Importance:Nearly 16% of pregnant individuals have multiple chronic conditions (MCC), and the risk of severe maternal morbidity and mortality increases in a dose-response manner with the number of preexisting conditions. However, little is known about newborn outcomes in this population. Objective:To examine the association of the number of preexisting maternal chronic conditions, as well as the presence of MCC complexity, cardiometabolic MCC, and MCC severity, with the risk of severe neonatal morbidity or mortality (SNM-M). Design, Setting, and Participants:This population-based cohort study was conducted in Ontario, Canada, among all live births from 2012 to 2021. Data were analyzed from September 2024 to November 2025. Exposure:Maternal MCC measured in the 2 years before conception. Main Outcomes and Measures:Modified Poisson regression was performed to generate adjusted relative risks (aRRs) for SNM-M by the number of chronic conditions, MCC complexity (≥3 chronic conditions in ≥3 body systems), co-occurring cardiometabolic conditions, and MCC severity marked by a prenatal hospitalization for a chronic illness. Multivariable models were adjusted for age, parity, immigration status, income quintile, and rurality. Results:The cohort comprised 1 018 968 newborns, including 20 934 to mothers with 3 or more chronic conditions (mean [SD] maternal age, 30.0 [6.3] years), 73 768 to mothers with 2 chronic conditions (mean [SD] maternal age, 30.3 [5.8] years), 276 765 to mothers with 1 chronic condition (mean [SD] maternal age, 30.7 [5.4] years), and 647 501 to mothers with 0 chronic conditions (mean [SD] maternal age, 31.0 [5.1] years). Compared with newborns of mothers with 0 chronic conditions, the aRR for SNM-M increased in a dose-response fashion in newborns of mothers with 1 (1.26; 95% CI, 1.24-1.28), 2 (1.58; 95% CI, 1.54-1.62), and 3 or more (2.01; 95% CI, 1.94-2.09) chronic conditions. The aRRs were also increased with complex MCC (1.97; 95% CI, 1.88-2.06), cardiometabolic MCC (2.67; 95% CI, 2.24-3.19), and severe MCC (3.11; 95% CI, 2.55-3.79). Conclusions and relevance:In this study, risks of SNM-M increased with an increasing number of preexisting maternal chronic conditions. These findings suggest that women and adolescents with MCC may benefit from preconception counseling to optimize chronic disease management, monitoring in pregnancy for earlier identification of complications, and enhanced newborn supports.

Older adults commonly present to the emergency department after a fall. Head imaging is frequently ordered for these patients. Occasionally, head imaging finds evidence of chronic stroke when there is no clinical history of stroke. The clinical implications of undiagnosed prior stroke are unknown. Our objective was to explore the association between undiagnosed prior stroke and short-term mortality after a fall. This was a secondary analysis of a prospective multicenter cohort study enrolling patients ≥ 65 years presenting to the emergency department after a fall. Patients were included if they had a head CT scan during their visit, and their vital status was known at 42 days. We used a logistic regression model to examine the relationship between previously undiagnosed prior stroke and death within 42 days. The model adjusted for age, sex, use of antiplatelet/anticoagulant medications, and Clinical Frailty Scale score. Among 4308 enrolled patients, 2698 had a head CT scan at the index visit, of whom 2307 were known to be alive or dead at 42 days. The median age was 84 (IQR 77–89) years, and 62

OBJECTIVE:To assess the risks of perinatal emergency department (ED) use, hospitalisation and severe maternal morbidity or mortality (SMM-M) associated with preconception MCC, according to the number of chronic conditions, complex MCC and co-occurring cardiometabolic conditions. DESIGN:Population-based cohort study. SETTING:Ontario, Canada. POPULATION:Females aged 13-54 years, with a recognised pregnancy, 2012-2021. METHODS:Modified Poisson regression was used to generate adjusted relative risks (aRRs) according to the number of chronic conditions, complex MCC (≥ 3 chronic conditions affecting ≥ 3 body systems) and co-occurring cardiometabolic conditions. aRRs were adjusted for age, parity, income quintile, rurality and immigrant/refugee status. MAIN OUTCOME MEASURES:ED use, hospitalisation and SMM-M from the estimated date of conception to 42 days postpartum. RESULTS:In total, 894 042 individuals had no pre-pregnancy chronic condition; 357 398 had 1; 94 427 had 2; and 27 326 had ≥ 3 chronic conditions. Relative to those without a chronic condition, the aRR for ED use increased with 1 (1.26, 95% CI 1.25-1.27), 2 (1.55, 1.54-1.56) and ≥ 3 (1.86, 1.85-1.88) conditions. For hospitalisations, the corresponding aRRs were 1.45 (1.43-1.47), 2.06 (2.02-2.10) and 3.18 (3.09-3.27). For SMM-M, the corresponding aRRs were 1.38 (1.35-1.42), 1.82 (1.75-1.90) and 2.75 (2.59-2.92). SMM-M risk was even more pronounced with complex MCC (aRR 2.92, 95% CI 2.72-3.14), and ≥ 3 cardiometabolic conditions (aRR 5.45, 95% CI 4.29-6.91). CONCLUSIONS:MCC, especially complex or cardiometabolic MCC, is associated with elevated risk of maternal morbidity. Multidisciplinary patient-centred care may mitigate these risks.

