Prolonged Itraconazole Therapy as Sole Treatment for Patients with Allergic Fungal Rhinosinusitis.

BACKGROUND: Currently, the mainstay of treatment for allergic fungal rhinosinusitis (AFRS) is surgical debridement along with topical or systemic steroids. However, prolonged systemic steroid therapy comes with side effects and is also sometimes contraindicated. Systemic antifungals have been used earlier as an adjunct to steroids or in refractory cases, but they have not been used as the sole primary treatment. OBJECTIVE: To study the effectiveness of sole Itraconazole therapy in patients with AFRS by comparison of clinical, radiological, and biochemical parameters before and after treatment. METHODS: Thirty-four patients diagnosed with localized sino-nasal AFRS were recruited and started on the tablet Itraconazole 200 mg orally twice daily for 3 months with q2weekly monitoring of liver function tests. The baseline clinical, radiological, and biochemical parameters were then compared with those after completion of 3 months of Itraconazole therapy. RESULTS: There was significant difference between all the parameters-clinical: SNOT-22 score (p < 0.001) and Meltzer endoscopy score (p < 0.001), radiological: Lund-Mackay score (p = 0.004) and 20-point CT score (p = 0.002), and biochemical: serum total IgE (p < 0.001), Aspergillus-specific IgE (p < 0.001), and absolute eosinophil count (p < 0.001). The clearance of the disease was more in anterior sinuses than the posterior ones. CONCLUSION: Prolonged Itraconazole can be given as sole therapy in AFRS, especially in patients for whom steroids are contraindicated or in those who are awaiting surgery. It can result in symptomatic and radiological improvement, but surgery still remains the definitive treatment option for AFRS for complete clearance of disease. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:545-551, 2024.

Utilization of extended temporomandibular joint replacements in patients with hemifacial microsomia.

Hemifacial microsomia (HFM) patients may benefit from extended temporomandibular joint replacements (eTMJR) to improve function and quality of life. A cross-sectional survey was sent to surgeons who place alloplastic temporomandibular joints regarding their experience with and complications encountered when placing eTMJR in patients with HFM. Fifty-nine responded to the survey. Thirty-six (61.0%) reported treating patients with HFM and 30 (50.8%) of those reported placing an alloplastic temporomandibular joint (TMJ) prosthesis for patients with HFM. Twenty-three of the 30 surgeons (76.7%) placing alloplastic TMJ prostheses reported using an eTMJR in patients with HFM. The average maximum inter-incisal opening (MIO) after an eTMJR in HFM patients was repor ted as> 25 mm by 82.6% of the participants, and between 16 mm and 25 mm by 17.4%. No participants reported MIO < 15 mm. To avoid condylar sag and open bite changes postoperatively, over 70% reported using some form of modification to stabilize the occlusion. Respondents reported good functional outcomes for eTMJR in patients with HFM with relatively few complications. Therefore, eTMJR could be considered a viable option in the management of this patient population.

Predictability of the virtual surgical plan for orthognathic surgery with the mandible surgery first sequence.

The aim of this study was to compare the virtually planned position to the postoperative position of the maxilla, having performed the maxilla-first sequence or mandible-first sequence orthognathic surgery. An audit of 64 patients who underwent bimaxillary surgery between 2017 and 2020 was performed. Thirty patients had maxilla-first surgery and 34 had mandible-first surgery. The planned and post-surgical positions were analyzed using specific skeletal landmarks. Differences were calculated and the two-sample t-test was used to compare the groups. Measured differences between the planned and postoperative results differed significantly between the mandible-first and maxillary-first surgery groups (P < 0.001). The maxillary central incisors were under-advanced in the anterior-posterior direction in both groups. Most data points showed deviation from the surgical plan ≤ 2 mm and ≤ 4°. Secondarily, maxillary under-advancement in the mandible-first cohort was evaluated; these patients were subdivided into rigid and non-rigid fixation groups. The non-rigid fixation group showed less accuracy compared to the rigid fixation group, which was statistically significant (P = 0.014). The findings of this study demonstrate that virtual surgical planning can be less accurate in predicting the maxillary incisor position when performing mandible-first surgery, but this inaccuracy is within the acceptable range and can be mitigated by rigid fixation of the mandible.

