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Background Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests. Methods Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development. Results The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: “Intrapersonal” – fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation “Interpersonal” – pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; “Environment/context” – guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology Conclusion This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.

RationaleThe chronic mild stress (CMS) paradigm was first described almost 40 years ago and has become a widely used model in the search for antidepressant drugs for major depression disorder (MDD). It has resulted in the publication of almost 1700 studies in rats alone. Under the original CMS procedure, the expression of an anhedonic response, a key symptom of depression, was seen as an essential feature of both the model and a depressive state. The prolonged exposure of rodents to unpredictable/uncontrollable mild stressors leads to a reduction in the intake of palatable liquids, behavioral despair, locomotor inhibition, anxiety-like changes, and vegetative (somatic) abnormalities. Many of the CMS studies do not report these patterns of behaviors, and they often fail to include consistent molecular, neuroanatomical, and physiological phenotypes of CMS-exposed animals.ObjectivesTo critically review the CMS studies in rats so that conceptual and methodological flaws can be avoided in future studies.ResultsAnalysis of the literature supports the validity of the CMS model and its impact on the field. However, further improvements could be achieved by (i) the stratification of animals into ‘resilient’ and ‘susceptible’ cohorts within the CMS animals, (ii) the use of more refined protocols in the sucrose test to mitigate physiological and physical artifacts, and (iii) the systematic evaluation of the non-specific effects of CMS and implementation of appropriate adjustments within the behavioral tests.ConclusionsWe propose methodological revisions and the use of more advanced behavioral tests to refine the rat CMS paradigm, which offers a valuable tool for developing new antidepressant medications.

BackgroundNeonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies.ObjectivesTo describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed.Eligibility criteriaHuman neonates ≤1 month of corrected age.Sources of evidenceA protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center’s librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020.Charting methodsA single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction).ResultsOf the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band.ConclusionsNeonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.

A recent study validated a scoring system that incorporates weighted risk factors based on their contribution to gastric cancer development.7 However, in Hong Kong's public hospitals, oesophagogastroduodenoscopy (OGD) is primarily indicated for suspected or confirmed cases of peptic ulcer disease, GI bleeding, oesophageal or gastric cancer; it is also indicated for symptoms such as indigestion, acid reflux, or dysphagia.8By the time diagnostic symptoms appear, most patients display advanced cancer beyond curative treatment, resulting in poor survival outcomes. [...]a comprehensive screening model for upper GI cancers is urgently needed. [...]the model was developed and validated in the UK, primarily using data from a Western population.17 18 Variations in cancer risk factors among ethnic groups are well documented; for example, the incidence of gastric cancer is higher in Asian populations due to gene-environment interactions.19 Therefore, the hazard ratios for risk factors derived from the UK population may not be suitable for the Southern Chinese population in Hong Kong. [...]the existing model heavily relies on the presence of ‘alarm symptoms' for gastroesophageal cancer reported by patients to their general practitioners, such as dysphagia, abdominal pain, and appetite loss. The use of de-identified clinical data from patients previously diagnosed with oesophageal and gastric cancers, accessible through the Clinical Data Analysis and Reporting System of the Hospital Authority, would enable the development of a prediction model tailored to the Hong Kong population.

Although postgraduate medical education programs in North America have committed to addressing equity, diversity, and inclusion (EDI) issues, learning environment inequities persist and negatively impact learning outcomes. We conducted an exploratory qualitative study to identify mechanisms contributing to ongoing discrimination experiences. We took an intercategorical intersectional approach to conduct a qualitative thematic analysis that focused on unequal social relations as the unit of analysis. Participants were recruited from paediatrics, neurosurgery, and plastic surgery residency training programs. We performed multi-level inductive and deductive coding of semi-structured interviews informed by intersectionality and systemic and aversive racism. 13 participants were interviewed. Participants identified their social identities as marginalized or dominant, and reported intersectional exclusion experiences related to the former that disadvantaged them compared to their peers. Persistent unequal social relations could be mechanistically accounted for by aversive or systemic racism regardless of intersectional identities. Aversive discrimination appeared through performative EDI commitments, microaggressions, and social exclusion. Systemic discrimination contributed to exclusion stemming from the operationalization of cultural norms such as scheduling, social events, and censorship of taboo topics. Participants described variably successful compensatory strategies to overcome their marginalization. Systemic and aversive discrimination contribute to reproducing unequal social relations. Evidence-based approaches exist to address these mechanisms and make learning environments fairer.

Older adults are increasingly adopting digital technologies, with the majority of adults ages 65 and over being Internet users. These technologies can help support older adults’ well-being by improving access to and engagement with healthcare information. However, digital accessibility may continue to be an obstacle for adults who experience age-related functional changes, such as loss of vision and hearing or decline in cognitive and motor skills. While guidelines do exist for ensuring accessibility among people with disabilities, these guidelines do not always provide older adults with positive user experiences. A variety of frameworks have been proposed to support age-friendly user engagement with websites and mobile applications, with several centered on improving comprehension of text, location of information, and recognition of access links. In this presentation, we will explore the nuanced needs of users across different age groups, with special consideration given to the design of interfaces that can support both care partners and older adults. This presentation will cover a range of topics, such as optimizing user interaction patterns and enhancing readability, to provide practical insights into the concept of age-friendly design for user interfaces.