Study objective To examine the effectiveness of an education intervention on emergency physician accuracy in identifying pregnancy-related findings from first-trimester point-of-care ultrasound. Case features associated with the odds of a correct response were also determined. Methods This was a multicenter prospective cross-sectional study in a convenience sample of emergency physicians in the United States and Canada. The unsupervised web-based education intervention included first-trimester point-of-care ultrasound cases acquired through the transabdominal (n=200 cases) or transvaginal (n=200 cases) approach. Physicians deliberately practiced identifying pregnancy-related imaging findings until they achieved a mastery standard. Results In 204 participants, there were learning gains in accuracy (15.2%; 95% confidence interval [CI] 14.6 to 15.8), sensitivity (15.1%; 95% CI 14.3 to 15.9), and specificity (14.3%; 95% CI 13.7 to 15.0). Of these, 132 (64.7%) achieved the mastery standard in a median of 60 cases (interquartile range 58 to 83). Case features associated with an increased odds of a correct intrauterine pregnancy “present” diagnosis were transvaginal versus transabdominal-acquired images (odds ratio [OR]=1.5; 95% CI 1.3 to 1.8) and fetal heartbeat (OR=4.3; 95% CI 3.4 to 5.5). A decreased odds was associated with an eccentrically located intrauterine pregnancy (OR=0.2; 95% CI 0.1 to 0.2), subchorionic hemorrhage (OR=0.5; 95% CI 0.4 to 0.6), adnexal mass (OR=0.7; 95% CI 0.6 to 0.9), and endometrial collection (OR=0.1; 95% CI 0.09 to 0.2). Conclusions This study’s intervention was effective in teaching first-trimester point-of-care ultrasound image interpretation and identified the specific variables that posed the greatest diagnostic challenges. The methods and results from this work can serve to expand learning opportunities for this critical skill in emergency medicine.

BACKGROUND:The Canadian CT Head Rule (CCTHR) is validated in adults who hit their head and experience loss of consciousness, amnesia, or disorientation. There is less evidence to guide brain imaging when the fall history is unclear. METHODS:This is a secondary analysis of a prospective study on adults aged ≥ 65 who presented to 11 emergency departments across Canada and the United States after a ground level fall. We reported the prevalence of adjudicated clinically important intracranial bleeding within 42 days of the emergency department visit among (a) patients who hit their head and met the application criteria for the CCTHR (experienced loss of consciousness, amnesia, or disorientation), (b) patients who hit their head and did not meet the CCTHR application criteria, (c) patients with an unclear history of the CCTHR application criteria, (d) patients with an unclear head injury history, and (e) patients with no head injury. RESULTS:4303 participants were analyzed. The prevalence of clinically important intracranial bleeding in the subgroups was (a) patients who fulfilled the CCTHR application criteria, 7.7% (54/703, 95% confidence interval [CI]: 5.9%-9.9%), (b) patients who hit their head but did not meet CCTHR application criteria, 2.5% (30/1204, 95% CI: 1.8%-3.5%), (c) patients with head injury but an unclear history of the CCTHR application criteria, 7.6% (19/251, 95% CI: 4.9%-12.0%), (d) patients with an unclear history of head injury, 4.6% (23/502, 95% CI: 3.2%-6.8%), and (e) patients who did not hit their head, 0.8% (13/1643, 95% CI: 0.5%-1.3%). CONCLUSIONS:Older adults presenting after a fall with an unclear history of head injury, or an unclear history of head injury-associated loss of consciousness, amnesia, or disorientation have an elevated risk for clinically important intracranial bleeding that merits emergency brain imaging.

OBJECTIVES:We aimed to identify the most diagnostically challenging features in first-trimester point-of-care ultrasound (FT-POCUS) images. We also sought to determine the physician image review behaviors associated with increased diagnostic accuracy. METHODS:We conducted a multicenter prospective cross-sectional study in a convenience sample of emergency physicians in the United States and Canada. The web-based intervention included 400 FT-POCUS cases acquired via the transabdominal or transvaginal approach. Participants reviewed FT-POCUS cases to identify pregnancy-related imaging findings. We captured clickstream-level data with each case encounter, including the correctness of a participant's response and physician image review behaviors. RESULTS:We enrolled 317 participants, who collectively generated 16,295 case interpretations. The most diagnostically challenging imaging findings included eccentrically located gestational sac and endometrial collection/heterogeneous uterine material (p < 0.001 for all comparisons). Participants who reported "definite" certainty, as opposed to "probable," demonstrated a significantly higher odds of getting the diagnosis of intrauterine pregnancy (IUP) present or absent correct (OR = 4.48; 95% CI 4.00, 5.01) and a lower odds of time spent reviewing cases (OR = 0.46; 95% CI 0.40, 0.51). Those who reviewed a higher proportion of available views per case were more likely to accurately identify a fetal heartbeat (OR = 1.51; 95% 1.34, 1.69), multiple IUPs (OR = 1.33; 95% CI 1.10, 1.61), and adnexal structures (OR = 1.11; 95% CI 1.04, 1.17), but less likely to correctly identify an IUP (OR = 0.93; 95% CI 0.88, 0.99) and endometrial fluid collection/heterogeneous uterine material (OR = 0.96; 95% CI 0.92, 0.99). CONCLUSIONS:Emergency physicians interpreting FT-POCUS images encountered specific diagnostic challenges that may increase risks to patient safety. We found that higher diagnostic confidence correlated with greater diagnostic accuracy and efficiency. Reviewing a larger proportion of available images improved diagnostic accuracy for some findings, but not for others.

[See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.231493][1] In this issue of CMAJ , Alston and colleagues describe the urgent and complex problem of homelessness among older adults,[1][2] a growing population nationwide.[2][3] The latest report from the Canadian Institute for Health

OBJECTIVE:Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS:This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS:There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS:There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.