Safety and immunogenicity of the live-attenuated varicella vaccine in pediatric solid organ transplant recipients: A systematic review and meta-analysis.

This study aimed to synthesize the available evidence on the immunogenicity, safety, and effectiveness of live-attenuated varicella vaccine in solid organ transplant recipients. Medline and EMBASE were searched using predefined search terms to identify relevant studies. The included articles reported varicella vaccine administration in the posttransplant period in children and adults. A pooled proportion of transplant recipients who seroconverted and who developed vaccine-strain varicella and varicella disease was generated. Eighteen articles (14 observational studies and 4 case reports) were included, reporting on 711 transplant recipients who received the varicella vaccine. The pooled proportion was 88.2% (95% confidence interval 78.0%-96.0%, 13 studies) for vaccinees who seroconverted, 0% (0%-1.2%, 13 studies) for vaccine-strain varicella, and 0.8% (0%-4.9%, 9 studies) for varicella disease. Most studies followed clinical guidelines for administering live-attenuated vaccines, with criteria that could include being at least 1 year posttransplant, 2 months postrejection episode, and on low-dose immunosuppressive medications. Varicella vaccination in transplant recipients was overall safe in the included studies, with few cases of vaccine-strain-induced varicella or vaccine failure, and although it was immunogenic, the proportion of recipients who seroconverted was lower than that seen in the general population. Our data support varicella vaccination in select pediatric solid organ transplant recipients.

Effects of COVID-19 pandemic on anxiety and depression in primary care: A cohort study in Ontario, Canada.

Context: Many people have experienced poorer mental health and increased distress during the COVID-19 pandemic. It is unclear to what extent this has resulted in increases in the number of patients presenting with anxiety and/or depression in primary care. Objective: To determine if there are more patients are visiting their family doctor for anxiety/depression during the COVID-19 pandemic compared to before the pandemic, and to determine whether these effects varied based on patient demographic characteristics. Study Design: A retrospective cohort study of family medicine patients from 2017-2020. Data Source: Electronic medical records (EMRs) from the University of Toronto Practice Based-Research Network (UTOPIAN) Data Safe Haven. The majority of physicians in the UTOPIAN EMR database practice in the Greater Toronto Area, a high-COVID region of Canada. Population Studied: Active family practice patients aged 10 and older with at least 1 year of EMR data. Outcome Measures: Visits for anxiety and/or depression; prescriptions for antidepressant medications. Results: Changes in visits for anxiety and depression during the COVID-19 pandemic were consistent with an increased demand for mental healthcare and an increase in the number of individuals with anxiety and depression. Increases in visits for anxiety and depression were larger for younger patients, women, and later in the pandemic. Among younger patients, prescriptions for antidepressants were substantially reduced during the first few months of the pandemic (April-May 2020) but incidences rates increased later in 2020. Increases in visit volume during the pandemic were consist with more frequent visits for anxiety/depression and more new patients presenting with anxiety or depression. Conclusion: The COVID-19 pandemic has resulted in an increased demand for mental health services from family physicians. Increases in anxiety and depression were especially pronounced among younger female patients and increased throughout the pandemic. Our findings highlight the need for continued efforts to support and addresses mental health concerns in primary care.

Prescription Trends of Thiazide Diuretics in a Canadian Primary Care Population From 2015 to 2021.

