Context.Healthcare contributes approximately 5% of global greenhouse gas emissions, yet the carbon footprint of clinical laboratory activity has been studied almost entirely from the perspective of laboratory operations (instrumentation, consumables, freight, and facility energy use). A critical but unmeasured component is patient travel for phlebotomy, which is required for nearly all outpatient laboratory testing. No prior studies have quantified the carbon impact of this travel at a population level. Objective To estimate the annual greenhouse gas emissions associated with patient travel for community phlebotomy in a large metropolitan health system. Design This population-based analysis used travel distance to phlebotomy clinic to estimate greenhouse gas emissions for 198,883 phlebotomy visits. Results The mean round-trip distance for a phlebotomy visit was 24.98 km, corresponding to a maximal estimate of 6.235 kg CO2e emitted per patient trip. Scaled to the Calgary urban population, patient travel for phlebotomy produced up to 7,440 tonnes CO2e per year, or 5.45 kg CO2e per capita annually. These travel-related emissions substantially exceed published estimates of laboratory operational emissions (reagents, consumables, analyzer energy use, staff travel, and waste). Conclusions Patient travel is a dominant and previously unrecognized contributor to the carbon footprint of outpatient laboratory testing. These findings indicate that laboratory decarbonization strategies must consider not only laboratory operations but also the emissions associated with patient mobility.

Nocardiae are ubiquitous environmental soil pathogens that primarily cause invasive infections by inhalation or direct skin inoculation in immunocompromised patients. This multi-year population-based study compared epidemiological and clinical features of all cases diagnosed in our region. Patients were enrolled in our large integrated healthcare region with culture-proven nocardiosis between 2010 and 2021. Clinical chart reviews were conducted to determine the clinical manifestations, risk factors, treatment and mortality including survival analysis. Ninety-four adults had a mean age of 61 ± 17 years. More cases occurred in males (57

INTRODUCTION:Assessment of clinical performance has traditionally been a numbers game based upon Likert scale ratings. But, thanks to advances in the science of natural language processing (NLP), it is now possible to incorporate rich narrative data into assessment. In this study, our objective was to evaluate the validity of lexicon-based sentiment analysis of medical students' clinical performance from in-training evaluation reports (ITERs) with a view to fully integrating this as a machine-based process into future assessment decisions. METHODS:This was a mixed methods, retrospective derivation/validation cohort study structured around Kane's validity framework. We used content analysis to create a lexicon of performance descriptors, performed a G-study, and calculated the positive likelihood ratio (LR+) for descriptors (scoring). To evaluate generalisation, we calculated the intraclass correlation coefficient and compared descriptors in derivation and validation cohorts. We then performed [human] lexicon-based sentiment analysis and compared the number of descriptors of different types between cohorts of highest performing students (HPS) and lowest performing students (LPS). RESULTS:In our G-study, 86.6% of variance was attributed to the student. The ICC between raters for identification of descriptors was 0.93. The mean number of neutral descriptors was similar between HPS and LPS cohorts, but the number of negative descriptors was higher for LPS (11.4 (10.8) versus 1.4 (1.6) for HPS, p < 0.01, d = 1.37) and the number of positive descriptors was higher for HPS (19 (14) versus 1.4 (1.5) for LPS, p < 0.001, d = 1.86). DISCUSSION:In the midst of their busy clinical work schedule, preceptors find time to tell a story about a medical student and these narrative data enrich the assessment portfolio. Based upon our validity argument, we feel there is a role for lexicon-based sentiment analysis of clinical performance descriptors in ITERs and that these results can contribute meaningfully to assessment decisions.

