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Conflicting recommendations exist related to which facial protection should be used by health care workers to prevent transmission of acute respiratory infections, including pandemic influenza. We performed a systematic review of both clinical and surrogate exposure data comparing N95 respirators and surgical masks for the prevention of transmissible acute respiratory infections. We searched various electronic databases and the grey literature for relevant studies published from January 1990 to December 2014. Randomized controlled trials (RCTs), cohort studies and case–control studies that included data on health care workers wearing N95 respirators and surgical masks to prevent acute respiratory infections were included in the meta-analysis. Surrogate exposure studies comparing N95 respirators and surgical masks using manikins or adult volunteers under simulated conditions were summarized separately. Outcomes from clinical studies were laboratory-confirmed respiratory infection, influenza-like illness and workplace absenteeism. Outcomes from surrogate exposure studies were filter penetration, face-seal leakage and total inward leakage. We identified 6 clinical studies (3 RCTs, 1 cohort study and 2 case–control studies) and 23 surrogate exposure studies. In the meta-analysis of the clinical studies, we found no significant difference between N95 respirators and surgical masks in associated risk of (a) laboratory-confirmed respiratory infection (RCTs: odds ratio [OR] 0.89, 95% confidence interval [CI] 0.64–1.24; cohort study: OR 0.43, 95% CI 0.03–6.41; case–control studies: OR 0.91, 95% CI 0.25–3.36); (b) influenza-like illness (RCTs: OR 0.51, 95% CI 0.19–1.41); or (c) reported workplace absenteeism (RCT: OR 0.92, 95% CI 0.57–1.50). In the surrogate exposure studies, N95 respirators were associated with less filter penetration, less face-seal leakage and less total inward leakage under laboratory experimental conditions, compared with surgical masks. Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings.

Invasive fungal infections pose an important threat to public health and are an under-recognized component of antimicrobial resistance, an emerging crisis worldwide. Across a period of profound global environmental change and expanding at-risk populations, human-infecting pathogenic fungi are evolving resistance to all licensed systemic antifungal drugs. In this Review, we highlight the main mechanisms of antifungal resistance and explore the similarities and differences between bacterial and fungal resistance to antimicrobial control. We discuss the research and innovation topics that are needed for risk reduction strategies aimed at minimizing the emergence of resistance in pathogenic fungi. These topics include links between the environment and One Health, surveillance, diagnostics, routes of transmission, novel therapeutics and methods to mitigate hotspots for fungal adaptation. We emphasize the global efforts required to steward our existing antifungal armamentarium, and to direct the research and development of future therapies and interventions.The impacts of fungal infections on human health are of increasing concern, and resistance of pathogenic fungi to all licensed systemic antifungals has been documented. In this Review, Fisher, Verweij and colleagues discuss the research and innovation topics that are needed to understand and minimize the occurrence and impact of antifungal resistance.

BACKGROUND Prior data suggest that vancomycin-resistant Enterococcus (VRE) bacteremia is associated with worse outcomes than vancomycin-sensitive Enterococcus (VSE) bacteremia. However, many studies evaluating such outcomes were conducted prior to the availability of effective VRE therapies. OBJECTIVE To systematically review VRE and VSE bacteremia outcomes among hospital patients in the era of effective VRE therapy. METHODS Electronic databases and grey literature published between January 1997 and December 2014 were searched to identify all primary research studies comparing outcomes of VRE and VSE bacteremias among hospital patients, following the availability of effective VRE therapies. The primary outcome was all-cause, in-hospital mortality, while total hospital length of stay (LOS) was a secondary outcome. All meta-analyses were conducted in Review Manager 5.3 using random-effects, inverse variance modeling. RESULTS Among all the studies reviewed, 12 cohort studies and 1 case control study met inclusion criteria. Similar study designs were combined in meta-analyses for mortality and LOS. VRE bacteremia was associated with increased mortality compared with VSE bacteremia among cohort studies (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.38-2.35; I2=0%; n=11); the case-control study estimate was similar, but not significant (OR, 1.93; 95% CI, 0.97-3.82). LOS was greater for VRE bacteremia patients than for VSE bacteremia patients (mean difference, 5.01 days; 95% CI, 0.58-9.44]; I2=0%; n=5). CONCLUSIONS Despite the availability of effective VRE therapy, VRE bacteremia remains associated with an increased risk of in-hospital mortality and LOS when compared to VSE bacteremia. Infect. Control Hosp. Epidemiol. 2015;37(1):26-35.

