BACKGROUND:The rising prevalence of diabetes disproportionately impacts socially-disadvantaged communities. We aimed to determine whether trends of diabetes prevalence vary by age, sex, and neighbourhood socioeconomic status (SES). METHODS:We conducted a population-based cross-sectional time-series analysis using health administrative data for adults aged ≥20 years (>90% type 2 diabetes) from 2015 (N=10,935,448) to 2021 (N=11,885,060). Annual crude and age-sex standardized prevalence rates were estimated using a validated administrative case definition. Neighbourhood SES was measured using the Material Deprivation Domain of the Ontario Marginalization Index and categorized into quintiles (Q1 least deprived to Q5 most deprived). RESULTS:Age-sex standardized prevalence of diabetes increased nearly 6% from 10.8 in 2015 to 11.4% in 2021. Increases were consistent across all age and sex groups, with the largest relative increases among adults aged 20-34 years (males +17.1%, females +11.3%). Diabetes prevalence rose across all neighbourhood deprivation quintiles, remaining highest in the most deprived areas from 2015 to 2021 (13.3% to 14.1%). Relative increases ranged from 5.8% in the most deprived areas to 7.1% in the least deprived areas. A clear socioeconomic gradient was observed where diabetes prevalence was 42% higher in the most deprived neighbourhoods (Q5 RR 1.42, 95% CI 1.41-1.44; all p<0.0001) compared to the least (Q1) deprived areas, underscoring the structural nature of diabetes inequities. CONCLUSIONS:Diabetes prevalence continues to increase in the lowest income areas, calling for more tailored and culturally sensitive policy interventions and programs to reduce the future burden of diabetes among populations living with social disadvantage.

AIMS:To measure the prevalence of diabetic kidney disease (DKD) among immigrants and long-term residents with type 2 diabetes (T2D). METHODS:We conducted a population-based retrospective cohort study in Ontario, Canada among adults aged 20-79 years with T2D. The exposure was world region of birth (immigrants); long-term residents were the comparison group. The outcome was DKD, defined by the Kidney Disease: Improving Global Outcomes (KDIGO) categories. We measured the age-sex standardized prevalence of DKD and constructed logistic regression models to compute adjusted odds ratios (OR) estimating the association between the exposure and outcome. RESULTS:We included 210,693 immigrants (mean age 59.8 [standard deviation 10.8] years, 54.3 % male) and 539,632 long-term residents (mean age 64.1 [10.4] years, 56.1 % male). Immigrants born in East Asia had the highest prevalence and adjusted odds of the KDIGO low-risk category (76.6 %, OR 1.59, 1.53-1.64). Immigrants born in Southeast Asia had the lowest prevalence of the KDIGO low-risk category (64.0 %), and the highest prevalence and adjusted odds of the moderately-increased, high, and very-high risk KDIGO categories (OR: 1.21, [1.18-1.25]; 1.20, 1.14-1.26; 1.18, 1.12-1.25) compared to long-term residents. CONCLUSIONS:There is substantial variation in the prevalence of DKD among immigrants according to world region of birth.

