American Industrial Hygiene Association Journal, Dec 1, 1995
American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun&qu... more American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun" Paul Hérouxa Tammy Clifford^ Vanda Sadilek3 Franklin Hamadea "Department of Occupational Health, Faculty of Medicine, McGill University, 1130 Pine Avenue West, Montréal ...
Canadian Journal of Emergency Medicine, Nov 1, 2009
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call "outcome feedback." Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is "essential" (62.6%) or "beneficial" (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (active) outcome feedback in 7.5% of all cases. The great majority of participants (97.3%) stated that they would like to receive more outcome feedback and believed that this would improve diagnostic accuracy (97.3%), clinical efficiency (85.5%), treatment outcomes (95.6%) and job satisfaction (95.1%). When asked to indicate "any possible negative effects that might arise from increased outcome feedback," 62.1% indicated none.However, 17.9% hypothesized negative emotional effects and 11.5% suggested increased time requirements. The overwhelming majority of EPs receive very little outcome feedback. Most would like more outcome feedback and believe it would improve the practice of EM.
Elbow injuries in children are a common presenting complaint to the emergency department. Althoug... more Elbow injuries in children are a common presenting complaint to the emergency department. Although radiography is a valuable tool in the diagnosis of this injury, x-rays of the injured elbow are inherently difficult to interpret. As a result, comparison views of the uninjured arm have traditionally been recommended to provide an anatomically "normal" radiograph. Recent studies have questioned the use of comparison views in the pediatric emergency department. The primary objective of this study was to determine current practices of non-pediatric emergency physicians in the use of comparison views for the diagnosis of elbow injuries in children. A self-administered mail survey was sent to 300 randomly selected emergency physicians, using the Canadian Association of Emergency Physicians database. Two hundred and forty-two (81%) responses were received; 26 were excluded based on pre-determined criteria. Of eligible respondents, 95% ordered comparison views selectively and 64% ...
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call "outcome feedback." Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is "essential" (62.6%) or "beneficial" (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (...
We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial ... more We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral. A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED. Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, ...
American Industrial Hygiene Association Journal, 1995
American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun&qu... more American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun" Paul Hérouxa Tammy Clifford^ Vanda Sadilek3 Franklin Hamadea "Department of Occupational Health, Faculty of Medicine, McGill University, 1130 Pine Avenue West, Montréal ...
Buckle fractures are the most common wrist fractures in children, yet there is little literature ... more Buckle fractures are the most common wrist fractures in children, yet there is little literature regarding their management. This study examined the management of these fractures and attitudes toward their immobilization by pediatric emergency department (ED) physicians and pediatric orthopedic surgeons. A standardized survey was mailed to all pediatric orthopedic surgeons and pediatric ED physicians at 8 Canadian children's hospitals. Eighty-seven percent of physicians responded, including 33 of 39 pediatric orthopedic surgeons and 84 of 96 pediatric ED physicians. Sixty-four percent of respondents believe that wrist buckle fractures always need to be immobilized; pain control was most frequently cited for this belief. Physicians who did not believe that all buckle fractures need to be immobilized indicated that these fractures are inherently stable and have a low risk of refracture. Forty-eight percent of the orthopedic surgeons prefer below-elbow casts, 30% prefer a combinati...
Gastric decontamination with single-dose activated charcoal (SDAC) is a mainstay in emergency dep... more Gastric decontamination with single-dose activated charcoal (SDAC) is a mainstay in emergency department (ED) treatment of ingestions. Guidelines updated in 2005 encourage practitioners to use SDAC only in toxic ingestions presenting within 1 hour. Despite these guidelines, adult studies demonstrate a significant lack of consensus. This study examined the proposed use of SDAC for gastric decontamination in common pediatric ingestion scenarios by emergency physicians working in Canadian pediatric EDs. A standardized survey consisting of 5 clinical scenarios was mailed to all physicians with a primary clinical appointment to the ED at 9 Canadian children's hospitals. One hundred thirty-one physicians were surveyed, and 95 (72%) responded. The majority of respondents were pediatricians (68.1%) with a mean of 15.0 years of experience (SD, 6.8 years). Of those surveyed; 91 (97.8%) would use SDAC for a toxic ingestion presenting in less than 1 hour; 35 (36.8%) would use SDAC for a toxic ingestion presenting after 3 hours; 61 (64.9%) would use SDAC for a nontoxic exploratory ingestion presenting in less than 1 hour; and 29 (30.5%) would use SDAC for a mildly symptomatic intentional ingestion presenting at an unknown time. Eleven (11.7%) would use SDAC for an ingestion of a substance that does not adsorb to SDAC. There is variation in the use of SDAC among emergency physicians working in Canadian pediatric EDs. This variation suggests that optimal management is not clear and that continued education and research are required.
