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Objectives: Urban greenness has been shown to confer many health benefits including reduced risks of chronic disease, depression, anxiety, and, in a limited number of studies, loneliness. In this first Canadian study on this topic, we investigated associations between residential surrounding greenness and loneliness and social isolation among older adults. Methods: This cross-sectional analysis of the Canadian Longitudinal Study on Aging included 26,811 urban participants between 45 and 86 years of age. The Normalized Difference Vegetation Index (NDVI), a measure of greenness, was assigned to participants’ residential addresses using a buffer distance of 500 m. We evaluated associations between the NDVI and (i) self-reported loneliness using the Center for Epidemiological Studies Depression Scale, (ii) whether participants reported “feeling lonely living in the local area”, and (iii) social isolation. Logistic regression models were used to characterize associations between greenness and loneliness/social isolation while adjusting for individual socio-economic and health behaviours. Results: Overall, 10.8% of participants perceived being lonely, while 6.5% reported “feeling lonely in their local area”. Furthermore, 16.2% of participants were characterized as being socially isolated. In adjusted models, we observed no statistically significant difference (odds ratio (OR) = 0.99; 95% confidence interval (CI) 0.93–1.04) in self-reported loneliness in relation to an interquartile range (IQR) increase of NDVI (0.06). However, for the same change in greenness, there was a 15% (OR = 0.85; 95% CI 0.72–0.99) reduced risk for participants who strongly agreed with “feeling lonely living in the local area”. For social isolation, for an IQR increase in the NDVI, we observed a 7% (OR = 0.93; 95% CI 0.88–0.97) reduction in prevalence. Conclusion: Our findings suggest that urban greenness plays a role in reducing loneliness and social isolation among Canadian urbanites.

BACKGROUND: The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes. METHODS: We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit. RESULTS: There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean [+ or -] standard deviation [SD] 4.93 [+ or -] 3.86 v. 3.50 [+ or -] 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]). INTERPRETATION: Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723, Countries with well-functioning primary care systems have realized better health outcomes and health equity. (1,2) Health care systems worldwide are rearranging primary care to be proactive versus reactive, to focus [...]

BACKGROUND: Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department. METHODS: We constructed the clinical chemistry score (CCS) (range 0-5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT). RESULTS: For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [Cl] 99.5%-100%), with 8.9% (95% CI 8.1%-9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%-100%), with 10.5% (95% CI 9.6%-11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% Cl 95.0%-97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%-99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% Cl 96.0%-97.2%; 11.2% [95% CI 10.3%-12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%-94.7%; 13.1% [95% Cl 12.1%-14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3-94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3-75.2). INTERPRETATION: The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457, The use of a single high-sensitivity cardiac troponin (hs-cTn) test concentration on presentation to the emergency department has been proposed for triage and early decision-making in patients with suspected acute [...]

AbstractOptimizing research on the developmental origins of health and disease (DOHaD) involves implementing initiatives maximizing the use of the available cohort study data; achieving sufficient statistical power to support subgroup analysis; and using participant data presenting adequate follow-up and exposure heterogeneity. It also involves being able to undertake comparison, cross-validation, or replication across data sets. To answer these requirements, cohort study data need to be findable, accessible, interoperable, and reusable (FAIR), and more particularly, it often needs to be harmonized. Harmonization is required to achieve or improve comparability of the putatively equivalent measures collected by different studies on different individuals. Although the characteristics of the research initiatives generating and using harmonized data vary extensively, all are confronted by similar issues. Having to collate, understand, process, host, and co-analyze data from individual cohort studies is particularly challenging. The scientific success and timely management of projects can be facilitated by an ensemble of factors. The current document provides an overview of the ‘life course’ of research projects requiring harmonization of existing data and highlights key elements to be considered from the inception to the end of the project.

Background and aims: Performance-based tests of mobility or physical function such as the Timed Up and Go (TUG), gait speed, chair-rise, and single-leg stance (SLS) are often administered using different protocols in aging populations, however, the reliability of their assessment protocols is not often considered. The purpose of this study was to examine the reliabilities of frequently used assessment protocols for the TUG, gait speed, chair-rise, and SLS in different age groups. Methods: We administered the following assessment protocols in an age-stratified (50–64, 65–74, 75+ years) sample of participants (N= 147) from the Canadian Longitudinal Study on Aging (CLSA): TUG fast pace and TUG normal pace: TUG-cognitive counting backwards by ones and counting back by threes, gait speed with 3-m and 4-m course, chair-rise with arms crossed and allowing the use of arms, and SLS using preferred leg or both legs—on two occasions within 1 week. We assessed the relative (intra-class correlation) and absolute reliability (standard error of measurement, SEM and minimal detectable change, MDC) for each protocol variation and provided recommendations based on relative reliability. Results: For participants aged 50–64 years, our results suggest better reliability for TUG fast-pace compared with normal-pace (ICC and 95% CI 0.70; 0.41–0.85 versus 0.38; 0.12–0.59). The reliability values for 3-m gait speed were potentially higher than for 4-m gait speed (ICC 0.75; 0.67–0.82 versus 0.64; 0.54–0.73) and values for chair-rise suggested better reliability allowing participants to use their arms than with arms crossed (ICC 0.79; 0.66–0.86 versus 0.64; 0.45–0.77) for participants overall. For participants aged 75+ years, ICCs for SLS with the preferred leg showed better reliability than for both legs (ICC = 0.62–0.79 versus 0.30–0.39). Conclusions and discussion: These reliability data and the recommendations can help guide the selection of the most appropriate performance-based test protocols for measuring mobility in middle-aged and older community-dwelling adults.