1550 Background: With improvements in the early detection and treatment of cancer, there is a growing population of cancer survivors; with a corresponding increase in acute care use among cancer survivors. However, models of inpatient care delivery for cancer survivors differ between hospitals and regions, which may impact resource use and outcomes. Understanding how different models influence outcomes may help define optimal models for inpatient care delivery for this population. Methods: We created a multicenter cohort of all cancer patients admitted to medical wards across 26 hospitals in Ontario, Canada from 2015 to 2022, and deterministically linked population-level administrative data including ambulatory oncology data, with each hospital’s patient-level electronic information (pharmacy, orders, notes, laboratory/imaging and results). Multivariable regression models compared characteristics and outcomes between patients admitted on oncology wards vs non-oncology wards adjusting for age, sex and co-morbidity scores. Results: In total, there were 370,118 hospitalizations from 191,990 unique patients. Among these hospitalizations, 38,075 episodes (10.3%) were on an oncology ward. The median time from cancer diagnosis to hospitalization was 4 years. The most common disease sites were genitourinary (21%), gastrointestinal (20%), breast (12%), and lung (10%). The most discharge diagnoses from oncology wards were inpatient chemotherapy (9%), febrile neutropenia (7%), non-Hodgkin’s lymphoma (4%), acute myeloid leukemia (4%), myeloma (3%); while for non-oncology wards were heart failure (5%), palliative care (4%), UTI (2%), pneumonia (2%), acute renal failure (2%). In general, cancer patients admitted on oncology wards were younger (64 vs 76), had shorter length of stay (LOS; 9.6 vs 10.1 days), less in-hospital mortality (7.5% vs 11.4%), greater 30-day re-admission rates (29% vs 14%) and were also more likely to undergo CTs (28% vs 21%), MRIs (11% vs 9%) and interventional procedures (8% vs 6%) (all comparisons, p<0.001). Subgroup analysis focusing on the top 5 discharge diagnoses from non-oncology wards, showed that despite higher in-hospital mortality rates (aOR 1.27 95% CI [1.15-1.40] p<0.001), admission to a non-oncology ward for those diagnoses was associated with a shorter LOS (aOR 0.96 [0.92-1.00] p=0.03), reduced 30-day re-admission rates (aOR 0.77 [0.69-0.87] p<0.001), and reduced use of CTs (aOR 0.74 [0.68-0.82] p<0.001), MRIs (aOR 0.80 [0.68-0.95] p=0.01), and interventional procedures (aOR 0.84 [0.69-1.01] p=0.07). Conclusions: There are differences in both resource use and outcomes for cancer survivors hospitalized on oncology versus non-oncology wards, including for patients with the same discharge diagnosis. To optimize inpatient cancer care delivery for hospitalized cancer survivors, further exploration is needed.

Introduction and Objective: It is unclear whether DKD incidence varies by world region of birth. We examined whether the incidence of DKD (defined as the Kidney Disease Improving Global Outcomes (KDIGO) categories 2-4) differs between immigrants and long-term residents (LTRs) with T2D in Ontario, Canada. Methods: This retrospective cohort study used population-based linked databases to examine age-sex standardized incidence rates of DKD based on the most recent creatinine and urinary albumin-creatinine ratio (ACR) during the baseline (2012-16) and observation (2017-21) periods among adults aged 20-80 years with pre-existing T2D. We used the gamma distribution method to test for significant differences between immigrants and LTRs. Results: We included 647,210 individuals (mean age 61.6 years, 44.9% female, 152,778 immigrants). Overall standardized incidence varied (category 2: 76.4; 3: 31.0; 4: 15.9 per 1000 person-years). Immigrants from Southeast Asia had significantly higher incidence of categories 2 and 3 (91.1, 36.4 respectively; p<0.05) and a similar incidence of category 4 (16.6) versus LTRs. Incidence of categories 2-4 was lower among immigrants from East Asia (62.2, 18.5, 7.2 respectively) and several other regions versus LTRs (p<0.05). Disparities in incidence narrowed as KDIGO category increased. Conclusion: DKD incidence varies substantially by world region of birth. Disclosure S. Mohamed: None. J. Lipscombe: None. L. Lipscombe: Other Relationship; Novo Nordisk Canada Inc. C. Kenaszchuk: None. D. Thiruchelvam: None. G.S. Fazli: None. B.R. Shah: None. L. Rosella: None. C. Ke: Advisory Panel; Sanofi. Speaker's Bureau; AstraZeneca. Funding Novo Nordisk Network for Healthy Populations

OBJECTIVES:Gestational diabetes mellitus (GDM) is a common pregnancy complication. Studies have shown that the prevalence of GDM is rising worldwide. In this study, we aimed to describe the prevalence of GDM in Ontario, Canada, between 2015 and 2021. METHODS:Population-based linked health-care administrative databases were used to identify women with GDM via a validated algorithm. Age-standardized GDM prevalence was described for each year between 2015 and 2021. Crude GDM prevalence trends were stratified according to age and income, and trend over time was evaluated using negative binomial regression. RESULTS:Crude GDM prevalence was 9.5% within this period, with age-standardized prevalence increasing by 35% over the duration of the study (p<0.0001). Prevalence declined in the first year of the COVID-19 pandemic, but it rose again the next year. Prevalence was directly associated with age (p<0.0001) and inversely associated with income (p=0.04), but these disparities did not change over time. CONCLUSIONS:GDM prevalence is rising, but the transient decline in the first year of the pandemic may reflect forgone GDM screening. Disparities in prevalence by age and income are not worsening. GDM is creating a growing burden for the health-care system, particularly for lower income individuals.

