Abstract Introduction: Guidelines for thromboprophylaxis after hip fracture surgery suggest parenteral anticoagulants, based on low-certainty evidence. Emerging data suggest that direct oral anticoagulants (DOACs) or acetylsalicylic acid (ASA) might be safe and effective alternatives. We conducted a survey to inform the design of a randomized controlled trial (RCT) in this setting. Methods: We recruited a convenience sample of physicians who could prescribe thromboprophylaxis after hip fracture surgery. The survey was disseminated in Aug–Dec 2023. Participants answered 14 questions on demographics, current practices for thromboprophylaxis after hip fracture surgery, the need for an RCT on this topic, and acceptable interventions for a future RCT. Results: 204 participants from 28 countries completed the survey. Of these, 172 (84%, 95% CI 79%;89%) indicated the need for an RCT. Respondents reported using the following regimens: low-molecular-weight heparin (LMWH) alone (59%, 95% CI: 52%;66%), LMWH followed by rivaroxaban/apixaban (27%, 95% CI: 21%;33%), and rivaroxaban/apixaban without LMWH (25%, 95% CI: 19%;31%). LMWH or LMWH followed by rivaroxaban/apixaban were ranked highest among interventions to be tested in an RCT. Only 64 participants (31%, 95% CI: 25%;37%) were comfortable with ASA alone, and 82 (40%, 95% CI: 33%;47%) with ASA after a short course of anticoagulation. Conclusions: Among respondents, LMWH and DOACs were the most prescribed agents for thromboprophylaxis after hip fracture surgery. For an RCT, respondents were most comfortable with comparing LMWH with LMWH followed by rivaroxaban/apixaban.
Introduction: D-dimer (DD) testing is widely used to exclude proximal deep vein thrombosis (DVT) in patients not receiving anticoagulation who have low or intermediate pretest probability, in whom it demonstrates high sensitivity and negative predictive value (NPV). However, its diagnostic accuracy in patients already receiving direct oral anticoagulants (DOACs) remains uncertain. This study aimed to evaluate the diagnostic accuracy of DD testing for excluding proximal DVT in patients receiving DOACs. Methods: A retrospective cohort study was conducted including adults receiving DOACs who presented to the emergency department with suspected DVT between January 2010 and September 2022. All included patients underwent both DD testing and compression ultrasonography. The diagnostic performance of the conventional DD threshold of 500 µg/L was assessed, focusing on sensitivity and NPV. Exploratory analyses of the age-adjusted DD threshold and sensitivity analyses restricted to definite proximal DVT were also performed. Results: Seventy-one patients were included (mean age, 74.6 years; 52% women). Nine patients were diagnosed with new thrombosis, of which 7 were proximal. Using the conventional threshold, DD sensitivity was 71% (95% CI, 29–96) and NPV was 89% (95% CI, 67–99). The age-adjusted threshold had a lower sensitivity of 57% (95% CI, 18–90), with a similar NPV (91%; 95% CI, 76–98). In sensitivity analyses restricted to definite proximal DVT ( n = 5), the sensitivity of the conventional DD threshold was 80% (95% CI, 28–99), with an NPV of 94% (95% CI, 73–100). Discussion: In contrast to patients not receiving anticoagulation, DD testing showed low sensitivity and NPV in patients receiving DOACs who had suspected DVT. These findings suggest that DD testing cannot safely exclude proximal DVT in this population. Compression ultrasonography should remain the preferred diagnostic strategy. Larger prospective studies are warranted to explore the role of DD testing in patients receiving anticoagulation and to develop a new diagnostic algorithm.
