Search

Background The estimated effect of cigarette graphic warning labels (GWL) on smoking rates is a key input to the Food and Drug Administration's (FDA) regulatory impact analysis (RIA), required by law as part of its rule-making process. However, evidence on the impact of GWLs on smoking prevalence is scarce. Objective The goal of this paper is to critically analyse FDA's approach to estimating the impact of GWLs on smoking rates in its RIA, and to suggest a path forward to estimating the impact of the adoption of GWLs in Canada on Canadian national adult smoking prevalence. Methods A quasi-experimental methodology was employed to examine the impact of adoption of GWLs in Canada in 2000, using the USA as a control. Findings We found a statistically significant reduction in smoking rates after the adoption of GWLs in Canada in comparison with the USA. Our analyses show that implementation of GWLs in Canada reduced smoking rates by 2.87-4.68 percentage points, a relative reduction of 12.1-19.6%; 33-53 times larger than FDA's estimates of a 0.088 percentage point reduction. We also demonstrated that FDA's estimate of the impact was flawed because it is highly sensitive to the changes in variable selection, model specification, and the time period analysed. Conclusions Adopting GWLs on cigarette packages reduces smoking prevalence. Applying our analysis of the Canadian GWLs, we estimate that if the USA had adopted GWLs in 2012, the number of adult smokers in the USA would have decreased by 5.3-8.6 million in 2013. Our analysis demonstrates that FDA's approach to estimating the impact of GWLs on smoking rates is flawed. Rectifying these problems before this approach becomes the norm is critical for FDA's effective regulation of tobacco products. [ABSTRACT FROM AUTHOR]

Background Fewer than half of individuals with a mental disorder seek formal care in a given year. Much research has been conducted on the factors that influence service use in this population, but the methods generally used cannot easily identify the complex interactions that are thought to exist. In this paper, we examine predictors of subsequent service use among respondents to a population health survey who met criteria for a past-year mood, anxiety or substance-related disorder. Methods To determine service use, we use an administrative database including all physician consultations in the period of interest. To identify predictors, we use classification tree (CART) analysis, a data mining technique with the ability to identify unsuspected interactions. We compare results to those from logistic regression models. Results We identify 1213 individuals with past-year disorder. In the year after the survey, 24% (n=312) of these had a mental health-related physician consultation. Logistic regression revealed that age, sex and marital status predicted service use. CART analysis yielded a set of rules based on age, sex, marital status and income adequacy, with marital status playing a role among men and by income adequacy important among women. CART analysis proved moderately effective overall, with agreement of 60%, sensitivity of 82% and specificity of 53%. Conclusion Results highlight the potential of data-mining techniques to uncover complex interactions, and offer support to the view that the intersection of multiple statuses influence health and behaviour in ways that are difficult to identify with conventional statistics. The disadvantages of these methods are also discussed. [ABSTRACT FROM AUTHOR]

Objective Graduated Driver Licensing (GDL) has been implemented in Australia, Canada, New Zealand, USA and Israel. We conducted an exploratory summary of available data to estimate whether GDL effects varied with age. Methods We searched MEDLINE and other sources from 1991-2011. GDL evaluation studies with crashes resulting in injuries or deaths were eligible. They had to provide age-specific incidence rate ratios with CI or information for calculating these quantities. We included studies from individual states or provinces, but excluded national studies. We examined rates based on person-years, not license-years. Results Of 1397 papers, 144 were screened by abstract and 47 were reviewed. Twelve studies from 11 US states and one Canadian province were selected for meta-analysis for age 16, eight were selected for age 17, and four for age 18. Adjusted rate ratios were pooled using random effects models. The pooled adjusted rate ratios for the association of GDL presence with crash rates was 0.78 (95% CI 0.72 to 0.84) for age 16 years, 0.94 (95% CI 0.93 to 0.96) for 17 and 1.00 (95% CI 0.95 to 1.04) for 18. The difference between these three rate ratios was statistically significant: p<0.001. Conclusions GDL policies were associated with a 22% reduction in crash rates among 16-year-old drivers, but only a 6% reduction for 17-year-old drivers. GDL showed no association with crashes among 18-year-old drivers. Because we had few studies to summarise, particularly for older adolescents, our findings should be considered exploratory. [ABSTRACT FROM AUTHOR]

The article discusses a survey on smokers that assessed if the relationship between beliefs and smoking behaviors was in consistent with Cognitive Dissonance Theory. It included adult smokers from Canada, U.S., Great Britain and Australia. The findings revealed that smokers with no intetion of quitting across the three waves, were inclined towards the highest levels of rationalizations for smoking. It suggests studies to determine if the change in beliefs has any effect on intentions to quit.