Background The relation between age at diagnosis of type 2 diabetes (T2D) and hospitalization for heart failure (HHF) is unclear. We assessed the association between age at diagnosis of T2D and HHF. Methods and Results We conducted a population‐based cohort study using administrative health databases from the Canadian province of Ontario, including participants without prior heart failure. We identified people with new‐onset T2D between April 1, 2005 and March 31, 2015, and matched each person with 3 diabetes‐free adults, according to birth year and sex. We estimated adjusted hazard ratios (HRs) and rate ratios (RRs) for the association between age at T2D diagnosis and incident HHF, which was assessed until March 31, 2020. Among 743 053 individuals with T2D and 2 199 539 matched individuals without T2D, 126 241 incident HHF events occurred over 8.9 years. T2D was associated with a greater adjusted hazard of HHF at younger ages (eg, HR at age 30 years: 6.94 [95% CI, 6.54–7.36]) than at older ages (eg, HR at age 60 years: 2.50 [95% CI, 2.45–2.56]) relative to matched individuals. Additional adjustment for mediators (hypertension, coronary artery disease, and chronic kidney disease) marginally attenuated this relationship. Age at T2D diagnosis was associated with a greater number of HHF events relative to matched individuals at younger ages (eg, RR at age 30 years: 6.39 [95% CI, 5.76–7.08]) than at older ages (eg, RR at age 60 years: 2.65 [95% CI, 2.54–2.76]). Conclusions Younger age at T2D diagnosis is associated with a disproportionately elevated HHF risk relative to age‐matched individuals without T2D.

Introduction & Objectives: While A1c is a strong predictor of conversion from prediabetes to type 2 diabetes, it is unclear whether A1c values within the prediabetes range confer the same risk of conversion to type 2 diabetes within different adult age groups. Methods: Using linked population-based administrative health databases, we investigated the progression from prediabetes to diabetes among adults (≥20 years) with laboratory criteria for prediabetes living in Ontario, Canada between 2012-2022. New diabetes cases were captured using a well-validated administrative data algorithm. Competing risk and Cox proportional hazards models were used to assess the association between A1c increments (~0.2%) within the prediabetes range (5.70-6.49%, vs <5.7%) and diabetes incidence in different decades. Results: Among 3,022,169 individuals with prediabetes, 139,450 (4.6%; mean age 54.1 ± 15.8 yrs) progressed to diabetes over a mean follow up of 4.78 years. The cumulative incidence of diabetes was greatest among those with baseline A1C levels of 6.30-6.49% in both younger (20-29 yrs: 34.5%) and older adults (≥70 yrs: 19.2%). Increased A1c conferred a far greater relative risk of progression to diabetes in adults aged 20-29 and 30-39 (A1c 6.30-6.49%: HR 51.7, 95% CI 45.0-59.3 and HR 41.3, 38.8-44.0, respectively). Relative conversion rates were more modest in adults aged ≥70 years across all A1c categories (A1c 6.30-6.49%: HR 9.7, 9.3-10.1). Conclusion: Baseline A1c was a stronger predictor of conversion from prediabetes to diabetes among younger adults, suggesting that diabetes prevention efforts should consider baseline A1C and age to reduce future risk of progression. Disclosure G.S. Fazli: None. L. Lipscombe: Other Relationship; Novo Nordisk Canada Inc. D. Thiruchelvam: None. C. Kenaszchuk: None. B.R. Shah: None. C. Ke: Advisory Panel; Sanofi. Speaker's Bureau; AstraZeneca. F.M. Ali: None. L. Rosella: None. G.L. Booth: None.

