Initiation of opioid agonist therapy after hospital visits for opioid poisonings in Ontario.

BACKGROUND: Emergency department visits and hospital admissions for opioid toxicity are opportunities to initiate opioid agonist therapy (OAT), which reduces morbidity and mortality in patients with opioid use disorder (OUD). The study objectives were to evaluate OAT initiation rates after a hospital encounter for opioid toxicity in Ontario, Canada, and determine whether publication of a 2018 Canadian OUD management guideline was associated with increased initiation. METHODS: We conducted a retrospective, population-based serial cross-sectional study of hospital encounters for opioid toxicity among patients with OUD between Jan. 1, 2013, and Mar. 31, 2020, in Ontario, Canada. The primary outcome was OAT initiation (methadone, buprenorphine-naloxone, or slow-release oral morphine) within 7 days of discharge, measured quarterly. We examined the impact of the release of the OUD management guideline on OAT initiation rates using Autoregressive Integrated Moving Average models. RESULTS: Among 20 702 hospital visits for opioid toxicity among patients with OUD, the median age was 35 years, and 65.1% were male. Over the study period, the percentage of visits leading to OAT initiation within 7 days rose from 1.7% or less (Q1 2013) to 5.6% (Q1 2020); however, the publication of the Canadian OUD management guideline was not associated with a significant increase in these rates (0.14% slope change, 95% confidence interval -0.11% to 0.38%; p = 0.3). INTERPRETATION: Among hospital encounters for opioid toxicity, despite rising prevalence over time, only 1 in 18 patients were dispensed OAT within a week of discharge in early 2020. These findings highlight missed opportunities to initiate therapies proven to reduce mortality in patients with OUD.

A Quality Improvement Initiative to Reduce Pediatrician Burnout Led by the American Academy of Pediatrics Section on Internal Medicine and Pediatrics (Med-Peds).

Physician burnout impacts care (of self and patient), productivity, longevity of career, and overall cost to the system. While burnout rates for pediatricians are lower than average, they have not improved significantly over time. While strategies at the system level have been more successful than those at the individual level, both aspects are vital. This quality improvement study explores physician wellness and burnout trends of a sample population of pediatricians at the 2018 and 2019 AAP National Conference and Exhibition (NCE), using the Physician Health and Wellness Booth (PHWB). A rapid cycle approach with the Plan-Do-Check-Act (PDCA) framework was utilized. The aim was to observe if reported burnout decreased by 20% over six months. Of the pediatricians who interacted with the PHWB, 56 were randomly selected to participate. This included men and women and those in various practice settings, ranging from resident physicians to providers in practice for over 20 years. Baseline surveys included elements from a modified Maslach Burnout Inventory and the Stanford Physician Wellness Survey, focusing on burnout components (emotional exhaustion, depersonalization, and fulfillment) and wellness activities. Individual-based interventions were provided at the PHWB, including adult preventative health guidelines, resources on sleep, stress mitigation, and complementary medicine. Participants received a movie ticket and Starbucks gift card. Follow-up included six monthly newsletters with strategies from seven wellness domains. Post-intervention surveys at six months assessed all baseline questions plus the effectiveness of monthly newsletters. A second PDCA cycle was conducted from the 2019 NCE. All individual-based interventions continued with an added aromatherapy oil station. Additional system-based resources included sample institutional wellness initiatives and burnout cost analyses, all focusing on advocating for cultural change at their respective home organizations. Interactive monthly wellness calendars addressing seven wellness domains were emailed for six months follow-up.  Results from 10 post-intervention surveys (10/56=18% of respondents) from the initial cohort reported an average of 25% decrease in burnout (p=0.09). This was measured on a scale of 1-10 (from "never" burned out to "very often") and improved from 6.68 ("sometimes" to "often" burned out) to 5.0 ("rarely" to "sometimes" burned out). Results from Cohort 2 reflected a decrease in burnout from 4.94 ("rarely" to "sometimes" burned out) to 2.85 ("never" to "rarely" burned out) in return from 20 post-intervention surveys (20/48=42% of respondents, p=0.003). Participants noted a lack of control over work schedules and a disconnect with organizational values as drivers of burnout. Both the PHWB and monthly newsletters were rated as valuable as reminders about wellness practices. Limitations included low response rate, which was notable, and inability to prove causation of improvement from our intervention. Future steps include utilizing subject identification numbers to allow for anonymity in a prospective cohort study with a third PDCA cycle. This would allow anonymous but matched same-subject comparison of pre- and post-survey results despite the small sample size. Follow-up incentives could be beneficial. Lastly, data from both cohorts revealed the highest level of burnout in early career physicians within 10 years of training, paving an opportunity for future study.

