Changes in Media Reporting Quality and Suicides Following National Media Engagement on Responsible Reporting of Suicide in Canada: Changements de la Qualité des reportages dans les médias sur les suicides suite à l'engagement des médias nationaux à la déclaration responsable du suicide au Canada

OBJECTIVE

Responsible media reporting is an accepted strategy for preventing suicide. In 2015, suicide prevention experts launched a media engagement initiative aimed at improving suicide-related reporting in Canada; its impact on media reporting quality and suicide deaths is unknown.

METHOD

This pre-post observational study examined changes in reporting characteristics in a random sample of suicide-related articles from major publications in the Greater Toronto Area (GTA) media market. Articles (n = 900) included 450 from the 6-year periods prior to and after the initiative began. We also examined changes in suicide counts in the GTA between these epochs. We used chi-square tests to analyse changes in reporting characteristics and time-series analyses to identify changes in suicide counts. Secondary outcomes focused on guidelines developed by media professionals in Canada and how they may have influenced media reporting quality as well as on the overarching narrative of media articles during the most recent years of available data.

RESULTS

Across-the-board improvement was observed in suicide-related reporting with substantial reductions in many elements of putatively harmful content and substantial increases in all aspects of putatively protective content. However, overarching article narratives remained potentially harmful with 55.2% of articles telling the story of someone's death and 20.8% presenting an other negative message. Only 3.6% of articles told a story of survival. After controlling for potential confounders, a nonsignificant numeric decrease in suicide counts was identified after initiative implementation (ω = -5.41, SE  =  3.43, t  =  1.58, p  =  0.12).

CONCLUSIONS

We found evidence that a strategy to engage media in Canada changed the content of reporting, but there was only a nonsignificant trend towards fewer suicides. A more fundamental change in media narratives to focus on survival rather than death appears warranted.

Fatal Traffic Risks With a Total Solar Eclipse in the US

This case-control study describes the incidence of fatal traffic crashes in the US during the 2017 total solar eclipse.

The Limits of Clinician Vigilance as an AI Safety Bulwark

This Viewpoint examines the potential problems of clinician reliance on the use of artificial intelligence (AI) in health care and offers suggestions on how AI could be designed to promote clinician vigilance.

Syncope and Traffic Crash: A Population-Based Case-Crossover Analysis

BACKGROUND

Among individuals with recent syncope, recurrence of syncope while driving might incapacitate a driver and cause a motor vehicle crash. Current driving restrictions assume that some forms of syncope transiently increase crash risk. We evaluated whether syncope is associated with a transient increase in crash risk.

METHODS

We performed a case-crossover analysis of linked administrative health and driving data from British Columbia, Canada (2010 to 2015). We included licensed drivers who visited an emergency department with "syncope and collapse" and who were involved as a driver in an eligible motor vehicle crash, both within the study interval. Using conditional logistic regression, we compared the rate of emergency visits for syncope in the 28 days before crash (the "pre-crash interval") with the rate of emergency visits for syncope in 3 self-matched 28-day control intervals (ending 6, 12, and 18 months before the crash).

RESULTS

Among eligible crash-involved drivers, 47 of 3026 pre-crash intervals and 112 of 9078 control intervals had emergency visits for syncope, indicating syncope was not significantly associated with subsequent crash (1.6% vs 1.2%; adjusted odds ratio [OR], 1.27; 95% confidence interval [CI], 0.90-1.79; P = 0.18). There was no significant association between syncope and crash in subgroups at higher risk for adverse outcomes after syncope (eg, age > 65 years, cardiovascular disease, cardiac syncope).

CONCLUSIONS

In the context of prevailing modifications of driving behaviour after syncope, an emergency department visit for syncope did not transiently increase the risk of subsequent traffic collision. Overall crash risks after syncope appear to be adequately addressed by current driving restrictions.

COVID Vaccine Hesitancy and Long-Term Traffic Risks

BACKGROUND

COVID vaccine hesitancy identifies a discrepancy between personal decisions and public guidelines. We tested whether COVID vaccine hesitancy was associated with the long-term risks of a traffic crash.

METHODS

We conducted a population-based longitudinal cohort analysis of adults by determining COVID vaccination status through linkages to electronic medical records. Traffic crashes requiring emergency medical care were defined by multicenter outcome ascertainment of all hospitals throughout the region over the subsequent year.

RESULTS

We identified 11,598,549 total individuals, of whom 1,210,754 had not received a COVID vaccine. A total of 54,558 were subsequently injured in traffic crashes during the 1-year follow-up interval, equal to a risk of 4704 per million. Those who had not received a COVID vaccine had a 58% higher risk than those who had received a COVID vaccine (6983 vs 4438 per million, P < .001). The increased traffic risks among unvaccinated individuals included diverse subgroups, were accentuated for single-vehicle crashes, extended to fatal outcomes, exceeded the risks associated with sleep apnea, and persisted after adjustment for baseline characteristics. The increased risks were validated in analyses using Artificial Intelligence techniques and generally larger than the risks of other adverse events frequently ascribed to COVID vaccination.

CONCLUSIONS

COVID vaccine hesitancy is associated with significant increased long-term risks of a traffic crash. A greater awareness of traffic risks might encourage patients to take protective actions for personal safety.

Syncope While Driving and the Risk of a Subsequent Motor Vehicle Crash

STUDY OBJECTIVE

Syncope that occurs while driving can result in a motor vehicle crash. Whether individuals with a prior syncope-related crash exhibit an exceptional risk of subsequent crash remains uncertain.

METHODS

We performed a population-based retrospective observational study of patients diagnosed with 'syncope and collapse' at any of 6 emergency departments in British Columbia, Canada (2010 to 2015). Data were obtained from chart abstraction, administrative health records, insurance claims and police crash reports. We compared crash-free survival among individuals with crash-associated syncope (a crash and an emergency visit for syncope on the same date) to that among controls with syncope alone (no crash on date of emergency visit for syncope).

RESULTS

In the year following their index emergency visit, 13 of 63 drivers with crash-associated syncope and 852 of 9,160 controls with syncope alone experienced a subsequent crash as a driver (crash risk 21% versus 9%). After accounting for censoring and potential confounders, crash-associated syncope was not associated with a significant increase in the risk of subsequent crash (adjusted hazard ratio [aHR] 1.38, 95% confidence interval [CI] 0.78 to 2.47). Individuals with crash-associated syncope were 31-fold more likely to have physician driving advice documented during their index visit (prevalence ratio 31.0, 95% CI, 21.3 to 45.1). In the subgroup without documented driving advice, crash-associated syncope was associated with a significant increase in subsequent crash risk (aHR 1.88, 95% CI 1.06 to 3.36).

CONCLUSIONS

Crash risk after crash-associated syncope appears similar to crash risk after syncope alone.

On-call absences and academic recognition: A retrospective cohort analysis

BACKGROUND

Resident call schedules require careful planning and are vulnerable to unanticipated absences from unpredictable factors. We tested whether unplanned absences from resident call schedules were associated with the likelihood of subsequent academic recognition.

METHODS

We examined unplanned absences from call shifts for internal medicine residents at the University of Toronto from 2014 to 2022 (8 years). We identified institutional awards granted at the end of the academic year as an indicator of academic recognition. We defined the resident-year as the unit-of-analysis that started in July and ended in June of the subsequent year. Secondary analyses examined the association between unplanned absences and the likelihood of academic recognition in later years.

