BACKGROUND AND OBJECTIVES:Despite widespread benefits of physicians engaging in organizational quality & safety (Q&S) activities, such engagement often remains infrequent, informal, and inconsistent. This work aimed to design and implement uniquely-tailored and concurrent interventions to increase the size and Q&S competency levels of UHN's Physician Council on Q&S over a 2-year period. METHODS:Ten Q&S competency dimensions were tracked as outcome measures: Q&S science & methods, engaging stakeholders for success, aligning local projects with organizational priorities, building local Q&S infrastructure, navigating organizational Q&S processes, obtaining funding for Q&S, scholarly approach to Q&S, academic promotion through Q&S, career development through Q&S, and teaching Q&S. Competency levels were reported on a 4-point scale (ie, novice, competent, proficient, and expert). Process measures centered around change concepts and included the number of attendees at Q&S events, the number of mentorship pairings, the number of QI projects awarded grant funding, and the number of visits to our Q&S intranet site. RESULTS:Baseline results (n = 32) revealed participants were predominantly in the novice/competent categories for all dimensions. Competency levels were retested in 2023 (n = 41) and chi-square analyses revealed improvements in the expected direction on all dimensions. Statistically significant increases were observed for navigating UHN processes (P < .01) and building organizational Q&S infrastructure (P < .05). The Council grew over 5-fold in size from its 13 original members to 75 members with representation from all of our organization's programs, departments, and divisions. CONCLUSIONS:Results indicate that this approach to Educate and Connect (eg, rounds and summit), Promote and Support (eg, grants and awards), and provide Customized Resources (eg, playbook and intranet) was effective in growing a robust and competent physician Q&S community of practice.

BACKGROUND:We aimed to examine the impact of sedative prescription patterns in hospitalized older adults on post-discharge adverse drug events (ADEs), falls, and sleep. METHODS:We conducted a secondary analysis of the MedSafer randomized controlled trial (RCT; NCT03272607) which included hospitalized adults ≥ 65 years of age who were taking ≥ 5 medications. We identified patients who completed follow-up at 30 days post-discharge and provided patient-reported outcomes for sleep disturbance (PROMIS SD 4a). We grouped patients based on sedative use as follows: nonusers, continued home use (pre- and post-hospitalization), deprescribed home use, and new use at discharge. Using multivariable logistic regression, we compared the odds of patients having experienced ≥ 1 ADE (not necessarily ascribed to sedatives), a fall, or any adverse event within 30 days post-discharge. We also used ordinal logistic regression and a minimal important difference approach to compare the change in sleep disturbance at 30 days post-discharge. RESULTS:The cohort comprised 3630 patients with a median age of 78. A total of 2810 (77.4%) were categorized as nonusers; 475 (13.1%) continued home use; 293 (8.1%) deprescribed home use; and 52 (1.4%) new users at discharge. Compared to the continued home use group, the deprescribed group was substantially less likely to experience an ADE post-discharge (adjusted odds ratio [aOR], 0.39 [95% CI, 0.16-0.97]). Correspondingly, new users at discharge had substantially higher odds of falls (aOR, 2.51 [95% CI, 1.13-5.61]). Favorable changes in sleep disturbance were more likely among nonusers (aOR, 1.29 [95% CI, 1.05-1.58]) and deprescribed users (aOR, 1.11 [95% CI, 0.82-1.50]) when compared to continued users. CONCLUSIONS:In this cohort, patients who had their sedatives deprescribed were 61% less likely than continued users to have a post-discharge ADE, and new sedative use at discharge was associated with appreciable risk of falls. Hospitalization likely represents a window of opportunity to improve care by promoting sedative deprescription and avoiding new starts.

This study compares hospitalization and mortality outcomes in vaccinated older adults with vs without restricted access to nirmatrelvir-ritonavir in Ontario.

Since 2019, it is increasingly identified in illicit drug samples tested across Canada,[1][1] most commonly co-occurring with fentanyl,[1][1]–[3][2] and patients using illicit opioids may be unaware of its presence. There are reports that it increases euphoria and may prolong the effects of

We present the case of a man in his 70s who developed acute confusion from hypertensive encephalopathy triggered by indomethacin. He was recently prescribed indomethacin, a non-steroidal anti-inflammatory drug (NSAID) for headaches. However, his headaches were in the context of worsening hypertension that was treated with trandolapril. The use of indomethacin consequently worsened his underlying condition. On presentation to the emergency department, his blood pressure was 190/110 mmHg. Bloodwork including electrolytes, glucose, metabolic studies, renal and liver function were within normal limits; infectious workup including blood and urine cultures subsequently returned negative; and brain computed tomography and magnetic resonance imaging revealed no acute process to explain his presentation. Indomethacin was discontinued and the patient's hypertension was treated with amlodipine. Both his confusion and underlying headaches resolved as his blood pressure normalized. The patient was diagnosed with hypertensive encephalopathy triggered by indomethacin. NSAID use can trigger blood pressure decompensation, especially in patients with underlying hypertension; this effect is particularly pronounced in patients treated with anti-hypertensive medications that inhibit the renin-angiotensin-aldosterone (RAS) system. Symptomatic treatment with NSAIDs is not without potential harm; it is important to carefully consider a patient's underlying diagnosis, indication for therapy and risk for adverse effects.