Usefulness and effectiveness of community pharmacists-led mobile phone communication in identification and referral of presumptive tuberculosis cases in a selected district of Tamil Nadu.

BACKGROUND: Community pharmacists' usually are not able to be actively involved in the identification and referral of presumptive TB cases approaching their pharmacy for over-the-counter (OTC) drugs. The main barriers from their perspective were increased patient volume and work burden. Therefore, a new methodology was adopted by appointing an auxiliary pharmacist who will be actively involved in the identification and referral of presumptive TB cases. The present study aimed to assess the usefulness and effectiveness of community pharmacists-led mobile phone communication in identification and referral of presumptive tuberculosis cases in a selected district of Tamil Nadu. METHODS: A community intervention trial with pre and post-test comparison study was conducted among the community pharmacists in Tiruvallur district of Tamil Nadu. Knowledge about TB and referral practice of community pharmacists were captured and the same were taught to them. Details of the cases with the complaints of TB who came to the enrolled pharmacists for OTC drugs during the intervention period were collected by the community pharmacists and given to auxiliary pharmacist through WhatsApp. Auxiliary pharmacist called each patient and educated about TB and followed the patients. RESULTS: A total of 191 pharmacists were included in the study. 389 patients who approached pharmacy for OTC medications were suspected as TB by the community pharmacists based on their symptoms. 32 patients were not willing to give their details, while the details of others were collected by the community pharmacists and forwarded to auxiliary pharmacist through WhatsApp. 217 patients responded to phone calls made by the auxiliary pharmacist. Of them, 189 patients' health conditions were improved, while 28 patients suffered with symptoms and they had visited PHC and 2 patients were diagnosed as TB by clinician. CONCLUSION: Use of auxiliary pharmacist in collaboration with community pharmacists through phone communication is a useful and comfortable mode of collection of presumptive TB cases from the community pharmacies. Similarly, health education and follow-up of the presumptive cases via phone call is an effective way in the identification and referral of presumptive tuberculosis cases.

A Real-World Comparative Effectiveness Analysis of Thromboprophylactic Use of Enoxaparin Versus Unfractionated Heparin in Abdominal Surgery Patients in a Large U.S. Hospital Database.

Introduction: Little is known about outcomes associated with enoxaparin versus unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in abdominal surgery patients in U.S. clinical practice. The purpose of this study was to compare VTE, all-cause mortality, PE-related in-hospital mortality, and hospital costs during abdominal surgery hospitalization and the 90 days post-discharge between patients who received enoxaparin versus UFH prophylaxis. Materials and Methods: Using the Premier Healthcare Database, abdominal surgery patients who received at least 1 day of VTE prophylaxis with enoxaparin or UFH were identified between January 1, 2010 and September 30, 2016. Clinical outcomes were assessed using multivariable logistic regression models and cost outcomes were assessed using generalized linear models. Results: Of 363,669 patients identified, 59% received enoxaparin and 41% UFH. In adjusted analyses, there were statistically significant lower odds of VTE (OR 0.80; 95% CI 0.65-0.97), all-cause mortality (OR 0.67; 95% CI 0.60-0.75), and major bleeding (OR 0.88; 95% CI 0.82-0.94) during the hospitalization for enoxaparin versus UFH, but no differences during the 90-days post-discharge or for PE-related mortality. There was a statistically significant lower total hospital cost with enoxaparin versus UFH during index hospitalization ($8,913 vs $9,017, P < .0001), but not post-discharge ($3,342 vs $3,368, P = .42). Unadjusted rates of heparin-induced thrombocytopenia (index:0.1% vs 0.3%; post-discharge: 0.02% vs 0.06%) were reported for enoxaparin and UFH, respectively. Conclusion: In contemporary U.S. hospital practice, statistically significant lower odds of VTE, all-cause mortality and major bleeding with enoxaparin versus UFH prophylaxis were found during abdominal surgery hospitalizations.