The role of specific Nocardia species in human infections continues to expand as advanced methods enable species/species complex identification. We conducted a multiyear population-based (2010-2022) characterization of invasive Nocardia spp. Isolates were analyzed using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene sequencing. A total of 94 cases and 117 unique 16S rRNA gene sequences were evaluated from pulmonary (53%), skin and soft tissues (SSTIs) (29%), central nervous system (CNS) (7%), bloodstream (6%), and other sites of infection. Infections were mainly caused by three species complexes: N. farcinica (n = 20, 21.3%), N. cyriacigeorgica (n = 16, 17%), and N. nova (n = 15, 16%). Phylogenetic analysis correlated with the clinical site of infection. Most N. cyriciageorgica (92%) complex isolates caused SSTIs or pulmonary infections, and most N. farcinica complex (67%) and N. nova complex (69%) isolates caused pulmonary and CNS infections, respectively. Several other unique Nocardia spp. rarely caused invasive infections (≤5 cases): (i) pulmonary (N. abscessus complex, N. amamiensis, N. asteroides, N. otitidiscaviarum complex, N. sputorum, N. transvalensis complex, Nocardiopsis spp., Pseudonocardia spp.); (ii) SSTIs (N. otitidiscaviarum complex); and (iii) CNS (N. flavorosea and N. paucivorans complex). Nocardia species were highly susceptible to amikacin, trimethoprim-sulfamethoxazole, moxifloxacin, and linezolid. Imipenem resistance occurred in the N. farcinica complex and N. nova complex, while ceftriaxone resistance only occurred in the former. Antibiotic profiles varied for rare Nocardia spp. Species-level Nocardia identification using MALDI-TOF MS and 16S rRNA gene sequencing improves understanding of these organisms' unique roles in causing invasive disease.IMPORTANCENocardia spp. are a rare cause of invasive infections, particularly in immunocompromised patients. The role of specific Nocardia species in human infections continues to expand as advanced methods enable species/species complex identification. We conducted a multiyear population-based (2010-2022) characterization of invasive Nocardia spp. Isolates were analyzed using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene sequencing. A total of 94 cases included pulmonary infections (53%), skin and soft tissue infections (29%), central nervous system infections (7%), bloodstream infections (6%), and septic arthritis and intra-abdominal infections (5%). One hundred seventeen unique 16S rRNA gene sequences from clinical isolates were analyzed. Phylogenetic analysis correlated with the clinical site of infection. Nocardia species were highly susceptible to amikacin, trimethoprim-sulfamethoxazole, moxifloxacin, and linezolid. Imipenem resistance only occurred in N. farcinica complex and N. nova complex strains, and ceftriaxone resistance only occurred in the former. Species-level Nocardia identification using MALDI-TOF MS and 16S sequencing improves understanding of these organisms' unique roles in invasive disease.

IntroductionBacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and Trichomonas vaginalis (TV) commonly cause infectious vaginitis in women, especially those of reproductive age. Characterization of the epidemiology of infectious vaginitis in a contemporary population-based cohort was done to determine the longitudinal age-standardized and sex-based testing, positivity, and incidence rates and ratios of infectious vaginitis in a large Canadian healthcare region.MethodsWe conducted a population-based cohort study from March 2015 through March 2018 using the Alberta Precision Laboratories (APL) microbiology database. Calgary 2016 census data was used to calculate incidence rates (IR) and ratios (IRR) for cases and testing rates.ResultsFor testing and positivity, female sex, and younger age groups were associated with increased risk of BV, VVC, and TV infections. The annual mean population in 2016 was 1,411,660 individuals (50.3% female). A total of 40,259 cases/293,853 tests (13.7%) of BV, 32,894 cases/293,853 tests (11.2%) of VVC, and 2018 cases/342,986 tests (0.7%) of TV were identified. The overall IR for BV ranged from 0 to 609 cases per 10,000 person-years. The overall IR for VVC ranged from 0 to 445 per 10,000 person-years. The overall IR for TV ranged from 0 to 27 per 10,000 person-years. The highest age-specific testing positivity rate and IR rate for BV and VVC occurred in women aged 20–34 years and 20–34 years. For TV, female IR for BV, VVC, and TV remained stable during the study.DiscussionThese unique regional data provide insight for the development of appropriate age-specific clinical testing criteria according to relative risk of acquisition of each vaginitis agent.

