Genomic Epidemiology of Large Blastomycosis Outbreak, Ontario, Canada, 2021.

Using phylogenomic analysis, we provide genomic epidemiology analysis of a large blastomycosis outbreak in Ontario, Canada, caused by Blastomyces gilchristii. The outbreak occurred in a locale where blastomycosis is rarely diagnosed, signaling a possible shift in geographically associated incidence patterns. Results elucidated fungal population genetic structure, enhancing understanding of the outbreak.

Wastewater Surveillance to Confirm Differences in Influenza A Infection between Michigan, USA, and Ontario, Canada, September 2022-March 2023.

Wastewater surveillance is an effective way to track the prevalence of infectious agents within a community and, potentially, the spread of pathogens between jurisdictions. We conducted a retrospective wastewater surveillance study of the 2022-23 influenza season in 2 communities, Detroit, Michigan, USA, and Windsor-Essex, Ontario, Canada, that form North America's largest cross-border conurbation. We observed a positive relationship between influenza-related hospitalizations and the influenza A virus (IAV) wastewater signal in Windsor-Essex (ρ = 0.785; p<0.001) and an association between influenza-related hospitalizations in Michigan and the IAV wastewater signal for Detroit (ρ = 0.769; p<0.001). Time-lagged cross correlation and qualitative examination of wastewater signal in the monitored sewersheds showed the peak of the IAV season in Detroit was delayed behind Windsor-Essex by 3 weeks. Wastewater surveillance for IAV reflects regional differences in infection dynamics which may be influenced by many factors, including the timing of vaccine administration between jurisdictions.

Saccharomyces boulardii improves clinical and paraclinical indices in overweight/obese knee osteoarthritis patients: a randomized triple-blind placebo-controlled trial.

PURPOSE: This study aimed to determine the effect of the probiotic Saccharomyces boulardii (S. boulardii) in patients with knee osteoarthritis (KOA). METHODS: In this study, 70 patients with KOA were recruited via outpatient clinics between 2020 and 2021 and randomly assigned to receive probiotics or placebo supplements for 12 weeks. The primary outcome was a change in pain intensity according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. RESULTS: Sixty-three patients completed the trial. A linear mixed analysis of covariance (ANCOVA) model analysis showed that probiotic was better than placebo in decreasing the pain intensity measured by visual analogue scale (VAS) [-2.11 (-2.59, -1.62) in probiotic group and -0.90 (-1.32, -0.48) in placebo group, p = 0.002] and WOMAC pain score [-3.57 (-4.66, -2.49) in probiotic group and -1.43 (-2.33, -0.53) in placebo group, p < 0.001]. The daily intake of acetaminophen for pain management significantly decreased in the probiotic group [-267.18 (-400.47, -133.89) mg, p < 0.001] that was significantly better than placebo (p = 0.006). Probiotic significantly decreased the serum levels of high-sensitivity C-reactive protein (hs-CRP) inflammatory index [-2.72 (-3.24, -2.20) µg/ml] and malondialdehyde (MDA) oxidative stress index [-1.61 (-2.11, -1.11) nmol/ml] compared to the placebo (p = 0.002 and p < 0.001, respectively). Probiotic was better than placebo in increasing the scores of role disorder due to physical health (p = 0.023), pain (p = 0.048) and physical health (p = 0.031). CONCLUSION: Probiotic S. boulardii supplementation in patients with KOA significantly improved pain intensity, some dimensions of QoL, and inflammatory and oxidative stress biomarkers with no severe side effects. TRIAL REGISTRY: Registered on the Iranian clinical trial website ( http://www.irct.ir : IRCT20161022030424N4) on 2019-09-02.

Adverse childhood events and self-harming behaviours among individuals in Ontario forensic system: the mediating role of psychopathy.

