Search

Background: Rigorously designed longitudinal studies can inform how best to reduce the widening health gap between Indigenous and non-Indigenous children.Methods: A systematic review was performed to identify and present the breadth and depth of longitudinal studies reporting the health and well-being of Indigenous children (aged 0-18 years) globally. Databases were searched up to 23 June 2020. Study characteristics were mapped according to domains of the life course model of health. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Reported level of Indigenous involvement was also appraised; PROSPERO registration CRD42018089950.Results: From 5545 citations, 380 eligible papers were included for analysis, representing 210 individual studies. Of these, 41% were located in Australia (n = 88), 22.8% in the USA (n = 42), 11.9% in Canada (n = 25) and 10.9% in New Zealand (n = 23). Research tended to focus on either health outcomes (50.9%) or health-risk exposures (43.8%); 55% of studies were graded as 'good' quality; and 89% of studies made at least one reference to the involvement of Indigenous peoples over the course of their research.Conclusions: We identified gaps in the longitudinal assessment of cultural factors influencing Indigenous child health at the macrosocial level, including connection to culture and country, intergenerational trauma, and racism or discrimination. Future longitudinal research needs to be conducted with strong Indigenous leadership and participation including holistic concepts of health. This is critical if we are to better understand the systematic factors driving health inequities experienced by Indigenous children globally. [ABSTRACT FROM AUTHOR]

Copyright of Developmental Medicine & Child Neurology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Developmental Medicine & Child Neurology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: Suicide is a leading cause of death, yet the accurate prediction of suicidal behavior is an elusive target for clinicians and researchers. The current paper examines the predictive validity of the Mini Neuropsychiatric Interview (MINI) Suicidality subscale for suicide attempts (SAs) for a homeless population with mental illness.Methods: Two thousand two hundred and fifty-five homeless individuals with mental illness across five Canadian cities enrolled in the At Home/Chez Soi Housing First trial interviewed at baseline using the MINI Suicidality subscale with 2-year follow-up of self-reported SAs.Results: Two thousand two hundred and twenty-one participants were included in the analysis. High rates of mood and substance use disorders were present (56.5% and 67.4%, respectively). The mean MINI Suicidality subscale score was 7.71. Among 1,700 participants with follow-up data, 11.4% reported a SA over the 2-year study period. MINI Suicidality subscale scores were predictive of SAs (AUC ≥ 0.70) among those with and without a history of SAs, even among those with missing answers. A positive predictive value of 0.20 and a negative predictive value of 0.95 were demonstrated, with a relatively low number needed to assess of 4.5-5.Conclusion: The MINI Suicidal subscale shows promise as an easy to use and accurate suicide risk prediction tool among homeless individuals with mental illness. [ABSTRACT FROM AUTHOR]

Background: Lone parents and their children experience higher than average levels of adverse health and social outcomes, much of which are explained by high rates of poverty. Many high income countries have attempted to address high poverty rates by introducing employment requirements for lone parents in receipt of welfare benefits. However, there is evidence that employment may not reduce poverty or improve the health of lone parents and their children.Methods: We conducted a systematic review of qualitative studies reporting lone parents' accounts of participation in welfare to work (WtW), to identify explanations and possible mechanisms for the impacts of WtW on health and wellbeing. Twenty one bibliographic databases were searched. Two reviewers independently screened references and assessed study quality. Studies from any high income country that met the criteria of focussing on lone parents, mandatory WtW interventions, and health or wellbeing were included. Thematic synthesis was used to investigate analytic themes between studies.Results: Screening of the 4703 identified papers and quality assessment resulted in the inclusion of 16 qualitative studies of WtW in five high income countries, USA, Canada, UK, Australia, and New Zealand, covering a variety of welfare regimes. Our synthesis found that WtW requirements often conflicted with child care responsibilities. Available employment was often poorly paid and precarious. Adverse health impacts, such as increased stress, fatigue, and depression were commonly reported, though employment and appropriate training was linked to increased self-worth for some. WtW appeared to influence health through the pathways of conflict and control, analytical themes which emerged during synthesis. WtW reduced control over the nature of employment and care of children. Access to social support allowed some lone parents to manage the conflict associated with employment, and to increase control over their circumstances, with potentially beneficial health impacts.Conclusion: WtW can result in increased conflict and reduced control, which may lead to negative impacts on mental health. Availability of social support may mediate the negative health impacts of WtW. [ABSTRACT FROM AUTHOR]

Copyright of Developmental Medicine & Child Neurology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction and Aims: Tranquilizer use is associated with negative health outcomes among people who use drugs. This paper aims to estimate the incidence rate (initiation) and identify predictors of tranquilizer misuse (TM) among cocaine users.Design and Methods: A prospective cohort study was conducted in Montreal, Canada. Interviewer-administered questionnaires were carried out at 3-month intervals. Initiation was defined as misusing a tranquilizer for the first time during follow-up. 'Lasting-initiation', defined as reporting TM at the next visit following first use, was also examined. Cox proportional hazard regression analyses were carried out to assess predictors of initiation to TM.Results: Among the 245 participants who were eligible for the initiation analyses, 123 started TM during follow-up for an incidence rate of 40.49 per 100 person-years (95% confidence interval, CI: 33.80-48.15). Of the 123 initiates, 35.7% were still using at the interview following initiation for an incidence rate of 14.70 per 100 person-years (95% CI: 10.82-19.56). Multivariate models showed that independent predictors of initiation and 'lasting initiation' were identical as having had a criminal activity as the main source of income, having been recently in treatment for a substance use disorder (SUD) and reporting non-medical use of prescription opioids.Discussion and Conclusions: The incidence rate of TM initiation was high among a sample of cocaine users. Initiation was predicted by a problematic drug use pattern involving polydrug use, involvement in the street economy and having been in treatment for a SUD. These findings have implications for prevention and harm reduction strategies. [ABSTRACT FROM AUTHOR]

Background: The Stroke Canada Optimization of Rehabilitation by Evidence-Implementation Trial (SCORE-IT) showed that a facilitated knowledge translation (KT) approach to implementing a stroke rehabilitation guideline was more likely than passive strategies to improve functional walking capacity, but not gross manual dexterity, among patients in rehabilitation hospitals. This paper presents the results of a planned process evaluation designed to assess whether the type and number of recommended treatments implemented by stroke teams in each group would help to explain the results related to patient outcomes.Methods: As part of a cluster randomized trial, 20 rehabilitation units were stratified by language and allocated to a facilitated or passive KT intervention group. Sites in the facilitated group received the guideline with treatment protocols and funding for a part-time nurse and therapist facilitator who attended a 2-day training workshop and promoted guideline implementation for 16 months. Sites in the passive group received the guideline excluding treatment protocols. As part of a process evaluation, nurses, and occupational and physical therapists, blinded to study hypotheses, were asked to record their implementation of 18 recommended treatments targeting motor function, postural control and mobility using individualized patient checklists after treatment sessions for 2 weeks pre- and post-intervention. The percentage of patients receiving each treatment pre- and post-intervention and between groups was compared after adjusting for clustering and covariates in a random-effects logistic regression analysis.Results: Data on treatment implementation from nine and eight sites in the facilitated and passive KT group, respectively, were available for analysis. The facilitated KT intervention was associated with improved implementation of sit-to-stand (p = 0.028) and walking (p = 0.043) training while the passive KT intervention was associated with improved implementation of standing balance training (p = 0.037), after adjusting for clustering at patient and provider levels and covariates.Conclusions: Despite multiple strategies and resources, the facilitated KT intervention was unsuccessful in improving integration of 18 treatments concurrently. The facilitated approach may not have adequately addressed barriers to integrating numerous treatments simultaneously and complex treatments that were unfamiliar to providers.Trial Registration: Unique identifier- NCT00359593. [ABSTRACT FROM AUTHOR]

Background: Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.Methods: A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.Discussion: This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.Trial Registration: ClinicalTrials.gov ID: NCT02800291 , retrospectively registered June 7, 2016. [ABSTRACT FROM AUTHOR]

