An eHealth Program for Insomnia in Children With Neurodevelopmental Disorders (Better Nights, Better Days): Protocol for an Economic Evaluation of a Randomized Controlled Trial.

BACKGROUND: Children with neurodevelopmental disorders have a high risk of sleep disturbances, with insomnia being the most common sleep disorder (ie, chronic and frequent difficulties with going and staying asleep). Insomnia adversely affects the well-being of these children and their caregivers. Pediatric sleep experts recommend behavioral interventions as the first-line treatment option for children. Better Nights, Better Days for Children with Neurodevelopmental Disorders (BNBD-NDD) is a 5-session eHealth behavioral intervention delivered to parents to improve outcomes (eg, Pediatric Quality of Life Inventory [PedsQL]) for their children (ages 4-12 years) with insomnia and who have a diagnosis of mild to moderate attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, or fetal alcohol spectrum disorder. If cost-effective, BNBD-NDD can be a scalable intervention that provides value to an underserved population. OBJECTIVE: This protocol outlines an economic evaluation conducted alongside the BNBD-NDD randomized controlled trial (RCT) that aims to assess its costs, efficacy, and cost-effectiveness compared to usual care. METHODS: The BNBD-NDD RCT evaluates the impacts of the intervention on children's sleep and quality of life, as well as parents' daytime functioning and psychosocial health. Parent participants were randomized to the BNBD-NDD treatment or to usual care. The economic evaluation assesses outcomes at baseline and 8 months later, which include the PedsQL as the primary measure. Quality of life outcomes facilitate the comparison of competing interventions across different populations and medical conditions. Cost items include the BNBD-NDD intervention and parent-reported usage of private and publicly funded resources for their children's insomnia. The economic evaluation involves a reference case cost-effectiveness analysis to examine the incremental cost of BNBD-NDD per units gained in the PedsQL from the family payer perspective and a cost-consequence analysis from a societal perspective. These analyses will be conducted over an 8-month time horizon. RESULTS: Research funding was obtained from the Kids Brain Health Network in 2015. Ethics were approved by the IWK Health Research Ethics Board and the University of Calgary Conjoint Health Research Ethics Board in January 2019 and June 2022, respectively. The BNBD-NDD RCT data collection commenced in June 2019 and ended in April 2022. The RCT data are currently being analyzed, and data relevant to the economic analysis will be analyzed concurrently. CONCLUSIONS: To our knowledge, this will be the first economic evaluation of an eHealth intervention for insomnia in children with neurodevelopmental disorders. This evaluation's findings can inform users and stakeholders regarding the costs and benefits of BNBD-NDD. TRIAL REGISTRATION: ClinicalTrial.gov NCT02694003; https://clinicaltrials.gov/study/NCT02694003. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46735.

Relationship Between Time-Varying Achieved High-Density Lipoprotein Cholesterol and Risk of Coronary Events Depends on Haptoglobin Phenotype Within the ACCORD Lipid Study.

Background The Hp (haptoglobin)2-2 phenotype (~40% of people) is associated with dysfunctional high-density lipoprotein (HDL) that is heavily oxidized in hyperglycemia, which may explain why raising HDL-cholesterol (HDL-C) does not reliably prevent coronary artery disease (CAD) in diabetes. Methods and Results In this observational study using longitudinal data from the ACCORD (Action to Control Cardiovascular Risk in Diabetes) lipid trial, time-varying (achieved) HDL-C updated at 4, 8, and 12 months, and annually thereafter over a mean of 4.7 years, was analyzed in relation to risk of CAD and secondary outcomes using Cox proportional hazards regression with time-varying covariables among participants with (n=1781) and without (n=3191) the Hp2-2 phenotype. HDL-C did not differ between the phenotypes throughout the study. Having low HDL-C (<40 mg/dL for male participants and <50 mg/dL for female participants) was associated with a greater risk of CAD compared with non-low HDL-C among participants with the non-Hp2-2 phenotype (hazard ratio [HR], 1.48 [95% CI, 1.18-1.87]) but not among the Hp2-2 phenotype (HR, 0.97 [95% CI, 0.70-1.35]; P interaction=0.03). Similarly, an inverse relationship was observed between HDL-C quintiles and CAD risk among participants without the Hp2-2 phenotype, whereas no significant inverse relationship was observed among participants with the Hp2-2 phenotype (P interaction=0.38). Among the Hp2-2 phenotype group, having low HDL-C was associated with higher risk of CVD mortality (HR, 2.09 [95% CI, 1.05-4.13]), and compared with the lowest HDL-C quintile, higher quintiles were associated with lower risk of CVD mortality and congestive heart failure. Conclusions Hp phenotype modified the association between HDL-C and risk of CAD in the ACCORD lipid study, suggesting that HDL dysfunction in the Hp2-2 phenotype may hinder CAD-protective properties of HDL-C.