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]

Background and aims Bicycling may be less appealing in parts of the world where cycling is less safe. Differences between jurisdictions suggest route design is key to improving safety and increasing ridership. Previous studies faced difficulties in effectively assessing denominators for risk calculations and controlling confounding. This paper describes the advantages of the case-crossover design of the Bicyclists' Injuries and the Cycling Environment study to address these challenges to observational studies of cycling safety. Methods Injured cyclists were recruited from the emergency departments of five hospitals in Vancouver and Toronto, Canada. In 18 months, 690 participants were successfully recruited and interviewed. Each participant was interviewed to map the route of their injury trip, identify the injury site and select two control sites at random from the same route. Infrastructural characteristics at each study site were scored by site observers who were blinded as to whether sites were crash or comparison sites. Analyses will compare infrastructural variables between case and control sites with conditional logistic regression. Discussion This study presents a novel application of the case-crossover design to the evaluation of relationships between infrastructure and cycling safety while controlling confounders and exposure to risk. It is hoped that the value of this method and the efficiency of the recruitment process will encourage replication in other locations, to expand the range of cycling infrastructure compared and to facilitate evidence-based cycling infrastructure choices that can make cycling safer and more appealing. [ABSTRACT FROM AUTHOR]

Introduction E-cigarettes present a formidable challenge to regulators given their variety and the rapidly evolving nicotine market. The current study sought to examine the influence of e-cigarette product characteristics on consumer perceptions and trial intentions among Canadians. Methods An online discrete choice experiment was conducted with 915 Canadians aged 16 years and older in November 2013. An online commercial panel was used to sample 3 distinct subpopulations: (1) non-smoking youth and young adults (n=279); (2) smoking youth and young adults (n=264) and (3) smoking adults (n=372). Participants completed a series of stated-preference tasks, in which they viewed choice sets with e-cigarette product images that featured different combinations of attributes: flavour, nicotine content, health warnings and price. For each choice set, participants were asked to select one of the products or indicate 'none of the above' with respect to the following outcomes: interest in trying, less harm and usefulness in quitting smoking. The attributes' impact on consumer choice for each outcome was analysed using multinomial logit regression. Results Health warning was the most important attribute influencing participants' intentions to try e-cigarettes (42%) and perceived efficacy as a quit aid (39%). Both flavour (36%) and health warnings (35%) significantly predicted perceptions of product harm. Conclusions The findings indicate that consumers make trade-offs with respect to e-cigarette product characteristics, and that these trade-offs vary across different subpopulations. Given that health warnings and flavour were weighted most important by consumers in this study, these may represent good targets for e-cigarette regulatory frameworks. [ABSTRACT FROM AUTHOR]

Background Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. Objective The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. Methods The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. Results Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. Conclusions Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required. [ABSTRACT FROM AUTHOR]

Objective To analyse the evolution and diffusion of health warnings on cigarette packs around the world, including tobacco industry attempts to block this diffusion. Methods We analysed tobacco industry documents and public sources to construct a database on the global evolution and diffusion of health warning labels from 1966 to 2012, and also analysed industry strategies. Results Health warning labels, especially labels with graphic elements, threaten the tobacco industry because they are a low-cost, effective measure to reduce smoking. Multinational tobacco companies did not object to voluntary innocuous warnings with ambiguous health messages, in part because they saw them as offering protection from lawsuits and local packaging regulations. The companies worked systematically at the international level to block or weaken warnings once stronger more specific warnings began to appear in the 1970s. Since 1985 in Iceland, the tobacco industry has been aware of the effectiveness of graphic health warning labels (GWHL). The industry launched an all-out attack in the early 1990s to prevent GHWLs, and was successful in delaying GHWLs internationally for nearly 10 years. Conclusions Beginning in 2005, as a result of the World Health Organisation Framework Convention on Tobacco Control (FCTC), GHWLs began to spread. Effective implementation of FCTC labelling provisions has stimulated diffusion of strong health warning labels despite industry opposition. [ABSTRACT FROM AUTHOR]

Background Super slim cigarettes are a relatively new type of cigarette in Canada, and an analysis of select toxicants in the mainstream smoke emissions of the super slim cigarette was conducted. Method The yields of selected toxicants in the mainstream smoke emissions of six brands of super slim cigarettes were compared with the Canadian Benchmark, which represents the cigarette designs most commonly found in Canada. A super slim cigarette was also compared with a 'Reference Cigarette' to study the impact of the significantly reduced circumference on mainstream smoke emissions. Results Compared with the Canadian Benchmark, the yields of carbon monoxide, the carbonyls, volatiles and the aromatic amines were significantly lower for the super slim cigarette, but the yields of formaldehyde and ammonia were significantly higher. For brands containing a mixed tobacco blend, the yields of tobacco-specific nitrosamines were increased significantly. The reduced circumference of the super slim cigarette resulted in a lower tobacco weight, which together with filter ventilation resulted in lower yields of many toxicants. However, the reduced circumference increased significantly the yields of formaldehyde and phenols in mainstream smoke emissions. Conclusions The notably slimmer design of the super slim cigarette resulted in lower yields of some toxicants in the mainstream smoke emissions. However, there were also significant increases in some toxicant levels in the mainstream smoke emissions including formaldehyde, ammonia and the phenols. There are no changes in emission levels that have been shown to reduce exposure or risk in a way that is meaningful, and therefore, the super slim cigarette should not be considered a 'less harmful' cigarette. [ABSTRACT FROM AUTHOR]

