Introduction: This study compared societal costs of care between two settings of palliative care delivery and death (home versus hospital) in an integrated palliative care program in Toronto. Methods: 186 terminal cancer patients participated in the study. Total societal cost of end-of-life care was compared between patients who died in the home and patients who died in the hospital. Total societal cost of end-of-life care was modeled as a function of the number of days the patients spent at home during the palliative trajectory. Results: There was no statistically significant difference in total cost of end-of-life care between home death and hospital death patients (p>0.05). Furthermore, an additional day the patient spent at home led to a significant increase in the total cost of end-of-life care (p<0.05). Conclusion: The results demonstrated that from a societal perspective, providing palliative care under an integrated palliative care program at home may be just as expensive (if not more expensive) as caring for them in the hospital.

Athlete-centred coaching is proposed to enhance performance (Lyle, 2002), develop life skills (Kidman &amp; Lombardo, 2010), and prevent athlete maltreatment (Kerr &amp; Stirling, 2008). Despite the consistent recommendation, very little is known empirically about athlete-centred coaching, the extent to which it is implemented, or athletes&rsquo; experiences with this style of coaching. The purpose of this study therefore was to examine recently retired elite athletes&rsquo; perspectives on their most athlete-centred coach. Semi-structured interviews were conducted with eight male and female recently retired Olympians. The findings of this study provided mixed evidence for coaching behaviours characterized as athlete-centred coaching as defined within the literature. Specifically, at least half of the coaches did not use stimulating questions, one of the most central athlete-centred tenets. Explanations for the mixed findings are discussed and a continuum of athlete-centred coaching is proposed. Lastly, suggestions for future research and practical implications are presented.

Introduction: This study compared societal costs of care between two settings of palliative care delivery and death (home versus hospital) in an integrated palliative care program in Toronto. Methods: 186 terminal cancer patients participated in the study. Total societal cost of end-of-life care was compared between patients who died in the home and patients who died in the hospital. Total societal cost of end-of-life care was modeled as a function of the number of days the patients spent at home during the palliative trajectory. Results: There was no statistically significant difference in total cost of end-of-life care between home death and hospital death patients (p>0.05). Furthermore, an additional day the patient spent at home led to a significant increase in the total cost of end-of-life care (p<0.05). Conclusion: The results demonstrated that from a societal perspective, providing palliative care under an integrated palliative care program at home may be just as expensive (if not more expensive) as caring for them in the hospital.

Background: Ethnic and immigrant groups represent a large and growing segment of the Canadian population, however, little is known about how these groups differ in their cardiovascular risk factor profiles when compared to the White population. This thesis describes three large, population-based studies examining cardiovascular risk among people of White, South Asian, Chinese and Black ethnicity living in Ontario. It was hypothesized that ethnic groups would differ significantly in their cardiovascular risk factor profiles. Methods: The study population included 154 653 White, 3364 South Asian, 3038 Chinese, and 2742 Black subjects derived from Statistics Canada’s National Population Health Survey and Canadian Community Health Surveys. In Project 1, the age- and sex-standardized prevalence of cardiovascular risk factors, heart disease, and stroke were compared across the four ethnic groups. In Project 2, the degree to which cardiovascular risk factor profiles differed between recent immigrants and long-term residents was compared across ethnic groups. In Project 3, a subsample of the study population was used to compare the ethnic-specific incidence and age at diagnosis of diabetes. We also derived ethnically appropriate body-mass index (BMI) cutoff values for obesity for assessing diabetes risk. Results: Ethnic groups living in Ontario differ strikingly in their cardiovascular risk profiles. The Chinese group had the most favourable cardiovascular risk factor profile, with 4.3% of the population reporting ≥2 major cardiovascular risk factors (i.e., smoking, obesity, diabetes, hypertension), followed by the South Asian (7.9%), White (10.1%) and Black (11.1%) groups. For all ethnic groups, cardiovascular risk factor profiles were worse among those with longer duration of residency in Canada. Nonwhite subjects developed diabetes at a higher rate, at an earlier age, and at lower ranges of BMI than White subjects. For the equivalent incidence rate of diabetes at a BMI of 30 in White subjects, the BMI cutoff value was 24, 25, and 26 in South Asian, Chinese, and Black subjects, respectively. Interpretation: These findings highlight the need for designing ethnically tailored cardiovascular disease prevention strategies and for lowering current targets for ideal body weight for nonwhite populations.