Background: It is unclear whether participation in a randomized controlled trial (RCT), irrespective of assigned treatment, is harmful or beneficial to participants. We compared outcomes for patients with the same diagnoses who did ('insiders') and did not ('outsiders') enter RCTs, without regard to the specific therapies received for their respective diagnoses. Methods: By searching the MEDLINE (1966-2010), Embase (1980-2010), CENTRAL (1960-2010) and PsyclNFO (1880-2010) databases, we identified 147 studies that reported the health outcomes of 'insiders' and a group of parallel or consecutive 'outsiders' within the same time period. We prepared a narrative review and, as appropriate, meta-analyses of patients' outcomes. Results: We found no clinically or statistically significant differences in outcomes between 'insiders' and 'outsiders' in the 23 studies in which the experimental intervention was ineffective (standard mean difference in continuous outcomes -0.03, 95% confidence interval [Cl] -0.1 to 0.04) or in the 7 studies in which the experimental intervention was effective and was received by both 'insiders' and 'outsiders' (mean difference 0.04, 95% Cl -0.04 to 0.13). However, in 9 studies in which an effective intervention was received only by 'insiders,' the 'outsiders' experienced significantly worse health outcomes (mean difference -0.36, 95% Cl -0.61 to -0.12). Interpretation: We found no evidence to support clinically important overall harm or benefit arising from participation in RCTs. This conclusion refutes earlier claims that trial participants are at increased risk of harm., When people are asked to participate in a randomized controlled trial (RCT), it is natural for them to ask several questions in return. How safe are these treatments? How many [...]

ABSTRACTBackgroundFatigue is common in inflammatory bowel disease (IBD) patients, however, there is no consensus on the optimal measurement tool to assess fatigue.AimTo identify standardised patient-reported outcome measures (PROMs) of fatigue that are used in adults with IBD, to evaluate their psychometric properties, and recommend PROM(s) that are psychometrically robust and feasible for research and clinical use.MethodsEight databases were first searched from 2015–2020 to identify fatigue PROMs used in IBD clinical research. Studies on each PROM’s psychometric properties were then searched in MEDLINE, EMBASE, CINAHL, and PsycINFO from inception to September 2020. The study quality, psychometric robustness of the PROMs, and quality of evidence were evaluated following the Consensus-based Standards for the Selection of Health Measurement Instruments guideline.ResultsThe first search included 111 articles and identified 16 PROMs. The second search identified 9 articles on psychometric properties for 8 PROMs only. Content validity (with high quality evidence) was demonstrated only for the IBD-Fatigue scale (IBD-F) (English). All 8 PROMs demonstrated construct validity (with moderate to high quality evidence) and 5 PROMs demonstrated reliability (intraclass correlation coefficient: 0.65–0.98; with very low to low quality evidence). Responsiveness (with high quality evidence) and minimal clinically important changes were only demonstrated in the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). Evidence on content validity, structural validity, cross-cultural validity, internal consistency, and responsiveness of PROMs was lacking for most PROMs.ConclusionThe IBD-F(English) is recommended for research and clinical use. Further research is required to establish responsiveness and minimal clinically important change.

Background and study objectives: The chronic respiratory questionnaire (CRQ), a widely used measure of health-related quality of life (HRQL) in patients with chronic airflow limitation, includes an individualized dyspnea domain [...]

Objective: To examine proportions and predictors of change in alcohol intake and binge drinking during the first 2 waves of the COVID-19 pandemic among middle-aged and older participants in the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Questionnaire Study. Methods: A total of 28,559 (67.2% of the potential sample) CLSA participants consented to the study with 24,114 completing the exit survey (fall 2020). Descriptive statistics and logistic regressions to examine predictors of change (increase or decrease) in alcohol intake and binge drinking were performed. Results: Among alcohol users, 26.3% reported a change in alcohol consumption during the first 10 months of the pandemic. Similar percentages increased (13.0%) or decreased (13.3%) consumption. In our mutually adjusted logistic regression model, odds of change in alcohol intake were greater for younger age, higher income, current cannabis smoker, positive screen for depression, anxiety, and loneliness. The magnitude of all associations for decreased intake was less than that of increased intake, and the directions were opposite for male sex and age. Predictors of current binge drinking (27.9% of alcohol users) included male sex, younger age, higher education and income, cannabis use, depression, and anxiety. Conclusion: Factors predictive of potentially worrisome alcohol use (i.e. increased intake, binge drinking) included younger age, sex, greater education and income, living alone, cannabis use, and worse mental health. Some of these factors were also associated with decreased intake, but the magnitudes of associations were smaller. This information may help direct screening efforts and interventions towards individuals at risk for problematic alcohol intake during the pandemic.

Study objectives: Previous studies with short recall periods have suggested that informed administration (previous responses available) may improve the responsiveness and validity of health-related quality-of-life (HRQL) questionnaires in comparison to [...]

Study objectives: To systematically review the evidence of randomized trials evaluating the effects of residential air filtration systems on patients with asthma. Data sources: We searched for published and unpublished [...]

We identified 16 randomized controlled trials (RCTs) of methods for weaning patients from mechanical ventilation, 8 of which were trials of discontinuation assessment strategies, 5 of which were trials of [...]

We identified 65 observational studies of weaning predictors that had been reported in 70 publications. After grouping predictors with similar names but different thresholds, the following predictors met our relevance [...]

We identified 10 randomized trials that compared alternative management approaches to patient care during and following cardiovascular surgery. One overall strategy involved a modification of anesthesia, in particular, a reduction [...]