Introduction Health warning labels (HWLs) on tobacco packaging can be used to provide smoking cessation information, but the impact of this information is not well understood. Methods Online consumer panels of adult smokers from Canada, Australia and Mexico were surveyed in September 2012, January 2013 and May 2013; replenishment was used to maintain sample sizes of 1000 participants in each country at each wave. Country-stratified logistic Generalised Estimating Equation (GEE) models were estimated to assess correlates of citing HWLs as a source of information on quitlines and cessation websites. GEE models also regressed having called the quitline, and having visited a cessation website, on awareness of these resources because of HWLs. Results At baseline, citing HWLs as a source of information about quitlines was highest in Canada, followed by Australia and Mexico (33%, 19% and 16%, respectively). Significant increases over time were only evident in Australia and Mexico. In all countries, citing HWLs as a source of quitline information was significantly associated with self-report of having called a quitline. At baseline, citing HWLs as a source of information about cessation websites was higher in Canada than in Australia (14% and 6%, respectively; Mexico was excluded because HWLs do not include website information), but no significant changes over time were found for either country. Citing HWLs as a source of information about cessation websites was significantly associated with having visited a website in both Canada and Australia. Conclusions HWLs are an important source of cessation information. [ABSTRACT FROM AUTHOR]

Background: There appears to be considerable variation between different national jurisdictions and between different sectors of public policy in the use of evidence and particularly the use of randomised controlled trials (RCTs) to evaluate non-healthcare sector programmes. Methods: As part of a wider study attempting to identify RCTs of public policy sector programmes and the reasons for variation between countries and sectors in their use, we carried out a pilot study which interviewed 10 policy makers and researchers in six countries to elicit views on barriers to and facilitators of the use of RCTs for social programmes. Results: While in common with earlier studies, those interviewed expressed a need for unambiguous findings, timely results and significant effect sizes, users could, in fact, be ambivalent about robust methods and robust answers about what works, does not work or makes no difference, particularly where investment or a policy announcement was planned. Different national and policy sector cultures varied in their use of and support for RCTs. Conclusions: In order to maximise the use of robust evaluations of public programmes across the world it would be useful to examine, systematically, cross-national and cross-sectoral variations in the use of different methods including RCTs and barriers to and facilitators of their use. Sound research methods, whatever their scientific value, are no guarantee that findings will be useful or used. 'Stories' have been shown to influence policy; those advocating the use of RCTs may need to provide convincing narratives to avoid repetition about their value. [ABSTRACT FROM AUTHOR]

Background Although most countries now have at least some restrictions on tobacco marketing, the tobacco industry meet these restrictions by re-allocating expenditure to unregulated channels, such as at point-of-purchase. Methods Longitudinal data from 10 Canadian provinces in the International Tobacco Control Survey was analysed to examine adult smokers' support for a ban on tobacco advertising and displays in stores and whether this support is associated with noticing either advertising or displays in stores, and quit intentions, over time. In total, there were 4580 respondents in wave 5 (October 2006 to February 2007), wave 6 (September 2007 to February 2008) and wave 7 (October 2008 to June 2009). The surveys were conducted before, during and in some cases after the implementation of display bans in most Canadian provinces and territories. Results Smokers in all provinces showed strong support for a ban on tobacco displays over the study period. Levels of support for an advertising and display ban were comparable between Canadian provinces over time, irrespective of whether they had been banned or not. Noticing tobacco displays and signs in-store was demonstrably less likely to predict support for displays (OR=0.73, p=0.005) and advertising (OR=0.78, p=0.02) ban, respectively. Smokers intending to quit were more likely to support advertising and display bans over time. Conclusion This study serves as a timely reminder that the implementation of tobacco control measures, such as the removal of tobacco displays, appear to sustain support among smokers, those most likely to oppose such measures. [ABSTRACT FROM AUTHOR]

Background Learning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the educational benefits of failure, acknowledged as a critical resource for developing competence and resilience. While other educational domains allow failure in service of learning, however, we do not know whether or not this strategy applies to clinical training. Methods We conducted individual interviews of clinical supervisors, asking them whether they allowed failure for educational purposes in clinical training and eliciting their experiences of this phenomenon. Participants' accounts were descriptively analysed for recurring themes. Results Twelve women and seven men reported 48 specific examples of allowing trainee failure based on their judgement that educational value outweighed patient risk. Various kinds of failures were allowed: both during operations and technical procedures, in medication dosing, communication events, diagnostic procedures and patient management. Most participants perceived minimal consequences for patients, and many described their rescue strategies to prevent an allowed failure. Allowing failure under supervision was perceived to be important for supporting trainee development. Conclusion Clinical supervisors allow trainees to fail for educational benefit. In doing so, they attempt to balance patient safety and trainee learning. The educational strategy of allowing failure may appear alarming in the zero-error tolerant culture of healthcare with its commitment to patient safety. However, supervisors perceived this strategy to be invaluable. Viewing failure as inevitable, they wanted trainees to experience it in protected situations and to develop effective technical and emotional responses. More empirical research is required to excavate this tacit supervisory practice and support its appropriate use in workplace learning to ensure both learning and safety. [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]

Objectives To compare emergency hospital use for infants in Ontario (Canada) and England. Methods We conducted a population-based data linkage study in infants born ≥34 weeks' gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission. Results The percentage of infants with >1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥ 1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34-36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age. Conclusions Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community. [ABSTRACT FROM AUTHOR]

Background Obesity prevalence varies between geographic regions in Canada. The reasons for this variation are unclear but most likely implicate both individual-level and population-level factors. The objective of this study was to examine whether equalising correlates of body mass index (BMI) across these geographic regions could be reasonably expected to reduce differences in BMI distributions between regions. Methods Using data from three cycles of the Canadian Community Health Survey (CCHS) 2001, 2003 and 2007 for males and females, we modelled between-region BMI cross-sectionally using quantile regression and Blinder-Oaxaca decomposition of the quantile regression results. Results We show that while individual-level variables (ie, age, income, education, physical activity level, fruit and vegetable consumption, smoking status, drinking status, family doctor status, rural status, employment in the past 12 months and marital status) may be Caucasian important correlates of BMI within geographic regions, those variables are not capable of explaining variation in BMI between regions. Discussion Equalisation of common correlates of BMI between regions cannot be reasonably expected to reduce differences in the BMI distributions between regions. [ABSTRACT FROM AUTHOR]