RESULTS

We identified 1668 resident-years of training in internal medicine. In total, 579 (35%) had an unplanned absence, and the remaining 1089 (65%) had no unplanned absence. Baseline characteristics were similar between the two groups of residents. In total, 301 awards were received for academic recognition. The likelihood of receiving an award at the end of the year was 31% lower for residents who had any unplanned absence compared with those who had no absence (adjusted odds ratio = 0.69, 95% confidence interval 0.51-0.93, p = 0.015). The likelihood of receiving an award was further decreased for residents with multiple unplanned absences compared with those with none (odds ratio 0.54, 95% confidence interval 0.33-0.83, p = 0.008). An absence during the first year of residency was not significantly associated with the likelihood of academic recognition in later years of training (odds ratio 0.62, 95% confidence interval 0.36-1.04, p = 0.081).

CONCLUSIONS

The results of this analysis suggest unplanned absences from scheduled call shifts may be associated with a decreased likelihood of academic recognition for internal medicine residents. This association could reflect countless confounders or the prevailing culture of medicine.

Furosemide in pediatric intensive care: a retrospective cohort analysis

Introduction

Furosemide is the most commonly used medication in pediatric intensive care. Growing data indicates improved hemodynamic stability and efficacy of furosemide infusions compared to intermittent injections, thereby suggesting furosemide infusions might be considered as first line therapy in critically ill, paediatric patients. The objective of this study is to examine furosemide treatment as either continuous infusions or intermittent injections and subsequent patient outcomes.

Methods

This is a retrospective cohort analysis of patients treated in a pediatric intensive care unit (ICU) over a nine year period (July 31st 2006 and July 31, 2015). Eligible patients were admitted to either the general pediatric or cardiac specific ICU for a duration of at least 6 hours and who received intravenous furosemide treatment.

Results

A total of 7,478 patients were identified who received a total of 118,438 furosemide administrations for a total of 113,951 (96%) intermittent doses and 4,487 (4%) infusions running for a total of 1,588,750 hours. A total of 5,996 (80%) patients received exclusively furosemide injections and 1,482 (20%) patients received at least one furosemide infusion. A total of 193 patients died during ICU admission, amounting to 87 (6%) of the 1,482 patients who received an infusion and 106 (2%) of the 5,996 who received intermittent injections. Multivariable regression analysis showed no statistically significant decrease in adjusted mortality for patients who received furosemide injections compared to furosemide infusions (aOR 1.20, CI 0.76-1.89).

Discussion

This retrospective study observed similar mortality for patients who received furosemide infusions compared to furosemide injections. More research on furosemide in the ICU could provide insights on fluid management, drug effectiveness, and pharmacologic stewardship for critically ill children.

Contemporary trends in the incidence and timing of spinal metastases: A population-based study

Background

Spinal metastases are a significant complication of advanced cancer. In this study, we assess temporal trends in the incidence and timing of spinal metastases and examine underlying patient demographics and primary cancer associations.

Methods

In this population-based retrospective cohort study, health data from 2007 to 2019 in Ontario, Canada were analyzed (n = 37, 375 patients identified with spine metastases). Primary outcomes were annual incidence of spinal metastasis, and time to metastasis after primary diagnosis.

Results

The age-standardized incidence of spinal metastases increased from 229 to 302 cases per million over the 13-year study period. The average annual percent change (AAPC) in incidence was 2.2% (95% CI: 1.4% to 3.0%) with patients aged ≥85 years demonstrating the largest increase (AAPC 5.2%; 95% CI: 2.3% to 8.3%). Lung cancer had the greatest annual incidence, while prostate cancer had the greatest increase in annual incidence (AAPC 6.5; 95% CI: 4.1% to 9.0%). Lung cancer patients were found to have the highest risk of spine metastasis with 10.3% (95% CI: 10.1% to 10.5%) of patients being diagnosed at 10 years. Gastrointestinal cancer patients were found to have the lowest risk of spine metastasis with 1.0% (95% CI: 0.9% to 1.0%) of patients being diagnosed at 10 years.

Conclusions

The incidence of spinal metastases has increased in recent years, particularly among older patients. The incidence and timing vary substantially among different primary cancer types. These findings contribute to the understanding of disease trends and emphasize a growing population of patients who require subspecialty care.

A Dose of Reality About Dose-Response Relationships

Observational research can be strengthened by examining potential dose-response relationships that correlate a clinical intervention with a patient outcome. Despite being a classic criterion for establishing causality, dose-response testing can be difficult to interpret in clinical medicine due to multiple diverse pitfalls. This review introduces a cautionary framework for investigators considering dose-response relationships in observational research to support evidence-based medicine. Each pitfall is illustrated with a specific example relevant when analyzing a dose-response relationship. Several pitfalls stem from faulty interpretation including confounding by indication and fallible range selection. Additional pitfalls relate to improper analysis including fitting a nonlinear model and misclassification error. Further pitfalls arise in special situations including subjective self-report and artifacts from survival bias. These caveats are common sources of misunderstanding in analyses that examine the link between varying exposures and the intensity of clinical outcomes. Awareness of specific pitfalls, we suggest, might help advance the conduct, application, and translation of dose-response relationships in observational research to inform evidence-based medical care.

Costs for Long-Term Health Care After a Police Shooting in Ontario, Canada

Importance

Police shootings can cause serious acute injury, and knowledge of subsequent health outcomes may inform interventions to improve care.

Objective

To analyze long-term health care costs among survivors of police shootings compared with those surviving nonfirearm police enforcement injuries using a retrospective design.

Design, Setting, and Participants

This population-based cohort analysis identified adults (age ≥16 years) who were injured by police and required emergency medical care between April 1, 2002, and March 31, 2022, in Ontario, Canada.

Exposure

Police shootings compared with other mechanisms of injury involving police.

Main Outcomes and Measures

Long-term health care costs determined using a validated costing algorithm. Secondary outcomes included short-term mortality, acute care treatments, and rates of subsequent disability.

Results

Over the study, 13 545 adults were injured from police enforcement (mean [SD] age, 35 [12] years; 11 637 males [86%]). A total of 13 520 individuals survived acute injury, and 8755 had long-term financial data available (88 surviving firearm injury, 8667 surviving nonfirearm injury). Patients surviving firearm injury had 3 times greater health care costs per year (CAD$16 223 vs CAD$5412; mean increase, CAD$9967; 95% CI, 6697-13 237; US $11 982 vs US $3997; mean increase, US $7361; 95% CI, 4946-9776; P < .001). Greater costs after a firearm injury were not explained by baseline costs and primarily reflected increased psychiatric care. Other characteristics associated with increased long-term health care costs included prior mental illness and a substance use diagnosis.

Conclusions and Relevance

In this longitudinal cohort study of long-term health care costs, patients surviving a police shooting had substantial health care costs compared with those injured from other forms of police enforcement. Costs primarily reflected psychiatric care and suggest the need to prioritize early recognition and prevention.

