bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of 1-and 2- Minute Sitting Position Versus Immediately Lying Down of Hemodynamic Variables after Spinal Anesthesia with Hyperbaric Bupivacaine in Elective Cesarean Section
Authors:   M.B.Ch.B./FICMS A&IC/Al Shaheed Dr.Fairuz Hospital/Wasit Health Directory/ Ministry of Health and Environment, Iraq., Dawood Dr. Ahmed Salam , Latef Dr. Aimen Hameed ,   M.B.Ch.B./DA/FICMS A&IC/Consultant Anesthetist.
Published: September 2021

the aim of current study: was Comparison of 1-and 2- minute sitting position versus immediately lying down on hemodynamic variables after spinal anesthesia with hyperbaric bupivacaine in elective cesarean section. Patients and methods: This study was performed after the approval of the Iraqi Council for Medical Specialization in anesthesia and intensive care, and after obtaining the consents from 90 pregnant women (at term) who were candidate for cesarean section with spinal anesthesia were recruited in this study. They were collected from “AL-Imamain AL-Kademain Medical City Teaching Hospital” (July 2017 – January 2018) , All patients were premedicated with 10mg IV metoclopramide and 50mg IV ranitidine , Base line blood pressure and the pulse rate were recorded initially before intervention , the Lumbar puncture was performed in the sitting position under full aseptic teqnique , For assessment of blood pressure and pulse rate, ten readings were taken at (3, 5, 10, 15, 20, 25, 30, 35,40and 60 min) using an automated noninvasive blood pressure. Pulse rate monitored by electrocardiogram and oximetry (SPO2). Results: Current study showed higher means of pulse rate than the other two groups especially at early times after anesthesia induction. On the other hand, both group A1 and A2 showed higher mean of systolic, diastolic and mean blood pressure than group B especially 3, 5, 10 and 15 minutes after anesthesia induction, so the variation of pulse rate over the time in the three groups. Group B had higher pulse rate Journal of University of Shanghai for Science and Technology ISSN: 1007-6735 Volume 23, Issue 9, September – 2021 Page-7882 than the other two groups at 3,5,10, 25 and 40 minutes with significant difference (P8 in all groups. Conclusions: This study revealed that the patient’s position is an important factor, which affects the frequency of Hypotension and the onset of sensory block , as well as Administration of spinal anesthesia for cesarean section. Based on the findings, keeping the parturient seated for 1 Or 2 minutes after spinal anesthesia, compared to immediately lying down, could decrease the frequency of hypotension.
A comparison of sedation with midazolam–ketamine versus propofol–fentanyl during Endoscopic retrograde cholangiopancreatography in adults
Authors:   M.B.Ch.B., Dhi Qar Al-Rifa’I hospital., Alhajemi Dr.Ghassan Dakhel Ridha , Salman Prof. Dr. Ayad Abbas ,   M.B.Ch. B / DA/F. I.C.M.S /CAB&IC/FIPP, Acting chairman of the Scientific Counsel of Iraqi Board Of Anesthesia and Intensive Care Baghdad-Iraq.
Published: September 2021

Background: Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) require adequate sedation or general anesthesia. This prospective clinical study investigated the safety and efficacy of midazolam -Ketamine versus propofol-fentanyl during ERCP procedures. patients and Methods: The study included 80 patients who underwent ERCP following anesthesiologist-administered sedation with fentanyl-propofol and other group midazolam-Ketamine. Procedural data, oxygen saturation, blood pressure, heart rate, recovery time, discharge times the effectiveness of sedation during the procedure was assess according to Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scores. Results: Sedation related complications occurred in 13 of 40 patients in group Ketamine – midazolam and 5 of 40 patients in group fentanyl-propofol included nausea / vomiting, agitation and headache. Most events were minor and did not necessitate discontinuation of the procedure. Successful cannulation was performed in all patients. the time of recovery was significantly lower in group MK with 5.15 ± 1.3 min compared to 6.15 ± 2 in group FP, and discharge was significantly. lower in group FP with 20.35 ± 0.7 min, compared to 24.15 ± 3.4 min in group MK. this occurred due to the number of patients who had side effects in midazolam-Ketamine group was more than the other group. Conclusion: We concluded that FP, more suitable for sedation and less complications rather than MK. Although no significant complications were seen.
Comparison of hemodynamic effect between the spinal anesthesia and saddle block during transurethral resection of the prostate
Authors:   M.B.Ch. B/ F.I.B.M.S. , A &ICU/Ibn Al-Bitar specialized center for cardiac surgery., Abdulqader Dr. Farooq Taher , Mohammed Dr. Ali Abd-Alhameed ,   Consultant Anesthetist/M.B.Ch. B /D. A/F.I.B.M.S /F.A.C.M.S A&IC.
Published: September 2021

