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Ghayath Janoudi,1,2 Mara Uzun (Rada),3 Stephanie T Boyd,1 Deshayne B Fell,2,4 Joel G Ray,5 Angel M Foster,6 Randy Giffen,7 Tammy J Clifford,2,8 Mark C Walker1,2,9– 12 1Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; 2School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; 3Independent Researcher, Ottawa, ON, Canada; 4Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada; 5Departments of Medicine, Health Policy Management and Evaluation, and Obstetrics and Gynecology, St Michael’s Hospital, University of Toronto, Toronto, ON, Canada; 6Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada; 7IBM Canada, IBM, Toronto, ON, Canada; 8Canadian Institute of Health Research, Government of Canada, Ottawa, ON, Canada; 9International and Global Health Office, University of Ottawa, Ottawa, ON, Canada; 10Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada; 11Department of Obstetrics, Gynecology & Newborn Care, The Ottawa Hospital, Ottawa, ON, Canada; 12BORN Ontario, Children’s Hospital of Eastern Ontario, Ottawa, ON, CanadaCorrespondence: Mark C Walker, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Centre for Practice Changing Research, Box 241, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada, Tel +1 613-798-5555 x76655, Email mwalker@toh.caBackground: Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity. The management of preeclampsia has not changed much in more than two decades, and its aetiology is still not fully understood. Case reports and case series have traditionally been used to communicate new knowledge about existing conditions. Whether this is true for preeclampsia is not known.Objective: To determine whether recent case reports or case series have generated new knowledge and clinical discoveries about preeclampsia.Methods: A detailed search strategy was developed in consultation with a medical librarian. Two bibliographic databases were searched through Ovid: Embase and MEDLINE. We selected case reports or case series published between 2015 and 2020, comprising pregnant persons diagnosed with hypertensive disorders of pregnancy, including preeclampsia. Two reviewers independently screened all publications. One reviewer extracted data from included studies, while another conducted a quality check of extracted data. We developed a codebook to guide our data extraction and outcomes assessment. The quality of each report was determined based on Joanna Briggs Institute (JBI) critical appraisal checklist for case reports and case series.Results: We included 104 case reports and three case series, together comprising 118 pregnancies. A severe presentation or complication of preeclampsia was reported in 81% of pregnancies, and 84% had a positive maternal outcome, free of death or persistent complications. Only 8% of the case reports were deemed to be of high quality, and 53.8% of moderate quality; none of the case series were of high quality. A total of 26 of the 107 publications (24.3%) included a novel clinical discovery as a central theme.Conclusion: Over two-thirds of recent case reports and case series about preeclampsia do not appear to present new knowledge or discoveries about preeclampsia, and most are of low quality.Keywords: hypertensive disorders of pregnancy, eclampsia, HELLP syndrome, study design