Background Several cross-sectional studies have demonstrated associations between diet quality, including fruit and vegetable consumption, and mental health. However, research examining these associations longitudinally, while accounting for related lifestyle factors (eg, smoking, physical activity) is scarce. Methods This study used data from the National Population Health Survey (NPHS), a large, national longitudinal survey of Canadians. The sample included 8353 participants aged 18 and older. Every 2 years from 2002/2003 to 2010/2011, participants completed self-reports of daily fruit and vegetable consumption, physical activity, smoking and symptoms of depression and psychological distress. Using generalised estimating equations, we modelled the associations between fruit and vegetable consumption at each timepoint and depression at the next timepoint, adjusting for relevant covariates. Results Fruit and vegetable consumption at each cycle was inversely associated with next-cycle depression (β= -0.03, 95% CI -0.05 to -0.01, p<0.01) and psychological distress (β=-0.03, 95% CI -0.05 to -0.02, p<0.0001). However, once models were adjusted for other health-related factors, these associations were attenuated (β=-0.01, 95% CI -0.04 to 0.02, p=0.55; β=-0.00, 95% CI -0.03 to 0.02, p=0.78 for models predicting depression and distress, respectively). Conclusions These findings suggest that relations between fruit and vegetable intake, other health-related behaviours and depression are complex. Behaviours such as smoking and physical activity may have a more important impact on depression than fruit and vegetable intake. Randomised control trials of diet are necessary to disentangle the effects of multiple health behaviours on mental health. [ABSTRACT FROM AUTHOR]

Background: One component of effective sexually transmitted infections (STIs) control is ensuring those at highest risk of STIs have access to clinical services because terminating transmission in this group will prevent most future cases. Here, we describe the results of a validation study of a clinical prediction rule for identifying individuals at increased risk for chlamydia and gonorrhoea infection derived in Vancouver, British Columbia (BC), against a population of asymptomatic patients attending sexual health clinics in other geographical settings in BC.Methods: We examined electronic records (2000-2012) from clinic visits at seven sexual health clinics in geographical locations outside Vancouver. The model's calibration and discrimination were examined by the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (H-L) statistic, respectively. We also examined the sensitivity and proportion of patients that would need to be screened at different cut-offs of the risk score.Results: The prevalence of infection was 5.3% (n=10 425) in the geographical validation population. The prediction rule showed good performance in this population (AUC, 0.69; H-L p=0.26). Possible risk scores ranged from -2 to 27. We identified a risk score cut-off point of ≥8 that detected cases with a sensitivity of 86% by screening 63% of the geographical validation population.Conclusions: The prediction rule showed good generalisability in STI clinics outside of Vancouver with improved discriminative performance compared with temporal validation. The prediction rule has the potential for augmenting triaging services in STI clinics and enhancing targeted testing in population-based screening programmes. [ABSTRACT FROM AUTHOR]

Objectives: We determined trends over time in the prevalence of neonatal drug withdrawal syndrome (NWS) in England compared with that reported in the USA, Western (W) Australia and Ontario, Canada. We also examined variation in prevalence of NWS according to maternal age, birth weight and across the English NHS by hospital trusts.Design and Setting: Retrospective study using national hospital administrative data (Hospital Episode Statistics) for the NHS in England between 1997 and 2011. NWS was identified using international classification of disease codes in hospital admission records. We searched the research literature and contacted researchers to identify studies reporting trends in the prevalence of NWS.Main Outcome Measures: Prevalence of NWS by calendar year per 1000 live births for each country/state. For births in England, prevalence by maternal age group and birth weight group. Prevalence by NHS trust and region at birth, and funnel plot to show outlying English NHS hospital trusts (>3 SD of mean prevalence).Main Results: Mean prevalence rates of recorded NWS increased in all four countries. Rates stabilised in England and W. Australia from the early 2000s and rose steeply in the USA and Ontario during the late 2000s. The most recent prevalence rates were 2.7/1000 live births in England (2011; 1544 cases); 2.7/1000 in W. Australia (2009); 3.6/1000 in the USA (2009) and 5.1/1000 in Ontario (2011). The highest prevalence in England was among babies born to mothers aged 25-34 years at delivery and among babies born with low birth weight (1500-2500 g). In England in 2011, 8.6% of hospital trusts had a recorded prevalence outside 3 SD of the overall average (7% above, 1% below). The North East region of England had the highest recorded prevalence of NWS.Conclusions: Although recorded NWS is stable in England and W. Australia, rising rates in the USA and Ontario may reflect better recognition and/or increased use of prescribed opiate analgesics and highlight the need for surveillance. The extent to which different prevalence rates by hospital trust reflect variation in occurrence, recognition or recording requires further investigation. [ABSTRACT FROM AUTHOR]