Background: Administration of magnesium sulphate (MgSO4) to women with imminent preterm birth at <34 weeks is an evidence-based antenatal neuroprotective strategy to prevent cerebral palsy. Although a Society of Obstetricians and Gynaecologists of Canada (SOGC) national guideline with practice recommendations based on relevant clinical evidence exists, ongoing controversies about aspects of this treatment remain. Given this, we anticipated managed knowledge translation (KT) would be needed to facilitate uptake of the guidelines into practice. As part of the Canadian Institutes of Health Research (CIHR)-funded MAG-CP (MAGnesium sulphate to prevent Cerebral Palsy) project, we aimed to compare three KT methods designed to impact both individual health care providers and the organizational systems in which they work.Methods: The KT methods undertaken were an interactive online e-learning module available to all SOGC members, and at MAG-CP participating sites, on-site educational rounds and focus group discussions, and circulation of an anonymous 'Barriers and Facilitators' survey for the systematic identification of facilitators and barriers for uptake of practice change. We compared these strategies according to: (i) breadth of respondents reached; (ii) rates and richness of identified barriers, facilitators, and knowledge needed; and (iii) cost.Results: No individual KT method was superior to the others by all criteria, and in combination, they provided richer information than any individual method. The e-learning module reached the most diverse audience of health care providers, the site visits provided opportunity for iterative dialogue, and the survey was the least expensive. Although the site visits provided the most detailed information around individual and organizational barriers, the 'Barriers and Facilitators' survey provided more detail regarding social-level barriers. The facilitators identified varied by KT method. The type of knowledge needed was further defined by the e-learning module and surveys.Conclusions: Our findings suggest that a multifaceted approach to KT is optimal for translating national obstetric guidelines into clinical practice. As audit and feedback are essential parts of the process by which evidence to practice gaps are closed, MAG-CP is continuing the iterative KT process described in this paper concurrent with tracking of MgSO4 use for fetal neuroprotection and maternal and child outcomes until September 2015; results are anticipated in 2016. [ABSTRACT FROM AUTHOR]

Background: Metabolic risk factors, low cognitive function and history of depression are known risk factors for future depressive episodes. This paper aims to evaluate the potential interactions between these factors on the risk of a major depressive episodes in middle-age.Methods: Baseline and follow-up data from a population-based study of Quebec, Canada were used. The sample consisted of 1788 adults between 40 and 69 years of age without diabetes. Cognitive function and metabolic risk factors were assessed at baseline. Three cognitive domains were assessed: processing speed, episodic memory and executive function. History of depression was assessed five years later by a clinical interview. Logistic regression analysis was conducted to evaluate interactions between individual metabolic factors, low cognitive function, and depression history.Results: Participants with a comorbidity of at least one metabolic factor, history of depression and low cognitive function had the highest risk of experiencing a depressive episode in middle age. The highest risk was observed in individuals with abdominal obesity, low cognitive function, and a history of depression (OR= 8.66, 95% CI 3.83-19.59). The risks for those with abdominal obesity only, depression history only, and low cognitive function were 1.20 (95%CI 0.71-2.02), 3.10 (95%CI 1.81-5.24), and 1.39 (95%CI 0.72-2.67), respectively.Limitations: Depression was only assessed at follow-up.Conclusion: Metabolic risk factors comorbid with low cognitive function in middle-aged individuals with a history of depression were associated with an increased risk of a future depressive episode. This study highlights the importance of screening for metabolic and cognitive comorbidities in patients with a history of depression. [ABSTRACT FROM AUTHOR]

This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach - gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature. [ABSTRACT FROM AUTHOR]

Introduction: International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations. Methods: The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments. Results: Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions. Conclusions: These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings. [ABSTRACT FROM AUTHOR]

Improved measurement in early child development (ECD) is a strategic focus of the WHO, UNICEF and World Bank Nurturing Care Framework. However, evidence-based approaches to monitoring and evaluation (M&E) of ECD projects in low-income and middle-income countries (LMIC) are lacking. The Grand Challenges Canada®-funded Saving Brains® ECD portfolio provides a unique opportunity to explore approaches to M&E of ECD programmes across diverse settings. Focused literature review and participatory mixed-method evaluation of the Saving Brains portfolio was undertaken using an adapted impact framework. Findings related to measurement of quality, coverage and outcomes for scaling ECD were considered. Thirty-nine ECD projects implemented in 23 LMIC were evaluated. Projects used a 'theory of change' based M&E approach to measure a range of inputs, outputs and outcomes. Over 29 projects measured cognitive, language, motor and socioemotional outcomes. 18 projects used developmental screening tools to measure outcomes, with a trade-off between feasibility and preferred practice. Environmental inputs such as the home environment were measured in 15 projects. Qualitative data reflected the importance of measurement of project quality and coverage, despite challenges measuring these constructs across contexts. Improved measurement of intervention quality and measurement of coverage, which requires definition of the numerator (ie, intervention) and denominator (ie, population in need/at risk), are needed for scaling ECD programmes. Innovation in outcome measurement, including intermediary outcome measures that are feasible and practical to measure in routine services, is also required, with disaggregation to better target interventions to those most in need and ensure that no child is left behind. [ABSTRACT FROM AUTHOR]

Introduction: Validity of research linking built environments to health relies on the availability and reliability of data used to measure exposures. As cities transform, it is important to track when and where urban changes occur, to provide detailed information for urban health intervention research. This paper presents an online observation method of the implementation of traffic-calmingfeatures using Google Street View Time Machine. The method is used to validate an existingadministrative database detailing the implementation of curb extensions and speed bumps.Methods: Online observation of curb extensions and speed bumps was conducted for four boroughsin Montreal, Canada, in autumn 2016, and compared with administrative data documenting traffic-calming measures implemented between 2008 and 2014. All images available through the Time Machine function between 2007 and 2016 for 708 intervention sites were visualized online. Records in the administrative database were compared to real-world Google Street View observations and tested in terms of sensitivity, specificity, and positive predicted value.Results: Google Street View Time Machine allowed the visualization of a median of seven different dates per street intersection and six dates per street segment. This made it possible to analyze built environment changes within 3,973 distinct time periods at 708 locations. Validation of the administrative data regarding presence of an intervention showed 99% (95% CI=97%, 99%) sensitivity, 58% (95% CI=51%, 64%) specificity, and 77% (95% CI=73%, 81%) positive predictive value.Conclusions: Google Street View Time Machine allowed past (2007-2016) online documentation of microscale urban interventions-curb extensions and speed bumps. The proposed method offers a new way to document historic changes to the built environment, which will be useful for urban health intervention research. [ABSTRACT FROM AUTHOR]

Background: Ten U.S. states, Canada, and Uruguay have passed laws to legalize the production and sale of cannabis for non-medical purposes. Available research has documented rapidly falling prices and changing product mixes, but many details are not well understood: particularly, the popularity, prices, and product characteristics of different cannabis edibles and extract-based products - each offering different ways to consume cannabis, with unclear health consequences.Methods: This paper analyzes data from Washington's recreational cannabis market, which has recorded over 110 million retail item-transactions from July 2014 to October 2017. Previous research on price and product trends has focused mostly on herbal cannabis, which accounts for the majority, but a decreasing share, of sales. This paper applies advanced text-analytic methods to provide new insights, including (A) estimating potency data for edibles and (B) identifying extract sub-types. Patterns and trends are described, across product types, regarding THC and CBD profiles and price per THC.Results: Extracts accounted for 28.5% of sales in October 2017. Of extracts categorized to subtype, nearly half were identified as "dabs", and another half "cartridges". In October 2017, price per 10 mg THC was roughly $3 among edibles, 70 cents among extract cartridges, and 30-40 cents for other flower and other extracts; solid concentrates offered the lowest priced THC among extract products. Price declines continue but have slowed. High-CBD chemovars are becoming more common, but still are almost non-existent in flower marijuana and rare (1% of sales) among extract products.Conclusion: As Washington's recreational cannabis market has developed over three and a half years, trends identified in that market may serve as an early indication of potential issues in other states. Legislators and regulators in other jurisdictions with commercial non-medical cannabis markets may wish to establish policies responsive to these trends in product popularity, price, and potency. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to assess the prevalence of orthostatic hypotension (OH) in a sample of late life depression (LLD) patients and to determine the validity of a standardized questionnaire, the Orthostatic Hypotension Questionnaire (OHQ). Secondarily, we wished to assess variables associated with OH.Methods: We conducted a cross-sectional study on 82 consecutive geriatric outpatients presenting with LLD. OH was defined as a fall in systolic blood pressure of greater than 20 mm Hg and/or 10 mm Hg on diastolic blood pressure on an orthostatic stress test from sitting to standing. Logistic regressions were used to identify factors associated with OH.Results: The prevalence of OH as measured on the orthostatic stress test and on the OHQ was 28% and 57%, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the OHQ were 69.6% (95% CI 47%-87%), 47.5% (95%CI 34%-61%), 0.54 (95% CI: 0.43-0.64), 34% (95%CI 21%-49%), and 80% (95%CI 63%-92%), respectively. Females were more likely to have OH (OR: 3.96, 95%CI 1.06-14.89, P = .041), and those married or in a common-law relationship were less likely to have OH (OR: 0.25, 95% CI 0.08-0.72, P = .011).Conclusions: OH is common in patients with LLD conferring them a risk of gait instability and falls. Females had a higher risk of having OH while participants who were married or in a common-law relationship were less likely to have OH. Although the OHQ is a quick to administer paper-based screening test, it did not show adequate diagnostic accuracy in patients with LLD seen in a routine psychiatry clinic. [ABSTRACT FROM AUTHOR]