Background: The best technique for transurethral resection of prostate (TURP) is regional anesthesia. The hypotension is the major complication following spinal anesthesia. The hemodynamic changes is less with saddle block than spinal block. Aim and Objective: To compare hemodynamic effect between the spinal block and saddle block in TURP. Patients and methods: 50 patients between 50-70 years old ASA I – II prepared for TURP, divided randomly in two groups 25 pt. in each group. Group A received spinal 10 mg of hyperbaric bupivacaine (2 ml of 0.5%), were group B received saddle block 10 mg of hyperbaric bupivacaine (2 ml of 0.5%). The blood pressure, oxygen saturation, heart rate measured and recorded subsequently. The hypotension treated by 100 mcg bolus of phenylephrine. Results: In our study there was statically significant difference (p < 0.05) between group A which received spinal anesthesia and group B which received saddle block in hemodynamic effect. In which the incidence of hypotension and vasopressor requirement more in group A. Conclusion: Under saddle block the TURP can safely performed with low risk of hypotension and less requirement of vasopressor.
Handle outliers for Frechet distribution
Authors:   Higher Institute of Information Technology Badr City, Cairo., Ibrahim Hager Ahmad
Published: September 2021

This paper aims to handle outlier data for Frechet distribution. This study focused on two ways to deal with outliers. The rst way is to censor the ob- servation with the same percentage of outlier data. The second way is to trim outlier observations. A Monte Carlo simulation study is carried out to compare these ways in terms of estimate average, relative bias, and root mean square error (RMSE) using Mathematica-10.
Review On Ayurvedic Remedies For Fungal Infection
Authors:   Appasaheb Birnale College of Pharmacy, Sangli., S.S Jadhav , N.S Naikwade ,   Appasaheb Birnale College of Pharmacy, Sangli., R.B Hake ,   Appasaheb Birnale College of Pharmacy, Sangli., R.S Gavade ,   Appasaheb Birnale College of Pharmacy, Sangli., J.J Pawar ,   Appasaheb Birnale College of Pharmacy, Sangli., H.A Shingade ,   Appasaheb Birnale College of Pharmacy, Sangli.
Published: September 2021

In underdeveloped countries, microorganisms are frequently a cause of prevailing diseases, presenting a serious public health problem in a significant segment of the population as revealed by either private or officially granted health care systems. With the rise in-at risk patients, the number of invasive fungal infection has dramatically increased in both developed and developing countries. An antifungal drug is a medication used to cure fungal infections such as candidiasis (thrush), athlete’s foot, ringworm, serious systemic infections such as cryptococcal meningitis, and others. Such drugs are usually adviced by a medicinal practioner or purchased over-the–counter. But use of this types of drugs used in large way makes the unusable due to resistance to antibiotics and with the toxicity during prolonged treatment. There are large number drawback in synthetic drugs so people move towards herbal drugs which is safer. The presented review summarizes the information about introduction, treatment, herb and medicine for fungal infection and concerning the new profile of antifungal drugs obtaining from medicinal plants.
Quantum Computers - An Emerging Cybersecurity Threat
Authors: Jelčić Dubček Dajana
Published: September 2021

Quantum computational supremacy may potentially endanger the current cryptographic protection methods. Although quantum computers are still far from a practical implementation in information processing and storage, they should not be overlooked in the context of cybersecurity. Quantum computers operate with qubits - units of information that are governed by the fundamental principles of quantum physics, such as quantum superposition of states and quantum coherence. In order to address the new challenge that quantum computers pose to cybersecurity, the very principles of their operation have to be understood and are overviewed in this contribution.
Transcatheter Aortic Valve Implantation for Patients with Severe Symptomatic Aortic Stenosis
Authors: Young Calvin , Horton Jennifer
Published: September 2021

The cost-effectiveness of transcatheter aortic valve implantation (TAVI) compared to surgical aortic valve replacement was examined in patients with severe symptomatic aortic stenosis at high, intermediate, and low surgical risk, and the findings were mixed. When compared to surgical aortic valve replacement, some studies suggest that TAVI is cost-effective (less costly and/or more effective) and some studies suggest that TAVI is not cost-effective.

Factors such as the type of TAVI system used, the cost of treatment-associated expenses (such as post-operative follow-up costs and hospitalization costs), and the characteristics of patients selected for treatment likely impact the cost-effectiveness of TAVI for patients with severe symptomatic aortic stenosis.
Autologous Hematopoietic Stem Cell Transplantation for the Treatment of Multiple Sclerosis
Authors: Basharat Sinwan , Loshak Hannah
Published: September 2021

Autologous hematopoietic stem cell transplantation is an emerging health technology for treating multiple sclerosis, in particular for relapse-remitting forms of the disease. In 2019, transplant societies in the US and Europe both indicated the procedure may be provided as a standard of care for a subset of people with multiple sclerosis based on age and clinical classification criteria. The Canadian Multiple Sclerosis Working Group indicated in their 2020 treatment optimization recommendations that autologous hematopoietic stem cell transplantation may be considered for younger people (aged 18 to 31) who are early in their treatment course. The procedure is offered in 2 provinces, Alberta and Ontario, as an experimental treatment.