BACKGROUND: Adverse childhood events (ACEs), psychopathy, and self-harming behaviours are prevalent among individuals in the forensic psychiatry system. While existing literature suggests that ACEs, self-harm, and psychopathy are interrelated, little is known about the interplay of psychopathic traits in this relationship. The present study aimed to determine the mediating role of psychopathy in the relationship between ACEs and self-harming behaviours in forensic patients. METHODS: This was a retrospective study of patients under the Ontario Review Board (ORB) between 2014 and 2015. In the analysis, we included patients with complete data on ACEs, self-harming behaviours, and a Psychopathy Checklist-Revised (PCL-R) score - a measure of psychopathic traits and their severity conducted during the reporting period. Mediation analysis was based on the Baron and Kenny approach, and sensitivity analysis was performed based on the types of ACEs. RESULTS: ​​​The sample population (n = 593) was made up of adults, with a mean age of 41.21 (± 12.35) years and were predominantly males (92.37%). While there was a partial mediating effect of psychopathy on the relationship between ACEs and incidents of self-harming behaviours in the past year, the mediation was complete in the relationship between ACEs and a lifetime history of self-harming behaviours. Following sensitivity analysis based on the types of ACE, the mediating effects were more attributed to specific ACEs, especially having experienced child abuse or having an incarcerated household member before 18 years. CONCLUSION: Among forensic patients in Ontario, psychopathy mediates​ ​the relationship between experiencing ACEs and engaging in self-harming behaviours. Effective intervention to mitigate self-harming behaviours in this population should consider the potential role of psychopathy, especially among individuals who have experienced ACEs involving a history of child abuse and a family who was incarcerated.

Recommendations for Recovery of the COVID-19 Pandemic-related Diagnostic, Screening, and Procedure Backlog in Ontario: A Survey of Healthcare Leaders.

PURPOSE: The COVID-19 pandemic has resulted in a significant diagnostic, screening, and procedure backlog in Ontario. Engagement of key stakeholders in healthcare leadership positions is urgently needed to inform a comprehensive provincial recovery strategy. METHODS: A list of 20 policy recommendations addressing the diagnostic, screening and procedure backlog in Ontario were transformed into a national online survey. Policy recommendations were rated on a 7-point Likert scale (strongly agree to strongly disagree) and organized into those retained (≥75% strongly agree to somewhat agree), discarded (≥80% somewhat disagree to strongly disagree), and no consensus reached. Survey participants included a diverse sample of healthcare leaders with the potential to impact policy reform. RESULTS: Of 56 healthcare leaders invited to participate, there were 34 unique responses (61% response rate). Participants were from diverse clinical backgrounds, including surgical subspecialties, medicine, nursing, and healthcare administration and held institutional or provincial leadership positions. A total of 11 of 20 policy recommendations reached the threshold for consensus agreement with the remaining 9 having no consensus reached. CONCLUSION: Consensus agreement was reached among Canadian healthcare leaders on 11 policy recommendations to address the diagnostic, screening, and procedure backlog in Ontario. Recommendations included strategies to address patient information needs on expected wait times, expand health and human resource capacity, and streamline efficiencies to increase operating room output. No consensus was reached on the optimal funding strategy within the public system in Ontario or the appropriateness of implementing private funding models.

Capacity to Consent to Treatment of Substance Use Disorders at Ontario's Consent and Capacity Board: A Review of Past Reported Decisions.

Capacity to consent to treatment of substance use disorders at Ontario's Consent and Capacity Board: A review of past reported decisions.

An Ontario review of legal cases which have considered patients' ability to consent to substance use treatmentsPlain Language SummaryIn general, prescribers must consider whether informed consent was provided prior to starting a treatment. A patient is presumed to be capable to consent to a proposed treatment but could be incapable with respect to any medical treatment. While incapacity is often considered for psychiatric treatments, it could be relevant to substance use treatment like methadone or suboxone, which are also called "Opioid Agonist Therapies" or OAT. OAT is lifesaving and prevents relapse and overdose when a person has an opioid use disorder. If a patient is found incapable of consenting to a treatment, a Substitute Decisions Maker would become the decision maker. In such cases, the patient has the ability to contest or disagree with the finding, and this results in a tribunal hearing at the Consent and Capacity Board in Ontario (CCB). In certain circumstances, the CCB publishes what are known as its Reasons for Decision (RDs), which explain the tribunal's reasoning in coming to a decision in favour of the physician or the person found incapable. This information is publicly searchable. Our methods involved a search of all available CCB RDs in Ontario for search terms related to substance use treatment, such as "methadone". We found that between June 1, 2003 (the date on reporting of RDs began) and June 27, 2023, only 71 RDs involved substance use search terms, out of a total of 10,463 reported RDs. Only one case involved the CCB upholding a finding of incapacity with respect to methadone treatment. These results imply that there are few cases in which the CCB has considered incapacity with respect to substance use treatment, although it is possible that these cases are reported at a lower frequency than other cases.