This paper is based on a qualitative study conducted in a rural community in British Columbia, Canada. Ethnographic methods were used to: (1) to bring youth voice to the literature on emotional distress; and (2) to capture the ways in which context shapes young peoples' experiences of emotional distress within their everyday lives. Our findings demonstrate how socio-structural contextual factors such as the local economy, geographical segregation, racism, ageism, and cutbacks in health and social service programming operate to create various forms of disconnection, and intersect in young peoples' lives to shape their experiences of emotional distress. [ABSTRACT FROM AUTHOR]

Rationale: Bronchopulmonary dysplasia increases the risk of disability in extremely preterm infants. Although the pathophysiology remains uncertain, prior exposure to intermittent hypoxemia may play a role in this relationship. Objectives: To determine the association between prolonged episodes of intermittent hypoxemia and severe bronchopulmonary dysplasia. Methods: A post hoc analysis of extremely preterm infants in the Canadian Oxygen Trial who survived to 36 weeks' postmenstrual age was performed. Oxygen saturations <80% for ⩾1 minute and the proportion of time per day with hypoxemia were quantified using continuous pulse oximetry data that had been sampled every 10 seconds from within 24 hours of birth until 36 weeks' postmenstrual age. The study outcome was severe bronchopulmonary dysplasia as defined in the 2001 NIH Workshop Summary. Measurements and Main Results: Of 1,018 infants, 332 (32.6%) developed severe bronchopulmonary dysplasia. The median number of hypoxemic episodes ranged from 0.8/day (interquartile range, 0.2-1.1) to 60.2/day (interquartile range, 51.4-70.3) among the least and most affected 10% of infants. Compared with the lowest decile of exposure to hypoxemic episodes, the adjusted relative risk of severe bronchopulmonary dysplasia increased progressively from 1.72 (95% confidence interval, 1.55-1.90) at the 2nd decile to 20.40 (95% confidence interval, 12.88-32.32) at the 10th decile. Similar risk gradients were observed for time in hypoxemia. Significant differences in the rates of hypoxemia between infants with and without severe bronchopulmonary dysplasia emerged within the first week after birth. Conclusions: Prolonged intermittent hypoxemia beginning in the first week after birth was associated with an increased risk of developing severe bronchopulmonary dysplasia among extremely preterm infants. Clinical trial registered with www.isrctn.com (ISRCTN62491227) and www.clinicaltrials.gov (NCT00637169). [ABSTRACT FROM AUTHOR]

Objectives: To determine whether the genotypic resistance profile inferred from WGS could accurately predict phenotypic resistance for ESBL-producing Escherichia coli isolated from patient samples in Canadian hospital laboratories.Methods: As part of the ongoing CANWARD study, 671 E. coli were collected and phenotypically confirmed as ESBL producers using CLSI M100 disc testing criteria. Isolates were sequenced using the Illumina MiSeq platform, resulting in 636 high-quality genomes for comparison. Using a rules-based approach, the genotypic resistance profile was compared with the phenotypic resistance interpretation generated using the CLSI broth microdilution method for ceftriaxone, ciprofloxacin, gentamicin and trimethoprim/sulfamethoxazole.Results: The most common genes associated with non-susceptibility to ceftriaxone, gentamicin and trimethoprim/sulfamethoxazole were CTX-M-15 (n = 391), aac(3)-IIa + aac(6')-Ib-cr (n = 121) and dfrA17 + sul1 (n = 169), respectively. Ciprofloxacin non-susceptibility was most commonly attributed to alterations in both gyrA (S83L + D87N) and parC (S80I + E84V), with (n = 187) or without (n = 197) aac(6')-Ib-cr. Categorical agreement (susceptible or non-susceptible) between actual and predicted phenotype was 95.6%, 98.9%, 97.6% and 88.8% for ceftriaxone, ciprofloxacin, gentamicin and trimethoprim/sulfamethoxazole, respectively. Only ciprofloxacin results (susceptible or non-susceptible) were predicted with major error (ME) and very major error (VME) rates of <3%: ciprofloxacin (ME, 1.5%; VME, 1.1%); gentamicin (ME, 0.8%-31.7%; VME, 4.8%); ceftriaxone (ME, 81.8%; VME, 3.0%); and trimethoprim/sulfamethoxazole (ME, 0.9%-23.0%; VME, 5.2%-8.5%).Conclusions: Our rules-based approach for predicting a resistance phenotype from WGS performed well for ciprofloxacin, with categorical agreement of 98.9%, an ME rate of 1.5% and a VME rate of 1.1%. Although high categorical agreements were also obtained for gentamicin, ceftriaxone and trimethoprim/sulfamethoxazole, ME and/or VME rates were ≥3%. [ABSTRACT FROM AUTHOR]

Background: Compared with those with a higher socio-economic position (SEP), individuals with a lower SEP have higher cancer morbidity and mortality. However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and cancer morbidity and mortality.Methods: This study used a prospective observational cohort design. We combined eight cycles of the Canadian Community Health Survey (2000/2001-2011) as baseline data to identify a cohort of adults (≥35 years) without cancer at the time of survey administration (n = 309 800). The cohort was linked to the Discharge Abstract Database and the Canadian Mortality Database for cancer morbidity and mortality ascertainment. Individuals were followed from the date they completed the Canadian Community Health Survey until 31 March 2013. Dates of individual first hospitalizations for cancer and deaths due to cancer were captured during this time period. SEP was operationalized using a latent variable combining measures of education and household income. Self-reported modifiable risk factors, including smoking, excess alcohol consumption, low fruit-and-vegetable intake, physical inactivity and obesity, were considered as potential mediators. Generalized structural equation modelling was used to estimate the mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex.Results: Modifiable risk factors together explained 45.6% of associations between low SEP and overall cancer morbidity and mortality. Smoking was the most important mediator in the total population and for males, accounting for 15.5% and 40.2% of the total effect, respectively. For females, obesity was the most important mediator.Conclusions: Modifiable risk factors are important mediators of socio-economic inequities in cancer morbidity and mortality. Nevertheless, more than half of the variance in these associations remained unexplained. Midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short term. However, ultimately, upstream interventions that target structural determinants of health are needed to reduce overall socio-economic inequities in cancer morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: On 1 November 2018, Choosing Wisely Canada launched their Using Antibiotics Wisely primary care campaign, which aimed to reduce unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) through educational tools for patients and providers.Objectives: We explored the impact of this campaign on antibiotic utilization in Canada.Methods: We conducted a population-based study in Canada between January 2015 and December 2019. We used interventional autoregressive integrated moving average models to study the impact of the Using Antibiotics Wisely campaign on the prescribing rate (prescriptions per 1000 population) of RTI-indicated antibiotics. We analysed prescription rates overall and stratified by age group, drug class and province, in each month over the study period.Results: There was a 1.5% reduction in the annual prescribing rate of RTI-indicated antibiotics over the study period, which was generally consistent across age groups and provinces. Following the 2018 Using Antibiotics Wisely clinician toolkit release, we observed no significant change in RTI-indicated antibiotic prescribing rates nationally (P = 0.13). This was consistent by age group (children, P = 0.91; adults, P = 0.58; and older adults, P = 0.67) and drug class (narrow-spectrum penicillins, P = 0.88; macrolides, P = 0.85; broad-spectrum penicillins, P = 0.60; cephalosporins, P = 0.45; tetracyclines, P = 0.55; and fluoroquinolones, P = 0.98). In our secondary analysis of prescription rates in provinces that self-identified as prioritizing Using Antibiotics Wisely, we observed no significant change following the launch of the campaign.Conclusions: The introduction of the Using Antibiotics Wisely campaign in Canada has not caused a significant change in short-term antibiotic prescribing patterns. Community antibiotic stewardship campaigns that include components beyond education may be more impactful. [ABSTRACT FROM AUTHOR]

