Enhancing detection of SARS-CoV-2 re-infections using longitudinal sero-monitoring: demonstration of a methodology in a cohort of people experiencing homelessness in Toronto, Canada.

BACKGROUND: Accurate estimation of SARS-CoV-2 re-infection is crucial to understanding the connection between infection burden and adverse outcomes. However, relying solely on PCR testing results in underreporting. We present a novel approach that includes longitudinal serologic data, and compared it against testing alone among people experiencing homelessness. METHODS: We recruited 736 individuals experiencing homelessness in Toronto, Canada, between June and September 2021. Participants completed surveys and provided saliva and blood serology samples every three months over 12 months of follow-up. Re-infections were defined as: positive PCR or rapid antigen test (RAT) results > 90 days after initial infection; new serologic evidence of infection among individuals with previous infection who sero-reverted; or increases in anti-nucleocapsid in seropositive individuals whose levels had begun to decrease. RESULTS: Among 381 participants at risk, we detected 37 re-infections through PCR/RAT and 98 re-infections through longitudinal serology. The comprehensive method identified 37.4 re-infection events per 100 person-years, more than four-fold more than the rate detected through PCR/RAT alone (9.0 events/100 person-years). Almost all test-confirmed re-infections (85%) were also detectable by longitudinal serology. CONCLUSIONS: Longitudinal serology significantly enhances the detection of SARS-CoV-2 re-infections. Our findings underscore the importance and value of combining data sources for effective research and public health surveillance.

Epilepsy Surgery in Adult Stroke Survivors with New-Onset Drug-Resistant Epilepsy.

BACKGROUND: Despite its effectiveness, surgery for drug-resistant epilepsy is underutilized. However, whether epilepsy surgery is also underutilized among patients with stroke-related drug-resistant epilepsy is unclear. Therefore, our objectives were to estimate the rates of epilepsy surgery assessment and receipt among patients with stroke-related drug-resistant epilepsy and to identify factors associated with these outcomes. METHODS: We used linked health administrative databases to conduct a population-based retrospective cohort study of adult Ontario, Canada residents discharged from an Ontario acute care institution following the treatment of a stroke between January 1, 1997, and December 31, 2020, without prior evidence of seizures. We excluded patients who did not subsequently develop drug-resistant epilepsy and those with other epilepsy risk factors. We estimated the rates of epilepsy surgery assessment and receipt by March 31, 2021. We planned to use Fine-Gray subdistribution hazard models to identify covariates independently associated with our outcomes, controlling for the competing risk of death. RESULTS: We identified 265,081 patients who survived until discharge following inpatient stroke treatment, 1,902 (0.7%) of whom subsequently developed drug-resistant epilepsy (805 women; mean age: 67.0 ± 13.1 years). Fewer than six (≤0.3%) of these patients were assessed for or received epilepsy surgery before the end of follow-up (≤55.5 per 100,000 person-years). Given that few outcomes were identified, we could not proceed with the multivariable analyses. CONCLUSIONS: Patients with stroke-related drug-resistant epilepsy are infrequently considered for epilepsy surgery that could reduce morbidity and mortality.

Professional characteristics, attitudes, and practices associated with stress and quality of life among Canadian animal health workers.

Objective: To describe the knowledge, attitudes, and practices (KAP) towards COVID-19 of Canadian companion animal health workers (AHW); to measure their perceived stress and quality of life (QoL); and to explore professional risk factors associated with stress and QoL. Sample: We sampled 436 companion animal veterinarians and technicians. Procedure: The study had cross-sectional and cohort components. It was conducted online in August to December 2020, and repeated in May to July 2021, using a questionnaire assessing the respondents' professional characteristics, COVID-19 KAP, perceived stress, and QoL. Results: Overall, AHW had sufficient knowledge of COVID-19 transmission, and reported having adopted good preventive practices. Since the beginning of the pandemic, participants reported increases in new clients (76%), in refusal of new clients (53%), and in pet euthanasia (24%). Increased client refusal and pet euthanasia were associated with greater stress and poorer professional QoL, whereas perceived susceptibility to and adoption of measures against COVID-19 were associated with lower stress and better QoL. Conclusion and clinical relevance: For AHW, professional characteristics were associated with stress and professional QoL. This information is important for developing strategies to cope with the ongoing shortage of AHW and with future public health crises.

