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ObjectivesOur aim was to compare patterns of musculoskeletal-related healthcare utilisation between male and female patients before and after the diagnosis of inflammatory arthritis (IA).MethodsWe used Ontario administrative health data to create three inception cohorts of adult patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) diagnosed between April 2010 and March 2017. Healthcare utilisation indicators including visits to physicians, and use of musculoskeletal imaging and laboratory tests were assessed in each year for 3 years before and after diagnosis and compared between male and female patients using regression models adjusting for sociodemographic factors and comorbidities. Results were reported as ORs with 95% CIs for female patients compared with male patients.ResultsA total of 41 277 patients with RA (69% female), 8150 patients with AS (51% female) and 6446 patients with PsA (54% female) were analysed.Similar trends of sex-related differences were observed in all three cohorts. Before diagnosis, female patients were more likely to visit rheumatologists (OR 1.32–2.28) and family physicians (OR 1.03–1.15) for musculoskeletal reasons, whereas male patients were more likely to visit the emergency for musculoskeletal reasons (OR 0.76–0.87). A similar female predominance was observed regarding musculoskeletal imaging and laboratory tests before diagnosis. After diagnosis, female patients were more likely to remain in rheumatology care (OR 1.12–1.24).ConclusionFemale patients with IA have higher healthcare utilisation than male patients which may indicate biological differences in disease course or sociocultural differences in healthcare-seeking behaviour.

Psoriatic arthritis (PsA) is an inflammatory musculoskeletal disease with a chronic, progressive course. Various aspects of PsA, including its clinical features, disease course and response to treatment, are influenced by sociodemographic characteristics of the patient. This includes patient sex, the biological attributes associated with being male or female, and gender, a sociocultural construct that comprises attitudes, traits and behaviours associated with being a man or a woman. An understanding of sex- and gender-related differences in PsA, as well as their underlying mechanisms, is therefore important for individualized care. In this narrative review, the influence of sex and gender on PsA manifestation and course, patient function and quality of life, and their association with comorbidities are described. Sex- and gender-related disparities in response to advanced therapies and their potential underlying mechanisms are delineated. Differences in pathophysiological mechanisms between male and female patients including genetics, immune and hormonal mechanisms are discussed. Finally, fertility and pregnancy outcomes in PsA are outlined. By adopting sex and gender lenses, this review is aimed at highlighting key differences between male and female patients with PsA and uncovering mechanisms underlying these differences, ultimately promoting individualized care of men and women with PsA and informing future research in this area.

Our aim in this study was to explore the lived experience of adults living with type 1 and type 2 diabetes through an intersectional sex- and gender-based analysis plus lens.Qualitative interviews with 15 adults (9 women, 6 men) were conducted in February and March 2021. Interviews were recorded, transcribed and analyzed for semantic and latent themes noting differences in participants' accounts of living with diabetes by gender, age, race and ethnicity, type of diabetes and other key demographics.Participants' experiences differed substantively by gender, age and racialization. "Resilience" was identified as a central feature in participants' lives. Factors that contributed to resilience included supportive relationships, a feeling of agency and social acceptance; confounding factors included unsupportive relationships, a lack of agency and experiences of stigma, discrimination and microaggressions.Lived experiences of diabetes can best be understood through an intersectional lens that considers peoples' diverse socioeconomic locations and identities. Those who experience discrimination, including women, older individuals and racialized people, may also experience the compounding effects of multiple marginalization, requiring greater investment in factors that contribute to their resilience. Considering the varied needs of diverse individuals should be integrated into routine diabetes care.

Background Older women’s mental health may be disproportionally affected by the COVID-19 pandemic due to differences in gender roles and living circumstances associating with aging. Methods We administered an online cross-sectional nationwide survey between May 1st and June 30th, 2020 to a convenience sample of older adults aged ≥55 years. Our outcomes were symptoms of depression, anxiety, and loneliness measured by three standardized scales: the eight-item Center for Epidemiological Studies Depression Scale, the five-item Beck Anxiety Inventory, and the Three-Item Loneliness Scale. Multivariable logistic regression was used to compare the odds of depression, anxiety and loneliness between men and women, adjusting for relevant confounders. Results There were 1,541 respondents (67.8% women, mean age 69.3 ± 7.8). 23.3% reported symptoms of depression (29.4% women, 17.0% men), 23.2% reported symptoms of anxiety (26.0% women, 19.0% men), and 28.0% were lonely (31.5% women, 20.9% men). After adjustment for confounders, the odds of reporting depressive symptoms were 2.07 times higher in women compared to men (OR 2.07 [95%CI 1.50–2.87] p < .0001). The odds of reporting anxiety and loneliness were also higher. Conclusions Older women had twice the odds of reporting depressive symptoms compared to men, an important mental health need that should be considered as the COVID-19 pandemic unfolds.