Key words: mechanical ventilation; meta-analysis; methodology; systematic reviews; weaning Abbreviations: AHCPR = Agency for Health Care Policy and Research; CINAHL = Cumulative Index to Nursing and Allied Health Literature; EMBASE [...]

Background: Understanding the risk factors for ventilator-associated pneumonia can help to assess prognosis and devise and test preventive strategies. Objective: To examine the baseline and time-dependent risk factors for ventilator-associated pneumonia and to determine the conditional probability and cumulative risk over the duration of stay in the intensive care unit. Design: Prospective cohort study. Setting: 16 intensive care units in Canada. Patients: 1014 mechanically ventilated patients. Measurements: Demographic and time-dependent variables reflecting illness severity, ventilation, nutrition, and drug exposure. Pneumonia was classified by using five methods: adjudication committee, bedside clinician's diagnosis, Centers for Disease Control and Prevention definition, Clinical Pulmonary Infection score, and positive culture from bronchoalveolar lavage or protected specimen brush. Results: 177 of 1014 patients (17.5%) developed ventilator-associated pneumonia 9.0 [+ or -] 5.9 days (median, 7 days [interquartile range, 5 to 10 days]) after admission to the intensive care unit. Although the cumulative risk increased over time, the daily hazard rate decreased after clay 5 (3.3% at day 5, 2.3% at day 10, and 1.3% at day 15). Independent predictors of ventilator-associated pneumonia in multivariable analysis were a primary admitting diagnosis of burns (risk ratio, 5.09 [95% Cl, 1.52 to 17.03]), trauma (risk ratio, 5.00 [Cl, 1.91 to 13.11]), central nervous system disease (risk ratio, 3.40 [Cl, 1.31 to 8.81]), respiratory disease (risk ratio, 2.79 [Cl, 1.04 to 7.51]), cardiac disease (risk ratio, 2.72 [Cl, 1.05 to 7.01]), mechanical ventilation in the previous 24 hours (risk ratio, 2.28 [Cl, 1.11 to 4.68]), witnessed aspiration (risk ratio, 3.25 [Cl, 1.62 to 6.50]), and paralytic agents (risk ratio, 1.57 [Cl, 1.03 to 2.39]). Exposure to antibiotics conferred protection (risk ratio, 0.37 [Cl, 0.27 to 0.51]). Independent risk factors were the same regardless of the pneumonia definition used. Conclusions: The daily risk for pneumonia decreases with increasing duration of stay in the intensive care unit. Witnessed aspiration and exposure to paralytic agents are potentially modifiable independent risk factors. Exposure to antibiotics was associated with low rates of early ventilator-associated pneumonia, but this effect attenuates over time., It may be possible to prevent ventilator-associated pneumonia in critically ill patients. Researchers analyzed the risk factors for ventilator-associated pneumonia in 1,014 patients on a ventilator, of whom 177 developed ventilator-associated pneumonia. The risk of developing ventilator-associated pneumonia was highest during the first few days after the patients were placed on the ventilator and subsequently decreased. Burns, trauma, diseases of the heart, lungs or central nervous system, exposure to paralytic drugs and aspiration were risk factors for developing ventilator-associated pneumonia.

Summary points Several questionnaires on quality of life related to health are available, but interpreting their results may be difficult For some questionnaires, we now know that the smallest change [...]

Background: Stroke is a leading cause of death in the industrialized world, and hypercholesterolemia may be a risk factor for stroke. Objective: To determine whether reducing cholesterol levels with HMGcoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors or other antilipidemic interventions reduces risk for nonfatal and fatal stroke. Data Sources: A systematic search in the MEDLINE and EMBASE databases of the English-language and nonEnglish-language literature published from 1966 through October 1996. Study Selection: All randomized, controlled trials of any cholesterol-lowering intervention that reported data on nonfatal and fatal strokes, on death from coronary heart disease, and on overall mortality were included. Whether treatment effects differed according to the type of cholesterol-lowering intervention used was investigated. Data Extraction: Trials were reviewed for methods, inclusion and exclusion criteria, and outcomes. Data Synthesis: 28 trials (for a total of 49 477 study participants in the intervention group and 56 636 participants in the control group) were included. The risk ratio for nonfatal and fatal stroke with HMGcoA reductase inhibitors was 0.76 (95% Cl, 0.62 to 0.92; test of heterogeneity, P [is greater than] 0.2). The risk ratios for nonfatal and fatal stroke with fibrates, resins, and dietary interventions were all close to 1.0, and the difference between the HMGcoA reductase inhibitor effect and the pooled estimate for all other interventions would, under the null hypothesis, be unlikely to occur by chance (P = 0.01). Trials with HMGcoA reductase inhibitors also showed reductions in rates of death from coronary heart disease and overall mortality. Conclusion: This meta-analysis of randomized, controlled trials suggests that in hyperlipidemic patients who have not previously had stroke, HMGcoA reductase inhibitors reduce the incidence of stroke., HMGcoA reductase inhibitors may reduce the incidence of stroke as well as coronary heart disease. These drugs are used to lower elevated blood cholesterol levels. Researchers analyzed 28 clinical trials of all cholesterol-lowering methods, including HMGcoA reductase inhibitors, diet and cholesterol-binding resins. HMGcoA reductase inhibitors reduced the risk of stroke by 24%, whereas other cholesterol-lowering methods had no effect. Death rates from coronary heart disease were also reduced by HMGcoA treatment.

Trimethoprim-sulfamethoxazole appears to be effective in preventing Pneumocystis carinii pneumonia and toxoplasmosis compared to other preventive treatments among patients infected with HIV. Researchers pooled the results of 22 studies comparing at least two preventive treatments including trimethoprim-sulfamethoxazole, dapsone alone, dapsone with pyrimethamine, and pentamidine. The risk for contracting P. carinii pneumonia was significantly lower among patients treated with trimethoprim-sulfamethoxazole than pentamidine or dapsone with pyrimethamine. The risk for toxoplasmosis was mixed.

