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Background: Immigrants and refugees face unique challenges navigating the health care system to manage severe arthritis, because of unfamiliarity, lack of awareness of surgical options, or access. The purpose of this study was to assess total knee arthroplasty (TKA) uptake, surgical outcomes, and hospital utilization among immigrants and refugees compared with Canadian-born patients. Methods: We included all adults undergoing primary TKA from January 2011 to December 2020 in Ontario. Cohorts were defined as Canadian-born or immigrants and refugees. We assessed change in yearly TKA utilization for trend. We compared differences in 1-year revision, infection rates, 30-day venous thromboembolism (VTE), presentation to emergency department, and hospital readmission between matched Canadian-born and immigrant and refugee groups. Results: We included 158 031 TKA procedures. A total of 11 973 (7.6%) patients were in the immigrant and refugee group, and 146 058 (92.4%) patients were in the Canadian-born group. The proportion of TKAs in Ontario performed among immigrants and refugees nearly doubled over the 10-year study period (p < 0.001). After matching, immigrants were at relatively lower risk of 1-year revision (0.9% v. 1.6%, p < 0.001), infection (p < 0.001), death (p = 0.004), and surgical complications (p < 0.001). No differences were observed in rates of 30-day VTE or length of hospital stay. Immigrants were more likely to be discharged to rehabilitation (p < 0.001) and less likely to present to the emergency department (p < 0.001) than Canadian-born patients. Conclusion: Compared with Canadian-born patients, immigrants and refugees have favourable surgical outcomes and similar rates of resource utilization after TKA. We observed an underutilization of these procedures in Ontario relative to their proportion of the population. This may reflect differences in perceptions of chronic pain or barriers accessing arthroplasty. Contexte : Les personnes immigrantes et r fugi es la recherche de soins pour une arthrite grave sont confront es des difficult s particuli res lorsqu'elles veulent s'y retrouver dans les m andres du syst me de sant , cause d'une m connaissance du syst me et des options th rapeutiques ou de probl mes d'acc s. Cette tude avait pour but d' valuer le recours l'arthroplastie pour proth se totale du genou (PTG), les r sultats chirurgicaux et le recours aux ressources hospitali res chez les personnes immigrantes et r fugi es comparativement aux malades n s au Canada. M thodes : Nous avons inclus tous les adultes soumis une intervention pour PTG primaire de janvier 2011 d cembre 2020 en Ontario. Les cohortes taient n es au Canada ou immigrantes et r fugi es. Nous avons valu les changements annuels du recours la PTG pour d gager une tendance. Nous avons compar les diff rences de taux de r vision 1 an et d'infection, de thromboembolie veineuse (TEV) 30 jours, les consultations aux services d'urgence, et les r admissions entre les groupes de patients n s au Canada et immigrants et r fugi s. R sultats : Nous avons inclus 158 031 cas de PTG. En tout, 11 973 (7,6%) appartenaient au groupe de personnes immigrantes et r fugi es, et 146 058 (92,4%), au groupe n au Canada. La proportion de PTG effectu es chez des personnes immigrantes et r fugi es en Ontario a presque doubl au cours de la p riode de 10 ans tudi e (p < 0,001). Apr s appariement, les personnes immigrantes taient expos es un risque relativement moindre de r vision 1 an (0,9% c. 1,6%, p < 0,001), d'infection (p < 0,001), de mortalit (p = 0,004), et de complications chirurgicales (p < 0,001). On n'a observ aucune diff rence quant au taux de TEV 30 jours ou quant la dur e du s jour hospitalier. Les personnes immigrantes taient plus susceptibles de recevoir leur cong pour aller en centre de r adaptation (p < 0,001) et moins susceptibles de consulter dans un service d'urgence (p < 0,001) que les personnes n es au Canada. Conclusion : Comparativement aux personnes n es au Canada, les personnes immigrantes et r fugi es obtiennent de bons r sultats chirurgicaux et des taux similaires d'utilisation des ressources apr s leur PTG. Nous avons observ une sous-utilisation de ces interventions par rapport leur proportion dans la population. Cela pourrait t moigner des diff rences de perception de la douleur chronique ou des probl mes d'acc s l'arthroplastie., Total knee arthroplasty (TKA) is a successful procedure performed more than 75 000 times a year in Canada. (1) Whereas the outcomes of this procedure are well documented, there has [...]

