Comparing mortality and healthcare utilization in the year following a paramedic-attended non-fatal overdose among people who were and were not transported to hospital: A prospective cohort study using linked administrative health data.

BACKGROUND: As the overdose emergency continues in British Columbia (BC), paramedic-attended overdoses are increasing, as is the proportion of people not transported to hospital following an overdose. This study investigated risk of death and subsequent healthcare utilization for people who were and were not transported to hospital after a paramedic-attended non-fatal overdose. METHODS: Using a linked administrative health data set which includes all overdoses that come into contact with health services in BC, we conducted a prospective cohort study of people who experienced a paramedic-attended non-fatal overdose between 2015 and 2016. People were followed for 365 days after the index event. The primary outcomes assessed were all-cause mortality and overdose-related death. Additionally, we examined healthcare utilization after the index event. RESULTS: In this study, 8659 (84%) people were transported and 1644 (16%) were not transported to hospital at the index overdose event. There were 279 overdose deaths (2.7% of people, 59.4% of deaths) during follow-up. There was no significant difference in risk of overdose-related death, though people not transported had higher odds of a subsequent non-fatal overdose event captured in emergency department and outpatient records within 90 days. People transported to hospital had higher odds of using hospital and outpatient services for any reason within 365 days. CONCLUSIONS: Transport to hospital after a non-fatal overdose is an opportunity to provide care for underlying and chronic conditions. There is a need to better understand factors that contribute to non-transport, particularly among people aged 20-59 and people without chronic conditions.

Disparities in rate, triggers, and management in pediatric and adult cases of suspected drug-induced anaphylaxis in Canada.

INTRODUCTION: Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children. OBJECTIVE: We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada. METHODS: Children presenting to the Montreal Children's Hospital (MCH), British Columbia Children's Hospital (BCCH), and Children's Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests. RESULTS: From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases. CONCLUSIONS: Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required.

Anaphylaxis cases presenting to primary care paramedics in Quebec.

Data on anaphylaxis cases in pre-hospital settings is limited. As part of the Cross Canada Anaphylaxis Registry (C-CARE), we assessed anaphylaxis cases managed by paramedics in Outaouais, Quebec. A software program was developed to prospectively record demographic and clinical characteristics as well as management of cases meeting the definition of the anaphylaxis. Univariate and multivariate logistic regressions were compared to assess factors associated with severity of reactions and epinephrine use. Among 33,788 ambulance calls of which 23,486 required transport, 104 anaphylaxis cases were identified (anaphylaxis rate of 0.31% [95%CI, 0.25%, 0.37%] among all ambulance calls and 0.44% [95%CI, 0.36%, 0.54%] among those requiring transport). The median age was 46.8 years and 41.3% were males. The common triggers included food (32.7% [95%CI, 24.0%, 42.7%]), drugs (24.0% [16.4%, 33.6%]), and venom (17.3% [10.8%, 26.2%]). Among all reactions, 37.5% (95%CI, 28.4%, 47.6%) were severe. Epinephrine was not administered in 35.6% (95%CI, 26.6%, 45.6%) of all cases. Males were more likely to have severe reactions (Odds ratio [OR]: 2.50 [95%CI, 1.03, 6.01]). Venom-induced reactions and severe anaphylaxis were more likely to be managed with epinephrine (OR: 6.9 [95%CI, 1.3, 35.3] and 4.2 [95%CI, 1.5, 12.0], respectively). This is the first prospective study evaluating anaphylaxis managed by paramedics. Anaphylaxis accounts for a substantial proportion of the cases managed by paramedics in Outaouais, Quebec and exceeds prior reports of the proportion of Quebec emergency room visits attributed to anaphylaxis. Although guidelines recommend prompt use of epinephrine for all cases of anaphylaxis, more than a third of cases did not receive epinephrine. It is crucial to develop educational programs targeting paramedics to promote the use of epinephrine in all cases of anaphylaxis regardless of the specific trigger.

Cancer screening in patients with systemic lupus erythematosus.

OBJECTIVE: To examine whether patients with systemic lupus erythematosus (SLE) undergo cancer screening according to established guidelines, to compare their reported screening practices with information from the general population, and to examine potential predictors of screening within our SLE sample. METHODS: We conducted a patient survey of cancer screening practices within the Montreal General Hospital lupus cohort. We compared self-reported frequency of cancer screening to guidelines suggested for the general population, and to figures for cancer screening reported in the general population. We also developed logistic regression models to establish potential predictors of screening for patients with SLE, with cervical cancer screening being the outcome of interest in our primary analyses. RESULTS: Of 48 women aged 50-69, 53% (95% confidence interval, CI: 38-68) had had a mammogram in the past 12 months, compared to 74% (95% CI: 73-75) for similarly aged Quebec women. Of 51 subjects aged 50 and older, only 18% (95% CI: 8-34) reported screening (fecal occult blood check with or without endoscopy) within the recommended time frame, compared to 48% (95% CI: 45-51) for colorectal screening for persons > 50 in the general population. Only 9 of 27 patients with SLE aged less than 30 had Pap tests in the past 12 months (33%, 95% CI: 19-52), compared with a general population rate of 56% (95% CI: 53-59) for similarly aged Quebec women. Our logistic regression model suggested that, among the SLE patients, non-whites, those with lower education, and those with higher disease damage scores were less likely to undergo cervical Pap testing. CONCLUSION: These data suggest that appropriate cancer screening may be overlooked in patients with SLE.