A Population-Based Analysis of Long-Term Costs and Adverse Events after Pneumatic Retinopexy and Pars Plana Vitrectomy

PURPOSE

To comprehensively examine the cost effectiveness, reattachment rate, and complications of pneumatic retinopexy (PnR) compared with pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) within a universal health care system.

DESIGN

Population-based, multicenter, consecutive, retrospective longitudinal cohort analysis.

SUBJECTS

We identified consecutive adults aged ≥ 50 years requiring surgery for primary RRD over a 20-year interval between April 1, 2002, and March 31, 2022. Initial surgery was considered the index date for analyses.

INTERVENTION

Pneumatic retinopexy was compared with PPV in all analyses.

MAIN OUTCOME MEASURES

The primary analysis investigated the mean annualized health care costs comparing PnR to PPV over the 2 years after initial surgery. Secondary analyses examined the primary reattachment rate and complications.

RESULTS

In total, 25 665 eligible patients were identified, with 8794 undergoing PnR and 16 871 undergoing PPV. The mean patient age was 65 years and 39% were women. The mean annualized cost after PnR was $8924 and $11 937 after PPV (mean difference, $3013; 95% confidence interval, $2533-$3493; P < 0.001). The primary reattachment rate at 90 days after PnR was 83% and after PPV was 93% (P < 0.001). The risk of cataract or glaucoma surgery was lower after PnR, and the frequency of ophthalmology clinic visits, intravitreal injections, and anxiety was higher after PnR. Hospitalizations and long-term disability were less frequent after PnR.

CONCLUSIONS

Pneumatic retinopexy, when compared with PPV, was associated with lower long-term health care costs. Pneumatic retinopexy appeared to be effective, safe, and inexpensive, thus offering a viable option for improving access to RRD repair in appropriately selected cases.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Association of Different Prescribing Patterns for Oral Corticosteroids With Fracture Preventive Care Among Older Adults in the UK and Ontario

Importance

Identifying and mitigating modifiable gaps in fracture preventive care for people with relapsing-remitting conditions such as eczema, asthma, and chronic obstructive pulmonary disease who are prescribed high cumulative oral corticosteroid doses may decrease fracture-associated morbidity and mortality.

Objective

To estimate the association between different oral corticosteroid prescribing patterns and appropriate fracture preventive care, including treatment with fracture preventive care medications, among older adults with high cumulative oral corticosteroid exposure.

Design, Setting, and Participants

This cohort study included 65 195 participants with UK electronic medical record data from the Clinical Practice Research Datalink (January 2, 1998, to January 31, 2020) and 28 674 participants with Ontario, Canada, health administrative data from ICES (April 1, 2002, to September 30, 2020). Participants were adults 66 years or older with eczema, asthma, or chronic obstructive pulmonary disease receiving prescriptions for oral corticosteroids with cumulative prednisolone equivalent doses of 450 mg or higher within 6 months. Data were analyzed October 22, 2020, to September 6, 2022.

Exposures

Participants with prescriptions crossing the 450-mg cumulative oral corticosteroid threshold in less than 90 days were classified as having high-intensity prescriptions, and participants crossing the threshold in 90 days or more as having low-intensity prescriptions. Multiple alternative exposure definitions were used in sensitivity analyses.

Main Outcomes and Measures

The primary outcome was prescribed fracture preventive care. A secondary outcome was major osteoporotic fracture. Individuals were followed up from the date they crossed the cumulative oral corticosteroid threshold until their outcome or the end of follow-up (up to 1 year after index date). Rates were calculated for fracture preventive care and fractures, and hazard ratios (HRs) were estimated from Cox proportional hazards regression models comparing high- vs low-intensity oral corticosteroid prescriptions.

Results

In both the UK cohort of 65 195 participants (mean [IQR] age, 75 [71-81] years; 32 981 [50.6%] male) and the Ontario cohort of 28 674 participants (mean [IQR] age, 73 [69-79] years; 17 071 [59.5%] male), individuals with high-intensity oral corticosteroid prescriptions had substantially higher rates of fracture preventive care than individuals with low-intensity prescriptions (UK: 134 vs 57 per 1000 person-years; crude HR, 2.34; 95% CI, 2.19-2.51, and Ontario: 73 vs 48 per 1000 person-years; crude HR, 1.49; 95% CI, 1.29-1.72). People with high- and low-intensity oral corticosteroid prescriptions had similar rates of major osteoporotic fractures (UK: crude rates, 14 vs 13 per 1000 person-years; crude HR, 1.07; 95% CI, 0.98-1.15 and Ontario: crude rates, 20 vs 23 per 1000 person-years; crude HR, 0.87; 95% CI, 0.79-0.96). Results from sensitivity analyses suggested that reaching a high cumulative oral corticosteroid dose within a shorter time, with fewer prescriptions, or with fewer or shorter gaps between prescriptions, increased fracture preventive care prescribing.

Conclusions

The results of this cohort study suggest that older adults prescribed high cumulative oral corticosteroids across multiple prescriptions, or with many or long gaps between prescriptions, may be missing opportunities for fracture preventive care.

COVID-19 deaths on weekends

BACKGROUND

Mortality statistics about daily deaths might change on weekends due to delays in reporting, uneven staffing, a different mix of personnel, or decreased efficiency. We hypothesized that reported deaths for COVID-19 might increase on weekends compared to weekdays.

METHODS

We collected data from the World Health Organization COVID-19 database. All deaths from March 7, 2020 to March 7, 2022 were included (two years). The primary analysis evaluated mean daily deaths on weekends compared to the preceding five workdays. Analyses were replicated in ten individual countries: United States, United Kingdom, France, Germany, Italy, Spain, Russia, India, Brazil, and Canada.

RESULTS

The mean COVID-19 daily deaths was higher on weekends compared to weekdays (8,532 vs. 8,083 p < 0.001), equal to a 6% relative increase (95% confidence interval 3% to 8%). The highest absolute increase was in the United States (1,483 vs. 1,220 deaths, p < 0.001). The second highest absolute increase was in Brazil (1,061 vs. 823 deaths, p < 0.001). The increase in deaths on weekends remained significant during the earlier and later months of the pandemic, as well as during the greater and lesser weeks of the pandemic.

CONCLUSIONS

The apparent increased COVID-19 deaths reported on weekends might potentially reflect patient care, confound community trends, and affect the public perception of risk.

Does knowledge have a half-life? An observational study analyzing the use of older citations in medical and scientific publications

OBJECTIVES

In the process of scientific progress, prior evidence is both relied on and supplanted by new discoveries. We use the term 'knowledge half-life' to refer to the phenomenon in which older knowledge is discounted in favour of newer research. By quantifying the knowledge half-life, we sought to determine whether research published in more recent years is preferentially cited over older research in medical and scientific articles.

DESIGN

An observational study employing a directed, systematic search of current literature.

DATA SOURCES

BMJ, PNAS, JAMA, NEJM, The Annals of Internal Medicine, The Lancet, Science and Nature were searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eight high-impact medical and scientific journals were sampled examining original research articles from the first issue of every year over a 25-year span (1996-2020). The outcome of interest was the difference between the publication year of the article and references cited, termed 'citation lag'.

DATA EXTRACTION AND SYNTHESIS

Analysis of variance was used to identify significant differences in citation lag.