Neutrophil to lymphocyte ratio as a prognostic marker for non-metastatic renal cell carcinoma - does it add to what we already know?

AIM: To study the correlation of pre-operative neutrophil to lymphocyte ratio (NLR) with pathological stage, Fuhrman grade, sarcomatoid differentiation, tumor necrosis and lymph node positivity and its prognostic role in non-metastatic renal cell carcinoma (non-mRCC). MATERIALS AND METHODS: This retro-prospective, observational study was done at a tertiary care center in Mumbai, India. All patients with non-mRCC from July 2015 to April 2018 were included. Patients with co-existing systemic infection, prior immunotherapy, and long-term steroids were excluded. NLR closest to surgery, but within one month prior to surgery was used. Patients were stratified as NLR ≥ 3.0 or < 3. NLR was correlated with known prognostic factors by Pearson's correlation. RESULTS: 113 patients, aged 18-81 years (83 males and 30 females) were included. 75% had clear cell RCC. 62% had stage 1 disease. 58% patients had Fuhrman Grade 2. 10 patients had lymph node metastasis, 6 had sarcomatoid differentiation, 40 had tumor necrosis. The NLR was < 3 in 72 patients. Statistically significant correlation between NLR and tumor stage (p = 0.0054) as well as NLR and tumor necrosis (p = 0.0128) was shown. CONCLUSIONS: NLR correlates significantly with higher T stage and tumor necrosis. NLR may be integrated with well-established prognostic markers to improve the accuracy of prognostic scores.

DEVELOPING twin-specific 75-g oral glucose tolerance test diagnostic thresholds for gestational diabetes based on the risk of future maternal diabetes: a population-based cohort study.

OBJECTIVE: To develop twin-specific outcome-based oral glucose tolerance test (OGTT) diagnostic thresholds for GDM based on the risk of future maternal type-2 diabetes. DESIGN: A population-based retrospective cohort study (2007-2017). SETTING: Ontario, Canada. METHODS: Nulliparous women with a live singleton (n = 55 361) or twin (n = 1308) birth who underwent testing for gestational diabetes mellitus (GDM) using a 75-g OGTT in Ontario, Canada (2007-2017). We identified the 75-g OGTT thresholds in twin pregnancies that were associated with similar incidence rates of future type-2 diabetes to those associated with the standard OGTT thresholds in singleton pregnancies. RESULTS: For any given 75-g OGTT value, the incidence rate of future maternal type-2 diabetes was lower for women with a twin than women with a singleton pregnancy. Using women with a negative OGTT as reference, the risk of future maternal type-2 diabetes in twin pregnancies with a positive OGTT based on the standard OGTT thresholds (9.86 per 1000 person years, adjusted hazard ratio (aHR) 4.79, 95% CI 2.69-8.51) was lower than for singleton pregnancies with a positive OGTT (18.74 per 1000 person years, aHR 8.22, 95% CI 7.38-9.16). The twin-specific OGTT fasting, 1-hour and 2-hour thresholds identified in the current study based on correlation with future maternal type-2 diabetes were 5.8 mmol/l (104 mg/dl), 11.8 mmol/l (213 mg/dl) and 10.4 mmol/l (187 mg/dl), respectively. CONCLUSIONS: We identified potential twin-specific OGTT thresholds for GDM that are associated with a similar risk of future type-2 diabetes to that observed in women diagnosed with GDM in singleton pregnancies based on standard OGTT thresholds. TWEETABLE ABSTRACT: Potential twin-specific OGTT thresholds for GDM were identified.

MRI-Based Deep-Learning Method for Determining Glioma MGMT Promoter Methylation Status.

