Hereditary angioedema (HAE) is a rare autosomal dominant disorder characterized by recurrent episodes of painful swelling without urticaria that leads to substantial morbidity and even mortality if left untreated.

On this episode, Dr. Victoria Cook, an immunologist working in Victoria, BC, describes the case of a woman who had 6 emergency department presentations, 1 hospital admission and saw 5 different specialists over 11 months before finally being diagnosed with HAE.

Drs. Bigham and Omole, then speak with Dr. Ed Etchells about how physicians can work to strip away biases and cognitive obstacles that can prevent timely diagnoses of rare and challenging conditions. Dr. Etchells works in the division of General Internal Medicine at Women's College Hospital in the University of Toronto.

Article discussed

Transcript

CMAJ 

Many families of organ donors describe feeling alone and abandoned at the moment when their loved one is taken to the operating room for donation. Heather Talbot says she and her family were left on their own as her son was wheeled into the OR. The experience left her thinking, “Well, they got what they wanted and they’ve moved on.”

A qualitative study in CMAJ examined the experiences of donor families. They found that many families felt unsupported at critical transition periods. Authors of The experiences of family members of deceased organ donors and suggestions to improve the donation process conducted 271 in-depth interviews with family members of organ donors.

On this episode, Drs Bigham and Omole speak with the study’s lead author Dr. Aimee Sarti. Dr. Sarti is an ICU physician in Ottawa. But first, they speak with Heather Talbot. Ms. Talbot’s son Jonathan became an organ donor after his death in 2009.

Functional Neurological Disorders (FND) make up a significant portion of referrals to neurology, maybe as high as 30%. However, misconceptions regarding these disorders remain across medicine, and patients are frequently dismissed as “faking it.”

FND are neuropsychiatric conditions in which patients experience neurologic symptoms due to a “functional” disruption of brain networks rather than a “structural” disorder of the nervous system. 

On this episode, Drs Bigham and Omole speak with Peter Gill, a patient with FND. Mr. Gill describes his seven-year journey to diagnosis and his recent success with various approaches to therapy.

Next, Drs Bigham and Omole speak with Dr. Matthew Burke, a cognitive neurologist at Sunnybrook Hospital in Toronto and an expert in FND. They discuss the current understanding of the disorder, diagnostic criteria and therapeutic options.

Links:

Neurosymptoms.org

Functional neurologic disorder associated with SARS-CoV-2 vaccination

CMAJ

When contemplating issues of diversity and inclusion, medicine needs to consider menopause. A commentary in CMAJ argues that discussion about and, where needed, accommodation of menopause is a necessary step toward providing women physicians with a supportive and comfortable work environment.

On this episode, Drs. Bigham and Omole speak with the lead author of the commentary “Hot Flash: Experiencing menopause in medicine.” Dr. Marie Christakis is an OB-GYN at St Michael’s hospital in Toronto. She has completed a fellowship in Menopause and Mature Women’s Health at Mount Sinai Hospital.

They discuss why there has been little discussion on the effect, and potential burden, of menopause on mature- or potentially peak-career women physicians. And they explore what needs to be done to better support physicians through menopause.

Drs. Bigham and Omole also speak with Dr. Kim Wynd, an anesthesiologist who practices in Peterborough Ontario, about her experiences during menopause. Dr. Wynd began having symptoms of perimenopause in her early 40s at a time when her practice was thriving. 

This is an encore presentation of our most popular episode of the past year.

Postural orthostatic tachycardia syndrome (POTS) is a disorder that can profoundly affect patients' quality of life. Its main characteristic is tachycardia on standing without a drop in blood pressure. Patients complain of lightheadedness and palpitations when upright, which sometimes leads to syncope. This can cause substantial functional disability, which may be economically devastating.

Despite these serious consequences for patients, diagnosis can be delayed up to 6 years.