RESULTS

A total of 726 articles and 17 895 references were included with a mean citation lag of 7.5±8.4 years. Across all journals, >70% of references had been published within 10 years of the citing article. Approximately 15%-20% of referenced articles were 10-19 years old, and articles more than 20 years old were cited infrequently. Medical journals articles had references with significantly shorter citation lags compared with general science journals (p≤0.01). Articles published before 2009 had references with significantly shorter citation lags compared with those published in 2010-2020 (p<0.001).

CONCLUSIONS

This study found evidence of a small increase in the citation of older research in medical and scientific literature over the past decade. This phenomenon deserves further characterisation and scrutiny to ensure that 'old knowledge' is not being lost.

Is the narrative the message? The relationship between suicide-related narratives in media reports and subsequent suicides

OBJECTIVES

When journalists report on the details of a suicide, the way that they contextualize the meaning of the event (i.e. the 'narrative') can have significant consequences for readers. The 'Werther' and 'Papageno' narrative effects refer to increases and decreases in suicides across populations following media reports on suicidal acts or mastery of crises, respectively. The goal of this study was to investigate the impact of these different narrative constructs on subsequent suicides.

METHODS

This study examined the change in suicide counts over time in Toronto, Canada. It used latent difference score analysis, examining suicide-related print media reports in the Toronto media market (2011-2014). Articles (N = 6367) were coded as having a potentially harmful narrative if they described suicide in a celebrity or described a suicide death in a non-celebrity and included the suicide method. Articles were coded as having potentially protective narratives if they included at least one element of protective content (e.g. alternatives to suicide) without including any information about suicidal behaviour (i.e. suicide attempts or death).

RESULTS

Latent difference score longitudinal multigroup analyses identified a dose-response relationship in which the trajectory of suicides following harmful 'Werther' narrative reports increased over time, while protective 'Papageno' narrative reports declined. The latent difference score model demonstrated significant goodness of fit and parameter estimates, with each group demonstrating different trajectories of change in reported suicides over time: (χ2[6], N = 6367) = 13.16; χ2/df = 2.19; Akaike information criterion = 97.16, comparative fit index = 0.96, root mean square error of approximation = 0.03.

CONCLUSION

Our findings support the notion that the 'narrative' matters when reporting on suicide. Specifically, 'Werther' narratives of suicides in celebrities and suicides in non-celebrities where the methods were described were associated with more subsequent suicides while 'Papageno' narratives of survival and crisis mastery without depictions of suicidal behaviours were associated with fewer subsequent suicides. These results may inform efforts to prevent imitation suicides.

Analysis of Resident and Attending Physician End-of-Rotation Changeover Days and Association With Patient Length of Stay

Importance

End-of-rotation resident physician changeover is a key part of postgraduate training but could lead to discontinuity in patient care.

Objective

To test whether patients exposed to end-of-rotation resident changeover have longer hospital stays and whether this association is mitigated by separating resident and attending changeover days.

Design, Setting, and Participants

This retrospective cohort analysis included adult patients admitted to general internal medicine. The changeover day was the same day (first Monday of month) for both resident and attending physicians until June 30, 2013 (preseparation period), and then intentionally staggered by 1 or more days after July 1, 2013 (postseparation period). This was a multicenter analysis at 4 teaching hospitals in Ontario, Canada, from July 1, 2010, to June 30, 2019. Data analysis was conducted from July 2022 to January 2023.

Exposures

Patients were classified as changeover patients if the first Monday was a resident changeover day and as control patients if the first Monday was not a resident changeover day.

Main Outcomes and Measures

The primary outcome was length of hospital stay. Secondary outcomes were transfer to critical care, in-hospital death, and rate of discharge per 100 patients on the index day.

Results

Of 95 282 patients. 22 773 (24%; mean [SD] age, 67.8 [18.8] years; 11 156 [49%] female patients) were exposed to resident changeover, and 72 509 (76%; mean [SD] age, 67.8 [18.7] years; 35 293 [49%] female patients) were not exposed to resident changeover. Exposure to resident changeover day was associated with a slightly longer hospital stay compared with control days (0.20 [95% CI, 0.09-0.30] days; P < .001) and decreased relative risk of patient discharge on the index day (relative risk, 0.92; 95% CI, 0.86-1.00; P = .047). These associations were similar in the preseparation and postseparation periods. Resident changeover was not associated with an increased risk of transfer to critical care or in-hospital death.

Conclusions and Relevance

In this study, a small positive association between exposure to resident physician changeover and length of hospital stay as well as reduced rate of discharge was found. These findings suggest that separating changeover days for resident and attending physicians may not significantly change these associations.

Pedestrian Deaths During the COVID-19 Pandemic

The COVID pandemic provides a natural experiment examining how a 50-60% reduction in pedestrian activity might lead to a reduction in pedestrian deaths. We assessed whether the reduction in pedestrian deaths was proportional to a one-to-one matching presumed in statistics correlating mobility with fatality. The primary analysis examined New York (largest city in US), and the validation analysis examined Toronto (largest city in Canada). We identified pedestrian activity in each location from the Apple Mobility database, normalized to the baseline in January 2020. We calculated monthly pedestrian deaths from the Vision Zero database in each city with baseline data from 3 prior years. We found a large initial reduction in pedestrian deaths during the lockdown in New York that was transient and not statistically significant during the summer and autumn despite sustained reductions in pedestrian activity. Similarly, we found a large initial reduction in pedestrian deaths during the lockdown in Toronto that was transient and not sustained. Together, these data suggest the substantial reductions in pedestrian activity during the COVID pandemic have no simple correlation with pedestrian fatality counts in the same locations. An awareness of this finding emphasizes the role of unmeasured modifiable individual factors beyond pedestrian infrastructure or other structural contributors.

The Fallacy of a Single Diagnosis

BACKGROUND

Diagnostic reasoning requires clinicians to think through complex uncertainties. We tested the possibility of a bias toward an available single diagnosis in uncertain cases.

DESIGN

We developed 5 different surveys providing a succinct description of a hypothetical individual patient scenaric. Each scenario was formulated in 2 versions randomized to participants, with the versions differing only in whether an alternative diagnosis was present or absent. The 5 scenarios were designed as separate tests of robustness using diverse cases, including a cautious scenario, a risky scenario, a sophisticated scenario, a validation scenario, and a comparative scenario (each survey containing only 1 version of 1 scenario). Participants included community members (n = 1104) and health care professionals (n = 200) who judged the chances of COVID infection in an individual patient.

RESULTS

The first scenario described a cautious patient and found a 47% reduction in the estimated odds of COVID when a flu diagnosis was present compared with absent (odds ratio = 0.53, 95% confidence interval 0.30 to 0.94, P = 0.003). The second scenario described a less cautious patient and found a 70% reduction in the estimated odds of COVID in the presence of a flu diagnosis (odds ratio = 0.30, 95% confidence interval 0.13 to 0.70, P < 0.001). The third was a more sophisticated scenario presented to medical professionals and found a 73% reduction in the estimated odds of COVID in the presence of a mononucleosis diagnosis (odds ratio = 0.27, 95% confidence interval 0.10 to 0.75, P < 0.001). Two further scenarios-avoiding mention of population norms-replicated the results.

LIMITATIONS

Brief hypothetical scenarios may overestimate the extent of bias in more complicated medical situations.