Introduction: The role of invasive strategies such as catheter-directed thrombectomy in high-risk submassive pulmonary embolism remains uncertain, as pivotal trials have relied on surrogate end points. This study evaluated outcomes among patients with high-risk submassive pulmonary embolism treated with anticoagulation alone at a single institution and compared them with published interventional cohorts. Methods: A retrospective cohort study was conducted of adults admitted to the Centre Hospitalier Universitaire de Sherbrooke between 2018 and 2023 with confirmed pulmonary embolism, hemodynamic stability, and CT evidence of right ventricular strain (RV/LV > 0.9). Patients who initially received thrombolysis or catheter-based intervention were excluded. The primary outcome was major adverse events within 30 days, defined as a composite of death, hemodynamic or respiratory decompensation, or major bleeding. Results: Eighty-eight patients were included (mean age, 68.3 ± 11.7 years; 47.7% female; 69.3% with a simplified Pulmonary Embolism Severity Index score ≥ 1). Within 30 days, 2 patients (2.3%; 95% CI, 0.3%–8.0%) experienced major adverse events, consisting of hemodynamic decompensation ( n = 2), including 1 in-hospital death. No major bleeding or recurrent pulmonary embolism occurred. Prognostic markers, including the right ventricular-to-left ventricular ratio, troponin level, and simplified Pulmonary Embolism Severity Index score, were not significantly associated with outcomes. Results were comparable to those of interventional trials despite the study cohort being older and at higher risk. Discussion: Anticoagulation alone resulted in few adverse events and outcomes comparable to those reported in invasive thromboaspiration trials. Routine mechanical intervention may not be required for most patients with high-risk submassive pulmonary embolism. Future work should refine risk stratification, particularly for patients with cardiopulmonary comorbidities, who may represent a subgroup at greater risk.
Abstract Thrombus in transit, a free-floating clot that may be found within cardiac chambers, represents a spectrum of venous thromboembolism and can originate from deep vein thrombosis or be linked to atrial fibrillation, cardiomyopathy, hypercoagulability, or iatrogenic factors. This case report delves into one potential manifestation of thrombus in transit, encompassing both arterial and venous thromboembolism, and highlights its management.
Hospital readmissions are an important indicator of health care quality, but the rate and causes of hospital revisits among short-stay internal medicine (IM) patients has been understudied. In this study, we aimed to identify predictors of hospital revisits in two cohorts of patients: those seen by IM and discharged home without admission (DHWA) and those with IM admissions of less than 24 hours. We conducted a two-phase retrospective study of patients DHWA and with short IM admissions between 2017 and 2022. The outcomes of interest were the rate and predictors of a hospital revisit within 14 days of discharge. The associations of revisits with demographics, comorbidity, and other health care-related variables were analyzed and rational subgrouping was used to identify drivers of revisits among a purposely sampled subgroup of patients with a 14-day revisit. A total of 2,874 hospitalizations were analyzed and 135 chart reviews conducted. The hospital revisit rate was lower in the short-admission group (18.2% versus 26.4%, P <.001). Applying rational subgrouping, we grouped patients by symptom progression, along with frailty and residence status. Patients living with dementia re-presented with stable symptoms, and patients with inadequate follow-up often had frailty indicators and/or heart failure and respiratory diseases. This study demonstrates how a classical approach to risk factor analysis failed to lead to actionable root causes of hospital revisits in medically complex IM patients. Applying rational subgrouping helped understand deeper drivers of revisits, findings which can empower internists to make more informed discharge decisions and support the design of future quality improvement strategies.
By using multiple fasting blood glucose determinations before and after transplantation, we answer the following question: what are the prevalence, risk factors, and impact on prognosis of new onset diabetes in renal transplant patients? This was a single-centre, retrospective, observational cohort study of 289 adult patients without diabetes who underwent renal transplantation. New onset diabetes developed in 87 patients (30%) 1.83 months after discharge. Patients with new onset diabetes were treated with long-acting insulin (n = 63, 68%), metformin (n = 77, 80%), and glibenclamide (n = 62, 65%); more than 70% received statins and aspirin. Multivariate analysis (Cox regression analysis) showed that age (HR 1.034, 95% CI 1.013–1.055), body mass index (HR = 1.091, 95% CI 1.035–1.150), and transplant era (HR = 0.148, 95% CI 0.078–0.284) were the independent predictors of new onset diabetes. No difference was found in the incidence of cardiovascular events (log-rank = 0.207) and death (log-rank = 0.319). In patients free of diabetes before transplantation, de novo diabetes mellitus is common and related to discrete alterations in metabolic profile before transplantation. A careful evaluation of the metabolic profile of patients on the waiting list would identify patients prone to develop new onset diabetes. New onset diabetes was not related to the incidence of events or death.
