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Wu PE, Austin E. Xylazine in the illicit opioid supply. CMAJ 2024; 196:E133. [PMID: 38316456 PMCID: PMC10843436 DOI: 10.1503/cmaj.231603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Affiliation(s)
- Peter E Wu
- Department of Medicine (Wu) and Division of Clinical Pharmacology and Toxicology (Wu, Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children, Toronto, Ont.
| | - Emily Austin
- Department of Medicine (Wu) and Division of Clinical Pharmacology and Toxicology (Wu, Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children, Toronto, Ont
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Wu PE, Lee TC, McDonald EG. What Should I Know About Medication Deprescribing? JAMA Intern Med 2023; 183:891. [PMID: 37273220 DOI: 10.1001/jamainternmed.2023.2099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This JAMA Internal Medicine Patient Page describes the process of slowly and carefully cutting down on unnecessary medications with the guidance of a health care professional.
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Affiliation(s)
- Peter E Wu
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, McGill University Health Centre, Montreal, Quebec, Canada
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Pasricha SV, Bhayana R, Wu PE. Supine headache and papilledema: A case and review of cerebral venous sinus thrombosis. Clin Case Rep 2023; 11:e07329. [PMID: 37151935 PMCID: PMC10160420 DOI: 10.1002/ccr3.7329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/24/2023] [Indexed: 05/09/2023] Open
Abstract
Key clinical message Cerebral venous sinus thrombosis (CVST) should be on the differential for intracranial hypertension, and the preferred diagnostic tests are CT venogram or MR venography. Abstract Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is on the differential for intracranial hypertension. Non-contrast head CT is often normal. CT venogram or MR venography are the preferred diagnostic tests, as was required in our patient. We review the presentation, diagnosis, and management of CVST.
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Affiliation(s)
| | - Rajesh Bhayana
- Department of Medical ImagingUniversity of TorontoTorontoONCanada
| | - Peter E. Wu
- Department of MedicineUniversity of TorontoTorontoONCanada
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Halani S, Leong D, Wu PE. Le técovirimat dans le traitement de la variole simienne. CMAJ 2023; 195:E213-E214. [PMID: 36746480 PMCID: PMC9904816 DOI: 10.1503/cmaj.221210-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Sheliza Halani
- Département de médecine (Halani, Wu), et division de pharmacologie clinique et de toxicologie (Wu), Université de Toronto; Département de pharmacie (Leong), Réseau universitaire de santé, Toronto, Ont.
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Affiliation(s)
- Sheliza Halani
- Department of Medicine (Halani, Wu), and Division of Clinical Pharmacology and Toxicology (Wu), University of Toronto; Department of Pharmacy (Leong), University Health Network, Toronto, Ont.
| | - Derek Leong
- Department of Medicine (Halani, Wu), and Division of Clinical Pharmacology and Toxicology (Wu), University of Toronto; Department of Pharmacy (Leong), University Health Network, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Halani, Wu), and Division of Clinical Pharmacology and Toxicology (Wu), University of Toronto; Department of Pharmacy (Leong), University Health Network, Toronto, Ont
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Styra R, Hawryluck L, McGeer A, Dimas M, Lam E, Giacobbe P, Lorello G, Dattani N, Sheen J, Rac VE, Francis T, Wu PE, Luk WS, Nadarajah J, Gold WL. Support for health care workers and psychological distress: thinking about now and beyond the COVID-19 pandemic. Health Promot Chronic Dis Prev Can 2022; 42:421-430. [PMID: 35766916 PMCID: PMC9584174 DOI: 10.24095/hpcdp.42.10.01] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION This study explores the relationship between emotional support, perceived risk and mental health outcomes among health care workers, who face high rates of burnout and mental distress since the beginning of the COVID-19 pandemic. METHODS A cross-sectional, multicentred online survey of health care workers in the Greater Toronto Area, Ontario, Canada, during the first wave of the COVID-19 pandemic evaluated coping strategies, confidence in infection control, impact of previous work during the 2003 SARS outbreak and emotional support. Mental health outcomes were assessed using the Generalized Anxiety Disorder scale, the Impact of Event Scale - Revised and the Patient Health Questionnaire (PHQ-9). RESULTS Of 3852 participants, 8.2% sought professional mental health services while 77.3% received emotional support from family, 74.0% from friends and 70.3% from colleagues. Those who felt unsupported in their work had higher odds ratios of experiencing moderate and severe symptoms of anxiety (odds ratio [OR] = 2.23; 95% confidence interval [CI]: 1.84-2.69), PTSD (OR = 1.88; 95% CI: 1.58-2.25) and depression (OR = 1.88; 95% CI: 1.57-2.25). Nearly 40% were afraid of telling family about the risks they were exposed to at work. Those who were able to share this information demonstrated lower risk of anxiety (OR = 0.58; 95% CI: 0.48-0.69), PTSD (OR = 0.48; 95% CI: 0.41-0.56) and depression (OR = 0.55; 95% CI: 0.47-0.65). CONCLUSION Informal sources of support, including family, friends and colleagues, play an important role in mitigating distress and should be encouraged and utilized more by health care workers.