Results from a phase III randomized controlled trial, a systematic review of single-arm trials, and retrospective analyses from European transplant registries provides evidence that the procedure may provide effective disease control for patients who show high disease activity despite receiving disease-modifying therapies. Evidence also shows that the safety profile of the procedure has been improving over the past 25 years.

Although cost-effectiveness studies are not yet available, the one-time procedure may have important economic implications and may have the potential to provide cost-savings to health systems, as it may reduce the need for ongoing disease-modifying therapies that may be required for patients throughout their lives.

At least 3 additional phase III randomized controlled trials are ongoing and aim to provide a stronger evidence base to inform optimal treatment regimens and appropriate eligibility criteria. As results from these studies develop, this horizon scan aims to provide health care stakeholders in Canada with an early overview of the technology and existing evidence, while highlighting considerations related to health equity, the need for multidisciplinary care, and transplant centre infrastructure that would be important if there is to be wider use across Canada should emerging evidence demonstrate value.
Vitamin D Supplementation for the Prevention and/or Treatment of Cardiovascular Disease, Cancer, and Other Conditions in Residents of Long-Term Care Facilities
Authors: Farrell Keeley , Horton Jennifer
Published: September 2021

The results of 1 systematic review suggest that supplementation with vitamin D may provide some benefit for cancer-related mortality in older adults. It is unclear whether there is a benefit of vitamin D supplementation for all-cause mortality; however, no benefit was found for cardiovascular disease mortality, cardiovascular disease events, or cancer incidence.

There is limited and mixed evidence on the effectiveness of vitamin D supplementation for dementia and mild cognitive impairment in older adults.

The results of 1 systematic review suggest that vitamin D supplementation may provide protection against acute respiratory infections in the overall population; however, this result was not significant in the subgroup of patients older than 65 years.

No evidence-based guidelines were identified regarding vitamin D supplementation for the prevention and/or treatment of cardiovascular disease, cancer, and other conditions in elderly patients residing in long-term care facilities.
Point-of-Care Testing and N-Acetylcysteine for Acute Acetaminophen Overdose
Authors: Tran Khai , Horton Jennifer
Published: September 2021

Evidence on the clinical utility and cost-effectiveness of point-of-care devices could not be identified.

Two evidence-based guidelines recommend a 2-bag regimen of N-acetylcysteine, consisting of both a loading dose and maintenance dose, administered by IV for patients with acute acetaminophen overdose.
Encorafenib (Braftovi) in Combination With Binimetinib (Mektovi)
Authors: Team Reimbursement
Published: September 2021

CADTH recommends that Braftovi in combination with Mektovi should be reimbursed by public drug plans for the treatment of unresectable or metastatic melanoma with a BRAF V600 mutation if certain conditions are met.

Braftovi and Mektovi should only be reimbursed if used in combination and prescribed and monitored by clinicians with expertise in diagnosis and management of melanoma who are familiar with the toxicity profile associated with the Braftovi with Mektovi regimen and if it does not cost more than the least costly BRAF inhibitor and MEK inhibitor (BRAFi/MEKi) combination treatment.

Braftovi with Mektovi should only be covered to treat adult patients with advanced or metastatic melanoma who have a BRAF V600 gene mutation that has been identified through a validated test. Patients who have not received previous treatment and patients whose disease has progressed after first-line immunotherapy are eligible for coverage.
Encorafenib (Braftovi)
Authors: Team Reimbursement
Published: September 2021

CADTH recommends that Braftovi should be reimbursed by public drug plans for the treatment of metastatic colorectal cancer (mCRC) if certain conditions are met.

Braftovi should only be reimbursed when given in combination with cetuximab, prescribed by clinicians with experience in treating colorectal cancer, and the cost of Braftovi is reduced.

Braftovi should only be covered for patients who have BRAF V600E–mutated mCRC, have received at least 1 previous systemic treatment for mCRC, have good performance status, and have adequate organ function. Braftovi should not be reimbursed for patients who have had previous treatment with epidermal growth factor receptor (EGFR) inhibitors or BRAF inhibitors.
Drugs for Rare Diseases: A Review of National and International Health Technology Assessment Agencies and Public Payers’ Decision-Making Processes
Authors: Team Reimbursement Review
Published: September 2021

Drugs for rare diseases can address significant unmet therapeutic needs for patients living with seriously debilitating and life-threatening conditions; however, the high costs of these drugs can pose challenges for public drug programs and health care systems.

There are challenges with the application of standard health technology assessment methods for the assessment of drugs for rare diseases, including uncertainty with the clinical and economic evidence due to small sample sizes, poorly characterized natural history of disease, uncertain epidemiology, absence of comparative studies, heterogenous phenotypes, and lack of diagnostic accuracy. In addition, there are challenges applying commonly accepted economic benchmarks due to the very high cost of these drugs.