CONCLUSIONS

These results demonstrate that an available simple diagnosis can lead individuals toward premature closure and a failure to fully consider additional severe diseases.

HIGHLIGHTS

Occum's razor has been debated for centuries yet rarely subjected to experimental testing for evidence-based medicine.This article offers direct evidence that people favor an available simple diagnosis, thereby neglecting to consider additional serious diseases.The bias can lead individuals to mistakenly lower their judged likelihood of COVID or another disease when an alternate diagnosis is present.This misconception over the laws of probability appears in judgments by community members and by health care workers.The pitfall in reasoning extends to high-risk cases and is not easily attributed to information, incentives, or random chance.

COVID Vaccine Hesitancy and Risk of a Traffic Crash

BACKGROUND

Coronavirus disease (COVID) vaccine hesitancy is a reflection of psychology that might also contribute to traffic safety. We tested whether COVID vaccination was associated with the risks of a traffic crash.

METHODS

We conducted a population-based longitudinal cohort analysis of adults and determined COVID vaccination status through linkages to individual electronic medical records. Traffic crashes requiring emergency medical care were subsequently identified by multicenter outcome ascertainment of all hospitals in the region over a 1-month follow-up interval (178 separate centers).

RESULTS

A total of 11,270,763 individuals were included, of whom 16% had not received a COVID vaccine and 84% had received a COVID vaccine. The cohort accounted for 6682 traffic crashes during follow-up. Unvaccinated individuals accounted for 1682 traffic crashes (25%), equal to a 72% increased relative risk compared with those vaccinated (95% confidence interval, 63-82; P < 0.001). The increased traffic risks among unvaccinated individuals extended to diverse subgroups, was similar to the relative risk associated with sleep apnea, and was equal to a 48% increase after adjustment for age, sex, home location, socioeconomic status, and medical diagnoses (95% confidence interval, 40-57; P < 0.001). The increased risks extended across the spectrum of crash severity, appeared similar for Pfizer, Moderna, or other vaccines, and were validated in supplementary analyses of crossover cases, propensity scores, and additional controls.

CONCLUSIONS

These data suggest that COVID vaccine hesitancy is associated with significant increased risks of a traffic crash. An awareness of these risks might help to encourage more COVID vaccination.

Syncope and subsequent traffic crash: A responsibility analysis

BACKGROUND

Physicians are often asked to counsel patients about driving safety after syncope, yet little empirical data guides such advice.

METHODS

We identified a population-based retrospective cohort of 9,507 individuals with a driver license who were discharged from any of six urban emergency departments (EDs) with a diagnosis of 'syncope and collapse'. We examined all police-reported crashes that involved a cohort member as a driver and occurred between 1 January 2010 and 31 December 2016. We categorized crash-involved drivers as 'responsible' or 'non-responsible' for their crash using detailed police-reported crash data and a validated responsibility scoring tool. We then used logistic regression to test the hypothesis that recent syncope was associated with driver responsibility for crash.

RESULTS

Over the 7-year study interval, cohort members were involved in 475 police-reported crashes: 210 drivers were deemed responsible and 133 drivers were deemed non-responsible for their crash; the 132 drivers deemed to have indeterminate responsibility were excluded from further analysis. An ED visit for syncope occurred in the three months leading up to crash in 11 crash-responsible drivers and in 5 crash-non-responsible drivers, suggesting that recent syncope was not associated with driver responsibility for crash (adjusted odds ratio, 1.31; 95%CI, 0.40-4.74; p = 0.67). However, all drivers with cardiac syncope were deemed responsible, precluding calculation of an odds ratio for this important subgroup.

CONCLUSIONS

Recent syncope was not significantly associated with driver responsibility for traffic crash. Clinicians and policymakers should consider these results when making fitness-to-drive recommendations after syncope.

Telemedicine use and outcomes after transient ischemic attack and minor stroke during the COVID-19 pandemic: a population-based cohort study

BACKGROUND

The COVID-19 pandemic has led to an increase in telemedicine use. We compared care and outcomes in patients with transient ischemic attack (TIA) or minor ischemic stroke before and after the widespread adoption of telemedicine in Ontario, Canada, in 2020.

METHODS

In a population-based cohort study using linked administrative data, we identified patients with TIA or ischemic stroke discharged from any emergency department in Ontario before the widespread use of telemedicine (Apr. 1, 2015, to Mar. 31, 2020) and after (Apr. 1, 2020, to Mar. 31, 2021). We measured care, including visits with a physician, investigations and medication renewal. We compared 90-day death before and after 2020 using Cox proportional hazards models, and we compared 90-day admission using cause-specific hazard models.

RESULTS

We identified 47 601 patients (49.3% female; median age 73, interquartile range 62-82, yr) with TIA (n = 35 695, 75.0%) or ischemic stroke (n = 11 906, 25.0%). After 2020, 83.1% of patients had 1 or more telemedicine visit within 90 days of emergency department discharge, compared with 3.8% before. The overall access to outpatient visits within 90 days remained unchanged (92.9% before v. 94.0% after; risk difference 1.1, 95% confidence interval [CI] -1.3 to 3.5). Investigations and medication renewals were unchanged. Clinical outcomes were also similar before and after 2020; the adjusted hazard ratio was 0.97 (95% CI 0.91 to 1.04) for 90-day all-cause admission, 1.06 (95% CI 0.94 to 1.20) for stroke admission and 1.07 (95% CI 0.93 to 1.24) for death.

INTERPRETATION

Care and short-term outcomes after TIA or minor stroke remained stable after the widespread implementation of telemedicine during the COVID-19 pandemic. Our findings suggest that telemedicine is an effective method of health care delivery that can be complementary to in-person care for minor ischemic cerebrovascular events.

Syncope and the Risk of Subsequent Motor Vehicle Crash: A Population-Based Retrospective Cohort Study

IMPORTANCE

Medical driving restrictions are burdensome, yet syncope recurrence while driving can cause a motor vehicle crash (MVC). Few empirical data inform current driving restrictions after syncope.

OBJECTIVE

To examine MVC risk among patients visiting the emergency department (ED) after first-episode syncope.

DESIGN, SETTING, AND PARTICIPANTS

A population-based, retrospective observational cohort study of MVC risk after first-episode syncope was performed in British Columbia, Canada. Patients visiting any of 6 urban EDs for syncope and collapse were age- and sex-matched to 4 control patients visiting the same ED in the same month for a condition other than syncope. Patients' ED medical records were linked to administrative health records, driving history, and detailed crash reports. Crash-free survival among individuals with syncope was then compared with that among matched control patients. Data analyses were performed from May 2020 to March 2022.

EXPOSURES

Initial ED visit for syncope.

MAIN OUTCOMES AND MEASURES

Involvement as a driver in an MVC in the year following the index ED visit. Crashes were identified using insurance claim data and police crash reports.