Cinacalcet increases renal calcium excretion in PTHrP-mediated hypercalcemia: a case report.

BACKGROUND: In the acute setting, PTH-independent hypercalcemia is typically treated with anti-resorptive agents such as zoledronic acid or denosumab. When these agents are no longer able to control hypercalcemia, several case reports have shown the utility of cinacalcet. However, it is not known if cinacalcet can be effective in patients naïve to anti-resorptive therapy or how cinacalcet ameliorates the hypercalcemia. CASE PRESENTATION: A 47-year-old male with a history of alcohol-induced cirrhosis was admitted for left cheek bleeding and swelling from an infiltrative squamous cell carcinoma of the oral cavity. On admission, he was found to have an elevated albumin-corrected serum calcium of 13.6 mg/dL, a serum phosphorus of 2.2 mg/dL and an intact PTH of 6 pg/mL (normal 18-90) with a PTHrP of 8.1 pmol/L (normal < 4.3), consistent with PTHrP-dependent hypercalcemia. Aggressive intravenous saline hydration and subcutaneous salmon calcitonin were initiated, but his serum calcium remained elevated. Given tooth extractions scheduled for the next day and possible irradiation to the jaw in the near future, alternatives to antiresorptive therapy were sought. Cinacalcet was initiated at 30 mg twice daily then increased to 60 mg twice daily the following day. The albumin-corrected serum calcium level decreased from 13.2 to 10.9 mg/dL within 48 h. The fractional excretion of calcium increased from 3.7 to 7.0%. CONCLUSIONS: This case demonstrates the utility of cinacalcet for the treatment of PTHrP-mediated hypercalcemia without prior anti-resorptive therapy via increased renal clearance of calcium.

Characteristics of Pediatric Patients With Celiac Disease Identified Due to an Affected First-Degree Family Member.

The incidence of celiac disease in first-degree relatives of affected individuals is higher than in the general population, yet the clinical characteristics of this unique subset of patients has not been well described. Through a retrospective review of patients seen in a tertiary care pediatric celiac disease clinic, we identified 49 patients diagnosed with celiac disease following screening due to an affected first-degree relative. Although 51% of patients screened due to an affected first-degree relative were asymptomatic, their disease histology was as severe as those screened for symptoms suggestive of celiac disease. These findings support current recommendations to screen all first-degree relatives of patients with celiac disease regardless of clinical symptoms.

The association between pediatric mental health disorders and type 1 diabetes-related outcomes.

OBJECTIVE: Transition from pediatric to adult healthcare systems is a difficult process for young adults with Type 1 Diabetes (T1D) and most patients experience a deterioration in disease control. Mental health (MH) disorders are common in individuals with T1D and are believed to play a role in disease control and transition of care. We evaluated the association between the presence of pediatric MH disorder and measures of success in diabetes care in young adults who recently transitioned to adult care. RESEARCH DESIGN AND METHODS: Retrospective cohort study of young adults in a large adult endocrinology system who transitioned from a pediatric hospital system after 2009. MH disorders were diagnosed by clinical pediatric psychologists during routine care at the pediatric hospital. Measurements of Hemoglobin A1c, diabetes-related emergencies, clinic attendance and intervals in transition were assessed and compared between the pediatric and adult hospital systems. RESULTS: 237 young adults were identified and 100 (42%) of these were diagnosed with a MH disorder during pediatric care. Presence of a MH disorder was associated with higher Hemoglobin A1c levels prior to transition and increased rates of diabetes-related hospitalizations during the transition interval. Patients with a MH disorder were less likely to establish a pattern of consistent follow up after transition (p = 0.021). CONCLUSIONS: MH disorders are common and predict greater challenges with diabetes management and less effective transition into the adult endocrinology system. Early recognition of MH disorders may allow for allocation of more proactive and intensive support for affected patients.