Background: Total joint arthroplasty is a highly efficacious and cost-effective procedure for moderate to severe arthritis in the hip and knee. Although patient characteristics are considered to be important determinants [...]

Background Vitamin K has been widely promoted as a supplement for decreasing bone loss in postmenopausal women, but the long-term benefits and potential harms are unknown. This study was conducted to determine whether daily high-dose vitamin K1 supplementation safely reduces bone loss, bone turnover, and fractures. Methods and Findings This single-center study was designed as a 2-y randomized, placebo-controlled, double-blind trial, extended for earlier participants for up to an additional 2 y because of interest in longterm safety and fractures. A total of 440 postmenopausal women with osteopenia were randomized to either 5 mg of vitamin K1 or placebo daily. Primary outcomes were changes in BMD at the lumbar spine and total hip at 2 y. Secondary outcomes included changes in BMD at other sites and other time points, bone turnover markers, height, fractures, adverse effects, and health-related quality of life. This study has a power of 90% to detect 3% differences in BMD between the two groups. The women in this study were vitamin D replete, with a mean serum 25-hydroxyvitamin D level of 77 nmol/I at baseline. Over 2 y, BMD decreased by -1.28% and -1.22% (p = 0.84) (difference of -0.06%; 95% confidence interval [CI] -0.67% to 0.54%) at the lumbar spine and -0.69% and -0.88% (p =0.51) (difference of 0.19%; 95% CI -0.37% to 0.75%) at the total hip in the vitamin K and placebo groups, respectively. There were no significant differences in changes in BMD at any site between the two groups over the 2- to 4-y period. Daily vitamin K1 supplementation increased serum vitamin K1 levels by 10-fold, and decreased the percentage of undercarboxylated osteocalcin and total osteocalcin levels (bone formation marker). However, C-telopeptide levels (bone resorption marker) were not significantly different between the two groups. Fewer women in the vitamin K group had clinical fractures (nine versus 20, p = 0.04) and fewer had cancers (three versus 12, p = 0.02). Vitamin K supplements were well-tolerated over the 4-y period. There were no significant differences in adverse effects or health-related quality of life between the two groups. The study was not powered to examine fractures or cancers, and their numbers were small. Conclusions Daily 5 mg of vitamin K1 supplementation for 2 to 4 y does not protect against age-related decline in BMD, but may protect against fractures and cancers in postmenopausal women with osteopenia. More studies are needed to further examine the effect of vitamin K on fractures and cancers. Trial registration: ClinicalTrials.gov (#NCT00150969) and Current Controlled Trials (#ISRCTN61708241), Introduction Vitamin K is best known for its function in the blood coagulation pathway, but recent data suggest that the K vitamins play an important role in bone metabolism, perhaps [...]

Keywords: health care constraints; medical brokering; decision making; candidacy for orthopedic surgery; prioritizing; waiting lists. 773 ''Not Everyone Who Needs One Is Going to Get One'': The Influence of Medical [...]

Byline: Suzanne M. Cadarette (1,2), Warren J. McIsaac (3,4), Gillian A. Hawker (1,2,5), Liisa Jaakkimainen (3,6,7), Alison Culbert (3,7), Gihane Zarifa (3,4), Ebele Ola (3,4), Susan B. Jaglal (1,2,8) Keywords: Decision aids; Osteoporosis; Screening; Sensitivity; Specificity; Women Abstract: The purpose of this study was to determine the validity of the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST) chart and equation, and a criterion based on body weight for identifying women with asymptomatic primary osteoporosis. Prospective recruitment and chart abstractions from family practices of three University affiliated hospitals were completed for women aged 45 years or more with baseline bone mineral density (BMD) testing results by dual energy X-ray absorptiometry. Those taking bone active medication other than hormone therapy, with prior fragility fracture or with risk factors for secondary osteoporosis were excluded. Women were categorized as being normal, osteopenic or osteoporotic by lowest BMD T-score at either the femoral neck or lumbar spine (L1--L4). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve to identify those with osteoporosis were determined for each decision rule. The positive predictive value (PPV) for detecting osteoporosis after using a second cut point to convert each decision rule into a risk index (low, moderate or high risk) was also determined. The sensitivity of the decision rules to identify women with osteoporosis ranged from 92% to 95% and specificity from 35% to 46%. The area under the ROC curves were significantly better for the ORAI (0.80), OST chart (0.82) and OST equation (0.82) compared with the body weight criterion (0.73). PPV for detecting osteoporosis ranged from 30% to 58% among women deemed at high risk. These data confirm the validity of the ORAI, the OST chart and the OST equation as screening tools for BMD testing. Further evidence is required to confirm the validity of the body weight criterion. Author Affiliation: (1) Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (2) Osteoporosis Research Program, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, 76 Grenville Street, 10th Floor East, Toronto, ON, M5S 1B2 , Canada (3) Department of Family and Community Medicine, University of Toronto, Toronto, Canada (4) Mount Sinai Family Medicine Centre, Toronto, Canada (5) Division of Rheumatology, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, Toronto, Canada (6) Institute for Clinical Evaluative Sciences in Ontario, Toronto, Canada (7) Department of Family and Community Medicine, Sunnybrook and Women's College Health Sciences Centre, Toronto, Canada (8) Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Canada Article History: Registration Date: 10/11/2003 Received Date: 15/05/2003 Accepted Date: 22/10/2003 Online Date: 17/01/2004

