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Introduction: A clinical prediction tool to estimate life expectancy in community-dwelling individuals living with dementia could inform healthcare decision-making and prompt future planning. An existing Ontario-based tool for community-dwelling elderly individuals does not perform well in people living with dementia specifically. This study seeks to develop and validate a clinical prediction tool to estimate survival in community-dwelling individuals living with dementia receiving home care in Ontario, Canada., Methods and Analysis: This will be a population-level retrospective cohort study that will use data in linked healthcare administrative databases at ICES. Specifically, data that are routinely collected from regularly administered assessments for home care will be used. Community-dwelling individuals living with dementia receiving home care at any point between April 2010 and March 2020 will be included (N≈200 000). The model will be developed in the derivation cohort (N≈140 000), which includes individuals with a randomly selected home care assessment between 2010 and 2017. The outcome variable will be survival time from index assessment. The selection of predictor variables will be fully prespecified and literature/expert-informed. The model will be estimated using a Cox proportional hazards model. The model's performance will be assessed in a temporally distinct validation cohort (N≈60 000), which includes individuals with an assessment between 2018 and 2020. Overall performance will be assessed using Nagelkerke's R 2 , discrimination using the concordance statistic and calibration using the calibration curve. Overfitting will be assessed visually and statistically. Model performance will be assessed in the validation cohort and in prespecified subgroups., Ethics and Dissemination: The study received research ethics board approval from the Sunnybrook Health Sciences Centre (SUN-6138). Abstracts of the project will be submitted to academic conferences, and a manuscript thereof will be submitted to a peer-reviewed journal for publication. The model will be disseminated on a publicly accessible website (www.projectbiglife.com)., Trial Registration Number: NCT06266325 (clinicaltrials.gov)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The direction and magnitude of association between maternal exposure to ambient air pollutants across gestational windows and offspring risk of autism spectrum disorders (ASD) remains unclear. We sought to evaluate the time-varying effects of prenatal air pollutant exposure on ASD. We conducted a matched case-control study of singleton term children born in Ontario, Canada from 1-Apr-2012 to 31-Dec-2016. Provincial birth registry data were linked with applied behavioural analysis services and ambient air pollutant datasets to ascertain prenatal exposure to nitrogen dioxide (NO 2 ), ground-level ozone (O 3 ), fine particulate matter (PM 2.5 ), and ASD diagnoses. Covariate balance between cases and controls was established using coarsened exact matching. Conditional logistic regression was used to assess the association between prenatal air pollutant exposure and ASD. Distributed lag non-linear models (DLNM) were used to examine the effects of single-pollutant exposure by prenatal week. Sensitivity analyses were conducted to assess the impact of exposure period on the observed findings. The final sample included 1589 ASD cases and 7563 controls. Compared to controls, cases were more likely to be born to mothers living in urban areas, delivered by Caesarean section, and assigned male sex at birth. NO 2 was a consistent and significant contributor to ASD risk after accounting for co-exposure to O 3 , PM 2.5 and covariates. The odds ratio per interquartile range increase was 2.1 (95%CI 1.8-2.3) pre-conception, 2.2 (2.0-2.5) for the 1st trimester, 2.2 (1.9-2.5) for the 2nd trimester, and 2.1 (1.9-2.4) for the 3rd trimester. In contrast, findings for O 3 and PM 2.5 with ASD were inconsistent. Findings from DLNM and sensitivity analyses were similar. Exposure to NO 2 before and during pregnancy was significantly associated with ASD in offspring. The relationship between prenatal O 3 and PM 2.5 exposure and ASD remains unclear. Further investigation into the combined effects of multi-pollutant exposure on child neurodevelopment is warranted., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe delirium incidence before and during the COVID-19 pandemic and examine factors associated with delirium incidence in the long-term care setting., Methods: We conducted a retrospective cohort study of Ontario long-term care residents without severe cognitive impairment or baseline delirium with an assessment between February 1, 2019, and March 31, 2021. Data were collected from the interRAI Minimum Data Set (MDS) 2.0. The outcome of interest was delirium development. Selected independent variables were entered into univariate longitudinal generalized estimating equations, followed by multivariate analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported., Results: A total of 63,913 residents were included within the comparison sample from February 2019 to February 2020. The pandemic sample consisted of 54,867 residents from March 2020 to March 2021. Incidence of delirium in the comparison sample was 3.4% (2158 residents) compared to 3.2% (1746 residents) in the pandemic sample (P = 0.06). Residents who were older, cognitively impaired, and increasingly frail had greater odds of developing delirium. Increased odds were associated with a diagnosis of bipolar disorder (OR 1.27, 95% CI 1.07-1.51) and anxiolytic use (OR 1.12, 95% CI 1.01-1.25). Residents who were newly admitted (OR 0.65, 95% CI 0.60-0.71) and those dependent for activities of daily living (OR 0.46, 95% CI 0.33-0.64) had lower odds of delirium development., Conclusions and Implications: The incidence of delirium did not differ between the year prior to and the first year of the COVID-19 pandemic, indicating that preventative interventions employed by long-term care homes may have been effective. Long-term care residents who are older, frail, cognitively impaired, or had unstable health would benefit from targeted interventions to prevent delirium. Newly admitted residents or those dependent in activities of daily living had lower odds of developing delirium, which could indicate under detection in these groups., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Kennedy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Little is known about patient outcomes following treatment of malignant pleural effusions (MPE) in the real-world setting., Research Question: We aimed to compare post-procedure all-cause mortality between individuals who received indwelling pleural catheter (IPC) insertion versus chemical pleurodesis for managing MPEs., Study Design and Methods: We performed a retrospective population-based study using provincial health administrative data (Ontario, Canada) of adults with a MPE who underwent IPC insertion or chemical pleurodesis between 2015 and 2019. Individuals were followed until death or March 31, 2021. Difference in post-procedure mortality was calculated using inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazard regression analysis to balance potential confounders at baseline., Results: We identified 4,790 (77.3%) individuals who received an IPC and 1,407 (22.7%) who had chemical pleurodesis for MPE. IPC insertions are increasing and chemical pleurodesis procedures are decreasing. The majority of IPCs were inserted in outpatients (61%), by pulmonologists (64.2%) and at sites with higher annual IPC volume, while chemical pleurodesis procedures were generally done by thoracic surgeons (74%) and at sites with higher annual pleurodesis volumes. In unadjusted comparison median time from initial cancer diagnosis to intervention was significantly longer in the IPC group (244 days, interquartile range [IQR]:33-903) compared to pleurodesis group (81 days, IQR:10-737; p < 0.0001). Unadjusted median time from index procedure to death was significantly longer in the pleurodesis group (165[IQR:48-457] days vs. 81[IQR:29-256] days, p < 0.0001), however the difference between groups became insignificant after the IPTW was applied (HR 1.27, 95%CI 0.95-1.69). 35% of IPCs were removed prior to death or end of follow-up., Interpretation: After adjusting for differences in baseline characteristics there was no difference in post-procedure mortality between IPC and chemical pleurodesis groups. In the real world, there are significant differences in the characteristics of patients who receive these two procedures and notable regional practice variation between procedure use. Future research should evaluate these variations in care and their effect on patient outcomes., Competing Interests: Declarations Ethics Approval The use of the provincial (Ontario, Canada) health administrative data in this project was authorized under section 45 of Ontario’s Personal Health Information Protection Act (PHIPA), which does not require review by a Research Ethics Board. Details of publicly funded health services and individual-level characteristics are retained in health administrative databases housed at ICES an independent, non-profit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement Consent for publication Not applicable Competing interests The authors declare no competing interests. Clinical trial number Not applicable, (© 2024. The Author(s).)

Background: The real-world consequences of a Philips Respironics recall for positive airway pressure (PAP) devices distributed between 2009 and 2021 are unknown., Methods: We conducted a retrospective population-based study using health administrative databases (Ontario, Canada) on all new adult PAP users identified through the provincial funding system, free of cancer at baseline, who initiated (claimed) PAP treatment between 2012 and 2018. Everyone was followed from the PAP claim date to the earliest of incident cancer diagnosis, death or end of follow-up (March 2022). We used inverse probability of treatment weighting to balance baseline characteristics between individuals on recalled devices and those on devices from other manufacturers. Weighted hazard ratios of incident cancer were compared between groups., Results: Of 231 692 individuals identified, 58 204 (25.1%) claimed recalled devices and 173 488 (74.9%) claimed devices from other manufacturers. A meaningful baseline difference between groups (standardised difference ≥0.10) was noted only by location-relevant covariates; other variables were mostly equally distributed (standardised differences ≤0.06). Over a median (interquartile range) follow-up of 6.3 (4.9-8.0) years, 11 166 (4.8%) developed cancer: unadjusted rates per 10 000 person-years of 78.8 (95% CI 76.0-81.7) in the recall group versus 74.0 (95% CI 72.4-75.6) in others (p=0.0034). Propensity score weighting achieved excellent balance in baseline characteristics between groups (standardised differences ≤0.07). On a weighted sample, there was no statistical difference in the hazard of incident cancer between groups: cause-specific hazard ratio (recalled versus others) 0.97 (95% CI 0.89-1.06)., Conclusion: In our real-world population study, compared to other manufacturers and adjusting for confounders, recalled Philips Respironics PAP devices do not appear to be independently associated with developing cancer., Competing Interests: Conflict of interest: All authors declare they have no potential conflicts of interest. T. Kendzerska and A.S. Gershon are supported by the PSI (Physicians’ Services Incorporated) Foundation. Outside of the submitted work, S.R. Pendharkar has received honoraria from Jazz Pharmaceuticals, Paladin Labs and the International Centre for Professional Development in Health and Medicine for participation in educational activities, and grant funding from Jazz Pharmaceuticals. Outside of the submitted work, M. Povitz has received a fellowship grant from Paladin Labs and contract research from Jazz Pharmaceuticals. Outside of the submitted work, N. Ayas has received a speaker honorarium from ResMed, and has been a consultant with EISAI, Jazz and Powell Mansfield. Outside of the submitted work, M. Kaminska is a consultant for Biron Soins du Sommeil and reports a Philips investigator-initiated research grant (pending). Outside of the submitted work, the University of California San Diego (UCSD) Sleep Medicine Center received a donation from ResMed., (Copyright ©The authors 2024. For reproduction rights and permissions contact permissions@ersnet.org.)