Combined cerebral and somatic near-infrared spectroscopy oximetry monitoring during liver surgery: an observational and non-interventional study.

BACKGROUND: Cerebral oximetry using near-infrared spectroscopy (NIRS) is used for monitoring cerebral oxygen saturation during cardiac surgery and is correlated with clinical outcomes. Our goal was to explore cerebral and somatic NIRS in liver resections as a predictor of post-operative complications. METHODS: Prospective observational and non-interventional study from a tertiary care university hospital including adult patients undergoing liver resection monitored using NIRS at four sites before and during surgery. Those sites were: frontotemporal left and right zones, right thigh, and right arm. Anesthesiologists and surgeons were blinded to oximetry values. Correlations were assessed between baseline oximetry values and cerebro-somatic desaturation load (threshold of 80% from baseline) values with peri-operative events and complications. RESULTS: Ninety patients were distributed equally among gender with a mean age of 59.7 ± 13.1 years. Lower baseline cerebral and/or somatic values were associated with increased risk of delirium, respiratory failure, surgical and renal complications, blood transfusions, and length of stay in the intensive care unit and in the hospital (P < 0.05). The severity of somatic desaturation below 80% was the only parameter associated with blood losses (P = 0.030) and length of hospital stay (P = 0.047). CONCLUSIONS: Cerebral and somatic desaturation does occur in liver resection and can be used simultaneously during liver surgery. Both baseline cerebral and somatic NIRS values are correlated with complications and outcomes. However, thigh desaturation appears more sensitive than cerebral NIRS values in predicting some of these complications.

Transformative learning in an interprofessional student-run clinic: a qualitative study.

Student-run free clinics are increasingly seen as a way for students in health professions to have early authentic exposures to providing care to marginalized populations, often in the context of interprofessional teams. However, few studies characterize what and how students may learn from volunteering at a student-run free clinic. We aimed to examine shifts in attitude or practice that volunteers report after completing a placement at an interprofessional student-run clinic in Toronto, Ontario, Canada. Transcripts from semi-structured reflective focus groups were analyzed in an exploratory thematic manner and from the perspective of transformative learning theory. Volunteers reported attitude shifts toward greater self-awareness of assumptions, recognition of the need for systemic interventions, and seeing themselves as learning and contributing meaningfully in a team even without direct-client contact. Practice shifts emerged of individualizing assessment and treatment of patients as well as increased comfort working in interprofessional teams. Attitude and practice shifts were facilitated by authentic interactions with individuals from marginalized populations, taking a patient-centered approach, and an interprofessional context. Interprofessional student-run free clinics are suited to triggering disorienting dilemmas that set the stage for transformative learning, particularly when volunteers are guided to reflect.

Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers.

OBJECTIVES: Opioid-related emergency department (ED) visits have increased significantly in recent years. Our objective was to evaluate an ED-initiated buprenorphine/naloxone program, which provided rapid access to an outpatient community-based addictions clinic, for patients in opioid withdrawal. METHODS: A retrospective chart review was completed within a health system encompassing four community EDs in Ontario, Canada. Patients were screened for opioid withdrawal between April 2017-December 2017 and offered buprenorphine/naloxone treatment and referral to outpatient addictions follow-up. The main outcome measure was treatment retention in the six-month period after the index visit. RESULTS: The overall sample (N = 49) showed high healthcare utilization in the year prior to the index ED visit. 88% of patients (n = 43) consented to ED-initiated buprenorphine/naloxone and were referred to outpatient addictions follow-up, with 54% attending the initial follow-up visit. In the 6-month follow-up period from the index ED visit, 35% of patients were receiving ongoing buprenorphine/naloxone treatment and 2.3% were weaned off opioids. Patients with ongoing treatment had significantly lower number of ED visits at 3 and 6 months (3 and 10, respectively) compared to patients who did not show up for outpatient follow-up (28, 40) or started/stopped treatment (23, 41). CONCLUSIONS: Screening for opioid use disorder in the ED and initiating buprenorphine/naloxone treatment with rapid referral to an outpatient community-based addictions clinic led to a 6-month treatment retention rate of 37% and a significant reduction in ED visits at 3 and 6 months. Buprenorphine/naloxone initiation in the ED appears to be an effective intervention, but further research is needed.

