Participation in Special Olympics reduces the rate for developing diabetes in adults with intellectual and developmental disabilities.

AIM: Adults with intellectual and developmental disabilities (IDD) have a significantly higher prevalence of Type 2 diabetes than the general population. Evidence that lifestyle and/or behavioural interventions, such as participation in Special Olympics, decreases the risk of developing diabetes in adults with IDD could help minimize health disparities and promote overall health in this population. METHODS: This was a 20-year retrospective cohort study of adults with IDD (30-39 years) in the province of Ontario, Canada, that compared hazard rates of diabetes among Special Olympics participants (n = 4145) to non-participants (n = 31,009) using administrative health databases housed at ICES. Using cox proportional hazard models, crude and adjusted hazard ratios were calculated for the association between the primary independent variable (Special Olympics participation status) and the dependent variable (incident diabetes cases). RESULTS: After controlling for other variables, the hazard ratio comparing rates for developing diabetes between Special Olympics participants and non-participants was 0.85. This represents a 15% reduction in the hazard among Special Olympics participants when followed for up to 20 years. This result was statistically significant and represents a small effect size. CONCLUSIONS: Special Olympics could be considered a complex intervention that promotes physical activity engagement through sport participation, health screenings, and the promotion of healthy eating habits through educational initiatives. This study provides evidence that Special Olympics participation decreases the rate for developing diabetes.

The Association Between Prior Mental Health Service Utilization and Risk of Recidivism among Incarcerated Ontario Residents.

BACKGROUND: There is mixed evidence on the link between mental health and addiction (MHA) history and recidivism. Few studies have examined post-release MHA care. Our objective was to examine the association between prior (pre-incarceration) MHA service use and post-release recidivism and service use. METHODS: We conducted a population-based cohort study linking individuals held in provincial correctional institutions in 2010 to health administrative databases. Prior MHA service use was assigned hierarchically in order of hospitalization, emergency department visit and outpatient visit. We followed up individuals post-release for up to 5 years for the first occurrence of recidivism and MHA hospitalization, emergency department visit and outpatient visit. We use Cox-proportional hazards models to examine the association between prior MHA service use and each outcome adjusting for prior correctional involvement and demographic characteristics. RESULTS: Among a sample consisting of 45,890 individuals, we found that prior MHA service use was moderately associated with recidivism (hazard ratio (HR): 1.20-1.50, all P < 0.001), with secondary analyses finding larger associations for addiction service use (HR range: 1.34-1.54, all P < 0.001) than for mental health service use (HR range: 1.09-1.18, all P < 0.001). We found high levels of post-release MHA hospitalization and low levels of outpatient MHA care relative to need even among individuals with prior MHA hospitalization. DISCUSSION: Despite a high risk of recidivism and acute MHA utilization post-release, we found low access to MHA outpatient care, highlighting the necessity for greater efforts to facilitate access to care and care integration for individuals with mental health needs in correctional facilities.

Young adults with intellectual and developmental disabilities who participate in Special Olympics are less likely to be diagnosed with depression.

PURPOSE: People with intellectual and developmental disabilities (IDD) experience high rates of depression. Evidence indicates that physical activity, or participation in a sports club, in a supportive social environment has mental and physical health benefits. Adults with IDD, on average, engage in low levels of physical activity. The purpose of this study was to compare the rates of depression among young adult Special Olympics participants with IDD compared to non-participants with IDD. METHODS: This was a 20-year retrospective cohort study of young adults (19-29 years) with IDD in the province of Ontario, Canada that compared rates of depression among Special Olympics participants (n = 8710) to non-participants (n = 42,393) using administrative health databases housed at ICES (formerly the Institute for Clinical Evaluative Sciences). Using cox proportional hazard models, the crude hazard ratios were calculated for the association between each independent variable and the dependent variable. RESULTS: After controlling for other variables, the hazard rate for depression among Special Olympics participants compared to the hazard rate for depression among non-participants generated an adjusted hazard ratio of 0.51. Over the 20-year follow-up, the participants were 0.51 times as likely to develop depression as non-participants; this represents a 49% reduction in risk among Special Olympics participants. This result was statistically significant and represents a medium effect size. CONCLUSION: Future research is needed on how much of this risk reduction is related to a physiological response to physical activity/exercise, and how much is related to the social connectedness of being part of a group participating in Special Olympics.