Objectives: To examine the oxygen-prescribing habits and monitoring patterns on a medical teaching ward and to review the literature in this area. Design: A continuous quality improvement study. Setting: A 29-bed medical clinical teaching unit in a 453-bed university-affiliated tertiary care hospital. Patients: We studied 50 consecutive patients who required 79 oxygen treatments. Methods: We recorded the indication, prescriber, documentation of prior hypoxemia, method and mode of delivery, oxygenation assessment after initiation, and duration of therapy. Results: Patients received oxygen for a mean ([+ or -]SD) of 4.7[+ or -]4.5 days. Oxygen therapy was ordered on a continuous basis 60.3% of the time. It was ordered by house staff in 54 cases (68%); nurses initiated oxygen therapy in 14 cases (18%) but discontinued it more often than any other health care workers. The most common indications for starting oxygen therapy were dyspnea and tachypnea. In 15 patients (30%), none of the American College of Chest Physicians and National Heart, Lung, and Blood Institute criteria for starting oxygen therapy were fulfilled. For 16 patients (32%), arterial blood gas values were measured within 1 hour of oxygen administration; for 29 patients, oximetry was performed. For 9 patients (18%), no testing of adequate oxygenation was performed within 24 hours. Oxygenation status was assessed daily for 23 patients (46%). Conclusions: Oxygen prescribing and monitoring practices were suboptimal on our busy medical teaching ward. Practice guidelines based on best available evidence are needed to increase the efficiency of oxygen use. A physiologic, multidisciplinary educational focus on the benefits and hazards of supplemental oxygen is necessary, and randomized trials of such educational interventions should be conducted.

Objective: To measure the reliability of the assessment of mediastinal lymph node size in computed tomographic (CT) scans of the thorax. Design: Observer agreement study in which radiologists, blinded to [...]

Infection rates in the ICU population may increase to 80 percent as the duration of stay exceeds 5 days, causing considerable morbidity, mortality, and increased health care costs.[1] The incidence [...]

Background/objectives: Obesity is associated with increased health care use (HCU), but it is unclear whether this is consistent across all measures of adiposity. The objectives were to compare obesity defined by body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and percent body fat (%BF), and to estimate their associations with HCU. Subjects/methods: Baseline data from 30,092 participants aged 45–85 years from the Canadian Longitudinal Study on Aging were included. Measures of adiposity were recorded by trained staff and obesity was defined as BMI ≥ 30.0 kg/m2for all participants and WC ≥ 88 cm and ≥102 cm, WHR ≥ 0.85 and ≥0.90, and %BF > 35% and >25% (measured using dual energy x-ray absorptiometry) for females and males, respectively. Self-reported HCU in the past 12 months was collected for any contact with a general practitioner, specialist, emergency department, and hospitalization. Pearson correlation coefficients (r) compared each measure to %BF-defined obesity, the reference standard. Relative risks (RR) and risk differences (RD) adjusted for age, sex, education, income, urban/rural, marital status, smoking status, and alcohol use were calculated, and results were age- and sex-stratified. Results: Obesity prevalence varied by measure: BMI (29%), WC (42%), WHR (62%), and %BF (73%). BMI and WC were highly correlated with %BF (r≥ 0.70), while WHR demonstrated a weaker relationship with %BF, with differences by sex (r= 0.29 and r= 0.46 in females and males, respectively). There were significantly increased RR and RD for all measures and health care services, for example, WC-defined obesity was associated with an increased risk of hospitalization (RR: 1.40, 95% CI: 1.28–1.54 and RD per 100: 2.6, 95% CI:1.9–3.3). Age-stratified results revealed that older adult groups with obesity demonstrated weak or no associations with HCU. Conclusions: All measures of adiposity were positively associated with increased HCU although obesity may not be a strong predictor of HCU in older adults.

As the COVID-19 pandemic impacted mental health, this longitudinal study examined the effect of age-friendly communities (AFC) action plan on older adults’ depressive symptoms. Using the CLSA, the CLSA COVID-19 Questionnaire study, survey of Canadian municipalities, and the census, the depressive symptoms trajectories were modeled with multilevel multinomial regressions. Most respondents (66.1%) had non-depressed trajectories, 28.1% experienced a moderate increase in depressive symptoms, and 5.8% had a depressed trajectory. AFC action plans did not have a protective effect on these trajectories. Being a female, greater loneliness, lower income, ≥2 chronic conditions, inferior social participation, weaker sense of belonging, COVID-19 infection, and pandemic stressors predicted a depressed trajectory. Neighborhood’s deprivation had a weak protective effect on the declining trajectory. Although AFC action plans provided no benefits during the pandemic, volunteers facilitating resource access and social interactions could limit any increase in depressive symptoms.