Background: Ethnic and immigrant groups represent a large and growing segment of the Canadian population, however, little is known about how these groups differ in their cardiovascular risk factor profiles when compared to the White population. This thesis describes three large, population-based studies examining cardiovascular risk among people of White, South Asian, Chinese and Black ethnicity living in Ontario. It was hypothesized that ethnic groups would differ significantly in their cardiovascular risk factor profiles. Methods: The study population included 154 653 White, 3364 South Asian, 3038 Chinese, and 2742 Black subjects derived from Statistics Canada’s National Population Health Survey and Canadian Community Health Surveys. In Project 1, the age- and sex-standardized prevalence of cardiovascular risk factors, heart disease, and stroke were compared across the four ethnic groups. In Project 2, the degree to which cardiovascular risk factor profiles differed between recent immigrants and long-term residents was compared across ethnic groups. In Project 3, a subsample of the study population was used to compare the ethnic-specific incidence and age at diagnosis of diabetes. We also derived ethnically appropriate body-mass index (BMI) cutoff values for obesity for assessing diabetes risk. Results: Ethnic groups living in Ontario differ strikingly in their cardiovascular risk profiles. The Chinese group had the most favourable cardiovascular risk factor profile, with 4.3% of the population reporting ≥2 major cardiovascular risk factors (i.e., smoking, obesity, diabetes, hypertension), followed by the South Asian (7.9%), White (10.1%) and Black (11.1%) groups. For all ethnic groups, cardiovascular risk factor profiles were worse among those with longer duration of residency in Canada. Nonwhite subjects developed diabetes at a higher rate, at an earlier age, and at lower ranges of BMI than White subjects. For the equivalent incidence rate of diabetes at a BMI of 30 in White subjects, the BMI cutoff value was 24, 25, and 26 in South Asian, Chinese, and Black subjects, respectively. Interpretation: These findings highlight the need for designing ethnically tailored cardiovascular disease prevention strategies and for lowering current targets for ideal body weight for nonwhite populations.

The influence of estrogen deficiency in physically active women with functional hypothalamic amenorrhea (ExFHA) on cardiovascular regulation is unknown. Three mechanistic studies compared cardiovascular responses to exercise and orthostatic stress in ExFHA women with responses in physically active (ExOv) and sedentary (SedOv) eumenorrheic ovulatory women. Measures included calf blood flow (BF), brachial artery (BA) endothelial dependent and independent function, shear rate (SR), vascular resistance (VR), blood pressure (BP), heart rate (HR), HR variability (HRV), muscle sympathetic nervous activity (MSNA), and serum renin-angiotensin-aldosterone system (RAAS) components. Study one examined the effects of a single bout of dynamic exercise on vascular function in ExFHA (n=12), ExOv (n=14), and SedOv (n=15) women. Pre-exercise, calf BF and BA endothelium-dependent flow-mediated vasodilation (FMD%) were lower (p<0.05) in ExFHA versus ovulatory women in association with higher (p<0.05) calf VR and lower (p<0.05) SR, respectively. Endothelium-independent vasodilation, assessed at baseline only, was also lower (p<0.05) in ExFHA. Post-exercise, calf BF was increased and VR decreased (p<0.05) in ExFHA women, similar (p>0.05) to that observed in ovulatory women. FMD% and SR were augmented (p<0.05) post-exercise, but both remained lower (p<0.05) in ExFHA versus ovulatory women (p<0.05). Study two investigated neurohumoral (MSNA and RAAS) BP regulation during orthostatic stress in ExFHA (n=12) and ExOv (n=17) women. Baseline systolic BP was lower (p<0.05) in ExFHA versus ExOv. Neurohumoral measures did not differ (p>0.05) between the groups at baseline. However, during hypotensive stimuli, MSNA increased to a greater extent (p<0.05), yet angiotensin II and renin were not activated in ExFHA women. Study three examined autonomic control of HR during orthostatic stress in ExFHA (n=11), ExOv (n=17), and SedOv (n=17) women. Lower HR (p<0.05) at rest and during orthostatic stress in ExFHA was associated with markedly elevated (p<0.05) HRV due to higher (p<0.05) parasympathetic modulation. Sympathetic modulation did not differ (p>0.05) between the groups. These studies indicate altered cardiovascular regulation in otherwise healthy ExFHA women. The influence of estrogen deficiency per se in these alterations are not clear, but in light of the etiology of amenorrhea, it is likely that complex interactions between estrogen and energy deficiency and exercise training are involved.