At our centre, we introduced a continuous quality improvement (CQI) initiative during academic year 2018-19 targeting for repair multiple choice question (MCQ) items with discrimination index (D) < 0.1. The purpose of this study was to assess the impact of this initiative on reliability/internal consistency of our assessments. Our participants were medical students during academic years 2015-16 to 2020-21 and our data were summative MCQ assessments during this time. Since the goal was to systematically review and improve summative assessments in our undergraduate program on an ongoing basis, we used interrupted time series analysis to assess the impact on reliability. Between 2015-16 and 2017-18 there was a significant negative trend in the mean alpha coefficient for MCQ exams (regression coefficient -0.027 [-0.008, -0.047], p = 0.024). In the academic year following the introduction of our initiative (2018-19) there was a significant increase in the mean alpha coefficient (regression coefficient 0.113 [0.063, 0.163], p = 0.010) which was then followed by a significant positive post-intervention trend (regression coefficient 0.056 [0.037, 0.075], p = 0.006). In conclusion, our CQI intervention resulted in an immediate and progressive improvement reliability of our MCQ assessments.

Background The systematic review of clinical research papers is a labor-intensive and time-consuming process that often involves the screening of thousands of titles and abstracts. The accuracy and efficiency of this process are critical for the quality of the review and subsequent health care decisions. Traditional methods rely heavily on human reviewers, often requiring a significant investment of time and resources. Objective This study aims to assess the performance of the OpenAI generative pretrained transformer (GPT) and GPT-4 application programming interfaces (APIs) in accurately and efficiently identifying relevant titles and abstracts from real-world clinical review data sets and comparing their performance against ground truth labeling by 2 independent human reviewers. Methods We introduce a novel workflow using the Chat GPT and GPT-4 APIs for screening titles and abstracts in clinical reviews. A Python script was created to make calls to the API with the screening criteria in natural language and a corpus of title and abstract data sets filtered by a minimum of 2 human reviewers. We compared the performance of our model against human-reviewed papers across 6 review papers, screening over 24,000 titles and abstracts. Results Our results show an accuracy of 0.91, a macro F1-score of 0.60, a sensitivity of excluded papers of 0.91, and a sensitivity of included papers of 0.76. The interrater variability between 2 independent human screeners was κ=0.46, and the prevalence and bias-adjusted κ between our proposed methods and the consensus-based human decisions was κ=0.96. On a randomly selected subset of papers, the GPT models demonstrated the ability to provide reasoning for their decisions and corrected their initial decisions upon being asked to explain their reasoning for incorrect classifications. Conclusions Large language models have the potential to streamline the clinical review process, save valuable time and effort for researchers, and contribute to the overall quality of clinical reviews. By prioritizing the workflow and acting as an aid rather than a replacement for researchers and reviewers, models such as GPT-4 can enhance efficiency and lead to more accurate and reliable conclusions in medical research.

IMPORTANCE:Large language models (LLMs) like OpenAI's ChatGPT are powerful generative systems that rapidly synthesize natural language responses. Research on LLMs has revealed their potential and pitfalls, especially in clinical settings. However, the evolving landscape of LLM research in medicine has left several gaps regarding their evaluation, application, and evidence base. OBJECTIVE:This scoping review aims to (1) summarize current research evidence on the accuracy and efficacy of LLMs in medical applications, (2) discuss the ethical, legal, logistical, and socioeconomic implications of LLM use in clinical settings, (3) explore barriers and facilitators to LLM implementation in healthcare, (4) propose a standardized evaluation framework for assessing LLMs' clinical utility, and (5) identify evidence gaps and propose future research directions for LLMs in clinical applications. EVIDENCE REVIEW:We screened 4,036 records from MEDLINE, EMBASE, CINAHL, medRxiv, bioRxiv, and arXiv from January 2023 (inception of the search) to June 26, 2023 for English-language papers and analyzed findings from 55 worldwide studies. Quality of evidence was reported based on the Oxford Centre for Evidence-based Medicine recommendations. FINDINGS:Our results demonstrate that LLMs show promise in compiling patient notes, assisting patients in navigating the healthcare system, and to some extent, supporting clinical decision-making when combined with human oversight. However, their utilization is limited by biases in training data that may harm patients, the generation of inaccurate but convincing information, and ethical, legal, socioeconomic, and privacy concerns. We also identified a lack of standardized methods for evaluating LLMs' effectiveness and feasibility. CONCLUSIONS AND RELEVANCE:This review thus highlights potential future directions and questions to address these limitations and to further explore LLMs' potential in enhancing healthcare delivery.