Background Previous research suggests that medico-legal complaints often arise from various factors influencing patient dissatisfaction, including medical errors, physician-patient relationships, communication, trust, informed consent, perceived quality of care, and continuity of care. However, these findings are not typically derived from actual patients’ cases. This study aims to identify factors impacting the interpersonal dynamics between physicians and patients using real patient cases to understand how patients perceive doctor-patient relational problems that can lead to dissatisfaction and subsequent medico-legal complaints. Methods We conducted a retrospective study using data from closed medical regulatory authority complaint cases from the Canadian Medical Protective Association (CMPA) between January 1, 2015, and December 31, 2020. The study population included patients who experienced sepsis and survived, with complaints written by the patients themselves. A multi-stage standardized thematic analysis using Braun and Clarke’s approach was employed. Two researchers independently coded the files to ensure the reliability of the identified codes and themes. Results Thematic analysis of 50 patient cases revealed four broad themes: (1) Ethics in physician’s work, (2) Quality of care, (3) Communication, and (4) Healthcare system/policy impacting patient satisfaction. Key sub-themes included confidentiality, honesty, patient involvement, perceived negligence, perceived lack of concern, active engagement and empathy, transparency and clarity, informed consent, respect and demeanor, lack of resources, long wait times, and insufficient time with physicians. Conclusions This study identifies and categorizes various factors impacting relational issues between physicians and patients, aiming to increase patient satisfaction and reduce medico-legal cases. Improving physicians’ skills in areas such as communication, ethical practices, and patient involvement, as well as addressing systemic problems like long wait times, can enhance the quality of care and reduce medico-legal complaints. Additional training in communication and other skills may help promote stronger relationships between physicians and patients.

Background This study sought to describe the key medico-legal issues associated with end-of-life critical care interventions in Canada. We explored the most common themes of a disagreement between patients or substitute decision makers (SDM) and treating physicians related to intervention decisions, and complaints against physicians, that were identified and criticised by peer experts as contributing to medico-legal risk. Methods A national repository was retrospectively searched for cases involving end-of-life care that were supported by the Canadian Medical Protective Association (CMPA) between 2018 and 2022. The study involved patients admitted to surgical and medical intensive and critical care units, emergency departments and residents in long term care settings. The frequencies and proportions of the top risk factors leading to medico-legal risks and the most frequent allegations were calculated by exploring factors that contributed to each incident. Results We identified 93 eligible cases, involving 142 physicians. Family medicine was the most frequent specialty named in 32% of the cases. The median age of 93 unique patients was 78 years. Common reasons for complaints were communication breakdown between a physician and a patient/SDM and deficient assessment. The most frequent contributing factors criticised by peer experts were communication breakdown between a physician and a patient/SDM and inadequate documentation. Conclusions The most common omission identified by peer experts involved a physician’s communication with a patient/SDM. Physicians may reduce their medico-legal risk by exploring effective techniques for optimal communication to improve understanding in end-of-life discussions, with the goal of high-quality patient care.

•We examine the role of behavior change theories in improving healthcare worker (HCW) vaccination rates.•Psychological theories of behavior change successfully predict HCW influenza vaccination uptake.•Behavior change constructs successfully differentiate vaccinated and non-vaccinated HCW.•Attitudes, self-efficacy, perceived risk/benefit, cues to action, and social norms are key constructs.•Behavior change theories may help guide interventions to increase HCW vaccination uptake. Influenza vaccination of healthcare workers (HCW) is important for protecting staff and patients, yet vaccine coverage among HCW remains below recommended targets. Psychological theories of behavior change may help guide interventions to improve vaccine uptake. Our objectives were to: (1) review the effectiveness of interventions based on psychological theories of behavior change to improve HCW influenza vaccination rates, and (2) determine which psychological theories have been used to predict HCW influenza vaccination uptake. MEDLINE, EMBASE, CINAHL, PsycINFO, The Joanna Briggs Institute, SocINDEX, and Cochrane Database of Systematic Reviews were searched for studies that applied psychological theories of behavior change to improve and/or predict influenza vaccination uptake among HCW. The literature search yielded a total of 1810 publications; 10 articles met eligibility criteria. All studies used behavior change theories to predict HCW vaccination behavior; none evaluated interventions based on these theories. The Health Belief Model was the most frequently employed theory to predict influenza vaccination uptake among HCW. The remaining predictive studies employed the Theory of Planned Behavior, the Risk Perception Attitude, and the Triandis Model of Interpersonal Behavior. The behavior change framework constructs were successful in differentiating between vaccinated and non-vaccinated HCW. Key constructs identified included: attitudes regarding the efficacy and safety of influenza vaccination, perceptions of risk and benefit to self and others, self-efficacy, cues to action, and social-professional norms. The behavior change frameworks, along with sociodemographic variables, successfully predicted 85–95% of HCW influenza vaccination uptake. Vaccination is a complex behavior. Our results suggest that psychological theories of behavior change are promising tools to increase HCW influenza vaccination uptake. Future studies are needed to develop and evaluate novel interventions based on behavior change theories, which may help achieve recommended HCW vaccination targets.

