A key strategy to address system pressures on hip and knee arthroplasty through the COVID-19 pandemic has been to shift procedures to the outpatient setting. This was a retrospective cohort and ...case-control study. Using the Discharge Abstract Database and the National Ambulatory Care Reporting System databases, we estimated the use of outpatient hip and knee arthroplasty in Ontario, Canada. After propensity-score matching, we estimated rates of 90-day readmission, 90-day emergency department (ED) visit, 1-year mortality, and 1-year infection or revision. 204,066 elective hip and 341,678 elective knee arthroplasties were performed from 2010-2022. Annual volumes of hip and knee arthroplasties increased steadily until 2020. Following the start of the COVID-19 pandemic (March 1, 2020) through December 31, 2022 there were 7,561 (95% CI 5,435 to 9,688) fewer hip and 20,777 (95% CI 17,382 to 24,172) fewer knee replacements performed than expected. Outpatient arthroplasties increased as a share of all surgeries from 1% pre-pandemic to 39% (hip) and 36% (knee) by 2022. Among inpatient arthroplasties, the tendency to discharge to home did not change since the start of the pandemic. During the COVID-19 era, patients receiving arthroplasty in the outpatient setting had a similar or lower risk of readmission than matched patients receiving inpatient arthroplasty hip: RR 0.65 (0.56-0.76); knee: RR 0.86 (0.76-0.97); ED visits hip: RR 0.78 (0.73-0.83); knee: RR 0.92 (0.88-0.96); and mortality, infection, or revision hip: RR 0.65 (0.45-0.93); knee: 0.90 (0.64-1.26). Following the start of the COVID-19 pandemic in Ontario, the volume of outpatient hip and knee arthroplasties performed increased despite a reduction in overall arthroplasty volumes. This shift in surgical volumes from the inpatient to outpatient setting coincided with pressures on hospitals to retain inpatient bed capacity. Patients receiving arthroplasty in the outpatient setting had relatively similar outcomes to those receiving inpatient surgery after matching on known sociodemographic and clinical characteristics.
Each wave of the COVID-19 pandemic exhibited a unique combination of epidemiological, social and structural characteristics. We explore similarities and differences in wave-over-wave characteristics ...of patients hospitalised with COVID-19.
This was a population-based study in Ontario province, Canada. Patients hospitalised with SARS-CoV-2 between 26 February 2020 and 31 March 2022 were included. An admission was considered related to SARS-CoV-2 infection if the provincial inpatient or outpatient hospital databases contained the ICD-10 diagnostic codes U071/U072 or the Ontario Laboratories Information System indicated a positive SARS-CoV-2 test result (PCR or rapid antigen testing) during the admission or up to two weeks prior. The primary outcome was 90-day mortality (modified Poisson regression). Secondary outcomes were use of critical care during the admission (logistic regression) and total length-of-stay (linear regression with heteroskedastic-consistent standard-error estimators). All models were adjusted for demographic characteristics, neighbourhood socioeconomic factors and indicators of illness severity.
There were 73,201 SARS-CoV-2-related admissions: 6127 (8%) during wave 1 (wild-type), 14,371 (20%) during wave 2 (wild-type), 16,653 (23%) during wave 3 (Alpha), 5678 (8%) during wave 4 (Delta) and 30,372 (42%) during wave 5 (Omicron). SARS-CoV-2 was the most responsible diagnosis for 70% of admissions during waves 1-2 and 42% in wave 5. The proportion of admitted patients who were long-term care residents was 18% (n = 1111) during wave 1, decreasing to 10% (n = 1468) in wave 2 and <5% in subsequent waves. During waves 1-3, 46% of all admitted patients resided in a neighbourhood assigned to the highest ethnic diversity quintile, which declined to 27% during waves 4-5. Compared to wave 1, 90-day mortality was similar during wave 2 (adjusted risk ratio aRR: 1.00 95% CI: 0.95-1.04), but lower during wave 3 (aRR: 0.89 0.85-0.94), wave 4 (aRR: 0.85 0.79-0.91) and wave 5 (aRR: 0.83 0.80-0.88). Improvements in survival over waves were observed among elderly patients (p-interaction <0.0001). Critical care admission was significantly less likely during wave 5 than previous waves (adjusted odds ratio: 0.50 0.47-0.54). The length of stay was a median of 8.5 (3.6-23.8) days during wave 1 and 5.3 (2.2-12.6) during wave 5. After adjustment, the mean length of stay was on average -10.4 (-11.1 to -9.8) days, i.e. shorter, in wave 5 vs wave 1.
