Search

Background Immigrant women are at greater risk for postpartum depression than native-born women and face multiple barriers to accessing services. Service providers themselves face challenges in delivering accessible care for immigrant women with postpartum depression.Purpose This research explored provider perspectives on facilitators and barriers providers faced in terms of providing accessible services.Methods The study used an interpretive descriptive design, shaped by an integrated knowledge user–researcher partnership. Fourteen health and social service providers participated in individual in-depth interviews. Using a socioecological framework as an organizing structure, an inductive thematic content analysis was conducted.Results Providers identified attributes that foster relationship building, including building trust, addressing power dynamics, understanding women’s experiences, enacting cultural competence, involving family members, providing adequate time, and facilitating system navigation. Organizational features shaping accessibility included assessment and treatment approaches, wait times, gate keeping, and the ability to address social health determinants. Different organizational approaches could facilitate or discourage service coordination across organizations. Finally, providers believed that health and immigration system mechanisms could work more effectively for optimal postpartum depression support.Conclusion Health service providers are critical in supporting immigrant women with postpartum depression and facilitating service accessibility. Organizational and system gaps restrict optimal postpartum depression service provision and integration.

Study design:Cross-sectional.Objectives:The objective of the study was to determine and report agreement in fracture risk stratification of adults with spinal cord injury (SCI) using (1) Canadian Association of Radiologists and Osteoporosis Canada (CAROC) and Canadian Fracture Risk Assessment (FRAX) tools with and without areal bone mineral density (aBMD) and (2) SCI-specific fracture thresholds.Setting:Tertiary rehabilitation center, Ontario, Canada.Methods:Community-dwelling adults with chronic SCI (n=90, C2-T12, AIS A–D) consented to participation. Femoral neck aBMD values determined 10-year fracture risk (CAROC and FRAX). Knee-region aBMD and distal tibia volumetric BMD values were compared to SCI-specific fracture thresholds. Agreements between CAROC and FRAX risk stratifications, and between fracture threshold risk stratification, were assessed using prevalence- and bias-adjusted Kappa statistics (PABAK).Results:CAROC and FRAX assessment tools showed moderate agreement for post-menopausal women (PABAK=0.56, 95% confidence interval (CI): 0.27, 0.84) and men aged ⩾50 years (PABAK=0.51, 95% CI: 0.34, 0.67), with poor agreement for young men and pre-menopausal women (PABAK⩽0). Excellent agreement was evident between FRAX with and without aBMD in young adults and in those with motor incomplete injury (PABAK=0.86–0.92). In other subgroups, agreement ranged from moderate to substantial (PABAK=0.41–0.73). SCI-specific fracture thresholds (Eser versus Garland) showed poor agreement (PABAK⩽0).Conclusion:Fracture risk estimates among individuals with SCI vary substantially with the risk assessment tool. Use of SCI-specific risk factors to identify patients with high fracture risk is recommended until a validated SCI-specific tool for predicting fracture risk is developed.

Background: While chronic pain has been said to impact patient's response to methadone maintenance treatment for opioid dependence, the reported findings are inconsistent. These discrepancies may be a direct result of variations in the measurement of chronic pain or definitions of response to methadone treatment. The goal of this study is to evaluate the association between pain and substance use behaviour to determine the real impact of comorbid pain in the methadone population. We also aim to examine sources of variation across the literature with a specific focus on the measurement of pain. Methods/Design: We performed a systematic review using an electronic search strategy across CINAHL, MEDLINE, Web of Science, PsychINFO, EMBASE, and the Cochrane Library including Cochrane Reviews and the Cochrane Central Register of Controlled Trials databases. Title, abstract, as well as full text screening and extraction were performed in duplicate. Studies evaluating the association between chronic pain and methadone maintenance treatment response were eligible for inclusion in this review. Using a sample of 297 methadone patients from the Genetics of Opioid Addiction (GENOA) research collaborative, we assessed the reliability of patient self-reported pain and the validated Brief Pain Inventory (BPI) assessment tool. Results: After screening 826 articles we identified five studies eligible for full text extraction, of which three showed a significant relationship between the presence of pain and the increase in substance abuse among patients on methadone for the treatment of opioid dependence. Studies varied largely in the definitions and measurement of both pain and response to treatment. Results from our validation of pain measurement in the GENOA sample (n=297) showed the use of a simple self-reported pain question is highly correlated to the use of the BPI. Simply asking patients whether they have pain showed a 44.2% sensitivity, 88.8% specificity, 84.4% PPV and 53.6% NPV to the BPI. The area under the ROC curve was 0.67 and the Pearson ?2was 37.3; (p<0.0001). Discussion: The field of addiction medicine is at a lack of consensus as to the real effect of chronic pain on treatment response among opioid dependent patients. Whether it be the lack of a single “gold standard” measurement of response, or a lack of consistent measurement of pain, it is difficult to summarize and compare the results of these relatively small investigations. In comparison to the BPI, use of the simple self-reported pain has lower sensitivity for identifying patients with pain, suggesting the inconsistencies in these studies may result from differences in pain measurement. Future validation studies of pain measurement are required to address the predictive value of self-reported pain.