BACKGROUND:Non-alcoholic fatty liver disease (NAFLD) describes a spectrum of chronic fattening of liver that can lead to fibrosis and cirrhosis. Diabetes has been identified as a major comorbidity that contributes to NAFLD progression. Health systems around the world make use of administrative data to conduct population-based prevalence studies. To that end, we sought to assess the accuracy of diabetes International Classification of Diseases (ICD) coding in administrative databases among a cohort of confirmed NAFLD patients in Calgary, Alberta, Canada.METHODS:The Calgary NAFLD Pathway Database was linked to the following databases: Physician Claims, Discharge Abstract Database, National Ambulatory Care Reporting System, Pharmaceutical Information Network database, Laboratory, and Electronic Medical Records. Hemoglobin A1c and diabetes medication details were used to classify diabetes groups into absent, prediabetes, meeting glycemic targets, and not meeting glycemic targets. The performance of ICD codes among these groups was compared to this standard. Within each group, the total numbers of true positives, false positives, false negatives, and true negatives were calculated. Descriptive statistics and bivariate analysis were conducted on identified covariates, including demographics and types of interacted physicians.RESULTS:A total of 12,012 NAFLD patients were registered through the Calgary NAFLD Pathway Database and 100% were successfully linked to the administrative databases. Overall, diabetes coding showed a sensitivity of 0.81 and a positive predictive value of 0.87. False negative rates in the absent and not meeting glycemic control groups were 4.5% and 6.4%, respectively, whereas the meeting glycemic control group had a 42.2% coding error. Visits to primary and outpatient services were associated with most encounters.CONCLUSION:Diabetes ICD coding in administrative databases can accurately detect true diabetic cases. However, patients with diabetes who meets glycemic control targets are less likely to be coded in administrative databases. A detailed understanding of the clinical context will require additional data linkage from primary care settings.

Background Large language models (LLMs), which produce natural language responses to inputted prompts, can transform medical education by providing answers to difficult clinical questions, feedback on student responses, and aid in generating educational resources. Though their performance on simple fact-based medical questions is being explored, their ability to integrate complex pieces of information, such as medical history, physical exam findings, and investigation results, to arrive at well-reasoned clinical decisions has not been elucidated. In this study, we investigate the ability of the LLM ChatGPT to answer scenario-based questions designed to approximate real clinical decisions required of medical learners to ascertain its utility as an adjunct for learning this type of decision-making. Summary Of Work To assess the performance of ChatGPT on clinical scenario-based questions, a subset of 43 physician-generated, multiple-choice hematology questions routinely used by undergraduate medical students for self-study purposes were selected. The January 30th, 2023, version of ChatGPT was primed with a standardized phrase, and each question was inputted twice, with the answers and justifications being recorded. The model's performance was assessed by the number of correct responses and a qualitative review of the provided justifications. Summary Of Results The model's performance was robust, with 75.4% of clinical decision-making questions being answered correctly and featured substantial intra-question agreement (Cohen’s kappa of 0.62, and absolute agreement of 85%). The model struggled with questions requiring the interpretation of multiple numerical laboratory values and seemed to over-order investigations. Among correct answers, the justification provided by ChatGPT was significantly longer than that provided by the physician authors (p<0.0001) and largely used relevant scenario-specific details in its clinical reasoning process. Discussion And Conclusion The use of ChatGPT may enable students to effectively practice clinical decision-making by providing relevant, context-rich feedback in real-time without the need for resource and time-intensive processes involving senior medical practitioners. Further study is required to assess if using LLMs as support for learning clinical decision-making improves outcomes among undergraduate medical learners. Take Home Messages ChatGPT demonstrates robust performance on scenario-based clinical questions requiring integration of a variety of medical information and can provide scenario-relevant clinical justification, enabling their use as adjuncts for developing clinical decision-making skills among undergraduate medical learners.

