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Purpose: Patient-reported outcome measures (PROMs) such as the Neurological Disorders Depression Inventory in Epilepsy (NDDI-E), a 6-item epilepsy-specific PROM, is used to screen for major depressive disorder symptoms for patients with epilepsy (PWE). The validity and interpretation of PROMs can be affected by differential item functioning (DIF), which occurs when subgroups of patients with the same underlying health status respond to and interpret questions about their health status differently. This study aims to determine whether NDDI-E items exhibit DIF and to identify subgroups of PWE that exhibit DIF in NDDI-E items. Methods: Data were from the Calgary Comprehensive Epilepsy Program database, a clinical registry of adult PWE in Calgary, Canada. A tree-based partial credit model based on recursive partitioning (PCTree) was used to identify subgroups that exhibit DIF on NDDI-E items using patients' characteristics as covariates. Differences in the identified subgroups were characterized using multinomial logistic regression. Results: Of the 1,576 patients in this cohort, 806 (51.1%) were female, and the median age was 38.0 years. PCTree identified four patient subgroups defined by employment status, age, and sex. Subgroup 1 were unemployed patients ≤ 26 years old, subgroup 2 were unemployed patients > 26 years, subgroup 3 were employed females, while subgroup 4 were employed male patients. The subgroups exhibited significant differences on education level, comorbidity index scores, marital status, type of epilepsy, and driving status. Conclusion: PWE differed in their interpretation and responses to questions about their depression symptoms, and these differences were a function of sociodemographic and clinical characteristics. Plain English summary: Patient-reported depression screening measures are prone to differential item functioning (DIF), which occurs when patients with the same levels of depression respond to and interpret the questions on the measures differently, as a result of different socio-demographic characteristics. Heterogeneity in how epilepsy patients interpret and respond to depression measures, if not identified, could lead to measurement biases that threaten the validity of inferences from patient-reported outcome measure scores to inform clinical and healthcare decisions for epilepsy management. Using data from a clinical registry of patients with epilepsy, the tree-based item response theory model was used to examine the presence of DIF in the items comprising the patient-reported Neurological Disorders Depression Inventory in Epilepsy (NDDI-E) scale. Four subgroups of epilepsy patients were noted to exhibit DIF on NDDI-E items. These groups were defined by interactions among employment status, age and sex. These characteristics affect the interpretation of NDDI-E item scores. It is recommended that clinicians carefully scrutinize responses to individual items alongside the overall NDDI-E score in different patient groups to inform clinical decisions for epilepsy management. [ABSTRACT FROM AUTHOR]

Objectives: Adolescents and young adults (AYAs, 18–39 years) with cancer identifying as racially/ethnically minoritized or 2SLGBTQIA+ (Two‐Spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual and "+" referring to other queer identities) have been underrepresented in cancer research. This study explores the aspects of identity that hold significance for these minoritized AYAs and how these facets impact their healthcare experiences. Methods: Eligible participants comprised English‐speaking AYAs who self‐identified as racially/ethnically minoritized and/or 2SLGBTQIA+, were diagnosed with cancer between the ages of 15–39, currently aged > 18, and had received or were receiving cancer care within Canadian healthcare system. Additionally, four patient partners meeting the same criteria were recruited as research collaborators. Semi‐structured one‐on‐one virtual interviews guided by an interview script were conducted, and qualitative analysis employed a framework approach. Results: We recruited 23 participants from 4 Canadian provinces (mean age: 28, Range: 20–44); 17 identified as racially/ethnically minoritized, one as sexual/gender minoritized, and five as racially/ethnically and sexually/gender minoritized. Participants emphasized that their culture/ethnicity, religion/spirituality, sexuality, gender, family, career, and being an immigrant are important aspects of their identity, with only one participant recognizing their identity as a "person with cancer". A cancer diagnosis altered the aspects of identity deemed most significant by participants. Both visible and invisible aspects of identity shaped participants' experiences and influenced their level of trust in the healthcare system. Conclusion: Racially, ethnically, gender, or sexually minoritized AYAs with cancer place considerable importance on aspects of their identity that are shaped by their respective communities. Recognizing and respecting these identities are paramount for healthcare professionals to deliver safe and inclusive care. [ABSTRACT FROM AUTHOR]

Summary: We found that a standardized order set after hip fracture increased initiation of anti-osteoporosis medication and increased persistence at 1 year, but did not reduce secondary fractures. Background: A treatment gap exists after osteoporosis-related fractures. Introducing standardized care can improve treatment. We evaluated the impact of a hip fracture order set (OS) on anti-osteoporosis medication (AOM) initiation, persistence, and secondary fracture prevention. Methods: In 2015, one hospital in Manitoba, Canada, introduced a hip fracture OS including recommendations for the initiation of AOM (OS group). A control group was identified from the other hospitals in the same region. A retrospective cohort study was conducted using linked administrative health data. All individuals 50 + years with surgical treatment for low-energy hip fracture between 2010 and 2019 were included and followed for AOM initiation, medication persistence at 1 year, and secondary fractures. Between-group differences for each year were assessed using chi-square tests. Logistic regression models tested the impact of socio-demographic and clinical factors on initiation, persistence of AOM. Cox regression tested the risk of secondary fracture. Results: No baseline differences between OS group (813 patients) and control group (2150 patients) were observed in demographics, socioeconomic factors, or comorbidities. An increase in post-fracture AOM initiation was seen with OS introduction (OS group year before 16.7% versus year after 48.6%, p < 0.001). No change was seen in the control group. Persistence on AOM also increased (OS group year before 17.7% versus year after 28.4%, p < 0.001). No difference in secondary fractures was observed (OS group 19.8% versus control group 18.8%, p = 0.38). Conclusion: Introduction of a hip fracture OS significantly increased AOM initiation and persistence at 1-year post-fracture. There was no significant difference in secondary fractures. [ABSTRACT FROM AUTHOR]

Background: We estimated the short-term effects of an educational workshop and 10-week outdoor walk group (OWG) compared to the workshop and 10 weekly reminders (WR) on increasing outdoor walking (primary outcome) and walking capacity, health-promoting behavior, and successful aging defined by engagement in meaningful activities and well-being (secondary outcomes) in older adults with difficulty walking outdoors. Methods: In a 4-site, parallel-group randomized controlled trial, two cohorts of community-living older adults (≥ 65 years) reporting difficulty walking outdoors participated. Following a 1-day workshop, participants were stratified and randomized to a 10-week OWG in parks or 10 telephone WR reinforcing workshop content. Masked evaluations occurred at 0, 3, and 5.5 months. We modeled minutes walked outdoors (derived from accelerometry and global positioning system data) using zero-inflated negative binomial regression with log link function, imputing for missing observations. We modeled non-imputed composite measures of walking capacity, health-promoting behavior, and successful aging using generalized linear models with general estimating equations based on a normal distribution and an unstructured correlation matrix. Analyses were adjusted for site, participation on own or with a partner, and cohort. Results: We randomized 190 people to the OWG (n = 98) and WR interventions (n = 92). At 0, 3, and 5.5 months, median outdoor walking minutes was 22.56, 13.04, and 0 in the OWG, and 24.00, 26.07, and 0 in the WR group, respectively. There was no difference between groups in change from baseline in minutes walked outdoors based on incidence rate ratio (IRR) and 95% confidence interval (CI) at 3 months (IRR = 0.74, 95% CI 0.47, 1.14) and 5.5 months (IRR = 0.77, 95% CI 0.44, 1.34). Greater 0 to 3-month change in walking capacity was observed in the OWG compared to the WR group (βz-scored difference = 0.14, 95% CI 0.02, 0.26) driven by significant improvement in walking self-efficacy; other comparisons were not significant. Conclusions: A group, park-based OWG was not superior to WR in increasing outdoor walking activity, health-promoting behavior or successful aging in older adults with difficulty walking outdoors; however, the OWG was superior to telephone WR in improving walking capacity through an increase in walking self-efficacy. Community implementation of the OWG is discussed. Trial registration: ClinicalTrials.gov NCT03292510 Date of registration: September 25, 2017. [ABSTRACT FROM AUTHOR]