Caractéristiques professionnelles, attitudes et pratiques associées au stress et à la qualité de vie des travailleurs en santé animale au Canada. Objectif: Décrire les connaissances, attitudes et pratiques (KAP) envers la COVID-19 des travailleurs canadiens en santé des animaux de compagnie (AHW); mesurer leur stress perçu et leur qualité de vie (QoL); et explorer les facteurs de risque professionnels associés au stress et à la QoL. Échantillonnage: Nous avons échantillonné 436 médecins vétérinaires et techniciens en pratique des animaux de compagnie. Procédure: L'étude avait des composantes transversale et de cohorte. Elle a été menée en ligne d'août à décembre 2020, et répétée de mai à juillet 2021, à l'aide d'un questionnaire évaluant les caractéristiques professionnelles des répondants, leurs KAP envers la COVID-19, leur stress perçu et leur QoL. Résultats: Dans l'ensemble, les AHW avaient une connaissance suffisante de la transmission de la COVID-19 et ont déclaré avoir adopté de bonnes pratiques de prévention. Depuis le début de la pandémie, les participants ont signalé une augmentation du nombre de nouveaux clients (76 %), du refus de nouveaux clients (53 %) et de l'euthanasie des animaux de compagnie (24 %). L'augmentation du refus des clients et de l'euthanasie des animaux de compagnie était associée à un plus grand stress et à une QoL professionnelle plus faible, tandis que la perception du risque et l'adoption de mesures contre le COVID-19 étaient associées à un stress plus faible et à une meilleure QoL. Conclusion et pertinence clinique: Pour les AHW, les caractéristiques professionnelles étaient associées au stress et à la QoL. Ces informations sont importantes pour développer des stratégies pour faire face à la pénurie continue d'AHW et aux futures crises de santé publique.(Traduit par Dr Serge Messier).

Utilization of Immunotherapy in Patients with Cancer Treated in Routine Care Settings: A Population-Based Study Using Health Administrative Data.

INTRODUCTION: The introduction of immunotherapy (IO) in the treatment of patients with cancer has significantly improved clinical outcomes. Population level information on actual IO utilization is limited. METHODS: We conducted a retrospective cohort study using provincial health administrative data from Ontario, Canada to: (1) assess the extent of IO use from 2011 (pre-IO funding) to 2019; and (2) identify factors associated with IO use in patients with advanced cancers for which IO is reimbursed including melanoma, bladder, lung, head and neck, and kidney tumors. The datasets were linked using a unique encoded identifier. A Fine and Gray regression model with death as a competing risk was used to identify factors associated with IO use. RESULTS: Among 59 510 patients assessed, 8771 (14.7%) received IO between 2011 and 2019. Use of IO increased annually from 2011 (3.3%) to 2019 (39.2%) and was highest in melanoma (52%) and lowest in head and neck cancer (6.6%). In adjusted analysis, factors associated with lower IO use included older age (hazard ratio (HR) 0.91 (95% CI, 0.89-0.93)), female sex (HR 0.85 (95% CI, 0.81-0.89)), lower-income quintile, hospital admission (HR 0.78 (95% CI, 0.75-0.82)), high Charlson score and de novo stage 4 cancer. IO use was heterogeneous across cancer centers and regions. CONCLUSION: IO utilization for advanced cancers rose substantially since initial approval albeit use is associated with patient characteristics and system-level factors even in a universal healthcare setting. To optimize IO utilization in routine practice, survival estimates and potential inequity in access should be further investigated and addressed.

Hospitalizations During the COVID-19 Pandemic Among Recently Homeless Individuals: a Retrospective Population-Based Matched Cohort Study.

BACKGROUND: Hospitalizations fell precipitously among the general population during the COVID-19 pandemic. It remains unclear whether individuals experiencing homelessness experienced similar reductions. OBJECTIVE: To examine how overall and cause-specific hospitalizations changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. DESIGN: Population-based cohort study conducted in Ontario, Canada, between September 30, 2018, and September 26, 2020. PARTICIPANTS: In total, 38,617 IRHH, 15,022,368 housed individuals, and 186,858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden. MAIN MEASURES: Primary outcomes included medical-surgical, non-elective (overall and cause-specific), elective surgical, and psychiatric hospital admissions. KEY RESULTS: Average rates of medical-surgical (rate ratio: 3.8, 95% CI: 3.7-3.8), non-elective (10.3, 95% CI: 10.1-10.4), and psychiatric admissions (128.1, 95% CI: 126.1-130.1) between January and September 2020 were substantially higher among IRHH compared to housed individuals. During the peak period (March 17 to June 16, 2020), rates of medical-surgical (0.47, 95% CI: 0.47-0.47), non-elective (0.80, 95% CI: 0.79-0.80), and psychiatric admissions (0.86, 95% CI: 0.84-0.88) were significantly lower among housed individuals relative to equivalent weeks in 2019. No significant changes were observed among IRHH. During the re-opening period (June 17-September 26, 2020), rates of non-elective hospitalizations for liver disease (1.41, 95% CI: 1.23-1.69), kidney disease (1.29, 95% CI: 1.14-1.47), and trauma (1.19, 95% CI: 1.07-1.32) increased substantially among IRHH but not housed individuals. Distinct hospitalization patterns were observed among IRHH even in comparison with more medically and socially vulnerable matched housed individuals. CONCLUSIONS: Persistence in overall hospital admissions and increases in non-elective hospitalizations for liver disease, kidney disease, and trauma indicate that the COVID-19 pandemic presented unique challenges for recently homeless individuals. Health systems must better address the needs of this population during public health crises.