Validation of Ultrasound Dating Protocols Using Data From Twins Conceived Through In Vitro Fertilization in Nova Scotia: A Retrospective Cohort Study.

OBJECTIVES: Clinical practice guidelines recommend determining gestational age (GA) for twin pregnancies using the fetal crown rump length (CRL) of the larger fetus. This study investigated whether the CRL of the larger or smaller fetus at 11-14 weeks best predicted in vitro fertilization (IVF) assigned GA. METHODS: A retrospective cohort study of twin pregnancies conceived by IVF ± intracytoplasmic sperm injection, 2004-2022, generated GA estimations for each co-twin CRL at the 11-14 week ultrasound, to determine which fetus (smaller or larger) more consistently predicted IVF-assigned GA. Monoamniotic twins and twins with known structural or vascular abnormalities were excluded. Paired t tests evaluated the ability of CRL to predict GA, and logistic regression evaluated the predictive ability of each of the co-twin groups with increasing size differences. Statistical significance was set at P < 0.05. RESULTS: Viewpoint 6 identified 359 eligible twin pairs. CRL was closest with the smaller fetus (0.38 days); CRL for both the smaller (95% CI 0.16-0.61) and the larger (2.25 days, 95% CI 2.04-2.46) fetus showed deviation from IVF-assigned GA. As the absolute difference between the small and large fetus increased, the ultrasound-estimated GA of the smaller fetus was still consistently closer to IVF-assigned GA. CONCLUSIONS: In this selected population of twins with known GA, the CRL of the smaller fetus more accurately predicted IVF-assigned GA even with increasing differences in fetal size. These findings provide important information for appropriately dating pregnancies to facilitate adherence to national guidelines to monitor for pregnancy complications, and plan frequency and type of fetal surveillance, as well as timing of delivery.

Needs and expectations for artificial intelligence in emergency medicine according to Canadian physicians.

BACKGROUND: Artificial Intelligence (AI) is recognized by emergency physicians (EPs) as an important technology that will affect clinical practice. Several AI-tools have already been developed to aid care delivery in emergency medicine (EM). However, many EM tools appear to have been developed without a cross-disciplinary needs assessment, making it difficult to understand their broader importance to general-practice. Clinician surveys about AI tools have been conducted within other medical specialties to help guide future design. This study aims to understand the needs of Canadian EPs for the apt use of AI-based tools. METHODS: A national cross-sectional, two-stage, mixed-method electronic survey of Canadian EPs was conducted from January-May 2022. The survey includes demographic and physician practice-pattern data, clinicians' current use and perceptions of AI, and individual rankings of which EM work-activities most benefit from AI. RESULTS: The primary outcome is a ranked list of high-priority AI-tools for EM that physicians want translated into general use within the next 10 years. When ranking specific AI examples, 'automated charting/report generation', 'clinical prediction rules' and 'monitoring vitals with early-warning detection' were the top items. When ranking by physician work-activities, 'AI-tools for documentation', 'AI-tools for computer use' and 'AI-tools for triaging patients' were the top items. For secondary outcomes, EPs indicated AI was 'likely' (43.1%) or 'extremely likely' (43.7%) to be able to complete the task of 'documentation' and indicated either 'a-great-deal' (32.8%) or 'quite-a-bit' (39.7%) of potential for AI in EM. Further, EPs were either 'strongly' (48.5%) or 'somewhat' (39.8%) interested in AI for EM. CONCLUSIONS: Physician input on the design of AI is essential to ensure the uptake of this technology. Translation of AI-tools to facilitate documentation is considered a high-priority, and respondents had high confidence that AI could facilitate this task. This study will guide future directions regarding the use of AI for EM and help direct efforts to address prevailing technology-translation barriers such as access to high-quality application-specific data and developing reporting guidelines for specific AI-applications. With a prioritized list of high-need AI applications, decision-makers can develop focused strategies to address these larger obstacles.

Novel inflammatory mediator profile observed during pediatric heart surgery with cardiopulmonary bypass and continuous ultrafiltration.