To address these challenges, agencies and public payers have established separate or modified processes and programs to review and make reimbursement recommendations for drugs for rare diseases. There is a lack of consistency across agencies with respect to how drugs for rare diseases are defined and what aspects of the process are modified to address the challenges with these drugs; however, common features include greater acceptance of uncertainty with the clinical and economic evidence and a higher willingness-to-pay threshold.

The majority of health technology assessment agencies have highlighted that drugs for ultra-rare diseases are particularly challenging and warrant special consideration. This includes the creation of completely separate review processes for drugs indicated for use in the treatment of ultra-rare conditions in the UK (both England and Scotland).

The majority of processes for funding drugs for rare diseases by public drug programs included in this report manage the drugs through standard formulary processes involving the use of special authorization to ensure that patients meet the eligibility criteria for the drugs. Those that have specialized formularies have largely focused on providing access to ultra-rare conditions.
Deliberative Appraisal Processes in Health Technology Assessment
Authors: Richardson Marina , Mittmann Nicole , Kaunelis David
Published: September 2021

Deliberation — the bringing together of individuals with multiple perspectives, experiences, and values to critically examine evidence, share reasons and rationales, and reach a decision on a course of action — occurs at all stages of the health technology assessment (HTA) process.

The focus of this report is on deliberation at the committee appraisal stage of HTA.

The objectives are to review and conceptualize the evidence and key considerations for deliberative processes at the committee appraisal stage of HTA and the available guidance for assessing the quality of the deliberative process at this stage.

National and international practices for deliberative processes at the committee appraisal stage of HTA vary depending on contextual considerations (e.g., type of health technology and the medical condition being treated), the mandate of the HTA organization, health system and funding structures, and societal values.

Each aspect of the deliberative appraisal process should be rooted in the values of the health system and be principled, clear, transparent, purposeful, and reasoned.
Treat and Release for Patients Requiring Emergency Medical Services
Authors: Young Calvin , Horton Jennifer
Published: September 2021

“Treat and release” and “treat and refer” protocols or practices refer to the onsite treatment of patients by responding emergency medical services personnel that does not involve transporting patients to health care facilities for additional assessment and treatment. The goal of these protocols is to allow patients to be released from care or to be referred directly to non-emergency services by emergency medical services personnel when appropriate, diverting patients from emergency departments.

One health technology assessment that included a relevant randomized controlled trial and economic evaluation and 2 non-randomized studies were identified for inclusion. These studies examined treat and release or treat and refer protocols for treating hypoglycemia and exertional heat stroke, and for attending to older people following a fall.

Overall, the clinical evidence summarized in this report suggests that treat and release protocols are as good as, or better than, usual care (i.e., onsite treatment of immediate medical care followed by transportation to health care facilities). Across most reported outcomes, there were no significant differences between patients who received care using treat and release or treat and refer protocols, and those who received usual care; however, there were some instances where the use of these protocols was associated with improvements in some clinical outcomes, such as patient satisfaction, risk for future falls or fractures, and some measures of repeat access to health care services.

Findings related to the cost-effectiveness of treat and refer protocols were inconclusive because of the limited generalizability of the findings from the included economic evaluation. The economic evaluation estimated that implementing a treat and refer protocol for older patients who experienced a fall did not result in significant changes to health care resource utilization and did not generate improved health-related quality of life compared to usual care.

No evidence-based guidelines regarding the use of treat and release protocols for patients requiring emergency medical services were identified.
Funding and Access to Assistive Technologies: Electronic Aids to Daily Living
Authors: Marchand Dave K. , Nakhuda Humaira , Dolcine Bert , Li Yan , MacDougall Danielle
Published: September 2021

The overall objectives of this Environmental Scan were to identify and describe the essential components of an electronic aids to daily living (EADL) assistive technology (AT) program, circumscribe barriers and facilitators to equitable access, and identify and describe funding mechanisms. A literature search and stakeholder consultations informed this Environmental Scan.

There is a lack of consensus as to how to define EADLs, who should be eligible for EADLs and how they should be funded, as demonstrated by the heterogenous findings in both the literature and the consultations.

Funding mechanisms and eligibility criteria vary between jurisdictions with limited integration of funding available for EADLs and modified consumer product technologies.

The majority of included publications generally discussed AT devices and service provision, with a lack of availability of information specific to EADL devices.

User-centred approaches that are anticipatory of user needs in AT service delivery provision were noted in the literature as key to facilitating effective AT service delivery.