Background: Health systems had to rapidly implement infection control strategies to sustain their workforces during the COVID-19 pandemic. Various outbreak response tools, such as digital contact tracing (DCT), have been developed to monitor exposures and symptoms of health care workers (HCWs). Limited research evidence exists on the experiences with these technologies and the impacts of DCT innovations from the perspective of stakeholders in health care environments., Objective: This study aims to identify the factors influencing the adoption of DCT, highlight variations in perspectives across 3 key stakeholder groups concerning the impact of DCT, and provide benchmarking evidence for future pandemic preparedness., Methods: Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we conducted an exploratory qualitative study to investigate the implementation and impact of DCT at the Children's Hospital of Eastern Ontario between December 2022 and April 2023. We conducted 21 semistructured interviews with key stakeholders, including health care administrators (6/21, 29%), occupational health and safety specialists (8/21, 38%), and HCWs (7/21, 33%). Stakeholders were asked about the factors influencing engagement with the DCT tool, organizational-level uptake, the implementation process, long-term use and sustainability of DCT, and unintended consequences. Verbatim transcripts were subject to thematic analysis using NVivo (QSR International)., Results: The implementation of DCT was viable and well received. End users indicated that their engagement with the DCT tool was facilitated by its perceived ease of use and the ability to gain awareness of probable COVID-19 exposures; however, risk assessment consequences and access concerns were reported as barriers (reach). Participants commonly agreed that the DCT technology had a positive influence on the hospital's capacity to meet the demands of COVID-19 (effectiveness). Implementors and occupational specialists referred to negative staffing impacts and the loss of nuanced information as unintended consequences (effectiveness). Safety-focused communication strategies and having a DCT tool that was human-centered were crucial factors driving staff adoption of the technology. Conversely, adoption was challenged by the misaligned delivery of the DCT tool with HCWs' standard practices, alongside the evolving perceived threat of COVID-19. Stakeholders collectively agreed on the viability of DCT and its applicability to infectious disease practices (maintenance)., Conclusions: Hospital stakeholders were highly satisfied with DCT technology and it was perceived as feasible, efficient, and having a positive impact on organizational safety. Challenges related to the alignment and delivery of DCT, alongside the evolving perspectives on COVID-19, posed obstacles to continued adoption by HCWs. Our findings contribute to evidence-based practices and present benchmarks that can inform preparedness for future pandemics and infectious disease outbreaks and help other organizations implement similar technologies., (©Brynn O'Dwyer, Mirou Jaana, Charles Hui, Samia Chreim, Jennifer Ellis. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 05.11.2024.)

Objective: To evaluate the relationship between a predelivery history of concussion and risk of severe maternal mental illness., Methods: We conducted a population based cohort study of birthing people with a singleton livebirth accrued between 2007 and 2017 with follow-up to 2021 in Ontario, Canada. The primary outcome was severe maternal mental illness, defined as a psychiatric emergency department visit, psychiatric hospital admission, or self-harm or suicide in the 14 years after delivery. Cox proportional hazards regression generated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) comparing those with a history of a health care encounter for concussion between database inception and the index delivery date to those without a recorded health care encounter for concussion, adjusted for maternal age, parity, neighborhood income quintile, rural residence, immigration status, chronic conditions, history of interpersonal violence, and history of mental illness. Results were also stratified by history of mental illness., Results: There were n = 18,064 birthing people with a history of concussion and n = 736,689 without a history of concussion. Those with a history of concussion had an increased risk of severe maternal mental illness compared to those without this history (14.7 vs 7.9 per 1,000 person-years; aHR 1.25, 95% CI, 1.20-1.31). After stratification by predelivery history of mental illness, the association was strongest in individuals with no mental illness history (aHR 1.33, 95% CI, 1.23-1.44)., Conclusion: These findings indicate the need for early identification and screening of birthing people with a history of concussion, as well as ongoing long-term supports using trauma informed approaches to prevent adverse psychiatric outcomes., (© Copyright 2024 Physicians Postgraduate Press, Inc.)

Background: Although suspicions of cancer may be raised in patients who visit the emergency department, little is known about emergency department use before a cancer diagnosis. We sought to describe emergency department use among patients in Ontario within the 90 days before confirmed cancer diagnosis and to evaluate factors associated with this emergency department use., Methods: We conducted a retrospective, population-based study of patients aged 18 years or older who had a confirmed cancer diagnosis in Ontario from 2014 to 2021 using linked administrative databases. The primary outcome was any emergency department visit within 90 days before the cancer diagnosis date. We used multivariable logistic regression to evaluate factors associated with emergency department use, such as demographics (e.g., age, sex, rurality, Ontario Health region, indicators of marginalization), comorbidities, previous emergency department visits and hospital admissions, continuity of primary care, type of cancer, and year of cancer diagnosis., Results: We included 651 071 patients with cancer. Of these, 229 683 (35.3%) had an emergency department visit within 90 days before diagnosis, 51.4% of whom were admitted to hospital from the emergency department. Factors associated with increased odds of emergency department use before cancer diagnosis included rurality (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.13-1.17), residence in northern Ontario (North East region OR 1.14, 95% CI 1.10-1.17 and North West region OR 1.27, 95% CI 1.21-1.32, v. Toronto region), and living in the most marginalized areas (material resources OR 1.37, 95% CI 1.35-1.40 and housing OR 1.09, 95% CI 1.06-1.11, v. least marginalized quintile). We observed significant variation in emergency department use by cancer type, with high odds of emergency department use among patients with intracranial, pancreatic, liver or gallbladder, or thoracic cancer., Interpretation: Emergency department use is common before cancer diagnosis, with about one-third of patients with cancer in Ontario using the emergency department before diagnosis. Understanding why patients visit the emergency department before cancer diagnosis is important, particularly for patients who live in rural or marginalized areas, or those who have specific cancer types., Competing Interests: Competing interests:: Keerat Grewal reports grants from the Canadian Institutes of Health Research (CIHR) and the Canadian Association of Emergency Physicians. David Savage reports grants from CIHR, the Northern Ontario Academic Medical Association, the Natural Sciences and Engineering Research Council of Canada, and the Thunder Bay Regional Health Research Institute. Bjug Borgundvaag received speaker fees from the European Society of Emergency Medicine. Jonathan Irish is vice-president, clinical of Cancer Care Ontario–Ontario Health and participates on the board of the Canadian Cancer Society. Monika Krzyzanowska reports funding from Exilixis, Bayer, Eli Lilly, Novartis, and Eisai; honoraria from Eisai and Ipsen; participation on a data safety monitoring board with Novartis; and a leadership role with Cancer Care Ontario–Ontario Health. Venkatesh Thiruganasambandamoorthy reports funding from the Physician’s Service Incorporated Foundation and the University of Ottawa, consulting fees from the National Institute of Health, and chairships with the University of Ottawa and the Society for Academic Emergency Medicine. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has shown wastewater (WW) surveillance to be an effective means of tracking the emergence of viral lineages which arrive by many routes of transmission including via transportation hubs. In the Canadian province of Ontario, numerous municipal wastewater treatment plants (WWTPs) participate in WW surveillance of infectious disease targets such as SARS-CoV-2 by qPCR and whole genome sequencing (WGS). The Greater Toronto Airports Authority (GTAA), operator of Toronto Pearson International Airport (Toronto Pearson), has been participating in WW surveillance since January 2022. As a major international airport in Canada and the largest national hub, this airport is an ideal location for tracking globally emerging SARS-CoV-2 variants of concern (VOCs). In this study, WW collected from Toronto Pearson's two terminals and pooled aircraft sewage was processed for WGS using a tiled-amplicon approach targeting the SARS-CoV-2 virus genome. Data generated was analyzed to monitor trends of SARS-CoV-2 lineage frequencies. Initial detections of emerging lineages were compared between Toronto Pearson WW samples, municipal WW samples collected from the surrounding regions, and Ontario clinical data as published by Public Health Ontario. Results enabled the early detection of VOCs and individual mutations emerging in Ontario. On average, the emergence of novel lineages at the airport preceded clinical detections by 1-4 weeks, and up to 16 weeks in one case. This project illustrates the efficacy of WW surveillance at transitory transportation hubs and sets an example that could be applied to other viruses as part of a pandemic preparedness strategy and to provide monitoring on a mass scale., (© 2024. The Author(s).)