Summary: Osteoporosis Canada 2023 clinical practice guidelines increase the number of individuals recommended or suggested for anti-osteoporosis pharmacotherapy by refining treatment guidance for those who fell within the 2010 guidelines' moderate-risk category. Purpose: In 2023, Osteoporosis Canada updated its 2010 clinical practice guidelines based upon consideration of fracture history, 10-year major osteoporotic fracture (MOF) risk, and BMD T-score in conjunction with age. The 2023 guidelines eliminated risk categories, including the moderate-risk group that did not provide clear treatment guidance. The current study was performed to appreciate the implications of the shift from 2010 risk categories to 2023 treatment guidance. Methods: The study population consisted of 79,654 individuals age ≥ 50 years undergoing baseline DXA testing from January 1996 to March 2018. Each individual was assigned to mutually exclusive categories based on 2010 and 2023 guideline recommendations. Treatment qualification, 10-year predicted and 10-year observed MOF risk were compared. Results: Treatment reclassification under the 2023 guidelines only affected 33.8% of individuals in the 2010 moderate-risk group, with 13.0% assigned to no treatment, 14.4% to suggest treatment, and 6.4% to recommend treatment. During the mean follow-up of 7.2 years, 6364 (8.0%) individuals experienced one or more incidents of MOF. The observed 10-year cumulative incidence of MOF in the study population was 10.5% versus the predicted 10.7% (observed to predicted mean calibration ratio 0.98, 95% CI 0.96–1.00). Individuals reclassified from 2010 moderate risk to 2023 recommend treatment were at greater MOF risk than those in the 2010 moderate-risk group assigned to 2023 suggest treatment or no treatment, but at lower risk than those in the 2010 high-risk group. Conclusions: Osteoporosis Canada 2023 clinical practice guidelines affect individuals within the 2010 moderate-risk category, increasing the number for whom anti-osteoporosis pharmacotherapy is recommended or suggested. Increased treatment could reduce the population burden of osteoporotic fractures, though moderate-risk individuals now qualifying for treatment have a lower predicted and observed fracture risk than high-risk individuals recommended for treatment under the 2010 guidelines. [ABSTRACT FROM AUTHOR]

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Objective: The Royal Canadian Mounted Police (RCMP) Study includes longitudinal multimodal assessments of RCMP cadets from pre-training (i.e., starting the Cadet Training Program [CTP]) to post-deployment and for five years thereafter. The data allow for investigating the multidimensionality of volitional participation in digital health data collection frameworks within serial data collection platforms and the impact of participation inequalities by classifying cadets using the 90-9-1 rule. By classifying cadets as Lurkers, Contributors, and Superusers formally described by the 90-9-1 rule, where 90% of actors do not participate, 9% seldom contribute, and 1% contribute substantially allows for the assessing of relationships between participation inequalities in self-monitoring behaviors as well as whether mental health disorder symptoms at pre-training (i.e., starting the CTP) were associated with subsequent participation. Methods: Participants were asked to complete a Full Assessment prior to their training at CTP, as well as short daily surveys throughout their training. Participation frequency was described using a process where participants were rank ordered by the number of daily surveys completed and classified into one of three categories. Full assessment surveys completed prior to their training at CTP included screening tools for generalized anxiety disorder (GAD), major depressive disorder (MDD), posttraumatic stress disorder (PTSD), alcohol use disorder (AUD), and panic disorder (PD). The Kruskal-Wallis H test was used to assess differences in participation rates between mental health disorder symptom screening groups for each measure at pre-training, and Spearman's Rho was used to test for associations amongst self-reported Full Assessment screening tool responses and the number of daily surveys completed during CTP. Results: There were 18557 daily survey records collected from 772 participants. The rank-ordering of cadets by the number of daily surveys completed produced three categories in line with the 90-9-1 rule: Superusers who were the top 1% of cadets (n=8) and produced 6.4% of all recordings; Contributors who were the next 9% of cadets (n=68) and produced 49.2% of the recordings; and Lurkers who were the next 90% of cadets (n=695) and produced 44.4% of daily survey recordings. Lurkers had the largest proportion of positive screens for selfreported mental health disorders at pre-training. Conclusion: The creation of highly individualized, population-based mental health injury programs has been limited by an incomplete understanding of the causal relationships between protective factors and mental health. Disproportionate rates of disengagement from persons who screen positive for mental health disorders further compounds the difficulty in understanding the relationships between training programs and mental health. The current results suggest persons with mental health challenges may be less likely to engage in some forms of proactive mental health training. The current results also provide useful information about participation, adherence, and engagement that can be used to inform evidence-based paradigm shifts in health-related data collection in occupational populations. [ABSTRACT FROM AUTHOR]

Peak bone mineral density (BMD) is one of the most important factors influencing the development of osteoporosis. It was predicted that a 10% increase in peak BMD will delay the onset of osteoporosis by 13 years. However, changes in peak BMD over time are unknown. This study aimed to investigate secular trends in peak BMD among young adults in the United States. Based on the National Health and Nutrition Examination Survey from 1999–2018, 3,975 males aged 19–28 years and 2370 females aged 31–40 years were our target population for estimating peak lumbar spine BMD. BMD was measured by dual-energy X-ray absorptiometry. Generalized linear models adjusted for multiple covariates were used to examine the secular trends in peak BMD in males and females, respectively. Secular trends for peak lumbar spine BMD from 1999–2000 to 2017–2018 were not statistically significant in males or females (all Plinear and Pquadratic > 0.05). Similar results were observed in race/ethnicity subgroups (all Plinear and Pquadratic > 0.05). However, in stratified analyses by obesity category, peak lumbar spine BMD in obese males and females increased from 1999–2000 to 2009–2010 and then decreased until 2017–2018, while peak lumbar spine BMD in non-obese females decreased from 1999–2000 to 2005–2006 and then increased until 2017–2018 (all Pquadratic < 0.05). Peak lumbar spine BMD was greater in obese males and females than in non-obese males and females up to 2009–2010, but not from 2011–2012 onwards. Overall, there were no significant secular trends in peak lumbar spine BMD. However, secular trends differed between obese and non-obese groups. [ABSTRACT FROM AUTHOR]

Purpose: To measure the impact of beliefs, expectations, side effects, and their combined effects on the risk for medication nonpersistence. Patients and methods: Using a cross-sectional design, individuals from Saskatchewan, Canada who started a new antihypertensive, cholesterol-lowering, or antihyperglycemic medication were surveyed about risk factors for nonpersistence including: (a) beliefs measured by a composite score of three questions asking about the threat of the condition, importance of the drug, and harm of the drug; (b) incident side effects attributed to treatment; and (c) expectations for side effects before starting treatment. Descriptive statistics and logistic regression models were used to quantify the influence of these risk factors on the outcome of nonpersistence. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. Results: Among 3,029 respondents, 5.8% (n=177) reported nonpersistence within four months after starting the new drug. After adjustment for numerous covariates representing sociodemographics, health-care providers, medication experiences and beliefs, both negative beliefs (OR: 7.26, 95%CI: 4.98– 10.59) and incident side effects (OR: 8.00, 95%CI: 5.49– 11.68) were associated with the highest odds of nonpersistence with no evidence of interaction. In contrast, expectations for side effects before starting treatment exhibited an important interaction with incident side effects following treatment initiation. Among respondents with incident side effects (n=741, 24.5%), the risk for early nonpersistence was 11.5% if they indicated an expectation for side effects before starting the medication compared to 23.6% if they did not (adjusted OR: 0.38, 95%CI: 0.25– 0.60). Conclusion: Expectations for side effects may be a previously unrecognized but important marker of the probability to persist with treatment. A high percentage of new medication users appeared unprepared for the possibility of side effects from their new medication making them less resilient if side effects occur. [ABSTRACT FROM AUTHOR]

