Evaluating the Association between the Implementation of the PoET (Prevention of Error-Based Transfers) Southwest Spread Project and Palliative Care Provision: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

OBJECTIVES

The PoET (Prevention of Error-based Transfers) project seeks to align long-term care (LTC) home informed consent practices to existing legislation, thereby reducing consent-related error-based transfers to acute care. We sought to measure changes in resident-level palliative care provision after participating in the PoET Southwest Spread Project (PSSP), and to identify patient and LTC home characteristics associated with palliative care provision.

DESIGN

Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data.

SETTING

Sixty LTC homes (PSSP = 30; Control = 30) in Ontario, Canada, from November 2019 to December 2021.

METHODS

We matched 30 PSSP to 30 control homes and described incidence rates for resident-level palliative care provision (ie, physician palliative care encounters and palliative medication prescriptions) during the 7-month postimplementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and palliative care provision during the postimplementation period. We adjusted for resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent subcohort to measure palliative care provision patterns during the last 2 months of life.

RESULTS

We captured a matched cohort of 8894 residents (PSSP = 4103; Control = 4791). Incidence rates of palliative care encounters increased during the postimplementation period for PSSP (82.6 to 85.4 per 100 person-months) but not for control residents (68.8 to 65.3 per 100 person-months). After adjusting for key covariates, PSSP exposure was associated increased palliative care provision (incidence rate ratio 2.47, 95% CI 2.31-2.64) and palliative care medication prescription (1.16, 95% CI 1.12-1.20). Larger home size, certain health regions, and higher number of comorbidities were associated with increased physician palliative care encounters.

CONCLUSIONS AND IMPLICATIONS

By promoting correct informed consent practices in LTC, PSSP participation increased palliative care provision for PSSP LTC residents across all settings.

Direct Oral Anticoagulation Versus Warfarin in Patients with Atrial Fibrillation and Bioprosthetic Heart Valves: a Retrospective, Real-World Cohort Study

OBJECTIVE

In this retrospective cohort study of consecutive patients with atrial fibrillation and surgical or transcatheter bioprosthetic valve, we compared the efficacy and safety of direct oral anticoagulants with warfarin.

METHODS

Using linked health administrative databases housed at the Institute for Clinical Evaluative Sciences, we identified consecutive patients in Ontario (Canada) 65 years of age or older with AF who underwent bioprosthetic valve replacement between 1 April 2012 and 31 March 2017. We created a time-varying Cox model to examine the relationship between the type of anticoagulant and time to thrombotic or bleeding events after adjustment for baseline risk of thrombosis using the CHA2DS2-VASc score and risk of bleeding using the HAS-BLED scores. We conducted prespecified subgroup analyses according to whether valve implantation was surgical or transcatheter.

RESULTS

We identified 2245 eligible patients. The mean age was 79 years, 41% were female, and 39% had transcatheter aortic valve replacement. Risk of death or thrombosis was not different between direct oral anticoagulants and warfarin after adjustment for CHA2DS2-VASc score (hazard ratio [HR] 1.02, 95% confidence interval [CI], 0.83-1.25). Risk of death or bleeding was not different between direct oral anticoagulants and warfarin after adjustment for HAS-BLED score (HR 0.89, 95% CI 0.75-1.07). Subgroup analyses of surgical or transcatheter valves were consistent with overall results.

CONCLUSIONS

In a real-world population of patients with atrial fibrillation and bioprosthetic valve replacement, we found no difference between direct oral anticoagulants and warfarin with regard to the risk of thrombosis or bleeding.

SURGE: uncovering context-specific genetic-regulation of gene expression from single-cell RNA sequencing using latent-factor models

Genetic regulation of gene expression is a complex process, with genetic effects known to vary across cellular contexts such as cell types and environmental conditions. We developed SURGE, a method for unsupervised discovery of context-specific expression quantitative trait loci (eQTLs) from single-cell transcriptomic data. This allows discovery of the contexts or cell types modulating genetic regulation without prior knowledge. Applied to peripheral blood single-cell eQTL data, SURGE contexts capture continuous representations of distinct cell types and groupings of biologically related cell types. We demonstrate the disease-relevance of SURGE context-specific eQTLs using colocalization analysis and stratified LD-score regression.

Association of a Heart Failure Management Incentive in Primary Care With Clinical Outcomes: A Retrospective Cohort Study

BACKGROUND

We aim to examine the association between primary care physicians' billing of Q050A, a pay-for-performance heart failure (HF) management incentive fee code, and the composite outcome of mortality, hospitalization, and emergency department visits.

METHODS AND RESULTS

This population-based cohort study linked administrative health databases in Ontario, Canada, for patients with HF aged >66 years between January 1, 2008, and March 31, 2020. Cases were patients with HF who had a Q050A fee code billed. Cases and controls were matched 1:1 on age, sex, patient status on being rostered to a primary care physician, cardiologist, or internist visit in the 6 months before study enrollment, Johns Hopkins Adjusted Clinical Group resource use bands, days between HF diagnosis and study enrollment (±2 years), and the logit of the propensity score. A Cox proportional hazards model assessed the association of Q050A with the outcome. A total of 59 664 cases had a Q050A billed, whereas 244 883 patients did not. Before matching, patients who had a Q050A billed were more likely to be men (52% versus 49%), were rostered to a primary care physician (100% versus 96%), had a higher Charlson Comorbidity Index, and had higher health care costs. The mean follow-up was 481 days for cases and 530 days for controls. The composite outcome (hazard ratio, 1.11 [95% CI, 1.09-1.12]) was significantly higher for cases than controls.

CONCLUSIONS

The Q050A incentive improved financial compensation for primary care physicians managing patients with HF but was not associated with improvements in the outcome. Research on promoting evidence-based HF management is warranted.

Prediction of High-Risk Donors for Kidney Discard and Nonrecovery Using Structured Donor Characteristics and Unstructured Donor Narratives

Importance

Despite the unmet need, many deceased-donor kidneys are discarded or not recovered. Inefficient allocation and prolonged ischemia time are contributing factors, and early detection of high-risk donors may reduce organ loss.

Objective

To evaluate the feasibility of machine learning (ML) and natural language processing (NLP) classification of donors with kidneys that are used vs not used for organ transplant.

Design, Setting, and Participants

This retrospective cohort study used donor information (structured donor characteristics and unstructured donor narratives) from the United Network for Organ Sharing (UNOS). All donor offers to a single transplant center between January 2015 and December 2020 were used to train and validate ML models to predict donors who had at least 1 kidney transplanted (at our center or another center). The donor data from 2021 were used to test each model.

Exposures

Donor information was provided by UNOS to the transplant centers with potential transplant candidates. Each center evaluated the donor and decided within an allotted time whether to accept the kidney for organ transplant.

Main Outcomes and Measures

Outcome metrics of the test cohort included area under the receiver operating characteristic curve (AUROC), F1 score, accuracy, precision, and recall of each ML classifier. Feature importance and Shapley additive explanation (SHAP) summaries were assessed for model explainability.

Results

The training/validation cohort included 9555 donors (median [IQR] age, 50 [36-58] years; 5571 male [58.3%]), and the test cohort included 2481 donors (median [IQR] age, 52 [40-59] years; 1496 male [60.3%]). Only 20% to 30% of potential donors had at least 1 kidney transplanted. The ML model with a single variable (Kidney Donor Profile Index) showed an AUROC of 0.69, F1 score of 0.42, and accuracy of 0.64. Multivariable ML models based on basic a priori structured donor data showed similar metrics (logistic regression: AUROC = 0.70; F1 score = 0.42; accuracy = 0.62; random forest classifier: AUROC = 0.69; F1 score = 0.42; accuracy = 0.64). The classic NLP model (bag-of-words model) showed its best metrics (AUROC = 0.60; F1 score = 0.35; accuracy = 0.59) by the logistic regression classifier. The advanced Bidirectional Encoder Representations From Transformers model showed comparable metrics (AUROC = 0.62; F1 score = 0.39; accuracy = 0.69) only after appending basic donor information. Feature importance and SHAP detected the variables (and words) that affected the models most.

Conclusions and Relevance

Results of this cohort study suggest that models using ML can be applied to predict donors with high-risk kidneys not used for organ transplant, but the models still need further elaboration. The use of unstructured data is likely to expand the possibilities; further exploration of new approaches will be necessary to develop models with better predictive metrics.

Evaluating the Association between the Implementation of the PoET Southwest Spread Project and Reductions in Acute Care Transfers from Long-Term Care: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data

OBJECTIVES

To measure changes in resident-level acute care transfer rates after the PoET Southwest Spread Project (PSSP), and to identify patient and long-term care (LTC) home characteristics associated with acute care transfers after program launch.

DESIGN

Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data.

SETTING

Sixty publicly funded LTC homes (PSSP = 30; control = 30) in Ontario, Canada, from November 2019 to December 2021.

