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Background Randomized trials conducted in low- and middle-income settings demonstrated efficacy of influenza vaccination during pregnancy against influenza infection among infants <6 months of age. However, vaccine effectiveness (VE) estimates from settings with different population characteristics and influenza seasonality remain limited. Methods We conducted a test-negative study in Ontario, Canada. All influenza virus tests among infants <6 months from 2010 to 2019 were identified and linked with health databases to ascertain information on maternal-infant dyads. VE was estimated from the odds ratio for influenza vaccination during pregnancy among cases versus controls, computed using logistic regression with adjustment for potential confounders. Results Among 23 806 infants tested for influenza, 1783 (7.5%) were positive and 1708 (7.2%) were born to mothers vaccinated against influenza during pregnancy. VE against laboratory-confirmed infant influenza infection was 64% (95% confidence interval [CI], 50%–74%). VE was similar by trimester of vaccination (first/second, 66% [95% CI, 40%–80%]; third, 63% [95% CI, 46%–74%]), infant age at testing (0 to <2 months, 63% [95% CI, 46%–75%]; 2 to <6 months, 64% [95% CI, 36%–79%]), and gestational age at birth (≥37 weeks, 64% [95% CI, 50%–75%]; < 37 weeks, 61% [95% CI, 4%–86%]). VE against influenza hospitalization was 67% (95% CI, 50%–78%). Conclusions Influenza vaccination during pregnancy offers effective protection to infants <6 months, for whom vaccines are not currently available. [ABSTRACT FROM AUTHOR]

Introduction: Lower extremity amputation (LEA) is a life altering procedure, with significant negative impacts to patients, care partners, and the overall health system. There are gaps in knowledge with respect to patterns of healthcare utilization following LEA due to dysvascular etiology. Objective: To examine inpatient acute and emergency department (ED) healthcare utilization among an incident cohort of individuals with major dysvascular LEA 1 year post-initial amputation; and to identify factors associated with acute care readmissions and ED visits. Design: Retrospective cohort study using population-level administrative data. Setting: Ontario, Canada. Population: Adults individuals (18 years or older) with a major dysvascular LEA between April 1, 2004 and March 31, 2018. Interventions: Not applicable. Main outcome measures: Acute care hospitalizations and ED visits within one year post-initial discharge. Results: A total of 10,905 individuals with major dysvascular LEA were identified (67.7% male). There were 14,363 acute hospitalizations and 19,660 ED visits within one year post-discharge from initial amputation acute stay. The highest common risk factors across all the models included age of 65 years or older (versus less than 65 years), high comorbidity (versus low), and low and moderate continuity of care (versus high). Sex differences were identified for risk factors for hospitalizations, with differences in the types of comorbidities increasing risk and geographical setting. Conclusion: Persons with LEA were generally more at risk for acute hospitalizations and ED visits if higher comorbidity and lower continuity of care. Clinical care efforts might focus on improving transitions from the acute setting such as coordinated and integrated care for sub-populations with LEA who are more at risk. [ABSTRACT FROM AUTHOR]

Background: Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits. Methods: We used health administrative databases to conduct a population‐based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community‐dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk. Results: Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low‐income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines. Conclusions: History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia‐friendly and geriatric‐focused EDs. Collaborative medication review in the ED and closer follow‐up and engagement with community supports could improve patient care and experience. See related editorial by Shah and Hwang in this issue. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to provide real-world evidence on coronavirus disease 2019 vaccine effectiveness (VE) against symptomatic infection and severe outcomes caused by Omicron in children aged 5 to 11 years. METHODS: We used the test-negative study design and linked provincial databases to estimate BNT162b2 vaccine effectiveness against symptomatic infection and severe outcomes caused by Omicron in children aged 5 to 11 years between January 2 and August 27, 2022 in Ontario. We used multivariable logistic regression to estimate VE by time since the latest dose, compared with unvaccinated children, and we evaluated VE by dosing interval. RESULTS: We included 6284 test-positive cases and 8389 test-negative controls. VE against symptomatic infection declined from 24% (95% confidence interval [CI], 8% to 36%) 14 to 29 days after a first dose and 66% (95% CI, 60% to 71%) 7 to 29 days after 2 doses. VE was higher for children with dosing intervals of ≥56 days (57% [95% CI, 51% to 62%]) than 15 to 27 days (12% [95% CI, -11% to 30%]) and 28 to 41 days (38% [95% CI, 28% to 47%]), but appeared to wane over time for all dosing interval groups. VE against severe outcomes was 94% (95% CI, 57% to 99%) 7 to 29 days after 2 doses and declined to 57% (95%CI, -20% to 85%) after ≥120 days. CONCLUSIONS: In children aged 5 to 11 years, 2 doses of BNT162b2 provide moderate protection against symptomatic Omicron infection within 4 months of vaccination and good protection against severe outcomes. Protection wanes more rapidly for infection than severe outcomes. Overall, longer dosing intervals confer higher protection against symptomatic infection, however protection decreases and becomes similar to shorter dosing interval starting 90 days after vaccination. [ABSTRACT FROM AUTHOR]