12138 Background: Cancer prevalence is rising, with a corresponding increase in hospitalizations across the cancer continuum. However, little is known about how in-hospital patterns of care and outcomes of cancer survivors compare with non-cancer survivors as administrative data may not capture in-hospital details (e.g., investigations and medications) required for characterization. Understanding differences in how cancer and non-cancer inpatients are managed and their outcomes can help optimize their acute care delivery. Methods: In a multicenter registry of all patients (pts) admitted to medical wards across 26 hospitals (Ontario, Canada) from 2015-2022, we deterministically linked population-level administrative data, including ambulatory oncology data for cancer survivors, with each hospital’s electronic information (pharmacy, orders, notes, laboratory, imaging) at the patient level. Multivariable regression models compared resource use and outcomes between cancer and non-cancer pts for the top 5 discharge diagnoses among non-cancer pts. Results: Of 1,221,067 hospitalizations belonging to 666,569 pts, 30% of medical ward hospitalizations were for pts with a cancer history, with median admission date 4 years post-diagnosis; most common cancer sites were genitourinary (21%), gastrointestinal (20%), breast (12%), lung (10%). Most common discharge diagnoses among cancer pts were heart failure (HF) (5%), palliative care (5%), urinary tract infection (UTI) (2%), pneumonia (2%) renal failure (2%); while for non-cancer pts were HF (5%), myocardial infarction (3%), coronary artery disease (3%), COPD (2%) and UTI (2%). Compared to non-cancer pts, cancer pts were older (72 vs 66), had greater length of stay (LOS; 10 vs 8.7 days), in-hospital mortality (11% vs 6%) and 30 day re-admission rates (16% vs 11%) and were more likely to receive CTs (21% vs 15%), MRIs (9% vs 8%) and interventional procedures (6% vs 4%) (p < 0.001, all comparisons). When evaluating the top 5 discharge diagnoses among non-cancer patients, cancer survivors had higher LOS (aOR=1.06 95% [1.05-1.07] p<0.001), in-hospital mortality (aOR=1.20 [1.14-1.26] p<0.001), and 30 day re-admission rates (aOR=1.24 [1.14-1.35] p<0.001) and were more likely to receive CTs (aOR=1.25 [1.21-1.30] p<0.001), MRIs (aOR=1.36 [1.25-1.48] p<0.001) and interventional procedures (aOR=1.36 [1.25-1.47] p<0.001). Subgroup analyses focusing on cancer survivors admitted 3 and 5 years out from their diagnosis showed resource use and outcomes were closer to non-cancer patients. Conclusions: Cancer survivors represent a unique population on medical wards and have higher resource use, mortality and LOS compared to non-cancer patients, even for the same non-cancer diagnoses. Specialized models of care for hospitalized cancer survivors may be warranted, in particular for those admitted closer to their diagnosis date.

Background Coronavirus disease (COVID) vaccine hesitancy is a reflection of psychology that might also contribute to traffic safety. We tested whether COVID vaccination was associated with the risks of a traffic crash. Methods We conducted a population-based longitudinal cohort analysis of adults and determined COVID vaccination status through linkages to individual electronic medical records. Traffic crashes requiring emergency medical care were subsequently identified by multicenter outcome ascertainment of all hospitals in the region over a 1-month follow-up interval (178 separate centers). Results A total of 11,270,763 individuals were included, of whom 16% had not received a COVID vaccine and 84% had received a COVID vaccine. The cohort accounted for 6682 traffic crashes during follow-up. Unvaccinated individuals accounted for 1682 traffic crashes (25%), equal to a 72% increased relative risk compared with those vaccinated (95% confidence interval, 63-82; P < 0.001). The increased traffic risks among unvaccinated individuals extended to diverse subgroups, was similar to the relative risk associated with sleep apnea, and was equal to a 48% increase after adjustment for age, sex, home location, socioeconomic status, and medical diagnoses (95% confidence interval, 40-57; P < 0.001). The increased risks extended across the spectrum of crash severity, appeared similar for Pfizer, Moderna, or other vaccines, and were validated in supplementary analyses of crossover cases, propensity scores, and additional controls. Conclusions These data suggest that COVID vaccine hesitancy is associated with significant increased risks of a traffic crash. An awareness of these risks might help to encourage more COVID vaccination.