Barriers and facilitators to improving the cascade of HIV care in Ontario: a mixed method study.

BACKGROUND: Engagement in care is important for people living with HIV (PLH) to achieve optimal outcomes. Several strategies have been developed to improve client flow through the HIV care cascade, specifically targeting initiation of treatment, adherence to antiretroviral therapy (ART), retention in care, and engagement in care. We have previously identified effective care cascade strategies in a systematic review. Initiation of ART could be improved by mobile health interventions, and changes in healthcare delivery. Adherence to ART could be improved by mobile health interventions, incentives, counselling, and psychotherapy. Retention in care could be improved by mobile health interventions, incentives, education, and electronic interventions. The aim of this study was to investigate barriers and facilitators to implementing these effective interventions in HIV clinics in Ontario, Canada. METHODS: We conducted a sequential explanatory mixed methods study. In the quantitative strand, we administered a survey to health workers who provide care to PLH to identify barriers and facilitators. In the qualitative strand, we conducted in-depth interviews informed by the theoretical domains framework (TDF) with health workers and with PLH to explain our quantitative findings. Qualitative and quantitative data were merged to create meta-inferences. RESULTS: Twenty health workers from 8 clinics in 9 cities in Ontario took the survey. Nine PLH and 10 health workers participated in the qualitative interviews. Clinics in Ontario implemented all the effective interventions identified from the literature for initiation of treatment, adherence to ART, and retention in care despite concerns about resources. Barriers to physical and financial access to care, the workload for tailored care, and expertise were identified by both health workers and PLH. Key facilitators were virtual care and client preparedness through education and peer support. CONCLUSION: Clinics in Ontario appear to implement several evidence-based strategies to improve PLH engagement. There is a need for more health workers with skills to address unique PLH needs. Virtual care is beneficial to both health workers and PLH.

Perspectives on digital testing services for sexually transmitted and blood-borne infections from Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour living in Ontario, Canada.

OBJECTIVES: Increased sexually transmitted and blood-borne infections (STBBI) testing can reduce the burden of disease among Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour (2SGBTQ+ BIPOC). However, this population encounters barriers, such as discrimination, when accessing in-person STBBI testing services. Digital STBBI testing, such as self-testing/collection kits ordered online and digital requisitions, may address some of these barriers. Our aim was to understand acceptability of free digital STBBI testing among 2SGBTQ+ BIPOC living in Ontario, Canada. DESIGN: We approached this analysis using Implementation Science and Critical Race Theory. We conducted interviews and focus groups with 21 2SGBTQ + BIPOC individuals from 2020-2021. Participants were asked about their perceptions of the benefits and drawbacks of digital STBBI testing, populations that would benefit from using these services, and recommendations for how these services may be implemented in Ontario. Interviews and focus groups were transcribed verbatim and analyzed using reflexive thematic analysis. RESULTS: Six themes emerged. Digital STBBI testing services: (1) May reduce oppression experienced by 2SGBTQ + BIPOC when testing in-person; (2) Should address the unique needs that 2SGBTQ + BIPOC experience due to other intersecting identities they possess; (3) Should adapt their services to suit the varying cultural contexts and living circumstances of 2SGBTQ + BIPOC; (4) Should be accessible to 2SGBTQ + BIPOC who hold diverse or no documentation; (5) Should be offered in multiple languages; (6) May be inaccessible to those without Internet access or devices. CONCLUSION: Digital STBBI testing is one strategy that may reduce discrimination experienced by 2SGBTQ + BIPOC when getting tested in-person. However, digital STBBI testing services may not address all the needs of 2SGBTQ + BIPOC. Racism and other forms of oppression embedded into in-person and digital testing services will need to be addressed to meet the needs of this diverse population.