Eyal Cohen,1– 3 Péter Szentkúti,4 Erzsébet Horváth-Puhó,4 Hilary K Brown,3,5 Sonia M Grandi,2 Henrik Toft Sørensen,4,6 Joel G Ray2,3,7 1Department of Pediatrics and Edwin S.H. Leong Centre for Healthy Children, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; 2Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada; 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; 4Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; 5Department of Health & Society, University of Toronto Scarborough; 6Clinical Excellence Research Center, Stanford University, Stanford, CA, USA; 7St.Michael’s Hospital Department of Medicine, University of Toronto, Toronto, Ontario, CanadaCorrespondence: Eyal Cohen, Department of Pediatrics and Edwin S.H. Leong Centre for Healthy Children, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada, Tel +1 416-813-7654, Email eyal.cohen@sickkids.caBackground: The mother of an infant with a major congenital anomaly is at a higher risk of premature cardiometabolic disease, possibly from chronic caregiver stress and distraction from self-care, including maintaining a healthy lifestyle and body weight.Objective: To compare the interpregnancy weight gain in women whose first infant had a major congenital anomaly vs those without an affected child.Methods: Multivariable linear regression compared women whose infant had an anomaly vs those whose infant did not, adjusting for interpregnancy time interval, demographics, smoking and health status at the first pregnancy.Results: Of the 199,536 women who had two consecutive singleton births, 4035 (2.0%) had a child with an anomaly at the first birth. The mean (SD) maternal BMI at the start of the first pregnancy was 24.1 (4.7) and 23.7 (4.4) kg/m2 in women with, and without, an anomaly-affected newborn. By the start of the second pregnancy, 3 years later, they had gained a mean (SD) of 2.2 (5.5) and 1.8 (5.2) kg, respectively – an adjusted absolute higher gain of 0.26 kg (95% CI 0.10 to 0.42) in women with an anomaly-affected first-born infant compared to those with an unaffected pregnancy. The adjusted interpregnancy weight gain difference was greatest in women whose first-born infant had a multi-organ anomaly at 0.59 kg (95% CI 0.02 to 1.16). The adjusted odds ratio of moving from a normal BMI category of 18.5– 24.9 kg/m2 in the first pregnancy, to an overweight or obese BMI category of 25+ kg/m2 in the second, was 1.18 (95% CI 1.06 to 1.32) comparing mothers with vs without an anomaly-affected child in the first pregnancy.Conclusion: Mothers of an infant with a major congenital anomaly have a modestly higher interpregnancy weight gain and tend to climb to a higher BMI category. The long-term implications of this greater weight trajectory require further study.Keywords: weight gain, congenital anomaly, inter-pregnancy, body mass index

Hilary K Brown,1– 5 Andrew Wilton,5 Ning Liu,5 Joel G Ray,5,6 Cindy-Lee Dennis,6,7 Simone N Vigod3– 5 1Department of Health & Society, University of Toronto Scarborough, Toronto, ON, Canada; 2Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; 3Department of Psychiatry, University of Toronto, Toronto, ON, Canada; 4Women’s College Research Institute, Women’s College Hospital, Toronto, ON, Canada; 5ICES, Toronto, ON, Canada; 6Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada; 7Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, CanadaCorrespondence: Hilary K BrownDepartment of Health & Society, University of Toronto Scarborough, 1265 Military Trail, Toronto, ON, M1C 1A4, CanadaTel +1 416 208 2239Email hk.brown@utoronto.caBackground: Studies have demonstrated elevated risk for autoimmune disease associated with perinatal mental illness, but the extent to which this risk is specific to mental illness arising perinatally, and not mental illness generally, is unknown. Our objective was to compare the risk of autoimmune disease in women with mental illness arising within the perinatal period to (1) women with mental illness arising outside the perinatal period and (2) women who did not develop mental illness.Methods: We conducted a population-based matched cohort study of women aged 15– 49 years with no history of mental illness or autoimmune disease in Ontario, Canada, 1998– 2018. The exposed, 60,701 women with mental illness arising between conception and 365 days postpartum were propensity score-matched to (1) 264,864 women with mental illness arising non-perinatally and (2) 469,164 women who did not develop mental illness. Hazard ratios (HR) for autoimmune disease were generated using Cox proportional hazards models.Results: The incidence of autoimmune disease was similar among women with mental illness arising perinatally compared to those with mental illness arising non-perinatally (138.4 vs 140.7 per 100,000 person-years; HR 0.98, 95% CI 0.92– 1.05), and elevated among women with mental illness arising perinatally compared to those who did not develop mental illness (138.4 vs 88.9 per 100,000 person-years; HR 1.54, 95% CI 1.44– 1.64). The HR for the latter comparison was more pronounced for autoimmune disease with brain-reactive antibodies than other autoimmune disease.Conclusion: Perinatal mental illness is associated with increased risk of autoimmune disease that is no different than that of mental illness arising non-perinatally. Women with mental illness, regardless of the timing of onset, could benefit from early detection of autoimmune disease.Keywords: autoimmune diseases, cohort studies, mental disorders, women’s health