METHODS

We matched 30 PSSP homes to 30 control homes with similar characteristics and described incidence rates for resident-level acute care transfers during the 7-month post-implementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and acute care transfers during the post-implementation period. We adjusted resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent sub-cohort to measure transfer patterns during the last 2 months of life.

RESULTS

A matched cohort of 8894 residents (PSSP = 4103; control = 4791) was captured. Incidence rates of transfers increased during the post-implementation period for both PSSP (78.8 to 80.9 transfers per 1000 person-months) and control residents (66.9 to 67.9 transfers per 1000 person-months). After adjusting for covariates of interest, PSSP exposure was associated with a reduction in acute care transfers during the post-implementation period after adjusting for covariates (incidence rate ratio, 0.73; 95% CI, 0.62-0.87; P = .0002). Older age and select health regions were associated with reduced transfers, whereas higher comorbidity status and higher COVID-19 outbreak days were associated with increases. Similar patterns persisted for transfers during the last 2 months of life.

CONCLUSIONS AND IMPLICATIONS

This study systematically evaluated the impact of an ethics-based health care intervention in LTC using health care utilization databases. PoET implementation is associated with reduced acute care transfer rates, especially in the last 2 months of life in LTC.

A myeloid program associated with COVID-19 severity is decreased by therapeutic blockade of IL-6 signaling

Altered myeloid inflammation and lymphopenia are hallmarks of severe infections. We identified the upregulated EN-RAGE gene program in airway and blood myeloid cells from patients with acute lung injury from SARS-CoV-2 or other causes across 7 cohorts. This program was associated with greater clinical severity and predicted future mechanical ventilation and death. EN-RAGEhi myeloid cells express features consistent with suppressor cell functionality, including low HLA-DR and high PD-L1. Sustained EN-RAGE program expression in airway and blood myeloid cells correlated with clinical severity and increasing expression of T cell dysfunction markers. IL-6 upregulated many EN-RAGE program genes in monocytes in vitro. IL-6 signaling blockade by tocilizumab in a placebo-controlled clinical trial led to rapid normalization of EN-RAGE and T cell gene expression. This identifies IL-6 as a key driver of myeloid dysregulation associated with worse clinical outcomes in COVID-19 patients and provides insights into shared pathophysiological mechanisms in non-COVID-19 ARDS.

Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study

BACKGROUND

Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults.

METHODS

We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits.

RESULTS

We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14).

INTERPRETATION

Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.

CloudPred: Predicting Patient Phenotypes From Single-cell RNA-seq

Single-cell RNA sequencing (scRNA-seq) has the potential to provide powerful, high-resolution signatures to inform disease prognosis and precision medicine. This paper takes an important first step towards this goal by developing an interpretable machine learning algorithm, CloudPred, to predict individuals' disease phenotypes from their scRNA-seq data. Predicting phenotype from scRNA-seq is challenging for standard machine learning methods-the number of cells measured can vary by orders of magnitude across individuals and the cell populations are also highly heterogeneous. Typical analysis creates pseudo-bulk samples which are biased toward prior annotations and also lose the single cell resolution. CloudPred addresses these challenges via a novel end-to-end differentiable learning algorithm which is coupled with a biologically informed mixture of cell types model. CloudPred automatically infers the cell subpopulation that are salient for the phenotype without prior annotations. We developed a systematic simulation platform to evaluate the performance of CloudPred and several alternative methods we propose, and find that CloudPred outperforms the alternative methods across several settings. We further validated CloudPred on a real scRNA-seq dataset of 142 lupus patients and controls. CloudPred achieves AUROC of 0.98 while identifying a specific subpopulation of CD4 T cells whose presence is highly indicative of lupus. CloudPred is a powerful new framework to predict clinical phenotypes from scRNA-seq data and to identify relevant cells.

Sex-Specific Clinical Outcomes of the PACT-HF Randomized Trial

BACKGROUND

Transitional care may have different effects in males and females hospitalized for heart failure. We assessed the sex-specific effects of a transitional care model on clinical outcomes following hospitalization for heart failure.

METHODS

In this stepped-wedge cluster randomized trial of adults hospitalized for heart failure in Ontario, Canada, 10 hospitals were randomized to a group of transitional care services or usual care. Outcomes in this exploratory analysis were composite all-cause readmission, emergency department visit, or death at 6 months; and composite all-cause readmission or emergency department visit at 6 months. Models were adjusted for stepped-wedge design and patient age.

RESULTS

Among 2494 adults, mean (SD) age was 77.7 (12.1) years, and 1258 (50.4%) were female. The first composite outcome occurred in 371 (66.3%) versus 433 (64.1%) males (hazard ratio [HR], 1.04 [95% CI, 0.86-1.26]; P=0.67) and in 326 (59.9%) versus 463 (64.8%) females (HR, 0.83 [95% CI, 0.69-1.01]; P=0.06) in the intervention and usual care groups, respectively (P=0.012 for sex interaction). The second composite outcome occurred in 357 (63.8%) versus 417 (61.7%) males (HR, 1.03 [95% CI, 0.85-1.24]; P=0.76) and 314 (57.7%) versus 450 (63.0%) females (HR, 0.81 [95% CI, 0.67-0.99]; P=0.037) in the intervention and usual care groups, respectively (P=0.024 for sex interaction). The sex differences were driven by a reduction in all-cause emergency department visits among females (HR, 0.66 [95% CI, 0.51-0.87]; P=0.003), but not males (HR, 1.10 [95% CI, 0.85-1.43]; P=0.46), receiving the intervention (P<0.001 for sex interaction).

CONCLUSIONS

A transitional care model offered a reduction in all-cause emergency department visits among females but not males following hospitalization for heart failure. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02112227.

Type I interferon autoantibodies are associated with systemic immune alterations in patients with COVID-19

A subset of patients diagnosed with coronavirus disease 2019 (COVID-19) present with autoantibodies specific to type I interferons (IFNs). However, the systemic impacts of type I IFN–specific autoantibodies are not fully understood. Here, van der Wijst et al. longitudinally evaluated the relationship between type I IFN–specific autoantibody abundance and changes to the immune system of individuals with COVID-19. Using single-cell transcriptomics, the authors found that the presence of type I IFN autoantibodies correlated with reduced type I IFN–stimulated gene (ISG) expression in patients with critical COVID-19. Reduced ISG expression, in turn, correlated with increased expression of the inhibitory receptor, leukocyte-associated immunoglobulin-like receptor 1 (LAIR1), on monocytes. Together, these findings suggest that early evidence of type I IFN autoantibodies and increased LAIR1 expression may help distinguish severe cases of COVID-19.

Neutralizing autoantibodies against type I interferons (IFNs) have been found in some patients with critical coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, the prevalence of these antibodies, their longitudinal dynamics across the disease severity scale, and their functional effects on circulating leukocytes remain unknown. Here, in 284 patients with COVID-19, we found type I IFN–specific autoantibodies in peripheral blood samples from 19% of patients with critical disease and 6% of patients with severe disease. We found no type I IFN autoantibodies in individuals with moderate disease. Longitudinal profiling of over 600,000 peripheral blood mononuclear cells using multiplexed single-cell epitope and transcriptome sequencing from 54 patients with COVID-19 and 26 non–COVID-19 controls revealed a lack of type I IFN–stimulated gene (ISG-I) responses in myeloid cells from patients with critical disease. This was especially evident in dendritic cell populations isolated from patients with critical disease producing type I IFN–specific autoantibodies. Moreover, we found elevated expression of the inhibitory receptor leukocyte-associated immunoglobulin-like receptor 1 (LAIR1) on the surface of monocytes isolated from patients with critical disease early in the disease course. LAIR1 expression is inversely correlated with ISG-I expression response in patients with COVID-19 but is not expressed in healthy controls. The deficient ISG-I response observed in patients with critical COVID-19 with and without type I IFN–specific autoantibodies supports a unifying model for disease pathogenesis involving ISG-I suppression through convergent mechanisms.

Rates of rebleeding, thrombosis and mortality associated with resumption of anticoagulant therapy after anticoagulant-related bleeding

BACKGROUND:

Data on resuming oral anticoagulants (OACs) after bleeding are primarily from studies involving patients given warfarin, with few data on direct OACs (DOACs). We aimed to characterize prescribing patterns for OACs after OAC-related bleeding and compare the rates of bleeding, thrombosis and mortality in patients who resumed either type of OAC with those who did not.

METHODS:

We conducted a population-based cohort study of adults aged 66 years or older who were admitted to hospital for bleeding while receiving OACs from Apr. 1, 2012, to Mar. 31, 2017, using linked administrative health databases from Ontario. We used competing risk methods to calculate cause-specific adjusted hazard ratios (HRs) for thrombosis, bleeding and mortality with resumption of OACs adjusted as a time-varying covariate. We determined time to OAC resumption using the Kaplan–Meier method.