The transition of general practice into an academic discipline: tracing the origins through the first four professors in general practice/family medicine.

Being the 'mother' of most clinical specialties, general practice is as old as medicine itself. However, as a recognized academic discipline within medical schools, general practice has a relatively short life span. A decisive step forward was taken in 1956 when the University of Edinburgh established its Department of General Practice, and appointed the world's inaugural professor in the field in 1963. During the 1960s, the pioneering move in Edinburgh was followed by universities in the Netherlands (University of Utrecht), Canada (Western University, Ontario), and Norway (University of Oslo), marking the beginning of global academic recognition for general practice/family medicine. Despite its critical role in healthcare, the academic evolution of general practice has been sparingly documented, with a notable absence of comprehensive accounts detailing its integration into medical schools as an independent discipline with university departments and academic professors. Last year (2023) marked the 60th anniversary of Dr. Richard Scott's historic appointment as the first professor of General Practice/Family Medicine. Through the lens of the first four professors appointed between 1963 and 1969, we explore the 'birth' of general practice to become an academic discipline. In most western countries of today, general practice has become a recognized medical discipline and an important part of the medical education. But many places, this development is lagging behind. The global shaping of general practice into an academic discipline is therefore definitively not completed.

'Sometimes white doctors are not very friendly or inclusive': a Critical Race Theory analysis of racism within and beyond sexual health settings.

Many Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour in Canada encounter racism when testing for sexually transmitted and blood-borne infections. Our objective in this study was to understand how racism shapes testing experiences for these communities in Ontario, Canada. Four peer researchers conducted recruitment and data collection in consultation with a community advisory board. Focus groups and interviews took place with 21 participants and their narrative accounts were analysed using reflexive thematic analysis. Participants identified three interrelated issues when testing: (1) experiencing judgement and discomfort due to racism; (2) lack of community and cultural indicators in testing spaces; and (3) barriers to accessing testing centres and services. Systemic racism was linked to each of these barriers, including increased distance to testing centres due to racial segregation. Participant accounts signal the need for antiracist testing spaces and practices. Key implications include the need for antiracism training for health service providers and others working with Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour, and the organisations that serve them, in order to make testing spaces safer. Dismantling systemic racism is imperative to achieve health equity for members of these communities.

Cost Evaluation of the Ontario Virtual Urgent Care Pilot Program: Population-Based, Matched Cohort Study.

BACKGROUND: In 2020, the Ministry of Health (MoH) in Ontario, Canada, introduced a virtual urgent care (VUC) pilot program to provide alternative access to urgent care services and reduce the need for in-person emergency department (ED) visits for patients with low acuity health concerns. OBJECTIVE: This study aims to compare the 30-day costs associated with VUC and in-person ED encounters from an MoH perspective. METHODS: Using administrative data from Ontario (the most populous province of Canada), a population-based, matched cohort study of Ontarians who used VUC services from December 2020 to September 2021 was conducted. As it was expected that VUC and in-person ED users would be different, two cohorts of VUC users were defined: (1) those who were promptly referred to an ED by a VUC provider and subsequently presented to an ED within 72 hours (these patients were matched to in-person ED users with any discharge disposition) and (2) those seen by a VUC provider with no referral to an in-person ED (these patients were matched to patients who presented in-person to the ED and were discharged home by the ED physician). Bootstrap techniques were used to compare the 30-day mean costs of VUC (operational costs to set up the VUC program plus health care expenditures) versus in-person ED care (health care expenditures) from an MoH perspective. All costs are expressed in Canadian dollars (a currency exchange rate of CAD $1=US $0.76 is applicable). RESULTS: We matched 2129 patients who presented to an ED within 72 hours of VUC referral and 14,179 patients seen by a VUC provider without a referral to an ED. Our matched populations represented 99% (2129/2150) of eligible VUC patients referred to the ED by their VUC provider and 98% (14,179/14,498) of eligible VUC patients not referred to the ED by their VUC provider. Compared to matched in-person ED patients, 30-day costs per patient were significantly higher for the cohort of VUC patients who presented to an ED within 72 hours of VUC referral ($2805 vs $2299; difference of $506, 95% CI $139-$885) and significantly lower for the VUC cohort of patients who did not require ED referral ($907 vs $1270; difference of $362, 95% CI 284-$446). Overall, the absolute 30-day costs associated with the 2 VUC cohorts were $18.9 million (ie, $6.0 million + $12.9 million) versus $22.9 million ($4.9 million + $18.0 million) for the 2 in-person ED cohorts. CONCLUSIONS: This costing evaluation supports the use of VUC as most complaints were addressed without referral to ED. Future research should evaluate targeted applications of VUC (eg, VUC models led by nurse practitioners or physician assistants with support from ED physicians) to inform future resource allocation and policy decisions.