Background: Hypertension Canada 2017 guidelines favoured the use of thiazide (TZ)-like diuretics, such as CLTD (chlorthalidone) and indapamide (IND) over hydrochlorothiazide (HCTZ). Health Canada warned in 2019 that HCTZ may be associated with increased risk of skin cancer. Our study looked at the changes in TZ prescriptions from 2015 to 2021 in Ontario, Canada. Methods: A retrospective cohort study was conducted of adults with hypertension, using electronic medical record data from the University of Toronto Practice-Based Research Network database covering mostly the Greater Toronto area. Outcomes included the proportion of patients who received a prescription of HCTZ, CLTD, or IND each month. Interrupted time-series analysis was used to evaluate the change in outcomes after publication of the 2017 guidelines and 2019 safety warning. Prescription trends were stratified by prescribing physicians' sex and year of medical school graduation. Results: A total of 100,428 patients with hypertension were included in the cohort, with 31,700 patients who received at least one TZ prescription from 343 family physicians. We found a declining trend in HCTZ prescriptions over time, accompanied by an increase in IND and CLTD prescriptions, with statistically significant but transient changes in prescription rates after publication of the 2017 guidelines and the 2019 safety warning for all 3 medications. Female physician and early-career physician prescription rates changed faster than that of their counterparts immediately after the Health Canada safety warning was issued. Conclusions: TZ diuretic prescription patterns have changed in recent years, but Hypertension Canada's 2017 guidelines and the 2019 Health Canada safety warning did not have a sustained significant impact on the change in prescription rates of HCTZ, IND, and CLTD.

Contexte: Les lignes directrices 2017 d'Hypertension Canada accordaient la priorité à l'utilisation de diurétiques apparentés aux thiazidiques (TZ), comme la chlorthalidone (CLTD) et l'indapamide (IND), plutôt que l'hydrochlorothiazide (HCTZ). En 2019, Santé Canada a émis une mise en garde indiquant que le HCTZ pourrait être associé à un risque accru de cancer de la peau. Notre étude s'intéressait à l'évolution des taux de prescriptions des différents diurétiques TZ entre 2015 et 2021 en Ontario, au Canada. Méthodologie: Une étude de cohorte rétrospective a été menée auprès d'adultes atteints d'hypertension à l'aide des données des dossiers médicaux électroniques du réseau de recherche fondé sur la pratique de l'Université de Toronto, qui couvre principalement la région du Grand Toronto. Les issues évaluées comprenaient la proportion de patients se faisant prescrire HCTZ, CLTD ou IND chaque mois. Une analyse de série chronologique interrompue a été réalisée pour évaluer l'évolution des issues après la publication des lignes directrices de 2017 et la mise en garde de 2019. Les tendances observées dans les prescriptions ont été stratifiées selon le sexe et l'année d'obtention du diplôme de médecine du médecin prescripteur. Résultats: Au total, 100 428 patients atteints d'hypertension ont été inclus dans la cohorte; 31 700 d'entre eux se sont fait prescrire un TZ au moins une fois par l'un des 343 médecins de famille prescripteurs. Nous avons observé une tendance à la baisse quant aux prescriptions de HCTZ, laquelle s'accompagnait d'une augmentation du nombre de prescriptions d'IND et de CLTD. La variation des taux de prescriptions pour les trois médicaments était statistiquement significative, mais transitoire après la publication des lignes directrices de 2017 et de la mise en garde de 2019. Les taux de prescriptions immédiatement après la publication de la mise en garde de Santé Canada ont changé plus vite pour les femmes médecins et les médecins en début de carrière que pour les autres médecins. Conclusions: Les habitudes de prescription des diurétiques thiazidiques ont changé dans les dernières années, mais les lignes directrices 2017 d'Hypertension Canada et la mise en garde émise en 2019 par Santé Canada n'ont pas eu un effet significatif durable sur la variation des taux de prescriptions de HCTZ, d'IND et de CLTD.

Patient Perceived Barriers and Enablers to Medication Adherence in the Treatment of Depression: A Qualitative Study.