Cancer incidence and stage at diagnosis among people with recent-onset psychotic disorders: A retrospective cohort study using health administrative data from Ontario, Canada.

OBJECTIVE: Prior evidence on the relative risk of cancer among people with psychotic disorders is equivocal. The objective of this study was to compare incidence and stage at diagnosis of cancer for people with psychotic disorders relative to the general population. METHOD: We constructed a retrospective cohort of people with a first diagnosis of non-affective psychotic disorder and a comparison group from the general population using linked health administrative databases in Ontario, Canada. The cohort was followed for incident diagnoses of cancer over a 25-year period. We used Poisson and logistic regression models to compare cancer incidence and stage at diagnosis between people with psychotic disorders and the comparison group, adjusting for confounding factors. RESULTS: People with psychotic disorders had an 8.6% higher incidence (IRR = 1.09, 95%CI = 1.05,1.12) of cancer overall relative to the comparison group, with effect modification by sex and substantial variation across cancer sites. People with psychotic disorders also had 23% greater odds (OR = 1.23, 95%CI = 1.13,1.34) of being diagnosed with more advanced stage cancer relative to the comparison group. CONCLUSIONS: We found evidence of elevated cancer incidence in people with non-affective psychotic disorders relative to the general population. The higher odds of more advanced stage cancer diagnoses in people with psychotic disorders represents an opportunity to improve patient participation in recommended cancer screening, as well as timely access to services for cancer diagnosis and treatment. Future research should examine confounding effects of lifestyle factors and antipsychotic medications on the risk of developing cancer among people with psychotic disorders.

Family physician virtual care during COVID-19 in London-Middlesex, Ontario, Canada: a mixed methods exploration.

Context: On March 14, 2020, the Ontario, Canada health insurance plan approved COVID-19 physician virtual billing codes; family physicians (FPs) rapidly adopted a new model of care. Virtual care may remain post-pandemic; however, its future should be informed by evidence that considers access and continuity. Objective: 1) to determine FP virtual visit volumes and patient characteristics and 2) to explore FPs' perspectives on virtual visit adoption and implementation. Study Design: Mixed methods: Secondary analysis of health administrative (HA) data and semi-structured qualitative interviews with FPs. Setting or Dataset: London and Middlesex County, Ontario, Canada. HA data through ICES, Ontario entity holding data. Population studied: FPs and their patients. Outcome Measures: Volumes of FP in-person and virtual visits during early pandemic; characteristics of patients receiving care; FPs' perspectives on adopting and delivering virtual care. Results: Overall visit volume dropped by 36% during first wave, recovered to pre-pandemic levels by October 2020. Sharp in-person visit drop of 73% and virtual visit uptake from 0.08% of total visits to 57% within two weeks of March 2020. FPs described this initial drop in volume as patients not seeking care and practices lacking PPE. The move to virtual care was largely to telephone visits. Patient characteristics compared to pre-pandemic, the proportion seeking care were older (46 vs 50 years), more vulnerable (38% vs 41%), and more multimorbidity (33% vs 41%). This was consistent with FP reports that healthier patients stayed away, routine care deferred, sicker patients needed to be seen. FPs believed most vulnerable patients had access to care but cautioned highly vulnerable such as those homeless did not have cell phone access or a safe place to receive calls. Rural FPs reported access issues because of lack of high-speed internet. FPs attributed success of virtual care to the continuity in relationships they had with patients that were established in person pre-pandemic. Conclusions: FPs moved rapidly to virtual care. FP offices remained open despite PPE concerns but overall volumes dropped initially. Vulnerable and sicker patients received care but FPs expressed concern for highly vulnerable and rural residents. FPs believed they could offer patient-centred care over the phone but indicated the importance of maintaining in-person care to build relationships.

