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Background: Serious adverse effects of fluoroquinolone antibiotics have been described for more than decade. Recently, several drug regulatory agencies have advised restricting their use in milder infections for which other treatments are available, given the potential for disabling and possibly persistent side effects. We aimed to describe variations in fluoroquinolone use for initial treatment of urinary tract infection (UTI), acute bacterial sinusitis (ABS), and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the outpatient setting across Canada.Methods: Using administrative health data from six provinces, we identified ambulatory visits with a diagnosis of uncomplicated UTI, uncomplicated AECOPD or ABS. Antibiotic exposure was determined by the first antibiotic dispensed within 5 days of the visit.Results: We identified 4,303,144 uncomplicated UTI events among 2,170,027 women; the proportion of events treated with fluoroquinolones, mostly ciprofloxacin, varied across provinces, ranging from 18.6% (Saskatchewan) to 51.6% (Alberta). Among 3,467,678 ABS events (2,087,934 patients), between 2.2% (Nova Scotia) and 11.2% (Ontario) were dispensed a fluoroquinolone. For 1,319,128 AECOPD events among 598,347 patients, fluoroquinolones, mostly levofloxacin and moxifloxacin, ranged from 5.8% (Nova Scotia) to 35.6% (Ontario). The proportion of uncomplicated UTI and ABS events treated with fluoroquinolones declined over time, whereas it remained relatively stable for AECOPD.Conclusions: Fluoroquinolones were commonly used as first-line therapies for uncomplicated UTI and AECOPD. However, their use varied widely across provinces. Drug insurance formulary criteria and enforcement may be a key to facilitating better antibiotic stewardship and limiting potentially inappropriate first-line use of fluoroquinolones. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine if in utero selective serotonin reuptake inhibitor (SSRI) or selective serotonin norepinephrine inhibitor (SNRI) exposure is associated with developmental vulnerability in kindergarten among children whose mothers were diagnosed with prenatal mood or anxiety disorder. METHODS: Linkable administrative data were used to create a population-based cohort of 266 479 mother-child dyads of children born in Manitoba, Canada, between 1996 and 2014, with follow-up through 2015. The sample was restricted to mothers who had a mood or anxiety disorder diagnosis between 90 days before conception (N = 13 818). Exposed women had $2 SSRI or SNRI dispensations during pregnancy (n = 2055); unexposed mothers did not have a dispensation of an SSRI or SNRI during pregnancy (n = 10 017). The Early Development Instrument (EDI) was used to assess developmental health in kindergarten children. The EDI is a 104-component kindergarten teacher-administered questionnaire, encompassing 5 developmental domains. RESULTS: Of the 3048 children included in the study who met inclusion criteria and had an EDI, 21.43% of children in the exposed group were assessed as vulnerable on 2 or more domains versus 16.16% of children in the unexposed group (adjusted odds ratio = 1.43; 95% confidence interval 1.08-1.90). Children in the exposed group also had a significant risk of being vulnerable in language and/or cognition (adjusted odds ratio = 1.40; 95% confidence interval 1.03-1.90). CONCLUSIONS: Exposure to SSRIs or SNRIs during pregnancy was associated with an increased risk of developmental vulnerability and an increased risk of deficits in language and/or cognition. Replication of results is necessary before clinical implications can be reached. [ABSTRACT FROM AUTHOR]

We aimed to describe medication use in pregnancies that resulted in births and abortions, as well as use after a pregnancy-related visit to characterize the receipt of medication after knowledge of pregnancy. Abortions included both spontaneous and induced abortions. Rates of medication use among women with a pregnancy outcome (2001–2013) were described using the Manitoba Population Research Data Repository at the Manitoba Centre for Health Policy. Use was determined as ≥ 1 prescription filled during pregnancies that resulted in births (livebirth/stillbirth) and abortions. Rates were calculated at any time during pregnancy and after a pregnancy-related visit. Rates were additionally characterized by risk in pregnancy using Briggs classification (2017). Of 174,848 birth pregnancies, overall 64.9% filled ≥ 1 prescription during pregnancy (a significant increase from 62.3% to 68.8% from 2001–2013, p<0.0001); 55.4% filled ≥ 1 prescription after a pregnancy-related visit. Of 71,967 abortions, 44.7% filled ≥ 1 prescription (a significant increase from 42.6% to 46.8% from 2001–2013, p<0.0001). Only 3.7% of birth pregnancies had at least one prescription for a contraindicated medication (according to Briggs classification), whereas 10.8% of abortions filled a prescription for a contraindicated medication. The most common drugs used in pregnancy were amoxicillin, doxylamine, codeine combinations, nitrofurantoin, cephalexin, salbutamol and ranitidine. Fewer women filled prescriptions for undesirable medications according to Briggs classification during pregnancy after a pregnancy-related visit. [ABSTRACT FROM AUTHOR]

