Credit Valley Hospital

Abstract Stemming biodiversity loss requires greater investment in conservation and more efficient use of available resources. Prioritizing conservation actions that yield the most biodiversity benefit for the least cost can help maximize return on investment. Actions that have co‐benefits for other objectives, such as climate change mitigation, can also help mobilize additional funds for conservation. We used Priority Threat Management to identify actions to secure the greatest number of species groups of conservation concern for the least cost in the Lake Simcoe‐Rideau ecoregion, Ontario—one of Canada's biodiversity crisis ecoregions. We also estimated the carbon sequestration benefits of actions related to land protection and restoration. We found that without additional investment in conservation, 13 of 16 species groups were expected to have <50% probability of persistence in this ecoregion by 2050. Implementing all proposed strategies would yield the greatest biodiversity benefits and secure 12 of the 16 species groups with ≥60% probability of persistence, at a cost of CA$113 million per year over 27 years. In comparison, investing CA$97 million per year in landowner stewardship, habitat protection and restoration and regeneration strategies could secure 10 species groups and improve the probability of persistence of one additional group from 39% to 55%. The habitat protection and restoration strategies also deliver direct carbon benefits of around 11.2 Mt in total avoided CO 2 emissions and 137.6 Mt CO 2 in total potential sequestration, respectively, over the long‐term, thus supporting alignment with climate change mitigation targets and delivering co‐benefits that may further justify investment. Practical implication. By estimating the costs and demonstrating the expected benefits and potential carbon co‐benefits of conservation actions, Priority Threat Management can help maximize return on investment and identify actions that address multiple environmental crises.

Given the limited data regarding three-dimensional clavicular/scapular/humeral rotations of pain-free shoulders in older adults, additional data is required for surgical planning and rehabilitation goal-setting in this population. This observational study aims to provide normative data regarding three-dimensional clavicular/scapular/humeral range required for daily activities in 45-75 year-old individuals. Three-dimensional clavicular/scapular/humeral joint ranges were simultaneously recorded using digitization methods. Descriptive statistics were quantified during six functional reaching positions (n = 40 shoulders) for 45-75 year-old participants. Clavicular/scapular/humeral rotations that contributed to the total angle of humeral elevation in flexion, abduction, and during hand-to-head reaching were calculated. Specific movement patterns were identified in each of the six reaching positions. Normative data for "clavicular elevation:scapular lateral rotation:humeral elevation" ratios were 1°:2°:9° (flexion), 1°:3°:10° (hand-to-head; scapular-plane humeral elevation), and 1°:3°:11° (abduction). Coronal plane clavicular/scapular/humeral rotations contributed to arm elevation height. Transverse plane rotations contributed to positioning the arm toward/away from midline. Sagittal plane clavicular/scapular/humeral rotations contributed to arm positioning in-front/behind the body and subacromial joint alignment. This normative data regarding simultaneous three-dimensional clavicular/scapular/humeral rotations during functional reach enables comparative analysis when evaluating shoulder pain/pathology in older adults.

Incorporating shared decision-making (SDM) with children and families in hospitals was a top priority identified by patients, caregivers, and clinicians. Bronchiolitis, a common and costly reason for hospitalization in children, is an exemplar condition to study SDM in hospitals. Internationally, clinical practice guidelines differ when recommending intravenous (IV or parenteral) or nasogastric (NG or enteral) fluids for hospitalized infants with bronchiolitis who are unsafe to be fed orally. While evidence indicates that either IV or NG fluids are safe and effective, parent involvement in SDM in selecting IV or NG fluids is unknown. Our aim is to generate knowledge of SDM with parents in choosing between IV or NG fluids and the benefits and harms of these two treatment options for hospitalized children with bronchiolitis. This is a multicenter, prospective, observational study, including children aged <12 months admitted to hospital with bronchiolitis requiring supplemental IV or NG fluids. The primary outcome will evaluate the extent of SDM in choosing IV versus NG fluids using the validated CollaboRATE tool. Secondary outcomes include the proportion of parents provided a choice of IV versus NG fluids; parent knowledge of fluid therapy; rate of fluids; length of hospital stay; and complications. This study will evaluate the extent of SDM in hospitalized infants with bronchiolitis who require IV or NG fluids and will evaluate both patient-centered and clinical outcomes that are relevant to clinical practice.