Healthcare professionals' longitudinal perceptions of group phenomena as determinants of self-assessed learning in organizational communities of practice.

BACKGROUND: Given the importance of continuous learning as a response to the increasing complexity of health care practice, there is a need to better understand what makes communities of practice in health effective at fostering learning. Despite the conceptual stance that communities of practice facilitate individual learning, the scientific literature does not offer much evidence for this. Known factors associated with the effectiveness of communities of practice - such as collaboration, psychological safety within the community, and commitment to the community - have been studied in cross-sectional qualitative designs. However, no studies to date have used a quantitative predictive design. The objective of this study is to assess how members of a community of practice perceive interactions among themselves and determine the extent to which these interactions predict self-assessed learning over time. METHODS: Data was collected using validated questionnaires from six communities of practice (N = 83) in four waves of measures over the course of 36 months and was analysed by means of General Estimating Equations. This allowed to build a longitudinal model of the associations between perceptions of collaboration, psychological safety within the community, commitment to the community and self-assessed learning over time. RESULTS: Perception of collaboration in the community of practice, a personal sense of psychological safety and a commitment to the community of practice are predictors longitudinally associated with self-assessed learning. CONCLUSIONS: In terms of theory, conceptual links can be made between intensity of collaboration and learning over time in the context of a community of practice. Recent work on psychological safety suggests that it is still unclear whether psychological safety acts as a direct enhancer of learning or as a remover of barriers to learning. This study's longitudinal results suggest that psychological safety may enhance how and to what extent professionals feel they learn over time. Commitment towards the community of practice is a strong predictor of learning over time, which hints at differential effects of affective, normative and continuance commitment. Communities of practice can therefore apply these findings by making collaboration, psychological safety, commitment and learning regular reflexive topics of discussion.

Utility, Limitations and Opportunities for Using Linked Health Administrative Data to Study Homelessness in Ontario.

Homelessness is a significant social issue within Canada but is difficult to quantify at the population level. In this paper, we discuss the development and use of a case ascertainment algorithm that identifies people experiencing homelessness through health administrative data. We highlight the appropriateness of various uses of this method given its key strengths and limitations. Finally, we discuss plans to improve this methodology and broaden its use through the addition of linkable administrative data from non-health sectors, such as emergency shelters and social services organizations.

Is coronavirus disease 2019 associated with indicators of long-term bladder dysfunction?

OBJECTIVE: Early reports have suggested that coronavirus disease 2019 (COVID-19) can present with significant urinary frequency and nocturia, and that these symptoms correlate with markers of inflammation in the urine. We evaluated surrogate markers of chronic urinary symptoms to determine if they were more frequent after COVID-19 infection. METHODS: Routinely collected data from the province of Ontario was used to conduct a matched, retrospective cohort study. We identified patients 66 years of age or older who had a positive COVID-19 test between February and May 2020 and survived at least 2 months after their diagnosis. We matched them to two similar patients who did not have a positive COVID-19 test during the same time period. We measured the frequency of urology consultation, cystoscopy, and new prescriptions for overactive bladder medications during a subsequent 3-month period. Proportional hazard models were adjusted for any baseline differences between the groups. RESULTS: We matched 5617 patients with COVID-19 to 11,225 people who did not have COVID-19. The groups were similar, aside from a higher proportion of patients having hypertension and diabetes in the CoVID-19 cohort. There was no significantly increased hazard of new receipt of overactive bladder medication (hazards ratio [HR]: 1.04, p = 0.88), urology consultation (HR: 1.40, p = 0.10), or cystoscopy (HR: 1.14, p = 0.50) among patients who had COVID-19, compared to the matched cohort. CONCLUSION: Surrogate markers of potential bladder dysfunction were not significantly increased in the 2-5 months after COVID-19 infection.

Fracture profiles of a 4-year cohort of 266,324 first incident upper extremity fractures from population health data in Ontario.

