16 minute read
Safe medication
Dispelling myths:
By Julia Giannini and Certina Ho
Rachel is a 29-year-old lawyer who is actively trying to conceive her first child. She is both excited and nervous and has begun asking her family and friends advice on planning for pregnancy. She is wondering whether she should wait to begin taking prenatal vitamins until she is pregnant, as she does not want to take supplements unnecessarily.
MYTH #1: PRENATAL VITAMINS SHOULD NOT BE TAKEN UNTIL PREGNANCY IS CONFIRMED, AND NOT ALL WOMEN REQUIRE THEM
It is recommended that, if possible, women begin prenatal vitamin supplementation three months prior to conception. Most standard prenatal multivitamins contain folic acid, iron, and calcium. Talk to your doctor about your potential risks for fetal neural tube defects, to determine the correct dose of folic acid required. Every woman should be taking folic acid supplement prior to and during pregnancy.
Rachel has been taking Escitalopram for depression for the past five years. Her depression was well controlled, and she is now stable on her medication. She was told by a friend that since many medications are unsafe to the developing fetus, women should stop taking medications when they become pregnant. Rachel is extremely worried about this.
MYTH #2: ALL MEDICATIONS SHOULD BE STOPPED THROUGHOUT PREGNANCY
Not all medications are contraindicated in pregnancy and may be continued under safe and effective medication management. However, it is always important to talk to your doctor and consider individual patient factors, determining the benefits (of taking, continuing, or starting medication(s)) versus the risks (of not treating or managing your medical condition(s) during pregnancy). Pregnancy consists of three trimesters, where different stages of fetal development are taking place. Some medications should be avoided during the first trimester (e.g., decongestants). Other medications increase the chance of birth defects and should be avoided in the second and third trimesters (e.g., ACE Inhibitors that are used to lower blood pressure). Finally, some medications are absolutely contraindicated (e.g., isotretinoin, an acne medication, should not be taken during pregnancy or by women who may become pregnant, as it will very likely cause birth defects). [Readers can learn more about medication use during pregnancy at MyHealth.Alberta.ca https://myhealth. alberta.ca/Health/Pages/conditions. aspx?hwid=uf9707]
MYTH #3: PSYCHIATRIC MEDICATIONS, AS A CLASS, ARE HARMFUL TO A DEVELOPING FETUS
In the case of Rachel, she is stable on an antidepressant prior to becoming pregnant. No concrete evidence has been found to support an increased baseline risk of congenital anomalies with most of the first-line antidepressants, including her medication, Escitalopram. If a patient is on a medication at the time of pregnancy and the condition is under control, the recommendation is to continue treatment during and after pregnancy, to prevent relapse of the condition. One notable exception is Paroxetine, which may increase the risk of cardiac malformations in the first trimester. On the other hand, untreated depression can come with its own risks, such as early pregnancy loss, low birth weight, post-partum depression, and even suicidal ideation. The bottom line is that many psychiatric medications may be used safely during pregnancy, provided that the benefits outweigh the associated risks.
Rachel is now two-months pregnant and struggling with “morning sickness”. She is confused why her nausea occurs throughout the day, and not just in the morning. She would like to use medications to help her feel better. However, she heard from her sister that they aren’t very effective, and the morning sickness will usually pass after the first trimester, so it’s best to avoid additional medications.
MYTH #4: NAUSEA AND VOMITING IN PREGNANCY OCCUR ONLY IN THE MORNING, AND WOMEN USUALLY SEE RELIEF AFTER THE FIRST TRIMESTER
The term “morning sickness” is misleading, as nausea and vomiting often occur at all times of the day. Severity normally peaks at 11-13 weeks of gestation, and while many women experience relief after the first trimester, some continue to experience it throughout the remainder of pregnancy. Although evidence surrounding anti-nausea medications is conflicting, they are a reasonable and safe options, usually taken 4-6 hours before symptoms onset. If non-pharmacological management is preferred, oral ginger and acupressure options are also available. [Readers can learn more about nausea and vomiting of pregnancy at UpToDate.com https://www.uptodate.com/contents/nausea-and-vomiting-of-pregnancy-beyond-the-basics]
It is now seven months later, and Rachel has delivered a healthy baby. She has decided to exclusively breastfeed for the first six months. She believes that, similarly to pregnancy, medication use during breastfeeding should be avoided, since it can pass into breast milk and affect the baby.