Barriers to providing equitable access to EADLs include lack of awareness by both health professionals and users of AT devices and services, shortage of trained professional staff to provide individual supports, affordability and access to ATs, and limited user participation in decision-making with professionals in selecting ATs.
Using Health Care Resources Wisely During and Following the COVID-19 Pandemic
Authors: Born Karen B. , Levinson Wendy
Published: September 2021

In the pandemic era, the Choosing Wisely Canada campaign has taken on new meanings and urgency.
There are drops in utilization for necessary health care services and procedures during the pandemic; however, there is growing literature suggesting that some decreases in utilization have been driven by declines in low-value tests and treatments. As resources have shifted to pandemic priorities and essential care needs, these unnecessary tests and treatments have also declined.
Choosing Wisely Canada and CADTH are proactively working to highlight key recommendations from evidence-based lists of recommendations to inform priorities for rebuilding, which include avoiding low-value care. Rebuilding the health care system in the post-pandemic era needs to take into account a diversity of perspectives on how to prioritize high-value care for those who need it most, including clinician, patient, and policy expert perspectives.
Using Health Care Resources Wisely After the COVID-19 Pandemic: Recommendations to Reduce Low-Value Care
Authors: Basharat Sinwan , Born Karen
Published: September 2021

Low-value tests, treatments, and procedures are an important health care quality problem in Canada and across the world because they provide little clinical benefit, may be harmful for patients, and waste limited resources.

Due to the COVID-19 pandemic, health care systems face increased challenges of limited resources, reduced capacity, and a growing backlog of surgeries and other procedures. The pandemic has compelled health care professionals to make challenging decisions to prioritize health care services while coping with increased demand.

As Canada emerges from the pandemic and health care systems rebuild and begin to address the backlog of delayed or cancelled services, there is an imperative to introduce lasting changes to reduce low-value care and ensure high-quality care is available to everyone.

To help inform efforts for using health care resources wisely and to support decision-making, CADTH and Choosing Wisely Canada convened a 10-member multi-disciplinary panel of clinicians, patient representatives, and health policy experts to review areas of low-value care that can be reduced or limited. This panel reviewed, deliberated, and prioritized 19 recommendations of the more than 400 Choosing Wisely Canada recommendations, the implementation of which can help ensure high-value care after the pandemic.

Examples of the 19 recommendations include:

Avoiding unnecessary transfers for patients in long-term care to hospitals unless there is an urgent medical need.

Limiting blood tests and imaging unless required to answer a specific clinical question or guide treatment.

Not transfusing red blood cells for hemodynamically stable patients in the intensive care unit.

Not delaying palliative care for patients with serious illness because they are pursuing disease-directed treatment.

Moreover, the panel’s discussion highlighted how the selected recommendations can advance key priorities, including improving health equity and access to care, appropriately using limited resources, emphasizing patient-focused care, and addressing challenges the pandemic has presented for long-term care.
Conventional Disease-Modifying Antirheumatic Drugs for the Treatment of Rheumatoid Arthritis
Authors: Hill Shannon , Frey Nina
Published: September 2021

Nine evidence-based guidelines were identified that recommend the use of conventional synthetic disease-modifying antirheumatic drugs as a first-line therapy for patients with rheumatoid arthritis prior to using biologic disease-modifying antirheumatic drugs or Janus kinase inhibitors.

Methotrexate monotherapy was the most commonly recommended conventional synthetic disease-modifying antirheumatic drug recommended as first-line therapy by the included guidelines.

Eight of the included guidelines recommend combination therapy using multiple conventional synthetic disease-modifying antirheumatic drugs if monotherapy is ineffective and 4 included guidelines recommend the use of glucocorticoids in combination with conventional synthetic disease-modifying antirheumatic drugs.
Visual Examination Frequency for People Taking Ethambutol for Tuberculosis
Authors: Brett Kendra , Severn Melissa
Published: September 2021

CADTH identified 1 non-Canadian guideline that includes recommendations on the frequency of visual examinations for people with active tuberculosis who take ethambutol as part of their treatment. The guideline recommends testing for visual acuity and colour vision before starting treatment and at every health care visit throughout the course of treatment with ethambutol (recommendations based on clinical experience).
Single-Entry Models in Surgical Services
Authors: Harris Jonathan
Published: September 2021

In the health care system, common elements of SEMs include pooled referrals and waiting lists, centralized intake through a single-entry point, and triage for urgency and appropriateness.

Four programs including the use of SEMs from the Canadian context were examined: the Winnipeg Central Intake System for hip and knee replacements, the British Columbia Surgical Strategy, the Nova Scotia Hip and Knee Action Plan, and the Saskatchewan Surgical Initiative.

SEMs were generally implemented as 1 element of broader strategies to reduce surgical waits and enhance quality and safety of surgical services.Key success factors for implementation of SEMs included:

Concurrent investments in surgical capacity and health system resources.

The establishment of standardized clinical pathways to reduce care variation.

Strong leadership, including a focus on change management and use of clinician champions.

Standardized data collection and public reporting on key performance indicators.

Concurrent focus on quality improvement and patient-centred care.

Challenges for implementation of SEMs included:

Effectively managing change and resistance to change.

Challenges in other areas of the health system that could impact wait times.

Maintaining strategic focus and predictable funding, especially in the face of external shocks.
Abiraterone Acetate for Metastatic Castration-Sensitive Prostate Cancer
Authors: Shane Amanda , Walter Melissa
Published: September 2021

The use of abiraterone acetate for the treatment of metastatic castration-sensitive prostate cancer is clinically effective.