Throughout the pandemic, sociodemographic characteristics of patients hospitalised with SARS-CoV-2 changed over time, particularly in terms of ethnic diversity, but still disproportionately affected patients from more marginalised regions. Improved survival and reduced use of critical care during the Omicron wave are reassuring.
Population-level surveillance systems have demonstrated reduced transmission of non-SARS-CoV-2 respiratory viruses during the COVID-19 pandemic. In this study, we examined whether this reduction ...translated to reduced hospital admissions and emergency department (ED) visits associated with influenza, respiratory syncytial virus (RSV), human metapneumovirus, human parainfluenza virus, adenovirus, rhinovirus/enterovirus, and common cold coronavirus in Ontario.
Hospital admissions were identified from the Discharge Abstract Database and exclude elective surgical admissions and non-emergency medical admissions (January 2017-March 2022). Emergency department (ED) visits were identified from the National Ambulatory Care Reporting System. International Classification of Diseases (ICD-10) codes were used to classify hospital visits by virus type (January 2017-May 2022).
At the onset of the COVID-19 pandemic, hospitalizations for all viruses were reduced to near-trough levels. Hospitalizations and ED visits for influenza (9,127/year and 23,061/year, respectively) were nearly absent throughout the pandemic (two influenza seasons; April 2020-March 2022). Hospitalizations and ED visits for RSV (3,765/year and 736/year, respectively) were absent for the first RSV season during the pandemic, but returned for the 2021/2022 season. This resurgence of hospitalizations for RSV occurred earlier in the season than expected, was more likely among younger infants (age ≤6 months), more likely among older children (aged 6.1-24 months), and less likely to comprise of patients residing in higher areas of ethnic diversity (p<0.0001).
During the COVID-19 pandemic, there was a reduced the burden of other respiratory infections on patients and hospitals. The epidemiology of respiratory viruses in the 2022/23 season remains to be seen.
Young women wishing to become living kidney donors frequently ask whether nephrectomy will affect their future pregnancies.
We conducted a retrospective cohort study of living kidney donors involving ...85 women (131 pregnancies after cohort entry) who were matched in a 1:6 ratio with 510 healthy nondonors from the general population (788 pregnancies after cohort entry). Kidney donations occurred between 1992 and 2009 in Ontario, Canada, with follow-up through linked health care databases until March 2013. Donors and nondonors were matched with respect to age, year of cohort entry, residency (urban or rural), income, number of pregnancies before cohort entry, and the time to the first pregnancy after cohort entry. The primary outcome was a hospital diagnosis of gestational hypertension or preeclampsia. Secondary outcomes were each component of the primary outcome examined separately and other maternal and fetal outcomes.
Gestational hypertension or preeclampsia was more common among living kidney donors than among nondonors (occurring in 15 of 131 pregnancies 11% vs. 38 of 788 pregnancies 5%; odds ratio for donors, 2.4; 95% confidence interval, 1.2 to 5.0; P=0.01). Each component of the primary outcome was also more common among donors (odds ratio, 2.5 for gestational hypertension and 2.4 for preeclampsia). There were no significant differences between donors and nondonors with respect to rates of preterm birth (8% and 7%, respectively) or low birth weight (6% and 4%, respectively). There were no reports of maternal death, stillbirth, or neonatal death among the donors. Most women had uncomplicated pregnancies after donation.
Gestational hypertension or preeclampsia was more likely to be diagnosed in kidney donors than in matched nondonors with similar indicators of baseline health. (Funded by the Canadian Institutes of Health Research and others.).