MYTH #5: MEDICATIONS AVOIDED IN PREGNANCY ARE GENERALLY ALSO AVOIDED IN BREASTFEEDING
Not all medications that are unsafe in pregnancy are also unsafe during breastfeeding. Conversely, there are some medications that are safe in pregnancy, but generally avoided in breastfeeding. It is important to talk to your doctor about the benefits versus risks of medication use during breastfeeding, considering whether significant amounts of the drug are found in breast milk, and how the medication may affect the infant. It is also necessary to consider the maternal risks of not treating or managing medical condition(s) during breastfeeding.
Below is a list of other resources pertaining to safe medication use in pregnancy and breastfeeding: • MotherToBaby https://mothertobaby.org/ • Drugs and Lactation Database (LactMed®) https://www.ncbi.nlm.nih. gov/books/NBK501922/ • European Network of Teratology Information Services (ENTIS) https:// www.entis-org.eu/ • Teratogen Information System (TERIS) https://deohs.washington. edu/teris/ ■ H
We must learn from the pandemic to fix Canada’s crumbling healthcare systems
By Sara Allin
It is increasingly apparent to researchers and the public alike that Canada’s healthcare systems need urgent action to deal with some critical challenges. Even before the COVID-19 pandemic, the strains were already there. A growing and aging population with inadequate long-term and acute care across the continuum. The increasing burden of chronic illness and multi-morbidity. Inequitable access to high-quality care. A workforce struggling to meet the demand. Now, those strains have reached the breaking point, affecting all parts of our healthcare systems, including hospitals and the people who work in them.
While change is hard, it’s clear we can’t keep doing things the way we always have. Continuing to invest more in health but not changing the way we finance, govern and deliver healthcare won’t solve the problem. We can learn from the experiences of the pandemic to find new ways to create more sustainable and resilient healthcare systems.
On November 16, we released our report – Sustainability and Resilience in the Canadian Health System – as part of a new research initiative with the Partnership for Health System Sustainability and Resilience (PHSSR), a global collaboration between academic, non-governmental, life sciences, healthcare and business organizations. Using a framework developed by the London School of Economics, and with input from an expert panel of health system decision makers, leaders and researchers across Canada, the report identifies the strengths, weaknesses, opportunities and risks of Canada’s healthcare systems across seven key domains.
None of the findings will surprise anyone who works in Canada’s healthcare systems or who has had any interaction with them. The report recognizes the huge sums of money that governments spend on healthcare every year and a Conference Board of Canada forecast that spending must continue to increase in real terms over the next decade to ensure our health systems are adequately funded. But strengthening Canada’s ailing healthcare systems needs more than just money. That’s why the report makes a series of focused recommendations for systemic changes that could be implemented rapidly if all healthcare partners work together and collaborate.
Several recommendations relate directly to hospitals, but there are also others, such as reforming primary and long-term care that, if implemented, would help ensure patients receive care in the most appropriate setting. The report calls on governments to implement a Pan-Canadian Health Data Strategy that would support the effective creation, exchange and use of critical health data for the benefit of Canadians and the health systems they rely on. And it stresses the importance of adopting interoperable, integrated electronic patient records systems to support the shift from provider-centric to patient-centric data. A strengthened data infrastructure across Canada is critical to improving health system planning, including of the workforce, and in monitoring and improving performance.
A key issue for ensuring the longterm sustainability and resilience of Canada’s healthcare systems is how to support health workers and deal with shortages, burnout and other challenges. Recognizing the increased stresses caused by understaffing and the additional burdens created by COVID-19, the report recommends improving working environments and increasing access to mental health support services. It also calls for action to combat systemic dis-
crimination and racism in the health system, and to strengthen education pathways for health workers from Indigenous, racialized and low-income communities to address inequities in the system.