ImportanceResident crowding in nursing homes is associated with larger SARS-CoV-2 outbreaks. However, this association has not been previously documented for non-SARS-CoV-2 respiratory infections.ObjectiveWe sought to measure the association between nursing home crowding and respiratory infections in Ontario nursing homes prior to the COVID-19 pandemic.Design, Setting, and ParticipantsWe conducted a retrospective cohort study of nursing home residents in Ontario, Canada over a five-year period prior to the COVID-19 pandemic, between September 2014 and August 2019.ExposureUsing administrative data, we estimated the crowding index equal to the mean number of residents per bedroom and bathroom (residents / [0.5*bedrooms+0.5*bathrooms]).OutcomesThe incidence of outbreak-associated infections and mortality per 100 nursing home residents per year. We also examined infection and mortality outcomes for outbreaks due to 7 specific pathogens: coronaviruses (OC43, 229E, NL63, HKU1), influenza A, influenza B, human metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus/enterovirus.ResultsThere was one or more respiratory outbreak in 93.9% (588/626) nursing homes in Ontario. There were 4,921 outbreaks involving 64,829 cases of respiratory infection, and 1,969 deaths. Outbreaks attributable to a single identified pathogen were principally caused by influenza A (29%), rhinovirus (11.7%), influenza B (8.1%), and respiratory syncytial virus (6.1%). Among homes, 42.7% (251/588) homes had a high crowding index (≥ 2.0). After adjustment, more crowded homes had higher outbreak-associated respiratory infection incidence (aRR 1.89; 95% 1.64-2.18) and mortality incidence (aRR 2.28; 95% 1.84-2.84). More crowded homes had higher adjusted estimates of the incidence of infection and mortality for each of the 7 respiratory pathogens examined.Conclusions and RelevanceResidents of crowded nursing homes experienced more respiratory-outbreak infections and mortality due to influenza and other non-SARS-CoV-2 respiratory pathogens. Decreasing crowding in nursing homes is an important patient safety target beyond the COVID-19 pandemic.

ObjectivesOur primary objective was to estimate the association between loneliness and unmet healthcare needs and if the association changes when adjusted for demographic and health factors. Our secondary objective was to examine the associations by gender (men, women, gender diverse).Design, setting, participantsRetrospective cross-sectional data from 44 423 community-dwelling Canadian Longitudinal Study on Aging participants aged 45 years and older were used.Primary outcome measureUnmet healthcare needs are measured by asking respondents to indicate (yes, no) if there was a time when they needed healthcare in the last 12 months but did not receive it.ResultsIn our sample of 44 423 respondents, 8.5% (n=3755) reported having an unmet healthcare need in the previous 12 months. Lonely respondents had a higher percentage of unmet healthcare needs (14.4%, n=1474) compared with those who were not lonely (6.7%, n=2281). Gender diverse had the highest percentage reporting being lonely and having an unmet healthcare need (27.3%, n=3), followed by women (15.4%, n=887) and men (13.1%, n=583). In our logistic regression, lonely respondents had higher odds of having an unmet healthcare need in the previous 12 months than did not lonely (adjusted odd ratios (aOR) 1.80, 95% CI 1.64 to 1.97), adjusted for other covariates. In the gender-stratified analysis, loneliness was associated with a slightly greater likelihood of unmet healthcare needs in men (aOR 1.90, 95% CI 1.64 to 2.19) than in women (aOR 1.73, 95% CI 1.53 to 1.95). In the gender diverse, loneliness was also associated with increased likelihood of having an unmet healthcare need (aOR 1.38, 95% CI 0.23 to 8.29).ConclusionsLoneliness was related to unmet healthcare needs in the previous 12 months, which may suggest that those without robust social connections experience challenges accessing health services. Gender-related differences in loneliness and unmet needs must be further examined in larger samples.