BACKGROUND: Depression affects approximately 280 million individuals globally and it is a leading cause of disability. Despite effective medication options, 50% of patients prematurely discontinue antidepressants within 6 months. We sought to understand patients' perspectives regarding their needs and expectations related to antidepressants. OBJECTIVES: To identify and describe enablers and barriers that influence adult patients' medication adherence in depression treatment and to explore patients' educational needs on initiating or continuing antidepressant therapy. METHODS: Qualitative descriptive study was conducted using individual, semi-structured interviews of adult patients with depression who were prescribed an antidepressant within 3 months of study recruitment at an urban primary care clinic in Toronto, Canada. Thirteen participants were interviewed. Interviews were recorded and transcribed verbatim for inductive thematic analysis. RESULTS: Six themes emerged: safety and effectiveness of antidepressant, understanding of depression and its management, medication administration, healthcare experiences in the treatment of depression, and social influences and relationships. Barriers to adherence included adverse effects of antidepressants, preference for non-pharmacological therapies, uncertainty about therapeutic effects, and social stigma. In contrast, enablers were positive responses from antidepressants, fear of relapse, reminder aids, established routine, and a trusting patient-provider relationship. Participants desired access to reliable, evidence-based, and personalized educational information delivered through verbal, written, and digital formats to support antidepressant adherence. CONCLUSION: To overcome the identified barriers, educational strategies should involve both patients and their prescribers to identify patient-specific needs and treatment goals, engage in shared decision-making, and maintain consistent follow-up to support antidepressant adherence.

Perspectives of Older Adults on COVID-19 and Influenza Vaccination in Ontario, Canada.

INTRODUCTION/OBJECTIVES: Addressing vaccine hesitancy has become an increasingly important public health priority in recent years. There is a paucity of studies that have focused on vaccine hesitancy among older adults, who are known to be at greater risk of complications from infections such as COVID-19. We aim to explore the attitudes and beliefs of older adults regarding COVID-19 and influenza vaccines in Toronto, Ontario. METHODS: Older adults enrolled in the Student Senior Isolation Prevention Partnership (SSIPP) program at the University of Toronto were contacted to participate in a phone survey and semi-structured interview. Survey data was analyzed descriptively, and attitude toward vaccination was compared between sociodemographic groups by using Fisher's exact test. Interview audio files were transcribed verbatim and analyzed inductively for themes and sub-themes. RESULTS: All thirty-three (100%) older adults reported that they had received the first and second doses of the COVID-19 vaccine. Twenty-six (78.8%) participants reported intent to get vaccinated against influenza or had already received the influenza vaccine that year. Notably, only 2 out 7 (28.6%) individuals who did not plan to get vaccinated against influenza believed that vaccines offered by health providers are beneficial and only 3 out of 7 (42.9%) agreed that getting vaccines is a good way to protect oneself from disease. No other significant differences in attitudes among participants were found when compared by gender, ethnicity, or education level. The qualitative data analysis of interview transcripts identified 5 themes that impact vaccine decision making: safety, trust, mistrust, healthcare experience, and information dissemination and education. CONCLUSIONS: Our data showed that older adults in the SSIPP program generally had positive views toward vaccination, especially toward the COVID-19 vaccines. However, several concerns regarding the effectiveness of the vaccines were brought up in interviews, such as the speed at which the vaccines were produced and the inconsistency in government messaging.

Transit Time Theory for a Droplet Passing through a Slit in Pressure-Driven Low Reynolds Number Flows.