RESULTS:

We included 6793 patients with gastrointestinal (n = 4297, 63.3%), intracranial (n = 805, 11.9%) or other bleeding (n = 1691, 25.0%). At cohort entry, 3874 patients (57.0%) were prescribed warfarin and 2919 patients (43.0%) were prescribed a DOAC. The most common indication for OAC was atrial fibrillation (n = 5557, 81.8%), followed by venous thromboembolism (n = 1367, 20.1%). Oral anticoagulants were resumed in 4792 patients (70.5%) within 365 days of the index bleed. The median time to resumption was 46 (interquartile range 6–550) days. We found that resuming OAC was associated with reduced rates of thrombosis (adjusted HR 0.60, 95% confidence interval [CI] 0.50–0.72) and mortality (adjusted HR 0.54, 95% CI 0.48–0.60), and an increased rate of rebleeding (adjusted HR 1.88, 95% CI 1.64–2.17).

INTERPRETATION:

We found that resuming OAC is associated with a reduction in thrombosis and mortality but an increase in bleeding. Randomized controlled trials that evaluate the net benefit of strategies for resumption of OAC after a bleeding event are warranted.

Comparison of 4-Year Health Care Expenditures Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy

IMPORTANCE

Data on the long-term health care expenditures associated with bariatric surgery consisting of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are lacking.

OBJECTIVE

To compare 4-year health care expenditures after RYGB vs sleeve gastrectomy, identify factors independently associated with 4-year health care expenditures, and compare the procedures in terms of subsequent hospitalizations, bariatric procedures, and all-cause mortality.

DESIGN, SETTING, AND PARTICIPANTS

In this propensity score-matched cohort study, all residents of Ontario, Canada, who underwent publicly funded surgery with RYGB (n = 6301) or sleeve gastrectomy (n = 926) from March 1, 2010, to March 31, 2015, and consented to participate in the Ontario Bariatric Registry were eligible for the study. Follow-up was completed on March 31, 2019, and data were analyzed from May 5, 2020, to May 20, 2021.

INTERVENTIONS

RYGB and sleeve gastrectomy.

MAIN OUTCOMES AND MEASURES

Publicly funded health care expenditures, subsequent hospitalizations, bariatric procedures, and mortality during the 4 years after RYGB or sleeve gastrectomy.

RESULTS

The 1:1 matched study cohorts consisted of 1624 patients (812 per cohort) with a mean (SD) age of 48.0 (10.6) years, and 1242 women (76.5%). The mean body mass index (calculated as weight in kilograms divided by height in square meters) was 51.9 (8.3) for the RYGB cohort and 51.9 (8.9) for the sleeve gastrectomy cohort. The 4-year cumulative costs were not statistically significantly different between RYGB and sleeve gastrectomy (mean [SD], $33 682 [$31 169] vs $33 948 [$32 633], respectively; P = .86). Having a history of coronary artery disease was associated with a 35% increase in overall health care expenditures; chronic kidney disease, a 54% increase; and mental health admissions, a 67% increase. There were no statistically significant differences in all-cause mortality between RYGB and sleeve gastrectomy (1.5% vs 2.2%, respectively; P = .26) or the total number of hospitalizations (754 vs 669, respectively; P = .11) during the 4-year follow-up period. However, nonelective hospitalizations occurred more frequently with RYGB vs sleeve gastrectomy (472 vs 339, respectively; P = .002). Roux-en-Y gastric bypass was associated with relatively fewer subsequent bariatric procedures during the 4-year follow-up period (9 vs 40, respectively; P < .001).

CONCLUSIONS AND RELEVANCE

In this Canadian population-based study, key results indicated that 4-year health care expenditures, all-cause mortality, and number of hospital admissions associated with RYGB did not significantly differ from those for sleeve gastrectomy. The rate of subsequent bariatric surgery was lower with RYGB. This study identified important patient-level drivers of health care expenditures that need to be further investigated.

Effect of patient-centered transitional care services on patient-reported outcomes in heart failure: sex-specific analysis of the PACT-HF randomized controlled trial

AIMS

We assessed the effect of transitional care on patient-reported outcomes (PROs) in women and men hospitalized for heart failure.

METHODS AND RESULTS

In this sex-specific analysis of a stepped wedge cluster randomized trial in Canada, the effect of a patient-centered transitional care model was tested on pre-specified PROs of discharge preparedness (B-PREPARED score, range 0-22), quality of transition [Care Transitions Measure-3 (CTM-3) score, range 0-100], and health-related quality of life (HRQOL) (EQ-5D-5L, range 0-1). Among 986 patients (47.4% women), B-PREPARED at 6 weeks was greater with the intervention than usual care [mean difference (MD) 4.01 (95% confidence interval-CI 2.90-5.12); P < 0.001], with no sex differences (P sex-interaction = 0.24). CTM-3 at 6 weeks was greater with the intervention than usual care [MD 10.52 (95% CI 6.00-15.04); P < 0.001], with no sex differences (P sex-interaction = 0.69). EQ-5D-5L was greater with intervention than usual care at discharge [MD 0.17 (95% CI 0.12-0.22); P < 0.001], 6 weeks [MD 0.06 (95% CI 0.01-0.12); P = 0.02], and 6 months [MD 0.05 (95% CI -0.01 to 0.12); P = 0.09], although the 6-month difference was not statistically significant. At discharge, women reported lower EQ-5D-5L but experienced significantly greater treatment benefit than men (P sex-interaction = 0.02). Treatment effect on EQ-5D-5L was numerically greater in women than men at 6 weeks and 6 months, but there were no significant sex differences (P sex-interaction 0.18 and 0.19, respectively).

CONCLUSION

A patient-centered transitional care model improved discharge preparedness, transition quality, and HRQOL in the weeks following heart failure hospitalization, with effects largely consistent in women and men. However, women reported lower HRQOL and experienced greater treatment benefit in this endpoint than men at hospital discharge.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT02112227.

Derivation and validation of a two-variable index to predict 30-day outcomes following heart failure hospitalization

Background

The LACE index—length of stay (L), acuity (A), Charlson co‐morbidities (C), and emergent visits (E)—predicts 30‐day outcomes following heart failure (HF) hospitalization but is complex to score. A simpler LE index (length of stay and emergent visits) could offer a practical advantage in point‐of‐care risk prediction.

Methods and results

This was a sub‐study of the patient‐centred care transitions in HF (PACT‐HF) multicentre trial. The derivation cohort comprised patients hospitalized for HF, enrolled in the trial, and followed prospectively. External validation was performed retrospectively in a cohort of patients hospitalized for HF. We used log‐binomial regression models with LACE or LE as the predictor and either 30‐day composite all‐cause readmission or death or 30‐day all‐cause readmission as the outcomes, adjusting only for post‐discharge services. There were 1985 patients (mean [SD] age 78.1 [12.1] years) in the derivation cohort and 378 (mean [SD] age 73.1 [13.2] years) in the validation cohort. Increments in the LACE and LE indices were associated with 17% (RR 1.17; 95% CI 1.12, 1.21; C‐statistic 0.64) and 21% (RR 1.21; 95% CI 1.15, 1.26; C‐statistic 0.63) increases, respectively, in 30‐day composite all‐cause readmission or death; and 16% (RR 1.16; 95% CI 1.11, 1.20; C‐statistic 0.64) and 18% (RR 1.18; 95% CI 1.13, 1.24; C‐statistic 0.62) increases, respectively, in 30‐day all‐cause readmission. The LE index provided better risk discrimination for the 30‐day outcomes than did the LACE index in the external validation cohort.

Conclusions

The LE index predicts 30‐day outcomes following HF hospitalization with similar or better performance than the more complex LACE index.

Longitudinal single-cell epitope and RNA-sequencing reveals the immunological impact of type 1 interferon autoantibodies in critical COVID-19: Anti-IFN antibodies in critical COVID-19 correlate with poor ISG response and upregulation of LAIR1 surface protein in PBMCs

Type I interferon (IFN-I) neutralizing autoantibodies have been found in some critical COVID-19 patients; however, their prevalence and longitudinal dynamics across the disease severity scale, and functional effects on circulating leukocytes remain unknown. Here, in 284 COVID-19 patients, we found IFN-I autoantibodies in 19% of critical, 6% of severe and none of the moderate cases. Longitudinal profiling of over 600,000 peripheral blood mononuclear cells using multiplexed single-cell epitope and transcriptome sequencing from 54 COVID-19 patients, 15 non-COVID-19 patients and 11 non-hospitalized healthy controls, revealed a lack of IFN-I stimulated gene (ISG-I) response in myeloid cells from critical cases, including those producing anti-IFN-I autoantibodies. Moreover, surface protein analysis showed an inverse correlation of the inhibitory receptor LAIR-1 with ISG-I expression response early in the disease course. This aberrant ISG-I response in critical patients with and without IFN-I autoantibodies, supports a unifying model for disease pathogenesis involving ISG-I suppression via convergent mechanisms.