Evaluating the population-level effects of oxycodone restrictions on prescription opioid utilization in Ontario.

PURPOSE: To investigate the impact of restrictions on access to long acting oxycodone on prescription opioid use and opioid-related harms. METHODS: Administrative health data from Ontario, Canada was used to measure differences in opioids dispensed and emergency department (ED) visits for opioid-related overdose, poisoning, or substance use following provincial restrictions on access to publicly insured OxyContin (February 29, 2012) and OxyNeo (February 28, 2013). This study focused on the cohort of provincial drug insurance eligible people (people 65+ and select low-income populations) who were dispensed oxycodone prior to the restrictions. Difference-in-differences models with a propensity score matched comparison group of people who were dispensed non-oxycodone opioids were used to estimate the main effects. RESULTS: In 6 months following the delisting of OxyContin, milligrams of morphine equivalents (MMEs) per person per week for all opioids fell by an average of 7.5% in people dispensed oxycodone relative to the comparison group, and an average of 13.8% in chronic recipients of oxycodone. In the 6 months following the restrictions on OxyNeo, MMEs per person per week fell by an average of 3.1% in all people dispensed oxycodone, and 25.2% in chronic oxycodone recipients. The decline in oxycodone dispensing among chronic oxycodone recipients corresponded with an increase in dispensing of other opioid formulations, particularly hydromorphone and fentanyl. No important differences were observed for ED visits related to opioid poisoning, overdose, or substance use disorder. CONCLUSIONS: Province-wide restrictions on access to long acting oxycodone had an impact on quantities of all opioids dispensed to chronic recipients of oxycodone, but small impacts on the full population of people dispensed oxycodone; the decline in use was partially offset by increases in use of other publicly-funded opioid formulations. This study suggests that policies limiting access to specific prescription opioids led to overall reductions in publicly funded prescription opioid use, particularly in chronic oxycodone recipients, without immediate evidence of changes in opioid-related ED visits.

Healthcare utilization and costs following non-fatal powdered and non-powdered firearm injuries for children and youth.

Little is known about the healthcare and economic burdens of non-fatal firearm injuries for children/youth beyond the initial admission. This study sought to estimate healthcare utilization and total direct healthcare costs of non-fatal powdered and non-powdered (air gun) firearm injuries 1-year post-injury. Using administrative data from 2003 to 2018 on all children/youth 0-24 years old in Ontario, Canada, a matched 1:2 cohort study was conducted to compare children/youth who experienced powdered and non-powdered firearm injuries with those who did not. Mean and median number of healthcare encounters and costs, and respective 95% confidence intervals (CIs) and interquartile ranges (IQRs), were estimated for both weapon type groups and controls and by intent. Children/youth who experienced a powdered and non-powdered firearm injury had a higher number of healthcare encounters and costs per year than those who did not. Mean 1-year costs for those with powdered and non-powdered firearm injuries were $8825 ($8007-$9643) and $2349 ($2118-$2578), respectively, versus $812 ($567-$1058) and $753 ($594-$911), respectively, for those without. Mean 1-year costs were highest for handgun injuries ($12,875 [95% CI $9941-$15,808]), and for intentional assault-related ($13,498 [$11,843-$15,153]; $3287 [$2213-$4362]), and intentional self-injuries ($14,773 [$6893-$22,652]; $6005 [$2193-$9817]) for both powdered and non-powdered firearm injuries, respectively.   Conclusion: Firearm injuries have substantial healthcare and economic burdens beyond the initial injury-related admission; this should be accounted for when examining the overall impact of firearm injuries. What is Known: • Child/youth firearm injuries have significant health and economic burdens. • However, existing work has mainly examined healthcare utilization and costs of initial admissions and/or have been limited to single-center studies and no studies have provide cost estimates by weapon type and intent. What is New: • Children/youth who suffered powdered firearm injuries had higher mean healthcare utilization and costs than those with non-powdered firearm injuries as well as comparable healthy children/youth. • Mean 1-year costs were highest for handgun injuries ($12,875), and for intentional assault-related ($13,498; $3287), and intentional self-injuries ($14,773; $6005) for powdered and non-powdered firearm injuries, respectively.