Importance Police shootings can cause serious acute injury, and knowledge of subsequent health outcomes may inform interventions to improve care.Objective To analyze long-term health care costs among survivors of police shootings compared with those surviving nonfirearm police enforcement injuries using a retrospective design.Design, Setting, and Participants This population-based cohort analysis identified adults (age >= 16 years) who were injured by police and required emergency medical care between April 1, 2002, and March 31, 2022, in Ontario, Canada.Exposure Police shootings compared with other mechanisms of injury involving police.Main Outcomes and Measures Long-term health care costs determined using a validated costing algorithm. Secondary outcomes included short-term mortality, acute care treatments, and rates of subsequent disability.Results Over the study, 13 545 adults were injured from police enforcement (mean [SD] age, 35 [12] years; 11 637 males [86%]). A total of 13 520 individuals survived acute injury, and 8755 had long-term financial data available (88 surviving firearm injury, 8667 surviving nonfirearm injury). Patients surviving firearm injury had 3 times greater health care costs per year (CAD$16 223 vs CAD$5412; mean increase, CAD$9967; 95% CI, 6697-13 237; US $11 982 vs US $3997; mean increase, US $7361; 95% CI, 4946-9776; P < .001). Greater costs after a firearm injury were not explained by baseline costs and primarily reflected increased psychiatric care. Other characteristics associated with increased long-term health care costs included prior mental illness and a substance use diagnosis.Conclusions and Relevance In this longitudinal cohort study of long-term health care costs, patients surviving a police shooting had substantial health care costs compared with those injured from other forms of police enforcement. Costs primarily reflected psychiatric care and suggest the need to prioritize early recognition and prevention.

Importance Identifying and mitigating modifiable gaps in fracture preventive care for people with relapsing-remitting conditions such as eczema, asthma, and chronic obstructive pulmonary disease who are prescribed high cumulative oral corticosteroid doses may decrease fracture-associated morbidity and mortality. Objective To estimate the association between different oral corticosteroid prescribing patterns and appropriate fracture preventive care, including treatment with fracture preventive care medications, among older adults with high cumulative oral corticosteroid exposure. Design, Setting, and Participants This cohort study included 65 195 participants with UK electronic medical record data from the Clinical Practice Research Datalink (January 2, 1998, to January 31, 2020) and 28 674 participants with Ontario, Canada, health administrative data from ICES (April 1, 2002, to September 30, 2020). Participants were adults 66 years or older with eczema, asthma, or chronic obstructive pulmonary disease receiving prescriptions for oral corticosteroids with cumulative prednisolone equivalent doses of 450 mg or higher within 6 months. Data were analyzed October 22, 2020, to September 6, 2022. Exposures Participants with prescriptions crossing the 450-mg cumulative oral corticosteroid threshold in less than 90 days were classified as having high-intensity prescriptions, and participants crossing the threshold in 90 days or more as having low-intensity prescriptions. Multiple alternative exposure definitions were used in sensitivity analyses. Main Outcomes and Measures The primary outcome was prescribed fracture preventive care. A secondary outcome was major osteoporotic fracture. Individuals were followed up from the date they crossed the cumulative oral corticosteroid threshold until their outcome or the end of follow-up (up to 1 year after index date). Rates were calculated for fracture preventive care and fractures, and hazard ratios (HRs) were estimated from Cox proportional hazards regression models comparing high- vs low-intensity oral corticosteroid prescriptions. Results In both the UK cohort of 65 195 participants (mean [IQR] age, 75 [71-81] years; 32 981 [50.6%] male) and the Ontario cohort of 28 674 participants (mean [IQR] age, 73 [69-79] years; 17 071 [59.5%] male), individuals with high-intensity oral corticosteroid prescriptions had substantially higher rates of fracture preventive care than individuals with low-intensity prescriptions (UK: 134 vs 57 per 1000 person-years; crude HR, 2.34; 95% CI, 2.19-2.51, and Ontario: 73 vs 48 per 1000 person-years; crude HR, 1.49; 95% CI, 1.29-1.72). People with high- and low-intensity oral corticosteroid prescriptions had similar rates of major osteoporotic fractures (UK: crude rates, 14 vs 13 per 1000 person-years; crude HR, 1.07; 95% CI, 0.98-1.15 and Ontario: crude rates, 20 vs 23 per 1000 person-years; crude HR, 0.87; 95% CI, 0.79-0.96). Results from sensitivity analyses suggested that reaching a high cumulative oral corticosteroid dose within a shorter time, with fewer prescriptions, or with fewer or shorter gaps between prescriptions, increased fracture preventive care prescribing. Conclusions The results of this cohort study suggest that older adults prescribed high cumulative oral corticosteroids across multiple prescriptions, or with many or long gaps between prescriptions, may be missing opportunities for fracture preventive care.