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Affiliation(s)
- Rima Styra
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Laura Hawryluck
- Critical Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - Allison McGeer
- Division of Infectious Diseases, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Michelle Dimas
- Department of Research, William Osler Health System, Brampton, Ontario, Canada
| | - Eileen Lam
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Peter Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Gianni Lorello
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Neil Dattani
- Department of Emergency and Urgent Care, William Osler Health System, Brampton, Ontario, Canada
| | - Jack Sheen
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Valeria E Rac
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Ontario, Canada
| | - Troy Francis
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Ontario, Canada
| | - Peter E Wu
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
| | - Wing-Si Luk
- Patient Safety and Quality Improvement, University Health Network, Toronto, Ontario, Canada
| | - Jeya Nadarajah
- Division of Infectious Diseases, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Wayne L Gold
- Division of Infectious Diseases, University Health Network and Sinai Health System, Toronto, Ontario, Canada
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
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Soong C, Ethier C, Lee Y, Othman D, Burry L, Wu PE, Ng KA, Matelski J, Liu B. Reducing Sedative-Hypnotics Among Hospitalized Patients: a Multi-centered Study. J Gen Intern Med 2022; 37:2345-2350. [PMID: 34981347 PMCID: PMC9360352 DOI: 10.1007/s11606-021-07292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 11/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sedative-hypnotics are frequently prescribed for insomnia in hospital but are associated with preventable harms. OBJECTIVE, DESIGN, AND PARTICIPANTS We aimed to examine whether a sedative-hypnotic reduction quality improvement bundle decreases the rate of sedative-hypnotic use among hospitalized patients, who were previously naïve to sedative-hypnotics. This interrupted time series study occurred between May 2016 and January 2019. Control data for 1 year prior to implementation and intervention data for at least 16 months were collected. The study occurred on 7 inpatient wards (general medicine, cardiology, nephrology, general surgery, and cardiovascular surgery wards) across 5 teaching hospitals in Toronto, Canada. INTERVENTION Participating wards implemented a sedative-hypnotic reduction bundle (i.e., order set changes, audit-feedback, pharmacist-enabled medication reviews, sleep hygiene, daily sleep huddles, and staff/patient/family education) aimed to reduce in-hospital sedative-hypnotic initiation for insomnia in patients who were previously naïve to sedative-hypnotics. Each inpatient ward adapted the bundle prior to sustaining the intervention for a minimum of 16 months. MAIN MEASURES The primary outcome measure was the proportion of sedative-hypnotic-naïve inpatients newly prescribed a sedative-hypnotic for sleep in hospital. Secondary measures include prescribing rates of other sedating medications, fall rates, length of stay, and mortality. KEY RESULTS We included 8,970 patient discharges in the control period and 10,120 in the intervention period. Adjusted sedative-hypnotic prescriptions among naïve patients decreased from 15.48% (95% CI: 6.09-19.42) to 9.08% (p<0.001) (adjusted OR 0.814; 95% CI: 0.667-0.993, p=0.042). Unchanged secondary outcomes included mortality (adjusted OR 1.089; 95% CI: 0.786-1.508, p=0.608), falls (adjusted rate ratio 0.819; 95% CI: 0.625-1.073, p=0.148), or other sedating drug prescriptions (adjusted OR 1.046; 95% CI: 0.873-1.252, p=0.627). CONCLUSIONS A sedative-hypnotic reduction quality improvement bundle implemented across 5 hospitals was associated with a sustained reduction in sedative-hypnotic prescriptions.
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Affiliation(s)
- Christine Soong
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, 433-600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Centre for Quality and Patient Safety, University of Toronto, Toronto, ON, Canada.
| | - Cheryl Ethier
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada
| | - Yuna Lee
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Dalia Othman
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada
| | - Lisa Burry
- Divisions of General Internal Medicine and Hospital Medicine, Sinai Health System, Toronto, ON, Canada.,Department of Pharmacy, Sinai Health System, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Peter E Wu
- Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, ON, Canada
| | - Karen A Ng
- Division of Geriatric Medicine, Sinai Health System, Toronto, ON, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Barbara Liu
- Division of Geriatric Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Wu PE, Juurlink DN. Loperamide Cardiac Toxicity – Pathophysiology, Presentation and Management. Can J Cardiol 2022; 38:1378-1383. [DOI: 10.1016/j.cjca.2022.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/02/2022] Open
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McDonald EG, Wu PE, Rashidi B, Wilson MG, Bortolussi-Courval É, Atique A, Battu K, Bonnici A, Elsayed S, Wilson AG, Papillon-Ferland L, Pilote L, Porter S, Murphy J, Ross SB, Shiu J, Tamblyn R, Whitty R, Xu J, Fabreau G, Haddad T, Palepu A, Khan N, McAlister FA, Downar J, Huang AR, MacMillan TE, Cavalcanti RB, Lee TC. The MedSafer Study-Electronic Decision Support for Deprescribing in Hospitalized Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med 2022; 182:265-273. [PMID: 35040926 PMCID: PMC8767487 DOI: 10.1001/jamainternmed.2021.7429] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Scalable deprescribing interventions may reduce polypharmacy and the use of potentially inappropriate medications (PIMs); however, few studies have been large enough to evaluate the impact that deprescribing may have on adverse drug events (ADEs). OBJECTIVE To evaluate the effect of an electronic deprescribing decision support tool on ADEs after hospital discharge among older adults with polypharmacy. DESIGN, SETTING, AND PARTICIPANTS This was a cluster randomized clinical trial of older (≥65 years) hospitalized patients with an expected survival of more than 3 months who were admitted to 1 of 11 acute care hospitals in Canada from August 22, 2017, to January 13, 2020. At admission, participants were taking 5 or more medications per day. Data analyses were performed from January 3, 2021, to September 23, 2021. INTERVENTIONS Personalized reports of deprescribing opportunities generated by MedSafer software to address usual home medications and measures of prognosis and frailty. Deprescribing reports provided to the treating team were compared with usual care (medication reconciliation). MAIN OUTCOMES AND MEASURES The primary outcome was a reduction of ADEs within the first 30 days postdischarge (including adverse drug withdrawal events) captured through structured telephone surveys and adjudicated blinded to intervention status. Secondary outcomes were the proportion of patients with 1 or more PIMs deprescribed at discharge and the proportion of patients with an adverse drug withdrawal event (ADWE). RESULTS A total of 5698 participants (median [range] age, 78 [72-85] years; 2858 [50.2%] women; race and ethnicity data were not collected) were enrolled in 3 clusters and were adjudicated for the primary outcome (control, 3204; intervention, 2494). Despite cluster randomization, there were group imbalances, eg, the participants in the intervention arm were older and had more PIMS prescribed at baseline. After hospital discharge, 4989 (87.6%) participants completed an ADE interview. There was no significant difference in ADEs within 30 days of discharge (138 [5.0%] of 2742 control vs 111 [4.9%] of 2247 intervention participants; adjusted risk difference [aRD] -0.8%; 95% CI, -2.9% to 1.3%). Deprescribing increased from 795 (29.8%) of 2667 control to 1249 (55.4%) of 2256 intervention participants [aRD, 22.2%; 95% CI, 16.9% to 27.4%]. There was no difference in ADWEs between groups. Several post hoc sensitivity analyses, including the use of a nonparametric test to address the low cluster number, group imbalances, and potential biases, did not alter study conclusions. CONCLUSIONS AND RELEVANCE This cluster randomized clinical trial showed that providing deprescribing clinical decision support during acute hospitalization had no demonstrable impact on ADEs, although the intervention was safe and led to improvements in deprescribing. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03272607.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Peter E Wu
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto; Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, Ontario, Canada
| | - Babak Rashidi
- Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Marnie Goodwin Wilson
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Anika Atique
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Kiran Battu
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Andre Bonnici
- Department of Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sarah Elsayed
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Allison Goodwin Wilson
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Louise Papillon-Ferland
- Department of Pharmacy, Institut Universitaire de Geriatrie de Montreal, University of Montreal, Montreal, Quebec, Canada
| | - Louise Pilote
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Division of Epidemiology, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Sandra Porter
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Johanna Murphy
- Division of General Internal Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sydney B Ross
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada.,Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | | | - Robyn Tamblyn
- Division of Epidemiology, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Rachel Whitty
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Jieqing Xu
- Department of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Gabriel Fabreau
- Division of General Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Taleen Haddad
- Division of Geriatric Medicine, Queens University, Kingston, Ontario, Canada
| | - Anita Palepu
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nadia Khan
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Finlay A McAlister
- Division of General Internal Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - James Downar
- Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Allen R Huang
- Division of Geriatric Medicine, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Thomas E MacMillan
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo B Cavalcanti
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada.,Division of infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Wu PE, Austin E, Leong D. Fluvoxamine for symptomatic outpatients with COVID-19. CMAJ 2022; 194:E258. [PMID: 35045990 PMCID: PMC8863199 DOI: 10.1503/cmaj.220011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Peter E Wu
- Division of General Internal Medicine and Geriatrics (Wu), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), Department of Medicine, University of Toronto; Division of Emergency Medicine (Austin), St. Michael's Hospital; Ontario Poison Centre (Austin), Hospital for Sick Children; Department of Pharmacy (Leong), University Health Network, Toronto, Ont.