Purpose: Unsupervised item-response theory (IRT) models such as polytomous IRT based on recursive partitioning (IRTrees) and mixture IRT (MixIRT) models can be used to assess differential item functioning (DIF) in patient-reported outcome measures (PROMs) when the covariates associated with DIF are unknown a priori. This study examines the consistency of results for IRTrees and MixIRT models. Methods: Data were from 4478 individuals in the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease registry who received cardiac angiography in Alberta, Canada, and completed the Hospital Anxiety and Depression Scale (HADS) depression subscale items. The partial credit model (PCM) based on recursive partitioning (PCTree) and mixture PCM (MixPCM) were used to identify covariates associated with differential response patterns to HADS depression subscale items. Model covariates included demographic and clinical characteristics. Results: The median (interquartile range) age was 64.5(15.7) years, and 3522(78.5%) patients were male. The PCTree identified 4 terminal nodes (subgroups) defined by smoking status, age, and body mass index. A 3-class PCM fits the data well. The MixPCM latent classes were defined by age, disease indication, smoking status, comorbid diabetes, congestive heart failure, and chronic obstructive pulmonary disease. Conclusion: PCTree and MixPCM were not consistent in detecting covariates associated with differential interpretations of PROM items. Future research will use computer simulations to assess these models' Type I error and statistical power for identifying covariates associated with DIF. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this systematic review was to describe the prevalence and magnitude of response shift effects, for different response shift methods, populations, study designs, and patient-reported outcome measures (PROM)s. Methods: A literature search was performed in MEDLINE, PSYCINFO, CINAHL, EMBASE, Social Science Citation Index, and Dissertations & Theses Global to identify longitudinal quantitative studies that examined response shift using PROMs, published before 2021. The magnitude of each response shift effect (effect sizes, R-squared or percentage of respondents with response shift) was ascertained based on reported statistical information or as stated in the manuscript. Prevalence and magnitudes of response shift effects were summarized at two levels of analysis (study and effect levels), for recalibration and reprioritization/reconceptualization separately, and for different response shift methods, and population, study design, and PROM characteristics. Analyses were conducted twice: (a) including all studies and samples, and (b) including only unrelated studies and independent samples. Results: Of the 150 included studies, 130 (86.7%) detected response shift effects. Of the 4868 effects investigated, 793 (16.3%) revealed response shift. Effect sizes could be determined for 105 (70.0%) of the studies for a total of 1130 effects, of which 537 (47.5%) resulted in detection of response shift. Whereas effect sizes varied widely, most median recalibration effect sizes (Cohen's d) were between 0.20 and 0.30 and median reprioritization/reconceptualization effect sizes rarely exceeded 0.15, across the characteristics. Similar results were obtained from unrelated studies. Conclusion: The results draw attention to the need to focus on understanding variability in response shift results: Who experience response shifts, to what extent, and under which circumstances? [ABSTRACT FROM AUTHOR]

Background: Smoking is a risk factor for many chronic diseases. Multiple smoking status ascertainment algorithms have been developed for population-based electronic health databases such as administrative databases and electronic medical records (EMRs). Evidence syntheses of algorithm validation studies have often focused on chronic diseases rather than risk factors. We conducted a systematic review and meta-analysis of smoking status ascertainment algorithms to describe the characteristics and validity of these algorithms. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. We searched articles published from 1990 to 2022 in EMBASE, MEDLINE, Scopus, and Web of Science with key terms such as validity, administrative data, electronic health records, smoking, and tobacco use. The extracted information, including article characteristics, algorithm characteristics, and validity measures, was descriptively analyzed. Sources of heterogeneity in validity measures were estimated using a meta-regression model. Risk of bias (ROB) in the reviewed articles was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Results: The initial search yielded 2086 articles; 57 were selected for review and 116 algorithms were identified. Almost three-quarters (71.6%) of algorithms were based on EMR data. The algorithms were primarily constructed using diagnosis codes for smoking-related conditions, although prescription medication codes for smoking treatments were also adopted. About half of the algorithms were developed using machine-learning models. The pooled estimates of positive predictive value, sensitivity, and specificity were 0.843, 0.672, and 0.918 respectively. Algorithm sensitivity and specificity were highly variable and ranged from 3 to 100% and 36 to 100%, respectively. Model-based algorithms had significantly greater sensitivity (p = 0.006) than rule-based algorithms. Algorithms for EMR data had higher sensitivity than algorithms for administrative data (p = 0.001). The ROB was low in most of the articles (76.3%) that underwent the assessment. Conclusions: Multiple algorithms using different data sources and methods have been proposed to ascertain smoking status in electronic health data. Many algorithms had low sensitivity and positive predictive value, but the data source influenced their validity. Algorithms based on machine-learning models for multiple linked data sources have improved validity. [ABSTRACT FROM AUTHOR]

Osteoporosis and cardiovascular disease (CVD) are highly prevalent in older women, with increasing evidence for shared risk factors and pathogenesis. Although FRAX was developed for the assessment of fracture risk, we hypothesized that it might also provide information on CVD risk. To test the ability of the FRAX tool and FRAX-defined risk factors to predict incident CVD in women undergoing osteoporosis screening with DXA, we performed a retrospective prognostic cohort study which included women aged 50 yr or older with a baseline DXA scan in the Manitoba Bone Mineral Density Registry between March 31, 1999 and March 31, 2018. FRAX scores for major osteoporotic fracture (MOF) were calculated on all participants. Incident MOF and major adverse CV events (MACE; hospitalized acute myocardial infarction [AMI], hospitalized non-hemorrhagic cerebrovascular disease [CVA], or all-cause death) were ascertained from linkage to population-based healthcare data. The study population comprised 59 696 women (mean age 65.7 ± 9.4 yr). Over mean 8.7 yr of observation, 6021 (10.1%) had MOF, 12 277 women (20.6%) had MACE, 2274 (3.8%) had AMI, 2061 (3.5%) had CVA, and 10 253 (17.2%) died. MACE rates per 1000 person-years by FRAX risk categories low (10-yr predicted MOF <10%), moderate (10%–19.9%) and high (≥20%) were 13.5, 34.0, and 64.6, respectively. Although weaker than the association with incident MOF, increasing FRAX quintile was associated with increasing risk for MACE (all P -trend <.001), even after excluding prior CVD and adjusting for age. HR for MACE per SD increase in FRAX was 1.99 (95%CI, 1.96–2.02). All FRAX-defined risk factors (except parental hip fracture and lower BMI) were independently associated with higher non-death CV events. Although FRAX is intended for fracture risk prediction, it has predictive value for cardiovascular risk. [ABSTRACT FROM AUTHOR]

Aim: To identify the risk factors for optic nerve hypoplasia (ONH) and septo‐optic dysplasia (SOD). Method: A retrospective, population‐based study with case–control design was undertaken using the Population Research Data Repository at the Manitoba Center for Health Policy in Manitoba, Canada. Cases were 111 patients (63 males, 48 females; age range 1–35 years [mean 11 years 6 months, SD 7 years 2 months]) with ONH and SOD diagnosed from 1990 to 2019, matched to 555 unrelated population‐based controls (315 males, 240 females; age range 1–35 years [mean 11 years 6 months, SD 7 years 2 months]) on year of birth, sex, and area of residence. Additionally, 75 cases (46 males, 29 females; age range 2–35 years [mean 12 years 6 months, SD 7 years 2 months]) with ONH and SOD were matched one‐on‐one with sibling controls (40 males, 35 females; age range 0–33 years [mean 11 years 7 months, SD 7 years 10 months], the rest did not have siblings). Several antenatal maternal risk factors associated with ONH and SOD were tested for their association with case and control group membership using adjusted odds ratios (ORs) and 95% confidence intervals (CIs) from a multivariate conditional logistic regression model. The outcome was the risk of developing ONH and SOD. Results: Maternal age at conception (OR = 0.91, 95% CI = 0.86–0.96), primigravida (OR = 3.39, 95% CI = 1.92–6.01), and smoking (OR = 2.86, 95% CI = 1.61–5.05) were independently associated with ONH and SOD in the cohort matched to unrelated controls (p < 0.001). In the sibling cohort, smoking was an important risk factor (OR = 3.65, 95% CI = 1.2–11.1, p = 0.02). Interpretation: Unmodifiable and modifiable antenatal maternal risk factors are associated with ONH and SOD. Our investigation suggests that several risk factors reported in previous studies may have been due to confounding bias and that maternal smoking during pregnancy is the main modifiable risk factor associated with ONH and SOD. What this paper adds: Historically, many antenatal risk factors have been associated with optic nerve hypoplasia (ONH) and septo‐optic dysplasia (SOD).Population‐based data with matched controls for potential confounding bias are lacking.Young maternal age at conception, primigravida, and smoking during pregnancy are the main risk factors for ONH and SOD using a population‐based, case–control design. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. Methods: We performed a retrospective serial cross‐sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population‐representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30‐day readmission rates, and time‐to‐surgery. Results: The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30‐day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%–45%) and THA (0.2%–10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%–60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30‐day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). Conclusions: We observed substantial between‐country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence‐based surgical approaches. [ABSTRACT FROM AUTHOR]