BACKGROUND: Understanding the profiles of different upper extremity fractures, particularly those presenting as a 1st incident can inform prevention and management strategies. The purpose of this population-level study was to describe first incident fractures of the upper extremity in terms of fracture characteristics and demographics. METHODS: Cases with a first adult upper extremity (UE) fracture from the years 2013 to 2017 were extracted from administrative data in Ontario. Fracture locations (ICD-10 codes) and associated characteristics (open/closed, associated hospitalization within 1-day, associated nerve, or tendon injury) were described by fracture type, age category and sex. Standardized mean differences of at least 10% (clinical significance) and statistical significance (p < 0.01) in ANOVA were used to identify group differences (age/sex). RESULTS: We identified 266,324 first incident UE fractures occurring over 4 years. The most commonly affected regions were the hand (93 K), wrist/forearm(80 K), shoulder (48 K) or elbow (35 K). The highest number of specific fractures were: distal radius (DRF, 47.4 K), metacarpal (30.4 K), phalangeal (29.9 K), distal phalangeal (24.4 K), proximal humerus (PHF, 21.7 K), clavicle (15.1 K), radial head (13.9 K), and scaphoid fractures (13.2 K). The most prevalent multiple fractures included: multiple radius and ulna fractures (11.8 K), fractures occurring in multiple regions of the upper extremity (8.7 K), or multiple regions in the forearm (8.4 K). Tendon (0.6% overall; 8.2% in multiple finger fractures) or nerve injuries were rarely reported (0.3% overall, 1.5% in distal humerus). Fractures were reported as being open in 4.7% of cases, most commonly for distal phalanx (23%). A similar proportion of females (51.5%) and males were present in this fracture cohort, but there were highly variant age-sex profiles across fracture subtypes. Fractures most common in 18-40-year-old males included metacarpal and finger fractures. Fractures common in older females were: DRF, PHF and radial head, which exhibited a dramatic increase in the over-50 age group. CONCLUSIONS: UE fracture profiles vary widely by fracture type. Fracture specific prevention and management should consider fracture profiles that are highly variable according to age and sex.

Were Snowbirds Disproportionally Impacted by COVID-19? An Ontario Analysis.

Early in the first wave of the COVID-19 pandemic, many older adult Canadians who routinely spend the winter months in warmer regions (colloquially known as "snowbirds") returned to Canada. While numerous infections were attributed to travel-related exposure at that time, little is known about the impact of COVID-19 on returning snowbirds. This population-based analysis from Ontario suggests that snowbirds were not disproportionately impacted by the pandemic. However, as older adults, they remain at high risk of complications once infected. These findings underscore the need for continued caution in this older adult population.

Factors associated with endocrine therapy adherence among post-menopausal women treated for early-stage breast cancer in Ontario, Canada.

PURPOSE: Adherence to adjuvant endocrine therapy among post-menopausal breast cancer patients is an important survivorship care issue. We explored factors associated with endocrine therapy adherence and survival in a large real-world population-based study. METHODS: We used health administrative databases to follow women (aged ≥ 66 years) who were diagnosed with breast cancer and started on adjuvant endocrine therapy from 2005 to 2010. Adherence was measured by medical possession ratio (MPR) and characterized as low (< 39% MPR), intermediate (40-79% MPR), or high (≥ 80% MPR) over a 5-year period. We investigated factors associated with adherence using a multinomial logistic regression model. Factors associated with all-cause mortality (5 years after starting endocrine therapy) were investigated using a multivariable Cox proportional hazards model. RESULTS: We identified 5692 eligible patients starting adjuvant endocrine therapy who had low, intermediate, and high adherence rates of 13% (n = 749), 13% (n = 733), and 74% (n = 4210), respectively. Lower rates of adherence were associated with increased age [low vs. high adherence: odds ratio (OR) 1.03, 95% CI 1.02-1.05 (per year); intermediate vs. high adherence: OR 1.02, 95% CI 1.01-1.04 (per year)]. High adherence was associated with previous use of adjuvant chemotherapy (low versus high adherence OR 0.42, 95% CI 0.30-0.59) and short-term follow-up with a medical oncologist within 4 months of starting endocrine therapy (low versus high adherence OR 0.83, 95% CI 0.69-0.99). Unadjusted analysis showed increased survival among patients with high endocrine therapy adherence. However, an independent association was no longer clearly detected after controlling for confounders. CONCLUSION: Interventions to improve adjuvant endocrine therapy adherence are warranted. Non-adherence may be a more significant issue among elderly patients. Short-term follow-up visit by a patient's medical oncologist after starting endocrine therapy may help to improve compliance.

Determinants of Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis.