BACKGROUND: Cardiopulmonary bypass (CPB) is associated with systemic inflammation, featuring increased levels of circulating pro-inflammatory cytokines. Intra-operative ultrafiltration extracts fluid and inflammatory factors potentially dampening inflammation-related organ dysfunction and enhancing post-operative recovery. This study aimed to define the impact of continuous subzero-balance ultrafiltration (SBUF) on circulating levels of major inflammatory mediators. METHODS: Twenty pediatric patients undergoing cardiac surgery, CPB and SBUF were prospectively enrolled. Blood samples were collected prior to CPB initiation (Pre-CPB Plasma) and immediately before weaning off CPB (End-CPB Plasma). Ultrafiltrate effluent samples were also collected at the End-CPB time-point (End-CPB Effluent). The concentrations of thirty-nine inflammatory factors were assessed and sieving coefficients were calculated. RESULTS: A profound increase in inflammatory cytokines and activated complement products were noted in plasma following CBP. Twenty-two inflammatory mediators were detected in the ultrafiltrate effluent. Novel mediators removed by ultrafiltration included cytokines IL1-Ra, IL-2, IL-12, IL-17A, IL-33, TRAIL, GM-CSF, ET-1, and the chemokines CCL2, CCL3, CCL4, CXCL1, CXCL2 and CXCL10. Mediator extraction by SBUF was significantly associated with molecular mass < 66 kDa (Chi2 statistic = 18.8, Chi2 with Yates' correction = 16.0, p < 0.0001). There was a moderate negative linear correlation between molecular mass and sieving coefficient (Spearman R = - 0.45 and p = 0.02). Notably, the anti-inflammatory cytokine IL-10 was not efficiently extracted by SBUF. CONCLUSIONS: CPB is associated with a burden of circulating inflammatory mediators, and SBUF selectively extracts twenty of these pro-inflammatory factors while preserving the key anti-inflammatory regulator IL-10. Ultrafiltration could potentially function as an immunomodulatory therapy during pediatric cardiac surgery. Trial registration ClinicalTrials.gov, NCT05154864. Registered retrospectively on December 13, 2021. https://clinicaltrials.gov/ct2/show/record/NCT05154864 .

The Prevalence of Pregnancy-Specific Perinatal Anxiety in Nova Scotia.

OBJECTIVES: Pregnancy-Specific Perinatal Anxiety (PSPA) is an understudied mental health condition of pregnancy that may affect maternal-fetal health outcomes. The purpose of this study was to determine the prevalence of PSPA among pregnant women in the province of Nova Scotia, Canada, as well as the factors associated with it. METHODS: A sample of 90 pregnant women provided data on PSPA symptomology and demographic co-variables via a self-report online survey. The prevalence of PSPA in the sample was calculated and bivariate statistics and binomial logistic regression were conducted to assess the relationship between the presence of PSPA and the independent variables. RESULTS: The prevalence of PSPA in our sample was 17.8%. Smoking during pregnancy and a pre-pregnancy diagnosis of anxiety were significantly associated with meeting the criteria for PSPA (p = 0.008 and p = 0.013, respectively) and strongly predicted the presence of PSPA (odds ratio 8.54 and 3.44, respectively). CONCLUSIONS FOR PRACTICE: A significant proportion of participants in our sample experienced symptoms consistent with a diagnosis of PSPA. This underscores the importance of further research on PSPA as a unique phenomenon in pregnant women, and the impact it may have on fetal and maternal health outcomes. A greater clinical emphasis should be placed on screening for and treating mental health conditions of pregnancy, including PSPA.

Anxiety in pregnancy affects maternal, fetal, and child health outcomes. A distinction ­ in terms of definition and diagnostic criteria ­ exists between generalized anxiety disorder (GAD) affecting pregnant women and pregnancy-specific perinatal anxiety (PSPA). The latter is a condition that has been identified as affecting pregnant women uniquely and with distinct clinical impact, but few studies have made effort to distinguish it from GAD when studying its prevalence and impact on health. This study examines the prevalence of PSPA exclusively and the variables associated with it to provide insight on the importance of this distinct clinical phenomena.

Cardiovascular Outcomes in Nova Scotia During the Early Phase of the COVID-19 Pandemic.

BACKGROUND: This study sought to determine the impact of the COVID-19 pandemic response to healthcare delivery on outcomes in patients with cardiovascular disease. METHODS: This is a population-based cohort study performed in the province of Nova Scotia, Canada (population 979,499), between the pre-COVID (March 1, 2017-March 16, 2020) and in-COVID (March 17, 2020-December 31, 2020) periods. Adult patients (age ≥ 18 years) with new-onset or existing cardiovascular disease were included for comparison between periods. The main outcome measures included the following: cardiovascular emergency department visits or hospitalizations, mortality, and out-of-hospital cardiac arrest. RESULTS: In the first month of the in-COVID period, emergency department visits (n = 51,750) for cardiac symptoms decreased by 20.8% (95% confidence interval [CI] 14.0%-27.0%, P < 0.001). Cardiovascular hospitalizations (n = 20,609) declined by 48.1% (95% CI 40.4% to 54.9%, P < 0.001). The in-hospital mortality rate increased in patients with cardiovascular admissions in secondary care institutions by 55.1% (95% CI 10.1%-118%, P = 0.013). A decline of 20.4%-44.0% occurred in cardiovascular surgical/interventional procedures. The number of out-of-hospital cardiac arrests (n = 5528) increased from a monthly mean of 115 ± 15 to 136 ± 14, beginning in May 2020. Mortality for ambulatory patients awaiting cardiac intervention (n = 14,083) increased from 0.16% (n = 12,501) to 2.49% (n = 361) in the in-COVID period (P < 0.0001). CONCLUSIONS: This study demonstrates increased cardiovascular morbidity and mortality during restrictions maintained during the COVID-19 period, in an area with a low burden of COVID-19. As the healthcare system recovers or enters subsequent waves of COVID-19, these findings should inform communication to the public regarding cardiovascular symptoms, and policy for delivery of cardiovascular care.

