Credibility assessment of patient-specific biomechanical models to investigate proximal junctional failure in clinical cases with adult spine deformity using ASME V&V40 standard.

Computational models are increasingly used to assess spine biomechanics and support surgical planning. However, varying levels of model verification and validation, along with characterization of uncertainty effects limit the level of confidence in their predictive potential. The objective was to assess the credibility of an adult spine deformity instrumentation model for proximal junction failure (PJF) analysis using the ASME V&V40:2018 framework. To assess model applicability, the surgery, erected posture, and flexion movement of actual clinical cases were simulated. The loads corresponding to PJF indicators for a group of asymptomatic patients and a group of PJF patients were compared. Model consistency was demonstrated by finding PJF indicators significantly higher for the simulated PJF vs. asymptomatic patients. A detailed sensitivity analysis and uncertainty quantification were performed to further establish the model credibility.

Comparing the Ability of Physician-Reported Versus Patient-Reported Performance Status to Predict Survival in a Population-Based Cohort of Newly Diagnosed Cancer Patients.

AIMS: Performance status is an important prognostic tool in cancer. In oncology, the Eastern Cooperative Oncology Group (ECOG) measure is commonly used. Patient-reported functional status (PRFS) is an emerging method that allows patients to provide an estimate of their function; however, there is limited information about its prognostic significance. The aim of this study was to compare the predictive validity of functional status as reported by patients and physicians in relation to the observed survival after a new cancer diagnosis. MATERIALS AND METHODS: This was a retrospective, population-based study using observational data of newly diagnosed patients in Ontario, Canada. We included patients who had both PRFS and ECOG recorded on the same day during an outpatient cancer clinic visit between March 2013 and March 2018. The dataset was randomly divided into 60% training and 40% validation cohorts. One-year survival was estimated by modelling clinical characteristics with PRFS, with ECOG, and alone. RESULTS: In total, 13 045 patients met the inclusion criteria. Covariates were similar at baseline for both training and validation datasets. PRFS and ECOG scores were statistically significant predictors of overall survival. Higher PRFS and ECOG scores were both associated with inferior survival, hazard ratio = 1.71 (P < 0.0001) and hazard ratio = 1.90 (P < 0.0001), respectively. Models that included either PRFS or ECOG scores outperformed the model with clinical characteristics only. C statistics were 0.836, 0.839 and 0.811, respectively. CONCLUSIONS: PRFS adds to survival modelling and is equally predictive as the ECOG scale. PRFS may be used instead of ECOG in clinical or research settings for survival estimation.

A catalyst for transforming health systems and person-centred care: Canadian national position statement on patient-reported outcomes.

Background: Patient-reported outcomes (pros) are essential to capture the patient's perspective and to influence care. Although pros and pro measures are known to have many important benefits, they are not consistently being used and there is there no Canadian pros oversight. The Position Statement presented here is the first step toward supporting the implementation of pros in the Canadian health care setting. Methods: The Canadian pros National Steering Committee drafted position statements, which were submitted for stakeholder feedback before, during, and after the first National Canadian Patient Reported Outcomes (canpros) scientific conference, 14-15 November 2019 in Calgary, Alberta. In addition to the stakeholder feedback cycle, a patient advocate group submitted a section to capture the patient voice. Results: The canpros Position Statement is an outcome of the 2019 canpros scientific conference, with an oncology focus. The Position Statement is categorized into 6 sections covering 4 theme areas: Patient and Families, Health Policy, Clinical Implementation, and Research. The patient voice perfectly mirrors the recommendations that the experts reached by consensus and provides an overriding impetus for the use of pros in health care. Conclusions: Although our vision of pros transforming the health care system to be more patient-centred is still aspirational, the Position Statement presented here takes a first step toward providing recommendations in key areas to align Canadian efforts. The Position Statement is directed toward a health policy audience; future iterations will target other audiences, including researchers, clinicians, and patients. Our intent is that future versions will broaden the focus to include chronic diseases beyond cancer.

Lessons learned from a cancer knowledge translation grants program: results of an evaluation.