BACKGROUND AND PURPOSE: O6-Methylguanine-DNA methyltransferase (MGMT) promoter methylation confers an improved prognosis and treatment response in gliomas. We developed a deep learning network for determining MGMT promoter methylation status using T2 weighted Images (T2WI) only. MATERIALS AND METHODS: Brain MR imaging and corresponding genomic information were obtained for 247 subjects from The Cancer Imaging Archive and The Cancer Genome Atlas. One hundred sixty-three subjects had a methylated MGMT promoter. A T2WI-only network (MGMT-net) was developed to determine MGMT promoter methylation status and simultaneous single-label tumor segmentation. The network was trained using 3D-dense-UNets. Three-fold cross-validation was performed to generalize the performance of the networks. Dice scores were computed to determine tumor-segmentation accuracy. RESULTS: The MGMT-net demonstrated a mean cross-validation accuracy of 94.73% across the 3 folds (95.12%, 93.98%, and 95.12%, [SD, 0.66%]) in predicting MGMT methylation status with a sensitivity and specificity of 96.31% [SD, 0.04%] and 91.66% [SD, 2.06%], respectively, and a mean area under the curve of 0.93 [SD, 0.01]. The whole tumor-segmentation mean Dice score was 0.82 [SD, 0.008]. CONCLUSIONS: We demonstrate high classification accuracy in predicting MGMT promoter methylation status using only T2WI. Our network surpasses the sensitivity, specificity, and accuracy of histologic and molecular methods. This result represents an important milestone toward using MR imaging to predict prognosis and treatment response.

Formulation and characterization of zein/chitosan complex particles stabilized Pickering emulsion with the encapsulation and delivery of vitamin D3.

BACKGROUND: Pickering emulsions (PEs) which are stabilized by solid particles instead of surfactants have recently attracted tremendous attentions due to their non-toxic and long-term stable nature. In the current study, we fabricated and characterized zein (ZN)/chitosan (CS) complex particles (ZNCSPs) stabilized PE for the encapsulation and delivery of vitamin D3 . RESULTS: The ZNCSPs were synthesized with different ratios, i.e. 1:1, 1:1.5 and 1:2 to investigate the optimum ratio. Transmission electron microscopy observations showed the spherical nature with smooth surface of the obtained particles in the case of ZNCS ratio 1:1.5 and 1:2. Furthermore, ζ-potential values for the these particles were 32.53 ± 1.3 and 52.86 ± 0.68 mV respectively, indicating particles with (1:2) being more stable than 1:1.5. Thereafter, using these particles, the PEs were successfully formulated with different oil (medium chain triglyceride) fractions (330, 500 and 660 g kg-1 ). The emulsions were evaluated for stability during storage and against different environmental factors including pH, temperature and ionic strength on the creaming indices (CIs) of these emulsions. The results demonstrated that the PEs with oil fractions 330 and 500 g kg-1 exhibited significant stability during storage, particularly the ones with 500 g kg-1 oil fractions which were stable against all the tested parameters. Finally, the prepared PEs were evaluated as efficient delivery system by encapsulating and delivering vitamin D3 . In vitro drug release profile confirmed sustained and controlled release of the encapsulated vitamin D3 . CONCLUSION: Overall, our findings suggest that ZNCSPs can be promising stabilizers for stable PEs that can be used as potential delivery systems in food, cosmetic and pharmaceutical industries. © 2021 Society of Chemical Industry.

Data and debriefing observations on healthcare simulation to prepare for the COVID-19 pandemic.