Introduction:A breast cancer diagnosis may result in disabling effects which may persist after treatment. The aim of this study was to identify patient factors that are associated with increased cancer worry, fatigue, and impact on work. Methods:Women with a history of breast cancer, aged ≥18 years, and English-speaking were recruited through the Love Research Army between October and November 2019. Participants completed demographic and clinical questions alongside the BREAST-Q Cancer Worry, Fatigue, and Impact on Work scales. Univariable and multivariable regression analyses were used to identify participant characteristics associated with each scale. Results:Cancer Worry, Fatigue, and Impact on Work scales were completed by n= 1680, n= 1037, and n= 873 participants, respectively. Most participants were older than 50 (n= 1,470, 87.5%), married (n= 1229, 73.2%), white (n= 1557, 92.7%), and had undergone surgery for cancer treatment (n= 1,472, 87.6%). Increased Cancer Worry was significantly associated (P< .04) with younger age, less time since diagnosis, pain related to cancer/treatment, recurrence, prior chemotherapy, and ongoing breast edema. Increased Fatigue was significantly associated (P< .01) with elevated BMI, less time since diagnosis, ethnicity, employment status, recurrence, prior chemotherapy, ongoing pain, and difficulty sleeping secondary to treatment. Decreased Impact on Work scores was significantly associated (P< .04) with chemotherapy administration, shorter time since diagnosis, employment, fatigue related to treatment, breast edema, and ongoing pain. Conclusion:This study reveals patient characteristics associated with increased cancer worry, fatigue, and a negative impact on work following a breast cancer diagnosis. These findings can inform clinical and research initiatives to better support patients through treatment and survivorship.

ABSTRACTObjectivesThe aim of this study is to identify the types of community paramedicine programs and the training for each.MethodsA systematic review of MEDLINE, Embase, grey literature, and bibliographies followed a search strategy using common community paramedicine terms. All studies published in English up to January 22, 2018, were captured. Screening and extraction were completed in duplicate by two independent reviewers. The Mixed Methods Appraisal Tool (MMAT) was used to assess studies’ methodological quality (full methodology on PROSPERO: CRD42017051774).ResultsFrom 3,004 papers, there were 64 papers identified (58 unique community paramedicine programs). Of the papers with an appraisable study design (40.6%), the median MMAT score was 3 of 4 criteria met, suggesting moderate quality. Programs most often served frequent 911 callers (48.3%) and individuals at risk for emergency department admission, readmission, or hospitalization (41.4%); and 70.7% of programs were preventive home visits. Common services provided were home assessment (29.5%), medication management (39.7%), and referral and/or transport to community services (37.9%); and 77.6% of programs involved interprofessional collaboration. Community paramedicine training was described by 57% of programs and expanded upon traditional paramedicine training and emphasized technical skills. Study heterogeneity prevented meta-analysis.ConclusionCommunity paramedicine programs and training were diverse and allowed community paramedics to address a spectrum of population health and social needs. Training was poorly described. Enabling more programs to assess and report on program and training outcomes would support community paramedicine growth and the development of formalized training or education frameworks.

The cells of virtually all CLL cases, including those with unmutated (U) Ig gene heavy-chain variable regions ( IGHV) of poorer prognosis (U-CLL), exhibit variable degree of anergy. This is defined by (auto)antigen-mediated low surface immunoglobulin M (sIgM), but not sIgD, expression and signaling capacity, both reversible in vitro. In U-CLL there is also a tumor-related highly asymmetric use of IGHV1-69( 51p1allele) (~30% of all U-CLL vs ~1% of the normal B-cell repertoire), claiming selection by (auto)antigen. While the effect of (auto)antigen on sIgM down-modulation by endocytosis is well known, less is known about the biosynthetic mechanisms regulating sIgM expression.

It has largely been assumed that when an intentional community loses its charismatic leader for one reason or another, the group will most likely disband unless that individual’s charisma has become routinized. The Kashi Ashram in Sebastian, Florida, is a spiritual community that was established, thanks to the vision of their Guru, Ma Jaya Sati Bhagavati. Her students were so devoted to her that her physical death in 2012 could have initiated a crisis in the community. Although bureaucratic offices had been established to carry out some of the necessary functions of the Ashram, no one came close to filling her role as a spiritual teacher. And yet, more than 6 years later, new members are still joining the community and the way they describe Ma’s presence in their lives is little different from how older members that knew Ma in this lifetime talk about her. While I do not disagree that the routinization of charisma is an important step in ensuring the longevity of new religious movements, in this paper, I argue that an individual’s charisma may be transferred to a geographic place such that the Ashram becomes an active agent in the attraction and retention of new members.

This study sought to compare obstetrical outcomes for women with a cephalic presentation at birth resulting from successful external cephalic version (ECV) compared to those resulting from spontaneous cephalic version (SCV).

AbstractObjectivesThe consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a head injury on the functional outcomes six months post-injury in older adults who sustained a minor trauma.MethodsThis multicenter prospective cohort study in eight sites included patients who were aged 65 years or older, previously independent, presenting to the emergency department (ED) for a minor trauma, and discharged within 48 hours. To assess the functional decline, we used a validated test: the Older Americans’ Resources and Services Scale. The cognitive function of study patients was also evaluated. Finally, we explored the influence of a concomitant injury on the functional decline in the MT-HI group.ResultsAll 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 minor trauma without head injury. After six months, the functional decline was similar in both groups: 10.8% and 11.9%, respectively (RR=0.79 [95% CI: 0.55–1.14]). The proportion of patients with mild cognitive disabilities was also similar: 21.7% and 22.8%, respectively (RR=0.91 [95% CI: 0.71–1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR=1.35 [95% CI: 0.71–2.59]).ConclusionThis study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population, six months after injury.