Background: A novel way to build capacity in knowledge translation (kt) is through kt-focused grant competitions. Since 2009, the Knowledge Translation Research Network (KT-Net) has had a cancer-related kt grants program. We undertook an evaluation of the program to determine if KT-Net was achieving its aims of building capacity in cancer kt, advancing the science of kt, building partnerships, and leveraging funding. Methods: An adapted framework guided the evaluation. Nine funded studies from 4 competitions were included. Semi-structured telephone interviews were held with researchers, stakeholders (including knowledge users), members of grant review panels, and experts in kt. Interview transcripts were audio-recorded, transcribed, and analyzed thematically. A review of proposal and report documents was also conducted. Results: Funded researchers indicated that the grant competition was an essential funding program for cancer kt research. Competitions were perceived to build capacity in cancer kt among early-career researchers and to encourage innovative cancer kt research for which alternative funding sources are limited. The grants program resulted in incremental gains in advancing the science of kt. Suggestions to improve the program included stronger partnerships between the funder and the provincial cancer-system organization to optimize the application of research that is relevant to the organization's strategic objectives. Conclusions: The grants program met many of its aims by providing cancer researchers with an opportunity to gain capacity in cancer kt and by making incremental advances in kt science. Suggestions to improve the program included closer partnerships between the funder and the cancer-system organization.

Modular implant design affects metal ion release following metal-on-metal hip arthroplasty: a retrospective study on 75 cases.

Metal-on-Metal (MoM) total hip arthroplasty (THA) has been associated to wear and metal-ions release, controversially related to a variety of clinical complications. Little is known about the relevant design-dependent parameters involved in this process. The present study investigated the correlation between metal ion release in blood and revision rate as a function of: (i) specific MoM implant modular design parameters, (i.e. acetabular cup and femoral head diameters, taper adapter material and size, femoral neck material and modularity and stem size); (ii) MoM bilaterality. Co and Cr ions concentration levels in blood of 75 patients were retrospectively-evaluated with a mean follow-up of 4.8 years (range: 1.8-6.3). Patients were divided in a unilateral and a bilateral group. Statistical analysis was performed to find any significant difference related to acetabular cup diameter, femoral head diameter, taper adapter material/size, neck material/size and stem size. The bilateral MoM group had 4-times higher metal ion levels in blood than the unilateral one (p=0.017 only Cr), related to a higher revision rate (30% vs 20%): differences were 10-times higher particularly with a 48 mm femoral head diameter (p=0.012) and a Ti-alloy neck (p=0.041). Within the monolateral group using a shorter taper adapter and a shorter neutrally-oriented neck demonstrated higher ion levels (p=0.038 only Cr and p=0.008 only Co, respectively). The aforementioned design-features and MoM bilaterality are important risk-factors for metal-ion release in modular MoM THA.

Factors influencing the use by radiation therapists of cancer symptom guides: a mixed-methods study.

Background: Radiation therapists play an important role in helping patients to safely manage and triage potentially life-threatening symptoms. The purpose of the present study was to assess factors influencing the use by radiation therapists of evidence-informed symptom practice guides for patients experiencing cancer treatment-related symptoms. Methods: In a mixed-methods descriptive study guided by the Knowledge-to-Action framework, interviews and a barriers survey were conducted. Two independent reviewers conducted a content analysis of interview transcripts. Barriers survey data were analyzed using frequency distributions and univariate descriptive statistics. Open-ended data from the surveys underwent content analysis and were triangulated with interview findings. Results: Of 90 radiation therapists approached, 58 completed the survey (64%), and 14 were interviewed. Of the 98% who reported providing symptom management to patients undergoing radiation treatment, 53% used evidence-informed practice guidelines. Radiation therapists had moderate moral norms (4.6 of 7) and beliefs about the consequences of using costars (pan-Canadian Oncology Symptom Triage and Remote Support) practice guides (4.8), but neutral intention (3.4) and beliefs about their own capabilities (3.9). Environmental barriers included lack of time (2.0), lack of access (2.5), and neutral organizational support (3.0). Radiation therapists identified a need for training (5.5). Common unique barriers to practice guide use were lack of time during radiation treatments, unclear fit with scope of practice, disparate focus on site-specific symptoms, and lack of medication knowledge. Conclusions: The symptom practice guides were perceived by the radiation therapists to benefit patients, enhance their own knowledge of symptom management, and promote consistent practice. Additional work is required to identify the scope of practice of radiation therapists within the interprofessional team.

Factors associated with receipt of symptom screening in the year after cancer diagnosis in a universal health care system: a retrospective cohort study.