In this episode, Dr. Satish Raj, author of the recent CMAJ narrative review article Diagnosis and management of Postural Orthostatic Tachycardia Syndrome talks to our hosts about difficulties in making the diagnosis of POTS, its complex range of comorbidities, how patients are typically affected by the syndrome and treatment options.

The short answer to this question, according to a new guideline published in CMAJ, is “No.”

In this special episode, CMAJ editor in chief, Dr. Kirsten Patrick, talks to Dr. Eddy Lang, lead author of the guideline entitled Recommendation on instrument-based screening for depression during pregnancy and the postpartum period produced by the Canadian Task Force on Preventive Health Care. They discuss why there’s not enough evidence to support a recommendation to screen routinely, why that doesn’t mean that depression in pregnancy and the postpartum period is not important to diagnose, and in what circumstances use of a screening instrument might be helpful.

Blair and Jola will be back next episode.

In an effort to reduce the high burden of injury in Canadian youth ice hockey, most associations have restricted bodychecking nationally among leagues for younger players (age 11–12 yr), as well as in certain nonelite divisions of play in older age categories (age 13–17 yr.) This has been shown to be associated with reduced rates of injury, including concussion. 

However, despite the evidence, some argue that gaining earlier bodychecking experience may protect young players from injuries, including concussions, later on when they progress to play in leagues where bodychecking is allowed.

A study published in the CMAJ entitled Bodychecking experience and rates of injury among ice hockey players aged 15–17 years found the opposite, however. Players with more experience in bodychecking had a greater incidence of concussion.

On today’s episode, Drs. Omole and Bigham speak with two authors of the study. Paul Eliason is a postdoctoral fellow in the Sport Injury Prevention Research Centre at the University of Calgary and Carolyn Emery is a physiotherapist and epidemiologist at the University of Calgary.

They discuss the new study’s findings and their implications for policy in youth hockey. They also explore how hockey compares to other contact and non-contact sports and discuss how to keep kids both active and safe in sport.

Drug shortages are a persistent problem in Canada and around the world. They interfere with patients’ ability to consistently take medication to manage chronic diseases. And they disrupt urgent care as critical drugs like epinephrine and propofol face shortages. 

The COVID-19 pandemic led to concerns that the pandemic would exacerbate existing issues with drug shortages in Canada. Canadian policy-makers responded with several important measures in March 2020 in an attempt to ensure a steady supply of medication.

On this episode, Mina Tadrous discusses the impact of those measures as well as the ongoing challenges to Canada’s supply of pharmaceuticals. Mina Tadrous is coauthor of the paper, “COVID-19 in the prevalence of drug shortages in Canada,” published in CMAJ. He's an assistant professor at the University of Toronto. 

Drs. Bigham and Omole also speak with Andrew MacIsaac about the role Canadian manufacturing can play in easing the problem of drug shortages. Andrew Maclsaac is the CEO of Applied Pharmaceutical Innovation, or API. API is partnered with University of Alberta to create the Canadian Critical Drug Initiative. One of its goals is to make Canada less vulnerable to drug shortages. 

Links:

COVID-19 in the prevalence of drug shortages in Canada

Canadian Critical Drug Initiative

Applied Pharmaceutical Innovation

CMAJ

The author of a new study in CMAJ says the risk of suicidality among transgender youth, “is really a crisis.”  

Mila Kingsbury and her co-authors found that trans and non-binary teens were as much as 7 times more likely than cishet peers to have thought about or tried suicide. More than half of the trans 15-17 year olds in a nationally-representative Canadian survey said they’d thought about suicide, and about 40% had attempted suicide in their lifetime.

The research entitled Suicidality among sexual minority and transgender adolescents drew its data from the 2019 Canadian Health Survey on Children and Youth, a carefully-conducted cross-sectional survey. The researchers used a sub-sample of 6800 15-17 year olds.  

On this episode,  Drs. Blair Bigham and Dr. Mojola Omole discuss the implications of the study’s findings with one author, Mila Kingsbury. They then speak with Dr. Tyler Black, medical director of the pediatric psychiatric emergency inpatient unit at British Columbia Children's Hospital. He discusses the research on transgender teens in the broader context of what’s known about suicide risk amongst adolescents in Canada.