Background: Porcine reproductive and respiratory syndrome (PRRS) is one of the important endemic diseases in swine populations. Monitoring PRRS frequency in commercial herd populations has often been based on laboratory submissions. However, a limitation of this approach is that new clinical outbreaks of PRRS are challenging to identify if epidemiological information is not provided. This hinders the estimation of basic measures such as incidence., Objectives: The objectives of this study were to describe a system to monitor new clinical outbreaks in Ontario sow herds and to report the incidence of clinical PRRS outbreaks in a subset of Ontario sow herds., Procedure: We compared herd-level outbreak data from January 1, 2017 to December 31, 2019. Cases were confirmed as positive based on observation of sow herds with typical clinical signs suggestive of PRRS, followed by laboratory confirmation of the PRRS virus., Results and Conclusion: The incidences from year to year were similar ( P = 0.058) and were lower compared to estimates in the United States. Descriptively, the highest cumulative incidence was during 2018 (annual incidence risk = 0.067 cases per 100 sow herds, 95% CI = 0.050 to 0.090). This was characterized by an unusually high number of cases reported in the summer., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Objectives: To compare reoperation rates of acute versus delayed reverse total shoulder arthroplasty (RTSA) following a period of nonoperative treatment for proximal humerus fractures (PHFs). We also aimed to identify an optimal time interval from PHF to RTSA before the risk of reoperation significantly increased., Methods:  ., Design: Database review., Setting: Ontario, Canada., Patient Selection Criteria: Adults aged 50 years and older who sustained a PHF (OTA/AO 11A-C) between 2004 and 2019 were included. Exclusion criteria included polytrauma, open fractures, non-Ontario residents, invalid health insurance, and any operative treatment before RTSA., Outcome Measures and Comparisons: The primary outcome measure was reoperation within 2 years following RTSA. A risk-adjusted, restricted cubic spline was used to model the probability of reoperation according to the time elapsed between PHF and RTSA to identify a time point at which the risk of reoperation significantly increased. A multivariate logistics regression was used to identify predictors., Results: In total, 891 patients (685 acute, 206 delayed) underwent RTSA for PHF. The acute cohort had a significantly lower reoperation rate (3.9%) compared with the delayed cohort (8.3%) (P = 0.02). The odds of reoperation increased with a delay to RTSA greater than 28 days and continued to rise until 100 days after fracture. Patients who underwent RTSA 28 days after PHF were found to have a significantly higher odds of reoperation by 2 years (P = 0.03)., Conclusions: Among patients undergoing RTSA for acute PHFs, a delay to surgery greater than 28 days is associated with a greater odds of reoperation and may be useful when counseling patients., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Delays in promptly recognizing and appropriately managing hemorrhagic injuries contribute to preventable trauma related deaths nationwide. We sought to identify patient variables available at the time of emergency department arrival associated with meeting the critical administration threshold., Methodology: We conducted a trauma registry review from September 2016 to March 2020 of trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Our primary outcome was the frequency of meeting the critical administration threshold. Secondary outcomes included time to critical administration threshold, 24-h all-cause mortality, and 30-day all-cause mortality. Multivariate logistic regression identified factors independently associated with meeting the critical administration threshold., Results: We assessed 762 patients, of which 78 (10.2%) met the critical administration threshold. The median time to critical administration threshold was 28.9 min. Mortality at 24 h occurred in 58 (7.6%) patients. Four variables available upon patient arrival predicted the critical administration threshold, including systolic blood pressure ≤ 90 mmHg (OR 6.6; 95% CI 3.7-12.0), Glasgow Coma Scale ≤ 8 (OR 5.9; 95% CI 3.2-10.6), heart rate ≥ 100 beats/minute (OR 4.4; 95% CI 2.4-8.1), and respiratory rate ≥ 20 breaths/min (OR 2.2; 95% CI 1.2-4.0)., Conclusion: We identified four clinical variables readily available to physicians upon patient arrival associated with meeting the critical administration threshold: systolic blood pressure ≤ 90 mmHg, Glasgow Coma Scale ≤ 8, heart rate ≥ 100 beats/minute, and respiratory rate ≥ 20 breaths/min. Patients presenting with any of these clinical parameters should prompt physicians to consider ordering blood products immediately., Competing Interests: Declarations Conflict of interest The authors declare that they have no financial disclosures or conflicts of interest., (© 2024. The Author(s), under exclusive licence to the Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: For bloodstream infections (BSI), treatment and research have focused on short term mortality. The objective of this study was to describe the 1-year mortality and morbidity in survivors of bloodstream infection when compared to patients with negative blood cultures., Methods: We conducted a population-based retrospective cohort study using Ontario administrative databases. Patients were included if they had a blood culture taken from January 1, 2014, to December 31, 2021, and survived past 30 days from blood culture collection. They were followed for the subsequent year. Outcomes were compared among patients with BSI and those without BSI, including all-cause mortality, stroke, myocardial infarction (MI), congestive heart failure (CHF) exacerbation, new start dialysis and admission to a long-term care (LTC) facility. Prognostic factors were balanced using overlap weighting of propensity scores, and a survival or competing risk model was used to describe time-to-event., Results: Of 981,341 patients undergoing blood culture testing, 99,080 (10.1%) patients had a BSI and 882,261 (89.9%) patients did not. Outcomes were all more common among those with BSI as compared to those without BSI, including all-cause mortality (16,764 [16.9%] vs. 84,480 [9.6%]), stroke (1016 [1.0%] vs. 4680 [0.5%]), MI (1043 [1.1%] vs. 4547 [0.5%]), CHF exacerbation (2643 [2.7%] vs. 13,200 [1.5%]), new start dialysis (1703 [1.7%] vs. 2749 [0.3%]), and LTC admission (4231 [4.3%] vs. 13,016 [1.5%]). BSI had an adjusted hazard ratio of 1.10 (95% CI 1.08-1.12, P < 0.0001) for mortality, subdistribution hazard ratio (sHR) of 1.27 (95% CI 1.19-1.37, P < 0.0001) for stroke, sHR of 1.18 (95% CI 1.10-1.26, P < 0.0001) for MI, sHR of 1.05 (95% CI 1.01-1.10, P = 0.0176) for CHF exacerbation, sHR of 3.42 (95% CI 3.21-3.64, P < 0.0001) for new start dialysis and sHR of 1.87 (95% CI 1.80-1.94, P < 0.0001) for LTC admission., Conclusion: BSI survivors have substantial long-term mortality and morbidity including stroke, MI, new start dialysis and functional decline leading to LTC admission., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to disclose., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Use of a gestational ("surrogate") carrier is increasingly common. Risk for maternal and neonatal adversity is largely unknown in this birthing population., Objective: To determine the risk for severe maternal morbidity (SMM) and severe neonatal morbidity (SNM) in gestational carriers., Design: Population-based cohort study., Setting: All of Ontario, Canada., Participants: All singleton births at more than 20 weeks' gestation, from 2012 to 2021., Measurements: Exposure was type of conception, namely, gestational carriage (main exposure), unassisted conception (comparison group 1), and in vitro fertilization (IVF) (comparison group 2). Main composite outcomes were SMM and SNM. Modified Poisson regression models generated weighted relative risks (wRRs) using propensity score-based overlap weighting. Secondary outcomes included hypertensive disorders of pregnancy, cesarean delivery, preterm birth, and postpartum hemorrhage., Results: Of all eligible singleton births, 846 124 (97.6%) were by unassisted conception, 16 087 (1.8%) by IVF, and 806 (0.1%) by gestational carriage. Respective risks for SMM were 2.3%, 4.3%, and 7.8%. The wRRs were 3.30 (95% CI, 2.59 to 4.20) comparing gestational carriage with unassisted conception and 1.86 (CI, 1.36 to 2.55) comparing gestational carriage with IVF. Respective risks for SNM were 5.9%, 8.9%, and 6.6%, generating wRRs of 1.20 (CI, 0.92 to 1.55) for gestational carriage versus unassisted conception and 0.81 (CI, 0.61 to 1.08) for gestational carriage versus IVF. Hypertensive disorders, postpartum hemorrhage, and preterm birth at less than 37 weeks were also significantly higher contrasting gestational carriers to either comparison group., Limitation: Absence of information about indications for choosing a gestational carrier, and oocyte or sperm donor source., Conclusion: Among singleton births of more than 20 weeks' gestation, a higher risk for SMM and adverse pregnancy outcomes was seen among gestational carriers compared with women who conceived with and without assistance. Although gestational carriage was associated with preterm birth, there was less clear evidence of severe neonatal morbidity. Potential mechanisms for higher maternal morbidity among gestational carriers require elucidation, alongside developing special care plans for gestational carriers., Primary Funding Source: The Canadian Institutes of Health Research., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M24-0417.

Objective: To examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services., Design: Nested case-control study., Setting and Participants: Linked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December 31, 2019. New residents of assisted living were matched on age, sex, and initiation date of home care (± 7 days) to community-dwelling home care recipients in a 1:4 ratio., Methods: Clinical and functional status, health service use, sociodemographic variables, and community-level characteristics were examined; conditional logistic regression was used to model associations with a transition to an assisted living facility., Results: There were 2427 new residents of assisted living who were matched to 9708 home care recipients [mean (SD) age 85.5 (6.02) years, 72% female]. Most of the new residents were concentrated in urban communities and communities with higher income quintiles. New residents had an increased rate of physician-diagnosed dementia [adjusted hazard ratio (aHR), 1.28; 95% CI, 1.14-1.43], mood disorders (aHR, 1.17; 95% CI, 1.05-1.29), and cardiac arrhythmias (aHR, 1.19; 95% CI, 1.07-1.32). They also had higher rates of mild cognitive impairment (aHR, 1.43; 95% CI, 1.24-1.66), 2 or more falls (aHR, 1.29; 95% CI, 1.11-1.51), participation in activities of long-standing interest in the past 7 days (aHR, 1.29; 95% CI, 1.11-1.50), and a lower rate of a spouse or partner unpaid caregiver vs a child (aHR, 0.66; 95% CI, 0.56-0.79)., Conclusions and Implications: New residents of assisted living were mostly women, were cognitively impaired, had clinical comorbidities that could increase their risk of injuries, and had caregivers who were their children. These findings stress the importance of upscaling memory and dementia care in assisted living to address the needs of this population., Competing Interests: Disclosures The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Objective: With increased utilization of virtual care in mental health, examining its appropriateness in various clinical scenarios is warranted. This study aimed to compare the risk of adverse psychiatric outcomes following virtual versus in-person mental health follow-up care after a psychiatric emergency department (ED) visit., Methods: Using population-based health administrative data in Ontario (2021), we identified 28,232 adults discharged from a psychiatric ED visit who had a follow-up mental health visit within 14 days postdischarge. We compared those whose first follow-up visit was virtual (telephone or video) versus in-person on their risk for experiencing either a repeat psychiatric ED visit, psychiatric hospitalization, intentional self-injury, or suicide in the 15-90 days post-ED visit. Cox proportional hazard models generated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs), adjusted for age, income quintile, psychiatric hospitalization, and intentional self-injury in the 2 years prior to ED visit. We stratified by sex and diagnosis at index ED visits based on the International Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) coding., Results: About 65% ( n  = 18,354) of first follow-up visits were virtual, while 35% ( n  = 9,878) were in-person. About 13.9% and 14.6% of the virtual and in-person groups, respectively, experienced the composite outcome, corresponding to incidence rates of 60.9 versus 74.2 per 1000 person-years (aHR 0.95, 95% CI 0.89 to 1.01). Results were similar for individual elements of the composite outcome, when stratifying by sex and index psychiatric diagnosis, when varying exposure (7 days) and outcome periods (60 and 30 days), and comparing "only" virtual versus "any" in-person follow-up during the 14-day follow-up., Conclusions and Relevance: These results support virtual care as a modality to increase access to follow-up after an acute care psychiatric encounter across a wide range of diagnoses. Prospective trials to discern whether this is due to the comparable efficacy of virtual and in-person care, or due solely to appropriate patient selection may be warranted., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Understanding the experiences of people with developmental disabilities during the initial period of COVID-19 pandemic., Methods: Individuals with developmental disabilities and their caregivers completed baseline and up to five follow-up online surveys using the CRISIS-AFAR measures, between July 2020 and September 2021. We used qualitative (thematic analysis) and quantitative (MANOVA) analytic methods., Results: One hundred and eighteen participants (64 caregivers on individuals 6-62 years, 54 self-reporting individuals aged 17-55 years) completed baseline survey; 46 participants (23 caregivers, 23 self-reporting adults) completed ≥1 follow-up. Qualitative themes included uncertainty, and negative and positive influences on behaviours and routines, daily life and mental wellness. Those experiencing positive impacts did not stably perceive so longitudinally., Conclusions: Despite both negative and positive influences on individuals with developmental disabilities and their families, the prolonged pandemic had wide-ranging repercussions. Emergency preparedness planning should consider the disruptive effects of public health measures on routine and support for this vulnerable population., (© 2024 The Author(s). Journal of Applied Research in Intellectual Disabilities published by John Wiley & Sons Ltd.)