Purpose: Patient-reported symptom data are collected prospectively by a provincial cancer agency to mitigate the significant symptom burden that patients with cancer experience. However, an assessment of whether such symptom screening occurs uniformly for those patients has yet to be performed. In the present study, we investigated patient, disease, and health system factors associated with receipt of symptom screening in the year after a cancer diagnosis. Methods: Patients diagnosed with cancer between 2007 and 2014 were identified. We measured whether 1 or more symptom screenings were recorded in the year after diagnosis. A multivariable modified Poisson regression with robust error variance was used to identify predictors [age, comorbidity, rurality, socioeconomic status, immigration status, cancer site, registration at a regional cancer centre (cc), and year of diagnosis] of being screened for symptoms. Results: Of 425,905 patients diagnosed with cancer, 163,610 (38%) had 1 or more symptom screening records in the year after diagnosis, and 75% survived at least 1 year. We identified variability in symptom screening by primary cancer site, regional cc, age, sex, comorbidity, material deprivation, rurality of residence, and immigration status. Patients who had been diagnosed with melanoma or endocrine cancers, who were not registered at a regional cc, who lived in the most urban areas, who were elderly, and who were immigrants were least likely to undergo symptom screening after diagnosis. Conclusions: Our evaluation of the implementation of a population-based symptom screening program in a universal health care system identified populations who are at risk for not receiving screening and who are therefore future targets for improvements in population symptom screening and better management of cancer-related symptoms at diagnosis.

Combined cancer patient-reported symptom and health utility tool for routine clinical implementation: a real-world comparison of the ESAS and EQ-5D in multiple cancer sites.

Background: We assessed whether the presence and severity of common cancer symptoms are associated with the health utility score (hus) generated from the EQ-5D (EuroQol Research Foundation, Rotterdam, Netherlands) in patients with cancer and evaluated whether it is possible pragmatically to integrate routine hus and symptom evaluation in our cancer population. Methods: Adult outpatients at Princess Margaret Cancer Centre with any cancer were surveyed cross-sectionally using the Edmonton Symptom Assessment System (esas) and the EQ-5D-3L, and results were compared using Spearman correlation coefficients and regression analyses. Results: Of 764 patients analyzed, 27% had incurable disease. We observed mild-to-moderate correlations between each esas symptom score and the hus (Spearman coefficients: -0.204 to -0.416; p < 0.0001 for each comparison), with the strongest associations being those for pain (R = -0.416), tiredness (R = -0.387), and depression (R =-0.354). Multivariable analyses identified pain and depression as highly associated (both p < 0.0001) and tiredness as associated (p = 0.03) with the hus. The ability of the esas to predict the hus was low, at 0.25. However, by mapping esas pain, anxiety, and depression scores to the corresponding EQ-5D questions, we could derive the hus using partial esas data, with Spearman correlations of 0.83-0.91 in comparisons with direct EQ-5D measurement of the hus. Conclusions: The hus derived from the EQ-5D-3L is associated with all major cancer symptoms as captured by the esas. The esas scores alone could not predict EQ-5D scores with high accuracy. However, esas-derived questions assessing the same domains as the EQ-5D-3L questions could be mapped to their corresponding EQ-5D questions to generate the hus, with high correlation to the directly measured hus. That finding suggests a potential approach to integrating routine symptom and hus evaluations after confirmatory studies.

A pilot evaluation of the expanded prostate cancer index composite for clinical practice (EPIC-CP) tool in Ontario.

PURPOSE: To introduce the EPIC-CP symptom screening tool in routine ambulatory cancer care, and to evaluate its acceptability and perceived usefulness from the perspective of patients and clinicians. METHODS: Eligible prostate cancer patients from four cancer centres were recruited (November 2014-June 2015) from radiation or surgical oncology clinics. A physician and/or health care professional reviewed the EPIC-CP results as part of the clinical encounter. Patient experience with the tool was evaluated using a nine-item Patient Exit Survey (PES). Clinician experience was evaluated through semi-structured qualitative interviews. Patient and clinician results were compared to identify common themes. RESULTS: A total of 333 patients were enrolled, of whom, 287 completed the PES. Most patients had one clinical encounter, although the number of EPIC-CP assessments ranged from 1 to 11 per patient, for a total of 937 EPIC-CP questionnaires completed. Item completion rates were high (91-100%), with items addressing sexual health among the lowest (91-92%). On the PES, most patients (70%) agreed with the item: "Completing this questionnaire helped me tell the clinicians about how I have been feeling". Thematic analysis from clinician interviews revealed that the EPIC-CP captures essential prostate-specific effects that facilitated person-centred communication and customization of interventions. Targeted clinical education and patient resources were seen as necessary for uptake. CONCLUSIONS: EPIC-CP was generally endorsed by clinicians and patients. The implementation of a disease-specific measure in place of a generic symptom screening tool has the potential to improve the quality of the clinical encounter and provide outcome measures for further health services research. Provincial implementation of this tool as a standard of care is recommended.