The prevalence of human papillomavirus (HPV) in squamous cell carcinoma of unknown primary in the head and neck (SCCUPHN), and prognosis by HPV status of SCCUPHN patients has been difficult to ...estimate because of the rarity of this subtype. In MEDLINE, Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations, EMBASE, Cochrane library and Web of Science searches, observational studies and clinical trials that reported survival rates of patients with SCCUPHN by HPV status were identified. Meta‐analysis estimated the prevalence and prognosis (overall survival, OS; progression‐free survival, PFS) of SCCUPHN by HPV status, and compared them to studies of oropharyngeal squamous cell carcinoma (OPSCC) from the same institutions and across continents. In 17 SCCUPHN studies (n = 1,149) and 17 institution‐matched OPSCC studies (n = 6,522), the pooled HPV prevalence of SCCUPHN was 49%, which was only 10% (95%CI: 1–19%) lower than OPSCC prevalence in the underlying population. Estimated 5‐year OS for HPV‐negative SCCUPHN was 44% (95%CI: 36–51%) vs. HPV‐positive SCCUPHN of 91% (95%CI: 86–96%); hazard ratio (HR) for OS was 3.25 (95%CI: 2.45–4.31) and PFS was 4.49 (95%CI: 2.88–7.02). HRs by HPV status for OPSCC were similar to that in SCCUPHN. While North American SCCUPHNs had higher HPV prevalence than European SCCUPHNs (OR = 2.68 (95%CI: 1.3–5.6)), HR of OS for HPV‐negative vs. HPV‐positive patients were similar in both continents (HRs of 3.78–4.09). Prevalence of HPV among SCCUPHN patients were lower than in OPSCC. The survival benefit conferred by being HPV‐positive was similar in SCCUPHN as in OPSCCs, independent of continent.
Cervical cancer develops through progression from normal cervical epithelium through squamous intraepithelial lesions (SIL) to invasive cancer. Cervical cancer is associated with oncogenic human ...papillomavirus (HPV). The HPV E6 oncoprotein binds to the tumor suppressor gene product p53, promoting its degradation; the Arg allele of p53 Arg72Pro polymorphism binds more ardently with HPV E6 than the Pro variant. Here we evaluate the role of p53 Arg72Pro polymorphism and HPV status on the initiation, progression, and development of cervical cancer. A systematic review and meta-analysis were conducted. Events of interest were the initiation of neoplasia (SIL vs. normal), progression to invasive cancer (cervical cancer vs. SIL), and risk of invasive cancer (cervical cancer vs. normal) by HPV status. OR were extracted from individual studies and pooled using generic inverse variance and random effects modeling. Forty-nine studies were included. In individuals showing HPV positivity, there was a significantly higher odds of progression from SIL to cervical cancer with the p53 Arg allele OR 1.37; 95% confidence intervals (CI), 1.15-1.62; P < 0.001. This association was not seen in HPV-negative individuals. p53 Arg72Pro was not associated with the risk of cervical cancer or initiation of SIL in either HPV-positive or HPV-negative patient subsets. The Arg variant of p53 Arg72Pro is associated with progression of SIL to cervical cancer only in the presence of HPV positivity. There were no associations of this variant with overall risk or initiation of cancer in either HPV-positive or HPV-negative patients. Clin Cancer Res; 18(23); 6407-15.
Second-hand smoke (SHS; ie, exposure to smoking of friends and spouses in the household) reduces the likelihood of smoking cessation in noncancer populations. We assessed whether SHS is associated ...with cessation rates in lung cancer survivors.
Patients with lung cancer were recruited from Princess Margaret Cancer Centre, Toronto, ON, Canada. Multivariable logistic regression and Cox proportional hazard models evaluated the association of sociodemographics, clinicopathologic variables, and SHS with either smoking cessation or time to quitting.
In all, 721 patients completed baseline and follow-up questionnaires with a mean follow-up time of 54 months. Of the 242 current smokers at diagnosis, 136 (56%) had quit 1 year after diagnosis. Exposure to smoking at home (adjusted odds ratio aOR, 6.18; 95% CI, 2.83 to 13.5; P < .001), spousal smoking (aOR, 6.01; 95% CI, 2.63 to 13.8; P < .001), and peer smoking (aOR, 2.49; 95% CI, 1.33 to 4.66; P = .0043) were each associated with decreased rates of cessation. Individuals exposed to smoking in all three settings had the lowest chances of quitting (aOR, 9.57; 95% CI, 2.50 to 36.64; P < .001). Results were similar in time-to-quitting analysis, in which 68% of patients who eventually quit did so within 6 months after cancer diagnosis. Subgroup analysis revealed similar associations across early- and late-stage patients and between sexes.