Background: Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life., Objective: To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults., Design: Population-based cohort study., Participants: All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada., Exposures: Chinese ethnicity., Main Measures: Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation., Key Results: The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38)., Conclusions: Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Purpose: To study the proportion and predictors of outpatient physician follow-up within 60 days of substance-related emergency department (ED) visits for Ontario youth., Methods: We examined administrative data on substance-related ED visits before and during the COVID-19 pandemic among youths aged 10-24 years in Ontario, Canada. Substance-related visits were identified using International Classification of Diseases-10-CA codes. We described demographic characteristics, receipt of mental health services in the year before the ED visit, disposition from the ED, and follow-up services within 60 days of the ED visit., Results: Between April 1, 2017, and May 31, 2021, 64,236 youth had at least one ED visit for substance use. Visits for alcohol were the most common (49%), followed by cannabis (32.3%). ED visits for all substances were more prevalent during the pandemic than prepandemic, except visits for alcohol. The receipt of follow-up physician care for substance use was low (33.2% prepandemic) but increased during the pandemic (41.7%; adjusted odds ratio 1.34, 95% CI 1.28, 1.39) and varied between substances. Mental health service history in the year before the substance-related ED visit had the strongest association with receipt of follow-up physician care within 60 days (adjusted odds ratio 6.86, 95% CI 6.57, 7.17)., Discussion: Youth frequently do not receive physician follow-ups within two months of the substance-related ED visit, although higher follow-up proportions were seen during the pandemic after the implementation of virtual care. Further research is required to understand why follow-up is low and to examine interventions that can increase connection to care., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental condition and is characterized by inattention, hyperactivity, and impulsivity. Research suggests that some populations, such as females and individuals with high intelligence quotients may be a risk for late ADHD diagnosis and subsequent treatment. Our goal is to advance our understanding of ADHD diagnosis, by examining (1) how child sex and cognitive abilities together are related to the age of diagnosis and (2) whether symptom presentation, current internalizing and externalizing symptoms, and demographic factors are related to age of diagnosis., Methods: Our analyses contained children who completed the required tests (N = 568) from a pre-existing dataset of 1380 children with ADHD from the Province of Ontario Neurodevelopmental Disorders (POND) Network (pond-network.ca). First, we conducted a moderation analysis with sex as the predictor, cognitive abilities as the moderator, and age of diagnosis as the outcome. Second, we conducted correlation analyses examining how symptom presentation, current internalizing and externalizing symptoms, and demographic factors are related to age of diagnosis., Results: Higher IQ was related to a later age of diagnosis. Higher hyperactive-impulsive symptoms and externalizing symptoms were related to an earlier age of diagnosis. Internalizing symptoms were trend associated with a later age of diagnosis in girls. Higher socioeconomic status and non-White maternal ethnicity were related to later age of diagnosis., Conclusions: IQ, sex, ADHD symptomology, internalizing symptoms, externalizing symptoms, and socio-demographic factors affect the age of diagnosis., (© 2024 The Author(s). British Journal of Clinical Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society.)

Background: Little is known about how major trauma survivors access health services in the years following their injury. Our study sought to characterize patterns of health services use in trauma survivors following discharge from a provincial trauma center and to identify sociodemographic factors associated with service utilization., Methods: We conducted a population-based retrospective case-control study using linked administrative data on trauma survivors' population-based controls between April 1, 2011, and March 31, 2021. For each major trauma survivor, we matched four cases based on age and sex. The primary outcome was the composite rate (sum) of health service use episodes including outpatient visits to family physicians and specialists, emergency department visits, and acute care hospital admissions during the 5-year period following discharge from the trauma center. We used multivariate regression to compute rate ratios comparing the rates of health service use in trauma survivors versus controls and to assess for associations between sociodemographic variables and health services use., Results: The study cohort consisted of a total of 273,406 individuals: 55,060 trauma survivors and 218,346 controls. Trauma survivors were predominately males (71%) with a median age of 46 years (interquartile range, 26-65 years). Health service use in trauma survivors peaked within a year of hospital discharge but remained increased throughout the follow-up period. Trauma survivorship was associated with a 56% increase in overall health services use (adjusted rate ratio, 1.56; 95% confidence interval, 1.55-1.57), including an 88% increase in hospital admissions (adjusted rate ratio, 1.88; 95% confidence interval, 1.85-1.92). Male sex and rural residence were associated with a reduced overall use of health services but greater use of emergency department services., Conclusion: Major trauma survivors have long-term health services needs that persist for years after discharge from the trauma center. Future research should focus on the understanding why trauma survivors have prolonged health services requirements and ensure that care needs are aligned with service delivery., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: End-of-life (EOL) transitions to hospital can be burdensome for older adults and may contribute to poor outcomes. We investigated the association of disease trajectory and place of care with EOL burdensome transitions., Design: Retrospective cohort study using administrative data., Setting/participants: Ontarians aged ≥65 years who died between 2015 and 2018 and received long-term care (LTC) or home care 6 months before death., Methods: Disease trajectories were defined based on EOL functional decline: terminal illness, organ failure, frailty, sudden death, and other. Places of care included LTC, EOL home care, and non-EOL home care. Burdensome transitions were defined as early (≥3 hospitalizations for any reason or ≥2 hospitalizations due to pneumonia, urinary tract infection, sepsis, or dehydration in the last 90 days of life) or late (≥1 hospitalizations for any reason in the last 3 days of life). Multinomial logistic regression tested for effect modification between disease trajectory and places of care on burdensome transitions., Results: Of 110,776 decedents, 40.7% had organ failure, 37.5% had frailty, and 12.8% had a terminal illness, with the remainder in sudden death or other categories. Most were in LTC (62.5%), and 37.5% received home care, with 6.8% receiving designated EOL home care and 30.7% non-EOL home care. There was a significant interaction (P < .001) between disease trajectory and care settings. Compared with terminal illness, organ failure was associated with increased odds of early transitions across all care settings [odds ratios (ORs) ranging 1.14-1.21]. Frailty was associated with increased odds of early transitions solely for non-EOL home care recipients (OR 1.17, 95% CI 1.06-1.28). Organ failure and frailty were associated with increased odds of late transitions across all settings, with organ failure having greater odds in LTC (organ failure OR 2.29, 95% CI 2.02-2.60, vs frailty OR 1.79, 95% CI 1.58-2.04)., Conclusions and Implications: Disparities exist in burdensome transitions, notably for noncancer decedents with organ failure in LTC. Enhancing palliative care may help reduce burdensome transitions and improve patient outcomes., Competing Interests: Disclosures The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Aim: Adults with intellectual and developmental disabilities (IDD) have a significantly higher prevalence of Type 2 diabetes than the general population. Evidence that lifestyle and/or behavioural interventions, such as participation in Special Olympics, decreases the risk of developing diabetes in adults with IDD could help minimize health disparities and promote overall health in this population., Methods: This was a 20-year retrospective cohort study of adults with IDD (30-39 years) in the province of Ontario, Canada, that compared hazard rates of diabetes among Special Olympics participants (n = 4145) to non-participants (n = 31,009) using administrative health databases housed at ICES. Using cox proportional hazard models, crude and adjusted hazard ratios were calculated for the association between the primary independent variable (Special Olympics participation status) and the dependent variable (incident diabetes cases)., Results: After controlling for other variables, the hazard ratio comparing rates for developing diabetes between Special Olympics participants and non-participants was 0.85. This represents a 15% reduction in the hazard among Special Olympics participants when followed for up to 20 years. This result was statistically significant and represents a small effect size., Conclusions: Special Olympics could be considered a complex intervention that promotes physical activity engagement through sport participation, health screenings, and the promotion of healthy eating habits through educational initiatives. This study provides evidence that Special Olympics participation decreases the rate for developing diabetes., (© 2024 The Author(s). Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Background: Few studies have characterized the burden of late effects among childhood ependymoma survivors. To address this gap, we examined these sequelae using real-world health services data in a population-based ependymoma survivor cohort., Methods: All individuals younger than 18 years diagnosed with an ependymoma in Ontario, Canada between 1987 and 2015 who had survived at least 5 years from their latest pediatric cancer event (index date) were matched 1:5 with population controls. Following linkage with provincial health services data, the cumulative incidences of multiple medical and functional outcomes between survivors and controls were compared., Results: Among 96 survivors, 77.1% had been irradiated and 9.4% had received cisplatin. At 10 years post-index, survivors were at significantly higher risk of all-cause mortality (7.1%, 95% confidence interval [CI]: 1.0-13.3 vs. 0.3%, 95% CI: 0.0-1.0; p = .0002), non-obstetric hospitalization (45.1%, 95% CI: 32.6-56.7 vs. 10.6%, 95% CI: 7.6-14.1; p < .0001), stroke (6.5%, 95% CI: 2.3-13.7 vs. 0%; p < .0001), severe hearing loss requiring an amplification device (7.5%, 95% CI: 2.7-15.7 vs. 0%; p < .0001), receiving homecare service (27.6%, 95% CI: 18.5-37.5 vs. 7.7%, 95% CI: 5.3-10.7; p < .0001), and submitting a disability support prescription claim (24.0%, 95% CI: 14.8-34.3 vs. 5.4%, 95% CI: 3.5-7.8; p < .0001) compared to controls., Conclusions: Pediatric ependymoma survivors are highly vulnerable to severe late sequelae, including death, stroke, severe hearing loss, and disability. Urgent efforts are needed to improve risk-stratification approaches that mitigate exposure to toxic therapies for children with lower risk disease. Interventions to prevent or decrease the risk of developing late sequelae are critical to optimizing survivor long-term health., (© 2024 The Author(s). Pediatric Blood & Cancer published by Wiley Periodicals LLC.)