Purpose: In primary care, there is increasing recognition of the difficulty of treating patients' immediate health concerns when their overall well-being is shaped by underlying social determinants of health. We assessed the association of social complexity factors with the quality of care patients received in primary care settings.Methods: Eleven social complexity factors were defined using administrative data on poverty, mental health, newcomer status, and justice system involvement from the Manitoba Population Research Data Repository. We measured the distribution of these factors among primary care patients who made at least 3 visits during 2010-2013 to clinicians in Manitoba, Canada. Using generalized linear mixed modeling, we measured 26 primary care indicators to compare the quality of care received by patients with 0 to 5 or more social complexity factors.Results: Among 626,264 primary care patients, 54% were living with at least 1 social complexity factor, and 4% were living with 5 or more. Social complexity factors were strongly associated with poorer outcomes with respect to primary care indicators for prevention (eg, breast cancer screening; odds ratio [OR] = 0.77; 99% CI, 0.73-0.81), chronic disease management (eg, diabetes management; OR = 0.86; 99% CI, 0.79-0.92), geriatric care (eg, benzodiazepine prescriptions; OR = 1.63; 99% CI, 1.48-1.80), and use of health services (eg, ambulatory visits; OR = 1.09; 99% CI, 1.08-1.09).Conclusions: Linking health and social data demonstrates how social determinants are associated with primary care service provision. Our findings provide insight into the social needs of primary care populations, and may support the development of focused interventions to address social complexity in primary care. [ABSTRACT FROM AUTHOR]

Background: Assertive community treatment for first-episode psychosis programs have been shown to improve symptoms and reduce service use. There is little or no evidence on whether these programs can increase access to income assistance and improve medication adherence in first episode psychosis patients. This research examines the impact of the Early Psychosis Prevention and Intervention Service (EPPIS) on these outcomes. Methods: We extracted data on EPPIS patients held in the Data Repository at the Manitoba Centre for Health Policy. The Repository is a comprehensive collection of person-level de-identified administrative records, including data from Manitoba’s health services. We compared income assistance use and antipsychotic medication adherence in EPPIS patients to a historical cohort matched on pattern of diagnosis. Confounders were adjusted through propensity-score weighting with asymmetrical trimming. Odds ratios (OR), hazard ratios (HR) and 95% confidence intervals were calculated. Results: We identified a matched sample of 244 patients and 449 controls. EPPIS patients had a higher rate of income assistance use during the program (67·4% vs. 38·7%; p< 0·0001). EPPIS patients were more likely to have been prescribed at least one antipsychotic medication than the control cohort, both during the program (OR = 15·05; 95%CI 10·81 to 20·94) and after the program ended (OR = 5·20; 95%CI: 4·50 to 6·02). Patients in EPPIS were also more likely to adhere to their medication during the program (OR = 4·71; 95%CI 3·75 to 5·92), and after the program (OR = 2·54; 95%CI 2·04 to 3·16). Conclusion: Enrolment in the EPPIS program was associated with increased adherence to antipsychotic medication treatment and improved uptake of income assistance. [ABSTRACT FROM AUTHOR]

Background: Around 30% of the population will experience herpes zoster (HZ), 10% of whom develop postherpetic neuralgia (PHN). Together, these illnesses produce a significant economic burden to the healthcare system.Methods: Administrative healthcare data collected over the period of April 1st 1997 to March 31st 2014 were analyzed to determine the healthcare system burden of HZ using direct medical costs. Episodes of HZ were identified using international classification of disease (ICD) codes. Trends in age-adjusted (AA) HZ-rates were analyzed by piecewise-regression. Total annual and per-episode costs were determined for drug treatment, medical care, and hospitalizations within each year.Results: The incidence of HZ increased by 49.5% from 1997/98 to 2013/14. Piecewise-regression of AA-rates revealed a steady AA-rate of 4.7 episodes/1000 person-years (PY) from 1997/98 to a breakpoint in 2008/09, after which rates began to increase reaching 5.7 episodes/1000 PY in 2013/14. Drug costs rose significantly (p <0.03) from $89.77/episode (95% CI: $82.96, $96.59) to $127.34/episode (95% CI: $117.24, $137.44). Medical costs increased (p <0.0001) from $57.98/episode (95% CI; $55.26, $60.70) to $78.84/episode (95% CI; $74.08, $83.61). Hospitalization rates declined from 3.10% in 1997/98 to 1.36% in 2011/12, resulting in cost dropping from $397/episode (95% CI; $284, $511) to $195/episode (95% CI; $129, $260). Total annual costs of HZ and PHN were $1,997,183 in 2011/12, 4.7% lower than the 1997/98 costs of $2,095,633.Conclusion: A significant increase in annual number of HZ cases was observed, driven largely by demographic factors. A 21% increase in the AA-incidence reveals changes in HZ rates beyond those expected by population shifts. The large increase in incidence of HZ, with rising per episode medical and prescription costs were offset by dramatic drops in hospitalization rates, the net effect of which has been to hold the total costs relatively constant. However, the decrease in hospitalization rates slowed over the last half of the study, settling at 1.3% in the last 4 study years. The likely future of HZ burden is one of rising costs, primarily driven by the demographic shifts of an increasing and aging population. [ABSTRACT FROM AUTHOR]