OBJECTIF: Le nombre de consultations aux services des urgences (SU) motivées par l'usage des opioïdes a augmenté de façon importante au cours des dernières années. L'étude visait à évaluer l'efficacité d'un programme de traitement des troubles afférents par la buprénorphine (BPN) et la naloxone, entrepris au SU et suivi d'un accès rapide à des services communautaires de consultation externe pour le traitement de la dépendance chez les patients présentant un syndrome de sevrage aux opioïdes. MÉTHODE: Il s'agit d'un examen rétrospectif de dossiers médicaux, réalisé dans un réseau de santé constitué 4 SU communautaires, en Ontario, au Canada. Les patients présentant des symptômes de sevrage aux opioïdes ont d'abord été repérés entre avril 2017 et décembre 2017, puis se sont vu offrir un traitement par la BUP et la naloxone avec aiguillage vers un service de consultation externe pour le suivi. Le critère d'évaluation principal consistait en la poursuite du traitement au cours de la période de 6 mois suivant la consultation de référence. RÉSULTATS: L'analyse de l'échantillon global (n = 49) a révélé une forte utilisation des services de santé au cours de l'année précédant la consultation de référence au SU. Dans l'ensemble, 88% des patients (n = 43) ont accepté l'offre de traitement entrepris au SU, puis ont été dirigés vers un service de consultation externe pour le suivi; 54% de ces derniers sont allés à la première consultation. Durant le suivi de 6 mois après la consultation de référence au SU, 35% des patients étaient encore en traitement et 2,3% des participants étaient sevrés. Les patients encore fidèles au traitement ont connu un nombre significativement moins élevé de consultations au SU au bout de 3 mois et de 6 mois (3 et 10, respectivement) que les patients qui ne sont pas présentés au service de consultation externe (28, 40) ou qui ont entrepris le traitement mais qui ne l'ont pas poursuivi (23, 41). CONCLUSION: Le dépistage des troubles liés à l'usage des opioïdes, au SU, et l'instauration du traitement par la BUP et la naloxone avec aiguillage rapide vers un service communautaire de consultation externe pour le traitement de la dépendance se sont traduits par un taux de rétention des patients de 37% au bout de 6 mois et par une réduction significative du nombre de consultations au SU au bout de 3 mois et de 6 mois. L'instauration du traitement au SU semble donc une intervention efficace, mais il faudrait poursuivre la recherche sur le sujet.

Emergency Department Referrals for Adolescent Urgent Psychiatric Consultation: Comparison of Clinical Characteristics of Repeat-presentations and Single-presentation.

OBJECTIVE: a) to examine the demographic and clinical characteristics of repeat-presentations to an adolescent urgent psychiatric clinic, and b) to compare them with single-time presentation. METHOD: This 18-month retrospective study compared repeat-presenters to age and gender matched single-time presenters. Demographic variables included age gender and ethnicity. Clinical variables included reason for referral, family history, diagnosis, recommendations and compliance. Data were analyzed using descriptive statistics, McNemar's Chi-square tests for matched pairs, and conditional logistic regression. RESULTS: Of 624 assessments 24% (N=151) were repeat-presentations. Compared with single-presentation, repeat-presentation group had a higher proportion of Aboriginal youth (X2 (1) = 108.28 p < 0.01), a higher proportion in special educational placement (X2 (1) = 6.82, p < 0.01), a higher proportion with a family history of anxiety disorders (X2 (1) = 10.62, p = 0.01) and substance use disorder (X2 (1) = 18.99, p < 0.01). Conditional logistic regression results suggested that repeat-presentation group had higher odds of past hospital admission (OR: 3.50, p < 0.01) higher odds of family history of mood disorders (OR: 4.86, p < 0.01) and of antisocial disorders (OR: 4.97, p = 0.02), and lower odds of recommendation compliance (OR: 0.10, p < 0.01). CONCLUSION: Repeat-presentations for urgent psychiatric consultation constitute a quarter of referrals to the urgent psychiatric clinic. Identifying and addressing factors that contribute to repeat-presentations may, assist in improving treatment compliance by ensuring focused interventions and service delivery for these youth. In turn, this will improve access to the limited urgent services for other youth.