RESULTS

The study cohort included 43 589 patients (9223 patients with syncope and 34 366 controls; median [IQR] age, 54 [35-72] years; 22 360 [51.3%] women; 5033 [11.5%] rural residents). At baseline, crude MVC incidence rates among both the syncope and control groups were higher than among the general population (12.2, 13.2, and 8.2 crashes per 100 driver-years, respectively). In the year following index ED visit, 846 first crashes occurred in the syncope group and 3457 first crashes occurred in the control group, indicating no significant difference in subsequent MVC risk (9.2% vs 10.1%; adjusted hazard ratio [aHR], 0.93; 95% CI, 0.87-1.01; P = .07). Subsequent crash risk among patients with syncope was not significantly increased in the first 30 days after index ED visit (aHR, 1.07; 95% CI, 0.84-1.36; P = .56) or among subgroups at higher risk of adverse events after syncope (eg, age >65 years; cardiogenic syncope; Canadian Syncope Risk Score ≥1).

CONCLUSIONS AND RELEVANCE

The findings of this population-based retrospective cohort study suggest that patients visiting the ED with first-episode syncope exhibit a subsequent crash risk no different than the average ED patient. More stringent driving restrictions after syncope may not be warranted.

Differences in Suicide-Related Twitter Content According to User Influence

Background: The content of suicide-specific social media posts may impact suicide rates, and putatively harmful and/or protective content may vary by the author's influence. Aims: This study sought to characterize how suicide-related Twitter content differs according to user influence. Method: Suicide-related tweets from July 1, 2015, to June 1, 2016, geolocated to Toronto, Canada, were collected and randomly selected for coding (n = 2,250) across low, medium, or high user influence levels (based on the number of followers, tweets, retweets, and posting frequency). Logistic regression was used to identify differences by user influence for various content variables. Results: Low- and medium-influence users typically tweeted about personal experiences with suicide and associations with mental health and shared morbid humor/flippant tweets. High-influence users tended to tweet about suicide clusters, suicide in youth, older adults, indigenous people, suicide attempts, and specific methods. Tweets across influence levels predominantly focused on suicide deaths, and few described suicidal ideation or included helpful content. Limitations: Social media data were from a single location and epoch. Conclusion: This study demonstrated more problematic content vis-à-vis safe suicide messaging in tweets by high-influence users and a paucity of protective content across all users. These results highlight the need for further research and potential intervention.

Long-term mortality of academy award winning actors and actresses

Background

Social status gradients are powerful health determinants for individuals living in poverty. We tested whether winning an Academy award (Oscar) for acting was associated with long-term survival.

Methods

We conducted a longitudinal cohort analysis of all actors and actresses nominated for an Academy award in a leading or a supporting role. For each, a control was identified based on age, sex, and co-staring in the same film.

Results

Overall, 2,111 individuals were analyzed with 1,122 total deaths occurring during a median follow-up of 68.8 years. Comparisons of winners to controls yielded a 4.8% relative difference average life-span (95% confidence interval: 1.6 to 7.9, p = 0.004), a 5.1 year absolute increase in life expectancy (95% confidence interval: 3.0 to 7.2, p < 0.001), and a 41% improvement in mortality hazard (95% confidence interval: 19 to 68, p < 0.001). The increased survival tended to be greater in recent years, for individuals winning at a younger age, and among those with multiple wins. The increased survival replicated in secondary analyses comparing winners to nominees and was not observed in analyses comparing nominees to controls.

Conclusions

Academy award winning actors and actresses show a positive association between success and survival, suggesting the importance of behavioral, psychological, or other modifiable health factors unrelated to poverty.

Serious Adverse Events of Oral and Topical Carbonic Anhydrase Inhibitors

IMPORTANCE

Some ophthalmologists may be reluctant to prescribe oral carbonic anhydrase inhibitors, given the potential for life-threatening systemic adverse reactions.

OBJECTIVE

To conduct a population-based analysis of the safety of oral or topical carbonic anhydrase inhibitors in clinical care.

DESIGN, SETTING, AND PARTICIPANTS

This matched longitudinal cohort study took place in Ontario, Canada. Consecutive patients older than 65 years who were prescribed an oral or topical carbonic anhydrase inhibitor in Ontario, Canada, between January 1, 1995, and January 1, 2020, were identified. Patients were matched 1-to-1 based on age, sex, and diabetes status. Time zero was defined as the date of the first identified prescription for the medication, and the primary analysis focused on the first 120 days of follow-up.

MAIN OUTCOMES AND MEASURES

The primary end point was a severe complicated adverse event of either Stevens-Johnson syndrome, toxic epidermal necrolysis, or aplastic anemia.

RESULTS

Overall, 128 942 matched patients initiated an oral or topical carbonic anhydrase inhibitor during the 25-year study period. The mean (SD) age was 75 (6.6) years, 71 958 (55.8%) were women, and 25 058 (19.4%) had a diagnosis of diabetes. The oral and topical carbonic anhydrase inhibitor groups had similar baseline demographics. Patients prescribed an oral carbonic anhydrase inhibitor had an absolute risk of a severe complicated adverse event of 2.90 per 1000 patients, whereas patients prescribed a topical carbonic anhydrase inhibitor had an absolute risk of 2.08 per 1000 patients. This difference was equivalent to a risk ratio of 1.40, with a number needed to harm of 1 in 1220 patients (95% CI, 1.12-1.74; P = .003). This generally low risk was replicated in multivariable regression controlling for confounding factors. Additional risk factors for a severe complicated adverse event included patients with more comorbidities and those with more frequent clinic contacts.

CONCLUSIONS AND RELEVANCE

The risk of a serious adverse reaction following prescription of an oral or topical carbonic anhydrase inhibitor was low and similar between agents. Given the low risk of severe adverse reactions, this population-level analysis supports reconsidering the reluctance toward prescribing an oral carbonic anhydrase inhibitor.

Abstract WP72: Telemedicine Access, Care, And Outcomes For TIA And Minor Stroke

Introduction: Telemedicine is increasingly used, but its effectiveness for stroke prevention after minor stroke or TIA is not known. We compared the care and outcomes in patients discharged from an emergency department (ED) with TIA or stroke before and after the implementation of telemedicine stroke prevention clinics in Ontario, Canada. We hypothesized that care and outcomes will remain similar.

Methods: We used linked administrative data to identify community-dwelling adults discharged from the ED with TIA or ischemic stroke from April 2015 to March 2020 (pre-telemedicine) and April 2020 to March 2021 (post-telemedicine). We compared access to outpatient physician visits within 90 days, neuroimaging or vascular imaging within 14 days, and echocardiogram within 90 days using standardized differences (SD <0.1 indicates negligeable difference). We used Cox proportional hazard models to compare the adjusted Hazard Ratio (aHR) and 95% confidence intervals of death within 90 days pre- and post-telemedicine and cause-specific hazard models for stroke readmission with adjustment for comorbidities.

Results: We identified 47,869 patients (n=40,099 pre- and n=7,770 post-telemedicine), median age 73 years [62, 82], 49% female. Baseline characteristics were similar. There was a rapid uptake in telemedicine use (Figure 1). Physician visits (92.9% vs 93.1%, SD 0.01), neuroimaging (81.3% vs 80.5%, SD 0.02), and echocardiogram use (52.5% vs 53.9% SD 0.03) were similar, but use of vascular imaging increased (74.8% vs 84.3% SD 0.24). Readmission for stroke was stable (3.9% vs 4.0%, aHR 1.00 [0.89, 1.13]), but 90-day death was higher post- compared to pre-telemedicine (2.8% vs 3.6%, aHR 1.19 [1.05, 1.36]).