Background: Early interventions for psychosis have been shown to reduce psychotic symptoms and hospital use for first-episode patients, but the effect on suicidal and criminal behaviour has not been reliably determined. This study aimed to examine whether an early intervention for psychosis program (EPPIS) reduced criminal behaviour, suicide attempts, and hospital-based service use.Methods: The study utilized administrative data to match clients of EPPIS to historical controls. Regression was used to determine the effect of treatment by EPPIS on inpatient use, emergency department use, suicide attempts/deaths, and criminal accusations.Results: A sample of 244 patients was matched to 449 controls. EPPIS patients had lower odds of being accused of a crime both during and after treatment. Suicidal behavior was less frequent among patients, both during treatment (p<0.0001) and after (HR=0.39; 95% CI: 0.17 to 0.94). During treatment there were more emergency department visits for the patients (RR=2.54; 95% CI: 1.56 to 4.58), but no difference in inpatient usage compared to controls. Post-treatment, both emergency department and inpatient usage were higher among patients.Conclusions: EPPIS patients had reduced suicide attempts and criminal accusations. Increased emergency department use could indicate that encouraging treatment during a crisis may increase service use, while reducing suicidal and criminal behaviour. [ABSTRACT FROM AUTHOR]

The PATHS Data Resource is a unique database comprising data that follow individuals from the prenatal period to adulthood. The PATHS Resource was developed for conducting longitudinal epidemiological research into child health and health equity. It contains individual-level data on health, socioeconomic status, social services and education. Individuals’ data are linkable across these domains, allowing researchers to follow children through childhood and across a variety of sectors. PATHS includes nearly all individuals that were born between 1984 and 2012 and registered with Manitoba’s universal health insurance programme at some point during childhood. All PATHS data are anonymized. Key concepts, definitions and algorithms necessary to work with the PATHS Resource are freely accessible online and an interactive forum is available to new researchers working with these data. The PATHS Resource is one of the richest and most complete databases assembled for conducting longitudinal epidemiological research, incorporating many variables that address the social determinants of health and health equity. Interested researchers are encouraged to contact [mchp_access@cpe.umanitoba.ca] to obtain access to PATHS to use in their own programmes of research. [ABSTRACT FROM AUTHOR]

Background: Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications. The authors investigated whether preoperative diagnosis and prescription of continuous positive airway pressure therapy reduces these risks.Methods: Matched cohort analysis of polysomnography data and Manitoban health administrative data (1987 to 2008). Postoperative outcomes in adult OSA patients up to 5 yr before (undiagnosed OSA, n = 1,571), and any time after (diagnosed OSA, n = 2,640) polysomnography and prescription of continuous positive airway pressure therapy for a new diagnosis of OSA, were compared with controls at low risk of having sleep apnea (n = 16,277). Controls were matched by exact procedure, indication, and approximate date of surgery. Procedures used to treat sleep apnea were excluded. Follow-up was at least 7 postoperative days. Results were reported as odds ratio (95% CI) for OSA or subgroup versus controls.Results: In multivariate analyses, the risk of respiratory complications (2.08 [1.35 to 3.19], P < 0.001) was similarly increased for both undiagnosed and diagnosed OSA. The risk of cardiovascular complications, primarily cardiac arrest and shock, was significantly different (P = 0.009) between undiagnosed OSA (2.20 [1.16 to 4.17], P = 0.02) and diagnosed OSA patients (0.75 [0.43 to 1.28], P = 0.29). For both outcomes, OSA severity, type of surgery, age, and other comorbidities were also important risk modifiers.Conclusions: Diagnosis of OSA and prescription of continuous positive airway pressure therapy were associated with a reduction in postoperative cardiovascular complications. Despite limitations in the data, these results could be used to justify and inform large efficacy trials of perioperative continuous positive airway pressure therapy in OSA patients. [ABSTRACT FROM AUTHOR]

The article reports on the cohort study of association of proton pump inhibitors with increased risk of hospitalisation for community-acquired pneumonia. It informs that the study was conducted on the patients below 40 age group who were prescribed an oral nonsteroidal anti-inflammatory drugs (NSAID). It also mentions the examination of gastric acid suppressing medications and pneumonia.