BackgroundTo partially immunize more persons against COVID-19 during a time of limited vaccine availability, Canadian public health officials recommended extending the vaccine dose interval and brand mixing. Impact on the antibody response among the older ambulatory population was unclear.MethodsDecentralized prospective cohort study with self-report of adverse events and collection of dried blood spots. Data is presented for 1193 (93%) of the 911 older (aged >70 years) and 375 younger (30-50 years) recruits.FindingsLocal and systemic reactivity rates were high but short-lived, particularly in the younger cohort and with mRNA-1273 vaccine. After a single COVID-19 vaccine, 84% younger but only 46% older participants had positive IgG antibodies to both spike protein and receptor binding domain (RBD) antigens, increasing to 100/98% with the second dose respectively. In multivariable linear regression model, lower normalized IgG RBD antibody ratios two weeks after the second dose were statistically associated with older age, male gender, cancer diagnosis, lower body weight, BNT162b2 relative to mRNA-1273 and longer dose intervals. Antibody ratios in both cohorts declined 12 weeks post second vaccine dose.InterpretationWe report success of a decentralized serology study. Antibody responses were higher in the younger than older cohort and were greater for those with at least one mRNA-1273 dose. The immunity threshold is unknown but correlations between binding and neutralizing antibodies are strongly positive. Trends with time and at breakthrough infection will inform vaccine booster strategies.FundingSupported by the Public Health Agency of Canada and the University Health Network Foundation.

Drug-associated harm is common but difficult to detect in the hospital setting. In critically ill children, we sought to evaluate drug-associated hepatic injury following enteral acetaminophen error, defined as acetaminophen dosing that exceeds daily maximum recommendations. This retrospective cohort study took place in two pediatric intensive care units within a pediatric hospital center. The included patients are children ( 18 years of age) admitted to the pediatric and cardiac intensive care unit between January 2008 and January 2018, and receiving enteral acetaminophen. We defined acetaminophen dosing error as exceeding daily acetaminophen dosing by 10% the upper limit of maximum recommended dose for weight and age ( 82.5 mg/kg/day or 4400 mg/day). We included 14,146 admissions, who received 147,485 doses of acetaminophen. Acetaminophen dosing errors occurred 1 in every 9.5 patient-days on acetaminophen. ALT and AST decreased significantly over the course of ICU admission (p 0.0001). In patients with acetaminophen errors, ALT and AST measured in the 24 to 96 h post error were not significantly different than when measured outside this window. A sensitivity analysis using 100 mg/kg/day as the upper daily acetaminophen error cut-off did not reveal any subsequent significant increase in ALT or ALT in the 24 to 96-h post-error window, compared to measurements taken outside the window.Although the administration of acetaminophen in critically ill children frequently exceeds the daily recommended limit and vigilance is needed, we did not find any associated increase in liver transaminases following acetaminophen errors.• Acetaminophen dosing errors are common in pediatric outpatients. • Excessive acetaminophen dosing can be associated with harm, including hepatic injury.• Exceeding daily acetaminophen dosing limit occurs 1 in every 9.5 patient-days in children admitted to the critical care unit. • In patients with daily dose excess of acetaminophen, we did not find a significant increase in the measured liver enzymes in the 24 to 96 h following the overdosing.

Background Small observational studies have suggested that statin users have a lower risk of dying with COVID‐19. We tested this hypothesis in a large, population‐based cohort of adults in 2 of Canada’s most populous provinces: Ontario and Alberta. Methods and Results We examined reverse transcriptase–polymerase chain reaction swab positivity rates for SARS‐CoV‐2 in adults using statins compared with nonusers. In patients with SARS‐CoV‐2 infection, we compared 30‐day risk of all‐cause emergency department visit, hospitalization, intensive care unit admission, or death in statin users versus nonusers, adjusting for baseline differences in demographics, clinical comorbidities, and prior health care use, as well as propensity for statin use. Between January and June 2020, 2.4% of 226 142 tested individuals aged 18 to 65 years, 2.7% of 88 387 people aged 66 to 75 years, and 4.1% of 154 950 people older than 75 years had a positive reverse transcriptase–polymerase chain reaction swab for SARS‐CoV‐2. Compared with 353 878 nonusers, the 115 871 statin users were more likely to test positive for SARS‐CoV‐2 (3.6% versus 2.8%, P Conclusions Compared with statin nonusers, patients taking statins exhibit the same risk of testing positive for SARS‐CoV‐2 and those younger than 75 years exhibit similar outcomes within 30 days of a positive test. Patients older than 75 years with a positive SARS‐CoV‐2 test and who were taking statins had more emergency department visits and hospitalizations, but exhibited lower 30‐day all‐cause mortality risk.