Background: Identifying children at high risk of developing asthma can facilitate prevention and early management strategies. We developed a prediction model of children's asthma risk using objectively collected population‐based children and parental histories of comorbidities. Method s : We conducted a retrospective population‐based cohort study using administrative data from Manitoba, Canada, and included children born from 1974 to 2000 with linkages to ≥1 parent. We identified asthma and prior comorbid condition diagnoses from hospital and outpatient records. We used two machine‐learning models: least absolute shrinkage and selection operator (LASSO) logistic regression (LR) and random forest (RF) to identify important predictors. The predictors in the base model included children's demographics, allergic conditions, respiratory infections, and parental asthma. Subsequent models included additional multiple comorbidities for children and parents. Results: The cohort included 195,666 children: 51.3% were males and 17.7% had asthma diagnosis. The base LR model achieved a low predictive performance with sensitivity of 0.47, 95% confidence interval (0.45–0.48), and specificity of 0.67 (0.66–0.67) using a predicted probability threshold of 0.20. Sensitivity significantly improved when children's comorbidities were included using LASSO LR: 0.71 (0.69–0.72). Predictive performance further improved by including parental comorbidities (sensitivity = 0.72 [0.70–0.73], specificity = 0.69 [0.69–0.70]). We observed similar results for the RF models. Children's menstrual disorders and mood and anxiety disorders, parental lipid metabolism disorders and asthma were among the most important variables that predicted asthma risk. Conclusion: Including children and parental comorbidities to children's asthma prediction models improves their accuracy. [ABSTRACT FROM AUTHOR]

Optimal duration of bisphosphonate therapy was unknown until the FLEX study was published in 2006 showing a 5‐year course to be adequate for most women. In 2008, a link between long‐term bisphosphonate and atypical femoral fractures was reported and confirmed in later studies. We hypothesized these landmark observations should have led to a decrease in use of bisphosphonates for >5 or 10 years, from 2010 onward. The Manitoba Bone Mineral Density (BMD) Registry with linkage to provincial pharmacy data was used to determine the percentage of long‐ and very long‐term bisphosphonate users from therapy start. The cohort comprised women aged >50 years with BMD between 1995 and 2018 with oral bisphosphonate first prescribed for >90 days with adherence >75% in the first year. For each calendar year of continued therapy, the percentage of patients and medication possession rate was tabulated. The percentage of users beyond 5 years was compared among patients who started therapy in 1998–2004 (those taking 5 years of therapy still finish before 2010) versus 2005–2012 (all new therapy starts overlap 2010 in those taking ≥5 years of treatment). The cohort included 2991 women with mean follow‐up 8.8 (1.3) years, 64.9% of whom took continuous oral bisphosphonate for >5 years and 41.9% for >10 years. In the earlier versus later era, there were 74.4% versus 70.2% who completed 5 years. With respect to longer treatment, there were 68.0% and 60.5% of patients treated for 6 or more years (p < 0.0001) and 46.6% versus 33.5% treated for >10 years (p = 0.08). Medication possession rate was >79% in every year of therapy. Landmark studies leading to more limited bisphosphonate courses may have slightly reduced longer‐term treatment, but up to one‐third of adherent patients in the modern era still receive continuous bisphosphonate therapy for >10 years. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). [ABSTRACT FROM AUTHOR]

Background: Longitudinal studies of health-related quality of life (HRQoL) in multiple sclerosis (MS) are limited. Most have examined average changes within the population, rather than dynamic changes within individuals. Objective: To assess the between- and within-individual association between depression, anxiety, fatigue, cognition, physical functioning, and physical comorbidities and HRQoL. Methods: Adults with MS underwent physical and cognitive assessments and reported symptoms of fatigue (Daily Fatigue Impact Scale), depression and anxiety (Hospital Anxiety and Depression Scale (HADS)), and HRQoL (RAND-36) annually (n = 4 visits). We evaluated associations of elevated symptoms of anxiety (HADS-A) and depression (HADS-D), fatigue, physical function (timed-walk and nine-hole peg test), cognitive function and comorbidity count with physical (PCS-36) and mental (MCS-36) HRQoL using multivariable linear models—estimating between-person and within-person effects. Results: Of 255 participants with MS enrolled, 81.6% were women. After adjustment, within-person increases in depression and fatigue were associated with decreases in physical HRQoL. Increases in depression, anxiety, and comorbidity count were associated with decreases in mental HRQoL. Conclusions: Within-person increases in symptoms of depression, anxiety and fatigue, and comorbidity count are associated with HRQoL decreases among adults with MS, highlighting the potential magnitude of individual benefit of intervention for these symptoms. [ABSTRACT FROM AUTHOR]

Background: Accurate coding of diagnoses of SARS-CoV-2 infection in administrative data benefits population-based studies about the epidemiology, treatment and outcomes of COVID-19. We describe the validity of diagnoses of SARS-CoV-2 infection recorded in hospital discharge abstracts, emergency department records and outpatient physician service claims from 3 Canadian provinces. Methods: In this cohort study, population-based inpatient, emergency department and outpatient records were linked to SARS-CoV-2 polymerase chain reaction (PCR; reference standard) test results from British Columbia, Manitoba and Ontario for Apr. 1, 2020, to Mar. 31, 2021. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of diagnoses of SARS-CoV-2 infection were estimated for each quarter in the study period, overall and by province, age group and sex. Results: Our study encompassed more than 13 million SARS-CoV-2 PCR test results. Specificity and NPV of diagnoses of SARS-CoV-2 infection were consistently high (i.e., most estimates were > 95%). Overall sensitivity estimates were 86.2%, 60.4% and 20.3% in the first quarter for inpatient, emergency department and outpatient cohorts, and 66.2%, 47.5% and 25.0% in the last quarter, respectively. For inpatients, overall PPV estimates ranged from 50.0% to 66.4%. For emergency department patients, overall PPV estimates were 76.9% and 68.3% in the first and last quarters, respectively. For outpatients, PPV estimates were 6.8% and 29.1% in the first and last quarters, respectively. Interpretation: We found variations in the validity of diagnoses for SARS-CoV-2 infection recorded in different health care settings, geographic areas and over time. Our multiprovince validation study provides evidence about the potential use of inpatient and emergency department records as an alternative to population-based laboratory data for identification of patients with SARS-CoV-2 infection, but does not support the use of outpatient claims for this purpose. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Psychiatry is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective. To test the association of early disease severity with grade 12 standards test performance in individuals with childhood-onset chronic rheumatic diseases (ChildCRDs), including juvenile arthritis and systemic autoimmune rheumatic diseases. Methods. We used linked provincial administrative data to identify patients with ChildCRDs born between 1979 and 1998 in Manitoba, Canada. Primary outcomes were Language and Arts Achievement Index (LAI) scores and Math Achievement Index (MAI) scores from grade 12 standards test results as well as enrollment data. The secondary outcome was enrollment in grade 12 by 17 years of age. Latent class trajectory analysis identified disease severity groups using physician visits following diagnosis. Multivariable linear regression tested the association of disease severity groups with LAI and MAI scores, and logistic regression tested the association of disease severity with age-appropriate enrollment, after adjusting for sociodemographic factors and psychiatric morbidities. Results. The study cohort included 541 patients, 70.1% of whom were female. A 3-class trajectory model provided the best fit; it classified 9.7% of patients as having severe disease, 54.5% as having moderate disease, and 35.8% as having mild disease. After covariate adjustment, severe disease was associated with poorer LAI and MAI scores but not with age-appropriate enrollment. Conclusion. Among patients with ChildCRDs, those with severe disease performed more poorly on grade 12 standards tests, independent of sociodemographic and psychiatric risk factors. Clinicians should work with educators and policy makers to advocate for supports to improve educational outcomes of patients with ChildCRDs. [ABSTRACT FROM AUTHOR]