K. Rastle and M. Coltheart (1999) demonstrated that both nonwords and low-frequency regular words are named more slowly when mixed with first-phoneme irregular word fillers (e.g., CHEF) than when mixed with third-phoneme irregular word fillers (e.g., GLOW). Those authors suggested that their effects were due to a strategic de-emphasis of the nonlexical route when first-phoneme irregular fillers were used. An alternative explanation is that these results simply reflect a more lax position of a time criterion (S. J. Lupker, P. Brown, & L. Colombo, 1997) in the first-phoneme irregular filler condition. We contrasted these 2 accounts in 4 experiments. In all experiments, target naming latencies were longer when the fillers were harder to name, regardless of whether the fillers were nonwords or exception words. These results strongly favor a time-criterion account of K. Rastle and M. Coltheart's effects. [ABSTRACT FROM AUTHOR]

The present study investigated the role of spelling–sound consistency in naming printed disyllabic words. Participants in Experiment 1 named 1000 monomorphemic six-letter disyllabic words. Spelling–sound consistency measures for 11 orthographic segments were used to predict the naming latencies and error rates on the words. The consistency of vowel segments, particularly the one in the second syllable, contributed significantly to the prediction of naming latencies and error rates. In addition, the consistency of the BOB (body-of-the-BOSS, which is the orthographic segment containing the first vowel grapheme and as many following consonants as make an orthographically legal word ending) was also a significant predictor. The effect of the spelling–sound consistency of BOB and V2 segments was replicated in factorial experiments. These findings suggest that readers learn spelling–sound relationships not only for individual letters of graphemes but also for larger orthographic segments in disyllabic words, likely those that provide information about pronunciations beyond that of the individual letters of which they are composed. This study provides the kind of information that is needed to extend current models of word recognition beyond their current focus on monosyllabic words to more complex words. [Copyright &y& Elsevier]

Two experiments are reported which examined whether a prefixed word can be primed by a word sharing only the prefix letters in a masked priming paradigm. In addition the studies examined whether the size of the priming effect is influenced by the consistency with which a prefix letter pattern appears in real prefixed words. The ratio of real prefixed words to all words containing a prefix letter pattern was calculated and used to identify high-consistency prefixes, which are frequently used as prefixes (e.g., UN in UNHAPPY) and rarely appear as pseudoprefixes (e.g., UNCLE), and low-consistency prefixes, which appear in many pseudoprefixed words (e.g., DE in DESERT) but fewer truly prefixed words (e.g., DECODE). In Experiment 1, decision latencies for both types of prefixes were facilitated when real prefixed target words were preceded by real prefixed prime words in a short SOA masked priming paradigm, although the size of the priming effect for low-consistency prefixes was similar in size to that for orthographic controls. In Experiment 2, real prefixed target words were preceded by pseudoprefixed prime words. Facilitation in performance remained for high-consistency prefixes but was absent for low-consistency prefixes. These results support models of morphological processing that are sensitive to the statistical nature of the relationships between orthographic and semantic representations in a language. [Copyright &y& Elsevier]

Examines the effect of exposure to print on the efficiency of phonological and orthographic word recognition processes. Comparison of two groups of university students having similar reading comprehension scores but different levels of exposure to print.

Background: Complete physical examinations (CPE) can identify health disparities in persons with intellectual or developmental disabilities. The objective of this study was to determine and compare rates of CPE among Manitoba adults with and without intellectual or developmental disabilities over time and to identify factors that were associated with receiving a CPE. Method: A retrospective cohort study using linked administrative health and non‐health data from 1995 to 2015 was conducted. Poisson and logistic regression were used to calculate CPE rates and examine factors associated with CPE. Results: The rates of CPE are decreasing over time and are higher among Manitobans with an intellectual or developmental disability. Characteristics such as being male, living rurally, low socioeconomic status, and high continuity of care led to lower odds of receiving a CPE. Conclusions: The current state of CPE provision to adults with intellectual or developmental disabilities in Manitoba is encouraging but needs improvement. [ABSTRACT FROM AUTHOR]