OBJECTIVE: To describe trends and patient and system factors associated with direct discharge from critical care to home in a large health system. DESIGN: Population-based cohort study of direct discharge to home rates annually over 10 years. We used a multivariable, multilevel random-effects regression model to analyze current factors associated with direct discharge home in a subcohort from the most recent 2 years. SETTING: One hundred seventy-four ICUs in 101 hospitals in Ontario. PATIENTS: All patients discharged from an ICU between April 1, 2007, and March 31, 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Overall, 237,200 patients (21.1%) were discharged directly home from an ICU. The rate of direct discharge to home increased from 18.6% in 2007 to 23.1% in 2017 (annual increase of 1.02; 95% CI, 1.02-1.03). There were marked variations in rates of direct discharge to home across all critical care units. For medical and surgical units, the median odds ratio was 1.76 (95% CI, 1.59-1.92). In these units, direct discharge to home was associated with younger age (odds ratio, 0.36; 95% CI, 0.34-0.39 for age 80-105 vs age 18-39), fewer comorbidities (odds ratio, 1.74; 95% CI, 1.63-1.85 for Charlson comorbidity index of 0 vs 2), diagnoses of overdose/poisoning (odds ratio, 1.35; 95% CI, 1.23-1.47) and diabetic complications (odds ratio, 1.35; 95% CI, 1.2-1.51), and admission after a same-day procedure (odds ratio, 2.82; 95% CI, 2.46-3.23 compared with emergency department). ICU occupancy was inversely associated with direct discharge to home with an odds ratio of 0.88 (95% CI, 0.87-0.88) for each 10% increase. CONCLUSIONS: High rates of direct discharge to home with evidence of significant practice variation combined with identifiable patient characteristics suggest that further evaluation of this increasingly common transition in care is warranted.

Report on the 19th International Society of Blood Transfusion Platelet Immunology Workshop 2018.

BACKGROUND AND OBJECTIVES: The aims of the 19th International Society of Blood Transfusion Platelet Immunology Workshop were to compare the sensitivity and specificity of in-house and commercially available methods for the detection of alloantibodies against human platelet antigens. Survey regarding laboratory management of samples collected for the diagnosis of foetal neonatal alloimmune thrombocytopenia was also conducted. MATERIALS AND METHODS: Twenty-nine laboratories from 17 countries were invited to participate. Seven serum or plasma samples for antibody identification and eight DNA samples for genotyping were sent to participating laboratories. Additionally, samples, critical reagents, materials and instructions for three exercises, one using a commercial kit (Pak Lx), one on platelet preparation for the detection of anti-HPA-3 antibodies and one for testing four anti-CD109 monoclonal antibodies for anti-HPA-15 antibody detection, were provided. RESULTS: Anti-HPA-1a, anti-HPA-2b, anti-HPA-5b and anti-GPIV were detected by the majority of the 28 reporting laboratories using their respective in-house MAIPA assay and/or a commercially available assay. Conversely, very few laboratories correctly identified anti-HPA-3a and HPA-15b. DNA genotyping of HPA and HLA alleles was highly accurate, with just a few discrepancies relative to the expected results. The Pak Lx kit has proven reliable for detecting anti-HPA-1a, anti-HPA-5a and anti-HLA; however, it failed at identifying an anti-HPA-3a in a clinical sample. CONCLUSIONS: Some anti-platelet alloantibodies are reliably and consistently detected, yet others remain difficult to detect. Genotyping of HPA and HLA alleles has proven to be highly accurate and robust. Future work should focus on optimizing the detection of anti-HPA-3 and anti-HPA-15 antibodies.

Disparities in Deep Brain Stimulation Use for Parkinson's Disease in Ontario, Canada.

OBJECTIVE: To examine whether sociodemographic characteristics and health care utilization are associated with receiving deep brain stimulation (DBS) surgery for Parkinson's disease (PD) in Ontario, Canada. METHODS: Using health administrative data, we identified a cohort of individuals aged 40 years or older diagnosed with incident PD between 1995 and 2009. A case-control study was used to examine whether select factors were associated with DBS for PD. Patients were classified as cases if they underwent DBS surgery at any point 1-year after cohort entry until December 31, 2016. Conditional logistic regression modeling was used to estimate the adjusted odds of DBS surgery for sociodemographic and health care utilization indicators. RESULTS: A total of 46,237 individuals with PD were identified, with 543 (1.2%) receiving DBS surgery. Individuals residing in northern Ontario were more likely than southern patients to receive DBS surgery [adjusted odds ratio (AOR) = 2.23, 95% confidence interval (CI) = 1.15-4.34]; however, regional variations were not observed after accounting for medication use among older adults (AOR = 1.04, 95% CI = 0.26-4.21). Patients living in neighborhoods with the highest concentration of visible minorities were less likely to receive DBS surgery compared to patients living in predominantly white neighborhoods (AOR = 0.27, 95% CI = 0.16-0.46). Regular neurologist care and use of multiple PD medications were positively associated with DBS surgery. CONCLUSIONS: Variations in use of DBS may reflect differences in access to care, specialist referral pathways, health-seeking behavior, or need for DBS. Future studies are needed to understand drivers of potential disparities in DBS use.