Introduction: Royal Canadian Mounted Police (RCMP) officers self-report high levels of mental health disorder symptoms, such as alcohol use disorder, generalized anxiety disorder, major depressive disorder, panic disorder, and posttraumatic stress disorder. Participation in regular mental health monitoring has been associated with improved mental health disorder symptom reporting and may provide an accessible tool to support RCMP mental health. The current study assessed relationships between self-reported mental health disorder symptoms and the completion of daily surveys (i.e., daily mental health disorder symptom monitoring) by RCMP cadets during the Cadet Training Program (CTP). Methods: Participants were RCMP cadets (n = 394; 76.1% men) in ~2 weeks prior to deployment to the field). Symptoms of alcohol use disorder, generalized anxiety disorder, major depressive disorder, panic disorder, and posttraumatic stress disorder were assessed. Changes in mental health disorder symptom reporting from pre-training to pre-deployment were calculated. Spearman's rank correlations were estimated for number of daily surveys completed and change in mental health disorder symptom scores between pre-training and pre-deployment. Results: There were statistically significant inverse relationships between number of daily surveys completed and number of mental health disorder symptoms reported; specifically, cadets who completed more daily surveys during CTP reported fewer symptoms of alcohol use disorder, generalized anxiety disorder, major depressive disorder, panic disorder, and posttraumatic stress disorder. Conclusion: An inverse correlation between number of daily surveys completed and mental health disorder symptom scores indicated that participation in daily mental health monitoring was associated with improvements in self-reported mental health disorder symptoms between pre-training and pre-deployment. Regular self-monitoring of mental health disorder symptoms may help to mitigate mental health challenges among RCMP cadets and officers. [ABSTRACT FROM AUTHOR]

Purpose: Our aim is to advance response shift research by explicating the implications of published syntheses by the Response Shift – in Sync Working Group in an integrative way and suggesting ways for improving the quality of future response shift studies. Methods: Members of the Working Group further discussed the syntheses of the literature on definitions, theoretical underpinnings, operationalizations, and response shift methods. They outlined areas in need of further explication and refinement, and delineated additional implications for future research. Results: First, the proposed response shift definition was further specified and its implications for the interpretation of results explicated in relation to former, published definitions. Second, the proposed theoretical model was further explained in relation to previous theoretical models and its implications for formulating research objectives highlighted. Third, ways to explore alternative explanations per response shift method and their implications for response shift detection and explanation were delineated. The implications of the diversity of the response shift methods for response shift research were presented. Fourth, the implications of the need to enhance the quality and reporting of the response shift studies for future research were sketched. Conclusion: With our work, we intend to contribute to a common language regarding response shift definitions, theory, and methods. By elucidating some of the major implications of earlier work, we hope to advance response shift research. [ABSTRACT FROM AUTHOR]

Background: Evidence for a relationship between oxidative stress and osteoporotic fractures in humans is limited. Fluorescent oxidation products (FlOPs, excitation/emission wavelengths 320/420nm denoted FlOP_320; 360/420nm [FlOP_360]; and 400/475nm [FlOP_400]) are global biomarkers of oxidative stress, and reflect oxidative damage to proteins, phospholipids, and nucleic acids. We investigated the association between FlOPs and a recent osteoporotic fracture. Methods: We conducted a case-control study in a Chinese population aged 50 years or older. A recent osteoporotic fracture in the cases was confirmed by x-ray. Cases were matched with community-based non-fracture controls (1:2 ratio) for age (± 4 years) and sex. In addition, we conducted a sensitivity unmatched casecontrol study which included all fracture cases and all eligible non-fracture controls prior to matching. Plasma FlOPs were measured with a fluorescent microplate reader. We used unconditional logistic regression to analyze the association between FlOPs (per 1-SD increase in logarithmic scale) and fracture; odds ratios (OR) and 95% confidence intervals (95% CI) were reported. Results: Forty-four cases and 88 matched controls (mean age: 68.2 years) were included. After covariate adjustment (i.e., body mass index, physical activity, and smoking), higher FlOP_360 (OR = 1.85; 95% CI = 1.03 - 3.34) and FlOP_400 (OR = 13.29; 95% CI = 3.48 - 50.69) levels, but not FlOP_320 (OR = 0.56; 95% CI = 0.27 - 1.15), were associated with increased fracture risk. Subgroup analyses by fracture site and unmatched case-control study found comparable associations of FlOP_360 and FlOP_400 with hip and non-hip fractures. Conclusions: Higher FlOP_360 and FlOP_400 levels were associated with increased risk of fracture, and this association was comparable for hip and non-hip fractures. Prospective studies are warranted to confirm this finding. [ABSTRACT FROM AUTHOR]

Objective: Royal Canadian Mounted Police report experiencing extremely frequent potentially psychologically traumatic events (PPTE). In a recent study, approximately half of participating RCMP screened positive for one or more mental disorders, which is approximately five times the diagnostic proportion for the general Canadian population. Increased reporting of mental health symptoms been linked to PPTE exposures. Programs promoting physical activity may be useful interventions to supplement or pair with mental health interventions, providing anxiolytic, antidepressant, and stress-buffering effects. The current study was designed to assess the relationship between physical activity behaviors and reported mental health disorder symptoms of cadets during the Royal Mounted Canadian Police (RCMP) Cadet Training Program (CTP). The current study also examined the relationship between exercise and mental health disorder symptoms of cadets during the CTP. Methods: The study included data from 394 cadets (76.1% male). An analysis of variance (ANOVA) and a series of t-tests were used to assess several differences across sociodemographic groups. Bivariate Spearman’s Rank correlations were performed between the average number of active calories burned per day, as recorded by Apple Watches, and changes in self-reported mental health disorder symptoms (i.e., Generalized Anxiety Disorder [GAD], Major Depressive Disorder [MDD], Posttraumatic Stress Disorder [PTSD], Social Anxiety Disorder [SAD]. Alcohol Use Disorders [AUD], Panic Disorder [PD]) from pre-training (starting the CTP) to pre-deployment (completing the CTP) 26 weeks later. Results: There were statistically significant correlations between physical activity and self-reported mental health disorder symptom scores during CTP. Cadets who performed more physical activity from pre-training to pre-deployment had statistically significantly greater decreases in symptoms of GAD (ρ = −0.472, p < 0.001), MDD (ρ = −0.307, p < 0.001), PTSD (ρ = −0.343, p < 0.001), and AUD (ρ = −0.085, p < 0.05). There was no statistically significant relationship between physical activity and changes in PD symptoms (ρ = −0.037, p > 0.05). There were also no statistically significant relationships between pre-CTP mental health disorder symptom scores and the volume of physical activity performed during CTP. Conclusion: There was evidence of a significant relationship between reductions in mental health disorder symptom scores and physical activity during the 26-week CTP. The results highlight the role that exercise can play as an important tool for reducing mental health disorder symptoms, considering there was no relationship between pre-CTP baseline mental health scores and physical activity performed during CTP. Further research is needed to understand differences in physical activity behaviours among cadets and serving RCMP. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Psychiatry is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The Fracture Risk Assessment Tool (FRAX®) was created to predict major osteoporotic fractures (MOF) and hip fractures in the general population. Whether FRAX accurately predicts fractures in men with prostate cancer is unknown. Our objective was to assess the performance of FRAX for predicting incident fractures in men with prostate cancer. Men from the Manitoba Bone Mineral Density (BMD) Registry (1996–2018) with prostate cancer diagnoses in the 3 years prior to dual‐energy X‐ray absorptiometry (DXA) were identified. FRAX scores with and without BMD were calculated. From population‐based healthcare data we identified incident MOF, hip fracture, any osteoporotic fracture and death from the date of BMD testing to March 31, 2018. Cox regression was performed to estimate hazard ratios (HRs) with 95% confidence intervals (95% CIs) per standard deviation increase in FRAX score. Observed 10‐year probability (estimated with competing risk of mortality) was compared with 10‐year FRAX‐predicted fracture probability to assess calibration. The study population included 684 men with prostate cancer (mean age 74.6 years) and 8608 men without prostate cancer (mean age 65.5 years). FRAX stratified risk for MOF (HR 1.91, 95% CI 1.48–2.45 with BMD; HR 1.96, 95% CI 1.43–2.69 without BMD) and hip fracture (HR 3.37, 95% CI 1.90–6.01 with BMD; HR 4.58, 95% CI 2.17–9.67 without BMD) in men with prostate cancer. There was no effect modification observed with prostate cancer status or current androgen deprivation therapy. Observed 10‐year fracture probability in men with prostate cancer showed good agreement with FRAX with and without BMD included in the calculation (observed/predicted calibration ratios MOF 0.97, hip 1.00 with BMD; MOF 0.92, hip 0.93 with BMD). In conclusion, FRAX reliably predicts incident fractures in men with prostate cancer. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). [ABSTRACT FROM AUTHOR]