This episode focuses extensively on the issue of suicide.

If you are in crisis:

Call 911 or go to the nearest hospital.

Call the Canada Suicide Prevention Service (available 24/7) at 1-833-456-4566. For residents of Quebec, call 1 866 APPELLE (1-866-277-3553).

People who use drugs are at elevated risk of death due to the toxic illicit drug supply. Providing easy access to a supply of safe, clean substances may reduce overdose deaths, decrease harms associated with substance use, and improve users’ trust in addiction care. 

Safer Alternatives for Emergency Response (SAFER) is a low-barrier, flexible safe supply program that provides several replacement options for people who use illicit drugs, including fentanyl, and is integrated with other healthcare and social services. 

In this episode, Drs. Omole and Bigham speak with two physicians who work with the SAFER initiative. Dr. Sukhpreet Klaire is the lead author of the article in CMAJ entitled Low-Barrier, Flexible Safe Supply to Prevent Overdose. He is an addiction medicine specialist working in Vancouver. Dr. Melanie van Soeren is a family physician and addiction medicine specialist in Vancouver.

Drowning accounts for hundreds of deaths in Canada every year. A study published in CMAJ examines how pre-existing medical conditions contribute to drowning deaths. Drs Mojola Omole and Blair Bigham speak with the study’s lead author Dr. Cody Boone about what the study’s findings mean for physicians and patients.

They then speak with Audrey Giles, a professor of human kinetics at the University of Ottawa, about the high rates of drownings experienced by Northern Indigenous communities in Canada. Professor Giles has spent decades working with people in Northern regions to adapt and customize water safety programs so that they meet communities’ specific cultural and practical needs. She discusses issues from cold water drowning to cultural safety. 

Links:

The link between medical conditions and fatal drownings in Canada: a 10-year cross-sectional analysis

Decades of water safety training culturally “irrelevant” to First Nation people

CMAJ

In this episode, Dr. Kaveh Shonjania argues that despite the billions of dollars spent on clinical and quality improvement research, most of the interventions that are studied are shown not to work and those that do work produce only marginal benefits for some patients.

Dr. Shojania is the Vice Chair of Quality and Innovation for the Department of Medicine at the University of Toronto and past Editor-in-Chief of BMJ Quality and Safety. He joins Drs. Blair Bigham and Mojola Omole to discuss a study published in CMAJ recently, entitled Inappropriate Use of Clinical Practices in Canada: A Systematic Review, in which the authors sifted through 174 studies to identify ineffective clinical practices that are either overused, effective practices that are underused, or other practices that are just misused..  

Dr. Shojania wrote a short commentary related to the study, entitled What problems in health care quality should we target as the world burns around us? In which he called for health research resources to be shifted more towards research on the social determinants of health, for a greater return on investment.  Drs. Bigham, Omole and Shojaniadiscuss how this might actually work in practice.

A study of more than 3000 health care leaders in Canada found that while gender parity was present, racialized executives were substantially under-represented. Diversity among health care leaders in Canada: a cross-sectional study of perceived gender and race was published in CMAJ. It found that at the ministry level fewer than 7 percent of health care leaders were racialized. 

The representation gap between racialized executives in healthcare and the racial demographics of the population it serves ranged from a low of 7.3% for Prince Edward Island to a high of 27.5% for Manitoba. The gap was highest in geographic locations with a greater percentage of racialized residents. 

On this episode, Drs. Omole and Bigham speak with the lead author of the study Anjali Sergeant, a final year medical student at McMaster University.  She describes how researchers determined race, compares results in different parts of the country and discusses how closely the results of the study reflect what she is seeing in her medical school cohort.

