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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2005.06.034 Byline: Peter C. Austin (a)(b)(c), Muhammad M. Mamdani (a)(c)(f), David N. Juurlink (a)(c)(d)(e), David A. Alter (a)(c)(g), Jack V. Tu (a)(b)(c)(d)(e) Abstract: The benefits of statins for the secondary prevention of coronary heart disease are well established. Previous research indicates that patients at the greatest risk of cardiovascular events are the least likely to receive statins. We explored the potential reduction in mortality at the population level that could result from improving statin prescribing among patients least likely to be prescribed a statin after acute myocardial infarction (AMI). Author Affiliation: (a) Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (b) Department of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada (c) Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (f) Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (d) Clinical Epidemiology and Health Care Research Program (Sunnybrook and Women's College Site), University of Toronto, Toronto, Canada (e) Division of General Internal Medicine, Sunnybrook and Women's College Health, Sciences Centre and the University of Toronto, Toronto, Ontario, Canada (g) Division of Cardiology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada Article History: Received 18 March 2005; Accepted 17 June 2005 Article Note: (footnote) The Institute for Clinical Evaluative Sciences is supported in part by a grant from the Ontario Ministry of Health and Long-term Care. The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry of Health and Long-term Care or by the Institute for Clinical Evaluative Sciences is intended or should be inferred. This research was supported in part by operating grants from the Canadian Institutes of Health Research (CIHR) and the Heart and Stroke Foundation to the Canadian Cardiovascular Outcomes Research Team. Drs Austin, Mamdani, and Juurlink are supported by New Investigator awards from the CIHR. Dr Juurlink is also supported by the University of Toronto Drug Safety Research Group. Dr Alter is supported by a New Investigator award from the CIHR and the Heart and Stroke Foundation. Dr Tu is supported by a Canada Research Chair in Health Services Research.

Two population-based, nested case-control studies were conducted among case patients treated in the hospital for hypoglycemia and hyperglycemia. The experiment revealed that as compared with the use of other broad-spectrum oral antibiotics, including other fluoroquinolones, the use of gatifloxacin among outpatients is associated with an increased risk of in-hospital treatment for both hypoglycemia and hyperglycemia.

Objective. Croup is the most common form of airway obstruction in children. Known to be primarily viral, the seasonality of croup has been examined largely through its association with the human para-influenza viruses. This study examined the seasonal pattern of croup hospitalizations in relation to age and gender for the province of Ontario during a 14-year period. Methods. A retrospective, population-based study design was used to examine seasonal and temporal patterns of croup hospitalizations from April 1, 1988, to March 31, 2002. All residents of Ontario who were aged 0 to 4 years and eligible for universal health coverage during the study period were included for analysis. Time-series analyses then were conducted on monthly aggregations of hospitalizations. Results. This study found strong evidence of croup hospitalization seasonality, with a biennial midautumn peak and annual summer trough, evident throughout the 14-year study period (Fisher's [kappa] = 51.11; Bartlett Kolmogorov Smirnov = 0.552). The pattern was observed in all children aged 0 to 4, although boys were hospitalized 2 times more often than girls of the same age. Rates of croup hospitalization were lower for children aged I to 4 years than for children aged 0 to Conclusions. This study delineates a clear biennial pattern of seasonal croup hospitalizations, varying by age and gender, with a large decrease in hospitalizations after the winter of 1993/1994. It is expected that these findings will have important implications for the treatment and management of childhood croup. Pediatrics 2005;116:51-55; croup, hospital records, time, periodicity. ABBREVIATION. HPIV, human parainfluenza virus., Croup (laryngotracheobronchitis) is the most common form of airway obstruction in children between the ages of 6 months and 6 years, peaking between the ages of 1 and 2 years. [...]

The publication of Randomized Aldactone Evaluation Study (RALES) was associated with an abrupt increase in the rate of prescriptions for sprironolactone among older patients in Ontario who were treated with angiotensin-converting-enzyme (ACE) inhibitors, regardless of whether or not they had previously been hospitalized for heart failure is found. Closer laboratory monitoring and more judicious use of spironolactone may reduce the occurrence of this complication.

The association between physicians' treatment aggressiveness and baseline cardiovascular risk is examined. The study concluded that prescription of statins, diminished progressively as baseline cardiovascular risk and probability of death increased.