Iron deficiency (ID) and iron deficiency anemia (IDA) are common complications in people with cystic fibrosis (pwCF). While cystic fibrosis transmembrane receptor (CFTR) modulator therapy, specifically elexacaftor-tezacaftor-ivacaftor (ETI), has been shown to improve nutritional status and iron absorption, ID and IDA remain prevalent. This project evaluates the effectiveness of an iron therapy protocol (ITP) in reducing ID and IDA in pwCF. A retrospective chart review was conducted for 169 patients followed at an adult cystic fibrosis clinic serving the maritime provinces in Canada. Prevalence of ID and IDA was assessed in March 2022 and again in April 2024 following the implementation of an ITP in mid-March 2022. ID was defined by ferritin, serum iron, and transferrin saturation levels, while IDA was defined as ID in the presence of low hemoglobin. Treatment included oral and intravenous iron supplementation. An assessment for celiac disease was performed to ensure other causes of malabsorption were ruled out. In March 2022, ID was present in 27% and IDA in 6% of patients assessed. In April 2024, post-ITP implementation, the prevalence of ID decreased to 5% and IDA to 3%. ETI was introduced prior to protocol initiation, and no significant changes in ID or IDA were seen until the protocol was initiated. The clinic protocol significantly reduced the prevalence of ID and IDA in this quality improvement project. ETI may enhance nutritional status, among other benefits, but an organized approach to diagnosis and treatment of ID and IDA remains essential for managing iron-related complications in pwCF.
Inflammatory bowel disease (IBD) is a chronic immune-mediated disorder of the gastrointestinal tract that includes both Crohn's disease and ulcerative colitis. IBD not only causes gastrointestinal symptoms but is also associated with extraintestinal manifestations like inflammatory skin diseases. Recently, upadacitinib, a selective Janus kinase 1 inhibitor, was approved for the treatment of both IBD and atopic dermatitis.
Recent guidelines advocate a preference for low molecular weight heparin (LMWH) over unfractionated heparin (UFH) infusions to reduce the risk of major bleeding (MB) and heparin-induced thrombocytopenia, as well as to improve cost-effectiveness. 1–6 Canadian initiatives have been successful in eliminating UFH administration in unnecessary situations. 7 In this study, we analyzed UFH use at a tertiary centre in Canada to identify cases in which UFH could have been avoided, identify characteristics associated with bleeding, and examine the efficacy and safety of infusions where the initial bolus was administered or withheld. We identified adults who received between 48 and 96 hours of a UFH infusion in a tertiary care hospital between 2021 and 2023. Consecutive patients were reviewed for bleeding events, patient factors known to influence bleeding, and whether patients had a contraindication to LMWH or another anticoagulant. Patients were deemed to have “appropriate” use of UFH in preference to more desirable anticoagulants if they had recent or ongoing bleeding, required an imminent procedure or surgery, have severe renal dysfunction (eGFR <30 mL/min), or could foreseeably require thrombolysis. Of 127 patients, 16 (13%) were identified to have bleeding complications, including 14 episodes of MB. Bleeding episodes were significantly associated with any measured aPTT greater than 150 seconds (s) during treatment ( P = .0285). Omission of initial bolus dosing was not associated with reduced bleeding events or the incidence of any aPTT measurement >150s. Omission of initial bolus dosing was associated with subtherapeutic aPTT measurement at 6 hours (46%) and 12 hours (25%) post-UFH administration. We identified high rates (42%) of UFH selection where an alternative anticoagulant could have been used. We demonstrate a high rate of avoidable intravenous UFH selection at a tertiary Canadian centre. We observed high bleeding rates with UFH that were not mitigated by omitting the initial bolus. We suggest institutional policies to improve and restrict the use of UFH.
Despite significant investments in clinical research over the years, the pandemic illustrated Canada's limited ability to rapidly deploy research programs that could have generated immediately useful policy and health care information. This qualitative study aimed to identify the barriers, facilitators, and possible solutions to strengthen Canada's practice-changing clinical research enterprise (or ecosystem). Through purposive sampling, stakeholders representing various perspectives on Canada's clinical research ecosystem engaged in semi-structured interviews. We continued to gather stakeholders until reaching data sufficiency. The collected information was coded and analyzed using QDA Miner based on Lewin's force field framework. Thirteen participants identified four main driving forces—dynamic scientific community, involvement of patients and clinicians, innovation capacity, and research champions—and six barriers—legal, ethical, data access, administrative inefficiencies, protectionism and regionalism, and lack of incentives—that they believe explain the current state of clinical research across the country. In light of these barriers and facilitators, they proposed six strategies to fully realize Canada's clinical research potential: nationalization of the research infrastructure, prioritization of the portfolio, enhancement of representativeness, investment in health and scientific literacy, promotion of a cultural shift, and development of human resources for research. The proposed solutions require a degree of consensus and enhanced coordination among different levels of government. Given the numerous barriers and perceived constraints, meaningful changes to facilitate the implementation of practice-changing research within a learning health system in Canada will require both policy and cultural changes, which will also necessitate broad stakeholder support.