Empiric antibiotic therapy is often prescribed prior to the availability of bacterial culture results. In some cases, the organism isolated may not be susceptible to initial empiric therapy (inadequate empiric therapy or IET). In solid-organ transplant recipients, the overall incidence and clinical importance of IET is unknown. We performed a retrospective cohort study of patients admitted from 2002 to 2004. Multiple logistic regression analyses were conducted to determine associations between potential determinants and mortality. IET was administered in 169/312 (54%) patients, with a hospital mortality rate that was significantly greater than those receiving adequate therapy (24.9% vs. 7.0%; relative risk [RR] 3.55; 95% confidence interval [CI], 1.85–6.83; p < 0.001). Regression analysis demonstrated that an increasing duration of IET (adjusted odds ratio [OR] at 24h: 1.33; 95% CI: 1.15–1.53; p < 0.001), ICU-associated infections (adjusted OR: 6.27; 95% CI: 2.79–14.09; p < 0.001), prior antibiotic use (adjusted OR: 3.56; 95% CI: 1.51–8.41; p = 0.004) and increasing APACHE-II scores (adjusted OR: 1.26; 95% CI: 1.16–1.34; p < 0.001) were independently correlated with hospital mortality. IET is common and appears to be associated with an increased hospital mortality rate in the solid-organ transplant population.

Empiric antibiotic therapy is often prescribed prior to the availability of bacterial culture results. In some cases, the organism isolated may not be susceptible to initial empiric therapy (inadequate empiric therapy or IET). In solid-organ transplant recipients, the overall incidence and clinical importance of IET is unknown. We performed a retrospective cohort study of patients admitted from 2002 to 2004. Multiple logistic regression analyses were conducted to determine associations between potential determinants and mortality. IET was administered in 169312 (54) patients, with a hospital mortality rate that was significantly greater than those receiving adequate therapy (24.9 vs. 7.0; relative risk RR 3.55; 95 confidence interval CI, 1.85-6.83; p < 0.001). Regression analysis demonstrated that an increasing duration of IET (adjusted odds ratio OR at 24 h: 1.33; 95 CI: 1.15-1.53; p < 0.001), ICU-associated infections (adjusted OR: 6.27; 95 CI: 2.79-14.09; p < 0.001), prior antibiotic use (adjusted OR: 3.56; 95 CI: 1.51-8.41; p 0.004) and increasing APACHE-II scores (adjusted OR: 1.26; 95 CI: 1.16-1.34; p < 0.001) were independently correlated with hospital mortality. IET is common and appears to be associated with an increased hospital mortality rate in the solid-organ transplant population.

Introduction:eCTAS is a real time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The tool dynamically calculates a recommended CTAS score based on the presenting complaint, vital signs and selected clinical modifiers. The primary objective was to assess consistency of CTAS score distributions across 35 emergency departments (EDs) by 16 presenting complaints pre and post eCTAS implementation. Methods:This retrospective cohort study used population-based administrative data from January 2016 to December 2018 from all hospital EDs in Ontario that had implemented eCTAS with at least 9 months of data. Following a 3-month stabilization period, we compared data for 6 months post-eCTAS implementation to the same 6-month period the previous year (pre-implementation) to account for potential seasonal variation, patient volume and case-mix. We included triage encounters of adult (≥18 years) patients if they had one of 16 pre-specified high-volume, presenting complaints. A paired-samples t-test was used to determine consistency by estimating the absolute difference in CTAS distribution for each presenting complaint, by each hospital, pre and post eCTAS implementation, compared to the overall average of the 35 EDs. Results:There were 183,231 triage encounters in the pre-eCTAS cohort and 179,983 in the post-eCTAS cohort from 35 EDs across the province. Triage scores were more consistent with the overall average after eCTAS implementation in 6 (37.5%) presenting complaints: chest pain (cardiac features) (p < 0.001), extremity weakness/symptoms of cerebrovascular accident (p < 0.001), fever (p < 0.001), shortness of breath (p < 0.001), syncope (p = 0.02), and hyperglycemia (p = 0.03). Triage consistency was similar pre and post eCTAS implementation for the presenting complaints of altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication or vertigo. Conclusion:A standardized, electronic approach to performing triage assessments increased consistency in CTAS scores across many, but not all, high-volume CEDIS complaints. This does not reflect triage accuracy, as there are no known benchmarks for triage accuracy. Improvements in consistency were greatest for sentinel presenting complaints with a minimum allowable CTAS score.