Objective: Unintentional injuries are the leading cause of death for children under 19 years of age. For preschoolers, many injuries occur in the home. Addressing this issue, this study assessed if a storybook about home safety could be effective to increase preschoolers' safety knowledge and reduce their injury-risk behaviors.Methods: Applying a randomized controlled trial design, normally developing English speaking preschool children (3.5-5.5 years) in Southwestern Ontario Canada were randomly assigned to the control condition (a storybook about healthy eating, N = 30) or the intervention condition (a storybook about home hazards, N = 29). They read the assigned storybook with their mother for 4 weeks; time spent reading was tracked, and fidelity checks based on home visits were implemented.Results: Comparing postintervention knowledge, understanding score, and risk behaviors across groups revealed that children who received the intervention were able to identify more hazards, provide more comprehensive safety explanations, and demonstrate fewer risky behaviors compared with children in the control group (ηp2 = 0.13, 0.19, and 0.51, respectively), who showed no significant changes over time in safety knowledge, understanding, or risk behaviors. Compliance with reading the safety book and fidelity in how they did so were very good.Conclusions: A storybook can be an effective resource for educating young children about home safety and reducing their hazard-directed risk behaviors. [ABSTRACT FROM AUTHOR]

Study Question: What is the normal range of cervical mucus patterns and number of days with high or moderate day-specific probability of pregnancy (if intercourse occurs on a specific day) based on cervical mucus secretion, in women without known subfertility, and how are these patterns related to parity and age?Summary Answer: The mean days of peak type (estrogenic) mucus per cycle was 6.4, the mean number of potentially fertile days was 12.1; parous versus nulliparous, and younger nulliparous (<30 years) versus older nulliparous women had more days of peak type mucus, and more potentially fertile days in each cycle.What Is Known Already: The rise in estrogen prior to ovulation supports the secretion of increasing quantity and estrogenic quality of cervical mucus, and the subsequent rise in progesterone after ovulation causes an abrupt decrease in mucus secretion. Cervical mucus secretion on each day correlates highly with the probability of pregnancy if intercourse occurs on that day, and overall cervical mucus quality for the cycle correlates with cycle fecundability. No prior studies have described parity and age jointly in relation to cervical mucus patterns.Study Design, Size, Duration: This study is a secondary data analysis, combining data from three cohorts of women: 'Creighton Model MultiCenter Fecundability Study' (CMFS: retrospective cohort, 1990-1996), 'Time to Pregnancy in Normal Fertility' (TTP: randomized trial, 2003-2006), and 'Creighton Model Effectiveness, Intentions, and Behaviors Assessment' (CEIBA: prospective cohort, 2009-2013). We evaluated cervical mucus patterns and estimated fertile window in 2488 ovulatory cycles of 528 women, followed for up to 1 year.Participants/materials, Setting, Methods: Participants were US or Canadian women age 18-40 years, not pregnant, and without any known subfertility. Women were trained to use a standardized protocol (the Creighton Model) for daily vulvar observation, description, and recording of cervical mucus. The mucus peak day (the last day of estrogenic quality mucus) was used as the estimated day of ovulation. We conducted dichotomous stratified analyses for cervical mucus patterns by age, parity, race, recent oral contraceptive use (within 60 days), partial breast feeding, alcohol, and smoking. Focusing on the clinical characteristics most correlated to cervical mucus patterns, linear mixed models were used to assess continuous cervical mucus parameters and generalized linear models using Poisson regression with robust variance were used to assess dichotomous outcomes, stratifying by women's parity and age, while adjusting for recent oral contraceptive use and breast feeding.Main Results and the Role Of Chance: The majority of women were <30 years of age (75.4%) (median 27; IQR 24-29), non-Hispanic white (88.1%), with high socioeconomic indicators, and nulliparous (70.8%). The mean (SD) days of estrogenic (peak type) mucus per cycle (a conservative indicator of the fertile window) was 6.4 (4.2) days (median 6; IQR 4-8). The mean (SD) number of any potentially fertile days (a broader clinical indicator of the fertile window) was 12.1 (5.4) days (median 11; IQR 9-14). Taking into account recent oral contraceptive use and breastfeeding, nulliparous women age ≥30 years compared to nulliparous women age <30 years had fewer mean days of peak type mucus per cycle (5.3 versus 6.4 days, P = 0.02), and fewer potentially fertile days (11.8 versus 13.9 days, P < 0.01). Compared to nulliparous women age <30 years, the likelihood of cycles with peak type mucus ≤2 days, potentially fertile days ≤9, and cervical mucus cycle score (for estrogenic quality of mucus) ≤5.0 were significantly higher among nulliparous women age ≥30 years, 1.90 (95% confidence interval (CI) 1.18, 3.06); 1.46 (95% CI 1.12, 1.91); and 1.45 (95% CI 1.03, 2.05), respectively. Between parous women, there was little difference in mucus parameters by age. Thresholds set a priori for within-woman variability of cervical mucus parameters by cycle were examined as follows: most minus fewest days of peak type mucus >3 days (exceeded by 72% of women), most minus fewest days of non-peak type mucus >4 days (exceeded by 54% of women), greatest minus least cervical mucus cycle score >4.0 (exceeded by 73% of women), and most minus fewest potentially fertile days >8 days (found in 50% of women). Race did not have any association with cervical mucus parameters. Recent oral contraceptive use was associated with reduced cervical mucus cycle score and partial breast feeding was associated with a higher number of days of mucus (both peak type and non-peak type), consistent with prior research. Among the women for whom data were available (CEIBA and TTP), alcohol and tobacco use had minimal impact on cervical mucus parameters.Limitations, Reasons For Caution: We did not have data on some factors that may impact ovulation, hormone levels, and mucus secretion, such as physical activity and body mass index. We cannot exclude the possibility that some women had unknown subfertility or undiagnosed gynecologic disorders. Only 27 women were age 35 or older. Our study participants were geographically dispersed but relatively homogeneous with regard to race, ethnicity, income, and educational level, which may limit the generalizability of the findings.Wider Implications Of the Findings: Patterns of cervical mucus secretion observed by women are an indicator of fecundity and the fertile window that are consistent with the known associations of age and parity with fecundity. The number of potentially fertile days (12 days) is likely greater than commonly assumed, while the number of days of highly estrogenic mucus (and higher probability of pregnancy) correlates with prior identifications of the fertile window (6 days). There may be substantial variability in fecundability between cycles for the same woman. Future work can use cervical mucus secretion as an indicator of fecundity and should investigate the distribution of similar cycle parameters in women with various reproductive or gynecologic pathologies.Study Funding/competing Interest(s): Funding for the three cohorts analyzed was provided by the Robert Wood Johnson Foundation (CMFS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (TTP), and the Office of Family Planning, Office of Population Affairs, Health and Human Services (CEIBA). The authors declare that they have no conflict of interest.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Background: Stepping into the role of an unpaid caregiver to offer help is often considered a natural expectation of family members or friends. In Canada, such contributions are substantial in terms of healthcare provision but this comes at a considerable cost to the caregivers in both health and economic terms.Methods: In this study, we conducted a secondary analysis of a collection of qualitative interviews with 39 caregivers of people with chronic physical illness to assess how they described their particular roles in caring for a loved one. We used a model of caregiving roles, originally proposed by Twigg in 1989, as a guide for our analysis, which specified three predominant roles for caregivers - as a resource, as a co-worker, and as a co-client.Results: The caregivers in this collection spoke about their roles in ways that aligned well with these roles, but they also described tasks and activities that fit best with a fourth role of 'care-coordinator', which required that they assume an oversight role in coordinating care across institutions, care providers and often advocate for care in line with their expectations. For each of these types of roles, we have highlighted the limitations and challenges they described in their interviews.Conclusions: We argue that a deeper understanding of the different roles that caregivers assume, as well as their challenges, can contribute to the design and implementation of policies and services that would support their contributions and choices as integral members of the care team. We provide some examples of system-level policies and programs from different jurisdictions developed in recognition of the need to sustain caregivers in their role and respond to such limitations. [ABSTRACT FROM AUTHOR]