| | - Emily Austin
- Division of General Internal Medicine and Geriatrics (Wu), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), Department of Medicine, University of Toronto; Division of Emergency Medicine (Austin), St. Michael's Hospital; Ontario Poison Centre (Austin), Hospital for Sick Children; Department of Pharmacy (Leong), University Health Network, Toronto, Ont
| | - Derek Leong
- Division of General Internal Medicine and Geriatrics (Wu), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), Department of Medicine, University of Toronto; Division of Emergency Medicine (Austin), St. Michael's Hospital; Ontario Poison Centre (Austin), Hospital for Sick Children; Department of Pharmacy (Leong), University Health Network, Toronto, Ont
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Kobylianskii J, Austin E, Kumachev A, Wu PE. A 53-year-old woman with a suspected drug overdose. CMAJ 2022; 194:E163-E166. [PMID: 35131754 PMCID: PMC8900766 DOI: 10.1503/cmaj.211620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jane Kobylianskii
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont.
| | - Emily Austin
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont
| | - Alexander Kumachev
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Kobylianskii, Kumachev), University of Toronto; Division of Emergency Medicine, Department of Medicine (Austin), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology and Toxicology, Department of Medicine (Wu), University of Toronto; Division of General Internal Medicine, Department of Medicine (Wu), University of Toronto, Ont
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Dunbar-Yaffe R, Wu PE, Kay T, Mylopoulos M, McDonald-Blumer H, Gold WL, Stroud L. Understanding the Influence of the Junior Attending Role on Transition to Practice: A Qualitative Study. J Grad Med Educ 2022; 14:89-98. [PMID: 35222826 PMCID: PMC8848868 DOI: 10.4300/jgme-d-21-00728.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/27/2021] [Accepted: 12/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The Junior Attending (JA) role is an educational model, commonly implemented in the final years of training, wherein a very senior resident assumes the responsibilities of an attending physician under supervision. However, there is heterogeneity in the model's structure, and data are lacking on how it facilitates transition to independent practice. OBJECTIVE The authors sought to determine the value of the JA role and factors that enabled a successful experience. METHODS The authors performed a collective case study informed by a constructivist grounded theory analytical approach. Twenty semi-structured interviews from 2017 to 2020 were conducted across 2 cases: (1) Most Responsible Physician JA role (general internal medicine), and (2) Consultant JA role (infectious diseases and rheumatology). Participants included recent graduates who experienced the JA role, supervising attendings, and resident and faculty physicians who had not experienced or supervised the role. RESULTS Experiencing the JA role builds resident confidence and may support the transition to independent practice, mainly in non-medical expert domains, as well as comfort in dealing with clinical uncertainty. The relationship between the supervising attending and the JA is an essential success factor, with more productive experiences reported when there is an establishment of clear goals and role definition that preserves the autonomy of the JA and legitimizes the JA's status as a team leader. CONCLUSIONS The JA model offers promise in supporting the transition to independent practice when key success factors are present.
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Affiliation(s)
- Richard Dunbar-Yaffe
- Richard Dunbar-Yaffe, MDCM, MSc*, is a General Internist, Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, Ontario, Canada, and an Assistant Professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter E. Wu
- Peter E. Wu, MD, MSc*, is a General Internist and Clinical Pharmacologist/Toxicologist, Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, Ontario, Canada, and an Assistant Professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tatjana Kay
- Tatjana Kay, MSc, is a Research Assistant, University of Toronto, Toronto, Ontario, Canada
| | - Maria Mylopoulos
- Maria Mylopoulos, PhD, is a Scientist & Associate Director of Training Programs, Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - Heather McDonald-Blumer
- Heather McDonald-Blumer, MD, MSc, is a Rheumatologist, Division of Rheumatology, Sinai Health System, Toronto, Ontario, Canada, Associate Professor of Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wayne L. Gold
- Wayne L. Gold, MD, is a General Internist, Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, Ontario, Canada, and Infectious Disease Specialist, Division of Infectious Diseases, Sinai Health System and University Health Network, Toronto, Ontario, Canada, and a Professor of Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lynfa Stroud
- Lynfa Stroud, MD, MEd, is an Associate Professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada, Researcher, Wilson Centre, University of Toronto, Toronto, Ontario, Canada, and General Internist, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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13
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Styra R, Hawryluck L, Mc Geer A, Dimas M, Sheen J, Giacobbe P, Dattani N, Lorello G, Rac VE, Francis T, Wu PE, Luk WS, Ng E, Nadarajah J, Wingrove K, Gold WL. Surviving SARS and living through COVID-19: Healthcare worker mental health outcomes and insights for coping. PLoS One 2021; 16:e0258893. [PMID: 34758047 PMCID: PMC8580217 DOI: 10.1371/journal.pone.0258893] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/07/2021] [Indexed: 01/26/2023] Open
Abstract
Objective Explore how previous work during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak affects the psychological response of clinical and non-clinical healthcare workers (HCWs) to the current COVID-19 pandemic. Methods A cross-sectional, multi-centered hospital online survey of HCWs in the Greater Toronto Area, Canada. Mental health outcomes of HCWs who worked during the COVID-19 pandemic and the SARS outbreak were assessed using Impact of Events—Revised scale (IES-R), Generalized Anxiety Disorder scale (GAD-7), and Patient Health Questionnaire (PHQ-9). Results Among 3852 participants, moderate/severe scores for symptoms of post- traumatic stress disorder (PTSD) (50.2%), anxiety (24.6%), and depression (31.5%) were observed among HCWs. Work during the 2003 SARS outbreak was reported by 1116 respondents (29.1%), who had lower scores for symptoms of PTSD (P = .002), anxiety (P < .001), and depression (P < .001) compared to those who had not worked during the SARS outbreak. Multivariable logistic regression analysis showed non-clinical HCWs during this pandemic were at higher risk of anxiety (OR, 1.68; 95% CI, 1.19–2.15, P = .01) and depressive symptoms (OR, 2.03; 95% CI, 1.34–3.07, P < .001). HCWs using sedatives (OR, 2.55; 95% CI, 1.61–4.03, P < .001), those who cared for only 2–5 patients with COVID-19 (OR, 1.59; 95% CI, 1.06–2.38, P = .01), and those who had been in isolation for COVID-19 (OR, 1.36; 95% CI, 0.96–1.93, P = .05), were at higher risk of moderate/severe symptoms of PTSD. In addition, deterioration in sleep was associated with symptoms of PTSD (OR, 4.68, 95% CI, 3.74–6.30, P < .001), anxiety (OR, 3.09, 95% CI, 2.11–4.53, P < .001), and depression (OR 5.07, 95% CI, 3.48–7.39, P < .001). Conclusion Psychological distress was observed in both clinical and non-clinical HCWs, with no impact from previous SARS work experience. As the pandemic continues, increasing psychological and team support may decrease the mental health impacts.
