to assess the perform ance of prehospital trauma triage protocols, but they correlate weakly with the urgent needs of specialized trauma care interventions. This study aimed to develop a list of in-hospital urgent and specialized trauma care interventions that require direct transport to the highest-level trauma centre within the catchment area. Methods: Based on a list of potential participants we obtained using data on training, experience, geographic location, affliations and role within key trauma organizations, we recruited multidisciplinary trauma experts (including prehospital, emergency, surgery and intensive care clinicians, epidemiologists and clinician/decision-makers) from across Canada to complete a 3-round modified Delphi survey. We conducted a literature review of the criteria used to define urgent and specialized trauma care, and included all diagnostic and therapeutic interventions presented in previously published studies in the list of interventions to present to the panellists. The final list was determined by our advisory committee, 5 clinicians with experience in trauma care. Participants were asked to rate their level of agreement for potentially including the 38 items as urgent and specialized trauma care interventions on a 9-point Likert scale. Interventions were retained if more than 67% of participants moderately or strongly agreed (7-9 on the Likert scale). Interventions that did not reach consensus were presented again in the subsequent round. Results: Twenty-three panellists were recruited. The response rate was 91%, 96% and 83% for the 3 rounds. After the Delphi process, 30 of the 38 interventions, including endotracheal intubation, blood product administration and angioembolization, and abdominal, thoracic, neurosurgical, spinal and/or orthopedic operations (excluding hip or limb surgery, and toe or finger amputation), were selected. Hospital admission to the intensive care unit and/or for observation of brain, spinal, thoracic or abdominal injuries were also retained. Conclusion: We developed a Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions requiring direct transportation to a major trauma centre. This list should help standardize assessments of current protocols and derive new triage tools. Contexte : Les echelles de gravite des blessures sont habituellement utilisees pour evaluer les performances des protocoles de triage prehospitalier des traumatismes, mais elles sont inadaptees aux besoins urgents des interventions specialisees en traumatologie. La presente etude visait a concevoir une liste des interventions hospitalieres urgentes et specialisees en traumatologie necessitant un transport direct vers le centre de traumatologie du niveau le plus eleve de la circonscription hospitaliere. Methodes : Nous avons constitue une liste de participants potentiels d'apres des donnees sur la formation, l'experience, l'emplacement geographique, les affliations et le poste au sein d'etablissements majeurs en traumatologie pour recruter differents experts en traumatologie (dont des professionnels des soins prehospitaliers, des soins d'urgence, des soins intensifs et de la chirurgie, des epidemiologistes ainsi que des cliniciens decideurs) de tout le Canada a qui nous avons demande de remplir un questionnaire Delphi modife en 3 etapes. Nous avons effectue une revue de la litterature des criteres utilises pour definir les soins urgents et specialises en traumatologie et avons inclus l'ensemble des interventions diagnostiques et therapeutiques decrites dans les etudes precedentes a la liste des interventions presentees aux panelistes. Notre comite consultatif, 5 professionnels de la sante connaissant bien la traumatologie, s'est entendu sur la liste definitive. Les participants ont note la classification potentielle de 38 elements comme des interventions urgentes et specialisees en traumatologie sur une echelle de Likert en 9 points. Les interventions moderement ou fortement approuvees par plus de 67 % des participants (7-9 sur l'echelle de Likert) ont ete retenues, tandis que celles qui n'ont pas abouti a un consensus ont ete presentees a nouveau a l'etape suivante. Resultats : Vingt-trois panelistes ont ete recrutes et ont ete 91 %, 96 % et 83 % a repondre a chaque etape du sondage. A l'issue du processus Delphi, 30 des 38 interventions, dont l'intubation tracheale, l'administration de produits sanguins et l'angioembolisation, ainsi que les chirurgies abdominales, thoraciques, neurochirurgicales, orthopediques et du rachis (a l'exclusion de la chirurgie de la hanche ou des membres et l'amputation des orteils ou des doigts) ont ete selectionnees. L'hospitali sa tion en soins intensifs ou pour observation d'un traumatisme cranien, medullaire, tho ra cique ou abdominal a aussi ete retenue. Conclusion : Nous avons elabore une liste canadienne par consensus des interventions hospitalieres urgentes et specialisees en traumatologie necessitant un transport direct vers un grand centre de traumatologie afin de normaliser les evaluations des protocoles actuels pour en tirer de nouveaux outils de triage., Trauma is the leading cause of mortality, morbidity and health-related productivity loss among young adults and carries an estimated annual cost of $27 billion in Canada. (1) For critically injured [...]