e21533 Background: Clinical trial evidence showed that anti-PD1 ± anti-CTLA4 as well as BRAF ± MEK-inhibitors for BRAF-mutated tumours dramatically improved outcomes for patients with advanced melanoma. Large prospective data sets provide real-world insight into the management of patients with advanced melanoma in routine practice. Methods: Patients ≥ 18 years with unresectable or metastatic melanoma receiving therapy with first- (1L) or second-line (2L) anti-PD1 alone (PD1), with anti-CTLA4 (C-IO) or combination BRAF- and MEK-inhibitors (C-TT) were enrolled in a multi-centre prospective observational study across Canada. Data was collected from May 1, 2016 to November 30, 2021 and entered into the Canadian Melanoma Research Network Registry to include demographics and clinical details. Each patient was followed until death, up to 3 years, or date of data extraction, whichever occurred first. Results: Data for 401 (1L) and 128 (2L) patients was analyzed. There was a significant difference in the age at diagnosis for PD1 (69.2y), C-IO (57.8y), and C-TT (58.8y) in the 1L cohort (p &lt; 0.0001) and 2L cohort (59.5y, 50.8y, and 50.9y respectively; p = 0.036). Patients treated with either C-IO or C-TT had a significantly higher baseline LDH (p = 0.0003) and proportion with brain metastases (p = 0.021) compared to PD1. The probability of survival for PD1, C-IO, and C-TT at 1 year was 0.85, 0.78, and 0.66; and at 3 years was 0.63, 0.54, and 0.36 respectively. The probability of survival for 2L PD1, C-IO, and C-TT at 1 year was 0.81, 0.53, and 0.56; and at 3 years was 0.55, 0.42, and 0.20 respectively. When comparing treatment regimens, the overall survival (OS) in 1L and 2L showed a superior survival for PD1 when compared with C-TT using a pairwise log-rank comparison (p &lt; 0.0001 and p = 0.0009). There was no difference between C-IO and C-TT, or C-IO and PD1 in 1L or 2L. Using a Cox proportional hazard model for OS, the presence of brain metastases was significant only in 1L (HR 1.663, p = 0.01). There was no difference in OS based on age in either 1L or 2L for all treatments. When comparing regimens, the progression-free survival (PFS) in 1L showed no difference using a pairwise log-rank comparison; however, there was a significant improvement in PFS in 2L for PD1 compared with C-TT (p = 0.0014). There was no difference in PFS between C-IO and C-TT, or C-IO and PD1 in 2L. Conclusions: This real-world data suggests that patient selection is key when deciding on the most appropriate treatment in 1L or 2L as PD1 therapy appeared to have superior OS and PFS across comparisons. Patients with high-risk features such as high LDH and the presence of brain metastases received C-IO or C-TT more often than PD1. Age was not associated with OS in 1L or 2L for each treatment.

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 &lt; 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&lt;0.001), in-hospital mortality (aOR=1.20 [1.14-1.26] p&lt;0.001), and 30 day re-admission rates (aOR=1.24 [1.14-1.35] p&lt;0.001) and were more likely to receive CTs (aOR=1.25 [1.21-1.30] p&lt;0.001), MRIs (aOR=1.36 [1.25-1.48] p&lt;0.001) and interventional procedures (aOR=1.36 [1.25-1.47] p&lt;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.

We compared experiences of patients who reported usually being seen by a resident with those usually seen by a staff physician. We analyzed responses to a patient experience survey distributed at 13 family medicine teaching practices affiliated with the University of Toronto between May and June 2020. We analyzed responses to seven questions pertaining to timely access, continuity, and patient-centeredness. We compared responses between two types of usual primary care clinicians and calculated odds ratios before and after adjustment for patient characteristics. We analyzed data from 6,545 unique surveys; 18.6% reported their usual clinician was a resident physician. Resident patients were more likely to be older, born outside of Canada, report a high school education or less, and report having difficulty making ends meet. Compared to patients of staff physicians, patients of resident physicians had lower odds of being able to see their preferred primary care clinician and lower odds of getting nonurgent care in a reasonable time. They also had lower odds of reporting patient-centered care, but we found no significant differences in whether the time for an urgent appointment was about right or whether accessing care after hours was easy. In our setting, patients who reported usually seeing resident physicians had worse continuity of care and timeliness for nonurgent care than patients who reported usually seeing staff physicians despite resident patients being older, sicker, and having a lower socioeconomic position. Postgraduate training programs need to test models to support access and continuity for resident patient panels.