Abstract Background: The effectiveness of cervical cancer screening programs is well recognized; however, inappropriate screening practices result in either a woman being tested too often or not tested at the recommended intervals. The objectives of the study were to identify the characteristics of family physicians associated with over- and underscreening for eligible women aged 25-69 in Calgary, Alberta. Methods: We performed a population-based retrospective observational study linking the Calgary Laboratory Services database from 2014-2016 to the College of Physicians and Surgeons of Alberta database of family physicians practicing in Calgary. We matched physicians’ characteristics with their cervical screening practices. Panel size data was not directly available, so we used their laboratory test orders in 2016 as a proxy measure to estimate physician practice size. For the underscreening analysis, we excluded those physicians whose estimated practice size was lower than the number of screening tests ordered. Logistic regression models were applied to analyze the overscreening and underscreening patterns. Results: Among 807 physicians included in the overscreening analysis, 43% of physicians had over-screened their screen-eligible patients. Physician characteristics significantly associated with overscreening included more years of practice and having more female patients in the practice. Among the 317 physicians included in the underscreening analysis, 42% had under-screened during the three-year study period. Female physicians were less likely to underscreen their eligible female patients. Physicians practicing in the Northeast quadrant of the city also had higher odds of underscreening. Conclusions: Screening patterns of family physicians indicate both overuse and underuse, which indicates inconsistency in adherence to screening guideline recommendations. Addressing disparities and identifying strategies to improve guideline adherence among different physician demographic groups is critical for the success of screening programs.

BACKGROUND:Minimizing hemolysis during phlebotomy ensures accurate chemistry results and reduces test cancellations and specimen recollections. We developed videos demonstrating best practices to reduce hemolysis and tested whether distribution to clinical nurse educators (CNEs) for provision to nursing staff affected the degree of specimen hemolysis in hospital inpatient units and outpatient clinics. METHODS:Videos of common blood collections demonstrating best practices to reduce hemolysis were filmed and then distributed via email link to all hospital-based CNEs in Calgary, Alberta, Canada. (https://vimeo.com/user18866730/review/159869683/a0cec9827f). Roche Cobas hemolysis index (H-index) results from specimens collected +/- 12 months from the date of video distribution were extracted from Roche Cobas IT middleware (cITM) and linked to collection location. An interrupted time series (ITS) analysis with collection location as the unit of anlaysis was used to quantify impact of video distribution on the trajectory of weekly mean log-H-index weighted by inverse variance. RESULTS:In +/- 3 months of data flanking video distribution (n = 137 241 collections), where overall impact was strongest, H-index trajectory (change in units per week) decreased immediately following video distribution (-5.7% / week, p < 0.01). This was accompanied by a 22% drop in overall H-index from the week before to the week after video distribution (y-intercept change, or gap). There was also a small but significant overall decrease in the proportion of hemolyzed specimens (-0.3%, p < 0.01). These changes were not observed at all collection locations, and in fact increases occured at some locations. CONCLUSIONS:We developed a novel and convenient educational aid that, when distributed, was associated with beneficial changes in specimen hemolysis at hospital inpatient units and outpatient clinics. Including it in ongoing nursing education will fill a knowledge gap that may help to reduce specimen hemolysis.

Abstract Background Sexually transmitted and blood borne infection (STBBIs) remain a growing concern in North America with rates increasing dramatically since 2000. Although self-testing has been demonstrated to be valid and acceptable, no fully remote STBBI testing programs are available in Canada. To evaluate feasibility and acceptability of at-home STBBI testing, we implemented a fully remote, web-based platform of risk-responsive, non-invasive STBBI diagnostics in a large Canadian health zone. Methods A web-based risk assessment and intake form was developed using RedCap software through a community-facing website (athomestitesting.ca) in partnership with a local sexual health centre. Demographic, sexual practices, and medical history were collected from interested participants through the platform. Diagnostic kits inclusive of testing for gonorrhea/chlamydia (urine and self-swabs of vagina/pharyngeal/rectal) and syphilis/HIV/Hepatitis C (dried blood spot) were mailed to participants based on their survey responses, along with instructions and supplies for collection and return. Outcomes to be assessed include feasibility and acceptability of the web-based platform, testing and positivity rates for STIs, and time to testing and treatment (for positive cases). Results In the first month to date with limited launch, eleven participants completed the intake survey and were mailed testing kits through the platform. Of the completed testing, no new STIs were identified. The median age of the cohort was 38 years old (IQR 32, 41) and six identified as men, four as women and one non-binary. Regarding gender identity, seven identified as gay/queer/bisexual and three as straight/heterosexual. In a follow-up survey, all participants to date stated reported satisfaction or extremely satisfaction with the online testing. Conclusion The platform model demonstrates feasibility in the early pilot phase with acceptability based on participant responses. Next steps include expanded launch of the platform and assessment of testing rates and feasibility of a web-based model for STI diagnostics. Disclosures Caley B. Shukalek, MD, MSc, MPH, Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|Gilead Sciences: Honoraria|Merck Canada: Grant/Research Support|Merck Canada: Honoraria|PurposeMed Inc: Advisor/Consultant|PurposeMed Inc: Ownership Interest Ranjani Somayaji, M.D., CF Foundation: Grant/Research Support|CIHR: Grant/Research Support|Oncovir: Data and Safety Monitoring Board Fees|Vertex Pharmaceuticals: Advisor/Consultant|Vertex Pharmaceuticals: Grant/Research Support|Vertex Pharmaceuticals: Honoraria