Soft objects squeezing through small apertures are crucial for many in vivo and in vitro processes. Red blood cell transit time through splenic inter-endothelial slits (IESs) plays a crucial role in blood filtration and disease progression, while droplet velocity through constrictions in microfluidic devices is important for effective manipulation and separation processes. As these transit phenomena are not well understood, we sought to establish analytical and numerical solutions of viscous droplet transit through a rectangular slit. This study extends from our former theory of a circular pore because a rectangular slit is more realistic in many physiological and engineering applications. Here, we derived the ordinary differential equations (ODEs) of a droplet passing through a slit by combining planar Poiseuille flow, the Young-Laplace equations, and modifying them to consider the lubrication layer between the droplet and the slit wall. Compared to the pore case, we used the Roscoe solution instead of the Sampson one to account for the flow entering and exiting a rectangular slit. When the surface tension and lubrication layer were negligible, we derived the closed-form solutions of transit time. When the surface tension and lubrication layer were finite, the ODEs were solved numerically to study the impact of various parameters on the transit time. With our solutions, we identified the impact of prescribed pressure drop, slit dimensions, and droplet parameters such as surface tension, viscosity, and volume on transit time. In addition, we also considered the effect of pressure drop and surface tension near critical values. For this study, critical surface tension for a given pressure drop describes the threshold droplet surface tension that prevents transit, and critical pressure for a given surface tension describes the threshold pressure drop that prevents transit. Our solutions demonstrate that there is a linear relationship between pressure and the reciprocal of the transit time (referred to as inverse transit time), as well as a linear relationship between viscosity and transit time. Additionally, when the droplet size increases with respect to the slit dimensions, there is a corresponding increase in transit time. Most notably, we emphasize the initial antagonistic effect of surface tension which resists droplet passage but at the same time decreases the lubrication layer, thus facilitating passage. Our results provide quantitative calculations for understanding cells passing through slit-like constrictions and designing droplet microfluidic experiments.

Effects of COVID-19 pandemic on anxiety and depression in primary care: A retrospective cohort study.

BACKGROUND: Population-based surveys indicate that many people experienced increased psychological distress during the COVID-19 pandemic. We aimed to determine if there was a corresponding increase in patients receiving services for anxiety and depression from their family physicians. METHODS: Electronic medical records from the University of Toronto Practice Based-Research Network (UTOPIAN; N = 322,920 patients) were used to calculate incidence rates for anxiety/depression related visits and antidepressant prescriptions before the COVID-19 pandemic (January 2018-February 2020) and during the COVID-19 pandemic (March-December 2020). Data from the pre-pandemic period were used to predict expected rates during the pandemic period which was compared to the observed rate. RESULTS: The number of patients presenting with anxiety/depression symptoms in primary care varied across age groups, sex, and time since pandemic onset. Among the youngest patients (ages 10-18 years), there were fewer patients than pre-pandemic visiting for new episodes of anxiety/depression and being prescribed antidepressants in April 2020, but by the end of 2020 this trend had reversed such that incidence rates for anxiety/depression related visits were higher than pre-pandemic levels. Among older adults, incidence rates of anxiety/depression related visits increased in April 2020 with the onset of the pandemic, and remained higher than expected throughout 2020. LIMITATIONS: A convenience sample of 362 family physicians in Ontario was used. CONCLUSION: Demand for mental health services from family physicians varied by patient age and sex and changed with the onset of the COVID-19 pandemic. By the end of 2020, more patients were seeking treatment for anxiety/depression related concerns.

Impact of the COVID-19 pandemic on routine immunization coverage in children under 2 years old in Ontario, Canada: A retrospective cohort study.

BACKGROUND: The COVID-19 pandemic has caused a disruption in childhood immunization coverage around the world. This study aimed to determine the change in immunization coverage for children under 2 years old in Ontario, Canada, comparing time periods pre-pandemic to during the first year of the pandemic. METHODS: Observational retrospective open cohort study, using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN) database, from January 2019 to December 2020. Children under 2 years old who had at least 2 visits recorded in UTOPIAN were included. We measured up-to-date (UTD) immunization coverage rates, overall and by type of vaccine (DTaP-IPV-Hib, PCV13, Rota, Men-C-C, MMR, Var), and on-time immunization coverage rates by age milestone (2, 4, 6, 12, 15, 18 months). We compared average coverage rates over 3 periods of time: January 2019-March 2020 (T1); March-July 2020 (T2); and August-December 2020 (T3). RESULTS: 12,313 children were included. Overall UTD coverage for all children was 71.0% in T1, dropped by 5.7% (95% CI: -6.2, -5.1) in T2, slightly increased in T3 but remained lower than in T1. MMR vaccine UTD coverage slightly decreased in T2 and T3 by approximately 2%. The largest decreases were seen at ages 15-month and 18-month old, with drops in on-time coverage of 14.7% (95% CI: -18.7, -10.6) and 16.4% (95% CI: -20.0, -12.8) respectively during T2. When stratified by sociodemographic characteristics, no specific subgroup of children was found to have been differentially impacted by the pandemic. CONCLUSION: Childhood immunization coverage rates for children under 2 years in Ontario decreased significantly during the early period of the COVID-19 pandemic and only partially recovered during the rest of 2020. Public health and educational interventions for providers and parents are needed to ensure adequate catch-up of delayed/missed immunizations to prevent potential outbreaks of vaccine-preventable diseases.