Compared with standard of care, abiraterone acetate was associated with increased overall survival, increased prostate cancer–specific survival, increased progression-free survival, and improved quality of life.

Patients treated with abiraterone acetate were at higher risk for grade III to grade V adverse events (severe, life-threatening, or fatal) and were more likely to discontinue treatment compared with standard of care.

The incremental cost-effectiveness ratios for both brand and generic abiraterone acetate were estimated to be higher than common willingness-to-pay thresholds.
Treatment Programs for Substance Use Disorder
Authors: Tran Khai , McGill Sarah
Published: September 2021

Moderate to weak evidence suggests that patients with substance use disorders who received residential treatment were more likely than outpatients to complete treatment and be considered abstinent. Comparisons between residential treatment and outpatient programs for other outcomes were unclear.

Strong- to weak-quality evidence showed that residential treatment services for patients with substance use disorders was effective in improving various outcomes including substance use, social, criminal activity, and mental health outcomes. However, residential treatment was likely associated with poorest survival outcomes after discharge compared to other treatments.

Managed alcohol programs in hospital settings appeared to be effective and safe in preventing and treating alcohol withdrawal syndrome in surgical patients, trauma patients, or hospitalized patients. The level of evidence was not assessed.

There was evidence that managed alcohol programs in community settings improved drinking patterns, alcohol-related harm, criminal activity, mental health, and social and physical well-being. The level of evidence was not assessed.

The American Society of Addiction Medicine clinical practice guideline provides recommendations for the identification and management of alcohol withdrawal in inpatient and ambulatory settings. Patients’ current signs and symptoms, levels of risk for developing severe or complicated withdrawal or complications of withdrawal, and other dimensions should be taken into consideration in the assessment process to determine the appropriate level of care. Strength of recommendations was not assessed.

The Canadian Coalition for Seniors’ Mental Health recommends that patients with cannabis use disorder should be considered for residential treatment if they are unable to effectively reduce or cease their cannabis use (level of evidence: Low; strength of recommendation: Strong).
An Overview of Direct-to-Patient Virtual Visits in Canada
Authors: Gray Casey , Mason Jeff , Loshak Hannah
Published: September 2021

Direct-to-patient virtual visits are a way of providing health care to patients in their location of choice, using technology (e.g., phone, text messaging, video conferencing).

The use of virtual visits has the potential to overcome many of the barriers associated with in-person care, including improved access, convenience, and cost savings.

Many communities that are underserved by in-person care also face barriers to virtual care. There is a risk that current health inequities will be exacerbated if barriers such as, for example, reliable access to an internet-connected device, technology literacy, and language barriers are not addressed.

Virtual visits have been used safely and effectively for many types of health care visits.

There is a lack of evidence on the cost-effectiveness of virtual visits.

Regulations regarding the provision of virtual visits are needed to uphold equitable access to publicly funded health care as mandated by the Canada Health Act.
Smoke-Free Hospital Grounds
Authors: Harris Jonathan , Tucker Sheila
Published: September 2021

Smoke-free campus policies at inpatient health facilities are most effective when situated within comprehensive smoking cessation programs that include cessation support for staff and patients and effective communications and signage for staff, patients, and visitors.

Canadian jurisdictions such as Ontario, New Brunswick, Prince Edward Island, Alberta, British Columbia, and Northwest Territories have provincial smoke-free legislation that applies to the grounds of health facilities. This approach permits public health inspectors and peace officers to enforce the smoke-free grounds rules with the option of issuing fines to individuals or hospital corporations for non-compliance. There is very little existing evidence on the effectiveness of issuing fines as a means of enforcing smoke-free policies.

There can be unique considerations associated with implementing smoke-free policies in inpatient psychiatric facilities or units, given the relationship between mental health and substance use issues and tobacco use. Evidence shows that smoke-free policies are feasible and result in positive health outcomes in psychiatric facilities or units.

Staff may require additional education and training in smoking cessation and tools to support productive conversations with patients, visitors, or colleagues who are not in compliance with smoke-free policies. Examples of tools and communications materials used in other jurisdictions are provided in Appendix 1.
Extracorporeal Membrane Oxygenation for Adults and Children With Severe Respiratory Failure
Authors: Smith Andrea , Loshak Hannah
Published: September 2021

This review used a framework analysis to synthesize 9 included studies on the perspectives and experiences of patients, family members, and providers on extracorporeal membrane oxygenation (ECMO).

Patients’ perspectives on their experiences are limited due to their sedated status when treated with ECMO.

Supporting a relative treated with ECMO is stressful for family members. They feel anxious and worried about their relative because of the patient’s critical condition, and they struggle to juggle multiple roles at work and home while supporting their relative receiving ECMO.

Family members often have to travel to see their critically ill relative. Financial and logistical support for temporary relocation near the ECMO centre may ease the burden of travel.

Family members benefit from clear and frequent communication from health care providers as a source of support and reassurance while their loved ones are being treated with ECMO. There may be a role for informal or formal peer support for family members of patients receiving ECMO.