SHS is an important factor associated with smoking cessation in lung cancer survivors of all stages and should be a key consideration when developing smoking cessation programs for patients with lung cancer.
Observational studies have suggested that HER2 inhibition with trastuzumab may be associated with an increased incidence of intracranial metastatic disease (IMD) due to its ability to prolong ...survival. We hypothesized that prolonged survival associated with dual-agent HER2 inhibition may be associated with an even higher incidence of IMD. This study pooled estimates of IMD incidence and survival among patients with HER2-positive breast cancer receiving dual- versus single-agent HER2 targeted therapy, as well as trastuzumab versus chemotherapy, observation, or another HER2-targeted agent. We searched PubMed, EMBASE, and CENTRAL from inception to 25 March 2020. We included randomized controlled trials that reported IMD incidence for patients with HER2-positive breast cancer receiving trastuzumab as the experimental or control arm irrespective of disease stage. Among 465 records identified, 19 randomized controlled trials (32,572 patients) were included. Meta-analysis of four studies showed that dual HER2-targeted therapy was associated with improved overall survival (HR 0.76; 95% CI, 0.66-0.87) and progression-free survival (HR 0.77; 95% CI, 0.68-0.87) compared to single HER2-targeted therapy, but the risk of IMD was similar (RR 1.03; 95% CI, 0.83-1.27). Our study challenges the hypothesis that prolonged survival afforded by improved extracranial disease control is associated with increased IMD incidence.
In cancer epidemiological studies, determination of human papillomavirus (HPV) in oropharyngeal squamous cell carcinoma (OPSCC) typically depends on the availability of tumor tissue testing, and/or ...tumor tissue access. Identifying alternative methods for estimating HPV status can improve the quality of such studies when tissue is unavailable. We developed multiple predictive models for tumor HPV status and prognosis by combining both clinico‐epidemiological variables and either serological multiplex assays of HPV or multiple imputation of HPV status (HPVmi). Sensitivity, specificity and accuracy of these methods compared to either p16 immunostaining (p16 IHC) or survival were assessed. When compared to a reference of tumor tissue p16 IHC in 783 OPSCC patients, the clinic‐HPVsero model incorporating a composite of 20 HPV serological antibodies (HPVsero) and 4 clinical factors (c‐index: 0.96) performed better than using HPVsero (c‐index: 0.92) or HPVmi (c‐index: 0.76) alone. However, the model that contained a single HPV16 E6 antibody combined with four clinical variables, performed extremely well (clinic‐s1‐16E6; c‐index: 0.95). When defining HPV status by HPVsero, s1‐16E6, HPVmi or through p16 IHC, each of these definitions demonstrated improved overall and disease‐free survival in HPV‐positive OPSCC patients, when compared to HPV‐negative patients (adjusted hazard ratios between 0.25 and 0.63). Our study demonstrates that when blood samples are available, a model that utilizes a single s1‐16E6 antibody combined with several clinical features has excellent test performance characteristics to estimate HPV status and prognosis. When neither blood nor tumor tissue is available, multiple imputation, calibrated on local population characteristics, remains a viable, but suboptimal option.
What's new?
Oropharyngeal squamous cell carcinoma (OPSCC) exists in two distinct subtypes: HPV‐positive and HPV‐negative. HPV+ OPSCC typically has better prognosis and outcomes. Testing for HPV typically requires a tumor tissue sample, but this is impractical in certain situations. Here, the authors report on the effectiveness of other methods of determining HPV status. They tested two models; one based on clinico‐demographic factors, such as smoking, alcohol, and comorbidity data. The second included serological testing. The clinico‐serological combination model, they found, predicted HPV status better than either clinical variables or serological testing alone, and could serve as an acceptable substitute for tissue‐based testing.
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