Augmentation of the atrophic maxillary sinus floor: graft stiffness, implant shape and length.

This study investigates the characteristics of load transmission to bone of alternative treatments for posterior maxilla edentulism with relatively limited available bone volume. Implant shape (conical and cylindrical), augmentation technique and the effect of bone-graft stiffness were taken into consideration. The finite element models of the atrophic sinus implanted with short implant were compared to two grafted-sinus models implanted with longer implants, engaged bicortically. Bone-graft stiffness was varied to describe different stages of graft-maturation (from short-term to long-term). Stress and load distributions due to axial and bending loads were compared on the bony structures. In the short-term, axial force is supported almost equally by the cortical layers and the trabecular core, while a bending load is mainly supported by the crestal cortical layer and secondarily by the cortical floor, the bone-graft supported a negligible load. Bicortical engagement produces higher load transfer to the cortical floor under axial load. In the long-term, as the stiffness of the bone-graft increases, the load is transferred progressively towards the grafted region, progressively unloading other structures, particularly the internal cortical layer.

Analysis of the prophages carried by human infecting isolates provides new insight into the evolution of Group B Streptococcus species.

OBJECTIVES: Group B Streptococcus (GBS) emerged in the 1970s as a major cause of neonatal infections, and has been increasingly associated with infections in adults since the 1990s. Prophages have been suspected to have driven these epidemiological trends. We have characterized the prophages harboured by 275 human GBS isolates belonging to the major lineages. METHODS: We applied whole genome sequencing (WGS) to 14 isolates representative of the diversity within GBS species, located and identified their prophages. Using prediction tools, we searched for prophage elements potentially involved with the ability of GBS to infect humans. Using the data obtained by WGS, we designed a PCR-based tool and studied the prophage content of 275 isolates. RESULTS: WGS of the 14 isolates revealed 22 prophages (i) distributed into six groups (A-F), (ii) similar to phages and prophages from GBS and non-GBS streptococci recovered from livestock, and (iii) carrying genes encoding factors previously associated with host adaptation and virulence. PCR-based detection of prophages revealed the presence of at least one prophage in 72.4% of the 275 isolates and a significant association between neonatal infecting isolates and prophages C, and between adult infecting isolates and prophages A. CONCLUSIONS: Our results suggest that prophages (possibly animal-associated) have conditioned bacterial adaptation and ability to cause infections in neonates and adults, and support a role of lysogeny with the emergence of GBS as a pathogen in human.

Experiences of Canadian oncologists with difficult patient deaths and coping strategies used.

OBJECTIVES: We aimed to explore and identify what makes patient death more emotionally difficult for oncologists and how oncologists cope with patient death. METHODS: A convenience sample of 98 Canadian oncologists (50 men, 48 women) completed an online survey that included a demographics section and a section about patient death. RESULTS: More than 80% of oncologists reported that patient age, long-term management of a patient, and unexpected disease outcomes contributed to difficult patient loss. Other factors included the doctor-patient relationship, identification with the patient, caregiver-related factors, oncologist-related factors, and "bad deaths." Oncologists reported varying strategies to cope with patient death. Most prevalent was peer support from colleagues, including nurses and other oncologists. Additional strategies included social support, exercise and meditation, faith, vacations, and use of alcohol and medications. CONCLUSIONS: Oncologists listed a number of interpersonal and structural factors that make patient death challenging for them to cope with. Oncologists reported a number of coping strategies in responding to patient death, including peer support, particularly from nursing colleagues. No single intervention will be suitable for all oncologists, and institutions wishing to help their staff cope with the emotional difficulty of patient loss should offer a variety of interventions to maximize the likelihood of oncologist participation.