Evidence supports the use of point-of-care ultrasound (POCUS); however, POCUS is used in about 5% of internal medicine encounters. The theoretical domains framework (TDF) can be used to identify modifiable factors that influence health care practitioner behaviour. TDF was used to identify barriers and enablers to POCUS adoption by internists in a large academic centre via a quantitative survey and qualitative semi-structured interviews. Twenty-five (55%) internists completed the survey, and 10 were interviewed. Lack of time and training were identified as barriers by 100% (n = 25) and 80% (n = 20) of survey respondents, respectively. Lack of perceived benefit over current practices (4%, n = 1) and POCUS being outside an internist's scope of practice (8%, n = 2) were infrequently selected. In the interviews, nine domains were identified as relevant to changing POCUS behaviour. Four were barriers: (1) perceived inadequacy of training models and lack of repetition ( Skills, Reinforcements) that limit skill and comfort ( Beliefs about capabilities); (2) lack of time to perform and learn POCUS in a busy clinical environment ( Environmental context and resources); (3) diagnostic POCUS not being the standard of care or mandated by professional bodies ( Environmental context and resources) leading to a lack of relevance to practice ( Social/professional role and identity); and (4) perceived lack of added benefit to patient care or potential for patient harm ( Beliefs about consequences). Four key enablers identified were belief that procedural POCUS is a standard of care ( Environmental context and resources), perceived added benefit to patients ( Beliefs about consequences), colleagues’ enthusiasm about POCUS ( Optimism), and patient perceptions ( Social influences). Using the TDF, barriers and enablers to POCUS uptake in a large academic internal medicine division were identified. Interventions to promote uptake should focus on promoting enablers and addressing barriers.
The transition from junior to senior resident in internal medicine marks an increase in responsibilities, including leading teams, supervising trainees, and triaging patients on call. Unlike the structured transition programs available for new interns, no formal curriculum exists to support residents moving into senior roles. At the university-affiliated teaching hospital described in his report, internal medicine residents assume the senior resident role during their postgraduate year 2; however, the timing and structure of this transition may vary across Canadian residency programs. This report outlines the implementation of a structured educational intervention, Transition Rounds, to better prepare junior residents for the challenges of becoming senior residents. A longitudinal Transition Rounds curriculum was piloted at a university-affiliated teaching hospital in Toronto, Canada, from March to June 2024. The chief medical resident facilitated weekly 60-minute drop-in sessions for junior residents on the Clinical Teaching Unit. Topics were based on identified gaps in junior resident preparedness, including triaging patients, supervising junior trainees, and improving efficiency. Sessions incorporated real clinical scenarios, with senior residents providing peer mentorship. Attendance ranged from 4 to 10 residents per session. Case-based discussions and real-time feedback helped junior residents refine clinical decision-making and leadership skills. Informal participant feedback indicated reduced anxiety and increased confidence in managing senior-level responsibilities. The peer-led model proved feasible, leveraging existing resources without additional faculty burden. Transition Rounds provided a practical, low-resource approach to addressing an educational gap in residency training.
This article reviews hypertensive disorders of pregnancy (HDP), including chronic hypertension, gestational hypertension, and preeclampsia. They can be categorized according to chronological and clinical features. The presence of feto-maternal complications is typical in preeclampsia but can also occur in chronic hypertension. Treatment to limit the rise of blood pressure is essential to prevent cerebrovascular and cardiovascular adverse outcomes, but magnesium sulphate remain the preventive treatment for eclampsia. Despite delivery being the only curative treatment, blood pressure can rise in the first week postpartum. Ongoing monitoring of blood pressure is thus required postpartum to prevent adverse maternal issues. Awareness of long term maternal cardiometabolic and cerebrovascular complications is key and detailed counseling should be done for prevention. Research is ongoing to better understand associations with HDP and long term complications, and how to mitigate such risks.