Retrospective analysis of decision-making in post-traumatic posterior shoulder instability.

PURPOSE: This study aims to assess the clinical outcomes in the management of post-traumatic posterior shoulder instability (PSI) with a focus on the decision-making process for operative and conservative treatments. INTRODUCTION: PSI can result from traumatic events, impacting a patient's quality of life. This study delves to better indicate decision-making for operative indication of post-traumatic PSI patients. METHODS: Patients who sustained posterior shoulder dislocations were selected from a single surgeon's database within a five-year period. Cases of degenerative or genetically caused PSI were excluded, resulting in a cohort of 28. Patients were initially managed conservatively but indicated for surgery if they were unable to actively stabilize the shoulder or exhibited bony or cartilage defects confirmed through imaging. If conservative treatment did not yield significant improvements, it was classified as a failure, and operative intervention was recommended. The WOSI Score, ROM, and X-ray were employed to evaluate the success of treatment. RESULTS: Out of the 28 patients, 11 received conservative, seven immediate surgeries, and ten transitioned from conservative to operative treatment. The overall success rate showed 25 good to excellent results. In the persistent conservative treatment group, the initial WOSI score was significantly lower compared to the operative group. CONCLUSION: This study suggests that post-traumatic PSI can be successfully managed conservatively with initial low clinical symptoms (low WOSI score) and in the absence of absolute indications for operative treatment. When surgery is necessary, arthroscopic procedures proved effective in achieving good to excellent results in 16 out of 17 cases.

Clinical Impact of Thermotherapy and Spinal Twisting Massage on Chronic Non-Specific Spinal Pain.

As the prevalence of chronic non-specific spinal pain rises, the utilization of diverse massage devices for therapeutic intervention increases rapidly. However, research on their mechanisms, particularly those involving spinal twisting, is limited. This study was designed to evaluate the impact of heat application and spinal twisting massage techniques on individuals suffering from chronic non-specific spinal pain. A total of 36 individuals were divided into two groups: a control group (18 participants) and an experimental group (18 participants). The experimental group received heat treatment plus spinal twisting massage twice a week for four weeks, while the control group received heat therapy plus traditional vibration massage techniques. Effectiveness was measured using the Visual Analog Scale (VAS), the Pressure Pain Threshold (PPT), the Korean Western Ontario and McMaster Universities (K-WOMAC) Index, spine tilt, and Cobb angle. VAS, K-WOMAC, and PPT significantly improved in both groups at all three time points. VAS notably decreased in the experimental group compared to the control group (p-value: 0.0369). Despite improvements in K-WOMAC and PPT scores within the experimental group, statistical significance remained elusive. Furthermore, spine tilt and Cobb angle showed no significant differences from baseline to the 6th week. In conclusion, the application of thermotherapy coupled with twisting massage demonstrates significant efficacy in mitigating chronic non-specific spinal pain, surpassing the pain-relief outcomes achieved through heat therapy in combination with standard vibration massage techniques.

The effects of occupational and mental stress among home care rehabilitation professionals working during the COVID-19 pandemic: An exploratory qualitative study.