Cannabis legalization has enabled increased consumption in older adults. Age-related mental, physical, and physiological changes may lead to differences in effects of cannabis in older adults compared to younger individuals. To perform a scoping review to map the evidence regarding the health effects of cannabis use for medical and non-medical purposes in older adults. Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched for systematic reviews (SRs), randomized controlled trials (RCTs) and non-randomized/observational studies (NRSs) assessing the health effects and associations of cannabis use (medical or non-medical) in adults ≥ 50 years of age. Included studies met age-related inclusion criteria or involved a priori identified health conditions common among older adults. Records were screened using a liberal accelerated approach and data charting was performed independently by two reviewers. Descriptive summaries, structured tables, effect direction plots and bubble plots were used to synthesize study findings. From 31,393 citations, 133 publications describing 134 unique studies (26 SRs, 36 RCTs, 72 NRSs) were included. Medical cannabis had inconsistent therapeutic effects in specific patient conditions (e.g., end-stage cancer, dementia), with a number of studies suggesting possible benefits while others found no benefit. For medical cannabis, harmful associations outnumbered beneficial, and RCTs reported more negative effects than NRSs. Cannabis use was associated with greater frequencies of depression, anxiety, cognitive impairment, substance use and problematic substance use, accidents/injuries, and acute healthcare use. Studies often were small, did not consistently assess harms, and did not adjust for confounding. The effects of medical cannabis are inconsistent within specific patient conditions. For older adults, generally, the available evidence suggests cannabis use may be associated with greater frequencies of mental health issues, substance use, and acute healthcare use, and the benefit-to-risk ratio is unclear. Studies with a balanced assessment of benefits and harms may guide appropriate public health messaging to balance the marketing pressures of cannabis to older adults.

Protecting healthcare workers (HCWs) from Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a priority to maintain a safe and functioning healthcare system. Our objective was to describe and compare the epidemiology, clinical characteristics, and lethality of SARS-CoV-2 infections among HCWs compared to non-HCWs. Using reportable disease data at Public Health Ontario, we conducted a population-based cross-sectional study comparing demographic, exposure, and clinical variables between HCWs and non-HCWs with SARS-CoV-2 infections as of 30 September 2020. We calculated rates of infections over time and determined the frequency of within household transmissions using natural language processing based on residential address. We evaluated the risk of death using a multivariable logistic regression model adjusting for age, sex, comorbidities, symptoms, and long-term care home exposure. There were 7,050 (12.5%) HCW SARS-CoV-2 infections in Ontario, Canada, of whom 24.9% were nurses, 2.3% were physicians, and the remaining 72.8% other specialties, including personal support workers. Overall HCWs had an infection rate of 1,276 per 100,000 compared to non-HCWs of 346 per 100,000 (3.7 times higher). This difference decreased from a 7 times higher rate in April to no difference in September 2020. Twenty-six percent of HCWs had a household member with SARS-CoV-2 infection; 6.8% were probable acquisitions, 12.3% secondary transmissions, and 6.9% unknown direction of transmission. Death among HCWs was 0.2% compared to 6.1% of non-HCWs. The risk of death in HCWs remained significantly lower than non-HCWs after adjustment (adjusted odds ratio 0.09; 95%CI 0.05-0.17). HCWs represent a disproportionate number of diagnosed SARS-CoV-2 infections in Ontario, however this discrepancy is at least partially explained by limitations in testing earlier in the pandemic for non-HCWs. We observed a low risk of death in HCWs which could not be completely explained by other factors.

Background Medication-related safety incidents are more common in older adults than in younger populations. Medication review and optimization, including deprescribing, are essential components of strategies to reduce medication-related harm. Deprescribing aims to minimize therapeutic burden by reducing medications that no longer provide net clinical benefit or by substituting safer alternatives. Herein we sought to use a national pan-Canadian repository of medico-legal cases to identify opportunities for improving deprescribing practices in primary care for older adults. Methods We conducted a five-year retrospective review (2018–2022) of closed Canadian medico-legal cases relating to deprescribing involving family medicine physicians and patients age 65 or older. We analysed cases related to deprescribing and created composite case examples to illustrate both areas for improvement and examples of appropriate care despite the receipt of a complaint or civil legal action (collectively, medico-legal cases). Results We identified 31 medico-legal cases, of which 29 had undergone expert review. Experts identified areas of improvement related to deprescribing including conducting assessments to determine appropriateness of deprescribing, using a multidisciplinary approach to create a safe tapering plan that includes monitoring and follow-up, establishing clear communication with patients and their authorized substitute decision-makers, and documenting clearly and appropriately. Although experts often explicitly identified these elements as present, they were critical of the deprescribing-related care in half of cases. Conclusions Medico-legal cases highlight several key areas for improving deprescribing in primary care, particularly around comprehensive patient assessment to inform deprescribing decision-making and clear communication of treatment plans with relevant decision-makers. The cases also demonstrate that the process of deprescribing and the patient-physician relationship is complex and that complaints can occur even when physicians are safely deprescribing.

Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD. A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used. Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only. This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions. PROSPERO registration CRD42018090761.