Effect of socio-demographic and health factors on the association between multimorbidity and acute care service use: population-based survey linked to health administrative data

BACKGROUND

This study explores how socio-demographic and health factors shape the relationship between multimorbidity and one-year acute care service use (i.e., hospital, emergency department visits) in older adults in Ontario, Canada.

METHODS

We linked multiple cycles (2005-2006, 2007-2008, 2009-2010, 2011-2012) of the Canadian Community Health Survey (CCHS) to health administrative data to create a cohort of adults aged 65 and older. Administrative data were used to estimate one-year service use and to identify 12 chronic conditions used to measure multimorbidity. We examined the relationship between multimorbidity and service use stratified by a range of socio-demographic and health variables available from the CCHS. Logistic and Poisson regressions were used to explore the association between multimorbidity and service use and the role of socio-demographic factors in this relationship.

RESULTS

Of the 28,361 members of the study sample, 60% were between the ages of 65 and 74 years, 57% were female, 72% were non-immigrant, and over 75% lived in an urban area. Emergency department visits and hospitalizations consistently increased with the level of multimorbidity. This study did not find strong evidence of moderator or interaction effects across a range of socio-demographic factors. Stratified analyses revealed further patterns, with many being similar for both services - e.g., the odds ratios were higher at all levels of multimorbidity for men, older age groups, and those with lower household income. Rurality and immigrant status influenced emergency department use (higher in rural residents and non-immigrants) but not hospitalizations. Multimorbidity and the range of socio-demographic variables remained significant predictors of service use in the regressions.

CONCLUSIONS

Strong evidence links multimorbidity with increased acute care service use. This study showed that a range of factors did not modify this relationship. Nevertheless, the factors were independently associated with acute care service use, pointing to modifiable risk factors that can be the focus of resource allocation and intervention design to reduce service use in those with multimorbidity. The study's results suggest that optimizing acute care service use in older adults requires attention to both multimorbidity and social determinants, with programs that are multifactorial and integrated across the health and social service sectors.

Optimized design of single-cell RNA sequencing experiments for cell-type-specific eQTL analysis

Single-cell RNA-sequencing (scRNA-Seq) is a compelling approach to directly and simultaneously measure cellular composition and state, which can otherwise only be estimated by applying deconvolution methods to bulk RNA-Seq estimates. However, it has not yet become a widely used tool in population-scale analyses, due to its prohibitively high cost. Here we show that given the same budget, the statistical power of cell-type-specific expression quantitative trait loci (eQTL) mapping can be increased through low-coverage per-cell sequencing of more samples rather than high-coverage sequencing of fewer samples. We use simulations starting from one of the largest available real single-cell RNA-Seq data from 120 individuals to also show that multiple experimental designs with different numbers of samples, cells per sample and reads per cell could have similar statistical power, and choosing an appropriate design can yield large cost savings especially when multiplexed workflows are considered. Finally, we provide a practical approach on selecting cost-effective designs for maximizing cell-type-specific eQTL power which is available in the form of a web tool.

The Early Burden of Disability in Individuals With Mood and Other Common Mental Disorders in Ontario, Canada

IMPORTANCE

Large population-based data on the trajectory to disability after the first diagnosis of a mood disorder are lacking.

OBJECTIVE

To assess the time between an incident mood disorder diagnosis and the receipt of disability services during a follow-up period of as long as 20 years.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used health administrative and social service data from ICES for 1 902 792 adults aged 18 to 59 years living in Ontario, Canada. A narrow cohort of individuals who had a new diagnosis of a mood disorder between October 1, 1997, and March 31, 2007, matched by sex and age to individuals with no history of mood disorder, included 278 296 participants. A broader cohort of individuals who had a new diagnosis of other common mental disorders during the same period, matched by sex and age to individuals with no history of mental disorder diagnosis, included 1 624 496 individuals. All individuals were followed up to a maximum end date of March 31, 2017. Data analysis was conducted from November 2017 to June 2018.

EXPOSURE

Incident diagnosis of mood or common mental disorder.

MAIN OUTCOMES AND MEASURES

Disability outcomes were as follows: (1) entry into the Ontario Disability Support Program (ODSP), signifying long-term inability to work because of a disability, and (2) admission into a long-term care (LTC) residence, signifying the inability to live in independent housing. Cox proportional hazards models were used.

RESULTS

In the full cohort of 1 902 792 individuals, 278 296 participants (14.6%) were included in the mood disorder cohort (mean [SD] age, 37.5 [11.9] years; 157 386 [56.6%] women), and 1 624 496 participants (85.4%) were included in the common mental disorder cohort (mean [SD], 36.5 [11.8] years; 932 545 [57.4%] women). The incidence of ODSP initiation was greater among individuals with mood disorders than those without (51.5 per 10 000 person-years vs 25.5 per 10 000 person-years; adjusted hazard ratio [aHR], 2.03; 95% CI, 1.95-2.11) and for those with common mental disorders (45.0 per 10 000 person-years vs 27.6 per 10 000 person-years; aHR, 1.57; 95% CI, 1.55-1.60). The aHR for admission to LTC was also higher among individuals with mood disorders compared with those without (aHR, 2.20; 95% CI, 1.80-2.69) and those with common mental disorders compared with those without (aHR, 1.21; 95% CI, 1.14-1.29). Individuals with bipolar disorders had greater ODSP rates than individuals with major depressive disorders (crude rate ratio: 4.31 [95% CI, 3.56-5.17] vs 1.82 [95% CI, 1.36-2.43]).

CONCLUSIONS AND RELEVANCE

This cohort study found that mood disorders were associated with elevated and early rates of disability services. Effective early intervention strategies targeting functional impairment in this population are encouraged.

Using the clinical chemistry score in the emergency department to detect adverse cardiac events: a diagnostic accuracy study

BACKGROUND

The ability to rule out or in a major adverse cardiac event (MACE) in patients with suspected acute coronary syndrome at emergency department (ED) presentation would be beneficial to patient care and the health care system. The clinical chemistry score (CCS) was evaluated in this context.

METHODS

This diagnostic accuracy study evaluated 2 different ED cohorts with suspected acute coronary syndrome. For patients in cohort 1, who presented to the ED of 3 hospitals in Hamilton, Ontario, between May and August 2013, retrospective measurements were taken using the Ortho Clinical Diagnostics high-sensitivity cardiac troponin I (hs-cTnI) assay; for patients in cohort 2, who presented to the ED of the same 3 hospitals in Hamilton between November 2012 and February 2013, an ED cardiac presentation blood test panel was performed with the Abbott Diagnostics hs-cTnI assay. The sensitivity and specificity of the CCS (cut-offs of ≥ 1 and 5) and hs-cTnI alone (published cut-offs) were compared for MACE (composite of death, myocardial infarction, unstable angina, revascularization) at 30 days for both cohorts and at 90 days for cohort 2.

RESULTS

The incidence of MACE at 30 days was higher in cohort 1 (n = 1058) (19.4%, 95% confidence interval [CI] 16.8%-22.2%) than in cohort 2 (n = 5974) (14.6%, 95% CI 13.6%-15.6%). In cohort 1, a CCS of 1 or above yielded a sensitivity of 99.5% (95% CI 97.3%-99.9%). The sensitivity with an Ortho hs-cTnI cut-off of 1 ng/L or above was 91.2% (95% CI 86.5%-95.7%). The specificity of a CCS of 5 (97.8%, 95% CI 96.5%-98.7%) was higher than when the overall 99th-percentile cut-off for the Ortho hs-cTnI assay (> 11 ng/L; 90.1%, 95% CI 87.9%-92.0%) was used. A similar pattern was observed in cohort 2 at 30 days and persisted at 90 days with the Abbott hs-cTnI assay.

INTERPRETATION

The CCS derived with 2 different hs-cTnI assays and ED populations yielded higher sensitivity and specificity estimates for MACE than hs-cTnI alone. An intervention study is needed to evaluate the impact of the CCS at both the patient and hospital levels.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01994577.

Association of Roux-en-Y Gastric Bypass With Postoperative Health Care Use and Expenditures in Canada

Importance

Results of previous studies are mixed regarding the economic implications of a Roux-en-Y gastric bypass (RYGB).

Objective

To assess the 5-year incremental health care use and expenditures after RYGB.

Design, Setting, and Participants

This population-based cohort study conducted in Ontario, Canada, used a difference-in-differences approach to compare health care use and expenditures between patients who underwent a publicly funded RYGB from March 1, 2010, to March 31, 2013, and propensity score-matched control individuals who did not undergo a surgical bariatric procedure. The study period allowed for a minimum 60 months of follow-up because, at that time, the most recent date for which administrative data on health care and expenditures were available was March 31, 2018. Data sources included the Ontario Bariatric Registry linked to several Ontario health administrative databases and the Electronic Medical Record Administrative Data Linked Database. Health care use and expenditures data for 5 years before and 5 years after the index date (procedure date for RYGB group; random date for controls) were analyzed. Data analyses were performed March 12, 2019, to March 10, 2020.