It notes that, despite calls from experts and health workers alike, there is no Canada-wide approach to longterm workforce planning. Instead, workforce data and planning remain at the provincial or territorial level and vary significantly among jurisdictions and health professions. The report calls for strengthened integrated health human resource planning and evaluation, with enhanced workforce data infrastructure across occupations, sectors and jurisdictions, which could be supported by a pan-Canadian agency or body.
The report also examines governance within the healthcare system, calling for increased transparency in decision making and public reporting of health system performance at both the system level and the organization or practice level, including hospitals. Public reporting, enabled by high quality data across all parts of the system, may help inform and empower patients and communities. It can also strengthen the accountability of governments to the public for the how their tax dollars are spent, and the accountability of providers and organizations for the value they provide with those investments.
The report also looks at how to strengthen care in the community to keep people out of hospitals as much as possible, with a particular focus on primary care and home care. The report calls for scaling up innovative strategies and inter-professional teambased models of primary care, prioritizing underserved communities and optimizing the available workforce. It recommends taking a life-course perspective to plan for and invest in high-quality long-term care across the continuum of services and supports, along with improving the working conditions, education standards and full-time employment opportunities, with benefits and adequate wages, for aged care workers including unregulated workers.
In all, the report makes 29 recommendations across seven domains for improving the sustainability and resilience of Canada’s healthcare systems. The hope with this project is that the practical and action-oriented recommendations will be seriously considered by governments and health sector stakeholders. Their implementation will require a concerted effort by all involved.
Our healthcare systems have failed to evolve to meet the needs of Canadian patients and the healthcare professionals who care for them.
We know we need to do things differently.
We know it won’t be easy.
We also know that, if we don’t make some changes, we will not be ready for the next crisis and will never build the sustainable and resilient healthcare systems Canadians need and expect.
To read the full Canadian report, please visit: https://www.phssr.org/ findings ■ H
Sara Allin is Associate Professor, Institute of Health Policy, Management and Evaluation, University of Toronto; Director, The North American Observatory on Health Systems and Policies; and lead researcher, Sustainability and Resilience in the Canadian Health System
NEWS Plagues of the past have a lot to tell us about current crises, according to a new study
By Patrick Lejtenyi
As the COVID-19 pandemic settled in over the course of the first half of 2020, few authors enjoyed as much renewed interest as the Algerian-born French existentialist Albert Camus. His classic 1947 novel The Plague tells the story of a town beset and isolated by an outbreak of the bubonic plague. The plague drags on and health authorities struggle to contain it. The population experiences a breakdown of civic order, a crumbling trust in institutions and the gradual onset of general paranoia. Sound familiar?
Joel Bothello, associate professor of management at the John Molson School of Business, recently published a paper on the topic in The Academy of Management Review. In it he asserts that Camus’s fictional plague, along with the very real Black Death of the 14th century and the lethal waves that followed, can be better understood using event system theory (EST). This relatively new theory to management studies reframes societal disruptions from isolated events to being the result of slowly unfolding chains of connected events: what happened prior to the pandemic or Chernobyl or the 9/11 attack, and what came after?
The long lead-ups and aftermaths of a calamity can provide a deeper understanding than just the study of the disruption itself, argue the authors. “Rather than it being about one event, we should look at each of these disruptions as an accumulation of events leading toward transformation,” says Bothello, who co-wrote the article with Thomas Roulet from the University of Cambridge.
Joel Bothello: “Even though we are supposedly more sophisticated now, the patterns that we see of human behaviour are very similar.”
SIMILARITIES ACROSS THE AGES
Bothello and Roulet studied four books about past plague outbreaks, two fiction – The Plague and Daniel Defoe’s A Journal of the Plague Year – and two nonfiction – The Black Death and the Transformation of the West by David Herlihy and In the Wake of the Plague: The Black Death and the World It Made by Norman Cantor.
They found that the distance of centuries has not changed the fundamental nature of human responses to disruptions or the profound changes that follow them. In all four books they found evidence of societal stagnation, disorientation, polarization and repudiation.