BACKGROUND Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. OBJECTIVE This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. METHODS We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. RESULTS Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. CONCLUSIONS We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). CLINICALTRIAL ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/16966

Background: With an aging population, patients are increasingly likely to present with stroke and pre-existing dementia, which may lead to greater death and disability. Objective: To assess the risk of all-cause mortality and poor functional outcomes after ischemic stroke in patients with and without pre-existing dementia. Design, Participants, and Setting: We conducted a multicenter cohort study of all patients presenting to 12 tertiary care institutions participating in the Registry of the Canadian Stroke Network (RCSN) with a first ischemic stroke between 2003 and 2008. Individuals with pre-existing dementia were matched using propensity score methods with patients without dementia during their index hospitalization based on these characteristics: age (within 3 years), sex, stroke severity, stroke subtype (lacunar vs. non-lacunar), level of consciousness, vascular risk factors, dysphagia, glucose and creatinine on admission, Charlson index, residence prior to hospitalization (home vs. other), pre-admission dependency, hospital arrival via ambulance, admission to stroke unit, thrombolysis, and palliative care. A propensity score model for dementia was estimated that balanced prognostically-important baseline covariates between subjects with and without dementia. Data Sources: Registry of the Canadian Stroke Network (RCSN) and Registered Persons Database (RPDB) Main Outcome Measures: The primary outcome was all cause mortality at 30-days. Secondary outcomes included mortality at discharge and at 1 year, disability at discharge (modified Rankin scale ≥3), medical complications (pneumonia), and discharge disposition. A subgroup analysis assessing the risk of intracerebral hemorrhage among those receiving thrombolysis was also conducted. Results: We matched 877 patients with an acute ischemic stroke and pre-existing dementia to 877 stroke patients without dementia. Patients were well-matched. The mean age was 82 years and 58% were women. Mortality at discharge, 30 days and one year after stroke was similar in patients with and without dementia [for mortality at discharge: RR 0.88 (95% confidence interval (CI) 0.74 to 1.05); mortality at 30-days: RR 0.88 (95%CI 0.75 to 1.03) and mortality at 1 year: RR 1.01; 95%CI 0.92 to 1.11). Patients with pre-existing dementia had similar disability at discharge and home disposition. In the subgroup of patients who received thrombolysis, there were no differences between those with and without dementia in the risk intracerebral hemorrhage (RR 1.27; 95%CI 0.69- 2.35) and no differences in mortality or disability at discharge. Conclusions: Pre-existing dementia is not independently associated with mortality, disability, or institutionalization after ischemic stroke. Pre-existing dementia should not necessarily preclude access to thrombolytic therapy and specialized stroke care.

The rate of progression of Parkinson's disease (PD) is highly variable. Knowledge of factors associated with disease milestones and commonly used research outcome measures helps with patient counseling and guides the design and interpretation of clinical studies. The objective of the study was to identify prognostic factors for time to acquiring disability requiring dopaminergic therapy that are reproducible within 2 large prospectively followed cohorts. Potential prognostic factors were identified using data from the Deprenyl and Tocopherol Antioxidative Therapy of Parkinsonism (DATATOP) trial, and their reproducibility was examined using data from the Parkinson Research Examination of CEP-1347 trial (PRECEPT). In multivariable analyses of the DATATOP cohort, higher baseline Unified Parkinson's Disease Rating Scale (UPDRS) scores, full-time employment, a lesser smoking history, and onset on the left side were associated with a shorter time to disability requiring dopaminergic therapy. PRECEPT data confirmed the associations of higher baseline UPDRS scores and full-time employment with shorter time to requiring treatment. Any clinical trial using the end point of time to disability requiring dopaminergic therapy should ensure that groups are well balanced with respect to baseline UPDRS scores and the proportion of subjects employed full time and should consider including these variables as covariates in the statistical model for primary analysis of treatment effects. We suspect that individuals employed full time may have a lower threshold for requiring dopaminergic therapy because of occupational demands.