Clinicians’ decisions to offer, continue, and withdraw ECMO are based on their assessments of prognostic factors from patients’ medical histories and clinical conditions. Additional clinical research and/or refinements of prognostic guidance for ECMO may further support evidence-informed decision-making around ECMO.

Patients, family members, and clinical team members may differ in their assessment of the limits of ECMO treatment and the decision to transition from active treatment to the withdrawal of life support. These findings point to the role of ethical considerations and processes when engaging in transitioning to end-of-life support in the provision of ECMO.

After discharge, patients who had received ECMO and their family members continued to have feelings of anxiety, intrusive thoughts, and a need to process the event. ECMO programs that can offer continued or ongoing support or referral for patients and their family members’ mental health may help address these needs.
Wearable Respiratory Sensor for the Detection of Opioid-Induced Respiratory Depression
Authors: Farrell Keeley
Published: September 2021

This Horizon Scanning report summarizes information regarding an emerging health technology — a wearable respiratory sensor for the detection of opioid-induced respiratory depression

Devices that detect opioid-induced respiratory depression such as RESPMETER could help to prevent opioid overdose deaths by alerting first responders so that they can intervene earlier and administer naloxone.

RESPMETER, or devices like it, could play a role in opioid overdose management. However, information on its effectiveness and safety for detecting opioid-induced respiratory depression is needed.
Interventions to Address and Prevent Violence Toward Health Care Workers in the Emergency Department
Authors: Banerjee Srabani , MacDougall Danielle
Published: September 2021

Seven relevant systematic reviews (SRs) regarding interventions to address and prevent violence in the emergency department (ED) were identified. However, these SRs had a broad focus, and the included studies that were relevant for this current report were few and were generally of low quality.

Findings were inconsistent regarding education and training interventions for preventing violence in the ED; most relevant primary studies within identified SRs showed there was no difference in the occurrence of violence with interventions including education and training, and a few primary studies reported a reduction in the occurrence violence with interventions including education and training; however, statistical significance of the difference was not reported.

Pharmacological interventions with haloperidol, lorazepam, droperidol, risperidone, olanzapine, or quetiapine were effective in reducing aggressive behaviour and side effects were generally minimal.

Implementation of restraint documentation tools was associated with decrease in use of physical restraints to manage aggressive behaviour, and complications were minimal when physical restraints were used for a short duration.

These findings need to be interpreted with caution considering the limitations such as limited quantity and quality of evidence, and lack of details regarding the characteristics of the population.

No evidence-based guidelines were identified.
Hybrid Closed-Loop Insulin Delivery Systems for People With Type 1 Diabetes
Authors: Team Health Technology Assessment
Published: September 2021

The CADTH Health Technology Expert Review Panel (HTERP) suggests that hybrid closed-loop insulin delivery (HCL) systems hold promise for the care of people with type 1 diabetes. HTERP considers that, at present, there are insufficient long-term data on clinically relevant and patient-important outcomes to recommend how extensive the role of HCL systems should be in care.

HTERP recommends the collection of robust and comparative data for consideration of future reassessments that compare HCL systems to existing insulin delivery and glucose monitoring methods in terms of glycated hemoglobin (hemoglobin A1C); time-in-range; time above and below range; glycemic variability; quality of life; patient, parent or caregiver, and health care provider satisfaction; diabetes-related complications; discontinuation rates; and health system impact. Robust data are collected in well-designed comparative studies that are, among other considerations, of sufficient duration to ensure a clinically meaningful outcome assessment.
Psychedelic-Assisted Psychotherapy for Post-Traumatic Stress Disorder, Anxiety Disorders, Mood Disorders, or Substance Use Disorders
Authors: Chao Yi-Sheng , Horton Jennifer
Published: September 2021

Two systematic reviews, 3 randomized controlled trials, and 2 single-arm safety trials were identified that evaluated several combinations of psychedelic-assisted psychotherapy. Psilocybin was the psychedelic most tested. Other psychedelics identified in the systematic reviews and primary studies were 3,4-methylenedioxymethamphetamine (or MDMA), lysergic acid diethylamide (or LSD), ayahuasca (also named N,N-dimethyltryptamine [or DMT]), ibogaine, ketamine, and nitrous oxide.

Manualized therapy (not defined) and non-directive support (not defined) were the psychotherapies most studied in the relevant primary studies in the 2 systematic reviews. Other psychotherapies identified included integrative psychotherapy, cognitive behavioural therapy (CBT), CBT and motivational enhancement therapy, psychosocial interventions, non-directive support, group talk therapy, and guided support.

Clinical effectiveness lasting weeks to months was observed in 1 systematic review that reviewed primary studies examining various combinations of psychedelics and psychotherapy in patients with various mental health conditions. Significant improvement in symptom scores related to mental illnesses and no serious and long-term adverse events were reported in the other systematic review.