Objective: Caesarean section (CS) is more common following infertility treatment (IT) but the reasons why remain unclear and confounded. The Robson 10‐Group Classification System (TGCS) may further explain variation in CS rates. We assessed the association between mode of conception and CS across Robson groups. Design: Population‐based cohort study. Setting: Ontario, Canada, in a public healthcare system. Population: 921 023 births, 2006–2014. Methods: Modified Poisson regression produced relative risks (RR) and 95% confidence intervals, comparing the risk of CS among women with (1) subfertility without IT, (2) non‐invasive IT (OI, IUI) or (3) invasive IT (IVF)—each relative to (4) spontaneous conception (SC). Main outcome measures: CS rate according to one of four modes of conception, overall and stratified by each of the TGCS groups. Results: Relative to SC (26.9%), the risk of CS increased in those with subfertility without IT (RR 1.17, 95% CI 1.16–1.18), non‐invasive IT (RR 1.21, 95% CI 1.18–1.24) and invasive IT (RR 1.39, 95% CI 1.36–1.42). Within each Robson group, similar patterns of RRs were seen, but with markedly differing rates. For example, in Group 1 (nulliparous, singleton, cephalic at ≥37 weeks, with spontaneous labour), the respective rates were 15.0, 19.4, 18.7 and 21.9%; in Group 2 (nulliparous, singleton, cephalic at ≥37 weeks, without spontaneous labour), the rates were 35.9, 44.4, 43.2 and 54.1%; and in Group 8 (multiple pregnancy), they were 55.9, 67.5, 65.0 and 69.3%, respectively. Conclusions: CS is relatively more common in women with subfertility and those receiving IT, an effect that persists across Robson groups. Caesarean delivery is more common in women with infertility independent of demographics and prenatal conditions. Caesarean delivery is more common in women with infertility independent of demographics and prenatal conditions. [ABSTRACT FROM AUTHOR]

Study objective Most patients are admitted to the hospital through the emergency department (ED), and ED waiting times partly reflect the availability of inpatient beds. We test whether the balance between daily hospital admissions and discharges affects next-day ED length of stay. Methods We conducted a cross-sectional study of hospitals in metropolitan Toronto, served by a single emergency medical services provider in a publicly funded system. During a 3-year period, we evaluated the daily ratio of admissions to discharges at each hospital and the next-day median ED length of stay in the same hospital by using linear regression. Results Across hospitals, the daily mean (SD) 50th percentile ED length of stay averaged 218 (51) minutes. As the inpatient admission-discharge ratio increased or decreased, next-day ED length of stay changed accordingly. Compared with ratios of 1.0, those less than 0.6 were associated with an 11-minute (95% confidence interval [CI] 5 to 16 minutes) shorter next-day median ED length of stay; at admission-discharge ratios of 1.3 to 1.4, ED length of stay was significantly prolonged by 5 minutes (95% CI 3 to 6 minutes). Admission-discharge ratios on weekends and among medical inpatients had a stronger influence on next-day ED length of stay; effects were also greater among higher-acuity and admitted ED patients. Conclusion Disequilibrium between the number of admitted and discharged inpatients significantly affects next-day ED length of stay. Better matching of daily hospital discharges and admissions could reduce ED waiting times and may be more amenable to intervention than reducing admissions alone. The admission-discharge ratio may also provide a simple way of tracking and enhancing hospital system performance. [ABSTRACT FROM AUTHOR]

BACKGROUND: Distinguishing mild and moderate epithelial dysplasia is difficult and controversial. We demonstrated earlier that silver-stainable nucleolar organizer region (AgNOR) is a simple, inexpensive and quantifiable method which can standardize this distinction reliably. Objective: To establish a cut-point mean AgNOR count for epithelial dysplasia validated by bootstrapping. METHODS: One hundred oral leukoplakia biopsies at Dr R. Ahmed Dental College, Kolkata, India, examined for epithelial dysplasia using standard method (gold standard) were assessed for their mean AgNOR counts. A cut-point was selected employing receiver operating characteristic (ROC) curve. This estimate was stabilized by 10 000 resamples (with replacement) using parametric and non-parametric bootstrap, a Monte Carlo statistical method, corrected for bias to estimate standard errors (SE) of cut-point. RESULTS: Area under the curve (AUC) was 74%; non-parametric method suggested mean AgNOR cut-point = 2.42 AgNORs/nucleus; parametric method suggested cut-point = 2.57. The cut-point 95% confidence intervals (CIs) (bias corrected and accelerated) from parametric method (2.31; 2.66) was lower than non-parametric (2.43; 2.82). CONCLUSION: Applying a conservative paradigm, taking the lowest of all bootstrap 95% CIs, we suggest that mean AgNOR count of 2.3 be used as a cut-point for distinguishing between mild and moderate dysplasia. This strategy will provide an inexpensive, meaningful, definitive, reproducible and consistent diagnostic test for epithelial dysplasia. [ABSTRACT FROM AUTHOR]