Interventions to address sexual problems in people with cancer.

BACKGROUND: Sexual dysfunction in people with cancer is a significant problem. The present clinical practice guideline makes recommendations to improve sexual function in people with cancer. METHODS: This guideline was undertaken by the Interventions to Address Sexual Problems in People with Cancer Expert Panel, a group organized by the Program in Evidence-Based Care (pebc). Consistent with the pebc standardized approach, a systematic search was conducted for existing guidelines, and the literature in medline and embase for the years 2003-2015 was systematically searched for both systematic reviews and primary literature. Evidence found for men and for women was evaluated separately, and no restrictions were placed on cancer type or study design. Content and methodology experts performed an internal review of the resulting draft recommendations, which was followed by an external review by targeted experts and intended users. RESULTS: The search identified 4 existing guidelines, 13 systematic reviews, and 103 studies with relevance to the topic. The present guideline provides one overarching recommendation concerning the discussion of sexual health and dysfunction, which is aimed at all people with cancer. Eleven additional recommendations made separately for men and women deal with issues such as sexual response, body image, intimacy and relationships, overall sexual functioning and satisfaction, and vasomotor and genital symptoms. CONCLUSIONS: To our knowledge this clinical practice guideline is the first to comprehensively evaluate interventions for the improvement of sexual problems in people with cancer. The guideline will be a valuable resource to support practitioners and clinics in addressing sexuality in cancer survivors.

The Role of Stereotactic Ablative Body Radiotherapy in Gynaecological Cancers: A Systematic Review.

AIMS: To summarise and evaluate the current literature in gynaecological tumours treated with stereotactic ablative body radiotherapy (SABR) through a systematic review using the Preferred Reported Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. MATERIALS AND METHODS: A literature search through Medline, EMBASE and Cochrane databases resulted in 22 pertinent manuscripts. Selected studies evaluated the locoregional role of SABR in gynaecological tumours, regardless of SABR clinical indication. Data on local control, toxicity and SABR dose and technique were extracted by at least two investigators. RESULTS: In total, 330 patients received locoregional SABR for gynaecological tumour and had measurable clinical outcomes. Six different clinical scenarios were identified: (i) boost to external beam radiotherapy (EBRT) for cervical cancer as radical treatment; (ii) boost to EBRT for non-operable endometrial cancer; (iii) treatment for pelvic and/or para-aortic node metastases; (iv) adjuvant treatment after surgery in uterine/cervix cancers; (v) salvage of non-nodal pelvic recurrences and (vi) vulvar or vaginal malignancies. Except for SABR as a boost for non-operable endometrial cancer, local control over 80% was found in a range of median follow-up of 4-132 months. Local control in non-operable endometrial tumours receiving SABR was 53%. In salvage treatments for non-nodal pelvic relapses, SABR was associated with about a 20% grade 3-4 gastrointestinal toxicity. CONCLUSION: There is no clear consensus or evidence on the defined role of SABR in gynaecological tumours. Local control and toxicity associated with SABR seems reasonable for most clinical indications found by this review with a short median follow-up. When used for salvage of non-nodal pelvic recurrences, SABR may be associated with high rates of grade 3-4 late gastrointestinal toxicity.

Tunisian tomato by-products, as a potential source of natural bioactive compounds.

Consumption of tomato and tomato products is positively related to the reduction in cardiovascular disease and several types of cancer, thanks to the presence of natural compounds, such as antioxidants. Peels and seeds fractions of tomato, collected after industrial processing in Tunisian industries, were analysed for nutritional and antioxidants composition in perspective of its utilisation. Proximate composition, fatty acids profile, carotenoids, such as lycopene and beta-carotene, polyphenols contents, demonstrated the good potential of these residual products as a source of natural compounds, useful for food and nutraceuticals applications.

Phase diagram of binary colloidal rod-sphere mixtures from a 3D real-space analysis of sedimentation-diffusion equilibria.

Self-assembly of binary particle systems offers many new opportunities for materials science. Here, we studied sedimentation equilibria of silica rods and spheres, using quantitative 3D confocal microscopy. We determined not only pressure, density and order parameter profiles, but also the experimental phase diagram exhibiting a stable binary smectic liquid-crystalline phase (Sm2). Using computer simulations we confirmed that the Sm2-phase can be stabilized by entropy alone, which opens up the possibility of combining new materials properties at a wide array of length scales.