Changes in family medicine visits across sociodemographic groups after the onset of the COVID-19 pandemic in Ontario: a retrospective cohort study.

BACKGROUND: It has been suggested that the COVID-19 pandemic has worsened socioeconomic disparities in access to primary care. Given these concerns, we investigated whether the pandemic affected visits to family physicians differently across sociodemographic groups. METHODS: We conducted a retrospective cohort study using electronic medical records from family physician practices within the University of Toronto Practice-Based Research Network. We evaluated primary care visits for a fixed cohort of patients who were active within the database as of Jan. 1, 2019, to estimate the number of patients who visited their family physician (visitor rate) and the number of distinct visits (visit volume) between Jan. 1, 2019, to June 30, 2020. We compared trends in visitor rate and visit volume during the pandemic (Mar. 14 to June 30, 2020) with the same period in the previous year (Mar. 14 to June 30, 2019) across sociodemographic factors, including age, sex, neighbourhood income, material deprivation and ethnic concentration. RESULTS: We included 365 family physicians and 372 272 patients. Compared with the previous year, visitor rates during the pandemic period dropped by 34.5%, from 357 visitors per 1000 people to 292 visitors per 1000 people. Declines in visit volume during the pandemic were less pronounced (21.8% fewer visits), as the mean number of visits per patient increased during the pandemic (from 1.64 to 1.96). The declines in visitor rate and visit volume varied based on patient age and sex, but not socioeconomic status. INTERPRETATION: Although the number of visits to family physicians dropped substantially during the first few weeks of the COVID-19 pandemic in Ontario, patients from communities with low socioeconomic status did not appear to be disproportionately affected. In this primary care setting, the pandemic appears not to have worsened socioeconomic disparities in access to care.

Changes in the top 25 reasons for primary care visits during the COVID-19 pandemic in a high-COVID region of Canada.

PURPOSE: We aimed to determine the degree to which reasons for primary care visits changed during the COVID-19 pandemic. METHODS: We used data from the University of Toronto Practice Based Research Network (UTOPIAN) to compare the most common reasons for primary care visits before and after the onset of the COVID-19 pandemic, focusing on the number of visits and the number of patients seen for each of the 25 most common diagnostic codes. The proportion of visits involving virtual care was assessed as a secondary outcome. RESULTS: UTOPIAN family physicians (N = 379) conducted 702,093 visits, involving 264,942 patients between March 14 and December 31, 2019 (pre-pandemic period), and 667,612 visits, involving 218,335 patients between March 14 and December 31, 2020 (pandemic period). Anxiety was the most common reason for visit, accounting for 9.2% of the total visit volume during the pandemic compared to 6.5% the year before. Diabetes and hypertension remained among the top 5 reasons for visit during the pandemic, but there were 23.7% and 26.2% fewer visits and 19.5% and 28.8% fewer individual patients accessing care for diabetes and hypertension, respectively. Preventive care visits were substantially reduced, with 89.0% fewer periodic health exams and 16.2% fewer well-baby visits. During the pandemic, virtual care became the dominant care format (77.5% virtual visits). Visits for anxiety and depression were the most common reasons for a virtual visit (90.6% virtual visits). CONCLUSION: The decrease in primary care visit volumes during the COVID-19 pandemic varied based on the reason for the visit, with increases in visits for anxiety and decreases for preventive care and visits for chronic diseases. Implications of increased demands for mental health services and gaps in preventive care and chronic disease management may require focused efforts in primary care.