Byline: Susan B. Jaglal (1,2,5,7,9), Warren J. McIsaac (3,6), Gillian Hawker (2,4,5,7), June Carroll (3,6), Liisa Jaakkimainen (2,3), Suzanne M. Cadarette (5,7), Cathy Cameron (7), Dave Davis (3,5,8) Keywords: Family practice; Guidelines; Osteoporosis; Survey Abstract: The objectives of this study were to determine information needs of family physicians around issues in the management of osteoporosis and preferences for dissemination of this information. A mailed survey was sent to a stratified random sample of 1000 family physicians in Ontario in May 2001. Female physicians and those practicing in rural communities were over-sampled from the College of Family Physicians' database. Among the 505 respondents, 364 were still practicing (182 males and 182 females) and completed the full questionnaire. There were no statistically significant differences in responses by sex or region of practice. Over 80% of family physicians wanted to be more informed about bone density testing and the pharmacological and non-pharmacological management of osteoporosis. The presence of risk factors was one of the most influential factors (72%) for ordering bone density testing. Information in peer-reviewed journals was thought to be the most credible, with 80% rating the CMAJ as very credible compared to 47% for the Osteoporosis Society of Canada (OSC). Sixty-two percent found the OSC guidelines (1996) to be useful even though much of that information is now out of date. Almost 70% had not read the more recently published treatment guidelines from the Ontario Program for Optimal Therapeutics (2000). Over 80% were interested in a decision aid, which incorporates information on risk factors, fracture risk and a treatment algorithm. The perceived need and the lack of availability of clinically useful information on osteoporosis for the family practice setting highlights the failure of the current guideline implementation process and provides insight into where the process has to be improved. Author Affiliation: (1) Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Canada (2) Institute for Clinical Evaluative Sciences, Toronto, Canada (3) Department of Family and Community Medicine, University of Toronto, Toronto, Canada (4) Department of Medicine, University of Toronto, Toronto, Canada (5) Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (6) Mount Sinai Family Medicine Centre, University of Toronto, Toronto, Canada (7) Osteoporosis Research Program, Sunnybrook and Women's College Health Science Centre, Toronto, Canada (8) Knowledge Translation Program, Faculty of Medicine, University of Toronto, Toronto, Canada (9) Department of Rehabilitation Science, University of Toronto, 500 University Avenue, 8th Floor, Toronto, ON, M5G 1V7, Canada Article History: Received Date: 28/01/2003 Accepted Date: 07/04/2003 Online Date: 22/07/2003