OBJECTIF: a) Examiner les caractéristiques démographiques et cliniques des visites répétées à une clinique psychiatrique d'urgence pour adolescents et b) les comparer à celles d'une visite unique. MÉTHODE: Cette étude rétrospective sur 18 mois a comparé les visiteurs répétés avec des visiteurs uniques appariés selon l'âge et le sexe. Les variables démographiques comprenaient l'âge, le sexe et l'origine ethnique. Les variables cliniques étaient notamment la raison de l'aiguillage, les antécédents familiaux, le diagnostic, les recommandations et l'observance. Les données ont été analysées à l'aide de statistiques descriptives, de tests du chi carré de McNemar pour paires appariées, et de la régression logistique conditionnelle. RÉSULTATS: Sur les 624 évaluations, 24% (N = 151) étaient des visites répétées. Comparé aux visiteurs uniques, le groupe des visites répétées avait une proportion plus élevée de jeunes autochtones (X2 (1) = 108,28, p < 0,01), une proportion plus élevée de placements en éducation spécialisée (X2 (1) = 6,82, p < 0,01), et une proportion plus élevée de sujets ayant des antécédents familiaux de troubles anxieux (X2 (1) = 10,62, p = 0,01) et de troubles d'utilisation de substances (X2 (1) = 18,99, p < 0,01). Les résultats de la régression logistique conditionnelle suggéraient que le groupe des visites répétées avait des probabilités plus élevées d'hospitalisations passées (RC 3,50, p < 0,01), des probabilités plus élevées d'antécédents familiaux de troubles de l'humeur (RC 4,86, p < 0,01) et de troubles antisociaux (RC 4,97, p = 0,02), et des probabilités plus faibles d'observance des recommandations (RC 0,10, p < 0,01). CONCLUSION: Les visites répétées pour une consultation psychiatrique urgente constituent un quart de l'aiguillage à la clinique psychiatrique d'urgence. Identifier et aborder les facteurs qui contribuent aux visites répétées peut aider à améliorer l'observance du traitement en assurant des interventions ciblées et la prestation de services à ces jeunes. Cela améliorera ensuite l'accès aux services d'urgence limités pour les autres jeunes.

Investigating student perceptions at an interprofessional student-run free clinic serving marginalised populations.

Many health profession schools have student-run free clinics (SRFCs), but their educational relevance has not been well studied. The aim of this study was to evaluate the learning experiences and skills developed among interprofessional healthcare students at an SRFC serving marginalised populations, in order to provide data for ongoing programme improvement and recommendations for other SRFCs based on lessons learned. Under 1:1 supervision with a preceptor, interprofessional students completed three clinical shifts at an SRFC and attended a reflection session. A total of 101 out of 105 participants answered semi-structured pre- and post-programme surveys (response rate: 96%). Descriptive statistics and descriptive thematic analyses were used for quantitative and qualitative data, respectively. Numerous skills derived from learning objectives common to many healthcare professions were addressed while participating at the SRFC. Valued programme elements included working with and learning about inner city populations in an interprofessional care model. Interprofessional SRFCs encourage student learning about resources for inner city populations and interprofessional collaboration while providing an opportunity to develop skills related to the formal curriculum. This may provide a workable strategy to address an interprofessional education gap in the healthcare professional curriculum.

Preliminary Experience in Combined Somatic and Cerebral Oximetry Monitoring in Liver Transplantation.