Cancer-related sexual dysfunction is documented as one of the most distressing and long-lasting survivorship concerns of cancer patients. Canadian cancer patients routinely report sexuality concerns and difficulty getting help. In response to this gap in care, clinical practice guidelines were recently published in the Journal of Clinical Oncology. A sweeping trend is the creation of specialized clinics for patients' sexual health concerns. However, this much-needed attempt to address this service gap can be difficult to sustain without addressing the cancer care system from a broader perspective. Herein, we describe the implementation of a tiered systemic model of cancer-related sexual health programming in a tertiary cancer center. This program follows the Permission, Limited Information, Specific Suggestions, Intensive Therapy (PLISSIT) model, used previously for guiding individual practitioners. Visually, the model resembles a pyramid. The top 2 levels, corresponding to Intensive Therapy and Specific Suggestions, are comprised of group-based interventions for common cancer-related sexual concerns and a multi-disciplinary clinic for patients with complex concerns. The bottom 2 levels, corresponding to Permission and Limited Information, consist of patient education and provider education and consultation services. We describe lessons learned during the development and implementation of this program, including the necessity for group-based services to prevent inundation of referrals to the specialized clinic, and the observation that creating specialized resources also increased the likelihood that providers would inquire about patients' sexual concerns. Such lessons suggest that successful sexual health programming requires services from a systemic approach to increase sustainability. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to develop a patient-centered quality measurement framework to address a predefined vision statement and 7 strategic objectives for rheumatoid arthritis (RA) care that was developed in prior qualitative work with arthritis stakeholders.Methods: One hundred forty-seven RA-related performance measures (PMs) were identified from a systematic review. A candidate list of 26 PMs meeting predefined criteria and addressing the strategic objectives previously defined was then assessed during a 3-round (R) modified Delphi. Seventeen panelists with expertise in RA, quality measurement, and/or lived experience with RA rated each PM on a 1-9 scale based on the items of importance, feasibility, and priority for inclusion in the framework during R1 and R3, with a moderated discussion in R2. PMs with median scores ≥ 7 on all 3 items without disagreement were included in the final set, which then underwent public comment.Results: Twenty-one measures were included in the final framework (15 PMs from the Delphi and 6 published system-level measures on access to care and treatment). The measures included 4 addressing early access to care and timely diagnosis, 12 evidence-based care for RA and related comorbidities, 1 addressing patient participation as an informed partner in care, and 4 on patient outcomes.Conclusion: The proposed framework builds upon existing measures capturing early access to care and treatment in RA and adds important PMs to promote high-quality RA care and outcome measurement. In the next phase, the authors will test the framework in clinical practice in addition to addressing certain areas where no suitable PMs were identified. [ABSTRACT FROM AUTHOR]

Background: Trace elements' (TEs) contamination of parenteral nutrition (PN) solutions is an ongoing concern. The aims of this study were 1) to measure actual TE concentrations in PN admixtures compared with ordered concentrations and 2) compare TE intake with current recommendations.Methods: PN admixtures from discarded bags were collected from patients receiving home PN and on inpatient wards. Samples were collected from 72 patients (39 inpatients, 33 receiving home PN). Age, percentage energy intake from PN, and PN orders were collected from patients' charts. PN samples were analyzed for TEs, including chromium (Cr) and manganese (Mn), and concentration measurements compared with ordered concentrations and current recommendations.Results: Measured Cr and Mn concentrations were higher than ordered concentrations: 5.3 ± 1.7 vs 2.8 ± 1.5 µg/L; P < 0.0001 and 11.9 ± 5.9 vs 0.00 µg/L; P < 0.0001, respectively. Chromium contamination alone accounted for over 100% of current recommendations for patients 0-12 months and between 63% and 92% for children >1 year. Contamination of Mn provided all the measured Mn in PN admixtures, since Mn is excluded from PN orders at our institution. Between 70% and 120% of current Mn recommendations were met from contamination.Conclusions: Cr should be excluded from PN admixtures for children 0-12 months and only one-fourth the current recommendation should be added for pediatric patients >1 year. Manganese should also be excluded from PN admixture for pediatric patients but plasms monitoring 2-3 times per year is recommended for those on long-term PN. [ABSTRACT FROM AUTHOR]

Background: Worldwide, most adolescent girls do not meet physical activity (PA) recommendations and very few PA programs are tailored specifically towards them. Even fewer information exists about the long-term effects of such programs. Some Canadian schools have implemented the FitSpirit PA intervention designed specifically for girls aged 12 to 17 years old. This paper describes the protocol of a quasi-experimental study evaluating long-term changes in health behaviours and outcomes following FitSpirit participation.Methods: The study is conducted among schools that partner with FitSpirit every year. It started in 2018 and will be completed in 2022. The intervention comprises motivational talks, a turnkey running program, PA sessions and special events. Study participants fill out an online questionnaire twice a year. Follow-up questionnaires are sent at the end of each school year to the study participants who dropout from FitSpirit. The main outcome, changes in PA levels, is evaluated using questions validated for adolescents. Secondary outcomes are health (perceived health); lifestyle habits (sedentary activities, eating and sleeping habits); psychosocial outcomes (physical self-efficacy and body satisfaction); and FitSpirit appreciation (activity participation and satisfaction). Most questions originate from questionnaires validated for the adolescent population. Cross-sectional and longitudinal analyses will be performed.Discussion: This study will provide one of the first longitudinal reports on the impact of a large extra-curricular PA intervention designed specifically for adolescent girls. The current study will uniquely contribute to PA research by assessing outcomes additional to PA levels, including markers of health, lifestyle habits and psychosocial determinants.Trial Registration: NCT, NCT03804151 , Registered on January 22, 2019; retrospectively registered. [ABSTRACT FROM AUTHOR]

Objective: Observational studies have linked elevated homocysteine to vascular conditions. Folate intake has been associated with lower homocysteine concentration, although randomised controlled trials of folic acid supplementation to decrease the incidence of vascular conditions have been inconclusive. We investigated determinants of maternal homocysteine during pregnancy, particularly in a folic acid-fortified population.Design: Data were from the Ottawa and Kingston Birth Cohort of 8085 participants. We used multivariable regression analyses to identify factors associated with maternal homocysteine, adjusted for gestational age at bloodwork. Continuous factors were modelled using restricted cubic splines. A subgroup analysis examined the modifying effect of MTHFR 677C>T genotype on folate, in determining homocysteine concentration.Setting: Participants were recruited in Ottawa and Kingston, Canada, from 2002 to 2009.Participants: Women were recruited when presenting for prenatal care in the early second trimester.Results: In 7587 participants, factors significantly associated with higher homocysteine concentration were nulliparous, smoking and chronic hypertension, while factors significantly associated with lower homocysteine concentration were non-Caucasian race, history of a placenta-mediated complication and folic acid supplementation. Maternal age and BMI demonstrated U-shaped associations. Folic acid supplementation of >1 mg/d during pregnancy did not substantially increase folate concentration. In the subgroup analysis, MTHFR 677C>T modified the effect of folate status on homocysteine concentration.Conclusions: We identified determinants of maternal homocysteine relevant to the lowering of homocysteine in the post-folic acid fortification era, characterised by folate-replete populations. A focus on periconceptional folic acid supplementation and improving health status may form an effective approach to lower homocysteine. [ABSTRACT FROM AUTHOR]

Background: Up-to-date normative reference sets for cardiopulmonary exercise testing (CPET) are important to aid in the accurate interpretation of CPET in clinical or research settings.Research Question: This study aimed to (1) develop and externally validate a contemporary reference set for peak CPET responses in Canadian adults identified with population-based sampling; and (2) evaluate previously recommended reference equations for predicting peak CPET responses.Study Design and Methods: Participants were healthy adults who were ≥40 years old from the Canadian Cohort Obstructive Lung Disease who completed an incremental cycle CPET. Prediction models for peak CPET responses were estimated from readily available participant characteristics (age, sex, height, body mass) with the use of quantile regression. External validation was performed with a second convenience sample of healthy adults. Peak CPET parameters that were measured and predicted in the validation cohort were assessed for equivalence (two one-sided tests of equivalence for paired-samples and level of agreement (Bland-Altman analyses). Two one-sided tests of equivalence for paired samples assessed differences between responses in the derivation cohort using previously recommended reference equations.Results: Normative reference ranges (5th-95th percentiles) for 28 peak CPET parameters and prediction models for 8 peak CPET parameters were based on 173 participants (47% male) who were 64 ± 10 years old. In the validation cohort (n = 84), peak CPET responses that were predicted with the newly generated models were equivalent to the measured values. Peak cardiac parameters predicted by the previously recommended reference equations by Jones and colleagues and Hansen and colleagues were significantly higher.Interpretation: This study provides reference ranges and prediction models for peak cardiac, ventilatory, operating lung volume, gas exchange, and symptom responses to incremental CPET and presents the most comprehensive reference set to date in Canadian adults who were ≥40 years old to be identified with population-based sampling. [ABSTRACT FROM AUTHOR]

