To contrast changes in suicide-related media reporting quality during parallel initiatives to engage national media in Canada and Israel. We coded media articles in Canada’s and Israel’s highest circulating newspapers (major broadsheet and tabloid newspapers, respectively) for putatively harmful and putatively protective suicide-related content. A sample of 150 articles (30/year) from each country was randomly selected for three time points: 2012 (T1; prior to media engagement), 2016–2017 (T2; early media engagement), and 2018–2019 (T3; late media engagement). Chi-square tests and binary logistic regression investigated overall between-country differences in reporting quality over time. Following media engagement, adherence to guidelines improved over time in both countries for most variables. Over time, fewer Canadian and more Israeli articles covered celebrity suicide (OR = 4.97; 95

BACKGROUND:Alcohol sales increased at the onset of the coronavirus disease 2019 (Covid-19) pandemic, while alcohol-related emergency department (ED) visits decreased. It is unknown whether these patterns of alcohol use persisted or led to delayed effects on health. METHODS:We conducted a cross-sectional time series analysis of alcohol sales and alcohol-related adverse events in Ontario, Canada. We obtained 6 years of alcohol sales data from the largest regional alcohol distributor. We obtained monthly counts of alcohol-related ED visits, hospital admissions, and toxicity deaths. We defined our exposure as the start of the Covid-19 pandemic (March 1, 2020). We used linear mixed models to compare mean monthly alcohol sales and adverse events during prepandemic and pandemic periods. We used univariate Poisson regression models to generate incident rate ratios for alcohol-related adverse events comparing the prepandemic (February 28, 2016, to February 29, 2020) and pandemic (March 1, 2020, to February 26, 2022) periods. RESULTS:Alcohol sales increased, on average, by CA$43.5 million per month (95% confidence interval [CI], CA$26.1 million to CA$60.9 million; P<0.01) during the pandemic years compared with the prepandemic period. We observed a 7% increase (95% CI, 5 to 8) in the proportion of alcohol-related ED visits during the pandemic years, due to a modest decrease in alcohol-related ED visits and a larger decrease in all-cause ED visits. Overall, an average increase of 191 alcohol-related admissions occurred per month (95% CI, 101 to 282). We also observed an average increase of eight toxicity deaths per month (95% CI, 4 to 12). CONCLUSIONS:Alcohol sales and alcohol-related adverse events increased during the Covid-19 pandemic.

BACKGROUND:The quality of news reports about suicide can influence suicide rates. Although many researchers have aimed to assess the general safety of news reporting in terms of adherence to responsible media guidelines, none have focused on major US cable networks, a key source of public information in North America and beyond. AIMS:To characterise and compare suicide-related reporting by major US cable television news networks across the ideological spectrum. METHOD:We searched a news archive (Factiva) for suicide-related transcripts from 'the big three' US cable television news networks (CNN, Fox News and MSNBC) over an 11-year inclusion interval (2012-2022). We included and coded segments with a major focus on suicide (death, attempt and/or thoughts) for general content, putatively harmful and protective characteristics and overarching narratives. We used chi-square tests to compare these variables across networks. RESULTS:We identified 612 unique suicide-related segments (CNN, 398; Fox News, 119; MSNBC, 95). Across all networks, these segments tended to focus on suicide death (72-89%) and presented stories about specific individuals (61-87%). Multiple putatively harmful characteristics were evident in segments across networks, including mention of a suicide method (42-52%) - with hanging (15-30%) and firearm use (12-20%) the most commonly mentioned - and stigmatising language (39-43%). Only 15 segments (2%) presented a story of survival. CONCLUSIONS:Coverage of suicide stories by major US cable news networks was often inconsistent with responsible reporting guidelines. Further engagement with networks and journalists is thus warranted.

This Viewpoint discusses pitfalls of transitions of care from an intensive care unit to a general medical ward or step-down unit and introduces a checklist to support safe transfers.

Artificial intelligence models display human-like cognitive biases when generating medical recommendations. We tested whether an explicit forewarning, "Please keep in mind cognitive biases and other pitfalls of reasoning," might mitigate biases in OpenAI's generative pretrained transformer large language model. We used 10 clinically nuanced cases to test specific biases with and without a forewarning. Responses from the forewarning group were 50% longer and discussed cognitive biases more than 100 times more frequently compared with responses from the control group. Despite these differences, the forewarning decreased overall bias by only 6.9%, and no bias was extinguished completely. These findings highlight the need for clinician vigilance when interpreting generated responses that might appear seemingly thoughtful and deliberate.HighlightsArtificial intelligence models can be warned to avoid racial and gender bias.Forewarning artificial intelligence models to avoid cognitive biases does not adequately mitigate multiple pitfalls of reasoning.Critical reasoning remains an important clinical skill for practicing physicians.