Byline: Gillian Hawker (1), Rowena Ridout (1), Maria Ricupero (1), Susan Jaglal (1), Earl Bogoch (4) Keywords: Fracture clinic intervention Fragility fractures Osteoporosis Pre-post study Abstract: We examined the effect of a fracture clinic intervention in reducing previously documented undertreatment of osteoporosis (OP) in individuals with fragility fractures. Fragility fracture patients presenting to five community fracture clinics with no prior diagnosis of, or treatment for OP, and whose radiographic appearance was consistent with fragility fracture, were included. These individuals (intervention group) were informed of their OP risk, and advised to follow up with their physician for assessment. A standardized letter, intended for the physician and outlining the same was provided. Three months later, a telephone interview determined whether a physician visit had occurred, and if so, what investigation and treatment recommendations were made. These outcomes were compared with those for an equal number of age- and sex-matched fragility fracture 'controls,' selected from among fracture clinic attendees in the 6--9 months preceding the intervention. Logistic regression was used to examine the effect of having received the intervention on physician follow-up, bone density testing, and OP treatment recommendations. The mean age of the 278 participants (139 per group) was 66.0 years 74% were female. Adjusting for age, sex, hospital, and perceived diagnosis of OP, those who received the intervention were more likely to follow up with a physician (adjusted OR 1.85, p=0.02) and to be recommended bone density testing (adjusted OR 5.22, p&lt 0.0001), but were not more likely to receive an OP treatment recommendation (adjusted OR 2.07, p=0.07). It is concluded that a simple fracture clinic intervention increased follow-up and investigation, but not treatment for OP, in fragility fracture patients. Individuals recommended treatment for OP were more likely to perceive themselves as having OP and to have had a previous fragility fracture. Our findings suggest that future interventions should incorporate assessment of patients' OP health beliefs and education about risk factors for fracture, and should be coupled with physician education to achieve optimal results. Author Affiliation: (1) Osteoporosis Research Program, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada (2) Division of Endocrinology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada (3) Department of Rehabilitation Science, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada (4) The Mobility Program and the Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada (5) Department of Health Policy, Management and Evaluation, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada (6) Division of Rheumatology, Department of Medicine, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 76 Grenville Street, 10th floor, Room 1010, M5S 1B2, Toronto, Canada Article History: Received Date: 13/08/2002 Accepted Date: 17/12/2002 Article note: Electronic Publication

Many Canadians who might benefit from joint replacement therapy are not receiving it, and this is especially true of women. In a study of 1,751 women and 660 men with severe disabling arthritis, many men and women did not receive joint replacement therapy even though they were willing to have the surgery. Women were less likely to receive joint replacement therapy than men even though they were more likely to have arthritis and usually had worse symptoms and greater disability.

People living in Ontario, Canada may wait longer for orthopedic consultations and knee replacement surgeries than their counterparts in the United States, although post-surgery satisfaction rates appear to be similar. Researchers surveyed 1,623 people over age 65 who had knee replacement surgery between 1985 and 1989. Of these interviewees, 1,193 lived in the U.S. and 430 lived in Ontario. The median waiting time for an orthopedic consultation was two weeks for U.S. patients and one month for Ontarians. The median waiting time for knee replacement surgery was three weeks in the U.S. and two months in Ontario. Approximately 98% of U.S. patients and 92% of Ontarian patients felt that the consultation waiting time was acceptable. Ninety-five percent of U.S. patients and approximately 85% of Ontarians felt that the surgical waiting time was acceptable. Longer waiting times were associated with lower satisfaction levels among patients in both countries.

Background:Obstructive sleep apnea (OSA) has been reported to be a risk factor for cardiovascular (CV) disease. Although the apnea-hypopnea index (AHI) is the most commonly used measure of OSA, other less well studied OSA-related variables may be more pathophysiologically relevant and offer better prediction. The objective of this study was to evaluate the relationship between OSA-related variables and risk of CV events. Methods and Findings: A historical cohort study was conducted using clinical database and health administrative data. Adults referred for suspected OSA who underwent diagnostic polysomnography at the sleep laboratory at St Michael's Hospital (Toronto, Canada) between 1994 and 2010 were followed through provincial health administrative data (Ontario, Canada) until May 2011 to examine the occurrence of a composite outcome (myocardial infarction, stroke, congestive heart failure, revascularization procedures, or death from any cause). Cox regression models were used to investigate the association between baseline OSA-related variables and composite outcome controlling for traditional risk factors. The results were expressed as hazard ratios (HRs) and 95% CIs; for continuous variables, HRs compare the 75th and 25th percentiles. Over a median follow-up of 68 months, 1,172 (11.5%) of 10,149 participants experienced our composite outcome. in a fully adjusted model, other than AHI OSA-related variables were significant independent predictors: time spent with oxygen saturation Conclusion: OSA-related factors other than AHI were shown as important predictors of composite CV outcome and should be considered in future studies and clinical practice., Introduction Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that is characterized by repeated episodes of upper airway occlusion during sleep. OSA afflicts 3%-9% of women and 10%-17% of [...]

Correction for: Cheung AM, Tile L, Lee Y, Tomlinson G, Hawker G, et al. (2008) Vitamin K supplementation in postmenopausal women with osteopenia (ECKO Trial): A randomized controlled trial. PLoS [...]