Intervention

RYGB procedure.

Main Outcomes and Measures

The primary outcome was total health care expenditures.

Results

The final propensity score-matched cohorts comprised 1587 individuals in the RYGB group (mean [SD] age, 47 [10.2] years) and 1587 controls (mean [SD] age, 47 [12.2] years); each group had 1228 women (77.4%) and a mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 46. Mean total health care expenditures (2017 Canadian dollars) per patient in the RYGB group increased from CAD $15 594 (95% CI, CAD $14 743 to CAD $16 614) (US $12 008 [95% CI, US $11 353 to US $12 794]) in the 5 years before the procedure to CAD $30 389 (95% CI, CAD $28 789 to CAD $32 232) (US $23 401 [95% CI, US $22 169 to US $24 821]) over the 5 years after the procedure, a difference of CAD $14 795 (95% CI, CAD $13 172 to CAD $16 480) (US $11 393 [95% CI, US $10 143 to US $12 691]). For the control group, mean total health care expenditures per individual increased from CAD $16 109 (95% CI, CAD $14 727 to CAD $17 591) (US $12 405 [95% CI, US $11 341 to US $13 546]) 5 years before the index date to CAD $20 073 (95% CI, CAD $18 147 to CAD $22 169) (US $15 457 [95% CI, US $13 974 to US $17 071]) 5 years after the date, a difference of CAD $3964 (95% CI, CAD $2250 to CAD $5875) (US $3053 [95% CI, US $1733 to US $4524]). Overall, the difference-in-differences estimate of the net cost of RYGB was CAD $10 831 (95% CI, CAD $8252 to CAD $13 283) (US $8341 [95% CI, $6355 to $10 229]) over the 5-year period. This amount excluded the mean (SD) cost associated with the index date: CAD $6501 (CAD $1087) (US $5006 [US $837]) for the RYGB cohort and CAD $9 (CAD $72) (US $7 [US $55]) for the controls. The cost differential was primarily associated with increased hospitalizations in the first months immediately after RYGB. Expenditures leveled off in year 3 after the index date; differences in total expenditures between the RYGB and control cohorts were not statistically significantly different in years 4 and 5.

Conclusions and Relevance

Health care expenditures in the 3 years after publicly funded RYGB were higher in patients who underwent the procedure than in control individuals, but the costs were similar thereafter. This finding suggests the need to decrease hospital and emergency department readmissions after surgical bariatric procedures because such use is associated with increased spending.

Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department

For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012-February 2013 and April 2013-September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS < 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS > 2 (n = 3936) (p < 0.001). At 90 days, patients with CCS < 2 (median age = 52y (IQR = 46-60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32-0.82) for the composite outcome and patients with a CCS > 2 (median age = 74y (IQR = 64-82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98-3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS < 2, 2, or >2 respectively, had the composite outcome (p < 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care.

Epidemiological and virological findings during an outbreak of equine influenza in Uruguay in 2018

Equine influenza is one of the major respiratory infectious diseases in horses. In 2018, equine influenza virus (EIV) was confirmed as the cause of outbreaks of respiratory disease in horses in Chile and Argentina. In the same year, for the first time in Uruguay, EIV infection was confirmed by isolation and molecular analysis to be the cause of respiratory disease among hundreds of clinically affected thoroughbred horses in training and racing facilities. The virus was detected in nasopharyngeal swabs by a pan-reactive influenza type A realtime reverse transcription polymerase chain reaction (rRT-PCR). The partial nucleotide sequence of the haemagglutinin 1 (HA1 ) gene (994 base pairs) was determined and analysed phylogenetically using MEGA X software. Amino acid sequence alignments were constructed, and serum samples were tested by haemagglutination inhibition and single radial haemolysis. The diagnosis of EIV was confirmed by rRT-PCR, virus isolation and serological testing. The phylogenetic analysis of the partial HA1 gene sequence of the isolated virus indicated that it belongs to clade 1 of the Florida sub-lineage of the American lineage and is closely related to viruses isolated in the recent past. Study of the HA1 region (331 amino acids) of the virus identified in horses in racing facilities in Uruguay displayed the highest amino acid sequence identity with viruses detected in Argentina, Chile and the United Kingdom in 2018. The surveillance data reported illustrate the international spread of EIVs and support the recommendation of the World Organisation for Animal Health (OIE) Expert Surveillance Panel to include viruses of the Florida sub-lineage in vaccines.

Urologic complications after transplantation of 225 en bloc kidneys from small pediatric donors ≤20 kg: Incidence, management, and impact on graft survival

Pediatric en bloc kidney transplants (EBKs) from small deceased pediatric donors are associated with increased early graft loss and morbidity. Yet, urologic complications post-EBK and their potential impact on graft survival have not been systematically studied. We retrospectively studied urological complications requiring intervention for 225 EBKs performed at our center January 2005 to September 2017 from donors ≤20 kg into recipients ≥18 years. Overall ureteral complication incidence after EBK was 9.8% (n = 22) (12% vs 2% for EBK donors < 10 vs ≥ 10 kg, respectively [P = .031]). The most common post-EBK urologic complication was a stricture (55%), followed by urine leak (41%). In all, 95% of all urologic complications occurred early within 5 months posttransplant (median, 138 days). Urologic complications could be successfully managed nonoperatively in 50% of all cases and had no impact on graft or patient survival. In summary, urologic complications after EBK were common, associated with lower donor weights, occurred early posttransplant, and were often amenable to nonoperative treatment, without adversely affecting survival. We conclude that the higher urologic complication rate after EBK (1) should not prevent increased utilization of small pediatric donor en bloc kidneys for properly selected recipients, and (2) warrants specific discussion with EBK recipients during the preoperative consent process.

High-Sensitivity Cardiac Troponin I vs a Clinical Chemistry Score for Predicting All-Cause Mortality in an Emergency Department Population

BACKGROUND

For patients investigated for suspected acute coronary syndrome, there is uncertainty if a single measurement of high-sensitivity cardiac troponin I (hs-cTnI) at emergency department (ED) presentation can identify patients at both low and high risk for mortality.

METHODS

We included consecutive adult patients in the ED who had a Clinical Chemistry Score (CCS) taken at presentation (ie, combination of glucose, creatinine for estimated glomerular filtration rate determination, and hs-cTnI assay) in a Canadian city between 2012 and 2013. Outcomes were 3-month, 1-year, and 5-year all-cause mortality using the provincial death registry. Mortality rates and test performance (eg, sensitivity and specificity) with 95% confidence intervals (CIs) were obtained for the CCS or hs-cTnI assay alone using established cutoffs for these tests.

RESULTS

Our cohort included 5974 patients with a 1-year mortality rate of 17.2% (95% CI, 16.2-18.3). A CCS ≥ 1 yielded a sensitivity of 99.2% (95% CI, 98.4-99.6) compared with the hs-cTnI ≥ 5 ng/L cutoff sensitivity of 88.4% (95% CI, 86.3-90.3), with the mortality rate being significantly lower for patients with CCS < 1 (2.0%; 95% CI, 0.9-4.0) vs patients with hs-cTnI < 5 ng/L (5.0%; 95% CI, 4.2-6.0) at 1 year (P = 0.01). A CCS of 5 also yielded a higher specificity (88.5%; 95% CI, 87.5-89.3) compared with hs-cTnI > 26 ng/L (83.9%; 95% CI, 82.9-84.9), with no difference in mortality rates (37.4% vs 36.3%; P = 0.66). This trend was consistent at 3-month and 5-year mortality.

CONCLUSION

For patients in the ED with a potential cardiac issue, using the CCS cutoffs can better identify patients at low and high risk for mortality than using published cutoffs for hs-cTnI alone.

Perioperative Dexmedetomidine Improves Outcomes of Kidney Transplant

Graft function is crucial for successful kidney transplantation. Many factors may affect graft function or cause delayed graft function (DGF), which decreases the prognosis for graft survival. This study was designed to evaluate whether the perioperative use of dexmedetomidine (Dex) could improve the incidence of function of graft kidney and complications after kidney transplantation. A total of 780 patients underwent kidney transplantations, 315 received intravenous Dex infusion during surgery, and 465 did not. Data were adjusted with propensity scores and multivariate logistic regression was used. The primary outcomes are major adverse complications, including DGF and acute rejection in the early post‐transplantation phase. The secondary outcomes included length of hospital stay (LOS), infection, overall complication, graft functional status, post‐transplantation serum creatinine values, and estimated glomerular filtration rate (eGFR). Dex use significantly decreased DGF (19.37% vs. 23.66%; adjusted odds ratio, 0.744; 95% confidence interval, 0.564–0.981; P = 0.036), risk of infection, risk of acute rejection in the early post‐transplantation phase, the risk of overall complications, and LOS. However, there were no statistical differences in 90‐day graft functional status or 7‐day, 30‐day, and 90‐day eGFR. Perioperative Dex use reduced incidence of DGF, risk of infection, risk of acute rejection, overall complications, and LOS in patients who underwent kidney transplantation.