In this paper, we derive prediction distribution of future response(s) from the normal distribution assuming a generalized inverse Gaussian (GIG) prior density for the variance. The GIG includes as special cases the inverse Gaussian, the inverted chi-squared and gamma distributions. The results lead to Bessel-type prediction distributions which is in contrast with the Student-tdistributions usually obtained using the inverted chi-squared prior density for the variance. Further, the general structure of GIG provides us with new flexible prediction distributions which include as special cases most of the earlier results obtained under normal-inverted chi-squared or vague priors.

In this note, an alternative approach to the multivariate Behrens-Fisher problem is presented in the Bayesian setup. We use the Kullback-Leibler di-vergence measure to assess the discrepancy between the "null" model and the "alternative" model. We then use the Bayesian approach to minimize the posterior expectation of the distance between the two models. A simulation study using bootstrap methods in the bivariate case is presented to demonstrate the implementation of the test procedure derived.

In this note, an alternative approach to the multivariate Behrens-Fisher problem is presented in the Bayesian setup. We use the Kullback-Leibler divergence measure to assess the discrepancy between the "null" model and the "alternative" model. We then use the Bayesian approach to minimize the posterior expectation of the distance between the two models. A simulation study using bootstrap methods in the bivariate case is presented to demonstrate the implementation of the test procedure derived.

Introduction:Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1-2% of the population. Oral anticoagulation (OAC) reduces stroke risk by 60-80% in AF patients, but only 50% of indicated patients receive OAC. Many patients present to the ED with AF due to arrhythmia symptoms, however; lack of OAC prescription in the ED has been identified as a significant gap in the care of AF patients. Methods:This was a multi-center, pragmatic, three-phase before-after study, in three Canadian sites. Patients who presented to the ED with electrocardiographically (ECG) documented, nonvalvular AF and were discharged home were included. Phase 1 was a retrospective chart review to determine OAC prescription of AF patients in each ED; Phase 2 was a low-intensity knowledge translation intervention where a simple OAC-prescription tool for ED physicians with subsequent short-term OAC prescription was used, as well as an AF patient education package and a letter to family physicians; phase 3 incorporated Phase 2 interventions, but added immediate follow-up in a community AF clinic. The primaryoutcome of the study was the rate of new OAC prescriptions at ED discharge in AF patients who were OAC eligible and were not on OAC at presentation. Results:A total of 632 patients were included from June, 2015-November, 2016. ED census ranged from 30000-68000 annual visits. Mean age was 71±15, 67±12, 67±13 years, respectively. 47.5% were women, most responsible ED diagnosis was AF in 75.8%. The mean CHA2DS2-VASc score was 2.6±1.8, with no difference amongst groups. There were 266 patients eligible for OAC and were not on this at presentation. In this group, the prescription of new OAC was 15.8% in Phase 1 as compared to 54% and 47%, in Phases 2 and 3, respectively. After adjustment for center, components of the CHA2DS2-VASc score, prior risk of bleeding and most responsible ED diagnosis, the odds ratio for new OAC prescription was 8.0 (95%CI (3.5,18.3) p<0.001) for Phase 3 vs 1, and 10.0 (95%CI (4.4,22.9) p<0.001), for Phase 2 vs 1). No difference in OAC prescription was seen between Phases 2 and 3. Conclusion:Use of a simple OAC-prescription tool was associated with an increase in new OAC prescription in the ED for eligible patients with AF. Further testing in a rigorous study design to assess the effect of this practice on stroke prevention in the AF patients who present to the ED is indicated.

Although Health Canada approved generic warfarins in Year 2000, there is still controversy over the interchangeability of these products with brand-name Coumadin. Since a large population of patients require warfarin and it has a narrow margin of efficacy and safety, it is vital to ensure that generic brands can be safely interchanged with Coumadin.Multiple N-of-1 randomized double blind crossover trials switched outpatients between generic warfarin and Coumadin over a period of thirty weeks. Study patients were on each drug for 5 × 3-week periods with International Normalized Ratio (INR) measurements twice per period. Outcomes included mean INR results and proportion of dosage adjustments that were required with each brand. Inter-patient and intra-patient differences between generic warfarin and Coumadin were compared. Study patient results were also compared with those of a retrospective control group, maintained on Coumadin only.The 6 patients (96% power to detect a difference of greater than 0.5 INR units between warfarin brands) showed no significant difference between warfarin brands in terms of mean INR results (p = 0.485) and proportion of dosage adjustments required with each brand (p = 0.264). Study patients experienced less inter- and intra-subject INR variation than the historical control group, though the difference was not statistically significant. Patients can safely and effectively switch between generic warfarin and Coumadin.Clinical Pharmacology & Therapeutics (2004) 75, P27–P27; doi: 10.1016/j.clpt.2003.11.103