Network meta-analysis is increasingly used to allow comparison of multiple treatment alternatives... more Network meta-analysis is increasingly used to allow comparison of multiple treatment alternatives simultaneously, some of which may not have been compared directly in primary research studies. The majority of network meta-analyses published to date have incorporated data from randomized controlled trials (RCTs) only; however, inclusion of non-randomized studies may sometimes be considered. Non-randomized studies can complement RCTs or address some of their limitations, such as short follow-up time, small sample size, highly selected population, high cost, and ethical restrictions. In this paper, we discuss the challenges and opportunities of incorporating both RCTs and non-randomized comparative cohort studies into network meta-analysis for assessing the safety and effectiveness of medical treatments. Non-randomized studies with inadequate control of biases such as confounding may threaten the validity of the entire network meta-analysis. Therefore, identification and inclusion of non-randomized studies must balance their strengths with their limitations. Inclusion of both RCTs and non-randomized studies in network meta-analysis will likely increase in the future due to the growing need to assess multiple treatments simultaneously, the availability of higher quality non-randomized data and more valid methods, and the increased use of progressive licensing and product listing agreements requiring collection of data over the life cycle of medical products. Inappropriate inclusion of non-randomized studies could perpetuate the biases that are unknown, unmeasured, or uncontrolled. However, thoughtful integration of randomized and non-randomized studies may offer opportunities to provide more timely, comprehensive, and generalizable evidence about the comparative safety and effectiveness of medical treatments.
Although triptans are widely used in the acute management of migraine, there is uncertainty aroun... more Although triptans are widely used in the acute management of migraine, there is uncertainty around the comparative efficacy of triptans among each other and vs non-triptan migraine treatments. We conducted systematic reviews and network meta-analyses to compare the relative efficacy of triptans (alone or in combination with other drugs) for acute treatment of migraines compared with other triptan agents, non-steroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics. The Cochrane Library, MEDLINE, and EMBASE were searched for randomized controlled trials that compared triptans (alone or in combination with other drugs) with placebo-controlled or active migraine treatments. Study selection, data extraction, and quality assessment were completed independently by multiple reviewers. Outcome data were combined and analyzed using a Bayesian network meta-analysis. For each outcome, odds ratios, relative risks, and absolute proba...
The use of network meta-analysis has increased dramatically in recent years. WinBUGS, a freely av... more The use of network meta-analysis has increased dramatically in recent years. WinBUGS, a freely available Bayesian software package, has been the most widely used software package to conduct network meta-analyses. However, the learning curve for WinBUGS can be daunting, especially for new users. Furthermore, critical appraisal of network meta-analyses conducted in WinBUGS can be challenging given its limited data manipulation capabilities and the fact that generation of graphical output from network meta-analyses often relies on different software packages than the analyses themselves. We developed a freely available Microsoft-Excel-based tool called NetMetaXL, programmed in Visual Basic for Applications, which provides an interface for conducting a Bayesian network meta-analysis using WinBUGS from within Microsoft Excel. . This tool allows the user to easily prepare and enter data, set model assumptions, and run the network meta-analysis, with results being automatically displayed i...
Journal of pediatric gastroenterology and nutrition, 2014
The aim of the present study was to assess the prevalence and patterns of complementary and alter... more The aim of the present study was to assess the prevalence and patterns of complementary and alternative medicine (CAM) use among pediatric patients with gastrointestinal (GI) disorders at academic clinics in Canada. The survey was carried out at 2 hospital-based gastroenterology clinics: the Stollery Children's Hospital in Edmonton and the Children's Hospital of Eastern Ontario (CHEO) in Ottawa. CAM use at the Stollery was 83% compared with 36% at CHEO (P < 0.001). The most common reason for not using CAM was lack of knowledge about it. Most respondents felt comfortable discussing CAM in their clinic and wanted more information on CAM. The most common CAM products being taken were multivitamins (91%), calcium (35%), vitamin C (32%), probiotics (14%), and fish oil/omega-3 fatty acids (13%). The most common CAM practices being used were massage (43%), chiropractic (27%), faith healing (25%), and relaxation (18%). Most respondents believed that CAM was helpful, and most of t...
American Industrial Hygiene Association Journal, Dec 1, 1995
American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun&qu... more American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun&quot; Paul Hérouxa Tammy Clifford^ Vanda Sadilek3 Franklin Hamadea &quot;Department of Occupational Health, Faculty of Medicine, McGill University, 1130 Pine Avenue West, Montréal ...