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Affiliation(s)
- Rima Styra
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- * E-mail:
| | - Laura Hawryluck
- Intensive Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - Allison Mc Geer
- Division of Infectious Diseases, Sinai Health System & University Health Network, Toronto, Ontario, Canada
| | - Michelle Dimas
- Department of Research, William Osler Health System, Brampton, Ontario, Canada
| | - Jack Sheen
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Peter Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Neil Dattani
- Department of Emergency Medicine, William Osler Health System, Etobicoke, Ontario, Canada
| | - Gianni Lorello
- Department of Anesthesia, University Health Network, Toronto, Ontario, Canada
| | - Valeria E. Rac
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Ontario, Canada
| | - Troy Francis
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Ontario, Canada
| | - Peter E. Wu
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
| | - Wing-Si Luk
- Patient Safety & Quality Improvement, University Health Network, Toronto, Ontario, Canada
| | - Enoch Ng
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeya Nadarajah
- Infectious Disease, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Kaila Wingrove
- Intensive Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - Wayne L. Gold
- Division of Infectious Diseases, Sinai Health System & University Health Network, Toronto, Ontario, Canada
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
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14
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Bobrowski D, Kumar R, Wu PE, Lapointe‐Shaw L. Prolonged ketosis and glycosuria secondary to SGLT2 inhibitor therapy. Clin Case Rep 2021; 9:e05057. [PMID: 34786197 PMCID: PMC8577244 DOI: 10.1002/ccr3.5057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/25/2022] Open
Abstract
Clinicians should be aware of the potential for the pharmacologic activity of SGLT2 inhibitors to persist long after the standard drug clearance period of five half-lives, the typical duration used to guide pre-operative medication recommendations.
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Affiliation(s)
- David Bobrowski
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Reha Kumar
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Peter E. Wu
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
- Division of Clinical Pharmacology & ToxicologyUniversity of TorontoTorontoOntarioCanada
| | - Lauren Lapointe‐Shaw
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
- Division of General Internal Medicine and GeriatricsUniversity Health NetworkTorontoOntarioCanada
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15
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Rudolph M, Peng J, Wu PE. Cystadénome séreux bénin accompagné de toux et de lombalgie. CMAJ 2021; 193:E1650-E1651. [PMID: 34697106 PMCID: PMC8562988 DOI: 10.1503/cmaj.202850-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Madeleine Rudolph
- Faculté de médecine (Rudolph) et Département de médecine (Peng, Wu), Université de Toronto, Toronto, Ont.
| | - Jessie Peng
- Faculté de médecine (Rudolph) et Département de médecine (Peng, Wu), Université de Toronto, Toronto, Ont
| | - Peter E Wu
- Faculté de médecine (Rudolph) et Département de médecine (Peng, Wu), Université de Toronto, Toronto, Ont
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16
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Kobylianskii J, Austin E, Gold WL, Wu PE. Observation d’une toxicité chronique au lithium chez une femme de 54 ans. CMAJ 2021; 193:E1507-E1510. [PMID: 34580147 PMCID: PMC8486475 DOI: 10.1503/cmaj.210725-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jane Kobylianskii
- Département de médecine (Kobylianskii, Austin, Gold, Wu), Université de Toronto; Centre antipoison de l'Ontario (Austin), Hôpital pour enfants malades; Division de pharmacologie clinique et de toxicologie (Austin, Wu), Université de Toronto; Division de médecine interne générale (Gold, Wu), Réseau universitaire de santé/Système de santé Sinaï, Toronto, Ont.
| | - Emily Austin
- Département de médecine (Kobylianskii, Austin, Gold, Wu), Université de Toronto; Centre antipoison de l'Ontario (Austin), Hôpital pour enfants malades; Division de pharmacologie clinique et de toxicologie (Austin, Wu), Université de Toronto; Division de médecine interne générale (Gold, Wu), Réseau universitaire de santé/Système de santé Sinaï, Toronto, Ont
| | - Wayne L Gold
- Département de médecine (Kobylianskii, Austin, Gold, Wu), Université de Toronto; Centre antipoison de l'Ontario (Austin), Hôpital pour enfants malades; Division de pharmacologie clinique et de toxicologie (Austin, Wu), Université de Toronto; Division de médecine interne générale (Gold, Wu), Réseau universitaire de santé/Système de santé Sinaï, Toronto, Ont
| | - Peter E Wu
- Département de médecine (Kobylianskii, Austin, Gold, Wu), Université de Toronto; Centre antipoison de l'Ontario (Austin), Hôpital pour enfants malades; Division de pharmacologie clinique et de toxicologie (Austin, Wu), Université de Toronto; Division de médecine interne générale (Gold, Wu), Réseau universitaire de santé/Système de santé Sinaï, Toronto, Ont
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17
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Affiliation(s)
- Jane Kobylianskii
- Department of Medicine (Kobylianskii, Austin, Gold, Wu), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology & Toxicology (Austin, Wu), University of Toronto; Division of General Internal Medicine (Gold, Wu), University Health Network/Sinai Health System, Toronto, Ont.
| | - Emily Austin
- Department of Medicine (Kobylianskii, Austin, Gold, Wu), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology & Toxicology (Austin, Wu), University of Toronto; Division of General Internal Medicine (Gold, Wu), University Health Network/Sinai Health System, Toronto, Ont
| | - Wayne L Gold
- Department of Medicine (Kobylianskii, Austin, Gold, Wu), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology & Toxicology (Austin, Wu), University of Toronto; Division of General Internal Medicine (Gold, Wu), University Health Network/Sinai Health System, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Kobylianskii, Austin, Gold, Wu), University of Toronto; Ontario Poison Centre (Austin), Hospital for Sick Children; Division of Clinical Pharmacology & Toxicology (Austin, Wu), University of Toronto; Division of General Internal Medicine (Gold, Wu), University Health Network/Sinai Health System, Toronto, Ont
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18
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Rudolph M, Peng J, Wu PE. Benign serous cystadenoma presenting with cough and back pain. CMAJ 2021; 193:E1304. [PMID: 34426448 PMCID: PMC8412427 DOI: 10.1503/cmaj.202850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Madeleine Rudolph
- Faculty of Medicine (Rudolph) and Department of Medicine (Peng, Wu), University of Toronto, Toronto, Ont.