We report on data and debriefing observations in the context of an immersive simulation conducted to (a) train clinicians and (b) test new protocols and kits, developed in table-top exercises without prior clinical experience to fit anticipated clinical encounters in the setting of the rapidly expanding COVID-19 pandemic. We simulated scenarios with particular relevance for anesthesiology, perioperative and critical care, including (1) cardiac arrest, (2) emergency airway management, (3) tele-instruction for remote guidance and supervision, and (4) transporting an intubated patient. Using a grounded theory approach, three authors (MHA, DLR, EHS) developed emergent themes. First alone and then together, we sought consensus in uncovering overarching themes and constructs from the debriefings. We thus performed an informal qualitative thematic analysis based in a critical realist epistemological position - the understanding that our findings, while real, are affected by situational variables and the observer's perspective[1,2]. We compared data from videos and triangulated the data by member checking. All participants and course instructors volunteered to participate in this educational project and contributed as co-authors to this manuscript. During debriefing, we applied crisis resource management concepts including situation awareness, prioritization of tasks, and clear communication practices, conducting the debriefing with emphasis on current TeamStepps 2.0 terminology and concepts. [3,4] In addition, we re-evaluated formerly familiar processes, as shortcomings of protocols, kits, and interdisciplinary cooperation became apparent. The data provide detailed observations on how immersive simulation and debriefing among peers mitigated the unfamiliarity of individual clinicians and the organization at large with the demands of an unprecedented healthcare crisis. We also observed and report on the anxiety caused by resource constraints, risk to clinicians in the face of limited personal equipment, and the overall uncertainty surrounding COVID-19. We began to summarize, interpret, critique, and discuss our data and debriefing observations in a rapid co-publication in the Journal of Clinical Anesthesia. [Healthcare Simulation to Prepare for the COVID-19 Pandemic][5].

Prevalence and Incidence of Microhemorrhages in Adolescent Football Players.

BACKGROUND AND PURPOSE: SWI is an advanced imaging modality that is especially useful in cerebral microhemorrhage detection. Such microhemorrhages have been identified in adult contact sport athletes, and the sequelae of these focal bleeds are thought to contribute to neurodegeneration. The purpose of this study was to utilize SWI to determine whether the prevalence and incidence of microhemorrhages in adolescent football players are significantly greater than those of adolescent noncontact athletes. MATERIALS AND METHODS: Preseason and postseason SWI was performed and evaluated on 78 adolescent football players. SWI was also performed on 27 adolescent athletes who reported no contact sport history. Two separate one-tailed Fisher exact tests were performed to determine whether the prevalence and incidence of microhemorrhages in adolescent football players are greater than those of noncontact athlete controls. RESULTS: Microhemorrhages were observed in 12 football players. No microhemorrhages were observed in any controls. Adolescent football players demonstrated a significantly greater prevalence of microhemorrhages than adolescent noncontact controls (P = .02). Although 2 football players developed new microhemorrhages during the season, microhemorrhage incidence during 1 football season was not statistically greater in the football population than in noncontact control athletes (P = .55). CONCLUSIONS: Adolescent football players have a greater prevalence of microhemorrhages compared with adolescent athletes who have never engaged in contact sports. While microhemorrhage incidence during 1 season is not significantly greater in adolescent football players compared to adolescent controls, there is a temporal association between playing football and the appearance of new microhemorrhages.

Post-Traumatic Stress Disorder (Ptsd) Following Burn Injuries: A Comprehensive Clinical Review.

Burns are a global public health problem with a large number of psychosocial and psychological problems that may ensue after burn injuries. One of the commonest psychological problems seen after burn injuries is depression, anxiety and post-traumatic stress disorder (PTSD). The following paper reviews the existing literature on PTSD following burn injuries. The concept of PTSD is explained for the non-psychiatrist involved in burn rehabilitation. The various psychosocial factors that determine the causation and course of PTSD following burn injuries are discussed. PTSD following burn injuries in special populations like women, children and adolescents, intentional burns and self immolation are also discussed. The role of cultural factors in the development of PTSD are elucidated and future research needs are laid out. PTSD is a very common occurrence after burn injuries and needs a multidisciplinary team evaluation for its management.