Various combinations of psychedelics and psychotherapies were evaluated in 3 randomized controlled trials (RCTs) and 2 safety studies. Ketamine-assisted psychotherapies were associated with improvements in the symptoms related to substance use disorder in 2 RCTs. Psilocybin-assisted psychotherapy was reported to be efficacious in treating MDD in 1 RCT. No serious adverse effects were reported in the RCTs or in 2 safety trials using MDMA-assisted psychotherapy.

There were several limitations to the included studies, including small sample sizes (less than 20 in the majority of primary studies), relatively short follow-ups (1 week to 3 years; less than or equal to 1 year in 27 out of 31 relevant publications), differences in psychotherapy classification between systematic reviews, considerable heterogeneity between studies, and unclear generalizability and availability of the interventions in Canadian contexts. Therefore, findings should be interpreted with caution. No relevant guidelines were identified.
Semaglutide (Rybelsus)
Authors: Team Reimbursement
Published: September 2021

Clinical evidence suggests that Rybelsus should be reimbursed to treat type 2 diabetes in adults if it is used in addition to metformin or other antihyperglycemic agents and does not cost more than glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, and sodium-glucose cotransporter-2 inhibitors.

Rybelsus is more costly than most similar diabetes treatments.

Rybelsus is expected to increase budgets by more than $38 million over 3 years.

To account for the high treatment cost, the price of Rybelsus should be reduced.

If Rybelsus is not reimbursed as an add-on treatment for patients with type 2 diabetes, there are several other alternative treatments available for these patients.
Patiromer (Veltassa)
Authors: Team Reimbursement
Published: September 2021

Clinical evidence suggests that Veltassa should be reimbursed to treat hyperkalemia in adult patients with chronic kidney disease and who are receiving renin-angiotensin-aldosterone system inhibitor therapy.

Economic evidence suggests that at least an 85% price reduction is needed to ensure Veltassa is cost-effective at a $50,000 per quality-adjusted life-year threshold.

Higher price reductions may be required if Veltassa is used long term, more patients use the maximum dose, and/or the benefit of renin-angiotensin-aldosterone system inhibitor administration is lower.

Based on public list prices, the 3-year budget impact is $86,948,298.
Luspatercept (Reblozyl)
Authors: Team Reimbursement
Published: September 2021

Clinical evidence suggests that Reblozyl should be reimbursed to treat anemia associated with beta-thalassemia in adults who require blood transfusions on a regular basis if the cost is reduced.

Reblozyl is not cost-effective at the submitted price and would require a price reduction of at least 85% to be cost-effective at a $50,000 per quality-adjusted life-year (QALY) threshold.

Reblozyl is expected to increase budgets by at least $33,415,422 over 3 years.

If the price of Reblozyl is not reduced to a point that is affordable to public payers, this could delay access to the only treatment shown to reduce transfusion burden.
Implementation of Stereotactic Ablative Radiotherapy for the Treatment of Oligometastatic Cancer in Canada
Authors: Kumar Diksha , MacDougall Danielle
Published: September 2021

The aim of this Environmental Scan is to identify and describe the use of stereotactic ablative radiotherapy in Canada, the systems in place to manage the treatment of patients with oligometastatic cancer, and the barriers and facilitators to the implementation of this treatment. The findings are based on a literature review, 22 survey responses from stakeholders, and email- and video call-based follow-up consultations with select stakeholders. Ten Canadian jurisdictions were represented by the survey respondents, who were primarily radiation oncologists.

Stereotactic ablative radiotherapy for the treatment of oligometastatic cancer is currently being accessed in all Canadian provinces as a standard treatment option. Centres are primarily treating oligometastases in the lungs, bones (non-spine), lymph nodes, spine, and liver. Some cancer care centres have the capacity for stereotactic ablative radiotherapy to treat localized primary tumours but do not treat oligometastatic sites.

There is a variation in patient selection criteria and treatment guidelines across Canadian jurisdictions, with most facilities following institutional guidance for the processes required for patient prioritization and treatment. There is a lack of standardized consensus guidelines with common criteria.

Reported facilitators for the implementation of stereotactic ablative radiotherapy for the treatment of oligometastatic cancer include access to dedicated equipment and teams. Reported barriers to its implementation include the lack of standardized patient selection and treatment guidelines, and constraints in equipment and staff resources (including time).
Initiation of Biologic Disease-Modifying Antirheumatic Drugs for Rheumatoid Arthritis: A Budget Impact Analysis
Authors: Elliot Jesse , Cornelissen Tessa , Tsoi Bernice , Lee Karen
Published: September 2021

There is variation across Canadian jurisdictions in time to the initiation of biologic disease-modifying antirheumatic drug (bDMARD) therapy among adults with rheumatoid arthritis.
From a pan-Canadian perspective, harmonizing time to bDMARD initiation across jurisdictions may result in savings to publicly funded drug plans in some jurisdictions but increased drug expenditures in others.
The extent of savings or increased costs is dependent on jurisdiction, the number of new bDMARD users, and whether patients receive a biosimilar or originator bDMARD.