To evaluate the efficacy of computerized provider order entry with clinical decision support for preventing adverse drug events in long-term care.Cluster-randomized controlled trial.Two large long-term care facilities.One thousand one hundred eighteen long-term care residents of 29 resident care units.The 29 resident care units, each with computerized provider order entry, were randomized to having a clinical decision support system (intervention units) or not (control units).The number of adverse drug events, severity of events, and whether the events were preventable.Within intervention units, 411 adverse drug events occurred over 3,803 resident-months of observation time; 152 (37.0%) were deemed preventable. Within control units, there were 340 adverse drug events over 3,257 resident-months of observation time; 126 (37.1%) were characterized as preventable. There were 10.8 adverse drug events per 100 resident-months and 4.0 preventable events per 100 resident-months on intervention units. There were 10.4 adverse drug events per 100 resident-months and 3.9 preventable events per 100 resident-months on control units. Comparing intervention and control units, the adjusted rate ratios were 1.06 (95% confidence interval (CI)=0.92-1.23) for all adverse drug events and 1.02 (95% CI=0.81-1.30) for preventable adverse drug events.Computerized provider order entry with decision support did not reduce the adverse drug event rate or preventable adverse drug event rate in the long-term care setting. Alert burden, limited scope of the alerts, and a need to more fully integrate clinical and laboratory information may have affected efficacy.

Given that herbal medicinal products are widely used, vary greatly in content and quality, and are actively tested in randomized controlled trials (RCTs), such RCTs must clearly report the specifics of the intervention.Our objective was to develop recommendations for reporting RCTs of herbal medicine interventions.We identified and invited potential participants with expertise in clinical trial methodology, clinical trial reporting, pharmacognosy, herbal medicinal products, medical statistics, and/or herbal product manufacturing to participate in phone calls and a consensus meeting. Three phases were conducted: (1) Premeeting item generation via telephone calls, (2) Consensus meeting, and (3) Postmeeting feedback. Sixteen experts participated in premeeting phone calls for item generation, and 14 participants attended a consensus meeting in Toronto, Ontario, Canada, in June of 2004. During the consensus meeting, a modified Delphi technique was used to aid discussion and debate of information required for reporting RCTs of herbal medicines.After extensive discussion, the group decided that context-specific elaborations of nine Consolidated Standards of Reporting Trials (CONSORT) items to RCTs of herbal medicines were necessary: Item 1 (Title and Abstract), 2 (Background), 3 (Participants), 4 (Interventions), 6 (Outcomes), 15 (Baseline data), 20 (Interpretation), 21 (Generalizability), and 22 (Overall evidence).The elaboration of item 4 of the CONSORT statement outlines specific information required for complete reporting of the herbal medicine intervention. The reporting suggestions presented will support clinical trialists, editors, and reviewers in reporting and reviewing RCTs of herbal medicines and readers in interpreting the results.

The authors sought to determine the incidence of lithium-induced hypothyroidism in a population-based cohort of older adults beginning lithium therapy and thereby to inform clinical guidelines on the frequency of monitoring necessary in this group.The authors conducted a population-based observational cohort study using four administrative databases that contained information on over 1.3 million older adults in Ontario who receive universal healthcare coverage in terms of physician services, drugs, and hospitalizations. Over an 18-month period, they studied adults ageor=65 who were newly prescribed lithium or valproate, monitoring subjects for initiation of T4 therapy (as a proxy for hypothyroidism) while they continued their lithium use.The authors identified 1,705 new users of lithium and 2,406 new users of valproate with similar baseline characteristics. Lithium users were significantly more likely to be treated with T4 than were valproate users. The rate of T4 treatment per 100 person-years was 5.65 in the lithium group and 2.70 in the valproate group.T4 treatment was initiated in almost 6% of lithium-treated patients, suggesting the possibility that hypothyroidism developed twice as frequently among these patients as would be expected among a mixed-age population. Increased vigilance and continued monitoring of thyroid functioning for at least 2 years is necessary in older adults beginning lithium therapy.

It is not surprising that 6 English-language journals published in North America and the United Kingdom would tend to include articles on topics of interest to English-speaking patients, physicians and researchers in those industrialized, relatively wealthy countries, as reported by Paula Rochon and

Cardiovascular disease is a major health issue for the elderly patient. Many diagnostic, therapeutic and ethical issues are specific for the the older adult with heart disease. The Canadian Cardiovascular Society 2002 Consensus Conference provides recommendations for the most frequently encountered cardiac problems in the elderly patient. A common theme of the recommendations is the need to apply the best evidence based medicine together with an assessment of frailty, comorbidity and quality of life. A major goal of the conference was to identify treatments that are not optimally used in the older patient.