Home care rehabilitation professionals (hcRPs) provide health services for clients with a broad range of medical conditions. During the COVID-19 pandemic, home care rehabilitation professionals experienced exacerbations of pre-existing work-related stressors, increased risk of transmission of the COVID-19 virus, reduced resource availability, greater workloads, and staffing shortages. The primary aim of this study was to examine the experience and impact of occupational and mental stress on hcRPs working during the COVID-19 pandemic. Semi-structured interviews were conducted with 24 hcRPs working in Ontario, Canada during the COVID-19 pandemic. Inductive thematic analysis was used to interpret and organize the data into conceptualized themes. Interview data was organized into three themes: (a) unique challenges of a home care rehabilitation professional, (b) COVID-19 exacerbations of home care occupational and mental stress, and (c) personal and workplace coping strategies. Many participants reported reducing their hours or taking on adjunctive roles in different clinical settings outside of home care due to work-related stress exacerbated by the COVID-19 pandemic. With a focus on the effects of COVID-19 on the practice of home care, this study provides a unique perspective on the challenges experienced by hcRPs during an emergent and evolving global public health concern. The exploratory nature of this research works towards providing a framework of factors to be addressed when creating sustainable healthcare interventions, as well as recommendations to support hcRPs to benefit both the community and health-care providers.

Accidental paradiplomats? The curious case of Ontario school board budgets and Canadian soft power projection.

From the earliest studies of soft power in International Relations, the importance of educational exchanges has been well-established. Studies of international education in the context of Canadian soft power often draw on cases from the higher education sector. This article argues that greater attention should be paid to the K-12 level, especially as budgetary pressures in Ontario's education system are leading school boards to rapidly expand their international student recruitment efforts. Although this is not an example of intentional soft power projection, it nevertheless represents an important reminder that subnational actors may accidentally become paradiplomats whose actions have consequences on the international level. Further, this case reveals the importance of paying attention to actors typically overlooked by IR scholarship. Drawing on Joseph Nye's theory of soft power and in conversation with prior research on international education as a mechanism of soft power projection, this article traces the thread between budgetary pressures in Ontario school boards and the broader context of soft power projection.

Pulmonary Nontuberculous Mycobacteria, Ontario, Canada, 2020.

We measured annual prevalence of microbiologically defined nontuberculous mycobacterial lung disease in Ontario, Canada. Mycobacterium avium prevalence was 13 cases/100,000 persons in 2020, a 2.5-fold increase from 2010, indicating a large increase in true M. avium lung disease. During the same period, M. xenopi decreased nearly 50%, to 0.84 cases/100,000 persons.

Screening behaviours, demographics, and stage at diagnosis in the publicly funded Ontario Breast Screening Program.

PURPOSE: The Ontario Breast Screening Program (OBSP) offers free screening mammograms every 2 years, to women aged 50-74. Study objectives were to determine demographic characteristics associated with the adherence to OBSP and if women screened in the OBSP have a lower stage at diagnosis than non-screened eligible women. METHODS: We used the Ontario cancer registry (OCR) to identify 48,927 women, aged 51-74 years, diagnosed with breast cancer between 2010 and 2017. These women were assigned as having undergone adherent screening (N = 26,108), non-adherent screening (N = 6546) or not-screened (N = 16,273) in the OBSP. We used multinomial logistic regression to investigate the demographic characteristics associated with screening behaviour, as well as the association between screening status and stage at diagnosis. RESULTS: Among women with breast cancer, those living in rural areas (versus the largest urban areas) had a lower odds of not being screened (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.68, 0.78). Women in low-income (versus high-income) communities were more likely not to be screened (OR 1.42, 95% CI 1.33, 1.51). When stratified, the association between income and screening status only held in urban areas. Non-screened women were more likely to be diagnosed with stage II (OR 1.91, 95% CI 1.82, 2.01), III (OR 2.96, 95% CI 2.76, 3.17), or IV (OR 8.96, 95% CI 7.94, 10.12) disease compared to stage I and were less likely to be diagnosed with ductal carcinoma in situ (DCIS) (OR 0.91, 95% CI 0.84-0.98). CONCLUSIONS: This study suggests that targeting OBSP recruitment efforts to lower income urban communities could increase screening rates. OBSP adherent women were more likely to be diagnosed with earlier stage disease, supporting the value of this initiative and those like it.