CONTEXTE: Cette étude visait à déterminer les répercussions de la réponse à la pandémie de COVID-19 sur la prestation des soins de santé et son incidence sur les résultats obtenus par les patients atteints d'une maladie cardiovasculaire. MÉTHODOLOGIE: Il s'agit d'une étude de cohorte représentative de la population réalisée dans la province de la Nouvelle-Écosse, au Canada (population de 979 499 habitants), entre la période précédant le début de la pandémie de COVID-19 (du 1er mars 2017 au 16 mars 2020) et la période de pandémie (du 17 mars 2020 au 31 décembre 2020). Des patients adultes (âge ≥ 18 ans) atteints d'une maladie cardiovasculaire préexistante ou d'apparition récente ont été inclus pour la comparaison entre les périodes. Les principaux paramètres d'évaluation comprenaient les visites ou hospitalisations dans un service d'urgences cardiovasculaires, la mortalité et l'arrêt cardiaque en milieu extrahospitalier. RÉSULTATS: Au cours du premier mois de la période de pandémie, les visites aux services des urgences (n = 51 750) pour des symptômes cardiaques ont diminué de 20,8 % (intervalle de confiance [IC] à 95 % : 14,0 % ­ 27,0 %, p < 0,001). Les hospitalisations en raison d'un événement cardiovasculaire (n = 20 609) ont décliné de 48,1 % (IC à 95 % : 40,4 % ­ 54,9 %, p < 0,001). Le taux de mortalité hospitalière parmi les patients admis dans des établissements de soins secondaires a augmenté de 55,1 % (IC à 95 % : 10,1 % ­ 118 %, p = 0,013). Une baisse de 20,4 à 44,0 % du nombre d'interventions chirurgicales ou interventionnelles visant à prendre en charge un événement cardiovasculaire a également été enregistrée. Le nombre d'arrêts cardiaques survenus en milieu extrahospitalier (n = 5 528) est passé d'une moyenne mensuelle de 115 ± 15 à 136 ± 14, à compter de mai 2020. La mortalité des patients ambulatoires en attente d'une intervention cardiaque (n = 14 083) a augmenté, passant de 0,16 % (n = 12 501) à 2,49 % (n = 361) pendant la période de pandémie (p < 0,0001). CONCLUSIONS: Cette étude révèle une augmentation de la morbidité et de la mortalité cardiovasculaires durant le maintien des restrictions liées à la COVID-19 dans une région où le fardeau associé à cette maladie est faible. À mesure que le système de santé se rétablit ou affronte les vagues subséquentes de COVID-19, ces résultats devraient éclairer les communications au public concernant les symptômes cardiovasculaires et orienter la politique de prestation de soins cardiovasculaires.

Haptoglobin Phenotype Modifies the Effect of Fenofibrate on Risk of Coronary Event: ACCORD Lipid Trial.

OBJECTIVE: The haptoglobin (Hp)2-2 phenotype (∼35-40% of people) is associated with increased oxidation and dysfunctional HDL in hyperglycemia and may explain why drugs designed to pharmacologically raise HDL cholesterol and lower triglycerides have not reliably prevented cardiovascular disease in diabetes. We aimed to determine whether the effect of adding fenofibrate versus placebo to simvastatin on the risk of coronary artery disease (CAD) events depends on Hp phenotype in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) lipid trial. RESEARCH DESIGN AND METHODS: Cox proportional hazards regression models quantified the relationship between fenofibrate therapy and CAD events in the ACCORD lipid trial in participants with the Hp2-2 phenotype (n = 1,795) separately from those without (n = 3,201). RESULTS: Fenofibrate therapy successfully lowered the risk of CAD events in participants without the Hp2-2 phenotype (multivariable adjusted hazard ratio 0.74 [95% CI 0.60-0.90] compared with no fenofibrate therapy) but not in participants with the Hp2-2 phenotype (1.16 [0.87-1.56]; P interaction = 0.009). Subgroup analyses revealed that this protective effect of fenofibrate against CAD events among the non-Hp2-2 phenotype group was pronounced in participants with severe dyslipidemia (P interaction = 0.01) and in males (P interaction = 0.02) with an increased CAD risk from fenofibrate treatment observed in females with the Hp2-2 phenotype (P interaction = 0.002). CONCLUSIONS: The effect of fenofibrate added to simvastatin on risk of CAD events depends on Hp phenotype in the ACCORD lipid trial.

Exploring the health care utilization of children and youth in the care of child welfare: a retrospective matched cohort study.