Objective: To study the association between prematurity and grade 3 school performance in a contemporary cohort of children.Methods: Population-based retrospective cohort study in Manitoba, Canada. Children born between 1999 and 2011 who had their grade 3 school performance data available were eligible. Preterm birth (<37 weeks) was the exposure of interest assessed using multivariable logistic regression models. Our primary outcomes were 'needs ongoing help' or 'outside the range' in at least two of each of the (1) four numeracy and (2) three reading competencies.Results: Of the 186 956 eligible children, 101 436 children (7187 preterm (gestational age, median (IQR) 35 weeks (34, 36)) and 94 249 term (40 weeks (39,40)) were included. Overall, 19% of preterm and 14% of term children had the numeracy outcome (adjusted OR (aOR) 1.38; 95% CI 1.29 to 1.47, p<0.001), while 19% and 13% had the reading outcome (aOR 1.38; 1.29 to 1.48, p<0.001). These differences showed a gestational age gradient. Gestational age (for numeracy, <28 weeks aOR 4.93 (3.45 to 7.03), 28-33 weeks 1.72 (1.50 to 1.98), 34-36 weeks 1.24 (1.15 to 1.34); for reading, <28 weeks 3.51 (2.40 to 5.14), 28-33 weeks 1.72 (1.49 to 1.98), 34-36 weeks 1.24 (1.17-1.37)), male sex, small for gestational age and maternal medical and sociodemographic factors were associated with the numeracy and reading outcomes in this cohort.Conclusions and Relevance: Children born preterm had poorer performance in grade 3 numeracy and reading proficiencies than children born full term. All children born preterm, not just those born extremely preterm, should be screened for reading and numeracy performance in school and strategies implemented to address any deficits. [ABSTRACT FROM AUTHOR]

Key Points: Question: How do treatment patterns and outcomes for older patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Findings: In this study of 289 376 patients aged 66 years or older hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI across 6 health systems, adjusted 30-day and 1-year mortality rates were higher for low-income patients, whereas rates of cardiac catheterization and percutaneous coronary interventions were lower. High-income patients also had shorter length of stay and lower rates of readmissions. Meaning: These results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems. Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures: Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results: We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, −2.8 percentage points [95% CI, −4.1 to −1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, −9.1 percentage points [95% CI, −16.7 to –1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems. This serial cross-sectional cohort study compares whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. [ABSTRACT FROM AUTHOR]

Context: FRAX® estimates 10-year fracture probability from osteoporosis-specific risk factors. Medical comorbidity indicators are associated with fracture risk but whether these are independent from those in FRAX is uncertain. Objective: We hypothesized Johns Hopkins Aggregated Diagnosis Groups (ADG®) score or recent hospitalization number may be independently associated with increased risk for fractures. Methods: This retrospective cohort study included women and men age =40 in the Manitoba BMD Registry (1996-2016) with at least 3 years prior health care data and used linked administrative databases to construct ADG scores along with number of hospitalizations for each individual. Incident Major Osteoporotic Fracture and Hip Fracture was ascertained during average follow-up of 9 years; Cox regression analysis determined the association between increasing ADG score or number of hospitalizations and fractures. Results: Separately, hospitalizations and ADG score independently increased the hazard ratio for fracture at all levels of comorbidity (hazard range 1.2-1.8, all P<0.05), irrespective of adjustment for FRAX, BMD, and competing mortality. Taken together, there was still a higher than predicted rate of fracture at all levels of increased comorbidity, independent of FRAX and BMD but attenuated by competing mortality. Using an intervention threshold of major fracture risk >20%, application of the comorbidity hazard ratio multiplier to the patient population FRAX scores would increase the number of treatment candidates from 8.6% to 14.4%. Conclusion: Both complex and simple measures of medical comorbidity may be used to modify FRAX-based risk estimates to capture the increased fracture risk associated with multiple comorbid conditions in older patients. [ABSTRACT FROM AUTHOR]

Estimates of longitudinal change in the parameters of latent (i.e. unobserved) variables, including means, are affected by non-response on the items or indicators of the latent variable. This study used Monte Carlo simulation and a numeric example to compare four ordinal item non-response methods: non-negative matrix factorization (NNMF), multiple imputation with conditional proportional odds model (POM), full information maximum likelihood (FIML) and complete-case analysis, when estimating the longitudinal change in latent variable means. The mean squared error for the NNMF method was more than 40% lower than for the FIML and POM methods when the latent variable correlations over time were strong, percentage of missing data was 25% or more, and sample size was large. The NNMF method is a promising method to address item non-response. It is relatively efficient when sample size is large, and the percentage of missing data is high but has limitations under other data-analytic conditions. [ABSTRACT FROM AUTHOR]

Background: Public safety personnel (PSP; e.g., border services personnel, correctional workers, firefighters, paramedics, police, public safety communicators) are frequently exposed to potentially psychologically traumatic events. Such events contribute to substantial and growing challenges from posttraumatic stress injuries (PTSIs), including but not limited to posttraumatic stress disorder. Methods: The current protocol paper describes the PSP PTSI Study (i.e., design, measures, materials, hypotheses, planned analyses, expected implications, and limitations), which was originally designed to evaluate an evidence-informed, proactive system of mental health assessment and training among Royal Canadian Mounted Police for delivery among diverse PSP (i.e., firefighters, municipal police, paramedics, public safety communicators). Specifically, the PSP PTSI Study will: (1) adapt, implement, and assess the impact of a system for ongoing (i.e., annual, monthly, daily) evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; and, (4) assess the impact of providing diverse PSP with a tailored version of the Emotional Resilience Skills Training originally developed for the Royal Canadian Mounted Police in mitigating PTSIs based on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. Participants are assessed pre- and post-training, and then at a follow-up 1-year after training. The assessments include clinical interviews, self-report surveys including brief daily and monthly assessments, and daily biometric data. The current protocol paper also describes participant recruitment and developments to date. Discussion: The PSP PTSI Study is an opportunity to implement, test, and improve a set of evidence-based tools and training as part of an evidence-informed solution to protect PSP mental health. The current protocol paper provides details to inform and support translation of the PSP PTSI Study results as well as informing and supporting replication efforts by other researchers. Trial registration: Hypotheses Registration: aspredicted.org, #90136. Registered 7 March 2022—Prospectively registered. Trial registration: ClinicalTrials.gov, NCT05530642. Registered 1 September 2022—Retrospectively registered. The subsequent PSP PTSI Study results are expected to benefit the mental health of all participants and, ultimately, all PSP. Public significance statements/highlights: Research on how to mitigate posttraumatic stress injuries (PTSIs) among public safety personnel (PSP) who are exposed to potentially psychologically traumatic events is limited. The PSP PTSI Study has been designed to develop, implement, and assess the impact of tools and skills designed to proactively mitigate PTSIs. PSP recruited into the study to receive the augmented training are assessed before and after training, and again 1 year later. The PSP PTSI Study results are expected to benefit the mental health of all participants and other PSP by informing strategies to mitigate PTSI. [ABSTRACT FROM AUTHOR]