Conclusion: Telemedicine is a promising tool to support routine stroke prevention care. The higher mortality must be interpreted in the context of the COVID19 pandemic. Ongoing monitoring of stroke outcomes is needed.

Patterns of pre-operative opioid use affect the risk for complications after total joint replacement

Preoperative opioid use has been shown to increase the risk for complications following total joint arthroplasty (TJA); however, these studies have not always accounted for differences in co-morbidities and socio-demographics between patients that use opioids and those that do not. They have also not accounted for the variation in degree of pre-operative use. The objective of this study was to determine if preoperative opioid use is associated with risk for surgical complications after TJA, and if this association varied by degree of use. Population-based retrospective cohort study. Older adult patients undergoing primary TJA of the hip, knee and shoulder for osteoarthritis between 2002 and 2015 in Ontario, Canada were identified. Using accepted definitions, patients were stratified into three groups according to their preoperative opioid use: no use, intermittent use and chronic use. The primary outcome was the occurrence of a composite surgical complication (surgical site infection, dislocation, revision arthroplasty) or death within a year of surgery. Intermittent and chronic users were matched separately to non-users in a 1:1 ratio, matching on TJA type plus a propensity score incorporating patient and provider factors. Overall, 108,067 patients were included in the study; 10% (N = 10,441) used opioids on a chronic basis before surgery and 35% (N = 37,668) used them intermittently. After matching, chronic pre-operative opioid use was associated with an increased risk for complications after TJA (HR 1.44, p = 0.001) relative to non-users. Overall, less than half of patients undergoing TJA used opioids in the year preceding surgery; the majority used them only intermittently. While chronic pre-operative opioid use is associated with an increased risk for complications after TJA, intermitted pre-operative use is not.

Comparative effectiveness and safety of sodium-glucose cotransporter-2 inhibitors versus metformin in patients with type 2 diabetes: An observational study using data from routine care

AIM

To assess the effectiveness and safety of sodium-glucose cotransporter-2 (SGLT2) inhibitors in treatment-naïve patients compared with metformin.

PARTICIPANTS AND METHODS

We conducted a cohort study of US adults with type 2 diabetes mellitus who had not filled a prescription for a diabetes medication in the preceding year. We then identified patients who newly filled a prescription for an SGLT2 inhibitor or metformin between 2013 and 2018. The primary outcome was a composite of heart failure, myocardial infarction or stroke. Safety outcomes included hypoglycaemia, diabetic ketoacidosis, genital infection, lactic acidosis and acute kidney injury. After 1:1 propensity-score (PS) matching, proportional hazards models were fit to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

We identified 9964 individuals newly prescribed an SGLT2 inhibitor who were PS-matched to 9964 individuals newly prescribed metformin. The mean age was 54 years, 52% were women, and the duration of follow-up was 213 days for metformin and 147 days for SGLT2 inhibitors. The primary outcome occurred in 54 patients (7.2 events per 1000 person-years) who received an SGLT2 inhibitor, compared to 84 patients (8.5 per 1000 person-years) who received metformin (HR  0.82, 95% CI 0.58, 1.15). Similar results (HR 0.87, 95% CI 0.69, 1.09) were observed in an analysis with longer follow-up (ie, approximately 600 days). The rates of genital infection (HR 2.28, 95% CI 1.87, 2.78) and diabetic ketoacidosis (HR 1.58, 95% CI 0.92, 2.70) were higher for patients prescribed an SGLT2 inhibitor compared to metformin, while the rates of acute kidney injury (HR 0.94, 95% CI 0.60, 1.47) or hypoglycaemia (HR 0.83, 95% CI 0.48, 1.42) were not.

CONCLUSIONS

We observed a numerically lower rate of short-/mid-term cardiovascular events for patients newly prescribed an SGLT2 inhibitor compared to metformin, albeit with wide CIs that include the possibility of a null effect. SGLT2 inhibitors were associated with a higher rate of genital infection and diabetic ketoacidosis. Larger cohort studies and long-term clinical trials powered to assess cardiovascular events are necessary to understand the risk-benefit profile of SGLT2 inhibitors as first-line therapy for adults with type 2 diabetes mellitus.

Bans on Cellphone Use While Driving and Traffic Fatalities in the United States

BACKGROUND

As of January 2020, 18 of 50 US states comprehensively banned almost all handheld cellphone use while driving, 3 states and the District of Columbia banned calling and texting, 27 states banned texting on a handheld cellphone, and 2 states had no general cellphone ban for all drivers. However, it remains unknown whether these bans were associated with fewer traffic deaths and whether comprehensive handheld bans are more effective than isolated calling or texting bans. We evaluated whether cellphone bans were associated with fewer driver, non-driver, and total fatalities nationally.

METHODS

We conducted a longitudinal panel analysis of traffic fatality rates by state, year, and quarter. Population-based rate ratios and 95% CIs were estimated comparing state-quarters with and without cellphone bans.

RESULTS

From 1999 through 2016, 616,289 persons including 344,003 drivers died in passenger vehicle crashes in the United States. Relative to no ban, comprehensive handheld bans were associated with lower driver fatality rates (adjusted rate ratio aRR = 0.93, 95% CI = 0.90, 0.97) but not for non-driver fatalities (aRR = 1.01, 95% CI = 0.95, 1.07) or total fatalities (aRR = 0.98, 95% CI = 0.94, 1.01). We found no differences in driver fatalities for calling-only bans (aRR = 1.00, 95% CI = 0.97, 1.03), texting-only bans (aRR = 1.02, 95% CI = 0.99, 1.05), texting plus phone-manipulating bans (aRR = 0.99, 95% CI = 0.93, 1.04), or calling and texting bans (aRR = 0.98, 95% CI = 0.88, 1.09).

CONCLUSIONS

Comprehensive handheld bans were associated with fewer driver fatalities.

Association of Surgical Experience With Risk of Complication in Total Hip Arthroplasty Among Patients With Severe Obesity

IMPORTANCE

Severe obesity is a risk factor for major early complications after total hip arthroplasty (THA).

OBJECTIVE

To determine the association between surgeon experience with THA in patients with severe obesity and risk of complications.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study was performed in Ontario, Canada, from April 1, 2007, to March 31, 2017, with data analysis performed from March 2020 to January 2021. A cohort of patients who received a primary THA for osteoarthritis and who also had severe obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] ≥40) at the time of surgery was defined. These patients were identified using the Canadian Institute for Health Information Discharge Abstract Database and physician claims from the Ontario Health Insurance Plan. Generalized estimating equations were used to determine the association between overall THA and severe obesity-specific THA surgeon volume and the occurrence of complications after controlling for potential confounders. The study hypothesized that surgeon experience specific to patients with severe obesity could further reduce the risk of complications.

EXPOSURES

Primary THA.

MAIN OUTCOMES AND MEASURES

Complications were considered as a composite outcome (revision, infection requiring surgery, or dislocation requiring reduction), within 1 year of surgery. This was defined before the study, as was the study hypothesis.