Risks of preoperative anemia in women undergoing elective hysterectomy and myomectomy.

BACKGROUND: Hysterectomy is one of the most common surgeries performed worldwide. Identification of modifiable risk factors for complications or readmissions could lead to targeted interventions to improve patient care and reduce health care costs. Preoperative anemia has been identified as a risk factor for adverse postoperative outcomes following noncardiac surgery. However, studies have not focused on young and healthy surgical populations, such as women undergoing gynecologic surgery for benign indications. OBJECTIVE: The purpose of this study was to evaluate whether preoperative anemia in women undergoing elective hysterectomy or myomectomy for benign indications was associated with increased 30 day postoperative morbidity and mortality. STUDY DESIGN: In this retrospective, population-based cohort study, we followed up adult women (≥18 years of age) who underwent elective hysterectomy or myomectomy (laparoscopic/laparotomy) between the years 2013 and 2015 for benign indications in Ontario, Canada. We used linked administrative data from a government-administered, single-payer provincial health care system using Canadian Classification of Health Interventions intervention codes, International Classification of Diseases, 10th revision, diagnostic codes, physician billing codes, and laboratory data from both community and hospital laboratories across the province. Our exposure of interest was preoperative anemia, defined as a hemoglobin value <12 g/dL on the complete blood count measured closest to the date of surgery. Our primary outcome was the composite of 30 day postoperative morbidity and mortality. Secondary outcomes were 5 individual components of the primary outcome: death, transfusion, surgical site infection, venothromboembolism, and return to the hospital within 30 days. To adjust for confounding, we generated a propensity score using a multiple logistic regression model in which the presence of anemia was regressed on all baseline characteristics. We matched anemic to nonanemic patients on the logit of the propensity score. Using an unadjusted log-binomial model estimated using generalized estimating equations to account for the matched pairs, we calculated the relative risk, 95% confidence intervals, and P values to evaluate the effect of anemia on outcomes. RESULTS: Of the 16,218 women in the cohort, 3664 (22.6%) had anemia. After propensity matching, standardized differences in all baseline characteristics (n = 3261 per group) were <0.10. In the matched cohort, the primary outcome (death, complications, or readmission) occurred in 41.2% of anemic patients and 36.2% of nonanemic patients (relative risk, 1.14, 95% confidence interval, 1.07-1.21, P < .0001; absolute risk reduction, 5.03%, 95% confidence interval, 2.70-7.36; (number needed to harm = 20). The risk of transfusion was significantly higher in anemic patients (relative risk, 3.25, 95% confidence interval, 2.67-3.95, P < .0001; absolute risk reduction, 8.34%, 95% confidence interval, 7.06-9.63; number needed to harm = 12). There was no difference in other secondary outcomes. In a subgroup analysis (women >55 years vs ≤55, n = 736), older women were at increased risk of the primary outcome (relative risk, 1.40, 95% confidence interval, 1.12-1.76, P = .004), transfusion (relative risk, 4.20, 95% confidence interval, 1.65-10.72, P = .003), surgical site infection (relative risk, 1.35, 95% confidence interval, 1.01-1.81, P = .04), and return to the hospital (relative risk, 2.36, 95% confidence interval, 1.54-3.62, P < .0001). CONCLUSION: Preoperative anemia in women undergoing elective hysterectomy/myomectomy was common and is an independent risk factor for 30 day postoperative adverse outcomes, especially in older women.

[Organizational learning and health promotion: a Quebec project] / Apprentissage organisationnel en promotion de la santé : une expérience québécoise.

OBJECTIVE: This article focuses on health promotion laboratories, a Quebec professional development program offered by the Public Health Department of the Montréal Region to teams of professionals and managers working in health promotion within local public health organizations. The objective is to examine the process of translating the knowledge gained by participants as a result of the program over the longer term within the organization. METHOD: This was a qualitative descriptive study. The work was guided by Nonaka's Organizational Knowledge Creation Model. Data were collected from participants at several types of discussion and development events held in the three months following the end of the pilot project. A thematic content analysis was performed using a grid derived from Nonaka's model. RESULTS: The analysis revealed the presence of both externalization and internalization in two of the sites, as well as a considerable volume of combinations in the four sites studied. In the latter case, the learnings reused over the longer term were similar to those that had been transferred in the short term (e.g. ideas and methods relating to partnership, planning, etc.). CONCLUSION: These results are important, in that they confirm the laboratories' potential to propagate the learnings throughout the organization, beyond the short-term gains made by participants during the laboratories. These learnings could potentially pave the way for new practices.

