Key Message

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.

Key Message

As a first-line therapy for the treatment of secondary Raynaud phenomenon (RP), phosphodiesterase type 5 (PDE5) inhibitors are more effective than a placebo at reducing the frequency, severity, and the duration of RP attacks. PDE5 inhibitors were less effective than calcium channel blockers or selective serotonin reuptake inhibitors at reducing the severity of RP attacks. Patients treated with PDE5 inhibitors were more likely to experience an adverse event and to discontinue treatment compared with those treated with a placebo.

As a first-line therapy for the treatment of secondary digital ulcers, treatment with PDE5 inhibitors was less effective at preventing new digital ulcers than treatment with an endothelin receptor antagonist, but there was no difference in the time to healing or the size of the primary digital ulcer (findings based on 1 non-randomized study).

There is a lack of evidence on the clinical effectiveness of PDE5 inhibitors as second-line therapy (i.e., after failed treatment with calcium channel blockers) for treating secondary RP and/or digital ulcers.

There is a lack of evidence on the cost-effectiveness of PDE5 inhibitors for treating secondary RP and/or digital ulcers.

Two guidelines were identified that provide recommendations for treating RP secondary to systemic sclerosis. Two guidelines recommend calcium channel blockers as first-line therapy based on high-quality evidence; 1 guideline recommends angiotensin II receptor antagonists as first-line therapy, but this is based on weak evidence. The guidelines also include recommendations that PDE5 inhibitors, selective serotonin reuptake inhibitors, alpha blockers, and statin therapy be considered for treating RP secondary to systemic sclerosis. For severe cases of RP secondary to systemic sclerosis, IV iloprost is recommended.

Three guidelines were identified that provide recommendations for treating digital ulcers secondary to systemic sclerosis. Three guidelines recommend treatment with PDE5 inhibitors. The guidelines also recommend considering treatment with endothelin receptor antagonists, IV iloprost, and calcium channel blockers. For severe digital ulcers secondary to systemic sclerosis, treatment with IV iloprost or a PDE5 inhibitor is recommended.

A patient with lived experience with secondary RP and digital ulcers was involved in this report, and they identified outcomes that are important to patients with secondary RP and/or digital ulcers. These outcomes included pain, digit loss, fatigue, mental health, and function. None of the studies or guidelines in this report included direct measures of these patient-identified outcomes.

Key Message

Canada's Drug Agency 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).

Key Message

For treating active tuberculosis (TB), some 4-month treatment regimens may be as effective and safe as the standard 6-month treatment regimen. However, there are also 4-month treatment regimens that seem to be less effective than the 6-month treatment regimen for treating active TB. The effectiveness of these shortened treatment regimens depends on the combination of drugs and the dose schedule.

For treating active TB, a 3-month treatment regimen appears to be less effective than the standard 6-month regimen, as it is associated with a higher rate of TB recurring within 2 years after completing treatment.

Key Message

​In people at risk of occupational exposure to tuberculosis, targeted testing for latent tuberculosis infection (e.g., testing for high-risk individuals, testing after tuberculosis exposure) appears to be more cost-effective than repeated testing, such as testing once a year or every 3 years (findings based on 2 economic evaluations that assessed the cost-effectiveness of repeated latent tuberculosis infection screening in workers of health care settings).​

Key Message

• It is not known if screening for latent tuberculosis infection (LTBI) is useful for reducing the risk of tuberculosis reactivation among people at risk (no evidence was found).
• In people with LTBI, providing treatment for the latent infection may be helpful for preventing the development of active tuberculosis disease. (In addition, LTBI treatments do not appear to increase the risk for hepatotoxicity.) Treatment effectiveness may depend on the specific LTBI treatment regimen used.
• For people at an increased risk for tuberculosis ― including those from areas with high rates of tuberculosis ― guidelines recommend screening and treatment for LTBI, as this may help prevent TB reactivation. Treatment is recommended for those who are 65 years old or younger and with a positive LTBI result (recommendation from 1 high-quality guideline).

Key Message

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).

Key Message

In people who have been vaccinated with Bacillus Calmette-Guérin, the interferon gamma release assay appears to be related to fewer diagnoses for latent tuberculosis infection, fewer prescriptions of preventive tuberculosis therapy, and no difference in the number of active TB cases compared to the tuberculin skin test (findings based on 1 [non-randomized study] of low quality). No evidence-based guidelines were found regarding the identification of latent tuberculosis infection in people with previous Bacillus Calmette-Guérin vaccination.

Key Message

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.