Deep learning methods have been shown to achieve excellent performance on diagnostic tasks, but how to optimally combine them with expert knowledge and existing clinical decision pathways is still an open challenge. This question is particularly important for the early detection of cancer, where high-volume workflows may benefit from (semi-)automated analysis. Here we present a deep learning framework to analyze samples of the Cytosponge-TFF3 test, a minimally invasive alternative to endoscopy, for detecting Barrett's esophagus, which is the main precursor of esophageal adenocarcinoma. We trained and independently validated the framework on data from two clinical trials, analyzing a combined total of 4,662 pathology slides from 2,331 patients. Our approach exploits decision patterns of gastrointestinal pathologists to define eight triage classes of varying priority for manual expert review. By substituting manual review with automated review in low-priority classes, we can reduce pathologist workload by 57% while matching the diagnostic performance of experienced pathologists. A clinician-in-the-loop deep learning system streamlines the workflow of pathologists for detection of Barrett's esophagus and retains the diagnostic accuracy of full manual review., Author(s): Marcel Gehrung [sup.1] [sup.2] , Mireia Crispin-Ortuzar [sup.1] , Adam G. Berman [sup.1] , Maria O'Donovan [sup.3] [sup.4] , Rebecca C. Fitzgerald [sup.3] , Florian Markowetz [sup.1] Author Affiliations: [...]

At the start of the coronavirus disease 2019 (COVID-19) pandemic, hospitals and ambulatory surgical centres significantly decreased elective surgical procedures to facilitate capacity for in-hospital beds, preserve personal protective equipment (PPE), preserve anesthetic medications and limit spread of infection. Non-COVID-19-related ophthalmic disease continues to affect vision, and it is anticipated that the backlog of elective surgeries will require months to years to resolve. The delivery of ophthalmic surgical care in a prioritized, systematic and transparent way is vital to manage the surgical backlog while minimizing vision loss and consequent disability in the Canadian population. The Canadian Ophthalmology Society (COS) has modified the published Medically Necessary, Time Sensitive (MeNTS) Procedures scoring system to be applicable to all subspecialties within ophthalmology. This case prioritization process integrates medical necessity, consideration of resource preservation with risk of COVID-19 exposure, and factors unique to eye care. It provides guidance to Canadian ophthalmologists to facilitate decision making in triaging elective procedures., At the start of the coronavirus disease 2019 (COVID-19) pandemic, hospitals and ambulatory surgical centres significantly decreased elective surgical procedures in an effort to allow for in-patient bed capacity, preserve [...]

Byline: Anu. Gupta, Venugopalan. Vishnu, Mamta. Singh, Rohit. Bhatia, Roopa. Rajan, Deepti. Vibha, Arunmozhimaran. Elavarasi, Divya. Radhakrishnan, Ayush. Agarwal, Bhargavi. Ramanujam, Animesh. Das, Rajesh. Singh, Awadh. Pandit, Achal. Srivastava, Manjari. [...]

Author(s): Emmanuel Hei-Lok Cheung [sup.1] , Jonathan Chun-Hei Cheung [sup.1] , Yu-Yeung Yip [sup.2] Author Affiliations: (1) grid.490321.d, 0000000417722990, Intensive Care Unit, North District Hospital, , 9 Po Kin Road, [...]