BackgroundFrailty is a way to appreciate the variable vulnerability to declining health status of people as they age. No consensus for measuring frailty has been established. This study aimed to adapt a Frailty Index (FI) to the Canadian Longitudinal Study on Aging (CLSA) and evaluate its applicability in both younger and older adults.MethodsAn FI was created based on 90 potential health deficits collected from adults aged 45–85 years at recruitment (N=21 241, 49.0% male). The construct validity of this instrument and the factor structure of the health deficits were evaluated.ResultsThe direction of associations between the FI and other variables were consistent with a priorihypotheses for construct validity. FI values were significantly associated with age (r=0.17; p<0.001), falls (r=0.12; p<0.001), injuries (r=0.12; p<0.001), formal home care (r =0.30; p<0.001), informal home care (r=0.32; p<0.001) and use of assistive devices (r=0.40; p<0.001). Values were negatively associated with male sex (r=−0.12; p<0.001), income (r=−0.34; p<0.001) and education (r=−0.17; p<0.001). Key factors among the health indicators were physical functioning, satisfaction with life and depressive symptoms. Results did not change when the sample was stratified by age and sex.ConclusionThe FI is a feasible method to evaluate frailty and capture frailty-related heterogeneity in populations aged 45–85 years. In this study, the FI had good construct validity in middle-aged and older adults, showing expected correlations with sociodemographic factors consistently across age groups. This method can be easily reproduced in similar datasets, making the FI a generalisable instrument.

BackgroundWe examine the population impact on functional disability and social participation of physical and mental chronic conditions individually and in combination.MethodsCross-sectional, population-based data from community-dwelling people aged 45 years and over living in the 10 Canadian provinces in 2008–2009 were used to estimate the population attributable risk (PAR) for functional disability in basic (ADL) and instrumental (IADL) activities of daily living and social participation restrictions for individual and combinations of chronic conditions, stratified by age and gender, after adjusting for confounding variables.ResultsFive chronic conditions (arthritis, depression, diabetes, heart disease and eye disease) made the largest contributions to ADL-related and IADL-related functional disability and social participation restrictions, with variation in magnitude and ranking by age and gender. While arthritis was consistently associated with higher PARs across gender and most age groups, depression, alone and in combination with the physical chronic conditions, was associated with ADL and IADL disability as well as social participation restrictions in the younger age groups, especially among women. Compared to women, the combinations of conditions associated with higher PARs in men more often included heart disease and diabetes.ConclusionsOur findings suggest that in community-dwelling middle-aged and older adults, the impact of combinations of mental and physical chronic conditions on functional disability and social participation restriction is substantial and differed by gender and age. Recognising the differences in the drivers of PAR by gender and age group will ultimately increase the efficiency of clinical and public health interventions.

Abstract:Nous avons validé sept algorithmes d’évaluation de maladie chronique pour l’usage dans L’Étude longitudinale canadienne (ÉLCV) sur le vieillissement. Les algorithmes ont concerné le diabète type 2, parkinsonisme, obstruction chronique de flux d’air, ostéoarthrite de main, ostéoarthrite de hanche, ostéoarthrite de genou, et la maladie cardiaque ischémique. Notre recrutement de cible était 20 cas et contrôles par chaque maladie. Quelques cas ont été utilisés comme contrôles avec certaines maladies. Tous les participants ont répondu à des questionnaires au sujet des symptômes de la maladie et d’utilisation de médicaments. Les cas et les contrôles de diabète ont subi le test de jeûne de glucose et les cas et les contrôles de l’obstruction chronique de flux d’air ont subi le test de spirométrie. Pour chaque maladie, nous avons utilisé l’algorithme adapté pour classifier si les participants étaient positifs ou négatif pour la maladie. Nous avons également calculé la sensibilité et la spécificité utilisant le diagnostic de médecin comme norme. L’échantillon final a fait participer 176 participants, qui ont été recrutés dans trois villes canadiennes entre 2009 et 2011. La plupart des sensibilités et spécificités étaient 80% ou plus, indiquant que les sept algorithmes peuvent correctement identifier des personnes avec les maladies.Abstract:We validated seven chronic disease ascertainment algorithms for use in the Canadian Longitudinal Study on Aging. The algorithms pertained to diabetes mellitus type 2, parkinsonism, chronic airflow obstruction (CAO), hand osteoarthritis (OA), hip OA, knee OA, and ischemic heart disease. Our target recruitment was 20 cases and controls per disease; some cases were controls for unrelated diseases. Participants completed interviewer-administered disease symptom and medication use questionnaires. Diabetes cases and controls underwent fasting glucose testing; CAO cases and controls underwent spirometry testing. For each disease, the appropriate algorithm was used to classify participants’ disease status (positive or negative for disease). We also calculated sensitivity and specificity using physician diagnosis as the reference standard. The final sample involved 176 participants recruited in three Canadian cities between 2009 and 2011. Most estimated sensitivities and specificities were 80 per cent or more, indicating that the seven algorithms correctly identified individuals with the target disease.

To estimate the cumulative incidence of functional decline over 6 months following ED assessments of non-hospitalized injuries and to identify its main determinants.

To examine the association between cognitive function and dementia with vitamin D concentration in adults.