Les brûlures représentent un problème de santé publique mondial, avec un nombre élevé de séquelles psychologiques et psycho- sociales, les plus fréquentes étant l'anxiété et le SPT. Nous avons réalisé une revue de la littérature concernant le SPT, afin de l'expliquer aux brûlologues non psychiatres. Nous avons évalué les facteurs psycho- sociaux pouvant interférer avec la survenue et l'évolution du SPT ainsi que les rôles du terrain (femmes, enfants, adolescents) comme de la cause (agression, tentative de suicide). Les facteurs culturels ont aussi été étudiés. Des axes d'études futures sont proposés. Le SPT est fréquent après brûlure et doit faire l'objet d'une prise en charge multidisciplinaire.

Perinatal outcomes for untreated women with gestational diabetes by IADPSG criteria: a population-based study.

OBJECTIVE: To estimate the risk for adverse perinatal outcomes for women who met the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria but not the two-step criteria for gestational diabetes mellitus (GDM). DESIGN: Population-level cross-sectional study. SETTING: Ontario, Canada. POPULATION: A total of 90 140 women who underwent a 75-g oral glucose tolerance test. METHODS: Women were divided into those who met the diagnostic thresholds for GDM by two-step criteria and were therefore treated, those who met only the IADPSG criteria for GDM and so were not treated, and those who did not have GDM by either criteria. MAIN OUTCOME MEASURES: Hypertensive disorders of pregnancy, preterm delivery, primary caesarean section, large-for-gestational-age, shoulder dystocia and neonatal intensive care unit admission. RESULTS: Women who met the IADPSG criteria had an increased risk for all adverse perinatal outcomes compared with women who did not have GDM. Women with GDM by two-step criteria also had an increased risk of most outcomes. However, their risk for large-for-gestational-age neonates and for shoulder dystocia was actually lower than that of women who met IADPSG criteria. CONCLUSION: Women who met IADPSG criteria but who were not diagnosed with GDM based on the current two-step diagnostic strategy, and were therefore not treated, had an increased risk for adverse perinatal outcomes compared with women who do not have GDM. The current strategy for diagnosing GDM may be leaving women who are at risk for adverse events without the dietary and pharmacological treatments that could improve their pregnancy outcomes. TWEETABLE ABSTRACT: Women who meet IADPSG criteria for GDM have an increased risk for adverse perinatal outcomes compared with women without GDM.

Universal drug coverage and income-related disparities in glycaemic control.

AIMS: To examine whether income-related disparities in glycaemic control decline after the age of 65 years, when publicly funded universal drug insurance is acquired in Ontario, Canada. METHODS: We conducted a population-based cross-sectional study using linked administrative healthcare databases. Adults with diabetes, aged 40-89 years, with available HbA1c data were included (N = 716 297). Income was based on median neighbourhood household income. Multiple linear regression was used to test for effect modification of age ≥65 years on the relationship between income and HbA1c . RESULTS: There was a significant inverse association between income and HbA1c level. After adjusting for baseline factors, the effect of income on HbA1c level was significantly greater for individuals aged <65 years (mean difference HbA1c for lowest vs highest income group +2.5 mmol/mol, 95% CI +2.3 to +2.7 [+0.23%, 95% CI 0.21 to 0.24]) than for those aged ≥65 years (+1.2 mmol/mol, 95% CI +1.0 to +1.3 [+0.11%, 95% CI 0.10 to 0.12]; P < 0.0001 for interaction). CONCLUSIONS: Despite universal access to healthcare, people with diabetes with lower incomes had significantly worse glycaemic control compared with their counterparts on higher incomes. However, income gradients in glycaemic control were markedly reduced after the age of 65 years, possibly as a result of access to prescription drug coverage.