RESULTS

A total of 4781 eligible patients was identified. The median age was 63 (interquartile range [IQR], 56-69) years, and 3050 patients (63.8%) were women. Overall, 186 patients (3.9%) experienced a surgical complication within 1 year of surgery. The median overall THA surgeon volume was 70 (IQR, 46-106) cases/y, whereas the median obesity-specific surgeon volume was 5 (IQR, 2-9) cases/y. After controlling for patient and hospital factors, greater obesity-specific THA surgeon volume (adjusted odds ratio per additional 10 cases, 0.65 [95% CI, 0.47-0.89]; P = .007), but not greater overall THA surgeon volume (adjusted odds ratio per 10 additional cases, 0.97 [95% CI, 0.93-1.02]; P = .24), was associated with a reduced risk of complication.

CONCLUSIONS AND RELEVANCE

Increased surgeon experience performing THA in patients with severe obesity was associated with fewer major surgical complications. These findings suggest that surgeon experience is required to mitigate the unique anatomical challenges posed by surgery in patients with severe obesity. Referral pathways for patients with severe obesity to surgeons with high obesity-specific THA volume should be considered.

Testing for a Sweet Spot in Randomized Trials

Introduction

Randomized trials recruit diverse patients, including some individuals who may be unresponsive to the treatment. Here we follow up on prior conceptual advances and introduce a specific method that does not rely on stratification analysis and that tests whether patients in the intermediate range of disease severity experience more relative benefit than patients at the extremes of disease severity (sweet spot).

Methods

We contrast linear models to sigmoidal models when describing associations between disease severity and accumulating treatment benefit. The Gompertz curve is highlighted as a specific sigmoidal curve along with the Akaike information criterion (AIC) as a measure of goodness of fit. This approach is then applied to a matched analysis of a published landmark randomized trial evaluating whether implantable defibrillators reduce overall mortality in cardiac patients (n = 2,521).

Results

The linear model suggested a significant survival advantage across the spectrum of increasing disease severity (β = 0.0847, P < 0.001, AIC = 2,491). Similarly, the sigmoidal model suggested a significant survival advantage across the spectrum of disease severity (α = 93, β = 4.939, γ = 0.00316, P < 0.001 for all, AIC = 1,660). The discrepancy between the 2 models indicated worse goodness of fit with a linear model compared to a sigmoidal model (AIC: 2,491 v. 1,660, P < 0.001), thereby suggesting a sweet spot in the midrange of disease severity. Model cross-validation using computational statistics also confirmed the superior goodness of fit of the sigmoidal curve with a concentration of survival benefits for patients in the midrange of disease severity.

Conclusion

Systematic methods are available beyond simple stratification for identifying a sweet spot according to disease severity. The approach can assess whether some patients experience more relative benefit than other patients in a randomized trial.

Understanding Patient Personality in Medical Care: Five-Factor Model

Personality is the description of an individual's tendencies when acting or reacting to others. Clinicians spontaneously form impressions of a patient's apparent personality yet such unstructured impressions might lead to snap judgments or unhelpful labels. Here we review the evidence-based five-factor model from psychology science for understanding personalities (OCEAN taxonomy). Openness to experience is defined as the general appreciation for a variety of experiences. Conscientiousness is the tendency to exhibit self-discipline. Extraversion is the degree of engagement with the external world. Agreeableness is the general concern for social harmony. Neuroticism is the tendency to experience negative emotions. An awareness of these five dimensions might help clinicians avoid faulty judgments from casual contact. Expert assessment of personality requires extensive training and data, thereby suggesting that clinicians should take a humble view of their own unsophisticated impressions of a patient's personality.

Prenatal electrocardiogram testing and postpartum depression: A population-based cohort study

Background

Cardiovascular symptoms in pregnancy may be a clue to psychological distress. We examined whether electrocardiogram testing in pregnant women is associated with an increased risk of subsequent postpartum depression.

Methods

We conducted a population-based cohort study of pregnant women who delivered in Ontario, Canada comparing women who received a prenatal ECG to women who did not.

Results

In total, 3,238,218 women gave birth during the 25-year study period of whom 157,352 (5%) received an electrocardiogram during prenatal care. Receiving an electrocardiogram test was associated with a one-third relative increase in the odds of postpartum depression (odds ratio 1.34; 95% confidence interval 1.29–1.39, p < 0.001).

Conclusion

The association between prenatal electrocardiogram testing and postpartum depression suggests a possible link of organic disease with mental illness, and emphasizes that cardiovascular symptoms may be a clinical clue to the presence of an underlying mood disorder.

Association of socioeconomic status with medical assistance in dying: a case-control analysis

OBJECTIVES

Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints.

DESIGN

Population-based case-control study of adults who died.

SETTING

Ontario, Canada, between 1 June 2016 and 1 June 2019.

PATIENTS

Patients receiving palliative care under universal insurance with no user fees.

EXPOSURE

Patient's socioeconomic status identified using standardised quintiles.

MAIN OUTCOME MEASURE

Whether the patient received medical assistance in dying.

RESULTS

A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design.

CONCLUSIONS

Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.

Sodium-glucose co-transporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors and the risk of heart failure: A nationwide cohort study of older adults with diabetes mellitus

AIMS

To analyse the rate of heart failure hospitalization for older adults prescribed a sodium-glucose co-transporter-2 (SGLT2) inhibitor.

MATERIALS AND METHODS

The study cohort included adults aged 66 years and older diagnosed with diabetes mellitus in Ontario, Canada, between July 2015 and March 2019, who received either an SGLT2 inhibitor or a dipeptidyl peptidase-4 (DPP-4) inhibitor. The primary outcome was a composite of heart failure hospitalization and all-cause mortality. Secondary outcomes included diabetic ketoacidosis and hypoglycaemia.

RESULTS

A total of 29 916 adults prescribed an SGLT2 inhibitor were compared with 29 916 adults prescribed a DPP-4 inhibitor. The mean age was 72 years, 60% were men, the baseline glycated haemoglobin concentration was 8.2% and the baseline creatinine was 89 μmol/L. The incidence rate of the primary outcome was 19/1000 person-years for adults prescribed an SGLT2 inhibitor compared to 38/1000 person-years in those prescribed a DPP-4 inhibitor. This resulted in a hazard ratio (HR) of 0.49 (95% confidence interval [CI] 0.45, 0.54) and a rate difference (RD) of 19 fewer events per 1000 person-years (RD -19 [95% CI -22, -17]). Patients prescribed an SGLT2 inhibitor also had a lower rate of hypoglycaemia (HR 0.61 [95% CI 0.46, 0.81); RD -1.6 [95% CI -2.4, -0.8]), but a higher rate of diabetic ketoacidosis (HR 1.84 [95% CI 1.26, 2.70]; RD 1.0 [95% CI 0.4, 1.6]).

CONCLUSIONS

Older adults prescribed an SGLT2 inhibitor had a lower rate of heart failure hospitalization or death, and a lower rate of hypoglycaemia, but an increased rate of diabetic ketoacidosis compared to older adults prescribed a DPP-4 inhibitor.

Hand hygiene sprayed into eye

Hand hygiene is a practical, affordable, acceptable, reliable, and effective strategy to mitigate nosocomial infection risks in hospitals. Here we provide an image of clinical medicine that documents a potential error related to hand sanitizer dispenser malfunction. An awareness of this adverse event can lead to immediate modifiable changes in healthcare settings to reduce the risks of nosocomial infections.