Canadian Journal of Emergency Medicine, Nov 1, 2009
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;outcome feedback.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;essential&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (62.6%) or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;beneficial&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (active) outcome feedback in 7.5% of all cases. The great majority of participants (97.3%) stated that they would like to receive more outcome feedback and believed that this would improve diagnostic accuracy (97.3%), clinical efficiency (85.5%), treatment outcomes (95.6%) and job satisfaction (95.1%). When asked to indicate &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;any possible negative effects that might arise from increased outcome feedback,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; 62.1% indicated none.However, 17.9% hypothesized negative emotional effects and 11.5% suggested increased time requirements. The overwhelming majority of EPs receive very little outcome feedback. Most would like more outcome feedback and believe it would improve the practice of EM.
Elbow injuries in children are a common presenting complaint to the emergency department. Althoug... more Elbow injuries in children are a common presenting complaint to the emergency department. Although radiography is a valuable tool in the diagnosis of this injury, x-rays of the injured elbow are inherently difficult to interpret. As a result, comparison views of the uninjured arm have traditionally been recommended to provide an anatomically "normal" radiograph. Recent studies have questioned the use of comparison views in the pediatric emergency department. The primary objective of this study was to determine current practices of non-pediatric emergency physicians in the use of comparison views for the diagnosis of elbow injuries in children. A self-administered mail survey was sent to 300 randomly selected emergency physicians, using the Canadian Association of Emergency Physicians database. Two hundred and forty-two (81%) responses were received; 26 were excluded based on pre-determined criteria. Of eligible respondents, 95% ordered comparison views selectively and 64% ...
Emergency physicians (EPs) rarely find out what happens to patients after the patients leave thei... more Emergency physicians (EPs) rarely find out what happens to patients after the patients leave their care, a process we call "outcome feedback." Some suggest this hinders the practice of emergency medicine (EM); however, evidence is lacking. We sought to evaluate EPs' perception of the current and potential role of outcome feedback in EM. We surveyed practising French- and English speaking EPs from emergency departments within 100 km of Ottawa, Ont., in the provinces of Ontario and Quebec. The main outcomes included the prevalence, role and effect of outcome feedback. Of the 297 physicians surveyed, 231 (77.8%) respond ed. The sample contained good representation of language groups, practice settings, sexes and age groups. All participants indicated that knowing outcomes is "essential" (62.6%) or "beneficial" (37.4%) to gaining experience in EM. Participants reported currently receiving passive outcome feedback in 10.0% of all cases, and seeking out (...
We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial ... more We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral. A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED. Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, ...
American Industrial Hygiene Association Journal, 1995
American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun&qu... more American Industrial Hygiene association Journal 56:1215-1224 (1995) Authors William Q. Sun&quot; Paul Hérouxa Tammy Clifford^ Vanda Sadilek3 Franklin Hamadea &quot;Department of Occupational Health, Faculty of Medicine, McGill University, 1130 Pine Avenue West, Montréal ...
Buckle fractures are the most common wrist fractures in children, yet there is little literature ... more Buckle fractures are the most common wrist fractures in children, yet there is little literature regarding their management. This study examined the management of these fractures and attitudes toward their immobilization by pediatric emergency department (ED) physicians and pediatric orthopedic surgeons. A standardized survey was mailed to all pediatric orthopedic surgeons and pediatric ED physicians at 8 Canadian children's hospitals. Eighty-seven percent of physicians responded, including 33 of 39 pediatric orthopedic surgeons and 84 of 96 pediatric ED physicians. Sixty-four percent of respondents believe that wrist buckle fractures always need to be immobilized; pain control was most frequently cited for this belief. Physicians who did not believe that all buckle fractures need to be immobilized indicated that these fractures are inherently stable and have a low risk of refracture. Forty-eight percent of the orthopedic surgeons prefer below-elbow casts, 30% prefer a combinati...
Gastric decontamination with single-dose activated charcoal (SDAC) is a mainstay in emergency dep... more Gastric decontamination with single-dose activated charcoal (SDAC) is a mainstay in emergency department (ED) treatment of ingestions. Guidelines updated in 2005 encourage practitioners to use SDAC only in toxic ingestions presenting within 1 hour. Despite these guidelines, adult studies demonstrate a significant lack of consensus. This study examined the proposed use of SDAC for gastric decontamination in common pediatric ingestion scenarios by emergency physicians working in Canadian pediatric EDs. A standardized survey consisting of 5 clinical scenarios was mailed to all physicians with a primary clinical appointment to the ED at 9 Canadian children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospitals. One hundred thirty-one physicians were surveyed, and 95 (72%) responded. The majority of respondents were pediatricians (68.1%) with a mean of 15.0 years of experience (SD, 6.8 years). Of those surveyed; 91 (97.8%) would use SDAC for a toxic ingestion presenting in less than 1 hour; 35 (36.8%) would use SDAC for a toxic ingestion presenting after 3 hours; 61 (64.9%) would use SDAC for a nontoxic exploratory ingestion presenting in less than 1 hour; and 29 (30.5%) would use SDAC for a mildly symptomatic intentional ingestion presenting at an unknown time. Eleven (11.7%) would use SDAC for an ingestion of a substance that does not adsorb to SDAC. There is variation in the use of SDAC among emergency physicians working in Canadian pediatric EDs. This variation suggests that optimal management is not clear and that continued education and research are required.