Although forearm arteriovenous fistulas (AVFs) are the preferred initial vascular access for hemodialysis based on national guidelines, there are no population-level studies evaluating trends in creation of forearm vs upper arm AVFs and arteriovenous grafts (AVGs). The purpose of this study was to report temporal trends in first-time permanent hemodialysis access type, and to assess the effect of national initiatives on rates of AVF placement. Retrospective cross-sectional study (2012-2022) utilizing the Vascular Quality Initiative database. All patients older than 18 years with creation of first-time upper extremity surgical hemodialysis access were included. Anatomic location of the AVF or AVG (forearm vs upper arm) was defined based on inflow artery, outflow vein, and presumed cannulation zone. Primary analysis examined temporal trends in rates of forearm vs upper arm AVFs and AVGs using time series analyses (modified Mann-Kendall test). Subgroup analyses examined rates of access configuration stratified by age, sex, race, dialysis, and socioeconomic status. Interrupted time series analysis was performed to assess the effect of the 2015 Fistula First Catheter Last initiative on rates of AVFs. Of the 52,170 accesses, 57.9% were upper arm AVFs, 25.2% were forearm AVFs, 15.4% were upper arm AVGs, and 1.5% were forearm AVGs. From 2012 to 2022, there was no significant change in overall rates of forearm or upper arm AVFs. There was a numerical increase in upper arm AVGs (13.9 to 18.2 per 100; P =.09), whereas forearm AVGs significantly declined (1.8 to 0.7 per 100; P =.02). In subgroup analyses, we observed a decrease in forearm AVFs among men (33.1 to 28.7 per 100; P =.04) and disadvantaged (Area Deprivation Index percentile ≥50) patients (29.0 to 20.7 per 100; P =.04), whereas female (17.2 to 23.1 per 100; P =.03), Black (15.6 to 24.5 per 100; P <.01), elderly (age ≥80 years) (18.7 to 32.5 per 100; P <.01), and disadvantaged (13.6 to 20.5 per 100; P <.01) patients had a significant increase in upper arm AVGs. The Fistula First Catheter Last initiative had no effect on the rate of AVF placement (83.2 to 83.7 per 100; P =.37). Despite national initiatives to promote autogenous vascular access, the rates of first-time AVFs have remained relatively constant, with forearm AVFs only representing one-quarter of all permanent surgical accesses. Furthermore, elderly, Black, female, and disadvantaged patients saw an increase in upper arm AVGs. Further efforts to elucidate factors associated with forearm AVF placement, as well as potential physician, center, and regional variation is warranted. [ABSTRACT FROM AUTHOR]

Drug interactions are a major cause of hospital admissions among elderly patients, according to a study of all elderly Ontario residents who took glyburide, digoxin, or an ACE inhibitor between 1994 and 2000. Many of the patients were hospitalized with hypoglycemia, digoxin toxicity, or elevated potassium levels. These are all caused by other drugs that interact with glyburide, digoxin, or ACE inhibitors. Most of these interactions are known, and could be prevented.

Background: The primary aim of this study was to determine if screen use in early childhood is associated with overall vulnerability in school readiness at ages 4 to 6 years, as measured by the Early Development Instrument (EDI). Secondary aims were to: (1) determine if screen use was associated with individual EDI domains scores, and (2) examine the association between screen use and EDI domains scores among a subgroup of high screen users.Methods: This prospective cohort study was carried out using data from young children participating in a large primary care practice-based research network in Canada. Logistic regression analyses were run to investigate the association between screen use and overall vulnerability in school readiness. Separate linear regression models examined the relationships between children's daily screen use and each separate continuous EDI domain.Results: A total of 876 Canadian participants participated in this study. Adjusted logistic regression revealed an association between increased screen use and increased vulnerability in school readiness (p = 0.05). Results from adjusted linear regression demonstrated an association between higher screen use and reduced language and cognitive development domain scores (p = 0.004). Among high screen users, adjusted linear regression models revealed associations between increased screen use and reduced language and cognitive development (p = 0.004) and communication skills and general knowledge domain scores (p = 0.042).Conclusions: Screen use in early childhood is associated with increased vulnerability in developmental readiness for school, with increased risk for poorer language and cognitive development in kindergarten, especially among high users. [ABSTRACT FROM AUTHOR]