OBJECTIVE: The use of cerebral near-infrared spectroscopy (NIRS) has become widespread in cardiac surgery after research demonstrated an association between perioperative cerebral desaturations and postoperative complications. Somatic NIRS desaturation also is associated with an increased risk of postoperative complications and mortality. The objective of this study was to explore the trends of both somatic and cerebral NIRS during liver transplantation. DESIGN: A prospective, single-site, observational case series. SETTING: Tertiary care center. PARTICIPANTS: The study comprised 10 patients undergoing liver transplantation. INTERVENTIONS: NIRS sensors were placed on the forehead (cerebral regional oxygen saturation [rSO2]) and on the right arm and right leg (somatic rSO2) to measure tissue perfusion. Desaturation was defined as a 20% decrease of baseline values for 15 seconds. MEASUREMENTS AND MAIN RESULTS: In all patients, parallel changes in both cerebral and somatic rSO2 values were observed during phlebotomy, bleeding, transfusion, portal vein clamping, and the use of vasoactive agents. Induction of anesthesia increased cerebral rSO2 more than it did somatic values. However, ascites removal, abdominal manipulation, and clamping of the inferior vena cava (IVC) were associated with nonparallel changes in cerebral and somatic rSO2. Ascites removal was associated with increased somatic leg rSO2, and IVC clamping and abdominal hypertension were associated with a significant reduction in somatic leg rSO2. Somatic leg desaturation instead of arm or cerebral desaturation was associated with more postoperative complications. CONCLUSIONS: The use of combined NIRS monitoring allows for the identification of the source of somatic or cerebral desaturation. Compromised venous flow from the IVC from clamping or abdominal compartment syndrome typically is associated with the appearance of more pronounced leg than arm desaturation.

A survey of Canadian interprofessional student-run free clinics.

Student-run free clinics (SRFCs) have existed in Canada since 1971, providing interprofessional healthcare to underserved populations. SRFCs are seen as vehicles for socially accountable health professional education. Literature on how Canadian SRFC function is lacking. Web-based surveys were sent to student leaders from Canadian SRFCs regarding their 2014 activities. All six fully-functioning SRFCs responded reporting on the following: services provided, professions involved, governing structure, funding sources, clients seen, types of care sought, students and preceptors involved, as well as perceived strengths, weaknesses, opportunities and threats. In 2014, 2,159 clients were provided clinical care at Canadian SRFCs. The most common reasons for visiting included pain and infection. Strengths identified include autonomy, ability to adapt to client needs, serving the underserved, and real-world interprofessional teamwork. Weaknesses reported include high student and preceptor turnover. Threats include securing funding and liability coverage. Since there is little literature on Canadian SRFCs, we compared our results with United States (US) based SRFCs. Canadian SRFCs share core values with US-based SRFCs and report similar strengths and challenges. However, Canadian SRFCs differ in scope and appear to provide care for more acute concerns. Data from studies of US-based SRFCs may not be immediately applicable to Canadian SRFCs. Studies evaluating Canadian SRFCs are needed.

Child and Adolescent Emergency and Urgent Mental Health Delivery Through Telepsychiatry: 12-Month Prospective Study.

BACKGROUND: The significant gap between children and adolescents presenting for emergency mental healthcare and the shortage of child and adolescent psychiatrists constitutes a major barrier to timely access for psychiatric assessment for rural and remote areas. Unlike remote areas, urban emergency departments have in-house psychiatric consultation. Telepsychiatry may be a solution to ensure the same service for remote areas. However, there is a paucity of studies on the use of telepsychiatry for child and adolescent emergency consults. Thus, the aim of our study was to (1) assess patient satisfaction with telepsychiatry and (2) compare clinical characteristics and outcome of telepsychiatry with face-to-face emergency child and adolescent assessments. METHODS: This is a prospective study of telepsychiatry emergency assessments of children and adolescents referred by emergency physicians. The comparison group was age- and gender-matched patients seen for face-to-face urgent assessments. Data were gathered on demographic and clinical variables. Telepsychiatry satisfaction was assessed using a questionnaire. Descriptive statistics and chi-square tests were used to assess group differences for each variable. Logistic regression was used to assess impact of the variables on outcome after the consult. A p value <0.05 was used to determine statistical significance. RESULTS: Sixty (n = 60) assessments were conducted through telepsychiatry in 12 months. Among the telepsychiatry group, Aboriginal patients were over-represented (50% vs. 6.7%, p < 0.001), a higher proportion received a diagnosis of adjustment disorder (22% vs. 8.3%, p = 0.004) or no diagnosis (27% vs. 6.7%, p = 0.004) compared with controls. There was no statistically significant difference between groups on other clinical variables. Patients reported a high degree of satisfaction with telepsychiatry. CONCLUSIONS: Telepsychiatry is acceptable to patients and families for safe emergency assessment and follow-up, reducing unnecessary travel to urban centers. Longer time outcomes are needed to establish validity of telepsychiatry for emergency assessments.