Compression of hard core-soft shell nanoparticles at liquid-liquid interfaces: influence of the shell thickness.

Soft hydrogel particles show a rich structural and mechanical behaviour compared to hard particles, both in bulk and when confined in two dimensions at a fluid interface. Moreover, encapsulation into hydrogel shells makes it possible to transfer the tunability of soft steric interactions to hard nanoparticle cores, which bear interest for applications, e.g. in terms of optical, magnetic and reinforcement properties. In this work, we investigate the microstructures formed by hard core-soft shell particles at liquid-liquid interfaces upon compression. We produced model particles with the same silica core and systematically varied the shell-to-core ratio by synthesising shells with three different thicknesses. These particles were spread at an oil-water interface in a Langmuir-Blodgett trough and continuously transferred onto a solid support during compression. The transferred microstructures were analysed by atomic force and scanning electron microscopy. Quantitative image analysis provided information on the particle packing density, the inter-particle distance, and the degree of order of the monolayers. We discovered several essential differences compared to purely soft hydrogel particles, which shed light on the role played by the hard cores in the assembly and compression of these composite monolayers.

Temporal association between home nursing and hospital costs at end of life in three provinces.

BACKGROUND: Research has demonstrated that increases in palliative homecare nursing are associated with a reduction in the rate of subsequent hospitalizations. However, little evidence is available about the cost-savings potential of palliative nursing when accounting for both increased nursing costs and potentially reduced hospital costs. METHODS: Our retrospective cohort study included cancer decedents from British Columbia, Ontario, and Nova Scotia who received any palliative nursing in the last 6 months of life. A Poisson regression analysis was used to determine the association of increased nursing costs (in 2-week blocks) on the relative average hospital costs in the subsequent 2-week block and on the overall total cost (hospital costs plus nursing costs in the preceding 2-week block). RESULTS: The cohort included 58,022 cancer decedents. Results of the analysis for the last month of life showed an association between increased nursing costs and decreased relative hospital costs in comparisons with a reference group (>0 to 1 hour nursing in the block): the maximum decrease was 55% for Ontario, 31% for British Columbia, and 38% for Nova Scotia. Also, increased nursing costs in the last month were almost always associated with lower total costs in comparison with the reference. For example, cost savings per person-block ranged from $376 (>10 nursing hours) to $1,124 (>4 to 6 nursing hours) in British Columbia. CONCLUSIONS: In the last month of life, increased palliative nursing costs (compared with costs for >0 to 1 hour of nursing in the block) were associated with lower relative hospital costs and a lower total cost in a subsequent block. Our research suggests a cost-savings potential associated with increased community-based palliative nursing.

Quality of end-of-life cancer care in Canada: a retrospective four-province study using administrative health care data.

BACKGROUND: The quality of data comparing care at the end of life (eol) in cancer patients across Canada is poor. This project used identical cohorts and definitions to evaluate quality indicators for eol care in British Columbia, Alberta, Ontario, and Nova Scotia. METHODS: This retrospective cohort study of cancer decedents during fiscal years 2004-2009 used administrative health care data to examine health service quality indicators commonly used and previously identified as important to quality eol care: emergency department use, hospitalizations, intensive care unit admissions, chemotherapy, physician house calls, and home care visits near the eol, as well as death in hospital. Crude and standardized rates were calculated. In each province, two separate multivariable logistic regression models examined factors associated with receiving aggressive or supportive care. RESULTS: Overall, among the identified 200,285 cancer patients who died of their disease, 54% died in a hospital, with British Columbia having the lowest standardized rate of such deaths (50.2%). Emergency department use at eol ranged from 30.7% in Nova Scotia to 47.9% in Ontario. Of all patients, 8.7% received aggressive care (similar across all provinces), and 46.3% received supportive care (range: 41.2% in Nova Scotia to 61.8% in British Columbia). Lower neighbourhood income was consistently associated with a decreased likelihood of supportive care receipt. INTERPRETATION: We successfully used administrative health care data from four Canadian provinces to create identical cohorts with commonly defined indicators. This work is an important step toward maturing the field of eol care in Canada. Future work in this arena would be facilitated by national-level data-sharing arrangements.