Background: There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care-each one representing an interconnecting step in the "HIV Cascade."Methods: The main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes.Results: Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional-thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional.Conclusions: We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care-an area of life previously not subject to monetary exchanges. [ABSTRACT FROM AUTHOR]

Aim: To assess the Canadian Occupational Performance Measure's (COPM) ability to document change over 3 years in children with cerebral palsy (CP).Method: This was a prospective study with ambulatory children with CP, aged 2 to 6 years. Caregivers set one to three COPM goals which were rescored annually over 3 years. A ceiling effect for performance goals was operationalized as a score of 8. A Wald χ2 generalized estimating equations model adjusted for age, sex, and Gross Motor Function Classification System (GMFCS) level, evaluated change over time.Results: In total, 124 children (47 [37.9%] females, 77 [62.1%] males; mean age 3y 11mo [SD 1y 1mo]; GMFCS level I [n=78, 62.9%], II [n=21, 16.9%], and III [n=25, 20.2%]) were set 345 COPM goals at baseline. By Year 3, 106 participants (85.5%) rescored 287 of the goals (83.2%). Performance scores increased between baseline mean (SD) 2.93 (0.56), Year 1 5.98 (0.58) with 34.8% at ceiling; Year 2 6.74 (0.60) 48.3% at ceiling; and Year 3 7.37 (0.60) 59.6% at ceiling (Wald χ2 [3]=607.18, p<0.001). Satisfaction scores increased between baseline 4.42 (0.59), Year 1 6.82 (0.60) with 48% at ceiling; Year 2 7.53 (0.60) with 62.2% at ceiling (Wald χ2 [3]=208.48, p<0.001); with no significant increase by Year 3 7.82 (0.62) with 66.9% at ceiling.Interpretation: COPM performance scores increased steadily over 3 years. By Year 2, a ceiling effect was seen in about half of the goals. The COPM may have utility to measure change over 3 years; periodic resetting of the descriptors of goal success are required to minimize ceiling. [ABSTRACT FROM AUTHOR]

Background: We compared the cost-effectiveness of 10 weeks of outreach rehabilitation (intervention) versus usual care (control) for ambulatory nursing home residents after hip fracture.Methods: Enrollment occurred February 2011 through June 2015 in a Canadian metropolitan region. Seventy-seven participants were allocated in a 2:1 ratio to receive a 10-week rehabilitation program (intervention) or usual care (control) (46 intervention; 31 control). Using a payer perspective, we performed main and sensitivity analyses. Health outcome was measured by quality-adjusted life years (QALYs), using the EQ5D, completed at study entry, 3-, 6-, and 12-months. We obtained patient-specific data for outpatient visits, physician claims, and inpatient readmissions; the trial provided rehabilitation utilization/cost data. We estimated incremental cost and incremental effectiveness.Results: Groups were similar at study entry; the mean age was 87.9 ± 6.6 years, 54 (71%) were female and 58 (75%) had severe cognitive impairment. EQ5D QALYs scores were nonsignificantly higher for intervention participants. Inpatient readmissions were two times higher among controls, with a cost difference of -$3,350/patient for intervention participants, offsetting the cost/intervention participant of $2,300 for the outreach rehabilitation. The adjusted incremental QALYs/patient difference was 0.024 favoring the intervention, with an incremental cost/patient of -$621 for intervention participants; these values were not statistically significant. A sensitivity analysis reinforced these findings, suggesting that the intervention was likely dominant.Conclusion: A 10-week outreach rehabilitation intervention for nursing home residents who sustain a hip fracture may be cost-saving, through reduced postfracture hospital readmissions. These results support further work to evaluate postfracture rehabilitation for nursing home residents. [ABSTRACT FROM AUTHOR]

Objectives: We assessed the incidence, risk factors and adverse birth outcomes associated with elevated liver enzymes and low platelets (HELLP) syndrome.Design: A retrospective population-based cohort study.Setting: Canada (excluding Quebec), 2012/2013-2015/2016.Population: Mothers with a singleton hospital live birth or stillbirth at ≥24 weeks' gestation (n = 1 078 323).Methods: HELLP syndrome was identified using ICD-10-CA diagnostic code from delivery hospitalisation data. We used logistic regression to identify independent risk factors for HELLP syndrome by obtaining adjusted odds ratios (AOR) and 95% confidence intervals (CI), and to assess the associations with adverse outcomes.Main Outcome Measures: Adverse maternal (e.g. eclampsia) and fetal/neonatal outcomes (e.g. intraventricular haemorrhage, perinatal death).Results: The incidence of HELLP syndrome was 2.5 per 1000 singleton deliveries (n = 2663). Risk factors included: age ≥35 years, rural residence, nulliparity, parity ≥4, pre-pregnancy and gestational hypertension and diabetes, assisted reproduction, chronic cardiac conditions, systemic lupus erythematosus, obesity, chronic hepatic conditions, placental disorders (e.g. fetomaternal transfusion) and congenital anomalies. PROM and age <25 years were inversely associated with HELLP syndrome (P-values <0.05). Women with the syndrome had a 10-fold higher maternal mortality (95% CI 1.6-84.3) and elevated severe maternal morbidity (9.6 versus 121.7 per 1000; AOR 12.5, 95% CI 11.1-14.1); and higher perinatal mortality (4.3 versus 21.0 per 1000; AOR 4.5, 95% CI 3.5-5.9) and perinatal mortality/severe neonatal morbidity (21.2 versus 202.4 per 1000; AOR 10.7, 95% CI 9.7-11.8).Conclusion: HELLP syndrome is associated with specific pre-pregnancy and pregnancy risk factors, higher rates of maternal death, and substantially higher severe maternal morbidity, perinatal mortality and severe neonatal morbidity.Tweetable Abstract: HELLP syndrome is associated with higher maternal death rate, and substantially higher severe maternal and neonatal morbidity, and perinatal mortality. [ABSTRACT FROM AUTHOR]

Objective: Commercially available business (CAB) datasets for food environments have been investigated for error in large urban contexts and some rural areas, but there is a relative dearth of literature that reports error across regions of variable rurality. The objective of the current study was to assess the validity of a CAB dataset using a government dataset at the provincial scale.Design: A ground-truthed dataset provided by the government of Newfoundland and Labrador (NL) was used to assess a popular commercial dataset. Concordance, sensitivity, positive-predictive value (PPV) and geocoding errors were calculated. Measures were stratified by store types and rurality to investigate any association between these variables and database accuracy.Setting: NL, Canada.Participants: The current analysis used store-level (ecological) data.Results: Of 1125 stores, there were 380 stores that existed in both datasets and were considered true-positive stores. The mean positional error between a ground-truthed and test point was 17·72 km. When compared with the provincial dataset of businesses, grocery stores had the greatest agreement, sensitivity = 0·64, PPV = 0·60 and concordance = 0·45. Gas stations had the least agreement, sensitivity = 0·26, PPV = 0·32 and concordance = 0·17. Only 4 % of commercial data points in rural areas matched every criterion examined.Conclusions: The commercial dataset exhibits a low level of agreement with the ground-truthed provincial data. Particularly retailers in rural areas or belonging to the gas station category suffered from misclassification and/or geocoding errors. Taken together, the commercial dataset is differentially representative of the ground-truthed reality based on store-type and rurality/urbanity. [ABSTRACT FROM AUTHOR]

Objective: Studies have shown that Housing First, a recovery-oriented housing intervention, is effective in reducing service utilization among homeless individuals with mental illness, but less is known about how Housing First affects patterns of service use over time and about characteristics associated with various utilization trajectories. This analysis aimed to explore latent class trajectories of shelter utilization in a randomized controlled trial of Housing First conducted across five Canadian cities.Methods: Data from the At Home/Chez Soi trial were analyzed (N=2,058). Latent class growth analysis was performed using days of shelter utilization to identify trajectories over 24 months. Multinomial logistic regression was used to determine which baseline variables, including treatment group, could predict class membership.Results: Four shelter use trajectories were identified: consistently low (N=1,631, 79%); mostly low (N=120, 6%); early temporary increase (N=179, 9%); and higher use, late temporary increase (N=128, 6%). Treatment group was a significant predictor of class membership. Those enrolled in Housing First had lower odds of experiencing higher shelter use trajectories (mostly low: odds ratio [OR]=0.50, 95% confidence interval [CI]=0.34-0.72; early temporary increase: OR=0.21, 95% CI=0.15-0.31; higher use, late temporary increase: OR=0.14, 95% CI=0.09-0.22). Other variables associated with trajectory classes included older age and longer time homeless, both of which were associated with higher shelter use.Conclusions: Several participant characteristics were associated with different shelter use patterns. Knowledge of variables associated with more favorable trajectories may help to inform service planning and contribute to modeling efforts for homelessness. [ABSTRACT FROM AUTHOR]