| | - Jessie Peng
- Faculty of Medicine (Rudolph) and Department of Medicine (Peng, Wu), University of Toronto, Toronto, Ont
| | - Peter E Wu
- Faculty of Medicine (Rudolph) and Department of Medicine (Peng, Wu), University of Toronto, Toronto, Ont
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19
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Affiliation(s)
- Keith Gunaratne
- Department of Medicine (Gunaratne, Gold, Wu), University of Toronto; Divisions of Infectious Diseases (Gold) and of General Internal Medicine (Gold, Wu), University Health Network, Toronto, Ont.
| | - Wayne L Gold
- Department of Medicine (Gunaratne, Gold, Wu), University of Toronto; Divisions of Infectious Diseases (Gold) and of General Internal Medicine (Gold, Wu), University Health Network, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Gunaratne, Gold, Wu), University of Toronto; Divisions of Infectious Diseases (Gold) and of General Internal Medicine (Gold, Wu), University Health Network, Toronto, Ont
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20
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Kumachev A, Wu PE. Atteinte hépatique médicamenteuse. CMAJ 2021; 193:E746-E747. [PMID: 34001555 PMCID: PMC8177938 DOI: 10.1503/cmaj.202026-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Alexander Kumachev
- Département de médecine (Kumachev, Wu) et divisions de pharmacologie clinique et toxicologie ( Kumachev, Wu) et de médecine interne générale (Wu), Université de Toronto, Toronto, Ont
| | - Peter E Wu
- Département de médecine (Kumachev, Wu) et divisions de pharmacologie clinique et toxicologie ( Kumachev, Wu) et de médecine interne générale (Wu), Université de Toronto, Toronto, Ont.
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21
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Wu PE, Morris AM. Le remdésivir chez les patients atteints de la COVID-19. CMAJ 2021; 193:E495-E496. [PMID: 33824151 PMCID: PMC8049645 DOI: 10.1503/cmaj.202505-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Peter E Wu
- Département de médecine (Wu, Morris), Division de pharmacologie et de toxicologie clinique (Wu) et Division d'infectiologie (Morris), Université de Toronto; Division de médecine interne générale et de gériatrie (Wu), Réseau universitaire de santé; Division d'infectiologie (Morris), Système de santé Sinai et Réseau universitaire de santé, Toronto, Ont.
| | - Andrew M Morris
- Département de médecine (Wu, Morris), Division de pharmacologie et de toxicologie clinique (Wu) et Division d'infectiologie (Morris), Université de Toronto; Division de médecine interne générale et de gériatrie (Wu), Réseau universitaire de santé; Division d'infectiologie (Morris), Système de santé Sinai et Réseau universitaire de santé, Toronto, Ont
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22
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Kobylianskii J, Wu PE. Venlafaxine-induced hypoglycemia. CMAJ 2021; 193:E568. [PMID: 33875464 PMCID: PMC8084559 DOI: 10.1503/cmaj.78409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jane Kobylianskii
- Internal medicine resident, Department of Medicine, University of Toronto, Toronto, Ont
| | - Peter E Wu
- Internal medicine and clinical pharmacology/toxicology specialist, Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto, Toronto, Ont
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23
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Affiliation(s)
- Mei-Ni Belzile
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kiran Battu
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Peter E Wu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, Ontario, Canada
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24
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Affiliation(s)
- Alexander Kumachev
- Department of Medicine (Kumachev, Wu) and Divisions of Clinical Pharmacology and Toxicology (Kumachev, Wu) and General Internal Medicine (Wu), University of Toronto, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Kumachev, Wu) and Divisions of Clinical Pharmacology and Toxicology (Kumachev, Wu) and General Internal Medicine (Wu), University of Toronto, Toronto, Ont.
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25
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Affiliation(s)
- Derek Leong
- Department of Pharmacy (Leong) and Division of General Internal Medicine and Geriatrics (Wu), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), Department of Medicine, University of Toronto, Toronto, Ont.
| | - Peter E Wu
- Department of Pharmacy (Leong) and Division of General Internal Medicine and Geriatrics (Wu), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), Department of Medicine, University of Toronto, Toronto, Ont
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26
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Affiliation(s)
- Peter E Wu
- Department of Medicine (Wu, Morris) Division of Clinical Pharmacology & Toxicology (Wu) and Division of Infectious Diseases (Morris), University of Toronto; Division of General Internal Medicine and Geriatrics (Wu), University Health Network; Division of Infectious Diseases (Morris), Sinai Health and University Health Network, Toronto, Ont.
| | - Andrew M Morris
- Department of Medicine (Wu, Morris) Division of Clinical Pharmacology & Toxicology (Wu) and Division of Infectious Diseases (Morris), University of Toronto; Division of General Internal Medicine and Geriatrics (Wu), University Health Network; Division of Infectious Diseases (Morris), Sinai Health and University Health Network, Toronto, Ont
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27
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Goulding AM, Wu PE, Gold WL. A care escalation framework to address lapses in donning and doffing of personal protective equipment during the COVID-19 pandemic. Am J Infect Control 2020; 48:1566-1567. [PMID: 32771497 PMCID: PMC7409734 DOI: 10.1016/j.ajic.2020.07.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/23/2020] [Indexed: 12/01/2022]
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28
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Abstract
A 79-year-old man presented to the emergency department with a 1-week history of worsening confusion, falls and hearing impairment. An initial workup for infectious, metabolic and structural causes was unrevealing. However, further history discovered that he had been ingesting one to two bottles of Pepto-Bismol (bismuth subsalicylate) daily for gastro-oesophageal reflux symptoms. On his second day of admission, the plasma salicylate concentration was 2.08 mmol/L (reference range 1.10-2.20 mmol/L), despite no sources of salicylate in hospital. He was diagnosed with chronic salicylate toxicity and Pepto-Bismol use was discontinued. The patient was treated supportively with isotonic intravenous fluids only and plasma salicylate concentration fell to less than 0.36 mmol/L. Concurrently, all his symptoms resolved. This case highlights the potential adverse effects of over-the-counter medications. The diagnosis of chronic salicylate toxicity is challenging, specifically in the elderly and in undifferentiated presentations, as it can be missed if not suspected.