Background: Some have advocated that nabilone be used rather than opioids to manage chronic, noncancer pain, since the former drug may have a better safety profile., Objective: We compared the safety of incident nabilone use relative to incident opioid use with respect to multiple clinically important outcomes., Design: A population-based, retrospective cohort study., Setting: Province of Ontario, Canada., Participants: Persons aged 12 years and older, diagnosed with a musculoskeletal condition within the past 3 years prior to the index date., Exposures: Incident nabilone use, with incident opioid use serving as the reference group., Measurements: Within 3 months following the index date, we separately evaluated for pneumonia, motor vehicle accidents, falls or fractures, mental and behavioral disorder due to psychoactive substance use, and all-cause mortality., Results: A total of 18,863 incident nabilone users were propensity score matched to an equal number of opioid users. In the overall matched analysis, incident nabilone users vs. incident opioid users had significantly lower rates of pneumonia (hazard ratio [HR] 0.78, 95% CI 0.63-0.96), falls or fractures (HR 0.56, 95% CI 0.50-0.64), and all-cause mortality (HR 0.79, 95% CI 0.65-0.95), but significantly higher rate of mental or behavioral disorder (HR 2.23, 95% CI 1.45-3.43). There was no significant difference between groups with respect to rate of motor vehicle accidents., Limitations: Unmeasured confounding may have influenced results., Conclusions: While usage of nabilone relative to opioids was associated with reduced rates of pneumonia, falls or fractures, and all-cause mortality, it was simultaneously associated with an increased rate of adverse mental health outcomes. This picture of mixed safety results raises concerns with the policy approach of broadly substituting use of opioids with nabilone., Funding Source: Ontario Ministry of Health., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Introduction: To study digestive system cancer risks in individuals with inflammatory bowel diseases (IBDs) in the biologic era., Methods: We used population-level administrative and cancer registry data from Ontario, Canada, (1994-2020) to compare people with IBD to matched controls (1:10 by sex and birth year) on trends in age-sex standardized cancer incidence and risk ratios of incident cancers and cancer-related deaths., Results: Among 110,919 people with IBD and 1,109,190 controls, colorectal cancer incidence (per 100,000 person-years) declined similarly in people with ulcerative colitis (average annual percentage change [AAPC] -1.81; 95% confidence interval [CI] -2.48 to -1.156) and controls (AAPC -2.79; 95% CI -3.44 to -2.14), while small bowel cancer incidence rose faster in those with Crohn's disease (AAPC 9.68; 95% CI 2.51-17.3) than controls (AAPC 3.64; 95% CI 1.52-5.80). Extraintestinal digestive cancer incidence rose faster in people with IBD (AAPC 3.27; 95% CI 1.83-4.73) than controls (AAPC -1.87; 95% CI -2.33 to -1.42), particularly for liver (IBD AAPC 8.48; 95% CI 4.11-13.1) and bile duct (IBD AAPC 7.22; 95% CI 3.74-10.8) cancers. Beyond 2010, the incidences (and respective mortality rates) of colorectal (1.60; 95% CI 1.46-1.75), small bowel (4.10; 95% CI 3.37-4.99), bile duct (2.33; 95% CI 1.96-2.77), and pancreatic (1.19; 95% CI 1.00-1.40) cancers were higher in people with IBD., Discussion: Cancer incidence is declining for colorectal cancer and rising for other digestive cancers in people with IBD. Incidence and mortality remain higher in people with IBD than controls for colorectal, small bowel, bile duct, and pancreatic cancers., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Context: People with noncancer diagnoses have poorer access to palliative care units (PCUs) or hospices compared to those with cancer diagnoses. The COVID-19 pandemic disrupted how specialist palliative care services were delivered and utilized., Objective: To determine the association between the start of the COVID-19 pandemic and PCU/hospice utilization in hospitalized individuals with cancer and noncancer diagnoses with specialist palliative care needs., Methods: Retrospective cohort study using routinely collected data. Percentages of individuals experiencing each disposition from hospital, including discharge to PCU/hospice, were calculated monthly for the total, cancer, and noncancer cohorts and were analyzed descriptively. Hospitalized individuals with specialist palliative care needs at a single academic hospital in Toronto, Canada from January 1, 2017, to September 31, 2022 (pandemic start was defined as April 1, 2020)., Results: The cohort comprised 4349 individuals (median age=78 years; 52.4% female); 3065 (70.5%) and 1284 (29.5%) had cancer and noncancer diagnoses, respectively. Among individuals with noncancer diagnoses, the most significant absolute changes were a 13.0%-decrease in in-hospital deaths (prepandemic=49.6%; postpandemic=36.6%) and a 11.6%-increase in discharges to PCU/hospice (prepandemic=35.6%; postpandemic=47.3%). Among individuals with cancer, the most significant absolute changes were a 12.8%-increase in discharges home with formal care (prepandemic=2.3%; postpandemic=15.1%) and a 7.0%-decrease in in-hospital deaths (prepandemic=29.1%; postpandemic=22.0%)., Conclusion: Despite historically poor PCU/hospice access, the COVID-19 pandemic created circumstances that may have enabled unprecedented utilization in individuals with noncancer diagnoses in our cohort., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: There is a need to consider COVID-19 a syndemic; which calls for a comprehensive approach to tackle the associated interconnected challenges. The objective of this study is to investigate the potential syndemic nature of COVID-19, with a specific focus on understanding how viral infection, mental health (such as anxiety and depression), and pre-existing comorbidities interact and influence each other., Study Design: Retrospective population-based cohort study., Methods: We conducted a population-based retrospective cohort study using linked health administrative data from the Institute for Clinical Evaluative Sciences, Ontario. The study included 2,863,423 Ontario residents from January 2020 to March 2021. We analysed healthcare services utilisation (physician visits, emergency visits, and hospitalisations) for chronic conditions among individuals with both COVID-19 and either anxiety or depression, to understand the syndemic impact of COVID-19 and mental health issues among Ontario population., Results: Multiple regression models were used to explore the study's objective. In the final adjusted regression model for the sample, it was found that the individuals who were COVID-19 positive and had either anxiety or depression were more likely to utilise health services for chronic conditions of interest during the pandemic than those who were COVID-19-negative with mental health issues (odds ratio [OR]:, 1.33; 95% confidence interval [CI]: 1.12-1.58). A higher risk of morbidity was observed among males (OR: 1.28; CI: 1.16-1.41), as well as in individuals with diverse ethnic backgrounds and low socioeconomic status., Conclusions: The impact of COVID-19 on mental health, particularly among vulnerable populations with chronic diseases, can be seen as a syndemic. This complex interaction emphasises the need for integrated public health strategies., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Day-to-day variation in the measurement of SARS-CoV-2 in wastewater can challenge public health interpretation. We assessed a Bayesian smoothing and forecasting method previously used for surveillance and short-term projection of COVID-19 cases, hospitalizations, and deaths., Methods: SARS-CoV-2 viral measurement from the sewershed in Ottawa, Canada, sampled at the municipal wastewater treatment plant from July 1, 2020, to February 15, 2022, was used to assess and internally validate measurement averaging and prediction. External validation was performed using viral measurement data from influent wastewater samples from 15 wastewater treatment plants and municipalities across Ontario., Results: Plots of SARS-CoV-2 viral measurement over time using Bayesian smoothing visually represented distinct COVID-19 "waves" described by case and hospitalization data in both initial (Ottawa) and external validation in 15 Ontario communities. The time-varying growth rate of viral measurement in wastewater samples approximated the growth rate observed for cases and hospitalization. One-week predicted viral measurement approximated the observed viral measurement throughout the assessment period from December 23, 2020, to August 8, 2022. An uncalibrated model showed underprediction during rapid increases in viral measurement (positive growth) and overprediction during rapid decreases. After recalibration, the model showed a close approximation between observed and predicted estimates., Conclusion: Bayesian smoothing of wastewater surveillance data of SARS-CoV-2 allows for accurate estimates of COVID-19 growth rates and one- and two-week forecasting of SARS-CoV-2 in wastewater for 16 municipalities in Ontario, Canada. Further assessment is warranted in other communities representing different sewersheds and environmental conditions., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Developing accurate models for predicting the risk of 30-day readmission is a major healthcare interest. Evidence suggests that models developed using machine learning (ML) may have better discrimination than conventional statistical models (CSM), but the calibration of such models is unclear., Objectives: To compare models developed using ML with those developed using CSM to predict 30-day readmission for cardiovascular and noncardiovascular causes in HF patients., Methods: We retrospectively enrolled 10,919 patients with HF (> 18 years) discharged alive from a hospital or emergency department (2004-2007) in Ontario, Canada. The study sample was randomly divided into training and validation sets in a 2:1 ratio. CSMs to predict 30-day readmission were developed using Fine-Gray subdistribution hazards regression (treating death as a competing risk), and the ML algorithm employed random survival forests for competing risks (RSF-CR). Models were evaluated in the validation set using both discrimination and calibration metrics., Results: In the validation sample of 3602 patients, RSF-CR (c-statistic=0.620) showed similar discrimination to the Fine-Gray competing risk model (c-statistic=0.621) for 30-day cardiovascular readmission. In contrast, for 30-day noncardiovascular readmission, the Fine-Gray model (c-statistic=0.641) slightly outperformed the RSF-CR model (c-statistic=0.632). For both outcomes, The Fine-Gray model displayed better calibration than RSF-CR using calibration plots of observed vs predicted risks across the deciles of predicted risk., Conclusions: Fine-Gray models had similar discrimination but superior calibration to the RSF-CR model, highlighting the importance of reporting calibration metrics for ML-based prediction models. The discrimination was modest in all readmission prediction models regardless of the methods used., Competing Interests: Conflict of interest None reported., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: This study aimed to assess the impact of the implementation of legally sanctioned supervised consumption sites (SCS) in the Canadian province of Ontario on opioid-related deaths, emergency department (ED) visits and hospitalisations at the public health unit (PHU) level., Methods: Monthly rates per 100,000 population of opioid-related deaths, ED visits and hospitalisations for PHUs in Ontario between December 2013 and March 2022 were collected. Aggregated and individual analyses of PHUs with one or more SCS were conducted, with PHUs that instituted an SCS being matched to control units that did not. Autoregressive integrated moving average models were used to estimate the impact of SCS implementation on opioid-related deaths, ED visits and hospitalisations., Results: Twenty-one legally sanctioned SCS were implemented across nine PHUs in Ontario during the study period. Interrupted time series analyses showed no statistically significant changes in opioid-related death rates in aggregated analyses of intervention PHUs (increase of 0.02 deaths/100,000 population/month; p = 0.27). Control PHUs saw a significant increase of 0.38 deaths/100,000 population/month; p < 0.001. No statistically significant changes were observed in the rates of opioid-related ED visits in intervention PHUs (decrease of 0.61 visits/100,000 population/month; p = 0.39) or controls (increase of 0.403 visits; p = 0.76). No statistically significant changes to the rates of opioid-related hospitalisations were observed in intervention PHUs (0 hospitalisations/100,000 population/month; p = 0.98) or controls (decrease of 0.05 hospitalisations; p = 0.95)., Discussion and Conclusions: This study did not find significant mortality or morbidity effects associated with SCS availability at the population level in Ontario. In the context of a highly toxic drug supply, additional interventions will be required to reduce opioid-related harms., (© 2024 The Author(s). Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Background: Appropriate use of medication is a key indicator of the quality of care provided in long-term care (LTC). The objective of this study was to determine whether resident-facility language concordance/discordance is associated with the odds of potentially inappropriate prescribing of antipsychotics (PIP-AP) in LTC., Methods: We conducted a population-based, retrospective cohort study of LTC residents in Ontario, Canada from 2010 to 2019. We obtained resident language from standardized resident assessments, and derived facility language by determining the proportion of residents belonging to each linguistic group within individual LTC homes. Using linked administrative databases, we identified all instances of PIP-AP during a 1-year follow-up period. PIP-AP was defined using the STOPP-START criteria, which have previously been shown to predict adverse clinical events such as emergency department (ED) visits and hospitalizations. The association between linguistic factors and PIP-AP was assessed using adjusted multivariable logistic regression analysis., Results: We identified 198,729 LTC residents consisting of 162,814 Anglophones (81.9%), 6,230 Francophones (3.1%), and 29,685 Allophones (14.9%). The odds of PIP-AP of were higher for both Francophones (aOR 1.15, 95% CI 1.08-1.23) and Allophones (aOR 1.11, 95% CI 1.08-1.15) when compared to Anglophones. When compared to English LTC homes, French LTC homes had greater odds of PIP-AP (aOR 1.12, 95% CI 1.05-1.20), while Allophone homes had lower odds of PIP-AP (aOR 0.82, 95% CI 0.77-0.86). Residents living in language-discordant LTC homes had higher odds of PIP-AP when compared to LTC residents living in language-concordant LTC homes (aOR 1.07, 95% CI 1.04-1.10)., Conclusion: This study identified linguistic factors related to the odds of PIP-AP in LTC, suggesting that the linguistic environment may have an impact on the quality of care provided to residents., (© 2024. The Author(s).)