In prevalent cohort studies with follow-up, if disease duration is the focus, the date of onset must be obtained retrospectively. For some diseases, such as Alzheimer's disease, the very notion of a date of onset is unclear, and it can be assumed that the reported date of onset acts only as a proxy for the unknown true date of onset. When adjusting for onset dates reported with error, the features of left-truncation and potential right-censoring of the failure times must be modeled appropriately. Under the assumptions of a classical measurement error model for the onset times and an underlying parametric failure time model, we propose a maximum likelihood estimator for the failure time distribution parameters which requires only the observed backward recurrence times. Costly and time-consuming follow-up may therefore be avoided. We validate the maximum likelihood estimator on simulated datasets under varying parameter combinations and apply the proposed method to the Canadian Study of Health and Aging dataset. [ABSTRACT FROM AUTHOR]

Despite limited evidence on the association between physical activity (PA) and blood pressure (BP) in youth, experts recommend that adolescents engage regularly in moderate-to-vigorous PA. We examined the relationships between PA intensity and frequency and the likelihood of having high BP in a population-based cohort of adolescents from Montréal, Canada. PA was self-reported every 3 months from grade 7 to 11, and BP was measured at ages 12.8, 15.2, and 17.0 years on average. We analyzed data from 993 participants (mean [SD] age = 16.0 [1.0], 51.6% female) with BP data at ages 15.2 and/or 17.0 years, using pooled ordinal logistic regression. BP (normal/elevated/hypertensive range) was the outcome, and past-year PA intensity and frequency were potential predictors. Eight percent of participants had elevated BP (120-129/<80), and 3.2% had BP in the hypertensive range (≥130/≥80). Participants engaged in a median (interquartile range) of 7.0 (4.5, 9.3) and 5.5 (2, 10.8) moderate and vigorous PA sessions/week, respectively. After adjusting for age, sex, mother's education, use of alcohol and cigarette consumption, engaging in PA more intense than light during the previous year was associated with a lower odds of having BP in the hypertensive range (ORs [95% CIs] = 0.93 [0.88, 0.97] to 0.97 [0.94, 0.99]). The relationships were not altered by adjusting for BMI. Our findings support recommendations that adolescents engage in at least moderate PA on a regular basis to prevent development of BP in the hypertensive range. [ABSTRACT FROM AUTHOR]

Marginal structural models (MSMs) allow estimating the causal effect of a time-varying exposure on an outcome in the presence of time-dependent confounding. The parameters of MSMs can be estimated utilizing an inverse probability of treatment weight estimator under certain assumptions. One of these assumptions is that the proposed causal model relating the outcome to exposure history is correctly specified. However, in practice, the true model is unknown. We propose a test that employs the observed data to attempt validating the assumption that the model is correctly specified. The performance of the proposed test is investigated with a simulation study. We illustrate our approach by estimating the effect of repeated exposure to psychosocial stressors at work on ambulatory blood pressure in a large cohort of white-collar workers in Québec City, Canada. Code examples in SAS and R are provided to facilitate the implementation of the test. [ABSTRACT FROM AUTHOR]

Background Transgender (trans) women are overrepresented among people living with HIV, yet trans women living with HIV (WLWH) experience lower access to HIV care. Access to medical transition may facilitate access to HIV care among trans WLWH. This study sought to describe barriers and facilitators to access to medical transition among trans WLWH.Methods: This convergent parallel mixed-methods study drew on cross-sectional quantitative data from 48 trans WLWH analysed using descriptive and bivariate analyses, as well as qualitative semistructured interview data from a subsample of 11 participants analysed using framework analysis. The primary outcome was self-reported transition experience (completed or in the process of medical transition vs planning to but have not begun medical transition). Quantitative and qualitative results were merged and analysed for convergence, divergence and/or expansion of understanding.Results: Just over half the participants reported being fully completed medical transition or in the process of medical transition (52.1% (25/48); 95% confidence interval (CI) 37.5-67.6%), with one-fifth reporting planning to but not having begun medical transition (18.8% (9/48); 95% CI 8.3-29.2%). Factors significantly associated with not having begun one's medical transition included housing instability, transphobia, HIV-related stigma and barriers in access to care. Qualitative findings revealed varied transition experiences, influenced by community norms, passing and class privilege, HIV and structural barriers. Mixed-methods results showed positive relationships between trans WLWH and HIV care providers in terms of trans and HIV health care.Conclusions: HIV-related stigma and social determinants of health limit access to medical transition for trans WLWH. Stigma must be addressed in a broad range of healthcare settings, in addition to structural barriers, to increase access to gender-affirming HIV care and medical transition for trans WLWH. [ABSTRACT FROM AUTHOR]

Background: Persisting atopic dermatitis (AD) is known to be associated with more serious allergic diseases at later ages; however, making an accurate diagnosis during infancy is challenging. We assessed the diagnostic performance of questionnaire-based AD measures with criteria-based in-person clinical assessments at age 1 year and evaluated the ability of these diagnostic methods to predict asthma, allergic rhinitis and food allergies at age 5 years.Methods: Data relate to 3014 children participating in the Canadian Healthy Infant Longitudinal Development (CHILD) Study who were directly observed in a clinical assessment by an experienced healthcare professional using the UK Working Party criteria. The majority (2221; 73.7%) of these children also provided multiple other methods of AD ascertainment: a parent reporting a characteristic rash on a questionnaire, a parent reporting the diagnosis provided by an external physician and a combination of these two reports.Results: Relative to the direct clinical assessment, the area under the Receiver Operating Characteristic curve for a parental report of a characteristic rash, reported physician diagnosis and a combination of both were, respectively, 0.60, 0.69 and 0.70. The strongest predictor of asthma at 5 years was AD determined by criteria-based in-person clinical assessment followed by the combination of parental and physician report.Conclusions: These findings suggest that questionnaire data cannot accurately substitute for assessment by experienced healthcare professionals using validated criteria for diagnosis of atopic dermatitis. Combining the parental report with diagnosis by a family physician might sometimes be appropriate (eg to avoid costs of a clinical assessment). [ABSTRACT FROM AUTHOR]

Background: The care of infants with recurrent wheezing relies largely on clinical assessment. The lung clearance index (LCI), a measure of ventilation inhomogeneity, is a sensitive marker of early airway disease in children with cystic fibrosis, but its utility has not been explored in infants with recurrent wheezing.Objective: To assess ventilation inhomogeneity using LCI among infants with a history of recurrent wheezing compared with healthy controls.Methods: This is a case-control study, including 37 infants with recurrent wheezing recruited from outpatient clinics, and 113 healthy infants from a longitudinal birth cohort, the Canadian Healthy Infant Longitudinal Development study. All infants, at a time of clinical stability, underwent functional assessment including multiple breath washout, forced expiratory flows and body plethysmography.Results: LCI z-score values among infants with recurrent wheeze were 0.84 units (95% CI 0.41 to 1.26) higher than healthy infants (mean (95% CI): 0.26 (-0.11 to 0.63) vs -0.58 (-0.79 to 0.36), p<0.001)). Nineteen percent of recurrently wheezing infants had LCI values that were above the upper limit of normal (>1.64 z-scores). Elevated exhaled nitric oxide, but not symptoms, was associated with abnormal LCI values in infants with recurrent wheeze (p=0.05).Conclusions: Ventilation inhomogeneity is present in clinically stable infants with recurrent wheezing. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence and correlates of healthy vitamin D status in lactating Inuit women living in remote regions of the Arctic.Design: Cross-sectional.Setting: Households were selected randomly in thirty-six communities of Nunavut, Nunatsiavut and Inuvialuit Settlement Region. Dietary intake was assessed using a 24 h recall and an FFQ. Anthropometric measurements, household living conditions, supplement use and health status were assessed. In fasting samples, serum 25-hydroxyvitaimn D (25(OH)D) was measured using a chemiluminescent assay (LIAISON; Diasorin Inc.).Subjects: Lactating Inuit women participating in the 2007-2008 International Polar Year Inuit Health Survey conducted in the months of August to October.Results: Among participants (n 34), 8·8, 26·5 and 50·0 % had 25(OH)D concentrations at or above 75, 50 and 40 nmol/l, respectively. More than one-third of participants did not consume traditional foods during the previous day and only 11·3 % of total energy intake was derived from traditional foods. Only 14·7 % of the sample consumed the daily number of milk servings recommended by Canada's Food Guide (two servings) for First Nations, Inuit and Métis. Using multivariable logistic regression to examine 25(OH)D≥40 nmol/l, only higher body fat was inversely correlated with 25(OH)D concentration.Conclusions: The present study is the first to assess simultaneously vitamin D status and other known factors that affect it among lactating Inuit women living in remote communities in the Arctic. Healthy maternal vitamin D status was observed in 25 % of participants during the late summer and early autumn. This requires further assessment in a larger sample spanning more seasons. [ABSTRACT FROM AUTHOR]