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Affiliation(s)
- Sheliza Halani
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter E Wu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, Ontario, Canada
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29
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Affiliation(s)
- Peter E Wu
- Division of General Internal Medicine and Geriatrics, University Health Network.,Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto
| | - Derek Leong
- Department of Pharmacy, University Health Network
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30
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Wu PE, Styra R, Gold WL. Atténuer les effets psychologiques de la COVID-19 sur les travailleurs de la santé. CMAJ 2020; 192:E1341-E1342. [PMID: 33106311 PMCID: PMC7577572 DOI: 10.1503/cmaj.200519-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Peter E Wu
- Division de médecine interne (Wu, Gold), Division d'infectiologie (Gold) et Département de psychiatrie (Styra), Réseau universitaire de santé; Département de médecine (Wu, Gold) et Département de psychiatrie (Styra), Université de Toronto, Toronto, Ont.
| | - Rima Styra
- Division de médecine interne (Wu, Gold), Division d'infectiologie (Gold) et Département de psychiatrie (Styra), Réseau universitaire de santé; Département de médecine (Wu, Gold) et Département de psychiatrie (Styra), Université de Toronto, Toronto, Ont
| | - Wayne L Gold
- Division de médecine interne (Wu, Gold), Division d'infectiologie (Gold) et Département de psychiatrie (Styra), Réseau universitaire de santé; Département de médecine (Wu, Gold) et Département de psychiatrie (Styra), Université de Toronto, Toronto, Ont
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31
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Ross SB, Wilson MG, Papillon-Ferland L, Elsayed S, Wu PE, Battu K, Porter S, Rashidi B, Tamblyn R, Pilote L, Downar J, Bonnici A, Huang A, Lee TC, McDonald EG. COVID-SAFER: Deprescribing Guidance for Hydroxychloroquine Drug Interactions in Older Adults. J Am Geriatr Soc 2020; 68:1636-1646. [PMID: 32441771 PMCID: PMC7280600 DOI: 10.1111/jgs.16623] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVES Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection causes high morbidity and mortality in older adults with chronic illnesses. Several trials are currently underway evaluating the antimalarial drug hydroxychloroquine as a potential treatment for acute infection. However, polypharmacy predisposes patients to increased risk of drug‐drug interactions with hydroxychloroquine and may render many in this population ineligible to participate in trials. We aimed to quantify the degree of polypharmacy and burden of potentially inappropriate medications (PIMs) that older hospitalized adults are taking that would interact with hydroxychloroquine. METHODS We reanalyzed data from the cohort of patients 65 years and older enrolled in the MedSafer pilot study. We first identified patients taking medications with potentially harmful drug‐drug interactions with hydroxychloroquine that might exclude them from participation in a typical 2019 coronavirus disease (COVID‐19) therapeutic trial. Next, we identified medications that were flagged by MedSafer as potentially inappropriate and crafted guidance around medication management if contemplating the use of hydroxychloroquine. RESULTS The cohort contained a total of 1,001 unique patients with complete data on their home medications at admission. Of these 1,001 patients, 590 (58.9%) were receiving one or more home medications that could potentially interact with hydroxychloroquine, and of these, 255 (43.2%) were flagged as potentially inappropriate by the MedSafer tool. Common classes of PIMs observed were antipsychotics, cardiac medications, and antidiabetic agents. CONCLUSION The COVID‐19 pandemic highlights the importance of medication optimization and deprescribing PIMs in older adults. By acting now to reduce polypharmacy and use of PIMs, we can better prepare this vulnerable population for inclusion in trials and, if substantiated, pharmacologic treatment or prevention of COVID‐19. J Am Geriatr Soc 68:1636‐1646, 2020.
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Affiliation(s)
- Sydney B Ross
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marnie Goodwin Wilson
- Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Louise Papillon-Ferland
- Department of Pharmacy, Institut Universitaire de Gériatrie de Montreal, Montreal, Quebec, Canada
| | - Sarah Elsayed
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Peter E Wu
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kiran Battu
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Sandra Porter
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Babak Rashidi
- Division of General Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Robyn Tamblyn
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Louise Pilote
- Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada.,Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - James Downar
- Division of Palliative Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andre Bonnici
- Department of Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Allen Huang
- Division of Geriatric Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Todd C Lee
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada.,Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada.,Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada
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32
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Affiliation(s)
- Peter E Wu
- Division of General Internal Medicine (Wu, Gold), Division of Infectious Diseases (Gold) and Department of Psychiatry (Styra), University Health Network; Department of Medicine (Wu, Gold) and Department of Psychiatry (Styra), University of Toronto, Toronto, Ont.
| | - Rima Styra
- Division of General Internal Medicine (Wu, Gold), Division of Infectious Diseases (Gold) and Department of Psychiatry (Styra), University Health Network; Department of Medicine (Wu, Gold) and Department of Psychiatry (Styra), University of Toronto, Toronto, Ont
| | - Wayne L Gold
- Division of General Internal Medicine (Wu, Gold), Division of Infectious Diseases (Gold) and Department of Psychiatry (Styra), University Health Network; Department of Medicine (Wu, Gold) and Department of Psychiatry (Styra), University of Toronto, Toronto, Ont
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33
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Affiliation(s)
- Derek Leong
- University Health Network, University of Toronto, Toronto, Ontario, Canada (D.L., P.E.W.)
| | - Peter E Wu
- University Health Network, University of Toronto, Toronto, Ontario, Canada (D.L., P.E.W.)
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34
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Ross MSc Candidate SB, Wu PE, Atique Md Candidate A, Papillon-Ferland L, Tamblyn R, Lee TC, McDonald EG. Adverse Drug Events in Older Adults: Review of Adjudication Methods in Deprescribing Studies. J Am Geriatr Soc 2020; 68:1594-1602. [PMID: 32142161 DOI: 10.1111/jgs.16382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/15/2020] [Accepted: 01/29/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Polypharmacy is common in older adults and associated with adverse drug events (ADEs). Several methods have been described in studies to help correlate ADE causation. We performed a narrative review to identify methods for ADE adjudication. We compared their strengths and limitations to assess their applicability to deprescribing studies (of which clinical trials are a subset) and to encourage the use of a standardized method in future studies. DESIGN We performed a review of original articles (1946-2019) using the Medline (Ovid) and Cochrane databases. We also conducted a manual reference search of review articles. Abstracts were screened for relevance. MEASUREMENTS Adjudication methods were compared for advantages and limitations including validity, ease of use, and applicability to clinical trials with deprescribing as the primary intervention. RESULTS The search yielded 1881 articles of which 175 articles were included for full-text review. Following in-depth review, 135 were excluded: 79 had no ADE outcome data, 35 were not specific to older adults, 9 were not relevant, 6 were review articles, 5 contained duplicate data, and 1 was not written in French or English. Forty articles remained for analysis, from which we identified 10 unique ADE adjudication methods. No method was developed originally for use in a deprescribing setting. CONCLUSION A standard method to identify ADEs is important to capture the outcome reliably in deprescribing studies. All methods we identified had limitations in terms of capturing adverse events from the withdrawal of medications. Future work should focus on refining adjudication methods for capturing ADEs related not only to medication continuation and new drug starts but also to deprescribing and drug discontinuation. J Am Geriatr Soc 68:1594-1602, 2020.