Relevant local injury epidemiology In Ottawa, between 2005 and 2009 there was an annual average of 47.2 head injuries due to ice skating in children and youth (1-19 years of age) requiring a visit to the emergency department, with the highest rates among those aged 5-14 years. Between 2002 and 2007, only 6% of children were wearing a helmet during ice skating when the head injury occurred. During indoor public skating sessions, 93% of children (<10 years)-57% aged 10-12 years, 20% aged 13-17 years and 9% adults-wore helmets in the absence of a policy. Support for a helmet policy was high from public health, medical, political and community perspectives. Best practice Helmet policies in relation to cycling have demonstrated increases in helmet use and reduction of head injuries without decreasing physical activity. However, no known studies have examined the effect of indoor ice skating helmet policy coupled with education and promotional activities on helmet use, participation and attitudes towards helmet use. Implementation An ice skating helmet policy for children (<11 years of age) and those with limited skating experience at indoor rinks during public skating sessions was developed, implemented and evaluated. Supportive activities such as discount coupons, promotional materials, a media launch, social marketing and staff training are described. Discussion The helmet policy was associated with increased helmet use for young children and for older children, youth and adults not included in the policy, without decreasing attendance to public skating sessions. [ABSTRACT FROM AUTHOR]

Background Characteristics of social environments are potential risk factors for adolescent injury. Impacts of social capital on the occurrence of such injuries have rarely been explored. Methods General health questionnaires were completed by 8910 youth aged 14 years and older as part of the 2010 Canadian Health Behaviour in School- Aged Children study. These were supplemented with community-level data from the 2006 Canada Census of Population. Multilevel logistic regression models with random intercepts were fit to examine associations of interest. The reliability and validity of variables used in this analysis had been established in past studies, or in new analyses that employed factor analysis. Results Between school differences explained 2% of the variance in the occurrence of injuries. After adjustment for all confounders, community social capital did not have any impact on the occurrence of injuries in boys: OR: 1.01, 95% CI 0.80 to 1.29. However, living in areas with low social capital was associated with lower occurrence of injuries in girls (OR 0.78, 95% CI 0.63 to 0.96). Other factors that were significantly related to injuries in both genders were younger age, engagement in more risky behaviours, and negative behavioural influences from peers. Conclusions After simultaneously taking into account the influence of community-level and individual-level factors, community levels of social capital remained a relatively strong predictor of injury among girls but not boys. Such gender effects provide important clues into the social aetiology of youth injury. [ABSTRACT FROM AUTHOR]

The article presents a study on the differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage (SAH) from a traumatic lumbar puncture. Topics covered include acute non-traumatic headache, the diagnosis of SAH with a sensitivity of 100 percent, and the relatively wide confidence interval around the sensitivity.

Background Recent work in comparative social epidemiology uses an expenditures approach to examine the link between welfare states and population health. More work is needed that examines the impact of disaggregated expenditures within nations. This study takes advantage of provincial differences within Canada to examine the effects of subnational expenditures and a provincial welfare generosity index on population health. Methods Time-series cross-sectional data are retrieved from the Canadian Socio-Economic Information Management System II Tables for 1989-2009 (10 provinces and 21 years=210 cases). Expenditures are measured using 20 disaggregated indicators, total expenditures and a provincial welfare generosity index, a ombined measure of significant predictors. Health is measured as total, male and female age-standardised mortality rates per 1000 deaths. Estimation techniques include the Prais-Winsten regressions with panel-corrected SEs, a first-order autocorrelation correction model, and fixed-unit effects, adjusted for alternative factors. Results Analyses reveal that four expenditures effectively reduce mortality rates: medical care, preventive care, other social services and postsecondary education. The provincial welfare generosity index has even larger effects. For an SD increase in the provincial welfare generosity index, total mortality rates are expected to decline by 0.44 SDs. Standardised effects are larger for women (β=-0.57, z(19)=-5.70, p<0.01) than for men (β=-0.38, z(19)=-5.59, p<0.01). Conclusions Findings show that the expenditures approach can be effectively applied within the context of Canadian provinces, and that targeted spending on health, social services and education has salutary effects. [ABSTRACT FROM AUTHOR]

Background Despite the internet's broad reach and potential to influence consumer behaviour, there has been little examination of the volume, characteristics, and target audience of online tobacco and e-cigarette advertisements. Methods A full-service advertising firm was used to collect all online banner/video advertisements occurring in the USA and Canada between 1 April 2012 and 1 April 2013. The advertisement and associated meta-data on brand, date range observed, first market, and spend were downloaded and summarised. Characteristics and themes of advertisements, as well as topic area and target demographics of websites on which advertisements appeared, were also examined. Results Over a 1-year period, almost $2 million were spent by the e-cigarette and tobacco industries on the placement of their online product advertisements in the USA and Canada. Most was spent promoting two brands: NJOY e-cigarettes and Swedish Snus. There was almost no advertising of cigarettes. About 30% of all advertisements mentioned a price promotion, discount coupon or price break. e-Cigarette advertisements were most likely to feature messages of harm reduction (38%) or use for cessation (21%). Certain brands advertised on websites that contained up to 35% of youth (<18 years) as their audience. Conclusions Online banner/video advertising is a tactic used mainly to advertise e-cigarettes and cigars rather than cigarettes, some with unproven claims about benefits to health. Given the reach and accessibility of online advertising to vulnerable populations such as youth and the potential for health claims to be misinterpreted, online advertisements need to be closely monitored. [ABSTRACT FROM AUTHOR]