BACKGROUND: Children and youth whose lives intersect with child welfare systems are amongst the most vulnerable paediatric populations. Despite the increased rates of chronic conditions, these children and youth often experience unmet health care needs. OBJECTIVES: To examine patterns of health care utilization from birth for children and youth in the care of a child welfare authority. METHODS: This retrospective matched cohort design study examined children/youth aged 0-18 who had visited a paediatric tertiary care facility from 2016 April 1 to 2017 March 31 and had "social worker" documented as their guardian. A control cohort was matched based on age and sex. Primary outcomes of interest included primary health care, emergency, outpatient, and inpatient visits. Visits for immunizations, physiological development, well-baby checks, mental health, and oral health were also examined. RESULTS: A total of 200 cases and 200 controls were included in our cohort. No statistically significant differences were found between primary care visits, well-baby checks, inpatient admissions, outpatient mental health visits, or immunizations for children in care in comparison to their controls. There was a significant difference in oral health visits, lack of physiological development, and emergency department visits for children in care when compared to their controls. CONCLUSIONS: Our study revealed disparities in health care utilization amongst children in the care of child welfare in comparison to those who are not, highlighting the need for improved practice, policy, and research initiatives. A collaborative data collection/sharing system is needed to identify and track the health care of this vulnerable population.

Children and youth whose lives intersect with child welfare systems are amongst the most vulnerable pediatric populations. Despite the increased rates of chronic health conditions, these children and youth often experience unmet health care needs. Using a retrospective matched cohort design, we sought to examine patterns of health care utilization from birth to age 18 for children and youth in the care of a child welfare authority in comparison to children/youth who were not in the care of child welfare. No statistically significant differences were found between primary care visits, well-baby checks, inpatient admissions, outpatient mental health visits, or immunizations for children in care when compared to their counterparts not in care. There was a significantly higher number of oral health visits, physiological development concerns, and emergency department visits for children in care when compared to their controls. Our study revealed differences in health care use amongst children in the care of a child welfare in comparison to those who are not, highlighting the need for improved practice, policy and research initiatives. A collaborative data collection and sharing system is needed to help accurately identify and track the health care use of this vulnerable population.

Prediction of Hospitalizations in Systemic Lupus Erythematosus Using the Systemic Lupus International Collaborating Clinics Frailty Index.

OBJECTIVE: The Systemic Lupus International Collaborating Clinics (SLICC) frailty index (FI) predicts mortality and damage accrual in systemic lupus erythematosus (SLE), but its association with hospitalizations has not been described. Our objective was to estimate the association of baseline SLICC-FI values with future hospitalizations in the SLICC inception cohort. METHODS: Baseline SLICC-FI scores were calculated. The number and duration of inpatient hospitalizations during follow-up were recorded. Negative binomial regression was used to estimate the association between baseline SLICC-FI values and the rate of hospitalizations per patient-year of follow-up. Linear regression was used to estimate the association of baseline SLICC-FI scores with the proportion of follow-up time spent in the hospital. Multivariable models were adjusted for relevant baseline characteristics. RESULTS: The 1,549 patients with SLE eligible for this analysis were mostly female (88.7%), with a mean ± SD age of 35.7 ± 13.3 years and a median disease duration of 1.2 years (interquartile range 0.9-1.5) at baseline. Mean ± SD baseline SLICC-FI was 0.17 ± 0.08. During mean ± SD follow-up of 7.2 ± 3.7 years, 614 patients (39.6%) experienced 1,570 hospitalizations. Higher baseline SLICC-FI values (per 0.05 increment) were associated with more frequent hospitalizations during follow-up, with an incidence rate ratio of 1.21 (95% confidence interval [95% CI] 1.13-1.30) after adjustment for baseline age, sex, glucocorticoid use, immunosuppressive use, ethnicity/location, SLE Disease Activity Index 2000 score, SLICC/American College of Rheumatology Damage Index score, and disease duration. Among patients with ≥1 hospitalization, higher baseline SLICC-FI values predicted a greater proportion of follow-up time spent hospitalized (relative rate 1.09 [95% CI 1.02-1.16]). CONCLUSION: The SLICC-FI predicts future hospitalizations among incident SLE patients, further supporting the SLICC-FI as a valid health measure in SLE.

Environmental Correlates of Physical Activity, Sedentary Behavior, and Self-Rated Health in Chronic Obstructive Pulmonary Disease.