Background: Elevated total homocysteine levels are associated with a higher risk for venous thromboembolism. Whether decreasing homocysteine levels with vitamin therapy reduces the risk for venous thromboembolism is not known.Objective: To determine whether decreasing homocysteine levels alters the risk for symptomatic venous thromboembolism.Design: Secondary analysis of data from the randomized, placebo-controlled Heart Outcomes Prevention Evaluation 2 (HOPE-2) trial.Setting: 145 clinical centers in 13 countries.Participants: 5522 persons 55 years of age or older with known cardiovascular disease or diabetes mellitus and at least 1 other risk factor for vascular disease.Intervention: A daily supplement of 2.5 mg of folic acid, 50 mg of vitamin B(6), and 1 mg of vitamin B(12) or matching placebo for 5 years.Measurement: Prospectively diagnosed and confirmed symptomatic deep venous thrombosis or pulmonary embolism.Results: The geometric mean homocysteine level decreased by 2.2 micromol/L in the vitamin therapy group and increased by 0.80 micromol/L in the placebo group. Venous thromboembolism occurred in 88 participants during a mean follow-up of 5 years. The incidence rate of venous thromboembolism was the same in the vitamin therapy group and the placebo group (0.35 per 100 person-years; hazard ratio, 1.01 [95% CI, 0.66 to 1.53]). Vitamin therapy did not reduce the risk for deep venous thrombosis (hazard ratio, 1.04 [CI, 0.63 to 1.72]), pulmonary embolism (hazard ratio, 1.14 [CI, 0.57 to 2.28]), or unprovoked venous thromboembolism (hazard ratio, 1.21 [CI, 0.66 to 2.23]).Limitations: The proportion of patients with a previous episode of venous thromboembolism at enrollment was not known, and venous thromboembolism events were not centrally adjudicated.Conclusion: Decreasing homocysteine levels with folic acid and vitamins B6 and B12 did not reduce the risk for symptomatic venous thromboembolism. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To explore the association between giant cell arteritis (GCA) and subsequent cardiovascular disease in older adults. DESIGN: Population based retrospective cohort study. SETTING: The entire province of Ontario, Canada. PARTICIPANTS: Patients aged 66 years and older with newly diagnosed GCA (n = 1141), osteoarthritis (n = 172,953), or neither (n = 200,000). Patients with neither were randomly selected from the general population and formed the control group. MAIN OUTCOME MEASURES: The primary composite outcome was based on a subsequent diagnosis or surgical treatment for coronary artery disease, stroke, peripheral arterial disease, or aneurysm or dissection of the aorta. RESULTS: The composite end point was more common in seniors with GCA (12.1/1000 person-years) than in patients with osteoarthritis (7.3/1000 person-years) or neither condition (5.3/1000 person-years). The adjusted hazard ratio for cardiovascular disease was 1.6 (95% confidence interval (CI) 1.1 to 2.2) in patients with GCA versus patients with osteoarthritis, and 2.1 (95% CI 1.5 to 3.0) in patients with GCA versus unaffected controls. CONCLUSIONS: Older adults with GCA appear to be at increased risk for developing cardiovascular disease. Whether an aggressive approach to cardiovascular risk factor modification is particularly beneficial in these patients remains to be determined. [ABSTRACT FROM AUTHOR]