Background: When constipation is refractory to first‐line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. Methods: We conducted a population‐based, quasi‐experimental study with pre–post comparison of the intervention group and a non‐equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0–18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. Key Results: One hundred thirty‐eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35–1.75), outpatient visits (RR 1.05, 95% CI 0.91–1.18), or same‐day surgical procedures (RR 1.51, 95% CI 0.60–2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11–1.79), driven in part by device‐related complications. Conclusions and Inferences: Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision‐making. The observed increase in ED visits for device‐related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas. [ABSTRACT FROM AUTHOR]

Objective: To examine the combined association between metformin use and physical activity on HbA1c in adults with type 2 diabetes. Research Design and Methods: Adults with type 2 diabetes from NHANES continuous survey (1999‐2018, n = 6447) were classified as active and inactive based on self‐reported engagement in moderate‐to‐vigorous or vigorous physical activity (MVPA or VigPA) and metformin use over the last month. Results: There was a significant negative main effect of metformin usage on HbA1c levels, independent of whether individuals engaged in modest levels of MVPA or VigPA. Moreover, there was a higher prevalence of metformin users with a HbA1c < 6.5% than non‐metformin users with no differences by activity status (36.1%‐39.5% versus 24.9%‐29.7%, respectively). There was a significantly lower HbA1c level (P =.007) and trend for a higher odds of having a HbA1c that achieved the clinical target of <7% (OR, 95% CI = 1.2, 1.0‐1.4, P =.06) in the MVPA than non‐MVPA group for only those not using metformin. For those using metformin, there was no difference in HbA1c levels by either MVPA or VigPA (both P >.05). Conclusions: There appears to be independent benefits of metformin and regular physical activity on glucose control, but the impact of these two treatments are not necessarily additive. Based on this analyses, the benefit of physical activity on HbA1c levels in type 2 diabetes is likely more apparent in those not taking metformin, as compared to those who are. [ABSTRACT FROM AUTHOR]

Background: To investigate the prevalence of concomitant bacterial infection across common viral infections., Methods: This population-based cohort study included patients infected with influenza A and B (FLUA, FLUB) and respiratory syncytial virus (RSV) in Ontario between 2017 and 2019 and patients with SARS-CoV-2 between 2020 and 2021. Specific bacteria present in concomitant infections were identified. Concomitant infections were further classified into different categories (eg, coinfection -2 to +2 days from viral infection and secondary infection >2 days after viral infection). We used logistic regression models to estimate the odds of bacterial infections for FLUA, FLUB, and RSV relative to SARS-CoV-2 while adjusting for confounders., Results: A total of 4230 (0.5%, 885 004) viral cases had concomitant bacterial infections, encompassing 422 of FLUB (4.7%, 8891), 861 of FLUA (3.9%, 22 313), 428 of RSV (3.4%, 12 774), and 2519 of COVID-19 (0.3%, 841 026). The most prevalent species causing concomitant bacterial infection were Staphylococcus aureus , Streptococcus pyogenes , and Pseudomonas aeruginosa . When compared with SARS-CoV-2, the adjusted odds ratio for bacterial infection was 1.69 (95% CI, 1.48-1.93) for FLUA, 2.30 (95% CI, 1.97-2.69) for FLUB, and 1.56 (95% CI, 1.33-1.82) for RSV. The adjusted odds of coinfection in patients with SARS-CoV-2 were lower but higher for secondary infection as compared with the other viruses., Conclusions: A higher prevalence and risk of concomitant bacterial infection were found in FLUA, FLUB, and RSV as compared with SARS-CoV-2, although this is largely driven by coinfections. Ongoing surveillance efforts are needed to compare the risk of concomitant infections during periods when these viruses are cocirculating., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Introduction: We previously identified specific immigrant groups (West African and Caribbean) with increased incidence of prostate cancer in Ontario, Canada. In this population-level retrospective cohort study, we used administrative databases to compare stage of diagnosis, 5-year overall survival and prostate cancer-specific survival for immigrants versus long-term residents of Ontario., Methods: We linked several provincial-level databases available at ICES, an independent, non-profit research institute. We included all male Ontario residents 20-105 years of age who had an incident prostate cancer diagnosis date between March 31, 2008 and March 31, 2017, stratified into immigrants vs. long-term residents. We used multivariable logistic regression to determine the odds of early (stage I-II) vs. late (III-IV) stage of diagnosis, adjusting for age, co-morbidities, neighbourhood income and continuity of care. We produced Kaplan-Meier curves for 5-year overall survival and for 5-year prostate cancer-specific survival., Results: Compared to long-term residents, men from West Africa (adjusted odds ratio 1.66 [95% CI 1.16-2.38], East Africa (AOR 1.54 [95% CI 1.02-2.33]) and the Caribbean (AOR 1.22 [95% CI 1.01-1.47]) had a diagnostic stage advantage, and men from South Asia were most likely to be diagnosed at a late stage. In both unadjusted and adjusted analyses, overall and prostate cancer-specific survival were higher for immigrants than long-term residents. The highest five-year overall survival was seen for men from Sub-Saharan Africa and the Caribbean, and the lowest was seen for South Asian men, where 11.7% died within five years of diagnosis., Conclusion: Immigrant men in Ontario with prostate cancer are more likely to be diagnosed at an early stage and to survive for 5 years than long-term residents. Among immigrant men, men from the Caribbean and Sub-Saharan Africa have the greatest stage and survival advantage and South Asian men the least. Differences in awareness, diagnostic suspicion, genetic predisposition, and social factors may play a role in these findings., Competing Interests: Declaration of Competing Interest None, (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)