PURPOSE: Physical activity (PA) predicts important health outcomes in chronic obstructive pulmonary disease (COPD). In the general population, environmental factors have the potential to influence PA; however, data are limited in this clinical population. Therefore, we sought to investigate associations between the environment and PA, sedentary behavior, and self-rated health in COPD. METHODS: Sociodemographic, PA, sedentary behavior, and self-rated health data were collected from a prospective cohort of 418 individuals with COPD (65% female; 58 ± 8 yr), while environmental data were drawn from a national environmental data repository and individually matched to participant postal code. Environmental variables included social and material deprivation, urban form index, surrounding greenness, and air quality (concentrations of air pollution for fine particles, nitrogen dioxide, ozone, and sulphur dioxide). Logistic and multivariate linear regression models were used to investigate the strongest environmental predictors. RESULTS: The models showed a statistically significant negative correlation between PA level and ozone pollution (P = .023; adjusted OR = 0.85: 95% CI, 0.74-0.98). Urban form index was also significantly associated with sedentary behavior (ß = 0.113; t value = 1.71; P = .011). Self-rated health was significantly positively correlated with PA level (P = .006; adjusted OR = 2.22: 95% CI, 1.25-3.94), and significantly inversely correlated with sedentary behavior (ß = -0.159; t value =-2.42; P = .016). CONCLUSION: These new data may identify barriers to PA and assist clinicians in the prescription of exercise for individuals living with COPD.

Comorbidity and persistence of disease-modifying therapy use in relapsing remitting multiple sclerosis.

BACKGROUND: Comorbidity decreases the likelihood of initiating disease-modifying therapy (DMT) for multiple sclerosis (MS). Our objective was to characterize the relationship between comorbidity and initial DMT persistence along with reasons for DMT discontinuation. METHODS: We identified individuals with relapsing remitting MS or clinically isolated syndrome starting a platform DMT (interferon-ß, glatiramer acetate, dimethyl fumarate, teriflunomide) as initial therapy in the Canadian province of Nova Scotia from 2001 to 2016. Cases were identified using a clinic database for the only clinic providing specialty MS care in a province with universal publicly-funded health care. Comorbidity was determined by linkage of MS cases to provincial health administrative data using validated case definitions for mental health disorder, hypertension, hyperlipidemia, diabetes, chronic lung disease, ischemic heart disease, epilepsy, and inflammatory bowel disease. Cox proportional hazards models explored the relationship between comorbidity, as a count or individual comorbidities, and time to discontinuation of initial DMT. Logistic regression models explored reasons for DMT discontinuation. RESULTS: Among 1464 individuals starting platform therapy as initial DMT, the median duration on first DMT was 4 years (95% CI 4 - 4). Comorbidity count (0, 1, ≥2) was not associated with time to discontinuation of initial DMT. However, the presence of a mental health disorder was associated with an increased hazard of discontinuing DMT (hazard ratio 1.22, 95% CI 1.03-1.44). Comorbidity count was not associated with discontinuation for lack of efficacy or lack of tolerability after adjusting for covariates. CONCLUSION: Individuals with mental health comorbidity may have unique challenges that affect persistence on DMT after treatment initiation.

Children's Sleep During COVID-19: How Sleep Influences Surviving and Thriving in Families.

OBJECTIVE: The COVID-19 pandemic has the potential to disrupt the lives of families and may have implications for children with existing sleep problems. As such, we aimed to: (1) characterize sleep changes during the COVID-19 pandemic in children who had previously been identified as having sleep problems, (2) identify factors contributing to sleep changes due to COVID-19 safety measures, and (3) understand parents' and children's needs to support sleep during the pandemic. METHODS: Eighty-five Canadian parents with children aged 4-14 years participated in this explanatory sequential, mixed-methods study using an online survey of children's and parents' sleep, with a subset of 16 parents, selected based on changes in their children's sleep, participating in semi-structured interviews. Families had previously participated in the Better Nights, Better Days (BNBD) randomized controlled trial. RESULTS: While some parents perceived their child's sleep quality improved during the COVID-19 pandemic (14.1%, n = 12), many parents perceived their child's sleep had worsened (40.0%, n = 34). Parents attributed children's worsened sleep to increased screen time, anxiety, and decreased exercise. Findings from semi-structured interviews highlighted the effect of disrupted routines on sleep and stress, and that stress reciprocally influenced children's and parents' sleep. CONCLUSIONS: The sleep of many Canadian children was affected by the first wave of the COVID-19 pandemic, with the disruption of routines influencing children's sleep. eHealth interventions, such as BNBD with modifications that address the COVID-19 context, could help families address these challenges.

Potential of community-based risk estimates for improving hospital performance measures and discharge planning.

BACKGROUND: Risk-adjusted rates of hospital readmission are a common indicator of hospital performance. There are concerns that current risk-adjustment methods do not account for the many factors outside the hospital setting that can affect readmission rates. Not accounting for these external factors could result in hospitals being unfairly penalized when they discharge patients to communities that are less able to support care transitions and disease management. While incorporating adjustments for the myriad of social and economic factors outside of the hospital setting could improve the accuracy of readmission rates as a performance measure, doing so has limited feasibility due to the number of potential variables and the paucity of data to measure them. This paper assesses a practical approach to addressing this problem: using mixed-effect regression models to estimate case-mix adjusted risk of readmission by community of patients' residence (community risk of readmission) as a complementary performance indicator to hospital readmission rates. METHODS: Using hospital discharge data and mixed-effect regression models with a random intercept for community, we assess if case-mix adjusted community risk of readmission can be useful as a quality indicator for community-based care. Our outcome of interest was an unplanned repeat hospitalisation. Our primary exposure was community of residence. RESULTS: Community of residence is associated with case-mix adjusted risk of unplanned repeat hospitalisation. Community risk of readmission can be estimated and mapped as indicators of the ability of communities to support both care transitions and long-term disease management. CONCLUSION: Contextualising readmission rates through a community lens has the potential to help hospitals and policymakers improve discharge planning, reduce penalties to hospitals, and most importantly, provide higher quality care to the people that they serve.

