North York General Hospital

Acute coronary syndrome (ACS) is a life-threatening condition requiring accurate diagnosis for better outcomes. However, variability in signs and symptoms among racial subgroups could cause disparities in diagnostic accuracy. In this study, we use machine learning models to diagnose ACS, focusing on mitigating disparities and ensuring fairness between Black and non-Black populations. We built on a state-of-the-art random forest classifier to compare three mitigation strategies. The first two approaches involved resampling or partitioning the data prior to training, while the third approach proposed an innovative framework called adversarial debiasing. To evaluate our model performance, we used the receiver operating characteristic (ROC) curve and an operating point at 80% specificity for clinical importance. After mitigation with adversarial debiasing, the difference in sensitivities between the two subgroups decreased from 9.8% to 1.3%. Specifically, this approach achieved areas under the ROC of 0.810 and 0.817, and sensitivities of 70.1% and 71.4%, respectively for Black and non-Black subgroups. The proposed adversarial debiasing model outperformed the other two methods in both diagnostic accuracy and effectiveness in minimizing disparities. We expect this framework to achieve fair diagnostic models across diverse demographic populations globally and be generalizable to other outcomes.

Latent safety threats (LSTs) in operating room (OR) crisis management contribute to serious events such as Local Anesthetic Systemic Toxicity (LAST) and represent critical yet often overlooked risks. Although prior research has focused on clinician education for diagnosing and treating LAST, far less attention has been directed toward work-system factors (eg, workflow design, communication processes, environmental supports), even though education alone is insufficient. This study advances understanding of OR crises by systematically identifying and characterizing LSTs across all phases of LAST response, from briefing and diagnosis to treatment and care planning, capturing the broader system factors that influence team performance and patient safety. Thirty-eight staff (15 anesthesiologists, 16 nurses, 7 anesthesia assistants) participated in 8 simulations. Video recordings were analyzed to identify LSTs, which were inductively coded into themes/subthemes, categorized by clinical phase (briefing, diagnosis, management, treatment, care planning) and by system factor using a modified SEIPS framework (organization, environment, tasks, tools, teams, individuals). We identified 183 LSTs, with frequency varying by clinical phase (P < .001); nearly half (90/183; 49%) occurred during Management after diagnosis. LSTs spanned all SEIPS factors, most often Environment (55/183; 30.1%), Organization (54/183; 29.5%), and Tasks (38/183; 21.3%). The most common themes were Poor Physical Layout (43/183; 23.5%) and Role Allocation Deficiencies (42/183; 23%), both directly impairing performance (eg, delays retrieving the crash cart or administering intralipid). Additional LSTs included communication breakdowns, task overload, ambiguous dosing, tool usability issues, and unclear protocols. Knowledge gaps were least common and had minimal clinical impact. The findings highlight that improving LAST crisis response requires more than clinician education. Many LSTs arise from how clinical environments are structured, how teams communicate, and how workflows unfold under pressure. To strengthen LAST crisis response and other emergency interventions, systems must be redesigned to reflect the realities of team-based care and to support clinical workflows across all phases of the response.

In 2011, the Clinical and Laboratory Standards Institute revised its minimum inhibitory concentration (MIC) breakpoints for systemic cefazolin therapy to address rising antibiotic resistance. The revision was based on pharmacokinetic-pharmacodynamic analysis with limited real-world data. Institutional review led to anticipation of a shift in classification for a substantial proportion of isolates from "susceptible" to "intermediate sensitivity". This change would result in increased use of broad-spectrum antibiotics in situations where cefazolin therapy would previously have been suitable. To compare the risk of treatment failure, as defined by mortality, intensive care admission, relapse bacteremia, and/or antimicrobial escalation, in hospitalized adult patients with community-acquired monomicrobial Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis bacteremia using MIC of ≤ 4 μg/mL versus 8 μg/mL for definitive cefazolin therapy. This single-centre, retrospective chart review involved patients admitted to North York General Hospital, Toronto, Ontario, between January 1, 2015, and December 31, 2022. Multivariable logistic regression was used to model and compare treatment failure for MIC ≤ 4 μg/mL and MIC of 8 μg/mL. Of the 280 cultures eligible for analysis, 11 had MIC of 8 μg/mL, and the remaining 269 had MIC ≤ 4 μg/mL. For both groups, the treatment failure rate was 18.2%. With adjustment for confounding factors, there was a nonsignificant increase in the risk of treatment failure in patients with MIC of 8 μg/mL (odds ratio 1.29, 95% confidence interval 0.24-4.96, p = 0.74). Consistent with the existing literature, this study showed a trend toward increased risk of treatment failure with higher MIC. Future research should validate clinical outcomes with contemporary MIC breakpoints and investigate MIC susceptibility in gram-negative bacteremia from urinary sources.