PurposeThe transition towards Competency-Based Medical Education at the Cumming School of Medicine was accelerated by the reduced clinical time caused by the COVID-19 pandemic. The purpose of this study was to define a standard protocol for setting Entrustable Professional Activity (EPA) achievement thresholds and examine their feasibility within the clinical clerkship.MethodsAchievement thresholds for each of the 12 AFMC EPAs for graduating Canadian medical students were set by using sequential rounds of revision by three consecutive groups of stakeholders and evaluation experts. Structured communication was guided by a modified Delphi technique. The feasibility/consequence models of these EPAs were then assessed by tracking their completion by the graduating class of 2021.ResultsThe threshold-setting process resulted in set EPA achievement levels ranging from 1 to 8 across the 12 AFMC EPAs. Estimates were stable after the first round for 9 of 12 EPAs. 96.27% of EPAs were successfully completed by clerkship students despite the shortened clinical period. Feasibility was predicted by the slowing rate of EPA accumulation overtime during the clerkship.ConclusionThe process described led to consensus on EPA achievement thresholds. Successful completion of the assigned thresholds was feasible within the shortened clerkship.Practice pointsThe modified Delphi technique is a feasible methodology that can be used to propose achievement thresholds for all 12 EPAs for graduating undergraduate medical students.Recommended achievement thresholds for each EPA ranged from 1 (e.g. 'Participate in health quality improvement initiatives') to 8 (e.g. 'Obtain a history and perform a physical examination adapted to the patient's clinical situation').

Background Bloodstream infections (BSIs) among people with human immunodeficiency virus (PWH) remain a poorly studied source of morbidity and mortality. We characterize the epidemiology, microbiology, and clinical outcomes including reinfection, hospitalization, and mortality rates of both community-acquired and hospital-acquired BSI in PWH. Methods We identified all BSI, between January 1, 2000 and December 31, 2017 in PWH in care at Southern Alberta Clinic, by linking data from laboratory and clinical databases. Crude incidence rates per 1000 person-years for BSI and death were calculated. Cox proportional hazards models estimated crude and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) to conduct a risk factor analysis of BSI in PWH. Logistic regression models with generalized estimating equations estimated crude and adjusted odds ratios (aORs) to identify characteristics associated with 1-year mortality after BSI. Results Among 2895 PWH, 396 BSI episodes occurred in 228 (8%) PWH. There were 278 (72%) Gram-positive and 109 (28%) Gram-negative BSI. People with human immunodeficiency virus with lower CD4 nadirs, higher Charlson comorbidity indices, and hepatitis C virus were at highest risk for BSI. Long-term all-cause mortality was greater in those experiencing BSI (HR, 5.25; 95% CI, 4.21-6.55). CD4 count <200 cells/mm(3) measured closest to the time of BSI was associated with 1-year mortality after BSI (aOR, 3.88; 95% CI, 1.78-8.46). Repeat episodes (42%) and polymicrobial BSI (19%) were common. Conclusions Bloodstream infections continue to occur at an elevated rate among PWH with high reoccurrence rates and associated morbidity and mortality. To risk stratify and develop targeted interventions, we identified PWH at greatest risk for BSI. People with human immunodeficiency virus with low immunity at the time of BSI are at highest risk of poor outcomes. Despite a reduction with time, bloodstream infections continue to occur at an elevated rate among PWH with high reoccurrence, morbidity, and mortality. PWH with low immunity at the time of BSI are at highest risk of poor outcomes.