Diagnostic and therapeutic utility of indigenous technique of pleuroscopy in undiagnosed cases of exudative pleural effusions

Background and aims: In developing countries, there is a shortage of resources and skilled manpower and a large num-ber of patients. To overcome these problems, an indigenous technique of pleuroscopy has been developed in our institute. In this technique, medical thoracoscopy is done by using a set of patented conduits and a fibre-optic bronchoscope. In this study, we describe our experience with this technique of pleu-roscopy in undiagnosed cases of exudative pleural effusion. Methods: 156 undiagnosed cases of exudative pleural effu-sion were conducted over a period of two and half years. Indigenous technique of pleuroscopy, permitted thorough exploration of the pleural space, permitting multiple biopsies to clinch the diagnosis. Results: The appearance of pleura showed as inflamed/red-dened pleura in 29 (18.6%) cases, thin transparent adhesions in 31 (19.9%), thin transparent loculations in 26 (16.7%) , thick loculations in 12 (7.7%) , hard pleural surface in 11 (7%), large nodules/masses in 13 (8.4%), small milliary seedlings or sago grain appearance in 18 (11.5%), scattered masses or nodules in 13 (8.4%) and broncho-pleural fistula in 3 (1.9%) cases. Histopathological analysis showed chronic inflammation in 40.8% (58), Tubercular lesions in 25.4 % (36) of patients. There were three cases each of Primary Aspergillosis and malig-nant mesothelioma, and the rest 26.9% (42) were malignant metastasis in the pleura. The diagnostic yield of pleuroscopy pleural biopsy was 91% (142). Follow-up chest x-rays after six months showed significant reduction in residual pleural thickening (RPT).Conclusion: TheIndigenous Pleuroscopy technique is an efficient procedure and has good diagnostic and therapeutic yield for undiagnosed exudative pleural effusions. It also reduces morbidity, complications, disease progression, and has a significant role in reduction of RPT

Diabetes transition care and adverse events: a population-based cohort study in Ontario, Canada.

AIMS: To describe patterns of primary and diabetes care during transition age (17 to < 19 years) into early adulthood (age 19 to 26 years), and to evaluate the association of primary and diabetes care patterns during transition age with the risk of adverse events in early adulthood. METHODS: We conducted a population-based cohort study of individuals in Ontario, Canada who were diagnosed with diabetes aged < 15 years and who turned 17 between November 2006 and March 2011, followed until March 2015 (n = 2525). Using linked administrative databases, we examined healthcare use during: 'pre-transition-age' (15 to < 17 years), 'transition-age' (17 to < 19 years), and 'early adulthood' (19 to 26 years). The main outcomes were time to death or ketoacidosis and rate of diabetes-related admissions. The main exposures were the gap in diabetes care and primary care visits during transition age. RESULTS: There were < 6 deaths and 446 individuals (17.7%) had at least one admission for ketoacidosis during early adulthood. In all, 1188 individuals (47.0%) had a > 12-month gap in diabetes care and 241 (9.5%) had no primary care visits during transition age. A gap in diabetes care of > 12 months and no primary care visits during transition age were associated with an increased risk of ketoacidosis or death (adjusted hazard ratio 1.31, 95% CI 1.04-1.66 and adjusted hazard ratio 1.42, 95% CI 1.02-1.97, respectively). CONCLUSIONS: In Ontario, Canada, where physician and hospital-based services are universally covered, a high proportion of young adults with diabetes have insufficient care during transition age and this is associated with a higher risk of important adverse outcomes in early adulthood. Ensuring primary care involvement during transition may be a strategy to reduce morbidity.

Mental health visits and low socio-economic status in adolescence are associated with complications of Type 1 diabetes in early adulthood: a population-based cohort study.