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Affiliation(s)
| | - Peter E Wu
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada.,Division of Clinical Pharmacology and Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Louise Papillon-Ferland
- Department of Pharmacy, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada.,Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Robyn Tamblyn
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
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Affiliation(s)
- Peter E Wu
- University of Toronto, 200 Elizabeth Street, Toronto General Hospital, Toronto, ON, M5G 2C4, Canada
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Leong D, Wu PE. Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors. CMAJ 2019; 191:E894. [DOI: 10.1503/cmaj.190107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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McDonald EG, Wu PE, Rashidi B, Forster AJ, Huang A, Pilote L, Papillon‐Ferland L, Bonnici A, Tamblyn R, Whitty R, Porter S, Battu K, Downar J, Lee TC. The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care. J Am Geriatr Soc 2019; 67:1843-1850. [DOI: 10.1111/jgs.16040] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
- Clinical Practice Assessment Unit McGill University Health Centre Montréal Québec Canada
| | - Peter E. Wu
- Division of General Internal Medicine, Department of Medicine University of Toronto Toronto Ontario Canada
| | - Babak Rashidi
- Division of General Internal Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Alan J. Forster
- Division of General Internal Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Allen Huang
- Division of Geriatric Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Louise Pilote
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
| | | | - André Bonnici
- Department of Pharmacy McGill University Health Centre Montréal Québec Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health McGill University Montréal Québec Canada
| | - Rachel Whitty
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - Sandra Porter
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - Kiran Battu
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - James Downar
- Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Todd C. Lee
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
- Clinical Practice Assessment Unit McGill University Health Centre Montréal Québec Canada
- Department of Epidemiology, Biostatistics and Occupational Health McGill University Montréal Québec Canada
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Affiliation(s)
- Peter E Wu
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Wu PE, Leong D. Acute Kidney Injury Due to Concomitant Vancomycin and Piperacillin-Tazobactam. JAMA Intern Med 2018; 178:1137. [PMID: 30083734 DOI: 10.1001/jamainternmed.2018.2930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Peter E Wu
- Toronto General Hospital, Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Derek Leong
- Division of Clinical Pharmacy, University Health Network, Toronto, Ontario, Canada
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Gunaratne K, Austin E, Wu PE. Unintentional sulfonylurea toxicity due to a drug-drug interaction: a case report. BMC Res Notes 2018; 11:331. [PMID: 29784014 PMCID: PMC5963053 DOI: 10.1186/s13104-018-3404-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sulfonylureas are widely used for type 2 diabetes mellitus, but these medications carry a risk of hypoglycemia. Drug-drug interactions that inhibit sulfonylurea metabolism and thus increase systemic exposure can cause unintentional sulfonylurea toxicity. CASE PRESENTATION A 56-year-old man presented with severe, recurrent hypoglycemia. He had a history of type 2 diabetes mellitus and was taking the sulfonylurea gliclazide with no prior episodes of hypoglycemia. The onset of his hypoglycemia occurred within days after starting voriconazole and subsequently fluconazole for a fungal pneumonia. Unintentional sulfonylurea toxicity developed due to an adverse drug-drug interaction between gliclazide and these antifungals. Azole antifungals inhibit the metabolism of sulfonylureas resulting in increased systemic exposure and consequent toxicity. After the diagnosis of sulfonylurea toxicity was recognized, the patient was treated initially with dextrose and then administered octreotide to prevent recurrent hypoglycemia. He was successfully managed, his hypoglycemic episodes resolved, and his medications were adjusted to avoid any further adverse interactions. CONCLUSIONS Adverse drug-drug interactions continue to pose challenges to clinicians. Both individual vigilance and system wide strategies are needed to prevent and mitigate consequences. This case highlights an important drug-drug interaction and reviews the presentation, management and antidotal therapy of sulfonylurea toxicity.
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Affiliation(s)
- Keith Gunaratne
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emily Austin
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.,Division of Clinical Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada
| | - Peter E Wu
- Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Division of Clinical Pharmacology & Toxicology, University of Toronto, Toronto, ON, Canada. .,Division of General Internal Medicine, University Health Network, 200 Elizabeth St. 14EN206, Toronto, ON, M5G 2C4, Canada.
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Dunbar-Yaffe R, Gold WL, Wu PE. Junior Rounds: an educational initiative to improve role transitions for junior residents. BMC Res Notes 2017; 10:694. [PMID: 29208032 PMCID: PMC5717831 DOI: 10.1186/s13104-017-3027-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 11/29/2017] [Indexed: 11/26/2022] Open
Abstract
Objective At our institution, Morning Report focuses mostly on diagnostic reasoning. This makes it a challenge for first-year residents to learn to manage common on-call emergencies, such as hyperkalemia. We sought to improve their preparedness for the transitions they would encounter: from medical student to physician at the beginning of the academic year, and from junior resident to senior resident toward the end. In response to feedback, we developed the Junior Rounds curriculum: a weekly session focused on the approach to commonly encountered on-call emergencies and internal medicine referrals. Anonymous surveys were sent to trainees, and iterative analysis of monthly feedback led to changes to Junior Rounds. Results Junior Rounds was implemented from August 2015 to June 2016. Thirty-nine of 92 possible respondents (44%) completed surveys in that period. Most respondents agreed that Junior Rounds met their educational needs, was presented at an appropriate level, and was more important to their learning than other available educational activities. Our experience demonstrates that dedicated time for level-specific learning aimed to support the transitions of junior residents can be successfully achieved. Iterative adjustment to these rounds based on feedback allowed for evolution of the curriculum to meet the changing priorities of junior learners. Electronic supplementary material The online version of this article (10.1186/s13104-017-3027-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard Dunbar-Yaffe
- Division of General Internal Medicine, University of Toronto, Toronto, Canada. .,Toronto General Hospital, 200 Elizabeth St., Eaton Building 13EN-213, Toronto, ON, M5G 2C4, Canada.
| | - Wayne L Gold
- Division of Infectious Diseases and General Internal Medicine, University of Toronto, Toronto, Canada
| | - Peter E Wu
- Division of General Internal Medicine, University of Toronto, Toronto, Canada
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Affiliation(s)
- Peter E Wu
- University Health NetworkToronto, Ontario, Canada
| | - Andrew M Morris
- Sinai Health System/University Health NetworkToronto, Ontario, Canada
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Abstract
Loperamide is a nonprescription opioid widely used for the treatment of diarrhea. Although it is relatively safe at therapeutic doses, increasing reports describe its misuse and abuse at very high doses either for euphoric effects or to attenuate symptoms of opioid withdrawal. Life-threatening loperamide toxicity can result from the relatively new clinical syndrome of loperamide-induced cardiac toxicity. These patients are often young and may present in cardiac arrest or with unheralded, recurrent syncope in conjunction with ECG abnormalities, including marked QT-interval prolongation, QRS-interval widening, and ventricular dysrhythmias. Features of conventional opioid toxicity may also be present. The mainstays of treatment include advanced cardiac life support and supportive care, although selected patients may be candidates for overdrive pacing, intravenous lipid emulsion, or extracorporeal membrane oxygenation. In patients who survive loperamide toxicity, consideration should be given to the treatment of an underlying opioid use disorder, if present.