Drs Omole and Bigham also speak with Anna Greenberg, the Chief Regional Officer, Toronto and East for Ontario Health. Ms. Greenberg is also the agency’s Executive Lead for Equity, Inclusion, Diversity, and Anti-Racism. She discusses the efforts her agency is making to address this disparity. She also explains why it is important for healthcare leaders to ask themselves, “Why does this matter?”

COVID-19 disrupted the medical licensing examination system in Canada.  During the pandemic,  exams delivered by The College of Family Physicians of  Canada  (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) were delayed, canceled or adapted, disrupting the lives of hundreds of physicians.

However, those challenges prompted many to rethink the historical approach to medical licensure in Canada. 

In this episode, Drs. Brent Thoma and Teresa Chan discuss their proposal to shift away from all-or-nothing examinations and towards a system of graduated licensure. They are two authors of a recent CMAJ commentary entitled Replacing high-stakes summative examinations with graduated medical licensure in Canada.

Dr. Thoma is an emergency and trauma physician in Saskatoon and an associate professor of emergency medicine at the University of Saskatchewan.  Dr. Chan is an associate professor of medicine at McMaster University, where she is the Associate Dean of Continuing Professional Development.

Postural orthostatic tachycardia syndrome (POTS) is a disorder that can profoundly affect patients' quality of life. Its main characteristic is tachycardia on standing without a drop in blood pressure. Patients complain of lightheadedness and palpitations when upright, which sometimes leads to syncope. This can cause substantial functional disability, which may be economically devastating.

Despite these serious consequences for patients, diagnosis can be delayed up to 6 years.

In this episode, Dr. Satish Raj, author of the recent CMAJ narrative review article Diagnosis and management of Postural Orthostatic Tachycardia Syndrome talks to our hosts about difficulties in making the diagnosis of POTS, its complex range of comorbidities, how patients are typically affected by the syndrome and treatment options.

Physicians working in hospitals see the mountains of medical waste generated each day. Meanwhile, the climate crisis challenges the medical system to reduce its contribution to greenhouse gas emissions. Globally, healthcare systems contribute as much carbon dioxide as the airline industry. In Canada, healthcare accounts for 4.6% of our total emissions. The problem is urgent, but potential solutions are both easier and more complex than many might think. 

Guests on this episode are advocates in the climate and health space. Dr. Samantha Green is the co-author of the CMAJ article, Five Things to Know About Metered Dose Inhalers and their Impact on Climate Change. She's a family physician at Unity Health Toronto and the climate and health lead at the University of Toronto's Department of Family and Community Medicine.

In the article, she and her co-authors point out that pressurized metered-dose inhalers (pMDIs) are an important contributor to greenhouse gas emissions.  Dr. Green says measurements done in the United Kingdom by the National Health Service found that MDIs contribute 3.1% of the entire health system's carbon emissions. One MDI contributes the equivalent of driving 290km by car.

Meanwhile, dry powdered inhalers (DPIs) and soft mist inhalers (SMIs) are effective available alternatives with lower environmental impact. Dr. Green encourages physicians to make the switch for eligible patients and explains how her clinic has created resources to facilitate the prescribing change.

Addressing such low-hanging fruit of climate action in the healthcare system is important but, according to Dr. Andrea MacNeill, reducing waste, changing prescriptions, and recycling are the tip of the iceberg. What’s really needed is profound systemic change. Dr. MacNeill argues that emissions are driven by a system focused on providing the most complex and carbon-intensive care. 

“New healthcare funding seems to go into very complex resource-intensive treatments that modify very advanced disease processes. And I would suggest that we need to shift that focus upstream and start to think, okay, could we have prevented this from ever happening? And in many cases, the answer to that is yes,” says Dr. MacNeill.

Along with a focus on prevention, Dr. MacNeill argues healthcare systems need to put pressure on the supply chain, which accounts for the bulk of emissions. In England, the NHS is demanding that vendors match the NHS's climate target to decarbonize by 2030.

 Links to resources discussed on the episode:

Inhaler Toolkit for Physicians

Cascades

Planetary Health Lab

The clinical teaching unit is a widely-used clinical training model that requires reform to prepare physicians for practice in the 21st century.