Incidence, Risk Factors, and Outcomes of Neonatal Renal Vein Thrombosis in Ontario: Population-Based Cohort Study

Background

There are limited data at a population level on the burden, risk factors, and long-term outcomes of neonatal renal vein thrombosis (nRVT). We conducted a population-based cohort study to understand the epidemiology and outcomes of nRVT over a 25-year period in Ontario.

Methods

Using linked administrative health databases, all hospitalized neonates ≤28 days born in Ontario between 1992 and 2016 with nRVT were identified. The primary outcome was to calculate the incidence of nRVT and trend over time in Ontario. We also determined the risk factors associated with nRVT as well as the risk of long-term outcomes after nRVT, including CKD, ESKD, all-cause mortality, and hypertension (HTN) compared with the healthy neonatal population without nRVT.

Results

The annual incidence rate of nRVT was 2.6 per 100,000 live births (n=85). Presence of respiratory distress syndrome (OR, 8.01; 95% CI, 4.90 to 13.1), congenital heart disease (OR, 9.1; 95% CI, 5.05 to 16.4), central venous catheterization (OR, 3.9; 95% CI, 1.89 to 7.93), maternal preeclampsia (OR, 2.8; 95% CI, 1.6 to 4.79), and maternal diabetes (OR, 2.36; 95% CI, 1.36 to 4.07) conferred the highest risk for nRVT. Over a median follow-up of 15 years and after adjusting for confounders, neonates with nRVT versus the comparator cohort had a 15.5-fold risk of CKD, HTN, or death (n=49 [58%] versus n=90,050 [3%]; 95% CI, 11.7 to 20.6); 12.3-fold increased risk of CKD or death (n=39 [46%] versus n=32,016 [1%]; 95% CI, 8.9 to 16.8); and a 15.7-fold increased risk of HTN (n=33 [39%] versus n=64,458 [2%]; 95% CI, 11.1 to 21.1). None of the nRVT cohort developed ESKD. The median time to composite outcome of CKD, HTN, or death was 11.1 years.

Conclusions

Patients with a history of nRVT remain at higher risk than the general population for long-term morbidity or mortality, indicating the need for long-term follow-up.

Measuring multimorbidity series. An overlooked complexity - Comparison of self-report vs. administrative data in community-living adults: Paper 3. Agreement across data sources and implications for estimating associations with health service use

OBJECTIVE

The objective of this study is to describe agreement between administrative and self-report data on the number and type of chronic conditions (CCs) and determine whether associations between CC count and health service use differ by data source.

STUDY DESIGN AND SETTING

We linked Canadian Community Health Survey and administrative data for a cohort of adults aged 45+ years in Ontario and identified 12 CCs from both data sources. Agreement was described by count and constituent CCs. We estimated associations between CC count (self-report and administrative data) and health service use (administrative data only) over 1 year.

RESULTS

Among 71,317 adults, 26.9% showed agreement on both count and constituent CCs but agreement declined with increasing CCs. Health service use increased with CC count but the association was stronger when CCs were measured with administrative data. For example, when measured with administrative data, the odds of a general practitioner visit for 5+ CCs vs. none was 20.3 (95% CI 20.0-20.5) but when using self-report data, the estimate was 8.0 (95% CI 7.8-8.2).

CONCLUSION

Agreement on the number of CCs was low and resulted in different estimates on the association with health service use, illustrating the challenges in CC measurement and the ability to interpret the effects on outcomes.

Measuring multimorbidity series-an overlooked complexity comparison of self-report vs. administrative data in community-living adults: paper 2. Prevalence estimates depend on the data source

OBJECTIVE

The objective of the study was to compare multimorbidity prevalence using self-reported and administrative data and identify factors associated with agreement between data sources.

STUDY DESIGN AND SETTING

Self-reported cross-sectional data from four Canadian Community Health Survey waves were linked to administrative data in Ontario, Canada. Multimorbidity prevalence was examined using two definitions, 2+ and 3+ chronic conditions (CCs). Agreement between data sources was assessed using Kappa and Phi statistics. Logistic regression was used to estimate associations between agreement and sociodemographic, health behavior, and health status variables for each multimorbidity definition.

RESULTS

Regardless of multimorbidity definition, prevalence was higher using administrative data (2+ CCs: 55.5% vs. 47.1%; 3+ CCs: 30.0% vs. 24.2%). Agreement between data sources was moderate (2+ CCs K = 0.482; 3+ CCs K = 0.442), and while associated with sociodemographic, health behavior, and health status factors, the magnitude and sometimes direction of association differed by multimorbidity definition.

CONCLUSION

A better understanding is needed of what factors influence individuals' reporting of CCs and how they align with what is in administrative data as policy makers need a solid evidence base on which to make decisions for health planning. Our results suggest that data sources may need to be triangulated to provide accurate estimates of multimorbidity for health services planning and policy.

Trends in very early discharge from hospital for newborns under midwifery care in Ontario from 2003 to 2017: a retrospective cohort study

BACKGROUND

Very early discharge from hospital is an element of Ontario midwifery care. Our aim in the present study was to describe the frequency of very early hospital discharge for newborns in Ontario midwifery care over time.

METHODS

We conducted a retrospective population-based cohort study, including all midwife-attended singleton term cephalic newborns delivered by spontaneous vaginal birth at Ontario hospitals between April 2003 and February 2017. Our primary outcome was very early hospital discharge (< 6 h after birth) for newborns. Secondary outcomes were pediatric consultation before hospital discharge, phototherapy before hospital discharge and readmission for treatment of jaundice. We used generalized linear mixed models to estimate the relation between maternal, neonatal and hospital factors and very early discharge, while accounting for clustering by hospital.

RESULTS

The study cohort included 101 852 newborns born at 89 hospitals. Between 2003/04 and 2016/17, the unadjusted rate of very early discharge decreased from 34.3% to 30.7%. This trend was not significant after adjustment for covariates (odds ratio 1.0, 95% confidence interval 0.99-1.0). Unadjusted rates of pediatric consultation, phototherapy and readmission for jaundice all rose slightly over the study period. Hospital-specific risk-adjusted frequencies of very early discharge ranged from 5% (n = 1479) to 83% (n = 3459) across the 75 Ontario hospitals with at least 100 newborns included in the study cohort.

INTERPRETATION

Hospital-level factors contributed to the observed decrease in crude rates of very early discharge for midwifery clients. Wide variation in these rates across Ontario hospitals points to room for improvement to make more efficient use of health care resources by promoting optimal levels of very early discharge.

The hidden complexity of measuring number of chronic conditions using administrative and self-report data: A short report

OBJECTIVE

To examine agreement between administrative and self-reported data on the number of and constituent chronic conditions (CCs) used to measure multimorbidity.

STUDY DESIGN AND SETTING

Cross-sectional self-reported survey data from four Canadian Community Health Survey waves were linked to administrative data for residents of Ontario, Canada. Agreement for each of 12 CCs was assessed using kappa (κ) statistics. For the overall number of CCs, perfect agreement was defined as agreement on both the number and constituent CCs. Jackknife methods were used to assess the impact of individual CCs on perfect agreement.

RESULTS

The level of chance-adjusted agreement between self-report and administrative data for individual CCs varied widely, from κ = 5.5% (inflammatory bowel disease) to κ = 77.5% (diabetes), and there was no clear pattern on whether using administrative data or self-reported data led to higher prevalence estimates. Only 26.9% of participants had perfect agreement on the number and constituent CCs; 10.6% agreed on the number but not constituent CCs. The impact of each CC on perfect agreement depended on both the level of agreement and the prevalence of the individual CC.

CONCLUSION

Our results show that measuring agreement on multimorbidity is more complex than for individual CCs and that even small levels of individual condition disagreement can have a large impact on the agreement on the number of CCs.

RID: Evaluation of the Possible Inhibiting Effect of the Proinflammatory Signaling Induced by TNF-α through NF-κβ and AP-1 in Two Cell Lines of Breast Cancer

Receptor internalization and degradation (RID), is a transmembrane protein coded within the E3 region expression cassette of adenoviruses. RID downregulates the cell surface expression of epidermal growth factor receptor (EGFR), tumor necrosis factor receptor (TNFR), and apoptosis antigen 1 (FAS), causing a reduction of the effects of their respective ligands. In addition, RID inhibits apoptosis by decreasing the secretion of TNF-related apoptosis-inducing ligand (TRAIL) by normal tissue cells. In this article, we report that RID inhibited chemokine expression in human breast cancer cell line MDA-MB-231 but showed no effect in cell line MCF7. These dissimilar results may be due to the different molecular and functional properties of both cell lines. Therefore, it is necessary to replicate this study in other breast cancer cell models.