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Affiliation(s)
- Peter E Wu
- Department of Medicine, University Health Network, Toronto, Ontario, Canada; Division of Clinical Pharmacology and Toxicology and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - David N Juurlink
- Division of Clinical Pharmacology and Toxicology and Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical and Evaluative Sciences and Sunnybrook Research Institute, Toronto, Ontario, Canada
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Wu PE, Sivilotti MLA. Toxic Alcohol Calculations and Misinterpretation of Laboratory Results. JAMA Intern Med 2016; 176:1227-8. [PMID: 27479666 DOI: 10.1001/jamainternmed.2016.3714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Peter E Wu
- Ontario Poison Centre, Toronto, Ontario, Canada2Division of Clinical Pharmacology & Toxicology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Canada4Department of Biomedical & Molecular Science, Queen's University, Kingston, Canada
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Affiliation(s)
- Lilian L Y Vivas
- Department of Medicine (Vivas, Gold, Wu), Division of Physical Medicine and Rehabilitation (Vivas), University of Toronto; Division of Infectious Diseases (Gold), University Health Network; Department of Medical Imaging (Mandell), University of Toronto; Division of Neuroradiology (Mandell), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), University of Toronto, Toronto, Ont
| | - Wayne L Gold
- Department of Medicine (Vivas, Gold, Wu), Division of Physical Medicine and Rehabilitation (Vivas), University of Toronto; Division of Infectious Diseases (Gold), University Health Network; Department of Medical Imaging (Mandell), University of Toronto; Division of Neuroradiology (Mandell), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), University of Toronto, Toronto, Ont
| | - Daniel M Mandell
- Department of Medicine (Vivas, Gold, Wu), Division of Physical Medicine and Rehabilitation (Vivas), University of Toronto; Division of Infectious Diseases (Gold), University Health Network; Department of Medical Imaging (Mandell), University of Toronto; Division of Neuroradiology (Mandell), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), University of Toronto, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Vivas, Gold, Wu), Division of Physical Medicine and Rehabilitation (Vivas), University of Toronto; Division of Infectious Diseases (Gold), University Health Network; Department of Medical Imaging (Mandell), University of Toronto; Division of Neuroradiology (Mandell), University Health Network; Division of Clinical Pharmacology and Toxicology (Wu), University of Toronto, Toronto, Ont.
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Affiliation(s)
- Corey M Stein
- Department of Medicine (Stein, Wu), University of Toronto; Division of Clinical Pharmacology and Toxicology (Wu, Scott), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Scott), University of Toronto; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Stein, Wu), University of Toronto; Division of Clinical Pharmacology and Toxicology (Wu, Scott), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Scott), University of Toronto; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - James A Scott
- Department of Medicine (Stein, Wu), University of Toronto; Division of Clinical Pharmacology and Toxicology (Wu, Scott), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Scott), University of Toronto; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Adina S Weinerman
- Department of Medicine (Stein, Wu), University of Toronto; Division of Clinical Pharmacology and Toxicology (Wu, Scott), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Scott), University of Toronto; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.
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Pattani R, Wu PE, Dhalla IA. Other consequences of reduced duty hours. The authors respond. CMAJ 2015; 187:207. [PMID: 25691795 PMCID: PMC4330147 DOI: 10.1503/cmaj.115-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Reena Pattani
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital; Department of Medicine, (Pattani, Wu, Dhalla), University of Toronto; Department of Medicine (Wu), Toronto General Hospital; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
| | - Peter E Wu
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital; Department of Medicine, (Pattani, Wu, Dhalla), University of Toronto; Department of Medicine (Wu), Toronto General Hospital; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
| | - Irfan A Dhalla
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital; Department of Medicine, (Pattani, Wu, Dhalla), University of Toronto; Department of Medicine (Wu), Toronto General Hospital; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
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Affiliation(s)
- Reena Pattani
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont.
| | - Peter E Wu
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
| | - Irfan A Dhalla
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
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Affiliation(s)
- Peter E Wu
- Department of Medicine (Wu, Juurlink), University of Toronto; Department of Medicine (Wu), University Health Network - Toronto General Hospital; Department of Medicine (Juurlink), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Juurlink), Toronto, Ont.
| | - David N Juurlink
- Department of Medicine (Wu, Juurlink), University of Toronto; Department of Medicine (Wu), University Health Network - Toronto General Hospital; Department of Medicine (Juurlink), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Juurlink), Toronto, Ont
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Abstract
BACKGROUND Concern surrounding the effect of resident fatigue on patient care recently led the National Steering Committee on Resident Duty Hours to publish Canadian recommendations suggesting that duty periods of 24 or more consecutive hours without restorative sleep should be avoided. We sought to characterize how different training programs are preparing for the effect of such changes on education, patient care and provider well-being. METHODS Using constructivist grounded theory methodology, we conducted 18 one-on-one semistructured interviews with program directors, division directors and department chiefs from 11 residency programs affiliated with one Canadian medical school. We gathered and analyzed data iteratively until we reached theoretical saturation. RESULTS The key theme articulated by our participants was that changes in resident duty hours would potentially lead to gaps in the provision of clinical care. These changes affect acute care specialties based primarily in the inpatient setting (e.g., medicine, surgery) more than primarily ambulatory (e.g., family medicine) or shift-model based (e.g., emergency) specialties. Potential strategies to address gaps in clinical care include resident-based solutions, faculty-based solutions and solutions based on other providers (e.g., nonacademic physicians, physician extenders). Each solution has unique advantages and disadvantages in terms of education, continuity of care, preparedness for practice and provider well-being. INTERPRETATION Our data-driven framework serves as a guide for programs to anticipate challenges of satisfying clinical care needs in the face of changes to resident duty hours, while balancing education, care continuity, preparedness for practice and provider well-being. Our findings challenge the "one-size-fits-all" approach to changes to resident duty hours and endorse flexibility in enacting duty hour regulations based on specialty-specific factors.
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Affiliation(s)
- Peter E Wu
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Toronto General Hospital, Toronto, Ont
| | - Lynfa Stroud
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont
| | | | - Brian M Wong
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont. ; Centre for Quality Improvement & Patient Safety, University of Toronto, Toronto, Ont
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