Objectives: To quantify the real‐world survival benefit of re‐resection vs no re‐resection in patients diagnosed with T1 bladder cancer (BC) at the population level. Patients and Methods: Retrospective population‐wide observational cohort study based on pathology reports linked to health administrative data. We identified patients who were diagnosed with T1 BC in the province of Ontario (01/2001–12/2015) and used billing claims to ascertain whether they received re‐resection within 2–10 weeks. The time‐dependent effect of re‐resection on survival outcomes was modelled by Cox proportional hazards regression (unadjusted and adjusted for numerous assumed patient‐ and surgeon‐level confounding variables). Effect measures were presented as hazard ratios (HRs) and 95% confidence intervals (CIs). Results: We identified 7666 patients of which 2162 (28.7%) underwent re‐resection after a median (interquartile range) time of 45 (35–56) days. Patients who received re‐resection were less likely to die from any causes (HR 0.68, 95% CI 0.63–0.74, P < 0.001) and from BC (HR 0.66, 95% CI 0.57–0.76, P < 0.001) during any time of follow‐up. After adjusting for all assumed confounding variables, re‐resection was still significantly associated with a lower overall mortality (HR 0.88, 95% CI 0.81–0.95, P < 0.001), while the association with cancer‐specific survival marginally lost its statistical significance (HR 0.87, 95% CI 0.75–1.02, P = 0.08). Conclusions: A second transurethral resection within 2–6 weeks after the initial resection (i.e. re‐resection) is recommended for patients diagnosed with primary T1 BC as prior studies suggest therapeutic, diagnostic, and prognostic benefits. However, results on survival endpoints are sparse, conflicting, and often affected by various biases. To the best of our knowledge, the present population‐wide study represents the largest cohort of patients diagnosed with T1 BC and provides real‐world evidence supporting the utilisation of re‐resection in this group of patients. [ABSTRACT FROM AUTHOR]

Purpose: Prior research has shown that concordance with the guideline-endorsed recommendation to re-resect patients diagnosed with primary T1 bladder cancer (BC) is suboptimal. Therefore, the aim of this population-based study was to identify factors associated with re-resection in T1 BC. Materials and Methods: We linked province-wide BC pathology reports (January 2001 to December 2015) with health administrative data sources to derive an incident cohort of patients diagnosed with T1 BC in the province of Ontario, Canada. Re-resection was ascertained by a billing claim for transurethral resection within 2 to 8 weeks after the initial resection, accounting for systemrelated wait times. Multivariable logistic regression analysis accounting for the clustered nature of the data was used to identify various patient-level and surgeon-level factors associated with re-resection. P values <0.05 were considered statistically significant (2-sided). Results: We identified 7,373 patients who fulfilled the inclusion criteria. Overall, 1,678 patients (23%) underwent re-resection. Patients with a more aggressive tumor profile and individuals without sufficiently sampled muscularis propria as well as younger, healthier and socioeconomically advantaged patients were more likely to receive re-resection (all p <0.05). In addition, more senior, lower volume and male surgeons were less likely to perform re-resection for their patients (all p <0.05). Conclusions: Only a minority of all patients received re-resection within 2 to 8 weeks after initial resection. To improve the access to care for potentially underserved patients, we suggest specific knowledge translation/exchange interventions that also include equity aspects besides further promotion of evidence-based instead of eminence-based medicine. [ABSTRACT FROM AUTHOR]

Many elderly patients who take a statin drug to lower their cholesterol may stop taking the drug after a year or two, according to a study of 143,505 patients. Two years after they started, only 40% of those who had a heart attack were still taking the drug, only 36% who had coronary artery disease were still taking the drug, and only 25% who only had high cholesterol levels were taking still taking the drug., Context: Landmark clinical trials have demonstrated the survival benefits of statins, with benefits usually starting after 1 to 2 years of treatment. Research prior to these trials of older lipid-lowering agents demonstrated low levels of 1-year adherence. Objective: To compare 2-year adherence following statin initiation in 3 cohorts of patients: those with recent acute coronary syndrome (ACS), those with chronic coronary artery disease (CAD), and those without coronary disease (primary prevention). Design and Setting: Cohort study using linked population-based administrative data from Ontario. Patients: All patients aged 66 years or older who received at least 1 statin prescription between January 1994 and December 1998 and who did not have a statin prescription in the prior year were followed up for 2 years from their first statin prescription. There were 22379 patients in the ACS, 36106 in the chronic CAD, and 85020 in the primary prevention cohorts. Main Outcome Measures: Adherence to statins, defined as a statin being dispensed at least every 120 days after the index prescription for 2 years. Results: Two-year adherence rates in the cohorts were only 40.1 % for ACS, 36.1 % for chronic CAD, and 25.4% for primary prevention. Relative to the ACS cohort, nonadherence was more likely among patients receiving statins in the chronic CAD (relative risk [RR], 1.14; 95% Cl, 1.11-1.16) and primary prevention cohorts (RR, 1.92; 95% Cl, 1.87-1.96). Conclusions: Elderly patients with and without recent ACS have low rates of adherence to statins. This suggests that many patients initiating statin therapy may receive no or limited benefit from statins because of premature discontinuation.