Pregnant individuals commonly experience symptoms such as dyspnea, palpitations, and headache. While often benign and physiologic, these symptoms can also signal serious conditions that require urgent investigation and treatment. General Internists are increasingly called upon to assess such concerns in both outpatient and acute care settings. This review offers a symptom-based, practical approach to evaluating these presentations during pregnancy, with emphasis on balancing maternal and fetal safety. Dyspnea is frequently reported and usually reflects normal respiratory and cardiovascular adaptations. However, clinicians must be vigilant for life-threatening causes such as pulmonary embolism, peripartum cardiomyopathy, or preeclampsia-associated pulmonary edema. Palpitations are common due to increased heart rate and cardiac output, but may reflect arrhythmias that require prompt assessment and, in some cases, pharmacologic therapy. Headaches may be due to primary headache disorders like migraine, but new or worsening headache in pregnancy warrants careful evaluation for preeclampsia, stroke, or cerebral venous thrombosis. Throughout this review, we highlight key physiological adaptations in pregnancy, discuss relevant differential diagnoses, and provide practical guidance on investigations and treatment options that balance maternal and fetal safety. This article aims to equip internists with the tools to recognize when symptoms require further workup and to ensure pregnant individuals receive timely, evidence-informed care.
Physiologic changes occur during pregnancy to support the growth and development of the fetus. The placental hormones lead to symptomatic and biochemical adaptations in the antepartum and postpartum periods. There are anticipated changes to virtually every maternal system with most returning to the pre-pregnancy state in the postpartum period in due course. Pregnancy is often known as nature's stress test as the lack of predictable maternal adaption may indicate an underlying previously unrecognized medical condition. This article provides a systematic overview of the key physiologic changes in a healthy pregnancy and provides the foundation for physicians caring for pregnant individuals to distinguish normal physiology from pathology.
Liver disease in pregnancy is becoming increasingly common, and this includes both pre-existing liver disease and pregnancy-specific liver disease. Pre-existing liver disease, such as metabolic dysfunction–associated steatotic liver disease (MASLD), is associated with increased maternal and fetal risk. Preconception counselling and optimization of disease status pre-pregnancy is therefore essential. The anticipated physiologic and biochemical changes in pregnancy that affect liver function and enzymes impact what lab values are considered “normal” and what conditions are higher risk in pregnancy. A trimester-specific approach to elevated liver enzymes can be used to guide the work-up and differential diagnosis of a patient who presents with abnormal liver enzymes. Early identification and diagnosis of liver disease in pregnancy with delivery planning that includes a multidisciplinary team is crucial for improving maternal and fetal outcomes.
Substance use during pregnancy presents substantial challenges to both maternal and fetal health. In recent years, nearly 1 in 3 pregnancies in North America were impacted by substance use, regardless of level or type of substance involved. From 2017 to 2019, nearly 20% of all maternal deaths in Ontario and British Columbia were related to drug overdose. Opioids, alcohol, and stimulants are among the most misused substances. Managing substance use disorders in pregnancy requires a comprehensive understanding of pregnancy physiology, pharmacology of the substance involved, its effects on maternal and fetal health, as well as post-partum care considerations. In this article, we provide an evidence-based review of opioid, alcohol, and stimulant use disorders in pregnancy, examining risks, maternal and fetal implications and management strategies. We recognize that nicotine, tobacco, and marijuana use also pose significant risks in pregnancy, however they are beyond the scope of this review.
We examined the effect of the quality of primary care continuity on readmission to a general admitting clinical teaching unit (GACTU), any hospital readmission, and emergency department (ED) visits within 1 year of discharge from a GACTU in Ontario. Using a retrospective cohort design combining administrative and electronic medical record data, we categorized adult patients based on a time-varying covariate into four groups of quality of primary care continuity based on primary care use preceding each patient outcome in the follow-up period: (1) rostered and saw their rostered primary care physician (PCP), (2) rostered but did not see their rostered PCP, (3) non-rostered but saw the same PCP 2+ times, and (4) non-rostered and did not see the same PCP 2+ times. After adjusting for covariates, group 2 patients had greater risk of each outcome than group 1 patients (reference group): GACTU readmission (hazard ratio [HR]: 1.24; 95% CI 1.002 to 1.54; p = .048), hospital readmission (HR: 1.29; 95% CI 1.10 to 1.53; p = .002), and ED visit (HR: 1.22; 95% CI 1.06 to 1.40; p = .005). This exploratory study suggests higher quality of primary care continuity was associated with fewer re-encounters with acute care.
Tuberculosis (TB) is very much present in the underdeveloped parts of the world. Removal of international aid programs (food, shelter, employment, health care, and research) will lead to an increased incidence of debilitating disease and premature death. Multi-drug-resistant TB will surely increase in prevalence.