Background: Differential access to healthcare has contributed to a higher burden of illness and mortality among First Nations compared to other people in Canada. Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, First Nations organizations in Manitoba partnered with public health and Manitoba government officials to ensure First Nations had early, equitable and culturally safe access to COVID-19 diagnostic testing and vaccination. In this study, we examined whether prioritizing First Nations for vaccination was associated with faster uptake of COVID-19 vaccines among First Nations versus All Other Manitobans (AOM). Methods and findings: In this retrospective cohort study, we used linked, whole-population administrative data from the Manitoba healthcare system (February 2020 to December 2021) to determine rates of COVID-19 diagnostic testing, infection, and vaccination, and used adjusted restricted mean survival time (RMST) models to test whether First Nations received their first and second vaccine doses more quickly than other Manitobans. The cohort comprised 114,816 First Nations (50.6% female) and 1,262,760 AOM (50.1% female). First Nations were younger (72.3% were age 0 to 39 years) compared to AOM (51% were age 0 to 39 years) and were overrepresented in the lowest 2 income quintiles (81.6% versus 35.6% for AOM). The 2 groups had a similar burden of comorbidities (65.8% of First Nations had none and 6.3% had 3 or more; 65.9% of AOM had none and 6.0% had 3 or more) and existing mental disorders (36.9% of First Nations were diagnosed with a mood/anxiety disorder, psychosis, personality disorder, or substance use disorder versus 35.2% of AOM). First Nations had crude infection rates of up to 17.20 (95% CI 17.15 to 17.24) COVID-19 infections/1,000 person-months compared with up to 6.24 (95% CI 6.16 to 6.32) infections/1,000 person-months among AOM. First Nations had crude diagnostic testing rates of up to 103.19 (95% CI 103.06 to 103.32) diagnostic COVID-19 tests/1,000 person-months compared with up to 61.52 (95% CI 61.47 to 61.57) tests/1,000 person-months among AOM. Prioritizing First Nations to receive vaccines was associated with faster vaccine uptake among First Nations versus other Manitobans. After adjusting for age, sex, income, region of residence, mental health conditions, and comorbidities, we found that First Nations residents received their first vaccine dose an average of 15.5 (95% CI 14.9 to 16.0) days sooner and their second dose 13.9 (95% CI 13.3 to 14.5) days sooner than other Manitobans in the same age group. The study was limited by the discontinuation of population-based COVID-19 testing and data collection in December 2021. As well, it would have been valuable to have contextual data on potential barriers to COVID-19 testing or vaccination, including, for example, information on social and structural barriers faced by Indigenous and other racialized people, or the distrust Indigenous people may have in governments due to historical harms. Conclusion: In this study, we observed that the partnered COVID-19 response between First Nations and the Manitoba government, which oversaw creation and enactment of policies prioritizing First Nations for vaccines, was associated with vaccine acceptance and quick uptake among First Nations. This approach may serve as a useful framework for future public health efforts in Manitoba and other jurisdictions across Canada. Nathan C Nickel, Wanda Phillips-Beck and colleagues assess whether First Nations-led COVID-19 protective measures were associated with improved access to COVID-19 testing and vaccination compared to all other Manitobans. Author summary: Why was this study done?: Historically, pandemics have disproportionately affected marginalized groups, such as Indigenous Peoples, in a negative way. Evidence of the disporportionate burden of Coronavirus Disease 2019 (COVID-19) on First Nations people in the province of Manitoba, Canada, became clear when collection of Indigenous identifiers began in May 2020. First Nations organizations in Manitoba collaborated with the provincial government to develop and implement COVID-19 testing and vaccine administration strategies to improve access for First Nations people living in Manitoba. We wanted to know if First Nations-led efforts to improve access to COVID-19 protective measures were associated with higher COVID-19 testing rates, lower COVID-19 infection rates, and higher vaccination rates for First Nations people compared to other Manitobans. What did the researchers do and find?: We used a "Nations-based approach," meaning different Indigenous populations were not compared to one another in recognition of each population's unique characteristics. Instead, First Nations were compared to All Other Manitobans (AOM). We used whole-population data from the province of Manitoba to compare diagnostic testing, infection, and vaccination rates among Manitoba First Nations and AOM and examined how quickly vaccines were administered to each group once people were eligible to receive them. From this work, we found that while being prioritized, First Nations had higher testing rates, infection rates, and vaccination rates compared to AOM. As well, First Nations were vaccinated more quickly than AOM after becoming eligible for both first and second doses of the COVID-19 vaccine. What do these finding mean?: Our results suggest that First Nations-led advocacy and efforts to prioritize First Nations people for COVID-19 protective measures were associated with faster vaccine access and uptake by First Nations people and this may have prevented many severe illnesses and deaths. Availability of Indigenous identifiers through collaborative data sovereignty agreements has made this work possible, providing a clearer picture of the outcomes of First Nations' self-determination and public health sovereignty approaches. However, we did not have data on potential social and structural barriers to COVID-19 testing and vaccination faced by Indigenous and racialized people and this is an important area of future research. Broadly speaking, informative, inclusive, and participatory decision-making and policy creation are key to protecting health and preventing the spread of communicable illnesses among Indigenous populations. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of clinician prediction of risk to a standardized assessment of presentation status.Methods: All adult psychiatry emergency department consults in the two main hospitals in Winnipeg, Canada, were assessed using a standardized form (n = 5,376). This form includes two risk scales for a gestalt physician assessment of risk (Suicide Likelihood scale, suicide Attempt Likelihood scale) and the Columbia Classification Algorithm of Suicide Assessment (C-CASA). Regression determined whether assessments predicted future suicide attempts and deaths. The area under the curve (AUC) determined the prediction accuracy of these methods.Results: Although the regression results were significant, the AUCs were either moderate or poor. Clinician assessment was not effective at predicting deaths (AUC = .546, .36-.73), but moderately accurate at predicting future attempts (AUC = .728, .66-.79). C-CASA assessment was moderately accurate at predicting both attempts and deaths (AUC = .666 and .678).Conclusions: Clinician assessment does not significantly outperform a simple assessment of the occurrence of suicidal thoughts and behaviors during presentation to the emergency department. Behavior-based standardized assessments should be further researched in this field. Assessment of suicidality at presentation using C-CASA or similar assessment should be standard for psychiatric patients assessed in the emergency department. [ABSTRACT FROM AUTHOR]