Background: The overall impact of physician prescribers on population-level adherence rates are unknown. We aimed to quantify the influence of general practitioner (GP) physician prescribers on the outcome of optimal statin medication adherence. Methods: We conducted a retrospective cohort study using health administrative databases from Saskatchewan, Canada. Participants included physician prescribers and their patients beginning a new statin medication between January 1, 2012 and December 31, 2017. We grouped prescribers based on the prevalence of optimal adherence (i.e., proportion of days covered ≥ 80%) within their patient group. Also, we constructed multivariable logistic regression analyses on optimal statin adherence using two-level non-linear mixed-effects models containing patient and prescriber-level characteristics. An intraclass correlation coefficient was used to estimate the physician effect. Results: We identified 1,562 GPs prescribing to 51,874 new statin users. The median percentage of optimal statin adherence across GPs was 52.4% (inter-quartile range: 35.7% to 65.5%). GP prescribers with the highest patient adherence (versus the lowest) had patients who were older (median age 61.0 vs 55.0, p<0.0001) and sicker (prior hospitalization 39.4% vs 16.4%, p<0.001). After accounting for patient-level factors, only 6.4% of the observed variance in optimal adherence between patients could be attributed to GP prescribers (p<0.001). The majority of GP prescriber influence (5.2% out of 6.4%) was attributed to the variance unexplained by patient and prescriber variables. Interpretation: The overall impact of GP prescribers on statin adherence appears to be very limited. Even "high-performing" physicians face significant levels of sub-optimal adherence among their patients. [ABSTRACT FROM AUTHOR]

Purpose: Mixture item response theory (MixIRT) models can be used to uncover heterogeneity in responses to items that comprise patient-reported outcome measures (PROMs). This is accomplished by identifying relatively homogenous latent subgroups in heterogeneous populations. Misspecification of the number of latent subgroups may affect model accuracy. This study evaluated the impact of specifying too many latent subgroups on the accuracy of MixIRT models. Methods: Monte Carlo methods were used to assess MixIRT accuracy. Simulation conditions included number of items and latent classes, class size ratio, sample size, number of non-invariant items, and magnitude of between-class difference in item parameters. Bias and mean square error in item parameters and accuracy of latent class recovery were assessed. Results: When the number of latent classes was correctly specified, the average bias and MSE in model parameters decreased as the number of items and latent classes increased, but specification of too many latent classes resulted in modest decrease (i.e., < 10%) in the accuracy of latent class recovery. Conclusion: The accuracy of MixIRT model is largely influenced by the overspecification of the number of latent classes. Appropriate choice of goodness-of-fit measures, study design considerations, and a priori contextual understanding of the degree of sample heterogeneity can guide model selection. [ABSTRACT FROM AUTHOR]

Summary: We assessed post-fracture mortality in a population-based cohort of 122,045 individuals with cancers. Major fractures (hip, vertebrae, humerus, and forearm) were associated with early and long-term increased all-cause mortality. Introduction: Currently, there are no population-based data among cancer patients on post-fracture mortality risk across a broad range of cancer diagnoses. Our objective was to estimate the association of fracture with mortality in cancer survivors. Methods: Using Manitoba Cancer Registry data from the province of Manitoba, Canada, we identified all women and men with cancer diagnosed between January 1, 1987, and March 31, 2014. We then linked cancer data to provincial healthcare administrative data and ascertained fractures after cancer diagnosis and mortality to March 31, 2015. Hazard ratios for all-cause mortality in those with versus without fracture were estimated from time-dependent Cox proportional hazards models adjusted for multiple covariates. Results: The study cohort consisted of 122,045 cancer patients (median age 68 years, IQR 58–77, 49.2% female). During the median follow-up of 5.8 years from cancer diagnosis, we ascertained 7120 (5.8%) major fractures. All fracture sites, except for the forearm, were associated with increased mortality risk, even after multivariable adjustment. Excess mortality risk associated with a major fracture was greatest in the first year after fracture (HR 2.42, 95% CI 2.30–2.54) and remained significant > 5 years after fracture (HR 1.60, 95% CI 1.50–1.70) and for fractures occurring > 10 years after cancer diagnosis (HR 1.93, 95% CI 1.79–2.07). Conclusion: Fractures among cancer patients are associated with increased all-cause mortality. This excess risk is greatest in the first year and persists more than 5 years post-fracture; increased risk is also noted for fractures occurring up to and beyond 10 years after cancer diagnosis. [ABSTRACT FROM AUTHOR]

Summary: Fracture risk calculators may not be accurate for all ethnicity groups. The Manitoba bone density registry was used to test the Canadian CAROC tool for predicting fracture risk in Asian-Canadian women. The tool significantly over-estimated fracture risk, suggesting that it may not be ideal for Asian-Canadian patients. Purpose: Health risk prediction tools based on largely White populations may lead to treatment inequity when applied to non-White populations where outcome rates differ. We examined the calibration of the Canadian Association of Radiologists-Osteoporosis Canada (CAROC) fracture risk prediction tool in self-identified Asian-Canadian women. Methods: Retrospective cohort study of women over age 50 using the Manitoba BMD Registry. At first BMD, the intake questionnaire collected self-identification of ethnicity and fracture risk factors. 10-year fracture risk was estimated using CAROC and categorized into low, medium, or high fracture risk. Linked administrative databases identified incident osteoporotic fractures. Observed fracture rates were compared between White and Asian-Canadians and compared to the original CAROC risk stratification. Results: There were 63,632 and 1703 women who self-identified as White-Canadian or Asian-Canadian, respectively, covering approximately 600,000 patient-years follow-up. There were 6588 incident fractures; a similar percentage of patients were assigned to each risk stratum at baseline by CAROC. A progressive rise in 10-year observed fracture rates occurred for each CAROC stratum in the White-Canadian population but much lower fracture rates than predicted in Asian-Canadian patients (p < 0.001). Fracture incidence rate ratios were 1.9–2.6 fold higher in White- vs Asian-Canadian patients for all strata (p < 0.001). In the CAROC moderate and high-risk categories, observed fracture rates in Asian-Canadian patients were typically lower than predicted, indicating poor model calibration. Conclusion: In Asian-Canadian women, observed osteoporosis fracture rates are lower than predicted when using the CAROC tool. Over-estimation of fracture risk may influence shared decision-making discussions. [ABSTRACT FROM AUTHOR]

The Fracture Risk Assessment Tool (FRAX®) combines clinical risk factors and optionally femoral neck bone density to estimate major osteoporotic fracture (MOF) and hip fracture probability. Hip dual‐energy X‐ray absorptiometry (DXA) simultaneously measures the trochanter and total hip, but these regions are not considered by FRAX. Our aim was to determine whether discordance in trochanter and total hip bone density (defined as ≥1 T‐score difference from the femoral neck) affects fracture risk adjusted for fracture probability. Using the Manitoba bone density registry, we identified 84,773 women and men age 40 years or older undergoing baseline hip DXA. The outcomes were incident MOF and hip fracture. Cox regression hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for baseline fracture probability were used to test the association between hip T‐score discordance and incident fractures. Hip T‐score discordance affected more than one in five subjects (trochanter lower in 3.9%, higher in 14.2%; total hip lower in 0.3%, higher in 14.9%). After mean 8.8 years there were 8444 incident MOF including 2664 hip fractures. Discordantly lower trochanter and lower total hip T‐score (≥1 below femoral neck) was associated with increased risk for MOF (adjusted HRs 1.47 and 1.60) and hip fracture (HRs 1.85 and 2.12), while discordantly higher trochanter and total hip T‐score (≥1 above femoral neck) was associated with lower risk for MOF (HRs 0.83 and 0.71) and hip fracture (HRs 0.79 and 0.68). In models that examined the trochanter and total hip simultaneously, discordantly lower trochanter T‐score was associated with increased incident MOF and hip fracture risk (HRs 1.43 and 1.79) whereas discordantly higher total hip T‐score was associated with lower risk (HRs 0.73 and 0.75). In conclusion, trochanter and total hip regions frequently show T‐scores that are discordant with the femoral neck. This information strongly affects incident fracture risk independent of fracture probability scores computed with femoral neck bone density. © 2022 American Society for Bone and Mineral Research (ASBMR). [ABSTRACT FROM AUTHOR]