Team-Based Diabetes Care in Ontario and Hong Kong: a Comparative Review.

PURPOSE OF REVIEW: There are gaps in implementing and accessing team-based diabetes care. We reviewed and compared how team-based diabetes care was implemented in the primary care contexts of Ontario and Hong Kong. RECENT FINDINGS: Ontario's Diabetes Education Programs (DEPs) were scaled-up incrementally. Hong Kong's Multidisciplinary Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) evolved from a research-driven quality improvement program. Each jurisdiction had a mixture of non-team and team-based primary care with variable accessibility. Referral procedures, follow-up processes, and financing models varied. DEPs used a flexible approach, while the RAMP-DM used structured assessment for quality assurance. Each approach depended on adequate infrastructure, processes, and staff. Diabetes care is most accessible and functional when integrated team-based services are automatically initiated upon diabetes diagnosis within a strong primary care system, ideally linked to a register with supports including specialist care. Structured assessment and risk stratification are the basis of a well-studied, evidence-based approach for achieving the standards of team-based diabetes care, although flexibility in care delivery may be needed to meet the unique needs of some individuals. Policymakers and funders should ensure investment in skilled health professionals, infrastructure, and processes to improve care quality.

Changes in the Initiation of Antipsychotics and Trazodone Over Time: A Cohort Study of New Admissions to Nursing Homes in Ontario, Canada.

OBJECTIVES: To investigate whether trazodone is being initiated in lieu of antipsychotics following antipsychotic reduction efforts, this study described changes in medication initiation over time. METHODS: We conducted a retrospective cohort study of new admissions to nursing homes in Ontario, Canada between April 2010 and December 2019 using health administrative data (N = 61,068). The initiation of antipsychotic and trazodone use was compared by year of admission using discrete time survival analysis and stratified by history of dementia. RESULTS: Relative to residents admitted in 2014, antipsychotic initiation significantly decreased in later years (e.g., 2017 admission year hazard odds ratio [HOR2017]=0.72 [95% confidence interval (95%CI)=0.62-0.82]) while trazodone initiation modestly increased (e.g., HOR2017=1.09 [95%CI=0.98-1.21]). The relative increase in trazodone initiation was larger among residents with dementia (e.g., HOR2017Dem =1.22 [95%CI=1.07-1.39]). CONCLUSIONS: Differences in which medications were started following nursing home admission were observed and suggest trazodone may be initiated in lieu of antipsychotics.

Leprosy with type 1 reaction in a patient from Ontario, Canada without recent travel misdiagnosed as vasculitic neuropathy: a case report.

BACKGROUND: Leprosy is rare within non-endemic countries such as Canada, where cases are almost exclusively imported from endemic regions, often presenting after an incubation period of as many as 20 years. Due to its rarity and prolonged incubation period, diagnosis is often delayed, which may result in neurologic impairment prior to the initiation of treatment. In this report we describe a case that is novel in its incubation period, which is the longest reported to-date and may have contributed to diagnostic delay. The case also uniquely demonstrates the challenges of distinguishing leprosy reactions from new rheumatologic manifestations in a patient with established autoimmune disease. CASE PRESENTATION: We describe an 84-year-old male patient with rheumatoid arthritis on methotrexate and hydroxychloroquine, with no travel history outside Canada for 56 years, who presented in 2019 with new-onset paresthesias and rash. His paresthesias persisted despite a short course of prednisone, and his rash recurred after initial improvement. He underwent skin biopsy in May 2021, which eventually led to the diagnosis of leprosy. He was diagnosed with type 1 reaction and was started on rifampin, dapsone, clofazimine and prednisone, with which his rash resolved but his neurologic impairment remained. CONCLUSION: This case report serves to highlight the potential for leprosy to present after markedly prolonged incubation periods. This is especially relevant in non-endemic countries that is home to an aging demographic of individuals who migrated decades ago from endemic countries. The importance of this concept is emphasized by the persistent neurologic impairment suffered by our case due to untreated type 1 reaction. We also demonstrate the necessity of skin biopsy in distinguishing this diagnosis from other autoimmune mimics in a patient with known autoimmune disease.