Clinically meaningful population health outcomes for patients with spinal metastases are lacking. This study quantifies and validates days at home (DAH) after treatment of spinal metastases, and investigates factors associated with this patient-centered outcome. A population-based cohort study was conducted with the 2007–2019 Ontario Cancer Registry. Patients aged over 18 years undergoing surgery and/or radiation for a spinal metastasis were included. DAH was assessed at 3 months, 6 months (DAH-180), 1 year (DAH-365), and 2 years (DAH-730) after first treatment. Associations between DAH and primary cancer type, age, and frailty were assessed using multivariable quantile regression to estimate adjusted medians differences (aMD) in DAH. Predictive validity was determined with Spearman correlations between DAH-180 and longer-term DAH measures. We identified 36,233 treated patients. Median DAH for patients after 3 months, 6 months, 1 year, and 2 years from treatment were 79 days, 114 days, 120 days, and 121 days, respectively. Lower home time was associated with older age (aMD: -16 days per decade increase in age), and frailty (aMD: -36). Primary cancers associated with the least DAH included gastrointestinal cancer (aMD: -162 days), lung cancer (aMD: -165 days), and melanoma (aMD: -167 days). DAH-180 demonstrated predictive validity with longer term DAH-365 (p < 0.001), and DAH-730 (p < 0.001). These data help validate DAH as a reliable metric for patients treated for spinal metastases. Patients with older age, frailty, high health resource utilization, and primary melanoma, gastrointestinal or lung cancer were found to have the fewest DAH after treatment.

Randomized clinical trials provide reassurances that confounding factors are balanced at baseline whereas blinding is essential to assure the balance of extraneous factors thereafter. This article provides a three-part taxonomy of pitfalls that can arise because of inadequate blinding in clinical trials. We introduce a cautionary framework for readers interpreting a blinded randomized trial for evidence-based medicine. Each pitfall is illustrated with a relevant example of a potential bias resulting from knowledge of group assignment. Several pitfalls occur during the conduct of the study including inadequate blinding of the intervention group, control group, or responsible clinicians. Additional pitfalls relate to data analysis including unsubstantiated assertions of blinding and subverted tests for blinding. Further pitfalls arise due to surrounding oversight including unblinding of research ethics boards and scientific reviewers. These caveats are sources of misunderstanding when observing the apparent connection between a clinical intervention and patient outcomes. An awareness of specific pitfalls might help advance the interpretation and application of blinded randomized clinical trials to inform evidence-based medical care.

ImportanceA goal of health care is to reduce symptoms and improve health status, whereas continuing dubious treatments can contribute to complacency, discourage the search for alternatives, and lead to shortfalls in care.ObjectiveTo test a potential bias in intuitive reasoning following a marginal improvement in symptoms after a dubious treatment (post hoc bias).Design, Setting, and ParticipantsSurveys eliciting treatment recommendations for hypothetical patients were sent to community members throughout North America recruited via an online survey platform in the early winter months of 2023 and 2024 and presented to health care professionals (pharmacists who were approached in person using a secret shopper technique) in the summer months of 2023.ExposureRespondents received randomized versions of surveys that differed according to whether vague symptoms improved or remained unchanged after a dubious treatment.Main Outcomes and MeasuresThe primary outcome was a recommendation to continue treatment.ResultsIn total, 1497 community members (mean [SD] age, 38.1 [12.5] years; 663 female [55.3%]) and 100 health care professionals were contacted. The first scenario described a patient with a sore throat who took unprescribed antibiotics; respondents were more likely to continue antibiotics after initial treatment if there was a marginal improvement in symptoms vs when symptoms remained unchanged (67 of 150 respondents [45%] vs 25 of respondents [17%]; odds ratio [OR], 3.98 [95% CI, 2.33-6.78]; P < .001). Another scenario described a patient with wrist pain who wore a copper bracelet; respondents were more likely to continue wearing the copper bracelet after initial care was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (78 of 100 respondents [78%] vs 25 of 99 respondents [25%]; OR, 16.19 [95% CI, 5.32-19.52]; P < .001). A third scenario described a patient with fatigue who took unprescribed vitamin B12; respondents were more likely to continue taking vitamin B12 when initial treatment was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (80 of 100 respondents [80%] vs 33 of 100 respondents [33%]; OR, 7.91 [95% CI, 4.18-14.97]; P < .001). Four further scenarios involving dubious treatments found similar results, including when tested on health care professionals.Conclusions and RelevanceIn this study of clinical scenarios, a marginal improvement in symptoms led patients to continue a dubious and sometimes costly treatment, suggesting that clinicians should caution patients against post hoc bias.

Introduction: Americans have some of the highest traffic fatality risks and the most polarized national politics compared to other democracies. This study tested whether traffic fatality risks in the United States are associated with state-level presidential voting patterns. Methods: In this cross-sectional ecological analysis, we examined state-level popularity of the Republican presidential candidate with traffic fatality data from the National Highway Traffic Safety Administration. The analysis covered seven presidential elections from 1996 to 2020. Sensitivity analyses examined voter turnout as a non-partisan predictor, three health behaviors as negative control outcomes, and three medical causes of death as positive control outcomes. Results: A higher share of votes for the Republican presidential candidate in 2020 was correlated with higher traffic fatality risks (r = 0.63, p < 0.001). On average, a 1% increase in Republican popularity was associated with 20 extra traffic deaths per state annually (95% confidence interval = 13 to 28). This pattern replicated in six prior presidential elections and persisted across all ages, both sexes, diverse road users, and irrespective of alcohol influence. Conclusions: American states with a higher share of votes for the Republican presidential candidate tend to have higher traffic fatality risks. Clinicians, patients, and policymakers living in Republican states should be extra careful driving and at other times traveling on public roads in the community.