Social stratification and life course approaches are enlisted to study the effects of health and social events on early adult welfare use. Given the strong link between individual and parental economic disadvantage, the mechanisms by which social context affects welfare use are examined. This unique approach is made possible by the linkage of several administrative databases in Manitoba, Canada, allowing for the follow-up of a large population (n = 42,598) and subpopulation of siblings (n = 7920) from birth to age 26. Gradients of inequality were found for many of the predictors. Regardless of background, improved educational achievement and better childhood and adolescent mental health seem likely to decrease the use of welfare in early adulthood. Addressing the risk factors identified in this study would reduce inequities and lower the need for welfare in early adulthood. [ABSTRACT FROM AUTHOR]

Objective: To investigate differences in physician-diagnosed psychiatric disorders between women who gave birth to children with a fetal alcohol spectrum disorder (FASD) diagnosis (study group) compared to women who gave birth to children without FASD (comparison group).Methods: We linked population-level health and social services data to clinical data on FASD diagnoses to identify study group ( n = 702) and comparison group ( n = 2097) women matched 1:3 on date of birth of index child, region of residence, and socioeconomic status. Regression modeling produced relative rates (RRs) for outcomes.Results: Mothers who gave birth to children with FASD had higher adjusted rates of substance use disorder (RR, 12.65; 95% confidence interval [CI], 8.99-17.80), personality disorder (RR, 12.93; 95% CI, 4.88-34.22), and mood and anxiety disorders (RR, 1.75; 95% CI, 1.49-2.07) before the pregnancy of the child. These mothers also had higher adjusted rates of maternal psychological distress during pregnancy (RR, 5.35; 95% CI, 4.58-6.35) and higher rates of postpartum psychological distress (RR, 1.71; 95% CI, 1.53-1.90). These women also had higher adjusted rates for antidepressant prescriptions before, during, and after the pregnancy.Conclusions: A significant psychiatric burden exists for women giving birth to children with FASD. Clinicians should recognise the high rates of psychiatric concerns facing mothers who give birth to children with FASD and should offer treatment and support to these women to improve their health and well-being and prevent further alcohol-exposed pregnancies. [ABSTRACT FROM AUTHOR]

Introduction/objective: The Canadian Network for Observational Drug Effect Studies (CNODES), a network of researchers and databases, is a collaborating center of the Drug Safety and Effectiveness Network. CNODES' main mandate is to conduct observational studies of drug safety based on queries developed and submitted by Health Canada and other federal, provincial, and territorial stakeholders. Through a case study we explore several methodological opportunities and challenges that arise in distributed pharmacoepidemiology networks. Case study: We use as a case study a study of proton pump inhibitors and hospitalization for community-acquired pneumonia. Challenges arise in the design and conduct of studies at individual sites, and then with processes and methods for combining data. On the other hand, distributed networks provide opportunities, such as the ability to detect and understand heterogeneity, in sample sizes that would typically be impossible for a single study. Conclusions: Networks such as CNODES provide the opportunity to detect and quantify important safety signals from administrative data, and provide many challenges for methods research in pharmacoepidemiology using distributed data. As networks increase in size and scope of research questions, the need for methodological developments should continue to grow. [ABSTRACT FROM AUTHOR]