Prevalence of Mental Health and Addiction Service use Prior to and During Incarceration in Provincial Jails in Ontario, Canada: A Retrospective Cohort Study.

OBJECTIVE: Individuals with mental illness and addiction are overrepresented in prisons. Few studies have assessed mental health and addiction (MHA)-related service use among individuals experiencing incarceration using health administrative data and most focus on service use after prison release. The objective of this study was to determine the prevalence of MHA-related service use in the 5 years prior to and during incarceration. METHODS: We used linked correctional and administrative health data for people released from Ontario provincial jails in 2010. MHA-related service use in the 5 years prior to the index incarceration was categorized hierarchically into four mutually exclusive categories based on the type of service use: psychiatric hospitalization, MHA-related emergency department (ED) visit, MHA-related outpatient visit (from psychiatrist or primary care physician), and no MHA-related service use. Demographic, diagnostic, and incarceration characteristics were compared across the four service use categories. MHA-related service use during the index incarceration was assessed by category and length of incarceration. RESULTS: A total of 48,917 individuals were included. Prior to incarceration, 6,116 (12.5%) had a psychiatric hospitalization, 8,837 (18.1%) had an MHA-related ED visit, and 15,866 (32.4%) had an MHA-related outpatient visit. Of the individuals with any MHA-related service prior to incarceration, 60.4% did not receive outpatient care from a psychiatrist prior to incarceration and 65.6% did not receive MHA-related care during incarceration. CONCLUSION: Despite a high prevalence of mental illness and addiction among people experiencing incarceration, access to and use of MHA-related care prior to and during incarceration is poor. Increasing the accessibility and use of MHA-related services throughout the criminal justice pathway is warranted.

Survival after surgery for spinal metastases: a population-based study.

BACKGROUND: There are limited published data on population estimates of survival after spinal surgery for metastatic disease. We performed a population-based study to evaluate survival and complications among patients with cancer who underwent surgery for spinal metastases in Ontario, Canada, between 2006 and 2016. METHODS: We used health administrative databases to identify all patients who underwent surgery for spinal metastases in Ontario between Jan. 1, 2006, and Dec. 31, 2016. We assessed overall survival, mortality rates according to primary cancer lesion and complications after surgery. We contrast the results to those for a comparable cohort from 1991 to 1998. RESULTS: A total of 2646 patients (1194 women [45.1%]; mean age 62.5 yr [standard deviation 12.2 yr]) were identified. The median survival time was 236 (interquartile range 84-740) days. Mortality was highest for patients with melanoma, upper gastrointestinal cancer and lung cancer, with 50% dying within 90 days of surgery. The longest median survival times were observed for primary cancers of the thyroid (906 d) and breast (644 d), and myeloma (830 d). Overall 90-day and 1-year mortality rates were 29% and 59%, respectively. CONCLUSION: We identified differential survivorship based on primary tumour type and a shift in the distribution of operations performed for specific primary cancers over the past 2 decades in Ontario. Overall reductions in mortality associated with this shift in treatment may reflect the use of adjuvant therapies and more personalized treatment approaches.

Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study.