AIM: To determine the association of mental health visits and socio-economic status in late adolescence with the risk of mortality and acute and chronic diabetes complications in early adulthood. METHODS: We conducted a population-based cohort study of individuals in Ontario, Canada, who had their 20th birthday between January 1999 and March 2015 and a diagnosis of diabetes prior to their 15th birthday, using linked administrative databases (n=8491). The main outcome was death; other outcomes were hypoglycaemia or hyperglycaemia-related hospitalizations and emergency department visits and chronic diabetes complications (dialysis, ophthalmological and macrovascular complications). RESULTS: Over the course of 59 361 person-years there were 127 deaths.. Low socio-economic status and mental health visits were both associated with a higher risk of death [hazard ratio 2.03, (95% CI 1.13 to 3.64) and 2.45 (95% CI 1.71 to 3.51), respectively]. Those with the lowest socio-economic status and a mental health visit had a higher rate of diabetes-related hospitalizations (rate ratio 4.84, 95% CI 3.64 to 6.44) and emergency department visits (rate ratio 3.15, 95% CI 1.79 to 5.54). Low socio-economic status and mental health visits were both associated with an increased risk of any chronic complication [hazard ratio 1.54 (95% CI 1.21 to 1.96) and 1.57 (95% CI 1.35 to 1.81), respectively]. CONCLUSION: We identified significant socio-economic and mental health disparities in the risk of death and acute and chronic complications in early adulthood for people with childhood-onset diabetes. Targeted interventions to prevent adverse events for these adolescents at highest risk should be evaluated.

Differences in prevalence of diabetes among immigrants to Canada from South Asian countries.

AIMS: The prevalence of diabetes is high in South Asians migrants. However, most previous research has studied South Asians as a collective whole. The aim of this study was to examine diabetes prevalence among immigrants from five South Asian countries living in Ontario, Canada. METHODS: Population-based health care and immigration databases were used to compare crude and adjusted diabetes prevalence on 1 January 2012 between immigrants to Ontario from different South Asians countries and the non-immigrant population. The prevalence of diabetes was also stratified by various sociodemographic factors. RESULTS: There were 431 765 first-generation South Asian immigrants; 68 440 (crude prevalence of 15.9%) of whom had a diagnosis of diabetes. After standardization for age, sex and income, diabetes prevalence was highest among South Asians from Sri Lanka (26.8%) followed by Bangladesh (22.2%), Pakistan (19.6%), India (18.3%) and Nepal (16.5%) in comparison with the non-immigrant population (11.6%). Increased prevalence was evident among men compared with women in each country of South Asia. Sociodemographic indicators including income, education, English proficiency and refugee status were associated with increased prevalence of diabetes in specific populations from South Asia. CONCLUSION: Striking differences in the prevalence of diabetes are evident among immigrants from different countries of South Asia. Awareness of the heterogeneity will help in recognizing priorities for the delivery of primary care for specific South Asian migrant populations with a range of settlement needs that also encompass social determinants of health.

Smoking, Pain Intensity, and Opioid Consumption 1-3 Months After Major Surgery: A Retrospective Study in a Hospital-Based Transitional Pain Service.

Introduction: The present study investigated the associations between smoking, pain, and opioid consumption in the 3 months after major surgery in patients seen by the Transitional Pain Service. Current smoking status and lifetime pack-years were expected to be related to higher pain intensity, more opioid use, and poorer opioid weaning after surgery. Methods: A total of 239 patients reported smoking status in their presurgical assessment (62 smokers, 92 past smokers, and 85 never smokers). Pain and daily opioid use were assessed in hospital before postsurgical discharge, at first outpatient visit (median of 1 month postsurgery), and at last outpatient visit (median of 3 months postsurgery). Pain was measured using numeric rating scale. Morphine equivalent daily opioid doses were calculated for each patient. Results: Current smokers reported significantly higher pain intensity (p < .05) at 1 month postsurgery than never smokers and past smokers. Decline in opioid consumption differed significantly by smoking status, with both current and past smokers reporting a less than expected decline in daily opioid consumption (p < .05) at 3 months. Decline in opioid consumption was also related to pack-years, with those reporting higher pack-years having a less than expected decline in daily opioid consumption at 3 months (p < .05). Conclusions: Smoking status may be an important modifiable risk factor for pain intensity and opioid use after surgery. Implications: In a population with complex postsurgical pain, smoking was associated with greater pain intensity at 1 month after major surgery and less opioid weaning 3 months after surgery. Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.