Impact of the COVID-19 pandemic on the provision of routine childhood immunizations in Ontario, Canada.

BACKGROUND: The COVID-19 pandemic has a worldwide impact on all health services, including childhood immunizations. In Canada, there is limited data to quantify and characterize this issue. METHODS: We conducted a descriptive, cross-sectional study by distributing online surveys to physicians across Ontario. The survey included three sections: provider characteristics, impact of COVID-19 on professional practice, and impact of COVID-19 on routine childhood immunization services. Multivariable logistic regression identified factors associated with modification of immunization services. RESULTS: A total of 475 respondents answered the survey from May 27th to July 3rd 2020, including 189 family physicians and 286 pediatricians. The median proportion of in-person visits reported by physicians before the pandemic was 99% and dropped to 18% during the first wave of the pandemic in Ontario. In total, 175 (44.6%) of the 392 respondents who usually provide vaccination to children acknowledged a negative impact caused by the pandemic on their immunization services, ranging from temporary closure of their practice (n = 18; 4.6%) to postponement of vaccines in certain age groups (n = 103; 26.3%). Pediatricians were more likely to experience a negative impact on their immunization services compared to family physicians (adjusted odds ratio [aOR] = 2.64, 95% CI: 1.48-4.68), as well as early career physicians compared to their more senior colleagues (aOR = 2.69, 95% CI: 1.30-5.56), whereas physicians from suburban settings were less impacted than physicians from urban settings (aOR = 0.62, 95% CI: 0.39-0.99). Some of the proposed solutions to decreased immunization services included assistance in accessing personal protective equipment, dedicated centers or practices for vaccination, universal centralized electronic immunization records and education campaigns for parents. CONCLUSIONS: COVID-19 has caused substantial modifications to pediatric immunization services across Ontario. Strategies to mitigate barriers to immunizations during the pandemic need to be implemented in order to avoid immunity gaps that could lead to an eventual increase in vaccine preventable diseases.

Relationship between prostate-specific antigen bounce body fat distribution and body mass index in permanent seed brachytherapy for prostate cancer.

PURPOSE: To analyze the influence of body mass index (BMI) and adipose tissue distribution on prostate-specific antigen (PSA) bounce after iodine-125 prostate brachytherapy. METHODS AND MATERIALS: We studied 20 patients who had PSA bounce (≥0.50ng/mL) after exclusive prostate brachytherapy. These patients were compared with 48 patients without a bounce (<0.50ng/mL). All patients in the comparison group had a followup of ≥24 months and a last PSA ≤0.5ng/mL. Within these 48 patients, there was a group matched for age (n=20). Univariate and multivariate logistic models were estimated to assess the association between age, baseline PSA, prostate volume, D(90), visceral fat (VF) volume, and BMI on PSA-bouncing status. RESULTS: When comparing the patients with a bounce to those without, only BMI showed a significantly different distribution (mean, 25.18 vs. 27.47kg/m(2); p=0.0342). On a multivariate analysis, BMI had an odds ratio of 0.85 (95% confidence interval, 0.71-0.99, p=0.049), indicating that an increase of 1kg/m(2) in BMI is associated with a 15% reduction in the odds of having a bounce. In the univariate analysis with the matching patients, BMI was a significant predictor of a bounce (p=0.0147). In the multivariate conditional logistic model, BMI showed a trend toward an influence on a bounce (p=0.0615). All other factors, including VF, did not have any influence on a PSA bounce. CONCLUSIONS: Patients with a lower BMI are more likely to experience a PSA bounce ≥0.50ng/mL. VF did not have an influence on a PSA bounce.