BACKGROUND: Patients who receive palliative care are less likely to die in hospital. OBJECTIVE: To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness. RESEARCH DESIGN: Population-based decedent cohort study using linked health administrative data in Ontario, Canada. SUBJECTS: A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016. EXPOSURE: Physician annual rate of referral to palliative care (high, average, low). MEASURES: Odds of death in hospital versus home, adjusted for patient characteristics. RESULTS: There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)]. CONCLUSIONS AND RELEVANCE: An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

Postpartum mental illness during the COVID-19 pandemic: a population-based, repeated cross-sectional study.

BACKGROUND: It is unclear whether the clinical burden of postpartum mental illness has increased during the COVID-19 pandemic. We sought to compare physician visit rates for postpartum mental illness in Ontario, Canada, during the pandemic with rates expected based on prepandemic patterns. METHODS: In this population-based, repeated cross-sectional study using linked health administrative databases in Ontario, Canada, we used negative binomial regression to model expected visit rates per 1000 postpartum people for March-November 2020 based on prepandemic data (January 2016-February 2020). We compared observed visit rates to expected visit rates for each month of the pandemic period, generating absolute rate differences, incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). The primary outcome was a visit to a primary care physician or a psychiatrist for any mental disorder. We stratified analyses by maternal sociodemographic characteristics. RESULTS: In March 2020, the visit rate was 43.5/1000, with a rate difference of 3.11/1000 (95% CI 1.25-4.89) and an IRR of 1.08 (95% CI 1.03-1.13) compared with the expected rate. In April, the rate difference (10.9/1000, 95% CI 9.14-12.6) and IRR (1.30, 95% CI 1.24-1.36) were higher; this level was generally sustained through November 2020. From April-November, we observed elevated visit rates across provider types and for diagnoses of anxiety, depressive and alcohol or substance use disorders. Observed increases from expected visit rates were greater for people 0-90 days postpartum compared with 91-365 days postpartum; increases were small among people living in low-income neighbourhoods. Public health units in the northern areas of the province did not see sustained elevations in visit rates after July; southern health units had elevated rates through to November. INTERPRETATION: Increased visits for mental health conditions among postpartum people during the first 9 months of the COVID-19 pandemic suggest an increased need for effective and accessible mental health care for this population as the pandemic progresses.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis.

BACKGROUND: Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery. METHODS: This was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends. RESULTS: The difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was - 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours - 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy. CONCLUSIONS: We found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

Risk of Total Hip Arthroplasty After Acetabular Fracture Fixation: The Importance of Age.

BACKGROUND: Geriatric patients are the most rapidly growing cohort of patients sustaining acetabular fractures (AFs). The purpose of this study was to examine the risk of a secondary total hip arthroplasty (THA) in older patients (>60 year old) with a prior AF open reduction internal fixation (ORIF) compared with younger patients (<60 year old) with an AF ORIF on a large population level. METHODS: Using administrative health care data from 1996 to 2010 inclusive of all 202 hospitals in Ontario, Canada, all adult patients with an AF ORIF and a minimum of two year follow-up were identified and included. The risk of THA was examined using a Cox proportional hazards model adjusting for patient risk factors. Secondary outcomes included surgical complications and all-cause mortality. RESULTS: A total of 1725 patients had an AF ORIF; 1452 (84.2%, mean age of 38.3 ± 12.1 years) aged <60 years ("younger") and 273 (15.8%, mean age of 69.9 ± 7.8 years) > 60 years ("older"). The mean (SD) follow-up time for all patients was 6.9 (4.2) years. In older patients, 19.4% (53 of 273) went on to receive a secondary THA with a median time to event of 3.9 years, compared with 12.9% (187 of 1452) in the younger patient cohort with a median time of 6.9 years (HR 1.7, 95% CI: 1.2-2.3). As expected, older patients had a higher 90-day mortality rate compared with younger patients (7.7% vs. 0.7%, respectively; HR 9.2, 95% CI: 4.3-19.9; P < .001). CONCLUSION: Older patients with an AF ORIF are at a significantly higher risk for a secondary THA than younger patients with an AF ORIF.

Identification of incident pancreatic cancer in Ontario administrative health data: A validation study.