Introduction: Childhood vaccination rates in Manitoba populations with low socioeconomic status (SES) fall significantly below the provincial average. This study examined the impact of a pay-for-performance (P4P) program called the Physician Integrated Network (PIN) on health inequity in childhood vaccination rates. Methods: The study used administrative data housed at the Manitoba Centre for Health Policy. We included all children born in Manitoba between 2003 and 2010 who were patients at PIN clinics receiving P4P funding matched with controls at non-participating clinics. We examined the rate of completion of the childhood primary vaccination series by age 2 across income quintiles (Q1-Q5). We estimated the distribution of income using the Gini coefficient, and calculated concentration indices for vaccination to determine whether the P4P program altered SES-related differences in vaccination completion. We compared these measures between study cohorts before and after implementation of the P4P program, and over the course of the P4P program in each cohort. Results: The PIN cohort included 6,185 children. Rates of vaccination completion at baseline were between 0.53 (Q1) and 0.69 (Q5). Inequality in income distribution was present at baseline and at study end in PIN and control cohorts. SES-related inequity in vaccination completion worsened in non-PIN clinics (difference in concentration index 0.037; 95 % CI 0.013, 0.060), but remained constant in P4P-funded clinics (difference in concentration index 0.006; 95 % CI 0.008,0.021). Conclusions: The P4P program had a limited impact on vaccination rates and did not address health inequity. [ABSTRACT FROM AUTHOR]

Objective: It has only recently been accepted that attention-deficit hyperactivity disorder (ADHD) persists into adulthood. Accordingly, less is known about adult diagnostic and treatment prevalence. We aimed to determine the lifetime prevalence of ADHD diagnosis and psychostimulant prescriptions for young adults in the province of Manitoba and to explore how diagnosis differs according to sociodemographic characteristics and age at diagnosis; and to investigate whether a socioeconomic gradient exists within young adults with a lifetime ADHD diagnosis, as well as the variables that moderate the gradient. Methods: Using the Manitoba Population Health Research Data Repository, our cross-sectional analysis used 24 fiscal years of data (1984/85 to 2008/09) and included all adults aged 18 to 29 during 2007/08 to 2008/09 in Manitoba (n = 207 544) who had a lifetime diagnosis of ADHD (n = 14 762). Regression analyses tested for differences in rates by sex, region, age, age at diagnosis, and socioeconomic status. Results: Lifetime prevalence for ADHD diagnosis (7.11%) and psychostimulant prescriptions (3.09%) differed according to sex, region, and age. In contrast to previous Manitoban research on childhood ADHD, the socioeconomic gradient for ADHD diagnosis was not found in young adulthood. When region was accounted for, a small negative gradient in the urban population and a positive gradient in the rural population were evident. People from the highest income quintile were significantly less likely to be diagnosed before age 18, compared with other income quintiles. Conclusions: Given the high lifetime prevalence of ADHD in Manitoban young adults and significant socioeconomic correlates for diagnosis, further investigation into the trajectory of this relatively unexplored population is recommended. [ABSTRACT FROM AUTHOR]

Background: Characteristics of patients using newer 2nd and 3rd line antidiabetic drugs in a real-world setting are poorly understood. We described the characteristics of new users of sodium-glucose co-transporter-2 inhibitors (SGLT-2i), dipeptidyl peptidase-4 inhibitors (DPP-4i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA) in Canada and the United Kingdom (UK) between 2016 and 2018. Methods: We conducted a multi-database cohort study using administrative health databases from 7 Canadian provinces and the UK Clinical Practice Research Datalink. We assembled a base cohort of antidiabetic drug users between 2006 and 2018, from which we constructed 3 cohorts of new users of SGLT-2i, DPP-4i, and GLP-1 RA between 2016 and 2018. Results: Our cohorts included 194,070 new users of DPP-4i, 166,722 new users of SGLT-2i, and 27,719 new users of GLP-1 RA. New users of GLP-1 RA were more likely to be younger (mean ± SD: 56.7 ± 12.2 years) than new users of DPP-4i (67.8 ± 12.3 years) or SGLT-2i (64.4 ± 11.1 years). In Canada, new users of DPP-4i were more likely to have a history of coronary artery disease (22%) than new users of SGLT-2i (20%) or GLP-1 RA (15%). Conclusion: Although SGLT-2i, DPP-4i, and GLP-1 RAs are recommended as 2nd or 3rd line therapy for type 2 diabetes, important differences exist in the characteristics of users of these drugs. Contrary to existing guidelines, new users of DPP-4i had a higher prevalence of cardiovascular disease at baseline than new users of SGLT2i or GLP-1RA. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of early pregnancy loss on subsequent health care use and costs. Data Sources: Linked administrative health databases from Manitoba, Canada. Study Design: This was a population‐based cohort study. The exposure of interest was first recorded ectopic pregnancy or miscarriage (EPM). Outcomes included visits to all ambulatory care providers, family physicians (FPs), specialists, and hospitals, as well as the costs associated with these visits. We also assessed the impact of EPM on a global measure of health service utilization and the incidence and costs of psychotropic medications. Data Collection/Extraction Methods: We identified women who experienced their first recorded loss (EPM) from 2003–2012 and created a propensity score model to match these women to women who experienced a live birth, with outcome measures available through 31 December 2014. We used a difference in differences approach with multivariable negative binomial models and generalized estimating equations (GEE) to assess the impact of EPM on the aforementioned health care utilization indicators. Principal Findings: EPM was associated with a short‐term increase in visits to, and costs associated with, certain ambulatory care providers. These findings were driven in large part by increased visits/costs to FPs (rate difference [RD]: $19.92 [95% CI: $16.33, $23.51]) and obstetrician‐gynecologists (OB‐GYNs) (RD $9.41 [95% CI: $8.42, $10.40]) in the year immediately following the loss, excluding care associated with the loss itself. We also detected an increase in hospital stays and costs and a decrease in the use of psychotropic medications relative to matched controls. Conclusion: Pregnancy loss may lead to subsequent increases in certain types of health care utilization. While the absolute costs associated with post‐EPM care are relatively small, the observed patterns of service utilization are informative for providers and policy makers seeking to support women following a loss. [ABSTRACT FROM AUTHOR]