Introduction Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We consider factors underlying these two approaches. Methods We used a qualitative case study design employing in-depth interviews with 40 healthcare practitioners in a tertiary care hospital in Ontario, Canada. We conducted a thematic analysis, and compared the findings with the literature. Results 'Fixing and forgetting' was the main choice that most practitioners made in situations where they faced problems that they themselves could resolve. These situations included (A) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, (B) prioritising solving individual patients' safety problems, which were viewed as unique or one-time events and (C) encountering re-occurring safety problems, which were framed as inevitable, routine events. In only a few instances was 'fixing and reporting' mentioned as a way that the providers dealt with problems that they could resolve. Conclusions We found that generally healthcare providers do not prioritise reporting if a safety problem is fixed. We argue that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with recent calls for patient safety to be more preventive. We consider implications for practice. [ABSTRACT FROM AUTHOR]

Background There are limited data on the composition and smoke emissions of 'herbal' shisha products and the air quality of establishments where they are smoked. Methods Three studies of 'herbal' shisha were conducted: (1) samples of 'herbal' shisha products were chemically analysed; (2) 'herbal' and tobacco shisha were burned in a waterpipe smoking machine and main and sidestream smoke analysed by standard methods and (3) the air quality of six waterpipe cafés was assessed by measurement of CO, particulate and nicotine vapour content. Results We found considerable variation in heavy metal content between the three products sampled, one being particularly high in lead, chromium, nickel and arsenic. A similar pattern emerged for polycyclic aromatic hydrocarbons. Smoke emission analyses indicated that toxic byproducts produced by the combustion of 'herbal' shisha were equivalent or greater than those produced by tobacco shisha. The results of our air quality assessment demonstrated that mean PM2.5 levels and CO content were significantly higher in waterpipe establishments compared to a casino where cigarette smoking was permitted. Nicotine vapour was detected in one of the waterpipe cafés. Conclusions 'Herbal' shisha products tested contained toxic trace metals and PAHs levels equivalent to, or in excess of, that found in cigarettes. Their mainstream and sidestream smoke emissions contained carcinogens equivalent to, or in excess of, those of tobacco products. The content of the air in the waterpipe cafés tested was potentially hazardous. These data, in aggregate, suggest that smoking 'herbal' shisha may well be dangerous to health. [ABSTRACT FROM AUTHOR]

Background To examine unintentional drowning mortality by age and body of water across 60 countries, to provide a starting point for further in-depth investigations within individual countries. Methods The latest available three years of mortality data for each country were extracted from WHO Health Statistics and Information Services (updated at 13 November 2013). We calculated mortality rate of unintentional drowning by age group for each country. For countries using International Classification of Disease 10 (ICD-10) detailed 3 or 4 Character List, we further examined the body of water involved. Results A huge variation in age-standardised mortality rate (deaths per 100 000 population) was noted, from 0.12 in Turkey to 9.19 in Guyana. Of the ten countries with the highest age-standardised mortality rate, six (Belarus, Lithuania, Latvia, Russia, Ukraine and Moldova) were in Eastern Europe and two (Kazakhstan and Kyrgyzstan) were in Central Asia. Some countries ( Japan, Finland and Greece) had a relatively low rank in mortality rate among children aged 0-4 years, but had a high rank in mortality rate among older adults. On the contrary, South Africa and Colombia had a relatively high rank among children aged 0-4 years, but had a relatively low rank in mortality rate among older adults. With regard to body of water involved, the proportion involving a bathtub was extremely high in Japan (65%) followed by Canada (11%) and the USA (11%). Of the 13 634 drowning deaths involving bathtubs in Japan between 2009 and 2011, 12 038 (88%) were older adults aged 65 years or above. The percentage involving a swimming pool was high in the USA (18%), Australia (13%), and New Zealand (7%). The proportion involving natural water was high in Finland (93%), Panama (87%), and Lithuania (85%). Conclusions After considering the completeness of reporting and quality of classifying drowning deaths across countries, we conclude that drowning is a highpriority public health problem in Eastern Europe, Central Asia, Japan (older adults involving bathtubs), and the USA (involving swimming pools). [ABSTRACT FROM AUTHOR]

The article discusses a follow-up research to the Canadian National Breast Screening Study which investigated impact of annual mammography screening on breast cancer incidence and mortality. It explores survival of women whose breast cancer has been detected through annual mammography screening, the administration of annual physical breast examinations to two groups of women in the study, and primary outcomes recorded. Brief details about study design, setting, and funding are also offered.

Objective: To perform a more sophisticated analysis of previously published data that advances the understanding of the efficacy of pedestrian countdown signal (PCS) installation on pedestrian-motor vehicle collisions (PMVCs), in the city of Toronto, Canada. Methods: This is an updated analysis of the same dataset from Camden et al. A quasi-experimental design was used to evaluate the effect of PCS on PMVC. A Poisson regression analysis, using a one-group comparison of PMVC, pre-PCS installation to post-PCS installation was used, controlling for season and temporal effects. The outcome was the frequency of reported PMVC ( January 2000–December 2009). Similar models were used to analyse specific types of collisions defined by age of pedestrian, injury severity, and pedestrian and vehicle action. Incidence rate ratios with 95% CI are presented. Results: This analysis included 9262 PMVC, 2760 during or after PCS installation, at 1965 intersections. There was a 26% increase in the rate of collisions, pre to post-PCS installation (incidence rate ratio=1.26, 95% CI 1.11 to 1.42). Conclusions: The installation of PCS at 1965 signalised intersections in the city of Toronto resulted in an increase in PMVC rates post-PCS installation. PCSs may have an unintended consequence of increasing pedestrian-motor vehicle collisions in some settings. [ABSTRACT FROM AUTHOR]