Background: Characteristics of patients using newer 2nd and 3rd line antidiabetic drugs in a real-world setting are poorly understood. We described the characteristics of new users of sodium-glucose co-transporter-2 inhibitors (SGLT-2i), dipeptidyl peptidase-4 inhibitors (DPP-4i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA) in Canada and the United Kingdom (UK) between 2016 and 2018. Methods: We conducted a multi-database cohort study using administrative health databases from 7 Canadian provinces and the UK Clinical Practice Research Datalink. We assembled a base cohort of antidiabetic drug users between 2006 and 2018, from which we constructed 3 cohorts of new users of SGLT-2i, DPP-4i, and GLP-1 RA between 2016 and 2018. Results: Our cohorts included 194,070 new users of DPP-4i, 166,722 new users of SGLT-2i, and 27,719 new users of GLP-1 RA. New users of GLP-1 RA were more likely to be younger (mean ± SD: 56.7 ± 12.2 years) than new users of DPP-4i (67.8 ± 12.3 years) or SGLT-2i (64.4 ± 11.1 years). In Canada, new users of DPP-4i were more likely to have a history of coronary artery disease (22%) than new users of SGLT-2i (20%) or GLP-1 RA (15%). Conclusion: Although SGLT-2i, DPP-4i, and GLP-1 RAs are recommended as 2nd or 3rd line therapy for type 2 diabetes, important differences exist in the characteristics of users of these drugs. Contrary to existing guidelines, new users of DPP-4i had a higher prevalence of cardiovascular disease at baseline than new users of SGLT2i or GLP-1RA. [ABSTRACT FROM AUTHOR]

Purpose: Item non-response (i.e., missing data) may mask the detection of differential item functioning (DIF) in patient-reported outcome measures or result in biased DIF estimates. Non-response can be challenging to address in ordinal data. We investigated an unsupervised machine-learning method for ordinal item-level imputation and compared it with commonly-used item non-response methods when testing for DIF. Methods: Computer simulation and real-world data were used to assess several item non-response methods using the item response theory likelihood ratio test for DIF. The methods included: (a) list-wise deletion (LD), (b) half-mean imputation (HMI), (c) full information maximum likelihood (FIML), and (d) non-negative matrix factorization (NNMF), which adopts a machine-learning approach to impute missing values. Control of Type I error rates were evaluated using a liberal robustness criterion for α = 0.05 (i.e., 0.025–0.075). Statistical power was assessed with and without adoption of an item non-response method; differences > 10% were considered substantial. Results: Type I error rates for detecting DIF using LD, FIML and NNMF methods were controlled within the bounds of the robustness criterion for > 95% of simulation conditions, although the NNMF occasionally resulted in inflated rates. The HMI method always resulted in inflated error rates with 50% missing data. Differences in power to detect moderate DIF effects for LD, FIML and NNMF methods were substantial with 50% missing data and otherwise insubstantial. Conclusion: The NNMF method demonstrated comparable performance to commonly-used non-response methods. This computationally-efficient method represents a promising approach to address item-level non-response when testing for DIF. [ABSTRACT FROM AUTHOR]

Summary: Epidemiological studies show an inconsistent association between cancer and osteoporosis. In this nationally representative population-based study, we found that a prior cancer diagnosis was not associated with osteoporosis. This finding may primarily apply to cancer survivors seen many years after their cancer diagnosis. Background: Epidemiological studies show an inconsistent association between cancer and osteoporosis. We examined the association between a prior cancer diagnosis and osteoporosis in population-based data. Methods: We performed an age- and sex-matched case–control study (1:2 matching ratio) using the National Health and Nutrition Examination Survey, 2011–2018. Cases were determined by self-reported prior diagnosis of cancer; all controls were free of cancer at the time of bone density measurement with dual-energy x-ray absorptiometry. We defined osteoporosis as a T-score ≤ − 2.5 at femoral neck, total hip, or lumbar spine. Unconditional multivariable logistic regression was used to test the association between a prior cancer diagnosis and osteoporosis. Results: We identified 246 prior cancer cases and 492 controls (mean age: 65.8 years) in females, and 243 prior cancer cases and 486 controls (mean age: 68.0 years) in males. The most common types of cancer in females and males were breast cancer and prostate cancer, respectively. Osteoporosis prevalences were comparable between cases and controls among females (19.1% in cases vs. 18.7% in controls; P = 0.894) and males (5.8% in cases vs. 6.8% in controls; P = 0.594). After adjusting for covariates, a prior cancer diagnosis was not associated with osteoporosis in females (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.54–1.29) or males (OR: 1.09; 95% CI: 0.51–2.30). Results were unaffected by cancer severity, cancer type, or time since cancer diagnosis. Conclusions: A prior cancer diagnosis was not associated with osteoporosis in this nationally representative population. [ABSTRACT FROM AUTHOR]

The Royal Canadian Mounted Police (RCMP), like all public safety personnel (PSP), are frequently exposed to potentially psychologically traumatic events that contribute to posttraumatic stress injuries (PTSI). Addressing PTSI is impeded by the limited available research. In this protocol paper, we describe the RCMP Study, part of the concerted efforts by the RCMP to reduce PTSI by improving access to evidence-based assessments, treatments and training as well as participant recruitment and RCMP Study developments to date. The RCMP Study has been designed to (1) develop, deploy and assess the impact of a system for ongoing annual, monthly and daily evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; (4) augment the RCMP Cadet Training Program with skills to proactively mitigate PTSI; and (5) assess the impact of the augmented training condition (ATC) versus the standard training condition (STC). Participants in the STC (n = 480) and ATC (n = 480) are assessed before and after training and annually for 5 years on their deployment date; they also complete brief monthly and daily surveys. The RCMP Study results are expected to benefit the mental health of all participants, RCMP and PSP by reducing PTSI among all who serve. [ABSTRACT FROM AUTHOR]

Summary : The Danish Fracture Risk Evaluation Model (FREM) was found to predict fracture risk independent of 10-year fracture probability derived with the FRAX® tool including bone mineral density from DXA. Introduction : FREM was developed from Danish public health registers without DXA information to identify high imminent risk of major osteoporotic fracture (MOF) and hip fracture (HF), while FRAX® estimates 10-year fracture probability from clinical risk factors and femoral neck bone mineral density (BMD) from DXA. The FREM algorithm showed significant 1- and 2-year fracture risk stratification when applied to a clinical population from Manitoba, Canada. We examined whether FREM predicts 10-year fracture risk independent of 10-year FRAX probability computed with BMD. Methods: Using the Manitoba BMD Program registry, we identified women and men aged ≥ 45 years undergoing baseline BMD assessment. We calculated FREM and FRAX scores, and identified incident fractures over 10 years. Hazard ratios (HRs) for incident fracture were estimated according to FREM quintile, adjusted for FRAX probability. We compared predicted with observed 10-year cumulative fracture probability estimated with competing mortality. Results: The study population comprised 74,446 women, mean age 65.2 years; 7945 men, mean age 67.5 years. There were 7957 and 646 incident MOF and 2554 and 294 incident HF in women and men, respectively. Higher FREM scores were associated with increased risk for MOF (highest vs middle quintile HRs 1.49 women, 2.06 men) and HF (highest vs middle quintile HRs 2.15 women, 2.20 men) even when adjusted for FRAX. Greater mortality with higher FREM scores attenuated its effect on 10-year fracture probability. In the highest FREM quintile, observed slightly exceeded predicted 10-year probability for MOF (ratios 1.05 in women, 1.49 in men) and HF (ratios 1.29 in women, 1.34 in men). Conclusions: Higher FREM scores identified women and men at increased fracture risk even when adjusted for FRAX probability that included BMD; hence, FREM provides additional predictive information to FRAX. FRAX slightly underestimated 10-year fracture probability in those falling within the highest FREM quintile. [ABSTRACT FROM AUTHOR]