: Introduction: Strategies employing a single rapid diagnostic test (RDT) such as HIV self‐testing (HIVST) or “test for triage” (T4T) are proposed to increase HIV testing programme impact. Current guidelines recommend serial testing with two or three RDTs for HIV diagnosis, followed by retesting with the same algorithm to verify HIV‐positive status before anti‐retroviral therapy (ART) initiation. We investigated whether clients presenting to HIV testing services (HTS) following a single reactive RDT must undergo the diagnostic algorithm twice to diagnose and verify HIV‐positive status, or whether a diagnosis with the setting‐specific algorithm is adequate for ART initiation. Methods: We calculated (1) expected number of false‐positive (FP) misclassifications per 10,000 HIV negative persons tested, (2) positive predictive value (PPV) of the overall HIV testing strategy compared to the WHO recommended PPV ≥99%, and (3) expected cost per FP misclassified person identified by additional verification testing in a typical low‐/middle‐income setting, compared to the expected lifetime ART cost of $3000. Scenarios considered were as follows: 10% prevalence using two serial RDTs for diagnosis, 1% prevalence using three serial RDTs, and calibration using programmatic data from Malawi in 2017 where the proportion of people testing HIV positive in facilities was 4%. Results: In the 10% HIV prevalence setting with a triage test, the expected number of FP misclassifications was 0.86 per 10,000 tested without verification testing and the PPV was 99.9%. In the 1% prevalence setting, expected FP misclassifications were 0.19 with 99.8% PPV, and in the Malawi 2017 calibrated setting the expected misclassifications were 0.08 with 99.98% PPV. The cost per FP identified by verification testing was $5879, $3770, and $24,259 respectively. Results were sensitive to assumptions about accuracy of self‐reported reactive results and whether reactive triage test results influenced biased interpretation of subsequent RDT results by the HTS provider. Conclusions: Diagnosis with the full algorithm following presentation with a reactive triage test is expected to achieve PPV above the 99% threshold. Continuing verification testing prior to ART initiation remains recommended, but HIV testing strategies involving HIVST and T4T may provide opportunities to maintain quality while increasing efficiency as part of broader restructuring of HIV testing service delivery., Introduction Substantial scale‐up of HIV testing services (HTS) has contributed to tremendous progress towards global targets to diagnose 90% of people with HIV by 2020. In 2017, PEPFAR alone conducted [...]

Background: Identifying patients at high risk of colorectal cancer is essential to the provision of surgical care. At our site, the Facilitated Access to Surgical Treatment (FAST) program triages patients [...]

The findings of a case control study performed in Santa Clara County, CA, are reviewed to show the relation of medical triage and referral in child sexual abuse cases and an approach in the research for the prediction of positive medical findings. An important triage consideration is the choice of the child to be examined. The control study provides several hypotheses that are needed to be addressed such as age as a predictor of trauma evidence, selective referral of the sociolegal system, risk factor determination and inventory of variables predicting anatomic findings.

The development of a research agenda to evaluate triage and referral for medical examinations of sexually abused child is discussed. Several practices and beliefs about medical examinations are to be studied such as structure of medical care, process of care and sociolegal outcomes. The medical examination must focus on the social and legal structure and other community attributes. Sociolegal structure of care and outcomes are incorporated to the medical outcomes model for a more extensive evaluation that may influence patient prognosis.

Changes in the health care delivery system have resulted in an increasing reliance on the expertise of certified nurse-midwives (CNMs). A crucial role CNMs can fill is to efficiently evaluate, prioritize, and direct obstetric patients to appropriate services as they enter the emergency department. Guidelines for admittance and management of obstetric patients are presented based on the experience of a busy university hospital.

The role of certified nurse-midwives (CNMs) in some emergency departments has become more comprehensive. The jobs that CNMs perform in one large university hospital are presented. CNMs evaluate, prioritize, and sometimes treat obstetric patients as they enter the emergency department. Their responsibilities include tracking labor progress, evaluating abnormal bleeding or abortions at all stages of pregnancy, assessing urinary tract infections, and performing and evaluating some ultrasounds.

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a stimulated mother and to decide whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P < .05) or injured (P < .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P < .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions. In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician&apos;s interpretation of the information collected. Pediatrics 1992;89:701-706

Economic pressures require that patients not be hospitalized if they do not need to be. However, it is not always simple to determine which patients need what. Heart attack is one example of such a diagnostic problem. Patients who are having a heart attack should be sent to a coronary care unit. Conversely, it is wasteful to send patients to a coronary care unit who are not having a heart attack. Previous research has suggested that when the diagnosis of heart attack is uncertain, a 24-hour observation period is appropriate. A true heart attack will progress; if there are no heart attack symptoms after 24 hours, the diagnosis of heart attack is very unlikely. However, patients may not be sent home during this 24-hour period, and so even patients who are ultimately found not to have heart attacks nevertheless take up time and space in the hospital. Using a statistical model, clinicians have developed a strategy for deciding which patients are at low risk of heart attack; their method requires only a 12-hour monitoring period, and thus helps conserve hospital resources. The model was evaluated with 771 patients who did not have enzyme abnormalities or recurrent pain (which are indicative of heart attack) during the first 12 hours of observation. Only three patients died of heart attacks, and in all three cases the attacks occurred at least three days after the observation period. Life-threatening conditions which were not fatal occurred in an additional three patients. Overall, the complications in this group were infrequent, indicating that the series of decisions determined by the model is appropriate for use in the evaluation of emergency room patients presenting with chest pain or signs of an apparent heart attack. (Consumer Summary produced by Reliance Medical Information, Inc.)