Over the last 20 years, there has been a significant increase in fentanyl-related deaths in Ontario, Canada. This report examines toxicological findings in a series of death investigations in which fentanyl was quantitated to identify the prevalence, trends, and demographic data associated with fentanyl in Ontario, Canada, and to highlight the changes in these trends since fentanyl began appearing in casework in Ontario in the early 2000s. A retrospective study of all cases in which fentanyl was quantitated in blood, using liquid chromatography (LC)-tandem mass spectrometry (MS-MS), was conducted for the time period between 1 January 2020 and 31 December 2022. A total of 4395 cases were included; 77% of the decedents were male, and 23% was female with ages ranging from 0 to 95 years. The most frequently classified cause of death was mixed drug toxicity (69%) followed by fentanyl intoxication at 19%. Less than 10% of cases where fentanyl was quantitated were classified as nondrug-related deaths. Fentanyl concentrations in all cases ranged from 1.3 to >2000 ng/mL. Other drugs were frequently detected with fentanyl. In mixed drug toxicity cases, stimulants were the most frequently encountered class of drugs: cocaine was identified in 51.8%, and methamphetamine was observed in 43.0% of cases. Detailed reports for select cases were included to provide additional insight into the different case types and to show the difficulty in interpreting blood concentrations without additional detailed case histories. This study provides valuable information for the scientific and medical community regarding the continued use of fentanyl and how patterns of fentanyl use have evolved since it began to appear in forensic casework., (© The Author(s) 2024. Published by Oxford University Press.)

Objective: To describe and compare the characteristics of people with SUD and their use of healthcare services in two ways: 1) across varying levels of marginalization and 2) before and during the pandemic., Methods: We conducted a population-based cross-sectional study using administrative data from Ontario, Canada. We included individuals age 16+ with a recorded diagnosis of SUD between June 2018-2019 (pre-pandemic) and June 2021-2022 (during-pandemic). Baseline sociodemographic and clinical characteristics and use of healthcare services were enumerated across the five quintiles of the Ontario Marginalization Index., Results: 259,497 pre-pandemic and 276,459 during-pandemic people with SUD were identified. Over 40% belonged to the two highest marginalization quintiles (Q4/Q5). Most had an outpatient visit with similar percentages across quintiles, however the number of visits increased with increasing marginalization (pre-pandemic: mean 8.5 visits in Q1 vs 13.0 visits in Q5; during-pandemic: mean 9.5 in Q1 vs 13.4 in Q5). There was no consistent pattern in percent of people who sought alcohol-related outpatient care, however more marginalized people sought drug-related outpatient care (pre-pandemic: 19.1% in Q1 vs 31.7% in Q5; during-pandemic: 18.7% in Q1 vs 32.5% in Q5). Almost half of people with SUD had an emergency department (ED) visit, of which more belonged to higher marginalization quintiles (pre-pandemic: 43.5% in Q1 vs 49.8% in Q5; during-pandemic: 41.4% in Q1 vs 49.3% in Q5)., Conclusions: SUD prevalence and most health service utilization remained similar from pre- to during-pandemic. Increasing marginalization was associated with increased use of healthcare among people with SUD. Future research should aim to further explore the complex relationship between marginalization and substance use., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Chu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Working-age individuals have been disproportionately affected by the opioid crisis, prompting interest in the potential role of occupation as a contributor. This study aimed to estimate the risk of opioid-related poisonings and mental and behavioural disorders by occupation and industry within a cohort of 1.7 million formerly injured workers., Methods: Workers were identified in the Occupational Disease Surveillance System, a system linking workers' compensation data (1983-2019) to emergency department and hospitalisation records (2006-2020) in Ontario, Canada. Cox proportional hazards models were used to estimate HRs and 95% CIs for hospital encounters for opioid-related poisonings and mental and behavioural disorders by occupation and industry compared with all other workers, adjusted for age, sex and birth year., Results: In total, 13 702 opioid-related poisoning (p) events (n=10 064 workers) and 19 629 opioid-related mental and behavioural (mb) disorder events (n=11 755 workers) were observed. Elevated risks were identified among workers in forestry and logging (HR p =1.45, 95% CI 1.09 to 1.94; HR mb =1.70, 95% CI 1.34 to 2.16); processing (minerals, metals, clay, chemical) (HR p =1.27, 95% CI 1.14 to 1.42; HR mb =1.26, 95% CI 1.14 to 1.39); processing (food, wood, textile) (HR p =1.12, 95% CI 1.01 to 1.24; HR mb =1.19, 95% CI 1.09 to 1.31); machining (HR p =1.13, 95% CI 1.04 to 1.21; HR mb =1.17, 95% CI 1.09 to 1.25); construction trades (HR p =1.57, 95% CI 1.48 to 1.67; HR mb =1.59, 95% CI 1.51 to 1.68); materials handling (HR p =1.32, 95% CI 1.22 to 1.43; HR mb =1.22, 95% CI 1.13 to 1.31); mining and quarrying (HR mb =1.68, 95% CI 1.34 to 2.11); and transport equipment operating occupations (HR p =1.18, 95% CI 1.09 to 1.27). Elevated risks were observed among select workers in service, sales, clerical and health. Findings by industry were similar., Conclusions: Results provide additional evidence that opioid-related harms cluster among certain occupational groups. Findings can be used to strategically target prevention and harm reduction activities in the workplace., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Throughout the COVID-19 pandemic, youth have experienced substantial stress due to abrupt changes in education, finances, and social life, compounding pre-existing stressors. With youth (ages 15-26) often at critical points in development, they are vulnerable to long-term mental health challenges brought on by pandemic trauma., Methods: To identify youth experiences throughout the pandemic and examine changes over time, we conducted semi-structured interviews among n = 141 youth in two Canadian provinces (Ontario and British Columbia) and across the country of Ireland at three time points over the course of more than one year (August 2020-October 2021). We conducted a qualitative longitudinal analysis using an inductive content approach., Results: Categories identified were (1) coping with hardship; (2) opportunities for growth; (3) adapting to new ways of accessing services; (4) mixed views on the pandemic: attitudes, behaviour, and perception of policy response; (5) navigating COVID-19 information; (6) transitioning to life after the pandemic; and (7) youth-led recommendations for government and service response. The findings also reveal trends in health and wellness in accordance with prolonged periods of lockdown, changes in weather, and return to normalcy after the availability of COVID-19 vaccines. Key recommendations from youth include incorporating youth voice into decision making, communicating public health information effectively to youth, enhancing service delivery post-pandemic, and planning for future pandemics., Conclusions: These results provide insights into the extensive longitudinal impacts of the COVID-19 pandemic on young people across three geographical locations. Actively involving youth in decision making roles for future pandemics or public health emergencies is critical., (© 2024. The Author(s).)

Background and Objectives: Administrative data are invaluable for assessing outcomes at the population level. However, there are few validated patient-centered outcome measures that capture morbidity following traumatic brain injury (TBI) using these data. We sought to characterize and validate days at home (DAH) as a measure to quantify population-level outcomes after moderate to severe TBI. We additionally assessed the earliest feasible outcome assessment period for patients with TBI using this outcome measure., Methods: This multicenter retrospective cohort study used linked health administrative data sources to identify adults with moderate to severe TBI presenting to trauma centers in Ontario, Canada, between 2009 and 2021. DAH at 180 days (DAH 180 days ) reflects the total number of days spent alive and at home excluding the days spent institutionalized across care settings. Construct validity was determined using hierarchical quantile regression to assess the associations between clinical and injury covariates with DAH 180 days . Predictive validity was assessed using Spearman rank correlation. We estimated minimally important difference (MID) in DAH 180 days to aid with outcome measure interpretability., Results: There were 6,340 patients who met inclusion criteria. Median DAH 180 days was 70 days (interquartile range 0-144). Mortality occurred in 2,162 (34.1%) patients within 90 days following injury. Patients in the lower DAH 180 days group were more commonly older (absolute standardized difference [ASD] = 0.68) with higher preinjury health resource utilization (ASD = 0.36) and greater injury severity (ASD = 0.81). Increased baseline health resource utilization (-10.1 days, 95% CI -17.4 to -2.8, p = 0.0041), older age (-4.6 days, 95% CI -5.7 to -3.4, p < 0.001), higher cranial injury severity (-84.6 days, 95% CI -98.3 to -71.0, p < 0.001), and major extracranial injuries (-14.2 days, 95% CI -19.5 to -8.93, p < 0.001) were significantly associated with fewer DAH 180 days . DAH 180 days was positively correlated with DAH at up to 3 years ( r = 0.91, 95% CI 0.90-0.92) and negatively correlated with direct health care expenditure ( r s = -0.89, 95% CI -0.88 to -0.90). The average MID estimated from anchor-based and distribution-based methods was 18 days., Discussion: We validate DAH 180 days as a potentially useful outcome measure with construct, predictive, and face validity in a population with moderate to severe TBI. Given the intensity of acute care requirements for patients with TBI, our work highlights DAH 180 days as a feasible and sufficiently responsive outcome measure.

Background: High-cost users (HCU) represent important targets for health policy interventions. Sepsis is a life-threatening syndrome that is associated with high morbidity, mortality, and economic costs to the healthcare system. We sought to estimate the effect of sepsis on being a subsequent HCU., Methods: Using linked health-administrative databases, we conducted a population-based, propensity score-weighted cohort study of adults who survived a hospitalization in Ontario, Canada between January 2016 and December 2017. Sepsis was identified using a validated algorithm. The primary outcome was being a persistent HCU after hospital discharge (in the top 5% or 1% of total health care spending for 90 consecutive days), and the proportion of follow-up time since discharge as a HCU., Results: We identified 927,057 hospitalized individuals, of whom 79,065 had sepsis. Individuals who had sepsis were more likely to be a top 5% HCU for 90 consecutive days at any time after discharge compared to those without sepsis (OR 2.24; 95% confidence interval [CI] 2.04-2.46) and spent on average 42.3% of their follow up time as a top 5% HCU compared to 28.9% of time among those without sepsis (RR 1.46; 95% CI 1.45-1.48). Individuals with sepsis were more likely to be a top 1% HCU for 90 consecutive days compared to those without sepsis (10% versus 5.1%, OR 2.05 [95% CI 1.99-2.11]), and spent more time as a top 1% HCU (18.5% of time versus 10.8% of time, RR 1.68 [95% CI 1.65-1.70])., Conclusions: The sequelae of sepsis result in higher healthcare costs with important economic implications. After discharge, individuals who experienced sepsis are more likely to be a HCU and spend more time as a HCU compared to individuals who did not experience sepsis during hospitalization., (© 2024. The Author(s).)