Objectives To analyse the tobacco industry’s use of international trade agreements to oppose policies to strengthen health warning labels (HWLs). Design A review of tobacco industry documents, tobacco control legislation and international treaties. Results During the early 1990s, the tobacco industry became increasingly alarmed about the advancement of HWLs on cigarettes packages. In response, it requested legal opinions from British American Tobacco’s law firms in Australia and England, Britain’s Department of Trade and Industry and the World Intellectual Property Organisation on the legality of restricting and prohibiting the use of their trademarks, as embodied in cigarette packages. The consistent legal advice, privately submitted to the companies, was that international treaties do not shield trademark owners from government limitations (including prohibition) on the use of their trademarks. Despite receiving this legal advice, the companies publicly argued that requiring large HWLs compromised their trademark rights under international treaties. The companies successfully used these arguments as part of their successful effort to deter Canadian and Australian governments from enacting laws requiring the plan packaging of cigarettes, which helped delay large graphic HWLs, including ‘plain’ packaging, for over a decade. Conclusions Governments should not be intimidated by tobacco company threats and unsubstantiated claims, and carefully craft HWL laws to withstand the inevitable tobacco industry lawsuits with the knowledge that the companies’ own lawyers as well as authoritative bodies have told the companies that the rights they claim do not exist. [ABSTRACT FROM AUTHOR]

Background There is a growing interest in understanding the connection between mental illness (MI) and the onset of new physical illnesses among previously physically healthy individuals. Yet the role of gender is often forgotten in research focused on comorbidity of health problems. The objective of this study was to examine gender differences in the onset of physical illness in a cohort of respondents who met criteria for MI compared with a control cohort without mental health problems. Methods This cohort study, conducted in Ontario, Canada, used a unique linked dataset with information from the 2000-2001 Canadian Community Health Survey and medical records (n=15 902). We used adjusted Cox proportional survival analysis to examine risk of onset of four physical health problems (chronic obstructive pulmonary disorder, asthma, hypertension and diabetes) for those with and without baseline MI across a 10-year period (2002-2011) among respondents aged 18-74 years. We controlled for socioeconomic and health indicators associated with health. Results The incidence of physical illness in the MI cohort was 28.5% among women and 29.9% among men ( p=0.85) relative to controls (23.8% and 24%, respectively; p=0.48). Women in the MI cohort developed secondary physical health problems a year earlier than their male counterparts ( p=0.002). Findings from the Cox proportional survival regression showed that women were at 14% reduced risk of developing physical illness, meaning that men were more disadvantaged (HR=0.89, CI 0.80 to 0.98). Those in the MI cohort were at 10 times greater risk of developing a secondary physical illness over the 10-year period (HR=1.10, CI 0.98 to 1.21). There was no significant interaction between gender and MI cohort (HR=1.05, CI 0.85 to 1.27). Conclusions Policy and clinical practice have to be sensitive to these complex-needs patients. Genderspecific treatment and prevention practices can be developed to target those at higher risk of multiple health conditions. [ABSTRACT FROM AUTHOR]

Objectives The objectives of this study were to document the incidence rate and types of adverse events (AEs) among home care (HC) clients in Canada; identify factors contributing to these AEs; and determine to what extent evidence of completion of incident reports were documented in charts where AEs were found. Methods This was a retrospective cohort study based on expert chart review of a random sample of 1200 charts of clients discharged in fiscal year 2009-2010 from publicly funded HC programmes in Manitoba, Quebec and Nova Scotia, Canada. Results The results show that 4.2% (95% CI 3.0% to 5.4%) of HC patients discharged in a 12-month period experienced an AE. Adjusting to account for clients with lengths of stay in HC of less than 1 year, the AE incidence rate per client-year was 10.1% (95% CI 8.4% to 11.8%); 56% of AEs were judged preventable. The most frequent AEs were injuries from falls, wound infections, psychosocial, behavioural or mental health problems and adverse outcomes from medication errors. More comorbid conditions (OR 1.15; 95% CI 1.05 to 1.26) and a lower instrumental activities of daily living score (OR 1.54; 95% CI 1.16 to 2.04) were associated with a higher risk of experiencing an AE. Clients' decisions or actions contributed to 48.4% of AEs, informal caregivers 20.4% of AEs, and healthcare personnel 46.2% of AEs. Only 17.3% of charts with an AE contained documentation that indicated an incident report was completed, while 4.8% of charts without an AE had such documentation. Conclusions Client safety is an important issue in HC, as it is in institutionalised care. HC includes the planned delivery of self-care by clients and care provision by family, friends and other individuals often described as 'informal' caregivers. As clients and these caregivers can contribute to the occurrence of AEs, their involvement in the delivery of healthcare interventions at home must be considered when planning strategies to improve HC safety. [ABSTRACT FROM AUTHOR]