Background Multiple sclerosis (MS) is a chronic immune‐mediated disorder characterized by the degradation of the myelin sheath in the central nervous system. Research indicates that individuals with MS exhibit a higher susceptibility to stroke compared to the general population. This association is rooted in shared underlying mechanisms, specifically involving neuroinflammatory processes. Methodology We performed an extensive search on PubMed, MEDLINE, Embase, Scopus, and Google Scholar using specific terms. The search terms included variations of “multiple sclerosis,” “stroke,” “cerebrovascular disease,” “vascular risk factors,” “disease‐modifying therapies,” and “neuroinflammation.” The search was limited to articles published from January 1, 2000, up to 31 May, 2023. Results and Discussion Stroke, a global health burden characterized by significant mortality and adult disability, underscores the critical importance of understanding the link between MS and stroke. Despite a growing body of research establishing an elevated risk of stroke in MS patients, notable information gaps persist. Limited prospective multicenter studies on stroke incidence in MS patients contribute to an incomplete understanding of the precise relationship between these two conditions. Conclusion In conclusion, this review underscores the critical need for a thorough understanding of the complex relationship between MS and stroke. The identified risk factors and the influence of MS DMTs on stroke risk necessitate further investigation to inform evidence‐based preventive and therapeutic strategies. Bridging the existing information gaps through prospective multicenter studies is imperative for a comprehensive understanding of this association. The development of targeted diagnostic and therapeutic approaches for acute stroke risk in MS patients is paramount to mitigate the impact of these debilitating conditions. Ultimately, this review serves as a foundation for future efforts to enhance preventative measures and therapeutic interventions, thereby improving the overall quality of life for individuals with MS susceptible to strokes.

Previous literature has supported flywheel (FW) training with inducing muscular size and strength comparable to resistance training with free weights. However, it remains unclear how the biomechanical demands of these two training methods differ regarding reducing the risk of load-dependent injuries. With the growing population of female astronauts, this study aimed to compare patellofemoral joint kinetics and muscle activation when squatting to full depth on the barbell back squat (BBS) and a gravity-independent FW device utilizing technology to be deployed in future long-term space missions. Twenty recreationally trained females (22.3 ± 2.7 yrs, 1.6 ± 0.1 m, 59.8 ± 6.8 kg) with at least two years of experience in BBS training participated in this study. The first session involved one-repetition maximum (1RM) testing on the BBS and familiarizing the participants with squatting on the FW device (YoYo™ Multigym). In session two, the participants conducted: (1) one set of seven repetitions at 83% of their 1 RM in the BBS and (2) one set of seven maximal repetitions on the FW training device using an inertial load of 0.100 kg ⋅ m2. The order of the exercises in session two was randomized. Three-dimensional motion capture, force platforms, and electromyography assessed knee joint moments and muscle activation on the participants' dominant limb. Patellofemoral joint reaction forces (PFJRF) and patellofemoral joint stresses (PFJS) were calculated from biomechanical models incorporating joint moments and angles. Paired t-tests were conducted to compare these variables, with a significance set at p ≤ 0.05. Analysis revealed peak knee extensor moments were greater in the BBS (BBS: 2.14 ± 0.36 Nm/kg; FW: 1.94 ± 0.06 Nm/kg, p = 0.004). In addition, BBS was associated with greater PFJRF (BBS: 30.74±2.63; FW: 26.55±4.49, p = 0.001) and PFJS (BBS: 34.89±5.59 MPa; FW: 29.98±5.55 MPa, p < 0.001). The BBS elicited greater mean muscle activity over the set compared to FW squats in the following muscles: vastus lateralis: +5.68%, p = 0.015; bicep femoris: +4.63%, p < 0.001; gluteus maximus: +4.67%, p = 0.024; gluteus medius: +2.75%, p = 0.011; gastrocnemius lateralis: +3.09%, p = 0.028; gastrocnemius medius: +2.48%, p = 0.024. However, FW squats attained greater tibialis anterior activity (+5.56%, p = 0.04). There was no significant difference in muscle activity observed in the rectus femoris and vastus medialis. In conclusion, the findings of this study have demonstrated that squatting on the FW device was associated with statistically significant reductions in pKEM, PFJRF, and PFJS when compared to the traditional BBS. However, in general, there was greater muscular activation in the BBS. From an injury risk perspective, frequent utilization of the FW device may mitigate the development of pathology in the patellofemoral joint. In addition, those who are more susceptible to patellofemoral pain symptoms, such as in females, may benefit from squatting on the FW device as an alternative to the BBS.

Vancomycin, a bacterial cell wall inhibitor, can cause nephrotoxicity, typically presenting as acute tubular necrosis (ATN) but, in rare cases, can lead to acute interstitial nephritis (AIN). Risk factors include high doses, prolonged use, other nephrotoxic drugs and pre-existing kidney impairment. This case describes a man in his 70s with multiple comorbidities who developed AIN after 9 days of vancomycin therapy for a methicillin-resistant Staphylococcus aureus infection from infective endocarditis. His serum creatinine rose from 1.2 to 5.5 mg/dL, correlating with a supratherapeutic vancomycin level (40 mcg/mL). Despite stopping vancomycin, his renal function continued to worsen, leading to a diagnosis of AIN confirmed by renal biopsy. Despite high-dose corticosteroids, haemodialysis was required to stabilise renal function, emphasising the importance of early monitoring of vancomycin levels to mitigate nephrotoxicity risks.

Brachialis periosteal avulsion injury is an uncommon injury occurring in young children. The injury may be misinterpreted or overlooked because of misleading or subtle radiological findings. A case of 7-year-old child with post-traumatic elbow pain and subtle findings on elbow radiography is presented. The injury was initially misinterpreted as an avulsion fracture of the medial epicondyle. Following radiological review, a diagnosis of brachialis periosteal avulsion injury was made. The radiographic and magnetic resonance imaging (MRI) findings of this injury are presented to stress the value of comparing the radiographic findings with previous imaging and to increase awareness of this uncommon injury.