Big data have become increasingly important for policymakers and scientists but have yet to be employed for the development of spatially specific groundwater contamination indices or protecting human and environmental health. The current study sought to develop a series of indices via analyses of three variables: Non-E. coli coliform (NEC) concentration, E. coli concentration, and the calculated NEC:E. coli concentration ratio. A large microbial water quality dataset comprising 1,104,094 samples collected from 292,638 Ontarian wells between 2010 and 2021 was used. Getis-Ord Gi* (Gi*), Local Moran's I (LMI), and space-time scanning were employed for index development based on identified cluster recurrence. Gi* and LMI identify hot and cold spots, i.e., spatially proximal subregions with similarly high or low contamination magnitudes. Indices were statistically compared with mapped well density and age-adjusted enteric infection rates (i.e., campylobacteriosis, cryptosporidiosis, giardiasis, verotoxigenic E. coli (VTEC) enteritis) at a subregional (N = 298) resolution for evaluation and final index selection. Findings suggest that index development via Gi* represented the most efficacious approach. Developed Gi* indices exhibited no correlation with well density, implying that indices are not biased by rural population density. Gi* indices exhibited positive correlations with mapped infection rates, and were particularly associated with higher bacterial (Campylobacter, VTEC) infection rates among younger sub-populations (p < 0.05). Conversely, no association was found between developed indices and giardiasis rates, an infection not typically associated with private groundwater contamination. Findings suggest that a notable proportion of bacterial infections are associated with groundwater and that the developed Gi* index represents an appropriate spatiotemporal reflection of long-term groundwater quality. Bacterial infection correlations with the NEC:E. coli ratio index (p < 0.001) were markedly different compared to correlations with the E. coli index, implying that the ratio may supplement E. coli monitoring as a groundwater assessment metric capable of elucidating contamination mechanisms. This study may serve as a methodological blueprint for the development of big data-based groundwater contamination indices across the globe., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Data supporting routine infectious diseases (ID) consultation in gram-negative bloodstream infection (GN-BSI) are limited. We evaluated the association between ID consultation and mortality in patients with GN-BSI in a retrospective population-wide cohort study in Ontario using linked health administrative databases., Methods: Hospitalized adult patients with GN-BSI between April 2017 and December 2021 were included. The primary outcome was time to all-cause mortality censored at 30 days, analyzed using a mixed effects Cox proportional hazards model with hospital as a random effect. ID consultation 1-10 days after the first positive blood culture was treated as a time-varying exposure., Results: Of 30 159 patients with GN-BSI across 53 hospitals, 11 013 (36.5%) received ID consultation. Median prevalence of ID consultation for patients with GN-BSI across hospitals was 35.0% with wide variability (range 2.7%-76.1%, interquartile range 19.6%-41.1%). In total, 1041 (9.5%) patients who received ID consultation died within 30 days, compared to 1797 (9.4%) patients without ID consultation. In the fully adjusted multivariable model, ID consultation was associated with mortality benefit (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] .77-.88, P < .0001; translating to absolute risk reduction of -3.8% or number needed to treat [NNT] of 27). Exploratory subgroup analyses of the primary outcome showed that ID consultation could have greater benefit in patients with high-risk features (nosocomial infection, polymicrobial or non-Enterobacterales infection, antimicrobial resistance, or non-urinary tract source)., Conclusions: Early ID consultation was associated with reduced mortality in patients with GN-BSI. If resources permit, routine ID consultation for this patient population should be considered to improve patient outcomes., Competing Interests: Potential conflicts of interest . The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objective: To examine the association between precarious employment and risk of work-related COVID-19 infection in Ontario, Canada., Methods: We combined data from an administrative census of workers' compensation claims with corresponding labour force statistics to estimate rates of work-related COVID-19 infection between April 2020 and April 2022. Precarious employment was imputed using a job exposure matrix capturing temporary employment, low wages, irregular hours, involuntary part-time employment and a multidimensional indicator of 'low', 'medium', 'high' and 'very high' overall exposure to precarious employment. We used negative binomial regression models to quantify associations between precarious employment and accepted compensation claims for COVID-19., Results: We observed a monotonic association between precarious employment and work-related COVID-19 claims. Workers with 'very high' exposure to precarious employment presented a nearly fivefold claim risk in models controlling for age, sex and pandemic wave (rate ratio (RR): 4.90, 95% CI 4.07 to 5.89). Further controlling for occupational exposures (public facing work, working in close proximity to others, indoor work) somewhat attenuated observed associations. After accounting for these factors, workers with 'very high' exposure to precarious employment were still nearly four times as likely to file a successful claim for COVID-19 (RR: 3.78, 95% CI 3.28 to 4.36)., Conclusions: During the first 2 years of the pandemic, precariously employed workers were more likely to acquire a work-related COVID-19 infection resulting in a successful lost-time compensation claim. Strategies aiming to promote an equitable and sustained recovery from the pandemic should consider and address the notable risks associated with precarious employment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Regional variations in SARS-CoV-2 infection were observed in Canada and other countries. Studies have used multilevel analyses to examine how a context, such as a neighbourhood, can affect the SARS-CoV-2 infection rates of the people within it. However, few multilevel studies have quantified the magnitude of the general contextual effect (GCE) in SARS-CoV-2 infection rates and assessed how it may be associated with individual- and area-level characteristics. To address this gap, we will illustrate the application of the median rate ratio (MRR) in a multilevel Poisson analysis for quantifying the GCE in SARS-CoV-2 infection rates in Ontario, Canada., Methods: We conducted a population-based, two-level multilevel observational study where individuals were nested into regions (i.e., forward sortation areas [FSAs]). The study population included community-dwelling adults in Ontario, Canada, between March 1, 2020, and May 1, 2021. The model included seven individual-level variables (age, sex, asthma, diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease) and four FSA census-based variables (household size, household income, employment, and driving to work). The MRR is a median value of the rate ratios comparing two patients with identical characteristics randomly selected from two different regions ordered by rate. We examined the attenuation of the MRR after including individual-level and FSA census-based variables to assess their role in explaining the variation in rates between regions., Results: Of the 11 789 128 Ontario adult community-dwelling residents, 343 787 had at least one SARS-CoV-2 infection during the study period. After adjusting for individual-level and FSA census-based variables, the MRR was attenuated to 1.67 (39% reduction from unadjusted MRR). The strongest FSA census-based associations were household size (RR = 1.88, 95% CI: 1.71-1.97) and driving to work (RR = 0.68, 95% CI: 0.65-0.71)., Conclusions: The individual- and area-level characteristics in our study accounted for approximately 40% of the between-region variation in SARS-CoV-2 infection rates measured by MRR in Ontario, Canada. These findings suggest that population-based policies to address social determinants of health that attenuate the MRR may reduce the observed between-region heterogeneity in SARS-CoV-2 infection rates., (© 2024. The Author(s).)

Background: Worldwide, countries are examining whether to implement 1-dose human papillomavirus (HPV) vaccination instead of using 2 doses. To inform policy, we sought to project the population-level impact and efficiency of switching from 2-dose to 1-dose gender-neutral routine HPV vaccination in Canada., Methods: We used HPV-ADVISE, an individual-based transmission-dynamic model of HPV infections and diseases, to mathematically model vaccination programs in 2 provinces, Quebec, a province with high HPV vaccination coverage (around 85%), and Ontario, which has lower coverage (around 65%). We examined non-inferior and pessimistic scenarios of the efficacy (vaccine efficacy of 98% or 90%) and average vaccine duration (lifelong, 30 yr, or 25 yr) of 1 dose compared with 2 doses (98% vaccine efficacy, lifelong vaccine duration). Our main outcomes were the relative reduction in HPV-16 (by sex) and cervical cancers, and the number of doses needed to prevent 1 cervical cancer., Results: Our model projected that 1-dose HPV vaccination would avert a similar number of cervical cancers as 2 doses in Canada, under various scenarios. Under the most pessimistic scenario (25-yr vaccine duration), 1-dose vaccination would avert fewer cervical cancers than 2 doses, by about 3 percentage points over 100 years. All 1-dose scenarios were projected to lead to elimination of cervical cancer (< 4 cervical cancers/100 000 female-years) and to be a substantially more efficient use of vaccine doses than a 2-dose scenario (1-dose v. no vaccination = 800-1000 doses needed to prevent 1 cervical cancer; incremental doses for 2-dose v. 1-dose vaccination > 10 000 doses needed to prevent 1 additional cervical cancer)., Interpretation: If the average duration of 1-dose protection is longer than 25 years, a 1-dose HPV vaccination program would protect those vaccinated during their peak ages of sexual activity and prevent a similar number of HPV-related cancers as a 2-dose program, while being a more efficient use of vaccine doses., Competing Interests: Competing interests:: Chantal Sauvageau is a member of the Quebec Immunization Committee. Sarah Wilson is a member of the National Advisory Committee on Immunization. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Indigenous Peoples living on the land known as Canada are comprised of First Nations, Inuit, and Métis people and because of the Government of Canada's mandatory evacuation policy, those living in rural and remote regions of Ontario are required to travel to urban, tertiary care centres to give birth. When evaluating the risk of travelling for birth, Indigenous Peoples understand, evaluate, and conceptualise health risks differently than Eurocentric biomedical models of health. Also, the global COVID-19 pandemic changed how people perceived risks to their health. Our research goal was to better understand how Indigenous parturients living in rural and remote communities conceptualised the risks associated with evacuation for birth before and during the COVID-19 pandemic., Methods: To achieve this goal, we conducted semi-structured interviews with 11 parturients who travelled for birth during the pandemic and with 5 family members of those who were evacuated for birth., Results: Participants conceptualised evacuation for birth as riskier during the COVID-19 pandemic and identified how the pandemic exacerbated existing risks of travelling for birth. In fact, Indigenous parturients noted the increased risk of contracting COVID-19 when travelling to urban centres for perinatal care, the impact of public health restrictions on increased isolation from family and community, the emotional impact of fear during the pandemic, and the decreased availability of quality healthcare., Conclusions: Using Indigenous Feminist Methodology and Indigenous Feminist Theory, we critically analysed how mandatory evacuation for birth functions as a colonial tool and how conceptualizations of risk empowered Indigenous Peoples to make decisions that reduced risks to their health during the pandemic. With the results of this study, policy makers and governments can better understand how Indigenous Peoples conceptualise risks related to evacuation for birth before and during the pandemic, and prioritise further consultation with Indigenous Peoples to collaborate in the delivery of the health and care they need and desire., (© 2024. The Author(s).)