Background: Topical corticosteroids (TCS) are commonly prescribed to treat inflammatory skin diseases, and appropriate prescription is necessary for treatment success.Objective: To quantify differences between TCS prescribed by dermatologists at consultation and family physicians for patients treated for any skin condition.Methods: Using administrative health data in Ontario, we included all Ontario Drug Benefit recipients who filled at least one TCS prescription from a dermatologist at consultation and a family physician in the year prior between January 2014 and December 2019. We estimated mean differences and 95% confidence intervals in amount (in grams) and potency between the index dermatologist prescription and the highest and most recent family physician prescription amounts and potencies in the preceding year using linear mixed-effect models.Results: A total of 69,335 persons were included. The mean dermatologist amount was 34% larger than the highest amount and 54% larger than the most recent amount prescribed by family physicians. There were small but statistically significant differences in potency using established 7-category and 4-category potency classification systems.Conclusions: Compared to family physicians, dermatologists prescribed substantially larger amounts and similarly potent TCS at consultation. Further research is needed to determine the effect of these differences on clinical outcomes. ( J Am Acad Dermatol 2023;88:1291-9.)

Abstract Background We examined ethnic differences in the association between age at diagnosis of diabetes and the risk of cardiovascular complications. Methods We conducted a population-based cohort study in Ontario, Canada among individuals with diabetes and matched individuals without diabetes (2002-18). We fit Cox proportional hazards models to determine the associations of age at diagnosis and ethnicity (Chinese, South Asian, general population) with cardiovascular complications. We tested for an interaction between age at diagnosis and ethnicity. Results There were 453,433 individuals with diabetes (49.7% women) and 453,433 matches. There was a significant interaction between age at diagnosis and ethnicity (P < 0.0001). Young-onset diabetes (age at diagnosis < 40) was associated with higher cardiovascular risk [hazard ratios: Chinese 4.25 (3.05–5.91), South Asian: 3.82 (3.19–4.57), General: 3.46 (3.26–3.66)] than usual-onset diabetes [age at diagnosis ≥ 40 years; Chinese: 2.22 (2.04–2.66), South Asian: 2.43 (2.22–2.66), General: 1.83 (1.81–1.86)] versus ethnicity-matched individuals. Among those with young-onset diabetes, Chinese ethnicity was associated with lower overall cardiovascular [0.44 (0.32–0.61)] but similar stroke risks versus the general population; while South Asian ethnicity was associated with lower overall cardiovascular [0.75 (0.64–0.89)] but similar coronary artery disease risks versus the general population. In usual-onset diabetes, Chinese ethnicity was associated with lower cardiovascular risk [0.44 (0.42–0.46)], while South Asian ethnicity was associated with lower cardiovascular [0.90 (0.86–0.95)] and higher coronary artery disease [1.08 (1.01–1.15)] risks versus the general population. Conclusions There are important ethnic differences in the association between age at diagnosis and risk of cardiovascular complications.

Purpose: To comprehensively examine the cost effectiveness, reattachment rate, and complications of pneumatic retinopexy (PnR) compared with pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) within a universal health care system.Design: Population-based, multicenter, consecutive, retrospective longitudinal cohort analysis.Subjects: We identified consecutive adults aged >= 50 years requiring surgery for primary RRD over a 20-year interval between April 1, 2002, and March 31, 2022. Initial surgery was considered the index date for analyses.Intervention: Pneumatic retinopexy was compared with PPV in all analyses.Main Outcome Measures: The primary analysis investigated the mean annualized health care costs comparing PnR to PPV over the 2 years after initial surgery. Secondary analyses examined the primary reattachment rate and complications.Results: In total, 25 665 eligible patients were identified, with 8794 undergoing PnR and 16 871 undergoing PPV. The mean patient age was 65 years and 39% were women. The mean annualized cost after PnR was $8924 and $11 937 after PPV (mean difference, $3013; 95% confidence interval, $2533e$3493; P < 0.001). The primary reattachment rate at 90 days after PnR was 83% and after PPV was 93% (P < 0.001). The risk of cataract or glaucoma surgery was lower after PnR, and the frequency of ophthalmology clinic visits, intravitreal injections, and anxiety was higher after PnR. Hospitalizations and long-term disability were less frequent after PnR.Conclusions: Pneumatic retinopexy, when compared with PPV, was associated with lower long-term health care costs. Pneumatic retinopexy appeared to be effective, safe, and inexpensive, thus offering a viable option for improving access to RRD repair in appropriately selected cases.Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article. (c) 2023 by the American Academy of Ophthalmology

ABSTRACT The COVID-19 pandemic has likely influenced the epidemiology of bacterial infections through wide-ranging changes to clinical practices and infection control and prevention interventions. We sought to determine how the detection and incidence of bloodstream infections (BSIs) have been influenced by the pandemic. We performed a retrospective analysis of blood culture data in the province of Ontario, Canada, from 1 January 2017 to 31 December 2020. Outcomes included a weekly incidence of blood culture tests, BSIs, and contaminant results. Results were stratified by hospital, community, and long-term care (LTC) settings. An interrupted time series analysis using segmented regression models was used to determine changes in outcome incidence/prevalence during the pre- and peri-pandemic periods. Of the 14,083,853 individuals included, 129,329 (0.92%) developed a bloodstream infection. The blood culture ordering rate increased during the pandemic in the hospital setting only [Incidence rate ratio (IRR) 1.09, 95% confidence interval (CI) 1.01–1.19]. There was a decline in the incidence of community-acquired (IRR 0.95, 95% CI 0.91–0.99) and LTC-acquired (IRR 0.85, 95% CI 0.76–0.94) BSIs. Hospital-acquired BSIs were unchanged. The proportion of blood culture contaminants increased in the community (7% increase, P < 0.01) and LTC settings (14% increase, P < 0.05). There was decreased incidence of community-acquired Streptococcus pneumoniae (IRR 0.43, 95% CI 0.33–0.57) and Staphylococcus aureus (IRR 0.91, 95% CI 0.84–0.99) bacteremia. Pandemic-related changes in the performance of blood cultures and the epidemiology of BSIs have implications for current and future pandemic antimicrobial use, healthcare resource allocation, and hospital and laboratory policies. IMPORTANCE Bacterial infections are a significant cause of morbidity and mortality worldwide. In the wake of the COVID-19 pandemic, previous studies have demonstrated pandemic-related shifts in the epidemiology of bacterial bloodstream infections (BSIs) in the general population and in specific hospital systems. Our study uses a large, comprehensive data set stratified by setting [community, long-term care (LTC), and hospital] to uniquely demonstrate how the effect of the COVID-19 pandemic on BSIs and testing practices varies by healthcare setting. We showed that, while the number of false-positive blood culture results generally increased during the pandemic, this effect did not apply to hospitalized patients. We also found that many infections were likely under-recognized in patients in the community and in LTC, demonstrating the importance of maintaining healthcare for these groups during crises. Last, we found a decrease in infections caused by certain pathogens in the community, suggesting some secondary benefits of pandemic-related public health measures.

OBJECTIVES:Existing tools to predict the risk of complications among people with type 2 diabetes poorly discriminate high- from low-risk patients. Our aim in this study was to develop risk prediction scores for major type 2 diabetes complications using real-world clinical care data, and to externally validate these risk scores in a different jurisdiction. METHODS:Using health-care administrative data and electronic medical records data, risk scores were derived using data from 25,088 people with type 2 diabetes from the Canadian province of Ontario, followed between 2002 and 2017. Scores were developed for major clinically important microvascular events (treatment for retinopathy, foot ulcer, incident end-stage renal disease), cardiovascular disease events (acute myocardial infarction, heart failure, stroke, amputation), and mortality (cardiovascular, noncardiovascular, all-cause). They were then externally validated using the independent data of 11,416 people with type 2 diabetes from the province of Manitoba. RESULTS:The 10 derived risk scores had moderate to excellent discrimination in the independent validation cohort, ranging from 0.705 to 0.977. Their calibration to predict 5-year risk was excellent across most levels of predicted risk, albeit with some displaying underestimation at the highest levels of predicted risk. CONCLUSIONS:The DIabeteS COmplications (DISCO) risk scores for major type 2 diabetes complications were derived and externally validated using contemporary real-world clinical data. As a result, they may be more accurate than other risk prediction scores derived using randomized trial data. The use of more accurate risk scores in clinical practice will help improve personalization of clinical care for patients with type 2 diabetes.

IMPORTANCE Some ophthalmologists may be reluctant to prescribe oral carbonic anhydrase inhibitors, given the potential for life-threatening systemic adverse reactions. OBJECTIVE To conduct a population-based analysis of the safety of oral or topical carbonic anhydrase inhibitors in clinical care. DESIGN, SETTING, AND PARTICIPANTS This matched longitudinal cohort study took place in Ontario, Canada. Consecutive patients older than 65 years who were prescribed an oral or topical carbonic anhydrase inhibitor in Ontario, Canada, between January 1, 1995, and January 1, 2020, were identified. Patients were matched 1-to-1 based on age, sex, and diabetes status. Time zero was defined as the date of the first identified prescription for the medication, and the primary analysis focused on the first 120 days of follow-up. MAIN OUTCOMES AND MEASURES The primary end pointwas a severe complicated adverse event of either Stevens-Johnson syndrome, toxic epidermal necrolysis, or aplastic anemia. RESULTS Overall, 128 942 matched patients initiated an oral or topical carbonic anhydrase inhibitor during the 25-year study period. The mean (SD) age was 75 (6.6) years, 71 958 (55.8%) were women, and 25 058 (19.4%) had a diagnosis of diabetes. The oral and topical carbonic anhydrase inhibitor groups had similar baseline demographics. Patients prescribed an oral carbonic anhydrase inhibitor had an absolute risk of a severe complicated adverse event of 2.90 per 1000 patients, whereas patients prescribed a topical carbonic anhydrase inhibitor had an absolute risk of 2.08 per 1000 patients. This difference was equivalent to a risk ratio of 1.40, with a number needed to harm of 1 in 1220 patients (95% CI, 1.12-1.74; P = .003). This generally low risk was replicated in multivariable regression controlling for confounding factors. Additional risk factors for a severe complicated adverse event included patients with more comorbidities and those with more frequent clinic contacts. CONCLUSIONS AND RELEVANCE The risk of a serious adverse reaction following prescription of an oral or topical carbonic anhydrase inhibitor was low and similar between agents. Given the low risk of severe adverse reactions, this population-level analysis supports reconsidering the reluctance toward prescribing an oral carbonic anhydrase inhibitor.

(Atopic) eczema is commonly treated with oral corticosteroids (OCS), which increase fracture risk. Fracture-preventive medications, including bisphosphonates, are recommended to counter the negative effects of OCS on bone health when individuals are prescribed >=450mg prednisolone equivalent dose (PED) in 6 months. People with eczema are prescribed OCS in different patterns (e.g., continuously or intermittently). We hypothesised people receiving intermittent OCSs were less likely to receive adequate fracture-preventive care than people receiving the same cumulative OCS dose continuously. We conducted a nationwide cohort study using routinely collected UK general practice data (1998-2020). We identified 20,680 individuals aged 66+ with eczema who had received at least 450mg PED in 6 months. Of these, 13,240 were intermittent and 7,440 were continuous OCS users. Hazard ratios from Cox regression suggested those prescribed continuous OCSs had higher rates of fracture preventive care (bisphosphonates, calcium, vitamin D) than those prescribed OCSs intermittently (HR 5.11; 95%CI 4.63-5.63). Effect estimates were attenuated in analyses using different continuous/intermittent OCS definitions, however a strong positive association between continuous use and fracture preventive care prescribing remained. Those prescribed OCS continuously were at higher risk of major osteoporotic fractures (HR 1.46; 95%CI 1.18-1.82). Results were similar when we replicated analyses in a population-based cohort from Ontario, Canada. There may be missed opportunities for appropriate fracture preventative care in people with eczema prescribed intermittent OCSs, suggesting a need for updated treatment guidelines. Implementation research could explore potential solutions such as electronic medical record reminders for individuals receiving threshold cumulative OCS prescriptions.

Background Cardiovascular symptoms in pregnancy may be a clue to psychological distress. We examined whether electrocardiogram testing in pregnant women is associated with an increased risk of subsequent postpartum depression. Methods We conducted a population-based cohort study of pregnant women who delivered in Ontario, Canada comparing women who received a prenatal ECG to women who did not. Results In total, 3,238,218 women gave birth during the 25-year study period of whom 157,352 (5%) received an electrocardiogram during prenatal care. Receiving an electrocardiogram test was associated with a one-third relative increase in the odds of postpartum depression (odds ratio 1.34; 95% confidence interval 1.29–1.39, p < 0.001). Conclusion The association between prenatal electrocardiogram testing and postpartum depression suggests a possible link of organic disease with mental illness, and emphasizes that cardiovascular symptoms may be a clinical clue to the presence of an underlying mood disorder.