Background: Following bacterial contamination of a municipal water system in the rural town of Walkerton, Ontario, over 2,300 cases of acute gastroenteritis were documented. The Walkerton Health Study is currently underway to assess for long-term health sequelae among consenting inhabitants of Walkerton, related to the original outbreak. We explored whether the association between the acute exposure and preliminary long-term health outcomes may have been biased through differences between early- and late-recruited study participants.Methods: Using multiple data sources, including the 1996 and 2001 Canadian Census, and records from the Regional Health Unit, hospital and Walkerton Health Study, we determined both sample representativeness and the anticipated effects of intensifying study participant recruitment. Selection bias was assessed by examining for differences between initial and late participants, and their subsequent risk of having hypertension, proteinuria and reduced renal clearance.Results: Of the 4,315 participants, 2,756 were permanent residents of Walkerton, representing 55% of the town's total population. The sample was demographically similar to the population of interest, although statistically women were more likely to participate than men (55% of sample were women compared to 52% of population, p<0.01), and the proportion of both young and very elderly adults was smaller than expected (13% of sample were > or = 65 years of age compared to 18% of population, p<0.01). Comparing the initial 3,959 participants to the 356 persons additionally recruited with substantial effort, the latter were more likely to be free of symptoms during the outbreak (21% vs. 7%, p<0.001), but were otherwise similar in terms of age, sex, the use of medical care resources and underlying health state predating the outbreak. The risk of long-term hypertension or renal sequelae did not significantly differ between initial and late study recruits.Conclusions: Participants in the Walkerton Health Study represent the population of interest, and comprise those who were acutely ill during the infected water outbreak. The available study sample should provide reasonably unbiased estimates of the associated risk between acute bacterial gastroenteritis and long-term health sequelae. [ABSTRACT FROM AUTHOR]

Objective: Maternal obesity is likely a risk factor for neural tube defects (NTDs). By late 1997, it became mandatory in Canada that all refined wheat flour be fortified with folic acid. Because overweight women may consume greater quantities of refined wheat flour, we questioned whether their risk of NTD changed after flour fortification. Methods: A retrospective population-based study was conducted between 1994 and late 2000. We included all Ontarian women who underwent antenatal maternal screening at 15 to 20 weeks of gestation. Self-declared maternal date of birth, ethnicity, current weight, and the presence of pregestational diabetes mellitus were recorded in a standardized fashion on the maternal screening requisition sheet. The presence of NTDs was systematically detected both antenatally and postnatally. The risk of open NTD was evaluated across maternal weight quartiles and deciles, and an interaction between greater maternal weight and the presence of flour fortification was tested using multiple logistic regression analysis. Results: A total of 292 open NTDs were detected among 420,362 women. The adjusted odds ratio (OR) for NTD was 1.2 (95% confidence interval [CI] 1.1-1.3) per 10-kg incremental rise in maternal weight. Comparing the highest with the lowest quartile of maternal weight, the adjusted OR for NTD was 2.6 (95% CI 1.8-4.0). A similar finding was observed for the highest compared with lowest weight deciles (adjusted OR 3.3, 95% CI 1.7-6.2). The interaction between elevated maternal weight and the presence of folic acid flour fortification was of borderline significance (P = .09). Before fortification, greater maternal weight was associated with a modestly increased risk of NTD (adjusted OR 1.4, 95% CI 1.0-1.8); after flour fortification, this effect was more pronounced (adjusted OR 2.8, 95% CI 1.2-6.6). Conclusion: These data emphasize the higher risk of NTD associated with increased maternal weight, even after universal folic acid flour fortification. Beyond periconceptional folic acid use, consideration should be given to testing whether prepregnancy weight reduction is an independent means of preventing NTD. Level Of Evidence: II-2. [ABSTRACT FROM AUTHOR]

QUESTION: I knew that angiotensin-converting enzyme (ACE) inhibitors were risky to use during late pregnancy because they can cause renal shutdown in the fetus. Recently I heard of a study that claimed first-trimester exposure (when many patients still are unaware of their pregnancies) can also cause major malformations. Is this proven? ANSWER: A recent study did suggest an increased risk of malformations after first-trimester exposure to ACE inhibitors among women treated for hypertension. We believe this study had serious limitations that preclude drawing any conclusions at present. [ABSTRACT FROM AUTHOR]