PURPOSE: To validate three approaches for identifying incident cases of pancreatic cancer in Ontario administrative claims data. METHODS: We created a cohort using Ontario (Canada) administrative health data from 2002 to 2012 and identified cases of pancreatic cancer with three approaches, using the Ontario Cancer Registry (OCR) as the reference standard. In the any diagnosis approach, cases were defined by primary or secondary diagnostic codes for pancreatic cancer in outpatient or inpatient records. In the any inpatient diagnosis approach, cases were defined using only diagnoses in hospital discharge abstracts. In the algorithm approach, cases were identified by an algorithm that combined the first two approaches. Comparing each approach to the OCR, we calculated the expected value and 95% confidence interval (CI) of the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We also compared the event dates using each approach with those recorded in the OCR. RESULTS: Among a total of 12 060 837 patients in Ontario administrative health data sources, 13 999 incident pancreatic cancer cases were identified in the OCR. Sensitivity ranged from 72.5% (algorithm) to 97.5% (any diagnosis), and PPV ranged from 38.4% (any diagnosis) to 78.9% (any inpatient diagnosis). Specificity and NPV were ~100% for all approaches. The median absolute difference in cancer event date ranged 0 to 15 days. The any inpatient diagnosis method had the highest PPV (78.9%; 95% CI: 78.2-79.5%) and moderate sensitivity (86.6%; 95% CI: 86.0-87.2%). CONCLUSION: Inpatient diagnoses of pancreatic cancer in Ontario administrative heath data are suitable for pancreatic cancer case identification.

Stable rates of operative treatment of distal radius fractures in Ontario, Canada: a population-based retrospective cohort study (2004­2013)

Background: Rates of surgical management of distal radius fractures are increasing internationally despite the higher cost and limited outcome evidence to support this shift. This study examines the epidemiology of distal radius fractures and asks if the same shift has occurred in Ontario, Canada (population 13.9 million). Methods: This population-based, retrospective cohort study examined distal radius fractures in people aged 18 years and older over a 10-year period (2004­2013). The incidence analyses were based on the first occurrence of a fracture within a 2-year time period. The number of fractures, age-adjusted incidence rates and frequency of fracture treatment type by year were assessed. We used a Poisson regression with robust standard errors to determine if there was a statistically significant change in the frequency of fracture treatment type over time. Results: There were 25 355 distal radius fractures among Ontarians 18 years of age and older in 2013. Between 2004 and 2013, the age-adjusted incidence rate for people 35 years of age and older was stable, between 2.32 and 2.70 per 1000 population. Rates of cast immobilization remained stable between 82% and 84%. Of those patients treated surgically, the rate of open reduction and internal fixation rose from 7% in 2004 to 13% in 2013 at the expense of other types of surgical management. Conclusion: In Ontario, rates of cast immobilization are stable and there has been a movement toward open reduction and internal fixation among patients treated surgically.

Contexte: Le taux de prise en charge chirurgicale des fractures du radius distal augmente partout dans le monde, malgré le coût supérieur de l'intervention et le manque de données probantes sur les issues. Cette étude se penche sur l'épidémiologie des fractures du radius distal et cherche à savoir si cette augmentation se reflète en Ontario, au Canada (population : 13,9 millions). Méthodes: Cette étude de cohorte rétrospective basée sur la population examinait les fractures du radius distal chez les personnes âgées de 18 ans et plus sur une période de 10 ans (de 2004 à 2013). Les analyses de l'incidence étaient fondées sur la première occurrence de fracture en 2 ans. Le nombre de fractures, le taux d'incidence ajusté en fonction de l'âge et la fréquence annuelle des types de traitement des fractures ont été évalués. Nous avons utilisé une régression de Poisson avec des erreurs types robustes pour déterminer s'il y avait des changements statistiquement significatifs dans la fréquence des types de traitement des fractures au fil du temps. Résultats: Il y a eu 25 355 fractures du radius distal chez les Ontariens de 18 ans et plus en 2013. Entre 2004 et 2013, le taux d'incidence ajusté en fonction de l'âge pour les personnes de 35 ans et plus était stable, entre 2,32 et 2,70 pour 1000 personnes. Le taux d'immobilisation plâtrée est demeuré stable entre 82 % et 84 %. Chez les patients traités par chirurgie, le taux de réduction chirurgicale et de fixation interne est passé de 7 % en 2004 à 13 % en 2013, au détriment des autres types de prise en charge chirurgicale. Conclusion: En Ontario, le taux d'immobilisation plâtrée est demeuré stable et il y a eu une augmentation de la réduction chirurgicale et de la fixation interne chez les patients traités par chirurgie.