Background This study examined the impact of transportation infrastructure at intersection and nonintersection locations on bicycling injury risk. Methods In Vancouver and Toronto, we studied adult cyclists who were injured and treated at a hospital emergency department. A case-crossover design compared the infrastructure of injury and control sites within each injured bicyclist's route. Intersection injury sites (N=210) were compared to randomly selected intersection control sites (N=272). Non-intersection injury sites (N=478) were compared to randomly selected non-intersection control sites (N=801). Results At intersections, the types of routes meeting and the intersection design influenced safety. Intersections of two local streets (no demarcated traffic lanes) had approximately one-fifth the risk (adjusted OR 0.19, 95% CI 0.05 to 0.66) of intersections of two major streets (more than two traffic lanes). Motor vehicle speeds less than 30 km/h also reduced risk (adjusted OR 0.52, 95% CI 0.29 to 0.92). Traffic circles (small roundabouts) on local streets increased the risk of these otherwise safe intersections (adjusted OR 7.98, 95% CI 1.79 to 35.6). At non-intersection locations, very low risks were found for cycle tracks (bike lanes physically separated from motor vehicle traffic; adjusted OR 0.05, 95% CI 0.01 to 0.59) and local streets with diverters that reduce motor vehicle traffic (adjusted OR 0.04, 95% CI 0.003 to 0.60). Downhill grades increased risks at both intersections and non-intersections. Conclusions These results provide guidance for transportation planners and engineers: at local street intersections, traditional stops are safer than traffic circles, and at non-intersections, cycle tracks alongside major streets and traffic diversion from local streets are safer than no bicycle infrastructure. [ABSTRACT FROM AUTHOR]

Background Pedestrian incidents represent an increasing proportion of serious injuries resulting from motor vehicle collisions in Canada. However, few studies have examined the effect of pedestrian crossing location in urban areas on injury severity. The objective of this study was to investigate the relationship between pedestrian-motor vehicle collision injury severity and crossing location. Methods This study was a population-based analysis of police-reported pedestrian collision data. The study group was pedestrian collisions from 1 January 2000 to 31 December 2009 in Toronto. Main outcome measures were a binary indicator of severe injury, and a four-level categorical variable of injury severity. The exposure variable was crossing at mid-block with no traffic control compared to signalised intersection. Analysis was via binary and multinomial logistic regression models to estimate ORs of injury severity with 95% CIs. Results The analysis included 9575 pedestrian-motor vehicle collisions, of which 7325 occurred at signalised intersections when crossing and 2230 occurred at uncontrolled mid-block locations when crossing without right of way. Uncontrolled mid-block collisions resulted in greater injury severity when controlling for road type. The odds of severe injury were 1.75 (95% CI 1.07 to 2.86) for children, 2.55 (95% CI 2.13 to 3.05) for adults and 1.68 (95% CI 1.23 to 2.28) for older adults. The odds of death at uncontrolled mid-block crossings were 4.97 (95% CI 3.11 to 7.94) in adults and 3.49 (95% CI 2.07 to 5.89) in older adults. Conclusions Crossing at uncontrolled mid-block locations resulted in greater injury severity compared with crossing at signalised intersections. This has important implications for pedestrian behaviour and traffic environment design and emphasises the need for safe pedestrian crossings on urban roads. [ABSTRACT FROM AUTHOR]

Objective To assess the perceived effectiveness of cigarette health warnings in China, compared with picture and text-only warnings from other countries. Method 1169 individuals (adult smokers, adult nonsmokers and youth) from four Chinese cities (Beijing, Shanghai, Kunming and Yinchuan) viewed 10 health warnings on cigarette packages, which included (a) the current Chinese text warnings covering 30% of the front/back of the pack (introduced October 2008); (b) the former Chinese text warning located on the side of the pack; (c) four picture warnings covering 50% of the front/back of the pack from Canada (lung cancer), Singapore (mouth disease), Hong Kong (gangrene) and European Union (clogged arteries); and (d) the same four warnings without the picture. Participants rated and ranked the 10 warnings on dimensions including how effective each would be in motivating smokers to quit and in convincing youth not to start smoking. Results Both Chinese warnings were consistently rated as least effective, with the new Chinese warning rated only slightly higher than the old warning. The picture warnings were consistently ranked or rated as most effective, with the text-only versions in the middle. Results were consistent across subject group, city and sex. Conclusions (1) Picture warnings are rated as much more effective than the same warnings without pictures. (2) The revised health warnings in China, introduced in October 2008, are only marginally more effective than the previous warning and far less effective than even text warnings from other countries. These results, coupled with population-based evaluation studies, suggest that pictorial warnings would significantly increase the impact of health warnings in China. [ABSTRACT FROM PUBLISHER]

Background The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health. Objective To describe the role of predictive risk algorithms in a population setting. Methods First, predictive risk algorithms and how clinicians use them are described. Second, the population uses of risk algorithms are described, highlighting the strengths of risk algorithms for health planning. Lastly, the way in which predictive risk algorithms are developed is discussed briefly and a guide for algorithm assessment in population health presented. Conclusion For the past 20 years, absolute and baseline risk has been a cornerstone of population health planning. The most accurate and discriminating method to generate such estimates is the use of multivariable risk algorithms. Routinely collected data can be used to develop algorithms with characteristics that are well suited to health planning and such data are increasingly available. The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health. INSETS: Case example of risk prediction in clinical medicined algorithms.;Case example of population use of a clinical risk algorithm. [ABSTRACT FROM AUTHOR]