[Voir la version anglaise de l'article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.231603][1] Depuis 2019, on retrouve de plus en plus de xylazine dans les échantillons de drogues illicites analysés au Canada[1][2], principalement en présence de fentanyl[1][2]–[3][3]. Les personnes qui

This JAMA Internal Medicine Patient Page describes the process of slowly and carefully cutting down on unnecessary medications with the guidance of a health care professional.

Key clinical messageCerebral venous sinus thrombosis (CVST) should be on the differential for intracranial hypertension, and the preferred diagnostic tests are CT venogram or MR venography.AbstractCerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is on the differential for intracranial hypertension. Non‐contrast head CT is often normal. CT venogram or MR venography are the preferred diagnostic tests, as was required in our patient. We review the presentation, diagnosis, and management of CVST.

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.221210][1] Le técovirimat est un médicament antiviral capable de contrer l’action des orthopoxvirus[1][2]. Santé Canada l’a approuvé en novembre 2021 pour le traitement de la variole; d’autres pays l’ont

In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug–drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.

BACKGROUND:The Junior Attending (JA) role is an educational model, commonly implemented in the final years of training, wherein a very senior resident assumes the responsibilities of an attending physician under supervision. However, there is heterogeneity in the model's structure, and data are lacking on how it facilitates transition to independent practice.OBJECTIVE:The authors sought to determine the value of the JA role and factors that enabled a successful experience.METHODS:The authors performed a collective case study informed by a constructivist grounded theory analytical approach. Twenty semi-structured interviews from 2017 to 2020 were conducted across 2 cases: (1) Most Responsible Physician JA role (general internal medicine), and (2) Consultant JA role (infectious diseases and rheumatology). Participants included recent graduates who experienced the JA role, supervising attendings, and resident and faculty physicians who had not experienced or supervised the role.RESULTS:Experiencing the JA role builds resident confidence and may support the transition to independent practice, mainly in non-medical expert domains, as well as comfort in dealing with clinical uncertainty. The relationship between the supervising attending and the JA is an essential success factor, with more productive experiences reported when there is an establishment of clear goals and role definition that preserves the autonomy of the JA and legitimizes the JA's status as a team leader.CONCLUSIONS:The JA model offers promise in supporting the transition to independent practice when key success factors are present.

INTRODUCTION This study explores the relationship between emotional support, perceived risk and mental health outcomes among health care workers, who face high rates of burnout and mental distress since the beginning of the COVID-19 pandemic. METHODS A cross-sectional, multicentred online survey of health care workers in the Greater Toronto Area, Ontario, Canada, during the first wave of the COVID-19 pandemic evaluated coping strategies, confidence in infection control, impact of previous work during the 2003 SARS outbreak and emotional support. Mental health outcomes were assessed using the Generalized Anxiety Disorder scale, the Impact of Event Scale - Revised and the Patient Health Questionnaire (PHQ-9). RESULTS Of 3852 participants, 8.2% sought professional mental health services while 77.3% received emotional support from family, 74.0% from friends and 70.3% from colleagues. Those who felt unsupported in their work had higher odds ratios of experiencing moderate and severe symptoms of anxiety (odds ratio [OR] = 2.23; 95% confidence interval [CI]: 1.84-2.69), PTSD (OR = 1.88; 95% CI: 1.58-2.25) and depression (OR = 1.88; 95% CI: 1.57-2.25). Nearly 40% were afraid of telling family about the risks they were exposed to at work. Those who were able to share this information demonstrated lower risk of anxiety (OR = 0.58; 95% CI: 0.48-0.69), PTSD (OR = 0.48; 95% CI: 0.41-0.56) and depression (OR = 0.55; 95% CI: 0.47-0.65). CONCLUSION Informal sources of support, including family, friends and colleagues, play an important role in mitigating distress and should be encouraged and utilized more by health care workers.

Fluvoxamine is a selective serotonin reuptake inhibitor with potential anti-inflammatory and antiviral properties.[1][1] A meta-analysis of 2196 patients with COVID-19 from 3 randomized controlled trials concluded that fluvoxamine had a high probability of preventing hospital admission or

Key Points Question Does providing clinical decision support during an acute care hospitalization improve deprescribing of potentially inappropriate medications and 30-day postdischarge adverse drug events (ADEs) in older adults? Findings This cluster randomized multicenter trial of 5698 hospitalized participants found that providing electronically generated deprescribing reports did not have a significant impact on ADEs within 30 days despite increased deprescribing at discharge. Meaning The findings of this randomized clinical trial indicate that clinical decision support during hospitalization improves deprescribing but has little impact on medication harms in the short term.