January 2002, Health Canada issued an advisory, followed by a ban in August 2002, on the sale of herbal kava. One month after the advisory, 22 (67%) of 33 health food stores approached were selling kava. Two months after the ban, 17 (57%) of 30 stores continued to sell kava. These findings demonstrate that health food stores may need to be better informed about the sale of restricted natural health products. [ABSTRACT FROM AUTHOR]

Background: The negative impact of diabetes mellitus is well recognized, yet little is known about the effect of this disease on the liver, an organ susceptible to nonalcoholic fatty liver disease related to insulin resistance. We evaluated whether adults with newly diagnosed diabetes were at increased risk of serious liver disease.Methods: We used administrative health databases for the province of Ontario (1994-2006) to perform a population-based matched retrospective cohort study. The exposed group comprised 438 069 adults with newly diagnosed diabetes. The unexposed comparison group--those without known diabetes--consisted of 2 059 708 individuals, matched 5:1 to exposed persons, by birth year, sex and local health region. We excluded individuals with pre-existing liver or alcohol-related disease. The primary study outcome was the subsequent development of serious liver disease, namely, liver cirrhosis, liver failure and its sequelae, or receipt of a liver transplant.Results: The incidence rate of serious liver disease was 8.19 per 10 000 person-years among those with newly diagnosed diabetes and 4.17 per 10 000 person-years among those without diabetes. The unadjusted hazard ratio was 1.92 (95% confidence interval [CI] 1.83-2.01). After adjustment for age, income, urban residence, health care utilization and pre-existing hypertension, dyslipidemia, obesity and cardiovascular disease, the hazard ratio was 1.77 (95% CI 1.68-1.86).Interpretation: Adults with newly diagnosed diabetes appeared to be at higher risk of advanced liver disease, also known as diabetic hepatopathy. Whether this reflects nonalcoholic fatty liver disease or direct glycemic injury of the liver remains to be determined. [ABSTRACT FROM AUTHOR]

Canada mandated that cereal grains, especially white flour, be fortified with folic acid by mid-1998. Between 0.1 and 0.2 mg of additional synthetic folic acid per day has been provided through this initiative. The current paper describes how this took place, and the epidemiological effects that occurred in the Canadian population, including higher blood folate levels and a decline in the prevalence of neural tube defects. [ABSTRACT FROM AUTHOR]

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [< or = 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A). [ABSTRACT FROM AUTHOR]

Purpose: There is substantial evidence that women with schizophrenia in many parts of the world have fewer children than their peers. Our objective was to analyze recent trends in general and age-specific fertility rates among women with schizophrenia in Ontario, Canada.Methods: We conducted a repeated cross-sectional population-based study from 1996 to 2009 using population-based linked administrative databases for the entire province of Ontario. Women aged 15-49 years were classified into schizophrenia and non-schizophrenia groups in each successive 12-month period. Annual general and age-specific fertility rates were derived.Results: The general fertility rate (GFR) among women with schizophrenia was 1.16 times higher in 2007-2009 than in 1996-1998 (95% confidence interval [CI] 1.04-1.31). The annual GFR ratio of women with vs. without schizophrenia was 0.41 (95% CI 0.36-0.47) in 2009, which was slightly higher than the same ratio in 1996 of 0.30 (95% CI 0.25-0.35). Annual age-specific fertility rates (ASFR) increased over time among women with schizophrenia aged 20-24, 25-29, 35-39 and 40-44 years, but the increase was not always statistically significant. Among women aged 20-24 years, the ASFR ratio in women with vs. without schizophrenia was not significant by the end of the study period (0.93, 95% CI 0.70-1.22).Conclusions: The general fertility rate among women with schizophrenia appears to have increased modestly over the past 13 years. Clinical care and health policy should consider new strategies that focus on the mental health of women with schizophrenia as new mothers, while optimizing healthy pregnancies and child rearing. [ABSTRACT FROM AUTHOR]