Comparative risk of harm associated with trazodone or atypical antipsychotic use in older adults with dementia: a retrospective cohort study.

BACKGROUND: Trazodone is increasingly prescribed for behavioural and psychological symptoms of dementia, but little is known about its risk of harm. Our objective was to describe the comparative risk of falls and fractures among older adults with dementia dispensed trazodone or atypical antipsychotics. METHODS: The study cohort included adults with dementia (excluding patients with chronic psychotic illnesses) living in long-term care and aged 66 years and older. Data were obtained from routinely collected, linked health administrative databases in Ontario, Canada. We compared new users of trazodone with new users of atypical antipsychotics (quetiapine, olanzapine or risperidone) between Dec. 1, 2009, and Dec. 31, 2015. The primary outcome was a composite of fall or major osteoporotic fracture within 90 days of first prescription. Secondary outcomes were falls, major osteoporotic fractures, hip fractures and all-cause mortality. RESULTS: We included 6588 older adults dispensed trazodone and 2875 dispensed an atypical antipsychotic, of whom 95.2% received a low dose of these medications. Compared with use of atypical antipsychotics, use of trazodone was associated with similar rates of falls or major osteoporotic fractures (weighted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.73 to 1.07), major osteoporotic fracture (weighted HR 1.03, 95% CI 0.73 to 1.47), falls (weighted HR 0.91, 95% CI 0.75 to 1.11) and hip fractures (weighted HR 0.92, 95% CI 0.59 to 1.43). Use of trazodone was associated with a lower rate of mortality (weighted HR 0.75, 95% CI 0.66 to 0.85). INTERPRETATION: Trazodone is not a uniformly safer alternative to atypical antipsychotics, given the similar risk of falls and fractures among older adults with dementia.

Reporting and evaluating wait times for urgent hip fracture surgery in Ontario, Canada.

BACKGROUND: Although a delay of 24 hours for hip fracture repair is associated with medical complications and costs, it is unknown how long patients wait for surgery for hip fracture. We describe novel methods for measuring exact urgent and emergent surgical wait times (in hours) and the factors that influence them. METHODS: Adults aged 45 years and older who underwent surgery for hip fracture (the most common urgently performed procedure) in Ontario, Canada, between 2009 and 2014 were eligible. Validated data from linked health administrative databases were used. The primary outcome was the time elapsed from hospital arrival recorded in the National Ambulatory Care Reporting System until the time of surgery recorded in the Discharge Abstract Database (in hours). The influence of patient, physician and hospital factors on wait times was investigated using 3-level, hierarchical linear regression models. RESULTS: Among 42 230 patients with hip fracture, the mean (SD) wait time for surgery was 38.76 (28.84) hours, and 14 174 (33.5%) patients underwent surgery within 24 hours. Variables strongly associated with delay included time for hospital transfer (adjusted increase of 26.23 h, 95% CI 25.38 to 27.01) and time for preoperative echocardiography (adjusted increase of 18.56 h, 95% CI 17.73 to 19.38). More than half of the hospitals (37 of 72, 51.4%), compared with 4.8% of surgeons and 0.2% of anesthesiologists, showed significant differences in the risk-adjusted likelihood of delayed surgery. INTERPRETATION: Exact wait times for urgent and emergent surgery can be measured using Canada's administrative data. Only one-third of patients received surgery within the safe time frame (24 h). Wait times varied according to hospital and physician factors; however, hospital factors had a larger impact.