Stagnation refers to a population not recognizing or understanding the events within a chain and so fail to engage with it appropriately. Once the disruption occurs, the population experiences disorientation and no one knows how long it will take for life to return to normal. Polarization occurs when attempts to assign responsibility are shifted onto a particular group, often resulting in scapegoating and xenophobia. And then comes the repudiation of an existing system of beliefs and erosion of confidence in authorities, be they religious, civic or scientific. These in turn lead to macro-level changes to economic, political and cultural norms.
“Even though we are supposedly more sophisticated now, the patterns that we see of human behaviour are very similar,” Bothello notes.
CONCORDIA’S JOEL BOTHELLO USES HISTORICAL AND FICTIONAL ACCOUNTS OF THE BLACK DEATH TO ANALYZE HUMANITY’S RESPONSES TO DISRUPTIONS LIKE COVID-19
SUBJECTIVE AND OBJECTIVE PERSPECTIVES OF END TIMES
“We chose these particular books because they look at the Black Death through different levels of analysis,” he explains. “The novels capture the subjective experiences that, even though they are fictional, draw upon real events and real people. The nonfiction books look at the larger societal effects as well as the individual experiences of the people living through them.”
There is much to be learned from the disasters of the past, says Bothello, Concordia University Research Chair in Resilience and Institutions, given the right framework. “EST helps us reconceptualize disruption, because disruption has usually been treated as a one-time jolt,” he adds. “If we apply this new lens to it, we can look at how events happen at different levels, how they connect with one another and how they even intersect with different event chains. We can look at disruption from a holistic perspective to see how it leads to changes in organizations and societies.”
Read the cited paper: “An Event-System Perspective on Disruption: Theorizing the Pandemic and Other Discontinuities through Historical and Fictional Accounts of the Plague.” ■ H
A litmus test for the lungs
Arecent study led by Drs. Tereza Martinu and Bryan Coburn at Toronto General Hospital Research Institute looked at how chronic acid reflux – known as gastroesophageal reflux disease – affects the communities of microbes found in the lung.
The composition of microbial communities in the lung after transplantation differs between people and can be associated with lung dysfunction and inflammation.
“We wondered whether chronic reflux changed the microbial community, or microbiota, in the lung after transplantation,” says Dr. Martinu.
To explore the effect of chronic reflux on lung health after transplantation, the research team compared samples of lung microbiota from individuals who received a lung transplant between 2010 and 2015. Of these individuals, 24 of them experienced chronic acid reflux in the first year after transplant and 51 did not.
Analyses of the data revealed that the density and diversity of the microbial community differed in those with chronic reflux, compared to those without reflux. However, those with the condition were not more likely to experience inflammation and dysfunction of the lung.
When the team considered all samples from the 75 individuals that participated in the study, they identified three different types of microbial community profiles: the first type had high bacterial density, with species that are commonly found in the mouth. The second type had low bacterial density. And the third type had varying densities but with species that often cause infectious disease. This third type was more likely to be associated with lung inflammation and dysfunction.
Individuals with chronic acid reflux were more likely to have the first type of profile.
“We found that patients with chronic reflux had increased bacterial density with more species that are commonly found in the mouth,” says Dr. Martinu, who is also a lung trans-
plant physician at UHN’s Ajmera Transplant Centre and associate professor of Medicine at the University of Toronto (U of T). “Despite having higher levels of bacteria, these individuals did not experience more lung dysfunction than those without chronic reflux in general.”
“Chronic acid reflux is an important modulator of the microbial community in the lung after transplantation. Future studies of chronic reflux in the context of transplantation should include the microbial community profile as part of the assessment,” concludes Dr. Coburn, who is also an assistant professor of Laboratory Medicine & Pathobiology at the U of T.
Rapid tests for lung microbiota may be useful predictors of disease to help lung transplant recipients manage their health in the future.
This work was supported by the Canadian Institutes of Health Research, UHN’s Ajmera Transplant Centre, U.S. National Institutes of Health, Comprehensive Research Experience for Medical Students Program, Cystic Fibrosis Foundation and UHN Foundation. ■ H
The research team identified bacteria using fluid samples collected from transplanted lungs. Staphylococcus (illustrated above) was one of the disease-causing species of bacteria that was identified in a subset of lungs.
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