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.

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.

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 (omega = -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. Objectif Le reportage mediatique responsable est une strategie convenue pour prevenir le suicide. En 2015, les experts de la prevention du suicide ont lance une initiative d'engagement des medias visant a ameliorer les reportages lies au suicide au Canada; dont l'effet sur la qualite des reportages mediatiques et sur les deces par suicide n'est pas connu.Methode La presente etude observationnelle pre-post a examine les changements des caracteristiques des reportages dans un echantillon aleatoire d'articles lies au suicide des principales publications du marche des medias de la Region du Grand Toronto (RGT). Parmi les articles (n = 900), il y en avait 450 pendant la periode etalee 6 ans avant et apres le debut de l'initiative. Nous avons aussi examine les changements des nombres de suicides dans la RGT entre ces epoques. Nous avons utilise des tests du chi carre pour analyser les changements de caracteristiques des reportages, et des analyses de series chronologiques ont servi a identifier les changements des nombres de suicides. Les resultats secondaires portaient sur les lignes directrices elaborees par les professionnels des medias du Canada et sur la maniere dont elles ont pu influencer la qualite des reportages mediatiques ainsi que sur la narration globale des articles mediatiques durant les annees les plus recentes ou les donnees etaient disponibles.Resultats Une amelioration generale a ete observee dans les reportages sur le suicide ainsi que des reductions substantielles dans bien des elements du contenu potentiellement nocif et des augmentations substantielles dans tous les aspects du contenu possiblement protecteur. Toutefois, en globalite, les recits des articles demeuraient possiblement nocifs avec 55,2% des articles racontant l'histoire du deces de quelqu'un et 20,8% presentant un autre message negatif. Seulement 3,6% des articles relataient une histoire de survie. Apres un controle pour des confondants potentiels, une diminution numerique non significative des nombres de suicides a ete identifiee apres la mise en oe uvre de l'initiative (omega = -5,41, SE = 3,43, t = 1,58, p = 0,12).Conclusions Nous avons constate la preuve qu'une strategie d'engager les medias au Canada changeait le contenu des reportages, mais qu'il n'y avait qu'une tendance non significative a la reduction du nombre de suicides. Un changement des recits mediatiques qui seraient axes sur la survie plutot que sur le deces semble justifie.

IntroductionFurosemide 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.MethodsThis 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.ResultsA 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).DiscussionThis 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.

OBJECTIVE:This systematic review and meta-analysis compared minimally invasive surgery (MIS) to open surgery for treatment of spinal metastases with respect to perioperative outcomes. Few studies have systemically assessed the body of evidence on this topic. METHODS:A systematic review of EMBASE and PubMed from database inception to December 2023 was performed to identify studies comparing MIS with open surgery for the treatment of spine metastases. Nine outcomes were collected: estimated blood loss (EBL), operative time, hospital length of stay (LOS), risk of revision, risk of neurological deterioration, likelihood of receiving postoperative radiation therapy, time to radiation therapy, time to chemotherapy, and treatment of pain measured through patient-reported visual analog scale (VAS) scores. Meta regression was used to estimate adjusted mean differences (aMDs) and adjusted odds ratios (aORs) for outcomes. Certainty of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS:There were 34 eligible studies including 1656 patients with spinal metastases; 904 (54.6%) patients were treated with MIS and 752 (45.4%) were treated with open surgery. MIS was associated with significantly less blood loss (aMD -602 mL, 95% CI -1204 to -0.2 mL; I2 = 97%) with a moderate certainty of evidence. MIS was found to be noninferior with respect to operative time (aMD -2.6 minutes, 95% CI -53.3 to 48.1 minutes; I2 = 88%), risk of revision (aOR 0.9, 95% CI 0.8-1.1; I2 < 0.01), risk of neurological deterioration (aOR 0.9, 95% CI 0.8-1.0; I2 < 0.01), likelihood of postoperative radiation therapy (aOR 0.9, 95% CI 0.7-1.4; I2 < 0.01), and postoperative VAS score (aMD -0.6, 95% CI -1.5 to 0.4; I2 = 52%) with low certainty of evidence. MIS was associated with significantly shorter time to chemotherapy (MD -0.9 weeks, 95% CI -1.9 to -0.01 weeks; I2 = 22%), with very low certainty of evidence. Inferences for LOS and time to radiation were indeterminate; however, we found a trend toward earlier radiation therapy with MIS that was significant in the subgroup of patients treated with decompression and fusion. CONCLUSIONS:Treatment with MIS compared with open surgery was associated with reduced EBL, shorter time to chemotherapy, similar operative time, and similar reductions in postoperative pain. Limitations were largely due to heterogeneity across studies. Future research among subgroups is very likely to improve certainty in the comparative effect estimates.