The Cardiovascular Safety of Dutasteride.

PURPOSE: Randomized controlled trials suggest an increased risk of heart failure with dutasteride, which inhibits both the type 1 and type 2 isoforms of 5α-reductase. In contrast, no such association has been suggested for finasteride, which selectively inhibits the type 2 isoform. We investigated the risk of cardiovascular events among patients receiving dutasteride relative to finasteride. MATERIALS AND METHODS: We performed a population based cohort study of Ontario men 66 years old or older who commenced treatment with dutasteride or finasteride between October 1, 2005 and March 31, 2015. For each individual treated with dutasteride, we identified 1 treated with finasteride, matching on a propensity score and calendar quarter of treatment initiation to account for temporal changes in prescribing. The primary outcome was hospitalization for heart failure. Secondary analyses were done to examine acute myocardial infarction and stroke. Cox proportional hazards regression was used to adjust for differences between groups. RESULTS: We studied 36,311 men who commenced dutasteride and 36,311 treated with finasteride. In the primary analysis, we found no difference in the risk of heart failure among patients receiving dutasteride relative to those receiving finasteride (adjusted HR 0.98, 95% CI 0.88-1.08). Similarly, we found no difference in the risk of acute myocardial infarction (HR 0.94, 95% CI 0.82-1.08) or stroke (HR 1.03, 95% CI 0.88-1.20). CONCLUSIONS: In this population based cohort study of more than 72,000 older men, dutasteride was not associated with an increased risk of cardiovascular events relative to finasteride.

Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery.

Importance: Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Objective: To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases. Design, Setting, and Participants: Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). Exposure: Time elapsed from hospital arrival to surgery (in hours). Main Outcomes and Measures: Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia). Results: Among 42 230 patients with hip fracture (mean [SD] age, 80.1 years [10.7], 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 [6.5%] vs 790 [5.8%]; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 [12.2%]) vs 1383 [10.1%]; % absolute RD, 2.16; 95% CI, 1.43-2.89). Conclusions and Relevance: Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.

Prescription Stimulant Use and Hospitalization for Psychosis or Mania: A Population-Based Study.

Small studies suggest that prescription stimulants can precipitate psychosis and mania. We conducted a population-based case-crossover study to examine whether hospitalization for psychosis or mania was associated with initiation of stimulant therapy. Between October 1, 1999 and March 31, 2013, we studied 12,856 young people who received a stimulant prescription and were subsequently hospitalized for psychosis or mania. Of these, 183 commenced treatment during 1 of 2 prespecified 60-day intervals (defined as the "risk interval" and "control interval," respectively) prior to admission. We found that stimulant initiation was associated with an increased risk of hospitalization for psychosis or mania in the subsequent 60 days (odds ratio, 1.86; 95% confidence interval, 1.39-2.56). The risk was marginally higher in patients treated with antipsychotic drugs (odds ratio, 2.06; 95% confidence interval, 1.38-3.28), but remained in patients with no such history (odds ratio, 1.66; 95% confidence interval, 1.09-2.66). One third of subjects received another stimulant prescription after hospital discharge. Of these, 45% were readmitted with psychosis or mania shortly thereafter. We conclude that initiation of prescription stimulants is associated with an increased risk of hospitalization for psychosis or mania. Resumption of therapy is common, which may reflect a lack of awareness of the potential causative role of these drugs.

Peritoneal dialysis catheter implantation by nephrologists is associated with higher rates of peritoneal dialysis utilization: a population-based study.