A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital

Background

Acinetobacter baumannii causes frequently nosocomial infections worldwide. Its ability to survive on dry surfaces facilitates its spread and the persistence of endemic situations, especially in the intensive care units (ICUs).

The objective of this paper is to describe a multicomponent intervention program designed to control a hyperendemic persistence of multidrug-resistant A. baumannii (MDR-Ab) and to characterize its impact.

Methods

Design: Quasi-experimental intervention study based on open cohorts.

Setting: Public tertiary referral centre. Period: January 2009–August 2017.

Intervention: multifaceted program based on environmental decontamination, hand hygiene, antimicrobial stewardship, contact precautions, active surveillance, weekly reports and regular meetings.

Analysis: joinpoint regression and interrupted time-series analysis.

Results

The intervention was successfully implemented. Through the study period, the compliance with contact precautions changed from 0 to 100% and with hand hygiene, from 41.8 to 82.3%. Between 2012 and 2016, the antibiotic consumption decreased from 165.35 in to 150.44 daily-defined doses/1000 patients-days in the ICU. The incidence density of MDR-Ab in the ICU was 10.9 cases/1000 patients-days at the beginning of the intervention. After this moment, the evolution of the incidence density of MDR-Ab was: between months 0 and 6°, it remained stable; between months 7° and 10°: there was an intense decrease, with an average monthly percentage change (AMPC) = − 30.05%; from 11° month until the end, the decrease was lighter but continuous (AMPC:-2.77%), achieving an incidence density of 0 cases/1000 patients-days on the 18° month, without any new case for 12 months. From the 30° month until the end of the study period, several little outbreaks of MDR-Ab were detected, all of them rapidly controlled. The strains of MDR-Ab isolated during these outbreaks were not clonally related with the previously endemic one, which supports its eradication from the environmental reservoirs.

Conclusion

The multicomponent intervention performed by a multidisciplinary team was effective to eradicate the endemic MDR-Ab.

Determination of Low-Level Pesticide Residues in Soft Drinks and Sports Drinks by Liquid Chromatography with Tandem Mass Spectrometry: Collaborative Study

A collaborative study was conducted on a method for the measurement of 11 low-level pesticide residues in soft drinks and sports drinks by liquid chromatography with tandem mass spectrometry. The pesticide residues determined in this study were alachlor, atrazine, butachlor, isoproturon, malaoxon, monocrotophos, methyl paraoxon, phorate, phorate sulfone, phorate sulfoxide, and 2,4-dichlorophenoxyacetic acid (2,4-D). Blind fortification solutions containing 3 different levels of pesticide residues were provided to 9 collaborating laboratories to create test samples at concentrations of 0, 0.1, and 0.5 g/L with a 10-fold concentration for phorate in a total of 6 matrixes (2 colas, 1 diet cola, 1 clear lemon-lime soft drink, 1 orange soft drink, and 1 sports drink). Good qualitative performance of the method was demonstrated for all pesticide residues. Reproducibility relative standard deviation (RSDR) ranged from 7 to 151 for alachlor, atrazine, butachlor, isoproturon, malaoxon, monocrotophos, methyl paraoxon, phorate, phorate sulfone, phorate sulfoxide, and 2,4-D at the 0.1 g/L level (1.0 g/L for phorate). At 0.5 g/L (5.0 g/L for phorate), RSDR ranged from 9 to 57 for alachlor, atrazine, butachlor isoproturon, malaoxon, monocrotophos, methyl paraoxon, phorate, phorate sulfone, phorate sulfoxide, and 2,4-D in all matrixes. Repeatability relative standard deviation (RSDr), applicable to the diet cola and sports drink, ranged from 0 to 124 for the 11 pesticide residues at the 0.1 g/L level (1.0 g/L for phorate). At 0.5 g/L (5.0 g/L for phorate), RSDr ranged from 4 to 26. Recoveries for the 11 pesticide residues in all matrixes ranged from 84 to 300 at the 0.1 g/L level (1.0 g/L for phorate) and from 66 to 127 at the 0.5 g/L (5.0 g/L for phorate) level. Coefficients of determination (r2) of the matrix-matched calibration curves were 0.95. It is recommended that the method be accepted by AOAC as Official First Action with a limit of quantification of 0.5 g/L for alachlor, atrazine, butachlor, isoproturon, malaoxon, methyl paraoxon, monocrotophos, phorate sulfone, phorate sulfoxide, and 2,4-D and 5.0 g/L for phorate.

Determination of Pesticide Residues (>0.5 g/L) in Soft Drinks and Sports Drinks by Gas Chromatography with Mass Spectrometry: Collaborative Study

A collaborative study was conducted on a method for the measurement of 19 low-level pesticide residues in soft drinks and sports drinks by gas chromatography with mass spectrometry (GC/MS). The pesticide residues determined were 2,4-dichlorodiphenyldichloroethylene (2,4-DDE); 2,4-dichlorodiphenyldichloroethane (2,4-DDD); 4,4-dichlorodiphenyldichloroethylene (4,4-DDE); 2,4-dichlorodiphenyltrichloroethane (2,4-DDT); 4,4-dichlorodiphenyltrichloroethane (4,4-DDT); 4,4-dichlorodiphenyldichloroethane (4,4-DDD); -endosulfan; endosulfan-sulfate; dieldrin; aldrin; ethion; chlorpyrifos; -endosulfan; malathion; methyl-parathion; -hexachlorocyclohexane (-HCH); -HCH; -HCH; and -HCH. Blind fortification solutions containing 4 different levels of pesticide residues (0, 0.1, 0.5, and 1.0 g/L) were provided to 8 collaborating laboratories who used them to create test samples in 6 matrixes (also provided): 2 colas, a diet cola, a clear lemon-lime soft drink, an orange soft drink, and a sports drink. Reproducibility (RSDR) for all 19 pesticide residues in all matrixes ranged from 7 to 151 at the 0.1 g/L level, 11 to 121 at 0.5 g/L, and 14 to 67 at 1.0 g/L. Repeatability (RSDr), applicable to the diet cola and the sports drink, ranged from 1 to 76 for the 19 pesticide residues at the 0.1 g/L level, 9 to 38 at 0.5 g/L, and 9 to 38 at 1.0 g/L. Recoveries for the 19 pesticide residues in allmatrixes ranged from 77 to 645 at the 0.1 g/L level, 60 to 231 at 0.5 g/L, and 61 to 146 at 1.0 g/L. It is recommended that the method be accepted by AOAC as Official First Action with a limit of quantification (LOQ) equal to 0.5 g/L for 4,4-DDT; 2,4-DDT; 2,4-DDD; 4,4-DDE; 4,4-DDD; 2,4-DDE; aldrin; dieldrin; -endosulfan; endosulfan-sulfate; chlorpyrifos; and ethion, and an LOQ equal to 1.0 g/L for -endosulfan; -HCH; -HCH; -HCH; -HCH; methyl-parathion; and malathion.

Determination of Ephedrine Alkaloids in Botanicals and Dietary Supplements by HPLC-UV: Collaborative Study

An international collaborative study was conducted of a high-performance liquid chromatography (HPLC)-UV method for the determination of the major (ephedrine [EP] and pseudoephedrine [PS]) and minor (norephedrine [NE], norpseudoephedrine [NP], methylephedrine [ME], and methylpseudoephedrine [MP]) alkaloids in selected dietary supplements representative of the commercially available products. Ten collaborating laboratories determined the ephedrine-type alkaloid content in 8 blind replicate samples. Five products contained ephedra ground herb or ephedra extract. These 5 products included ground botanical raw material of Ephedra sinica, a common powdered extract of Ephedra sinica, a finished product containing only Ephedra sinica ground botanical raw material, a complex multicomponent dietary supplement containing Ma Huang, and a high-protein chocolate flavored drink mix containing Ma Huang extract. In addition, collaborating laboratories received a negative control and negative control spiked with ephedrine alkaloids at high and low levels for recovery studies. Test extracts were treated to solid-phase extraction using a strong-cation exchange column to help remove interferences. The HPLC analyses were performed on a polar-embedded phenyl column using UV detection at 210 nm. Repeatability relative standard deviations (RSD r) ranged from 0.64–3.0% for EP and 2.0–6.6% for PS, excluding the high protein drink mix. Reproducibility relative standard deviations (RSD R) ranged from 2.1–6.6% for EP and 9.0–11.4% for PS, excluding the high protein drink mix. Recoveries ranged from 84.7–87.2% for EP and 84.6–98.2% for PS. The data developed for the minor alkaloids are more variable with generally unsatisfactory HORRATS (i.e., &gt;2). However, since these alkaloids generally add little to the total alkaloid content of the products, the method gives satisfactory results in measuring total alkaloid content (RSD r 0.85–3.13%; RSDR 2.03–10.97%, HORRAT 0.69–3.23, exclusive of the results from the high protein drink). On the basis of these results, the method is recommended for Official First Action for determination of EP and PS in dietary supplements exclusive of the high protein drinks.