To conduct an environmental scan to identify the scope of literature on consumer products and injuries in seniors and to fill in some of the information gaps by exploring the relationship between assistive devices (AD) and fall-related injuries. The environmental scan included primary literature identified in Medline and EMBASE databases and grey literature was identified in Google and consumer product safety sites in the US, Canada, the UK, and Australia. Weighted logistic regression was then used to examine the relationship between socio-demographic factors, frailty indicators, and AD use at the time of the fall, and the type of health services utilized and psychological consequences of the fall based on data from the 2008–2009 Canadian Community Health Survey on Healthy Aging. The majority of the articles on consumer products and injuries reported secondary database sources and did not directly link the consumer product’s influence on a given injury. We found AD use at the time of a fall was associated with hospitalization, worry about re-injury, and limiting one’s activities due to this worry, even after adjustment for socio-demographic variables. When frailty variables were included in the model, however, AD use was no longer statistically significant. This study provides preliminary information on the relationship between AD use and fall-related outcomes. However, the current data are not sufficient to draw specific conclusions. More detailed questions regarding AD use for the entire population and additional questions regarding the contribution of the AD to the injury will help to provide a richer understanding of this relationship. Procéder à une analyse de l’environnement pour définir la portée de la documentation sur les produits de consommation et les blessures chez les personnes âgées et pour combler certaines données manquantes en explorant la relation entre les accessoires fonctionnels (AF) et les blessures liées aux chutes. L’analyse de l’environnement a inclus la documentation de base, répertoriée dans les bases de données Medline et EMBASE, et la littérature grise trouvée dans Google et sur les sites de sécurité des produits de consommation des États-Unis, du Canada, du Royaume-Uni et de l’Australie. Nous avons ensuite procédé à une analyse de régression logistique pondérée pour examiner la relation entre les facteurs sociodémographiques, les indicateurs de fragilité et l’utilisation d’AF au moment de la chute, d’une part, et le type de services de santé utilisés et les conséquences psychologiques de la chute, d’autre part, selon les données sur le vieillissement en santé dans l’Enquête sur la santé dans les collectivités canadiennes 2008–2009. La majorité des articles publiés sur les produits de consommation et les blessures citent des sources de données secondaires et ne font pas de lien direct entre les produits de consommation et tel ou tel type de blessure. Nous avons constaté que l’utilisation d’un AF au moment de la chute était associée à l’hospitalisation, à la crainte de se blesser à nouveau et à la restriction des activités en raison de cette crainte, même compte tenu des variables sociodémographiques. Quand nous avons inclus les variables de fragilité dans le modèle cependant, l’utilisation d’un AF n’était plus un facteur significatif. Notre étude donne des informations préliminaires sur la relation entre l’utilisation d’AF et les résultats sanitaires après une chute. Les données actuelles sont toutefois insuffisantes pour tirer des conclusions précises. Des questions plus détaillées sur l’utilisation des AF, à l’échelle de la population, et des questions supplémentaires sur le rôle des AF dans les blessures nous aideront à mieux comprendre la nature de cette relation.

Résumé:Les Canadiens vivent plus longtemps et les personnes plus âgées composent une part croissante de la population (14% en 2006, projeté d'atteindre 20% d'ici 2021). L'Étude longitudinale canadienne sur le vieillissement (ÉLCV) est une étude longitudinale nationale portant sur le développement adulte et le vieillissement qui recrutera 50 000 Canadien(ne)s âgé(e)s de 45 à 85 ans et qui les suivra pendant au moins 20 ans. Tous les participants fourniront un ensemble d'informations communes sur plusieurs aspects de la santé et du vieillissement, et 30 000 passeront un examen approfondi couplé au don de spécimens biologiques (sang et urine). L'ÉLCV deviendra une source de données riches pour l'étude d'inter-relations complexes entre les facteurs biologiques, physiques, psychosociaux et sociaux qui affectent le vieillissement en santé.Abstract:Canadians are living longer, and older persons are making up a larger share of the population (14% in 2006, projected to rise to 20% by 2021). The Canadian Longitudinal Study on Aging (CLSA) is a national longitudinal study of adult development and aging that will recruit 50,000 Canadians aged 45 to 85 years of age and follow them for at least 20 years. All participants will provide a common set of information concerning many aspects of health and aging, and 30,000 will undergo an additional in-depth examination coupled with the donation of biological specimens (blood and urine). The CLSA will become a rich data source for the study of the complex interrelationship among the biological, physical, psychosocial, and societal factors that affect healthy aging.

Résumé:Une des clés au succès de l'Étude longitudinale canadienne sur le vieillissement (ÉLCV) sera de tirer profit des sources de données secondaires, en particulier données relatives à l'utilisation des soins de santé (USS). Pour examiner les aspects pratiques, méthodologiques et éthiques d'accéder à des données sur l'USS, des entrevues qualitatives individuelles ont été réalisés auprès de 53 administrateurs de données et commissaires/ombudsman à la protection de la vie privée à travers le Canada. Les participants de l'étude ont indiqué que d'obtenir la permission d'accéder à des données sur l'USS est généralement possible; cependant, ils ont noté que ce processus sera complexe et long, exigeant des travaux préparatoires considérables et méticuleux afin de s'assurer que la documentation soit appropriée et que le tout soit conforme aux variations juridiques ainsi qu'aux lignes, législatives et politiques.Abstract:One of the keys to the success of the Canadian Longitudinal Study on Aging (CLSA) will be the leveraging of secondary data sources, particularly health care utilization (HCU) data. To examine the practical, methodological, and ethical aspects of accessing HCU data, one-on-one qualitative interviews were conducted with 53 data stewards and privacy commissioners/ombudsmen from across Canada. Study participants indicated that obtaining permission to access HCU data is generally possible; however, they noted that this will be a complex and lengthy process requiring considerable and meticulous preparatory work to ensure proper documentation and compliance with jurisdictional variations along legislative and policy lines.