In a systematic review in CMAJ, Dr. Brandon Tang and co-authors identified practices in internal medicine clinical teaching units that contribute to improved clinical education and health care delivery.

Dr. Tang, a PGY4 in general internal medicine at the University of Toronto, speaks with Drs. Blair Bigham and Mojola Omole about the findings of the review, his experience with CTUs, what inspired him to look into the research, and his thoughts on how CTUs can be reimagined to improve both learner and patient outcomes. 

Drs. Bigham and Omole then speak with Dr. Lisa Richardson, a clinician-educator in the U of T’s Division of General Internal Medicine, about other aspects of medical training that are due for a rethink.

Dr. Richardson, who also practices at the University Health Network and is an Education Researcher at the Wilson Centre, argues that medical training needs to create space for learners to bring their whole selves to their educational experience, rather than struggle to conform to a narrower sense of what it means to be a physician.

CMAJ is the journal of the Canadian Medical Association.

Reported gonorrhea cases have more than doubled in recent years. Untreated gonorrhea may occasionally cause potentially fatal conditions, such as infective endocarditis. 

In this episode, Dr. Carl Boodman, infectious disease and medical microbiology fellow at the University of Manitoba, discusses a case of disseminated gonococcal infection in a 54- year old man who presented to ER with a new heart murmur. The case was described in a recent CMAJ article, which explains that the patient had developed an aortic root abscess and a fistula from his right ventricle to the aortic root.

Dr. Boodman tells Dr. Blair Bigham and Dr. Mojola Omole that, while severe cases of disseminated gonococcal infection such as this remain relatively rare, he is seeing more of them in Manitoba. He emphasizes the importance of detecting and treating gonococcal infection before it has a chance to progress.

Gonorrhea is just one of the bacterial STIs on the rise. Drs. Bigham and Omole also speak with Dr. Jason Wong, a Public Health and Preventive Medicine specialist in BC, about what’s behind the rise in STIs and about what lessons can be learned from the relative decline in HIV infections.

Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel; however, the rate of maternal trauma following OVD in Canada greatly exceeds that of any other OECD country. In Canada, maternal trauma occurred in more than one-quarter of deliveries with forceps, whereas in the UK, the rate is 8%-12%, and in Australia, it sits at ​​9.3%-14.1%.

A research study published in CMAJ found that rates of trauma following OVD in Canada are higher than previously reported, irrespective of region, level of obstetric care and volume of instrument use among hospitals. The authors argue these results support a reassessment of OVD safety in Canada. 

In this episode, Dr. Bigham and Blair and Dr. Mojola Omole speak with Dr. Giulia Muraca, the lead author of Maternal and neonatal trauma following operative vaginal delivery: a national cohort study. They explore possible causes for these troubling findings.

They then speak with Dr. Nirmala Chandrasekaran, an OB/GYN and Maternal-Fetal-Medicine specialist at St. Michael’s hospital in Toronto. Dr. Chandrasakan trained in the UK, and she describes how exposure to OVD during residency differs in the two countries. She also discusses the vital role OVD plays in safe deliveries.

People with kidney failure who live in rural and remote areas of Canada do not have the same access to the full suite of dialysis modalities as urban dwellers. Many need to relocate for life-sustaining renal replacement therapy. Often this means moving hours away from their home communities for months, sometimes years, at a time.

In this episode, hosts Drs. Mojola Omole and Blair Bigham speak with Dr. Aaron Trachtenberg, a nephrologist at the University of Manitoba about his commentary in CMAJ, in which he and coauthors argued that patients who must leave their home communities for dialysis should be prioritized for the allocation of deceased donor kidney transplants.

They also speak with Vanessa Tait whose father needed to relocate to Winnipeg, twelve hours away from his home community of O-pipon-na-piwin Cree Nation, for dialysis. Ms. Tait became a living donor to her father in an effort to bring him back home. She talks about the toll relocation takes on patients from remote communities.

Commentary in CMAJ
CMAJ

The CMAJ podcast is taking a break for one episode as everyone enjoys their holidays and gets prepared for the year ahead. In this brief chat, Mojola and Blair preview some of the upcoming episodes and wish all our listeners a happy and safe holiday.

One simple question can offer clinicians a powerful insight into the lives of their vulnerable patients. Asking, “Do you ever have trouble making ends meet at the end of the month” can help physicians identify significant barriers to restoring the health of their patients.

The link between the social conditions in which we live and health outcomes is well-known. However, health provider action to address the social determinants of health is an emerging area of practice innovation and research. This episode looks at what social prescribing looks like in action and what the evidence tells us about its effectiveness.

Drs. Mojola Omole and Blair Bigham speak with Janet Rodriguez, a patient at St. Michael’s Family Health Care Clinic in Toronto. She describes the profound impact social interventions had on her physical and mental health.  

They also speak with Dr. Gary Bloch, a family physician at St. Michael’s Family Health Care Clinic and a co-author of the analysis published in CMAJ titled “An Evidence-Based Guide to Social Interventions in Primary Care.”

The pandemic recovery period presents an opportunity to address health inequities that have led to an unfair distribution of the burden and harms of COVID-19. 

New guidance for policy published in CMAJ  proposes 13 practical ways to address inequities exposed and worsened by COVID-19 in the pandemic recovery period, based on evidence that was accumulating before the pandemic.

In this special episode of the podcast, CMAJ interim editor-in-chief Dr. Kirsten Patrick talks to Dr. Nav Persaud, lead author on the new guideline, about its genesis, the evidence underpinning its recommendations, and the importance of positioning equity at the centre of policy-making as Canada emerges from the pandemic.

Pain is one of the most common complaints among patients visiting the ER, and pain management has become a quality of care indicator. But the options available for the treatment of acute pain that isn’t controlled by over-the-counter medications are limited. 

With the opioid epidemic leading physicians to avoid prescribing narcotics, the anaesthetic drug, ketamine, is being reconsidered for the treatment of pain, as well as other indications. 

A practice article  in CMAJ argues that ketamine is an underutilized and effective analgesic and a safer alternative to opioids for the management of acute pain, with reported adverse effects at low doses occurring at the same frequency as placebo. 

In this episode, Blair and Mojola speak to Dr. William Silverstein, a co-author of the practice article “Five things to know about the use of ketamine in the treatment of acute pain” about ketamine’s indications and contraindications, how to prescribe it in the ambulatory care setting, and practical steps physicians can take to add ketamine to their pain-busting arsenal.

They also speak with Dr. Marshall Ross, a physician who also uses ketamine as an emergency physician, but has also pioneered its use in patients with treatment-resistant depression, using cutting edge techniques.

One in four women physicians report a diagnosis of infertility. One reason for this is physicians tend to delay attempts to become pregnant until “the time is right” for their career.  But, in the medical profession, it seems there is really no “good” time to have children. Parenthood, especially motherhood, is seen as an inconvenience during medical training and beyond. 

In this episode, Dr. Sophia Park speaks with hosts Dr. Mojola Omole and Dr. Blair Bigham about her personal struggle with infertility. And, Dr. Andrea Simpson, the lead author of a commentary in the CMAJ titled, “The inconvenience of motherhood during a medical career”  calls for systemic change in medicine to support parenthood.

Dr. Sophia Park is a medical biochemist at Royal Columbian Hospital and a Clinical Associate Professor at the UBC Department of Pathology and Laboratory Medicine.

Dr. Andrea Simpson is an obstetrician and minimally invasive gynaecologic surgeon at St. Michael’s Hospital. She is also an assistant professor at the University of Toronto.

She co-authored her commentary with Drs. Maria Cusimano and Nancy Baxter. It is published in CMAJ: https://www.cmaj.ca/content/193/37/E1465

Episode transcript: https://www.cmaj.ca/transcript-211255

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