Prediction of Damage Accrual in Systemic Lupus Erythematosus Using the Systemic Lupus International Collaborating Clinics Frailty Index.

OBJECTIVE: The Systemic Lupus International Collaborating Clinics (SLICC) frailty index (FI) has been shown to predict mortality, but its association with other important outcomes is unknown. We examined the association of baseline SLICC FI values with damage accrual in the SLICC inception cohort. METHODS: The baseline visit was defined as the first visit at which both organ damage (SLICC/American College of Rheumatology Damage Index [SDI]) and health-related quality of life (Short Form 36) were assessed. Baseline SLICC FI scores were calculated. Damage accrual was measured by the increase in SDI between the baseline assessment and the last study visit. Multivariable negative binomial regression was used to estimate the association between baseline SLICC FI values and the rate of increase in the SDI during follow-up, adjusting for relevant demographic and clinical characteristics. RESULTS: The 1,549 systemic lupus erythematosus (SLE) patients eligible for this analysis were mostly female (88.7%) with a mean ± SD age of 35.7 ± 13.3 years and a median disease duration of 1.2 years (interquartile range 0.9-1.5 years) at baseline. The mean ± SD baseline SLICC FI was 0.17 ± 0.08. Over a mean ± SD follow-up of 7.2 ± 3.7 years, 653 patients (42.2%) had an increase in SDI. Higher baseline SLICC FI values (per 0.05 increase) were associated with higher rates of increase in the SDI during follow-up (incidence rate ratio [IRR] 1.19 [95% confidence interval 1.13-1.25]), after adjusting for age, sex, ethnicity/region, education, baseline SLE Disease Activity Index 2000, baseline SDI, and baseline use of glucocorticoids, antimalarials, and immunosuppressive agents. CONCLUSION: Our findings indicate that the SLICC FI predicts damage accrual in incident SLE, which further supports the SLICC FI as a valid health measure in SLE.

Construction of a Frailty Index as a Novel Health Measure in Systemic Lupus Erythematosus.

OBJECTIVE: To construct a Frailty Index (FI) as a measure of vulnerability to adverse outcomes among patients with systemic lupus erythematosus (SLE), using data from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort. METHODS: The SLICC inception cohort consists of recently diagnosed patients with SLE followed annually with clinical and laboratory assessments. For this analysis, the baseline visit was defined as the first study visit at which sufficient information was available for construction of an FI. Following a standard procedure, variables from the SLICC database were evaluated as potential health deficits. Selected health deficits were then used to generate a SLICC-FI. The prevalence of frailty in the baseline dataset was evaluated using established cutpoints for FI values. RESULTS: The 1683 patients with SLE (92.1% of the overall cohort) eligible for inclusion in the baseline dataset were mostly female (89%) with mean (SD) age 35.7 (13.4) years and mean (SD) disease duration 18.8 (15.7) months at baseline. Of 222 variables, 48 met criteria for inclusion in the SLICC-FI. Mean (SD) SLICC-FI was 0.17 (0.08) with a range from 0 to 0.51. At baseline, 27.1% (95% CI 25.0-29.2) of patients were classified as frail, based on SLICC-FI values > 0.21. CONCLUSION: The SLICC inception cohort permits feasible construction of an FI for use in patients with SLE. Even in a relatively young cohort of patients with SLE, frailty was common. The SLICC-FI may be a useful tool for identifying patients with SLE who are most vulnerable to adverse outcomes, but validation of this index is required prior to its use.

Assessment of Current Mental Health Status in a Population-Based Sample of Canadian Men With and Without a History of Prostate Cancer Diagnosis: An Analysis of the Canadian Longitudinal Study on Aging (CLSA).