BACKGROUND: The likelihood of peritoneal dialysis (PD) utilization following a PD catheter insertion attempt is poorly described. We explored the risk factors for PD nonuse, focusing on the method of PD catheter implantation. METHODS: This population-based retrospective cohort study employed Ontario administrative health data to identify 3886 predialysis adults who had an incident PD catheter implantation between 2002 and 2010. The impact of the method of catheter implantation including open-surgical (open, n = 1884), surgical-laparoscopic (laparoscopic, n = 1154), nephrology-percutaneous (nephrology, n = 498) and radiology-percutaneous (radiology, n = 350) on rates of PD utilization (defined as four consecutive weeks of PD) was examined. RESULTS: Eighty-three percent of study patients received PD. After adjustment, relative to patients with openly inserted catheters, PD utilization was greater for those with nephrology-inserted catheters [adjusted hazard ratio (aHR) 1.59, 95% confidence interval (CI) 1.29-1.95] and similar for radiology-inserted catheters [aHR 1.16, 95% CI 0.94-1.43] or laparoscopic-inserted catheters [aHR 0.97 (95% CI 0.86-1.09)]. Among PD nonusers, death occurred in 10% of the open group, 6% of the laparoscopic group, 27% of the radiology group and in fewer than 3% of the nephrology group. Sixty-nine percent received hemodialysis in the open group, 63% in the laparoscopic group, 61% in the radiology group and 88% in the nephrology group. Those remaining predialysis comprised 12% of the open group, 22% of the laparoscopic group, 11% of the radiology group and <3% of the nephrology group. CONCLUSIONS: Nephrology insertion resulted in lower overall rates of PD nonuse, particularly due to death or remaining predialysis. Greater use may be related to insertion timing, technique or greater commitment on the part of nephrologists to the success of PD.

[Mineralogical and spectral characteristics of "Gaozhou stone" from Jiangxi Province].

The seal stone is a kind of artwork with historical and cultural characteristics of China, which has been playing an important role in Chinese traditional culture. "Gaozhou stone", a new kind of the seal stone, has been found in the market recently. To investigate the mineralogical and spectral characterastics of "Gaozhou stone", samples were studied by using XRF, XRD, FTIR, SEM and DTA. Measurements by XRD reveal that kaolin minerals (kaolinite, dickite), pyrophyllite and minor sericite and illite occur in the ores. When kaolinite and dickite are associated, it is not easy to differentiate them from each other. Although some reflections overlap others, kaolin polytypes can be differentiated by XRD patterns in the range 18°-40° (2θ), the reflections at 0. 395, 0. 379, 0. 343, 0. 326, 0. 294, 0. 280, 0. 232 and 0. 221 nm are diagnostic of dickite. The XRD results indicate the presence of transitional mineral of kaolinite and dickite in these samples. The main chemical components of "Gaozhou stone" are SiO2 and Al2O3 with minor Fe2O3, K2O and Na2O, corresponding with that of kaolin minerals. The OH groups in kaolin group minerals have attracted considerable attention as a sensitive indicator of structural disorder. In principle, dickite has three bands, whereas kaolinite has four bands at the OH-stretching region. According to the results of FTIR, transitional mineral of kaolinite and dickite in "Gaozhou stone" has 3 absorption bands of 3 670, 3 650 and 3 620 cm-1 in high frequency region. The intensity of 3 670 cm-1 band that belongs to outer layer hydroxyl vibration is approximately equal to the intensity of 3 620 cm band ascribing to inner layer OH vibration. This value will only have subtle changes due to the different component ratio of kaolinite and dickite layers. Micro-morphology viewed by SEM presents irregular platy or pseudo-hexagonal platy particles with an average diameter of 0. 5-4 µm of "Gaozhou stone". Such morphologies are quite similar to other seal stones of China that the formation environments of all these stones are of the same kind. DTA curves demonstrate that the disparity of dehydroxylation temperature can be seen as a differential feature for identifying kaolin group minerals, but that is not undoubted. And what's more, the size of the mineral grains seems has a greater effect on the disparity of dehydroxylation temperature. This research shows that the mineral type of "Gaozhou stone" is similar to "Four Famous stones of China", and it could be a viable substitute of other famous seal stones. In this point, "Gaozhou stone" has a broad market prospect.