Association Between High Environmental Heat and Risk of Acute Kidney Injury Among Older Adults in a Northern Climate: A Matched Case-Control Study.

BACKGROUND: An association between high heat and acute kidney injury (AKI) has been reported in warm climates. However, whether this association generalizes to a northern climate, with more variable temperatures, is unknown. STUDY DESIGN: Matched case-control study. SETTING & PARTICIPANTS: Our study focused on older adults (mean age, 80 years) in the northern climate of Ontario, Canada. 52,913 case patients who had a hospital encounter with AKI in April through September 2005 to 2012 were matched with 174,222 controls for exact date, age, sex, rural residence, income, and history of chronic kidney disease. PREDICTOR: Heat periods were defined as 3 consecutive days exceeding the 95th percentile of area-specific maximum temperature. OUTCOMES: Hospital encounter (inpatient admission or emergency department visit) with a diagnosis of AKI. MEASUREMENTS: ORs (95% CIs) were used to assess the association between heat periods and AKI. To quantify the effect in absolute terms, we multiplied the population incidence rate of AKI in the absence of heat periods by our adjusted OR (an approximate of relative risk). RESULTS: Heat periods were significantly associated with higher risk for AKI (adjusted OR, 1.11; 95% CI, 1.00-1.23). Heat periods in absolute terms were associated with an additional 182 cases of AKI per 100,000 person-years during the warm season. LIMITATIONS: We did not know how long persons were outside or if they had access to air conditioning. CONCLUSIONS: In a northern climate, periods of higher environmental heat were associated with a modestly higher risk for hospital encounter with AKI among older adults.

Antibiotic Prescribing for Nonbacterial Acute Upper Respiratory Infections in Elderly Persons.

BACKGROUND: Reducing inappropriate antibiotic prescribing for acute upper respiratory tract infections (AURIs) requires a better understanding of the factors associated with this practice. OBJECTIVE: To determine the prevalence of antibiotic prescribing for nonbacterial AURIs and whether prescribing rates varied by physician characteristics. DESIGN: Retrospective analysis of linked administrative health care data. SETTING: Primary care physician practices in Ontario, Canada (January-December 2012). PATIENTS: Patients aged 66 years or older with nonbacterial AURIs. Patients with cancer or immunosuppressive conditions and residents of long-term care homes were excluded. MEASUREMENTS: Antibiotic prescriptions for physician-diagnosed AURIs. A multivariable logistic regression model with generalized estimating equations was used to examine whether prescribing rates varied by physician characteristics, accounting for clustering of patients among physicians and adjusting for patient-level covariates. RESULTS: The cohort included 8990 primary care physicians and 185 014 patients who presented with a nonbacterial AURI, including the common cold (53.4%), acute bronchitis (31.3%), acute sinusitis (13.6%), or acute laryngitis (1.6%). Forty-six percent of patients received an antibiotic prescription; most prescriptions were for broad-spectrum agents (69.9% [95% CI, 69.6% to 70.2%]). Patients were more likely to receive prescriptions from mid- and late-career physicians than early-career physicians (rate difference, 5.1 percentage points [CI, 3.9 to 6.4 percentage points] and 4.6 percentage points [CI, 3.3 to 5.8 percentage points], respectively), from physicians trained outside of Canada or the United States (3.6 percentage points [CI, 2.5 to 4.6 percentage points]), and from physicians who saw 25 to 44 patients per day or 45 or more patients per day than those who saw fewer than 25 patients per day (3.1 percentage points [CI, 2.1 to 4.0 percentage points] and 4.1 percentage points [CI, 2.7 to 5.5 percentage points], respectively). LIMITATION: Physician rationale for prescribing was unknown. CONCLUSION: In this low-risk elderly cohort, 46% of patients with a nonbacterial AURI were prescribed antibiotics. Patients were more likely to receive prescriptions from mid- or late-career physicians with high patient volumes and from physicians who were trained outside of Canada or the United States. PRIMARY FUNDING SOURCE: Ontario Ministry of Health and Long-term Care, Academic Medical Organization of Southwestern Ontario, Schulich School of Medicine and Dentistry, Western University, and Lawson Health Research Institute.