Background: Depression and anxiety disorders are highly comorbid, and share significant symptom overlap. Whereas depression has been consistently associated with excess mortality, the association between anxiety and mortality is less clear. Our aim was to identify constellations of anxious and depressive symptoms and examine their associations with mortality.Method: This study considers respondents from the 1970 (n = 1203) and 1992 (n = 1402) cohorts of the Stirling County study. Symptoms of depression and anxiety were assessed using structured at-home interviews. Vital status of participants through 2011 was determined using probabilistic linkages to the Canadian Mortality Database.Results: Exploratory factor analysis yielded three correlated factors in each cohort. Items loading on each factor varied slightly between cohorts, but roughly corresponded to (1) depressive symptoms, (2) anxious symptoms, and (3) somatic symptoms. The depressive factor was associated with increased risk of mortality in both the 1970 (HR: 1.35, 95% CI: 1.12, 1.62) and 1992 (HR: 1.25, 95% CI: 1.05, 1.48) cohorts. Anxious symptoms were associated with a reduced risk of mortality in the 1992 sample (HR: 0.72; 95% CI: 0.53, 0.90). Somatic symptoms were associated with a reduced risk of mortality in the 1970 sample (HR: 0.83, 95% CI: 0.69, 0.99), but an elevated risk of mortality in the 1992 sample (HR: 1.29; 95% CI: 1.11, 1.51).Conclusions: This study provides evidence that symptoms of depression and anxiety may have differential associations with early mortality. Somatic symptoms such as upset stomach and loss of appetite may be protective against mortality, perhaps through increased use of health care services. Conversely, symptoms such as weakness and cold sweats may be indicative of failing health. [ABSTRACT FROM AUTHOR]

Researchers are increasingly using complex population-based sample surveys to estimate the effects of treatments, exposures and interventions. In such analyses, statistical methods are essential to minimize the effect of confounding due to measured covariates, as treated subjects frequently differ from control subjects. Methods based on the propensity score are increasingly popular. Minimal research has been conducted on how to implement propensity score matching when using data from complex sample surveys. We used Monte Carlo simulations to examine two critical issues when implementing propensity score matching with such data. First, we examined how the propensity score model should be formulated. We considered three different formulations depending on whether or not a weighted regression model was used to estimate the propensity score and whether or not the survey weights were included in the propensity score model as an additional covariate. Second, we examined whether matched control subjects should retain their natural survey weight or whether they should inherit the survey weight of the treated subject to which they were matched. Our results were inconclusive with respect to which method of estimating the propensity score model was preferable. In general, greater balance in measured baseline covariates and decreased bias was observed when natural retained weights were used compared to when inherited weights were used. We also demonstrated that bootstrap-based methods performed well for estimating the variance of treatment effects when outcomes are binary. We illustrated the application of our methods by using the Canadian Community Health Survey to estimate the effect of educational attainment on lifetime prevalence of mood or anxiety disorders. [ABSTRACT FROM AUTHOR]

Objective: Acute leukemia (AL) is associated with an immediate threat to life, an unpredictable clinical course, and substantial physical suffering. Traumatic stress symptoms that may meet criteria for acute stress disorder (ASD) may be common and disabling in this context, but have received little clinical attention. We investigated the incidence over time and risk factors for traumatic stress symptoms and ASD in the 3 months following diagnosis or relapse of AL.Methods: Individuals with AL were recruited at a tertiary cancer center in Canada within one month of diagnosis or relapse. Participants (N = 230) completed self-report measures, including the Stanford Acute Stress Reaction Questionnaire, at baseline and monthly over 3 months. The incidence of traumatic stress symptoms over time was examined, and a generalized logistic model was used to identify factors associated with ASD.Results: Participants were 60% male, with a mean age of 48.9 ± 15.2 years. Symptoms of ASD were identified on ≥1 assessment over the study period in 24.4% of participants at baseline and in an additional 12.6% at a subsequent follow-up. Of these, 55.3% reported symptoms on ≥2 assessments. ASD was associated with having young children, being unmarried, acute lymphocytic leukemia, and greater physical symptom burden. Persistent or recurrent ASD was associated with female sex, acute lymphocytic leukemia, greater attachment anxiety, less spiritual well-being, and less satisfactory patient-clinician communication.Conclusions: Symptoms of ASD are common and often persist or recur following diagnosis or relapse of AL. Research is urgently needed to determine the impact of interventions to prevent and treat psychological distress in this population. [ABSTRACT FROM AUTHOR]

Background: Arguably the uptake and usability of the physical activity (PA) guidelines for older adults has not been effective with only 12% of this population meeting the minimum guidelines to maintain health. Health promoters must consider innovative ways to increase PA adoption and long-term sustainability. Physical literacy (PL) is emerging as a promising strategy to increase lifelong PA participation in younger age-groups, yet there is relatively little evidence of PL being used to support older adults in achieving the PA guidelines.Methods: An iterative and mixed-methods consensus development process was utilized over a series of six informed processes and meetings to develop a model of physical literacy for adults aged 65 years and older.Results: A multi-disciplinary collaborative working group (n = 9) from diverse practice settings across Canada, and representative and reflective of the full range of key elements of PL, was assembled. Three consensus meetings and two Delphi surveys, using an international cohort of 65 expert researchers, practitioners, non-government organizations and older adults, was conducted. 45% responded on the first round and consensus was achieved; however, we elected to run a second survey to support our results. With 79% response rate, there was consensus to support the new PL model for older adults.Conclusion: Older adults are a unique group who have yet to be exposed to PL as a means to promote long-term PA participation. This new PL model uses an ecological approach to integrate PL into the lifestyles of most older adults. Understanding the interactions between components and elements that facilitate PL will ultimately provide a new and effective tool to target PA promotion and adherence for all older Canadians. [ABSTRACT FROM AUTHOR]

Background: Multiple external environmental exposures related to residential location and urban form including, air pollutants, noise, greenness, and walkability have been linked to health impacts or benefits. The Canadian Urban Environmental Health Research Consortium (CANUE) was established to facilitate the linkage of extensive geospatial exposure data to existing Canadian cohorts and administrative health data holdings. We hypothesize that this linkage will enable investigators to test a variety of their own hypotheses related to the interdependent associations of built environment features with diverse health outcomes encompassed by the cohorts and administrative data.Methods: We developed a protocol for compiling measures of built environment features that quantify exposure; vary spatially on the urban and suburban scale; and can be modified through changes in policy or individual behaviour to benefit health. These measures fall into six domains: air quality, noise, greenness, weather/climate, and transportation and neighbourhood factors; and will be indexed to six-digit postal codes to facilitate merging with health databases. Initial efforts focus on existing data and include estimates of air pollutants, greenness, temperature extremes, and neighbourhood walkability and socioeconomic characteristics. Key gaps will be addressed for noise exposure, with a new national model being developed, and for transportation-related exposures, with detailed estimates of truck volumes and diesel emissions now underway in selected cities. Improvements to existing exposure estimates are planned, primarily by increasing temporal and/or spatial resolution given new satellite-based sensors and more detailed national air quality modelling. Novel metrics are also planned for walkability and food environments, green space access and function and life-long climate-related exposures based on local climate zones. Critical challenges exist, for example, the quantity and quality of input data to many of the models and metrics has changed over time, making it difficult to develop and validate historical exposures.Discussion: CANUE represents a unique effort to coordinate and leverage substantial research investments and will enable a more focused effort on filling gaps in exposure information, improving the range of exposures quantified, their precision and mechanistic relevance to health. Epidemiological studies may be better able to explore the common theme of urban form and health in an integrated manner, ultimately contributing new knowledge informing policies that enhance healthy urban living. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Psychiatry is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)