Determination of Ephedrine Alkaloids in Human Urine and Plasma by Liquid Chromatography/Tandem Mass Spectrometry: Collaborative Study

A collaborative study was conducted to evaluate the accuracy and precision of a method for ephedrine-type alkaloids (i.e., norephedrine, norpseudoephedrine, ephedrine, pseudoephedrine, methylephedrine, and methylpseudoephedrine) in human urine and plasma. The amount of ephedrine-type alkaloids present was determined using liquid chromatography (LC) with tandem mass selective detection. The test samples were diluted to reflect a concentration of 5.00–100 ng/mL for each alkaloid. An internal standard was added and the alkaloids were separated using a 5 μm phenyl LC column with an ammonium acetate, glacial acetic acid, acetonitrile, and water mobile phase. Eight blind duplicates of human urine and eight blind duplicates of human plasma were analyzed by 10 collaborators. In addition to negative controls, test portions of urine and plasma were fortified at 3 different levels with each of the 6 ephedrine-type alkaloids at approximately 1, 2, and 5 μg/mL for urine and 100, 200, and 500 ng/mL for plasma. On the basis of the accuracy and precision results for this collaborative study, it is recommended that this method be adopted Official First Action for the determination of 6 different ephedrine-type alkaloids in human urine and plasma.

Determination of Ephedrine Alkaloids in Dietary Supplements and Botanicals by Liquid Chromatography/Tandem Mass Spectrometry: Collaborative Study

An interlaboratory study was conducted to evaluate the accuracy and precision of a method for ephedrine-type alkaloids [i.e., norephedrine (NE), norpseudoephedrine (NPE), ephedrine (E), pseudoephedrine (PE), methylephedrine (ME), and methylpseudoephedrine (MPE)] in dietary supplements and botanicals. The amount of ephedrine-type alkaloids present was determined using liquid chromatography with tandem mass selective detection. The samples were diluted to reflect a concentration of 0.0200 to 1.00 μg/mL for each alkaloid. An internal standard was added and the alkaloids were separated using a 5 μm phenyl LC column with an ammonium acetate, glacial acetic acid, acetonitrile, and water mobile phase. Eight blind duplicates of dietary supplements or botanicals were analyzed by 10 collaborators. Included was a negative control, ephedra nevadensis, and negative controls fortified at 2 different levels with each of the 6 ephedrine-type alkaloids. The spike levels were approximately 100 and 1000 μg/g for NE, 100 and 600 μg/g for NPE, 6500 and 65 000 μg/g for E, 1000 and 10 000 μg/g for PE, 300 and 3000 μg/g for ME, and 100 and 1000 μg/g for MPE. On the basis of the accuracy and precision results for this interlaboratory study, it is recommended that this method be adopted Official First Action for the determination of 6 different individual ephedrine-type alkaloids in dietary supplements and botanicals.

P6351A point-of-care risk score predicts 30-day readmission in patients hospitalized with heart failure (HF): derivation and validation of the LENT index

Background

Risk prediction models in heart failure (HF) are typically complex, derived retrospectively from administrative databases, and modest in their ability to discriminate between high, medium, and low risk categories. The complexity of these models makes them difficult to use at the point of care.

Purpose

To determine if a simple risk index using Length of hospital stay (L), number of Emergency department visits in the preceding 6 months (E), and either admission or discharge N-Terminal (NT) prohormone of Brain Natriuretic Peptide (pro-BNP) at the point of care can predict 30-day readmissions in patients hospitalized for HF.

Methods

This is a sub-study of the Patient-Centered Care Transitions in HF (PACT-HF) stepped-wedge cluster randomized trial. We included 772 patients hospitalized for HF at 10 Canadian hospitals. We used log-binomial regression models with Length of stay, Emergency department visits in the preceding 6 months, and either admission or discharge N-Terminal prohormone of Brain Natriuretic Peptide (NT-pro-BNP) as the predictor variables and 30-day all-cause readmission as the outcome. We derived the LENT risk score from the β-coefficients of the regression model (Fig. 1). All the models were adjusted for post-discharge services. We assessed model discrimination with C-statistics and model calibration with the net reclassification index (NRI). We used the bootstrapping approach with 100 runs for internal validation.

Results

The LENT index had a possible score ranging from 1 to 13 (Fig 1). Increments in the LENT risk score were associated with an increased risk of 30-day readmission; a 1-point increase in the LENT index using the admission and discharge NT-pro-BNP predicted a 23% and 19% increase in 30-day readmission risk, respectively. The internal validation produced similar results. Compared to a null model, the LE index had an NRI of 0.35 [95% CI 0.18, 0.53], and admission and discharge NT-pro-BNP further improved calibration of the LE index (NRI 0.15 [95% CI 0, 0.32] and 0.20 [95% CI 0.03, 0.37], respectively). The LENT index offered modest discrimination for 30-day readmission (C-statistic 0.64 [95% CI 0.59, 0.69]), similar to more complex risk models.

Figure 1. The LENT index scoring system

Conclusion

A simple risk index based on Length of stay, Emergent visits, and NT-pro-BNP at the point of care can reliably predict 30-day readmissions. The LENT index offers ease of use over traditional risk prediction models.

Acknowledgement/Funding

Canadian Institutes of Health Research, Ontario MOHLTC, Roche Diagnostics

Development and validation of a cardiovascular disease risk-prediction model using population health surveys: the Cardiovascular Disease Population Risk Tool (CVDPoRT)

BACKGROUND

Routinely collected data from large population health surveys linked to chronic disease outcomes create an opportunity to develop more complex risk-prediction algorithms. We developed a predictive algorithm to estimate 5-year risk of incident cardiovascular disease in the community setting.

METHODS

We derived the Cardiovascular Disease Population Risk Tool (CVDPoRT) using prospectively collected data from Ontario respondents of the Canadian Community Health Surveys, representing 98% of the Ontario population (survey years 2001 to 2007; follow-up from 2001 to 2012) linked to hospital admission and vital statistics databases. Predictors included body mass index, hypertension, diabetes, and multiple behavioural, demographic and general health risk factors. The primary outcome was the first major cardiovascular event resulting in hospital admission or death. Death from a noncardiovascular cause was considered a competing risk.

RESULTS

We included 104 219 respondents aged 20 to 105 years. There were 3709 cardiovascular events and 818 478 person-years follow-up in the combined derivation and validation cohorts (5-year cumulative incidence function, men: 0.026, 95% confidence interval [CI] 0.025-0.028; women: 0.018, 95% 0.017-0.019). The final CVDPoRT algorithm contained 12 variables, was discriminating (men: C statistic 0.82, 95% CI 0.81-0.83; women: 0.86, 95% CI 0.85-0.87) and was well-calibrated in the overall population (5-year observed cumulative incidence function v. predicted risk, men: 0.28%; women: 0.38%) and in nearly all predefined policy-relevant subgroups (206 of 208 groups).

INTERPRETATION

The CVDPoRT algorithm can accurately discriminate cardiovascular disease risk for a wide range of health profiles without the aid of clinical measures. Such algorithms hold potential to support precision medicine for individual or population uses. Study registration: ClinicalTrials.gov, no. NCT02267447.

Barriers to live and deceased kidney donation by patients with chronic neurological diseases: Implications for donor selection, donation timing, logistics, and regulatory compliance

Live and deceased kidney donation by the numerous patients with advanced, progressive systemic neurological diseases, and other chronic neurological conditions (eg, high C-spine injury) remains largely unexplored. In a review of our current clinical practice, we identified multiple regulatory and clinical barriers. For live donation, mandatory reporting of postdonation donor deaths within 2 years constitutes a strong programmatic disincentive. We propose that the United Network for Organ Sharing should provide explicit regulatory guidance and reassurance for programs wishing to offer live donation to patients at higher risk of death during the reporting period. Under the proposal, live donor deaths within 30 days would still be regarded as donation-related, but later deaths would be related to the underlying disease. For deceased donation, donation after circulatory death (DCD) immediately following self-directed withdrawal of life-sustaining treatment ("conscious DCD") is not universally covered by existing DCD agreements with donor hospitals. Organ procurement organizations should thus systematically strive to revise these agreements. Obtaining adequate first-person consent from these communicatively severely impaired patients may be challenging. Optimized preservation and allocation protocols may maximize utilization of these DCD kidneys. Robust public debate and action by all stakeholders is necessary to lower existing barriers and maximize donation opportunities for patients with chronic neurological conditions.