Network meta-analysis is increasingly used to allow comparison of multiple treatment alternatives... more Network meta-analysis is increasingly used to allow comparison of multiple treatment alternatives simultaneously, some of which may not have been compared directly in primary research studies. The majority of network meta-analyses published to date have incorporated data from randomized controlled trials (RCTs) only; however, inclusion of non-randomized studies may sometimes be considered. Non-randomized studies can complement RCTs or address some of their limitations, such as short follow-up time, small sample size, highly selected population, high cost, and ethical restrictions. In this paper, we discuss the challenges and opportunities of incorporating both RCTs and non-randomized comparative cohort studies into network meta-analysis for assessing the safety and effectiveness of medical treatments. Non-randomized studies with inadequate control of biases such as confounding may threaten the validity of the entire network meta-analysis. Therefore, identification and inclusion of non-randomized studies must balance their strengths with their limitations. Inclusion of both RCTs and non-randomized studies in network meta-analysis will likely increase in the future due to the growing need to assess multiple treatments simultaneously, the availability of higher quality non-randomized data and more valid methods, and the increased use of progressive licensing and product listing agreements requiring collection of data over the life cycle of medical products. Inappropriate inclusion of non-randomized studies could perpetuate the biases that are unknown, unmeasured, or uncontrolled. However, thoughtful integration of randomized and non-randomized studies may offer opportunities to provide more timely, comprehensive, and generalizable evidence about the comparative safety and effectiveness of medical treatments.
Although triptans are widely used in the acute management of migraine, there is uncertainty aroun... more Although triptans are widely used in the acute management of migraine, there is uncertainty around the comparative efficacy of triptans among each other and vs non-triptan migraine treatments. We conducted systematic reviews and network meta-analyses to compare the relative efficacy of triptans (alone or in combination with other drugs) for acute treatment of migraines compared with other triptan agents, non-steroidal anti-inflammatory drugs (NSAIDs), acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics. The Cochrane Library, MEDLINE, and EMBASE were searched for randomized controlled trials that compared triptans (alone or in combination with other drugs) with placebo-controlled or active migraine treatments. Study selection, data extraction, and quality assessment were completed independently by multiple reviewers. Outcome data were combined and analyzed using a Bayesian network meta-analysis. For each outcome, odds ratios, relative risks, and absolute proba...
The use of network meta-analysis has increased dramatically in recent years. WinBUGS, a freely av... more The use of network meta-analysis has increased dramatically in recent years. WinBUGS, a freely available Bayesian software package, has been the most widely used software package to conduct network meta-analyses. However, the learning curve for WinBUGS can be daunting, especially for new users. Furthermore, critical appraisal of network meta-analyses conducted in WinBUGS can be challenging given its limited data manipulation capabilities and the fact that generation of graphical output from network meta-analyses often relies on different software packages than the analyses themselves. We developed a freely available Microsoft-Excel-based tool called NetMetaXL, programmed in Visual Basic for Applications, which provides an interface for conducting a Bayesian network meta-analysis using WinBUGS from within Microsoft Excel. . This tool allows the user to easily prepare and enter data, set model assumptions, and run the network meta-analysis, with results being automatically displayed i...
Journal of pediatric gastroenterology and nutrition, 2014
The aim of the present study was to assess the prevalence and patterns of complementary and alter... more The aim of the present study was to assess the prevalence and patterns of complementary and alternative medicine (CAM) use among pediatric patients with gastrointestinal (GI) disorders at academic clinics in Canada. The survey was carried out at 2 hospital-based gastroenterology clinics: the Stollery Children's Hospital in Edmonton and the Children's Hospital of Eastern Ontario (CHEO) in Ottawa. CAM use at the Stollery was 83% compared with 36% at CHEO (P < 0.001). The most common reason for not using CAM was lack of knowledge about it. Most respondents felt comfortable discussing CAM in their clinic and wanted more information on CAM. The most common CAM products being taken were multivitamins (91%), calcium (35%), vitamin C (32%), probiotics (14%), and fish oil/omega-3 fatty acids (13%). The most common CAM practices being used were massage (43%), chiropractic (27%), faith healing (25%), and relaxation (18%). Most respondents believed that CAM was helpful, and most of t...
Uploads
Papers by Tammy Clifford