Disease maps are integral to spatial epidemiology and public health. The map appearance and analysis of corresponding data may both depend on a map projection used to transform the 3-dimensional world onto a 2-dimensional surface. Map projections necessarily introduce bias - an issue that has not received full attention in the literature. This study aims to demonstrate the impact map projections can have on spatial analysis and disease maps for public health. Case studies applied varying map projections, including the Lambert, Mercator and Robinson projections, to Israel, North Carolina and Southern Ontario as study areas. The effect of projections on various measures, estimates, tests and models was assessed. When the map projection was changed: (i) a distance in Israel increased by 30%; (ii) for Southern Ontario an areal size increased by almost 95%; Moran's I test switched from significant to not; and (iii) a single disease cluster in North Carolina converted into three distinct clusters. Visual bias in disease mapping is unavoidable and should be recognized. Disease maps and spatial analytical inferences, including disease clusters should be reported with their geographic projection. Using geographic coordinates can prevent analytical bias.

Azithromycin-resistant shigellosis is increasing globally. This retrospective analysis of Shigella flexneri serotype 2a isolates from 2016 to 2018 in Ontario found nearly half were azithromycin (47.7%, 72/151) and ciprofloxacin (50.7%, 77/152) resistant. Moreover, 34.7% (25/72) of azithromycin-resistant isolates were also ciprofloxacin-resistant. Four isolates were ceftriaxone-resistant, although all azithromycin-resistant isolates were ceftriaxone-susceptible. Overall, 83.6% (127/152) of all S. flexneri 2a isolates were recovered from males and 97.2% (70/72) of the azithromycin-resistant cases were males. Among the azithromycin-resistant cases, some (8/72) reported international travel. Phylogenetic analysis of azithromycin-resistant isolates revealed two large male-dominated clusters, and one cluster may have been due to importation of resistant strain. Comparison of plasmids isolated from the clusters in Ontario revealed the presence of incFII plasmid with high percentage of similarity to plasmids present in global outbreaks affecting mostly males including men who have sex with men (MSM). These two large azithromycin-resistant clusters are suggestive of an outbreak among MSM, though disease exposure or sexual orientation of patients was unknown. The presence of plasmid-borne azithromycin resistance in ciprofloxacin-resistant isolates is a public health concern. Antimicrobial surveillance is important for patient management, understanding the spread of novel resistance types in local communities which sometimes is introduced by travel. We found ongoing multidrug-resistant outbreaks spanning multiple years affecting males. Reduction of future outbreaks in high-risk communities like MSM requires consorted information flow between laboratory, public health, and physicians. We impart genomic and antimicrobial characteristics of multidrug S. flexneri 2a which may serve as reference by clinicians and public health.IMPORTANCEOral ciprofloxacin and azithromycin are generally considered as the first-line therapy of shigellosis. Here, we report the emergence and transmission of azithromycin and ciprofloxacin-resistant S. flexneri serotype 2a among male adults in Ontario during 2016-2018. The percentage of azithromycin and ciprofloxacin resistance among S. flexneri 2a is higher compared to previous reports from Canada and United States. Here, we show the genetic basis of the antimicrobial resistance among these unique groups of S. flexneri 2a isolates. We describe a domestically acquired azithromycin-resistant and ciprofloxacin-resistant S. flexneri 2a lineage in Ontario. Combining whole-genome sequencing (WGS) data with travel-associated data helped in understanding dissemination and transmission. We employed WGS, which not only helped us in understanding the genetic-relationship between isolates but also mine information regarding plasmids. In the future, linking WGS, travel-related data, and clinical data can provide enhanced contact tracing and improve public-health management., Competing Interests: The authors declare no conflict of interest.

Importance: Newborn immunity largely relies on maternal-fetal transfer of antibodies in utero. Incongruency in ABO blood groups between a mother and newborn may be associated with protection against serious infections, but data specific to newborn bacterial infections are lacking., Objective: To ascertain the association between maternal-newborn ABO blood group incongruence and lower risk of bacterial infection in newborns., Design, Setting, and Participants: This cohort study used linked patient-level datasets for all singleton live births between January 1, 2014, and December 31, 2020, in hospitals and health centers in Ontario, Canada. The cohort comprised maternal-newborn pairs with known ABO blood groups. Data analysis was conducted between February and May 2024., Exposure: Maternal-newborn ABO blood group incongruence vs congruence., Main Outcomes and Measures: The primary outcome was a bacterial infection arising in newborns within 30 days of birth. Bacterial infection was cultured from either blood, cerebrospinal fluid, urine, or lung specimen. Secondary outcomes were a bacterial infection with 7 days and 90 days of birth. Modified Poisson regression generated adjusted relative risks (ARRs) and 95% CIs, adjusted for neonatal sex and preterm birth., Results: A total of 138 207 maternal-newborn pairs (maternal mean [SD] age, 31.8 [5.1] years among those with ABO blood group incongruency and 31.5 [5.1] years among those with ABO blood group congruency; newborn mean [SD] gestational age, 38.5 [2.3] weeks among those with incongruency and 38.4 [2.5] weeks among those with congruency; 19 475 males [51.3%] with incongruency and 52 041 males [51.9%] with congruency) were analyzed. Of these pairs, 37 953 (27.5%) had ABO blood group incongruency and 100 254 (72.5%) had ABO blood group congruency. Within 30 days of birth, 328 (8.6 per 1000) newborns in the incongruent group and 1029 (10.3 per 1000) newborns in the congruent group experienced a bacterial infection, corresponding to an ARR of 0.91 (95% CI, 0.81-1.03). The ARRs for bacterial infection within 7 days and 90 days of birth were 0.89 (95% CI, 0.73-1.09) and 0.86 (95% CI, 0.78-0.94), respectively., Conclusions and Relevance: This cohort study found no association between maternal-newborn ABO blood group incongruence and risk of bacterial infection in newborns within 30 and 7 days of birth. However, incongruence was associated with a decreased risk of bacterial infection within 90 days of birth.

BackgroundLate outbreak identification is a common risk factor mentioned in case reports of large respiratory infection outbreaks in long-term care (LTC) homes.AimTo systematically measure the association between late SARS-CoV-2 outbreak identification and secondary SARS-CoV-2 infection and mortality in residents of LTC homes.MethodsWe studied SARS-CoV-2 outbreaks across LTC homes in Ontario, Canada from March to November 2020, before the COVID-19 vaccine rollout. Our exposure (late outbreak identification) was based on cumulative infection pressure (the number of infectious resident-days) on the outbreak identification date (early: ≤ 2 infectious resident-days, late: ≥ 3 infectious resident-days), where the infectious window was -2 to +8 days around onset. Our outcome consisted of 30-day incidence of secondary infection and mortality, based on the proportion of at-risk residents with a laboratory-confirmed SARS-CoV-2 infection with onset within 30 days of the outbreak identification date.ResultsWe identified 632 SARS-CoV-2 outbreaks across 623 LTC homes. Of these, 36.4% (230/632) outbreaks were identified late. Outbreaks identified late had more secondary infections (10.3%; 4,437/42,953) and higher mortality (3.2%; 1,374/42,953) compared with outbreaks identified early (infections: 3.3%; 2,015/61,714; p < 0.001, mortality: 0.9%; 579/61,714; p < 0.001). After adjustment for 12 LTC home covariates, the incidence of secondary infections in outbreaks identified late was 2.90-fold larger than that of outbreaks identified early (OR: 2.90; 95% CI: 2.04-4.13).ConclusionsThe timeliness of outbreak identification could be used to predict the trajectory of an outbreak, plan outbreak measures and retrospectively provide feedback for quality improvement, with the objective of reducing the impacts of respiratory infections in LTC home residents.

Background: An October, 2021 review of Public Health Ontario's COVID-19 guidance for congregate settings such as shelters and long-term care homes demonstrated that this guidance did not include references to ventilation or filtration. In April 2022, an interdisciplinary team with expertise in indoor air quality (IAQ), engineering, epidemiology, community programming and knowledge translation launched a virtual ventilation and filtration consultation program for community spaces in Toronto, Ontario. The program gives people working in community spaces direct access to IAQ experts through 25-min online appointments. The program aims to help reduce the risk of COVID-19 transmission in community spaces, and was designed to help compensate for gaps in public health guidance and action., Methods: Representatives from participating organizations (n. 27) received a link to an online survey via email in April 2023. Survey questions explored the impacts of the program on topics such as: purchase and use of portable air filters; maintenance and use of bathroom fans; and, maintenance and modification of HVAC systems. Survey participation was anonymous, and no demographic information was collected from participants., Results: Representatives from 11 organizations completed the survey (40%). Of those who responded, nine (82%) made changes as a result of the program, with eight (73%) making two or more changes such as purchasing portable air filters and increasing routine maintenance of HVAC systems., Conclusions: When presented with brief access to expert support and tailored plain language guidance, people working in community spaces increased their use of ventilation and filtration strategies for COVID-19 infection prevention and control., (© 2024. The Author(s).)

Background: Neighborhood-level income is inversely associated with cardiovascular events; however, it is uncertain whether this association varies with immigration status., Methods and Results: We conducted a population-based cohort study of 5.2 million (53% women, 19% immigrants) urban-dwelling people aged ≥40 years without a prior history of cardiovascular disease in Ontario, Canada. Neighborhood-level income was measured in quintiles from quintile 1 (lowest) to quintile 5 (highest), and immigrants were defined as those born outside of Canada who moved to Canada after 1985. We estimated the association between neighborhood-level income and the rate of incident cardiovascular events (hospitalization for stroke or myocardial infarction, or cardiovascular death) using multivariable cause-specific hazards models and added an interaction term to see if the association varies by immigration status. The absolute difference in the rate of cardiovascular events across income quintiles was less pronounced in immigrants than in long-term residents: age- and sex-adjusted rate per 1000 person-years in quintile 1 versus quintile 5: 5.69 versus 4.10 in immigrants and 8.37 versus 5.87 in long-term residents. In adjusted models, the interaction between immigration status and neighborhoodl evel was significant ( P interaction <0.001). The hazard of cardiovascular events declined with increasing income among long-term residents (hazard ratio [HR] Q1vsQ5 , 1.46 to HR Q4vsQ5 , 1.10) and immigrants, albeit with a smaller gradient (HR Q1vsQ5 , 1.43 to HR Q4vsQ5 , 1.20)., Conclusions: The association between neighborhood-level income and cardiovascular disease incidence varies by immigration status. Understanding the social and structural factors associated with residing in low-income neighborhoods can help with the development of prevention programs that improve health for all.