OBJECTIVES:It remains unclear whether vitamin D status is related to cancer risk. We examined this relationship using laboratory, administrative and survey data.DESIGN:Retrospective cohort study.SETTING:All care settings within Calgary, Alberta, Canada and surrounding rural communities.PARTICIPANTS:Patients tested for serum 25-hydroxyvitamin D from 2009 to 2013 without a past cancer diagnosis but with an ECG and body mass index ±3 months from testing were included. Age, sex, mean hours of daylight during month of testing were linked to census dissemination area-level indicators of socioeconomic status measured in 2011.PRIMARY AND SECONDARY OUTCOME MEASURES:Hospital discharge diagnoses for any cancer, major cancer (colorectal, breast, lung, prostate, skin) and other cancers >3 months from testing from 2009 to 2016. Cox proportional hazard models were used to examine associations with incident cancer after adjusting for potential confounders. Interactions were tested using multiplicative terms.RESULTS:Among 72 171 patients, there were 3439 cancer diagnoses over a median of 5.9 years. After adjustment, increasing quartile of serum 25-OH vitamin D was significantly associated with an increased risk of any cancer and major cancer, however this was completely driven by an increased risk of skin cancer (Q4 vs Q1: HR=2.56, 95% CI 1.70 to 3.86, p for linear trend <0.01). This association was strengthened among individuals residing in communities with higher proportions of non-citizens, recent immigrants, visible (non-white) minorities and those not speaking an official Canadian language (English or French) at home.CONCLUSIONS:Higher vitamin D status was associated with a greater risk of skin cancer in a large community population under investigation for cardiovascular disease. This association was likely due to sun exposure and may be modified by community variation in vitamin D supplementation.

This study analyzed patient-described barriers and facilitators related to diabetes management, focusing on how these differ by glycemia and across individual characteristics. A cross-sectional telephone survey was conducted with adult patients with diabetes in Alberta, Canada, asking two open-ended questions to describe the most helpful and difficult components of their diabetes management. Responses were analyzed using directed content analysis using the Theoretical Domains Framework as a template. The most frequently cited facilitator was care context and information, and the most frequently cited barriers were cognitive challenges and structural barriers, with patient-perceived barriers and facilitators varying by individual-level factors.

Aim: To study the predictors of mortality from nine major pathogens causing approximately 70% of cases over a 7-year period. Materials & methods: A population-based surveillance cohort of all adult and pediatric patients in the Calgary Zone with an initial episode of bloodstream infections (BSI). Results: The 1-year mortality was 29.2% among 9524 patients (5164 males [54%]). Incidence rates for BSI increased annually to 119.7/100,000 persons by 2016. Distinct survival curves were found for each specific pathogen. Age, comorbidity burden and infecting organism were significantly associated with increased hazard of death. No relationship occurred between the time to positivity for blood cultures and overall mortality. Conclusion: BSI has a high mortality, but overall survival depends on underlying host health and the type of pathogen acquired.

There is a growing mismatch with regard to demand, supply, and affordability in healthcare systems in developed countries. Innovation is required to address this, but roadmaps for innovation in laboratory medicine are largely lacking. Advances in process and instrument digitization are driving a revolution in medical laboratory practice but changes are not strategically focused on improved patient care. Laboratory services therefore largely remain transactional so that customer access and experience are suboptimal, especially for vulnerable populations. Laboratory medicine must be integrated back into clinical care pathways, thereby transforming services to be more responsive to end-user needs. Healthcare trends show that patients, physicians, and allied healthcare professionals will increasingly dictate what and how services are provided. Laboratories will be pressed to restructure to address these healthcare trends. Since the primary goal of ambulatory practice is to prevent expensive hospital admissions for patients with complex chronic diseases, specific services (e.g. ambulatory clinics, surgeries, deliveries, procedures) that could be safely provided in the community are moving out of acute care hospitals. This review addresses the existing barriers to innovation faced by medical/scientific and managerial services as well as outlines a systematic approach used by other industries to bring about transformative change. Enabling disruptive innovation that improves the clinical and economic effectiveness of laboratory practice is critical to sustain clinically relevant services as an essential cornerstone of patient care within the healthcare systems of developed countries.