&lt;p&gt;The purpose of this cross-sectional study is to assess the desire, need, perceptions, and knowledge of assisted reproductive technologies (ARTs) for women living with HIV (WLWHIV) and determine correlates of ART knowledge desire. WLWHIV of reproductive age were surveyed using the survey instrument "The HIV Pregnancy Planning Questionnaire" at HIV/AIDS service organizations across Ontario, Canada. Of our cohort of 500 WLWHIV, median age was 38, 88% were previously pregnant, 78% desired more information regarding ART, 59% were open to the idea of receiving ART, 39% felt they could access a sperm bank, and 17% had difficulties conceiving (self-reported). Age, African ethnicity, and residence in an urban center were correlated with desire for more ART information. Of participants, 50% wanted to speak to an obstetrician/gynecologist regarding pregnancy planning, and 74% regarded physicians as a main source of fertility service information. While the majority of participants in our cohort desire access to ART information, most do not perceive these services as readily accessible. Healthcare practitioners were viewed as main sources of information regarding fertility services and need to provide accurate information regarding access. Fertility service professionals need to be aware of the increasing demand for ART among WLWHIV.&lt;/p&gt;

&lt;p&gt;The purpose of this cross-sectional study is to assess the desire, need, perceptions, and knowledge of assisted reproductive technologies (ARTs) for women living with HIV (WLWHIV) and determine correlates of ART knowledge desire. WLWHIV of reproductive age were surveyed using the survey instrument "The HIV Pregnancy Planning Questionnaire" at HIV/AIDS service organizations across Ontario, Canada. Of our cohort of 500 WLWHIV, median age was 38, 88% were previously pregnant, 78% desired more information regarding ART, 59% were open to the idea of receiving ART, 39% felt they could access a sperm bank, and 17% had difficulties conceiving (self-reported). Age, African ethnicity, and residence in an urban center were correlated with desire for more ART information. Of participants, 50% wanted to speak to an obstetrician/gynecologist regarding pregnancy planning, and 74% regarded physicians as a main source of fertility service information. While the majority of participants in our cohort desire access to ART information, most do not perceive these services as readily accessible. Healthcare practitioners were viewed as main sources of information regarding fertility services and need to provide accurate information regarding access. Fertility service professionals need to be aware of the increasing demand for ART among WLWHIV.&lt;/p&gt;

Introduction: QTc interval prolongation is increasingly frequent as chronic kidney disease (CKD) advances and predicts death in dialysis. However, predictors and mortality risk in predialysis CKD are understudied. FGF23 induces left ventricular hypertrophy (LVH) which is associated with QTc interval prolongation and death, suggesting a possible pathway from FGF23 to death that entails LVH and QTc prolongation. We looked for links between FGF23 and prolonged QTc intervals mediated by LVH and for deaths associated with QTc prolongation in a prospective observational cohort of patients with predialysis CKD. Methods: Participants underwent protocolized baseline and semiannual FGF23 testing, baseline and study end echocardiograms, and baseline and annual electrocardiograms over 3 years. Results: A total of 2,254 participants (34.1% female; mean age: 68.7 years; mean glomerular filtration: rate 41.4 mL/min/m2) enrolled in the study. Baseline LVH (left ventricular mass index >131 g/m2 [>100 g/m2 if female]) was present in 10.8% and prolonged QTc intervals (≥500 ms) in 1.5% of participants. One hundred thirty-eight (6.1%) participants died during the study. In generalized mixed-effects regression, each unit increase in the natural log of FGF23 – but not LVH – predicted an odds ratio of 1.76 (1.15, 2.70, p = 0.009) for prolonged QTc intervals independently of 15 other covariates. Mediation analysis showed that only 13% of FGF23’s total effect on prolonged QTc intervals was mediated by LVH. Patients with prolonged QTc intervals had higher unadjusted (log rank p < 0.001) and adjusted (hazard ratio: 2.06 [1.08, 3.92, p = 0.028]) mortality rates than those with QTc intervals <500 ms. Discussion: QTc interval prolongation ≥500 ms was prospectively associated with FGF23 independently of LVH and with increased mortality risk in patients with predialysis CKD.