Background: Small-scale studies indicate an increase in mental health disorders among prostate cancer survivors compared to the general population, but large population-based data assessing this relationship are scarce. The present study examined the prevalence of lifetime history of prostate cancer in a cross-sectional sample of Canadian men and assessed the contribution of lifetime history of a prostate cancer diagnosis, multimorbidity, and current alcohol and smoking status to the association with current mental health outcomes in this population. Methods: The analytical sample included 25,183 men (aged 45 to 85 years old), who completed a survey as part of the Canadian Longitudinal Study on Aging (CLSA). The Center for Epidemiological Studies Depression Scale (CES-D10), Kessler's Psychological Distress Scale (K10), and self-reported mental health were mental health outcomes. Multiple logistic regression analyses, and controlling for the complexity of the design and covariates, evaluated the association between prostate cancer survivorship, multimorbidity, alcohol and smoking status, and current mental health outcomes. Results: The prevalence of lifetime history of prostate cancer diagnosis in this population-based sample of men was 4% (95% CI: 3.7, 4.4). Our results indicate statistically significantly higher odds of current psychological distress (aOR = 1.52, 95% CI: 1.09, 2.11) and screening positive for depression (aOR = 1.24; 95% CI: 1.02, 1.51) among survivors of prostate cancer, compared to men without a history of prostate cancer diagnosis in demographics controlled analyses. After addition of multimorbidity and substance use, the odds of screening positive for depression among survivors of prostate cancer are 1.32 (95% CI: 1.06, 1.64) higher compared to men who never had a history of prostate cancer diagnosis. Interpretation: Patient education and empowerment programs aimed at addressing concerns during the diagnosis and treatment and enhancing survivorship care plans by adding routine screening for mental distress to help survivors overcome poor mental health during the cancer survivorship journey, are warranted.

Does the inclusion of vehicle impoundment in provincial short-term administrative driver's license suspension programs reduce total and alcohol-related fatal collisions in Canada?

Objectives: To determine (1) whether the implementation of vehicle impoundment as part of provincial short-term administrative driver licensing suspension (ADLS) programs significantly reduced total and alcohol-related collision fatalities, and (2) if provinces with vehicle impoundment as part of their short-term ADLS programs see greater reductions in total and alcohol-related fatal collisions when compared to provinces without a vehicle impoundment law.Methods: Data on monthly total and alcohol-related fatal collisions from January 2005 to December 2016 are drawn from British Columbia (BC), Alberta (AB), Saskatchewan (SK), Manitoba (MB) and Ontario (ON). Changepoint time series analysis of fatal crashes is employed to detect within-province differences after implementing short-term impoundment programs, and between province differences comparing provinces with short-term impoundment programs (BC, introduced October 2010; AB, introduced July 2012; and SK, introduced July 2014) and those without (ON and MB). Outcome measures are the monthly per capita total and alcohol-related fatal collisions.Results: A significant reduction in per-capita alcohol-related fatal crashes was observed in British Columbia (-47.4%) in the period following the adoption of vehicle impoundment in their short-term ADLS. A significant decrease was also observed in Alberta (-37.5%), though this trend began prior to policy change; no significant effect was observed in per capita alcohol-related fatal crashes rates in Saskatchewan (-6.1%) in the two years following the introduction of vehicle impoundment. Ontario and Manitoba, two provinces without mandatory vehicle impoundment laws, also experienced significant reductions in per-capita alcohol-related fatal crashes between 2005 and 2016 (-36.4% and -35%, respectively).Conclusions: While mandatory vehicle impoundment programs for driving in the "warn" range (0.05%-0.08% BAC) have shown success in reducing fatal crashes in British Columbia, similar reductions in two other provinces with short-term vehicle impoundment were not observed. Moreover, large reductions in fatal crashes were observed in two provinces without vehicle impoundment as part of their short-term ADLS programs. Collectively, these findings suggest that vehicle impoundment, alone, has limited impact on fatal crash rates and that other factors help to explain the observed trends. Further analysis of new vehicle impoundment programs is warranted.

Severe Respiratory Syncytial Virus Infection in Preterm Infants and Later Onset of Asthma.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of viral lower respiratory tract infections in infants. Preterm infants are at increased risk for hospitalization with RSV (RSV-H), but there are few data on the relationship between RSV-H and asthma in preterm infants, or any data stratified by gestational age, and most studies have short follow-up periods. We sought to evaluate the relationship between serious RSV illness and onset of asthma up to 5 years of age in a cohort of preterm children and to quantify this association. METHODS: A retrospective birth cohort of preterm infants (29 weeks 0 days to 35 weeks 6 days gestational age) was constructed from a provincial population-based database, and children were followed forward for 5 years. Incidence rates of RSV-H and asthma were determined. In a Cox proportional hazards model, controlled for putative confounding factors for asthma, the hazard ratio and 95% CI of asthma in children with and without RSV-H was evaluated. RESULTS: Among 3916 premature children, the incidence rate of RSV-H was 25/1000 infants. The cumulative incidence rate of asthma at 5 years of age in children with RSV-H was 57.9/1000 person-years compared with 36.7 in those without RSV-H; the adjusted hazards ratio for asthma in RSV-H infants was elevated at 1.58 (95% CI: 1.03-2.41). CONCLUSIONS: In prematurely born children, there is a moderate association between severe RSV infection, as measured by RSV-H in the first year of life, and asthma up to 5 years of age.