ABSTRACT To evaluate the impact of implementing a Developmental Outreach Clinic within a primary care practice, we implemented a Developmental Outreach Clinic that involved relocating 2 developmental pediatricians to a primary care practice for one half day per week to conduct developmental assessments and consultations on‐site. This care model included co‐location, sharing of: administrative booking process, electronic medical record messaging, and a charting system between the developmental pediatricians and the family physicians. To evaluate this clinic, a retrospective chart review cohort study was conducted. We compared patients who participated in the Developmental Outreach clinic with those who received standard care (i.e., pre‐implementation, family physician referred to the hospital‐affiliated developmental pediatrics clinic serving the same catchment). Health charts of all patients who were booked for a consultation with Developmental Pediatrics 23 months prior to the implementation of the Developmental Outreach Clinic and 23 months following were reviewed. Main outcome measures included changes in service usage (i.e., number of completed assessments/consultations, time from referral to consult) from pre‐ to post‐clinic implementation. A greater number of non‐Autism Spectrum Disorder (ASD) assessments/consultations were completed after implementation of the Developmental Outreach Clinic, with no change in the number of ASD assessments/consultations conducted pre‐ to post‐implementation. The wait time from referral to first appointment was significantly lower for the post‐compared to the pre‐implementation cohort. A Developmental Outreach Clinic within a primary care practice may help improve access to developmental pediatricians through co‐location, including sharing of administrative processes and an Electronic Medical Record. This represents a relatively low‐cost way to reduce administrative inefficiencies while enabling specialists to support a greater number of families alongside family physicians.

Retinol dehydrogenases (RDHs) catalyze multiple steps in the visual cycle to regenerate 11-cis-retinal, a critical component in rod phototransduction. The structural homology between RDHs enables functional redundancy; yet Mendelian disorders are linked to RDHs. Variants in RDH12 and RDH5 cause non-syndromic inherited retinal dystrophy (IRD), whilst variants in RDH11 cause syndromic IRD. RDH11 is a minor isoenzyme catalyzing two reactions: (i) reduction of all-trans-retinal in rod photoreceptors alongside RDH12 and RDH8, and (ii) oxidation of 11-cis-retinol in the retinal pigment epithelium (RPE) alongside RDH5 and RDH10. Prior cases with RDH11 demonstrated a generalized photoreceptor dystrophy, similar to RDH12-retinopathy. We describe a visually asymptomatic 7-year-old boy carrying a homozygous null variant in RDH11 [NM_016026.4:c.216C>A:p.(Cys72*)] with autism, dysmorphic features, oligodontia, microcephaly and a novel IRD. This retinopathy consisted of yellow deposits and hyperpigmentation within the RPE with absent autofluorescence and a normal electroretinogram implying sub-optimal oxidation of 11-cis-retinol. These features are reminiscent of RDH5-retinopathy but milder. We termed this phenotype Retinal pigment Epitheliopathy due to Sub-Optimal Recycling of Vitamin A (RESORVA). We propose that the divergence in retinal phenotypes among RDH11 cases is likely due to variant-specific protein effects on paralogous gene functioning, such as differences in activation of transcriptional adaptation.

A significant proportion of epilepsy patients are resistant to conventional treatments. Functional mushrooms such as Reishi ( Ganoderma lucidum ) and Lion’s Mane ( Hericium erinaceus ) have recognized health benefits, including neuroprotective and anti-seizure effects. This mixed-methods study investigates the use of these mushrooms as adjunctive therapies for epilepsy among 19 participants, including caregivers on behalf of a minor. The majority (n = 14) met criteria for drug-resistant epilepsy (DRE). Participants completed surveys and structured interviews addressing functional mushroom use, quality of life (QoL), sleep quality, health outcomes, seizure activity, and caregiver burden. Qualitative data underwent thematic content analysis. Compared with the general population, participants utilizing functional mushrooms noted comparable scores in physical health, psychological health, social relationships, and environmental health. Self-report responses indicated improvements in seizure control, including reduced seizure frequency and severity, cognitive and developmental outcomes, and overall quality of life since starting use of functional mushrooms. Caregivers emphasized both benefits and ongoing challenges in managing epilepsy. Functional mushrooms are a sustainable and widely available resource, and the findings presented here suggest they could complement existing treatments for epilepsy, particularly in DRE, though further clinical trials are needed to establish efficacy, optimize dosing, and clarify mechanisms of action. • Functional mushrooms (Reishi and Lion’s Mane) were associated with reduced seizure severity and frequency in individuals with epilepsy, including drug-resistant cases. • Participants reported improvements in quality of life, cognitive functioning, and developmental outcomes, aligning with both quantitative and qualitative findings. • Caregivers noted reduced stress and burden when seizure severity decreased, pointing to broader family benefits. • A subset of participants with drug-resistant epilepsy showed signs of clinically meaningful improvement, with some likely to achieve seizure freedom. • Findings highlight the need for larger, controlled clinical trials to establish efficacy, dosing, and safety of functional mushrooms as adjunctive epilepsy treatments.