The influence of estrogen deficiency in physically active women with functional hypothalamic amenorrhea (ExFHA) on cardiovascular regulation is unknown. Three mechanistic studies compared cardiovascular responses to exercise and orthostatic stress in ExFHA women with responses in physically active (ExOv) and sedentary (SedOv) eumenorrheic ovulatory women. Measures included calf blood flow (BF), brachial artery (BA) endothelial dependent and independent function, shear rate (SR), vascular resistance (VR), blood pressure (BP), heart rate (HR), HR variability (HRV), muscle sympathetic nervous activity (MSNA), and serum renin-angiotensin-aldosterone system (RAAS) components. Study one examined the effects of a single bout of dynamic exercise on vascular function in ExFHA (n=12), ExOv (n=14), and SedOv (n=15) women. Pre-exercise, calf BF and BA endothelium-dependent flow-mediated vasodilation (FMD%) were lower (p<0.05) in ExFHA versus ovulatory women in association with higher (p<0.05) calf VR and lower (p<0.05) SR, respectively. Endothelium-independent vasodilation, assessed at baseline only, was also lower (p<0.05) in ExFHA. Post-exercise, calf BF was increased and VR decreased (p<0.05) in ExFHA women, similar (p>0.05) to that observed in ovulatory women. FMD% and SR were augmented (p<0.05) post-exercise, but both remained lower (p<0.05) in ExFHA versus ovulatory women (p<0.05). Study two investigated neurohumoral (MSNA and RAAS) BP regulation during orthostatic stress in ExFHA (n=12) and ExOv (n=17) women. Baseline systolic BP was lower (p<0.05) in ExFHA versus ExOv. Neurohumoral measures did not differ (p>0.05) between the groups at baseline. However, during hypotensive stimuli, MSNA increased to a greater extent (p<0.05), yet angiotensin II and renin were not activated in ExFHA women. Study three examined autonomic control of HR during orthostatic stress in ExFHA (n=11), ExOv (n=17), and SedOv (n=17) women. Lower HR (p<0.05) at rest and during orthostatic stress in ExFHA was associated with markedly elevated (p<0.05) HRV due to higher (p<0.05) parasympathetic modulation. Sympathetic modulation did not differ (p>0.05) between the groups. These studies indicate altered cardiovascular regulation in otherwise healthy ExFHA women. The influence of estrogen deficiency per se in these alterations are not clear, but in light of the etiology of amenorrhea, it is likely that complex interactions between estrogen and energy deficiency and exercise training are involved.

Objectives: To estimate the incremental cost per QALY in patients with Parkinson’s Disease (PD) with varying disease severity and to ascertain which patient subgroup would accrue the greatest net monetary benefits to Ontario’s public health perspective as a result of Deep Brain Stimulation (DBS). Design: A cost-utility study and a net monetary benefit framework approach were applied to 37 PD patients with varying disease stages who underwent DBS treatment. Results: DBS resulted in cost savings of $2,686.3, $2,752.4, and $7348.4 and QALY gains of 0.33, 0.09 and 0.04 in patients with mild, moderate and severe PD. The ICER was $16,076.2/QALY. At $50,000/QALY, the greatest net monetary benefits accrued to Ontario’s MOHLTC were from treating patients with mild PD with DBS. Conclusions: DBS surgery was found to be a cost-effective PD treatment compared to pharmacotherapy. The greatest net monetary benefits were from treating patients with mild PD severity.

Non-alcoholic fatty liver disease (NAFLD) includes simple hepatic steatosis (SS) and non-alcoholic steatohepatitis (NASH). NAFLD is tightly linked to obesity and is thought to be secondary to various noxious signals, some of which may originate from the intestinal microbiota (IM). Despite a growing body of evidence supporting a link between obesity and altered IM, there are no studies assessing the IM of patients with NAFLD. In this cross-sectional study we aimed at comparing fecal levels of total bacteria, Bacteroidetes, C. coccoides, C. leptum, Bifidobacteria, E. coli, and Archaea between healthy controls (HC) and patients with SS or NASH. We found higher C. coccoides levels in NASH compared to SS and lower percentage Bacteroidetes in NASH compared to SS and HC. Controlling for body mass index and fat intake we found an association between presence of NASH and percentage Bacteroidetes. The latter inversely correlated with insulin resistance.

Objectives: To estimate the incremental cost per QALY in patients with Parkinson’s Disease (PD) with varying disease severity and to ascertain which patient subgroup would accrue the greatest net monetary benefits to Ontario’s public health perspective as a result of Deep Brain Stimulation (DBS). Design: A cost-utility study and a net monetary benefit framework approach were applied to 37 PD patients with varying disease stages who underwent DBS treatment. Results: DBS resulted in cost savings of $2,686.3, $2,752.4, and $7348.4 and QALY gains of 0.33, 0.09 and 0.04 in patients with mild, moderate and severe PD. The ICER was $16,076.2/QALY. At $50,000/QALY, the greatest net monetary benefits accrued to Ontario’s MOHLTC were from treating patients with mild PD with DBS. Conclusions: DBS surgery was found to be a cost-effective PD treatment compared to pharmacotherapy. The greatest net monetary benefits were from treating patients with mild PD severity.