Résumé:Les procédures diagnostiques cliniques standards sont souvent inappropriées et fréquemment non applicables dans des études basées sur la population; pourtant, vérifier le statut précis d'une maladie est essentiel. Nous avons fait une revue systématique pour identifier des algorithmes, des critères, et des outils utilisés pour identifier 17 maladies chroniques, et avons fait la praticabilité de développer des algorithmes pour l'ÉLCV. Des 29 616 citations examinées, 668 papiers ont rencontré tous les critères d'inclusion. Nous avons déterminé que l'information incluse dans un algorithme de maladie différera selon le type de condition. Le diagnostic de quelques conditions symptomatiques, telles l'arthrose et l'arthrite, exigera la justification par des critères cliniques (par exemple, rayons X, mesure de densité osseuse) tandis que d'autres conditions, telles la dépression, se baseront seulement sur les dires des individus. Les conditions asymptomatiques, telles l'hypertension, sont plus difficiles à vérifier par les dires des individus et exigeront des mesures physiologiques additionnelles (par exemple, tension artérielle) et des mesures de laboratoire (par exemple, glucose). Cette étude pilote a identifié les outils nécessaires pour développer des algorithmes d'évaluation de diagnostic.Abstract:Standard clinical diagnostic procedures are often inappropriate and frequently not feasible to apply in population-based studies, yet ascertaining accurate disease status is essential. We conducted a systematic review to identify algorithms, criteria, and tools used to ascertain 17 chronic diseases, and assessed the feasibility of developing algorithms for the CLSA. Of the 29,616 citations screened, 668 papers met all inclusion criteria. We determined that the information included in a disease algorithm will differ by condition type. The diagnosis of some symptomatic conditions, such as osteoarthritis and arthritis, will require substantiation by clinical criteria (e.g., x-rays, bone density measurement) while other conditions, such as depression, will rely solely on self-report. Asymptomatic conditions, such as hypertension, are more difficult to ascertain by self-report and will require additional physiologic measures (e.g., blood pressure) as well as laboratory measures (e.g., glucose). This pilot study identified the tools necessary to develop disease ascertainment algorithms.

Résumé:La collecte de spécimens biologiques est une partie intégrale de beaucoup d'études épidémiologiques longitudinales. Il est important d'obtenir un haut taux de satisfaction de la part des participants pour que leur participation soit continue et pour assurer une qualité élevée des échantillons pour avoir des mesures précises pour les biomarqueurs. Nous avons réalisé une étude pour évaluer ces questions sur la collecte d'échantillons proposée pour l'Étude longitudinale canadienne sur le vieillissement (ÉLCV). Parmi les 85 participants recrutés, 65 ont été dirigés vers un laboratoire d'hôpital ou un laboratoire privé. Environ 100 mL de sang et un prélèvement aléatoire d'urine ont été collectés pour chaque participant, pour un total de 2 108 aliquots d'échantillon. Les niveaux de qualité ont été atteints pour plus de 90% des échantillons et étaient semblables pour les échantillons collectés dans les deux laboratoires. Plus de 90% des participants ont exprimé que leur satisfaction par rapport à la collecte était bonne ou excellente, et 84% serait prêts à répéter la collecte dans un à trois ans.Abstract:Biological specimen collection is an integral part of many longitudinal epidemiological studies. It is important to achieve high participant satisfaction for continuing involvement, and high sample quality for accurate biomarker measurement. We conducted a study to evaluate these issues on the sample collection proposed for the Canadian Longitudinal Study on Aging (CLSA). There were 85 participants recruited, and 65 attended either a hospital laboratory or private laboratory. Approximately 100 mL of blood and a random urine specimen were collected from each participant for a total of 2,108 sample aliquots. Quality standards were met for more than 90 per cent of samples and were similar for samples collected in both laboratories. More than 90 per cent of participants rated satisfaction with the collection as being good or excellent, and 84 per cent would be willing to repeat the collection in one to three years.

Purpose: Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients. Methods: In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives. Results: Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74yr(HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to &lt; 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3–2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4–2.0); physician prediction of ICU survival [&lt; 10% (HR 15.0, 6.7–33.6)], 10 to 40% [(HR 5.0, 2.3–11.2), 41 to 60% (HR 4.0, 1.8–9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6–9.4) or partial advanced life support (HR 3.2, 2.2–4.6) compared to full measures]. Conclusion: One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.

ABSTRACTObjective:To determine the ability of troponin I (TnI) measurement to predict the likelihood of a serious cardiac outcome over the subsequent 72 hours in patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndrome.Methods:This prospective observational study enrolled consecutive patients presenting to 2 urban tertiary care hospital EDs over a 5-week period. Eligible patients included those for whom a TnI test was ordered within 24 hours of arrival and in whom no serious cardiac outcome occurred before the test result was available. Patients were followed for 72 hours and serious cardiac outcomes documented; these included cardiovascular death, myocardial infarction, congestive heart failure, serious arrhythmia and refractory pain. We calculated likelihood ratios (LRs) to describe the association of the TnI result with serious cardiac outcomes.Results:Of the 352 enrolled patients, 20 had a serious cardiac outcome within 72 hours of ED presentation. The derived LRs (and 95% confidence interval [CI]) were 0.5 (0.3–0.9) for TnI values <0.5 µg/L, 1.6 (0.4–6.5) for TnI values from 0.5 to 2.0 µg/L, 5.8 (1.7–19.5) for TnI values from >2.0 to 10.0 µg/L and 14.4 (4.8–42.9) for TnI values >10.0 µg/L.Conclusions:TnI values >2.0 µg/L are associated with an increased probability of serious cardiac outcomes within 72 hours. TnI values between 0.5 and 2.0 µg/L are weakly positive predictors. TnI values <0.5 µg/L have LRs in the range of 0.5 and thus are weakly negative predictors, not substantially decreasing the likelihood of serious cardiac outcomes, particularly in patients with a moderate or high pretest probability.

The chronic respiratory questionnaire (CRQ), a widely used measure of health-related quality of life (HRQL) in patients with chronic airflow limitation, includes an individualized dyspnea domain (patients identify five important activities, and report the degree of dyspnea on a 7-point scale). Because the individualized domain is unwieldy in multicenter clinical trials, we developed a standardized version and tested its discriminative and evaluative properties.

Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors.