To assess anal oncogenic human papillomavirus (HPV) and anal cytology as screening tests for detecting high-grade anal intraepithelial neoplasia (AIN 2+), as this is an immediate anal cancer ...precursor.
Cross-sectional study of 401 HIV-positive men who have sex with men (MSM). The endpoint was histologically confirmed AIN 2+ obtained by high-resolution anoscopy. Cytology and biopsy specimens were assigned random numbers and independently assessed by two pathologists.
We did concomitant anal cytology, anal HPV testing and HRA with directed biopsies without knowing the results of each intervention. The main outcome measures were the sensitivity, specificity, negative predictive value and positive predictive value of anal cytology and oncogenic HPV for the detection of AIN 2+.
Cytology was abnormal in 67% of patients: high-grade squamous intraepithelial lesion, 12%; low-grade squamous intraepithelial lesion, 43% and atypical squamous cells of undetermined significance, 12%. Biopsies were abnormal in 68% of patients: AIN 2+, 25% and AIN 1, 43%. HPV was detected in 93% with multiple HPV types in 92% and oncogenic HPV types in 88%. Test performance characteristics for the detection of AIN 2+ using any abnormality on anal cytology were: sensitivity 84%, specificity 39%, negative predictive value 88% and positive predictive value 31%; using oncogenic HPV: sensitivity 100%, specificity 16%, negative predictive value 100% and positive predictive value 28%.
Anal cytology and HPV detection have high sensitivity but low specificity for detecting AIN 2+. HIV-positive men who have sex with men have a high prevalence of AIN 2+ and require high-resolution anoscopy for optimal detection of high-grade anal dysplasia.
Background. Women with inflammatory bowel disease (IBD) are at risk of certain pregnancy outcomes such as preterm delivery, infants small for gestational age (SGA), and Cesarean delivery. Whether ...regional variation in these outcomes exists remains unknown. We aimed to assess the geographical variation in these pregnancy outcomes in women with IBD. Methods. All pregnancies in women with and without IBD (2002-2013) were identified using Ontario health administrative datasets. Geographical variation in preterm delivery, infants SGA, and Cesarean delivery was assessed using age-adjusted odds ratios (aOR) with 95% confidence intervals (CI) comparing women with and without IBD, stratified by Ontario’s 14 health-service regions, known as Local Health Integration Networks (LHINs). Results. 1621 women with IBD (2466 pregnancies) and 855,425 women without IBD (1,280,493 pregnancies) were included. Women with IBD were more likely to have preterm delivery (aOR 1.56, 95% CI, 1.35–1.79), infants SGA (aOR 1.52, 95% CI, 1.23–1.88), and Cesarean section (aOR 1.34, 95% CI, 1.22–1.49). Significant geographical variation in these outcomes was detected, with the highest rates observed in the most northern rural areas (aOR for preterm delivery 2.78 (95% CI, 1.03–7.46), aOR for SGA 5.66 (95% CI, 1.67–19.14), and aOR for Cesarean delivery 2.48 (95% CI, 1.11–5.55)). There were no differences in these outcomes in women with and without IBD in more central urban LHINs. Conclusion. Significant regional variation was detected in rates of adverse pregnancy outcomes and Cesarean delivery in women with IBD. Further study is required to determine specific reasons for this variation.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Concurrent cohorts of 644,932 women aged 50–74 screened annually due to family history, dense breasts or biennially in the Ontario Breast Screening Program (OBSP) from 2011–2014 were linked to ...provincial administrative datasets to determine health system resource utilization and costs. Age-adjusted mean and median total healthcare costs (2018 CAD) and incremental cost differences were calculated by screening outcome and compared by recommendation using regression models. Healthcare costs were compared overall and 1 year after a false positive (n = 46,081) screening mammogram and 2 years after a breast cancer diagnosis (n = 6011). Mean overall healthcare costs by age were highest for those 60–74, particularly with annual screening for family/personal history (CAD 5425; 95% CI: 5308 to 5557) compared to biennial. Although the mean incremental cost difference was higher (23.4%) by CAD 10,235 (95% CI: 6141 to 14,329) per breast cancer for women screened annually for density ≥ 75% compared to biennially, the cost difference was 12.0% lower (−CAD 461; 95% CI: −777 to −114) per false positive result. In contrast, for women screened annually for family/personal history, the mean cost difference per false positive was 19.7% higher than for biennially (CAD 758; 95% CI: 404 to 1118); however, the cost difference per breast cancer was only slightly higher (2.5%) by CAD 1093 (95% CI: −1337 to CAD 3760). Understanding that associated costs of annual compared to biennial screening may balance out by age and outcome can assist decision-making regarding the use of limited healthcare resources.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK, VSZLJ
To evaluate the incidence, characteristics, and correlates of antidepressant drug therapy initiation among community-dwelling older adults following hip fracture.
Retrospective cohort study using ...linked, population-based administrative data.
Province of Ontario, Canada.
Older adults, aged 65 years or older, with a hip fracture and hip fracture surgery between April 1, 2003, and February 28, 2011. The study sample was restricted to individuals who returned home following surgery and who had not been dispensed an antidepressant in the year prior to their fracture (N=25,436).
We determined the incidence of new antidepressant use defined by the dispensing of antidepressant drug therapy within 90 days of discharge home. We identified independent correlates of antidepressant initiation using multivariate regression.
Overall, antidepressants were newly initiated in 8.8% of older adults with hip fracture in the 90 days following hospital discharge. There was a statistically significant, 1.3-fold increase in incidence of antidepressant prescribing from 2003 to 2010. Trazodone, frequently prescribed at a low dose, accounted for 39.0% of newly dispensed antidepressants, followed by selective serotonin reuptake inhibitors (36.9%). Rehabilitation admission, psychiatric evaluation, a diagnosis of dementia, and baseline benzodiazepine use were the strongest independent correlates of antidepressant initiation.
The period after a hip fracture is associated with a high rate of initiation of antidepressant therapy. The data raise the possibility that antidepressants are frequently prescribed off-label in these patients. Further research is needed to investigate the safety and efficacy of antidepressant use in this vulnerable population.
Our study was to determine breast cancer screening costs in Ontario, Canada for screenings conducted through a formal (Ontario Breast Screening Program, OBSP) and informal (non-OBSP) screening ...program using administrative databases. Included women were 49-74 years of age when receiving screening mammograms between 1 January 2013 to 31 December 2019. Each woman was followed for a screening episode with screening and diagnostic components, and costs were calculated as an average cost per woman per month in 2021 Canadian dollars. The final cohort of 1,546,386 women screened had a mean age of 59.4 ± 7.1 years and ~87% were screened via OBSP. The average total cost per woman per month was $136 ± $103, $134 ± $103 and $155 ± $104 for the entire, OBSP and non-OBSP cohorts, respectively. This was further disaggregated into the average total screening cost per month, which was $103 ± $8, $100 ± $4 and $117 ± $9 per woman, and the average total diagnostic cost per woman per month at $219 ± $166, $228 ± $165 and $178 ± $159. for the entire, OBSP and non-OBSP cohorts, respectively. These results indicate similar screening costs across the different cohorts, but higher diagnostic costs for the OBSP cohort.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK, VSZLJ
Background: HIV-positive men with a history of anal-receptive intercourse are at risk for anal cancer. We determined whether
human papilloma virus (HPV) biomarkers were correlated with anal pathology ...in these men.
Methods: HPV genotype was determined by PCR/line blot assay. Real-time PCR assays were done for viral load, E6 transcripts
for HPV genotypes 16, 18, and 31, and p16 transcripts.
Results: The most common oncogenic HPV types were HPV 16 (38%), 18 (19%), 45 (22%), and 52 (19%). HPV types 16, 18, 31, 52,
59, and 68 were associated with high-grade histology. The number of HPV genotypes per anal swab was higher for anal intraepithelial
neoplasia (AIN) 2/3 than for normal or AIN 1 histology median, 5 types (interquartile range) (IQR), 3-7 versus 3.5 (IQR),
2-6; P = 0.0005. HPV 16 viral load was also associated with AIN 2/3 histology. There was no difference in p16 or E6 transcripts
between histologic grades. In the multivariable logistic regression model, HPV genotypes 16 odds ratio, 2.58; 95% confidence
interval (95% CI), 1.31-5.08; P = 0.006 and 31 (odds ratio, 4.74; 95% CI, 2.00-11.22; P = 0.0004), baseline CD4 count < 400 cells/mm 3 (odds ratio, 2.96; 95% CI, 1.46-5.99; P = 0.0025), and Acquired Immunodeficiency Syndrome (AIDS)-defining illness (odds ratio, 2.42; 95% CI, 1.22-4.82; P = 0.01) were associated with high-grade histology after adjusting for age.
Conclusions: The presence of high-grade anal pathology (AIN 2/3) in HIV-positive men was associated with multiple HPV genotypes,
HPV genotypes 16 and 31, and HPV 16 viral load. (Cancer Epidemiol Biomarkers Prev 2009;18(7):1986–92)
The identification of contextual factors that modify associations between client frailty and their health and service use outcomes is essential for informed home health care and policy planning. Our ...objective was to examine variation in the associations between frailty and select 1-year health outcomes by caregiver distress and client sex among community-residing older care recipients.
We conducted a retrospective cohort study using linked population-based clinical and health administrative databases for all long-stay home care clients (n = 234,552) aged 66+ years assessed during April 2010-2013 in Ontario, Canada. Frailty was assessed using a previously validated 72-item frailty index (FI). Presence of caregiver distress was derived from clinical assessment items administered by trained home care assessors. Multivariable log-binomial regression models were used to examine variations in the associations between frailty and outcomes of interest (mortality, nursing home NH placement, all-cause and prolonged hospitalization) by caregiver distress, with further model stratification by client sex.
Frailty prevalence varied little by sex (19.3% women, 19.9% men) despite significant sex-differences in clients' sociodemographic and health characteristics. In both sexes, frailty was significantly associated with all outcomes, particularly NH placement (RR = 3.84, 95%CI 3.75-3.93) and death (RR = 2.32, 95%CI 2.27-2.37), though risk ratios were greater for women. Caregiver distress was more common with increasing frailty and for male clients, and a significant independent predictor of NH placement and prolonged hospitalization in both sexes. The association between frailty and NH placement (but not other outcomes) varied by caregiver distress for both men and women (p < 0.001 interaction terms), showing a greater magnitude of association among clients without (vs. with) a distressed caregiver.
As caregiver distress varies by client sex, represents a key driver of NH placement (even among relatively robust clients), and modifies the impact of other risk factors such as frailty, it should be routinely assessed. Further, sex-differences should be considered when developing and evaluating community-based services for older adults and their caregivers.
Abstract
Background
Antibiotic use is the strongest modifiable risk factor for the development of Clostridioides difficile infection, but prescribers lack quantitative information on comparative ...risks of specific antibiotic courses. Our objective was to estimate risks of C. difficile infection associated with receipt of specific antibiotic courses.
Methods
We conducted a longitudinal case-cohort analysis representing over 90% of Ontario nursing home residents, between 2012 and 2017. Our primary exposure was days of antibiotic receipt in the prior 90 days. Adjustment covariates included: age, sex, prior emergency department or acute care stay, Charlson comorbidity index, prior C. difficile infection, acid suppressant use, device use, and functional status. We examined incident C. difficile infection, including cases identified within the nursing home, and those identified during subsequent hospital admissions. Adjusted and unadjusted regression models were used to measure risk associated with 5- to 14-day courses of 18 different antibiotics.
Results
We identified 1708 cases of C. difficile infection (1.27 per 100 000 resident-days). Longer antibiotic duration was associated with increased risk: 10- and 14-day courses incurred 12% (adjusted relative risk ARR = 1.12, 95% confidence interval CI: 1.09, 1.14) and 27% (ARR = 1.27, 95% CI: 1.21,1.30) more risk compared to 7-day courses. Among 7-day courses with similar indications: moxifloxacin resulted in 121% more risk than amoxicillin (ARR = 2.21, 95% CI: 1.67, 3.08), ciprofloxacin engendered 89% more risk than nitrofurantoin (ARR = 1.89, 95% CI: 1.45, 2.68), and clindamycin resulted in 112% (ARR = 2.12, 95% CI: 1.32, 3.78) more risk than cloxacillin.
Conclusions
C. difficile infection risk increases with antibiotic duration, and there are wide disparities in risks associated with antibiotic courses used for similar indications.
We found large variations in C. difficile infection risk for antibiotic courses used for the same common indications. Risk could be substantially reduced if prescribers selected shorter durations of lower risk agents.
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