PURPOSE Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care-sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations. METHODS Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease-related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient's usual physician (eg, payment mechanism, sex, years in practice). RESULTS We included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93). CONCLUSIONS In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care-sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor. [ABSTRACT FROM AUTHOR]

Background: Adults with chronic disease are the most frequent users of the primary healthcare system. In Manitoba, patients are allowed to seek ambulatory (outpatient) care from the provider of their choosing (primary care physician or specialist), with referrals to specialists preferred but not always required. Some patients receive their routine care from specialists. We conducted this study to determine the patterns by which adults with chronic disease access ambulatory care as a prelude to exploring the impact these patterns may have on the quality of care received. Methods: Physician claims for all visits between 2007/8-2009/10 were extracted from the Data Repository at the Manitoba Centre for Health Policy. Patients included in the analysis made at least four ambulatory visits to a primary care physician or specialist within the study period, and met the definition criteria for at least one of six chronic diseases: diabetes mellitus; congestive heart failure; mood disorders; ischemic heart disease; total respiratory morbidity; and/or hypertension. Patients were "assigned" to the physician they visited most regularly. Physician visit patterns were assessed by dividing visits into nine visit types based on the type of physician patients visited (assigned primary care physician, other primary care physician, or specialist) and whether or not they received a referral. Results: 347,606 patients with 7,662,411 physician visits were included in the analysis. Most visits were to the patients' assigned primary care physician. About 50% of the visits to specialists were by referral from the assigned primary care physician. However, 26-29% of all visits to a primary care physician were not to the assigned primary care physician, and non-assigned physicians were more likely to refer patients to specialists than assigned primary care physicians. Conclusion: The findings suggest that the current primary care system in Manitoba may not adequately support coordination of ambulatory care. Ambulatory visits to a primary care provider who is not the patient's regular provider may represent a lost opportunity for coordination and continuity of care, and may affect the quality of care patients receive. Primary care renewal initiatives in this province should address this challenge to service provision. [ABSTRACT FROM AUTHOR]

Introduction: Acute care hospitals often inadequately prepare older adults to transition back to the community. Interventions that seek to improve this transition process are usually evaluated using healthcare use outcomes (e.g., hospital re-visit rates) only, and do not gather provider and patient perspectives about strategies to better integrate care. This protocol describes how we will use complementary research approaches to evaluate an in-hospital sub-acute care (SAC) intervention, designed to better prepare and transition older adults home. Methods: In three sequential research phases, we will assess (1) SAC transition pathways and effectiveness using administrative data, (2) provider fidelity to SAC core practices using chart audits, and (3) SAC implementation outcomes (e.g., facilitators and barriers to success, strategies to better integrate care) using provider and patient interviews. Results: Findings from each phase will be combined to determine SAC effectiveness and efficiency; to assess intervention components and implementation processes that 'work' or require modification; and to identify provider and patient suggestions for improving care integration, both while patients are hospitalized and to some extent after they transition back home. Discussion: This protocol helps to establish a blueprint for comprehensively evaluating interventions conducted in complex care settings using complementary research approaches and data sources. [ABSTRACT FROM AUTHOR]

Background The city of Winnipeg was the first among several jurisdictions in Manitoba, Canada, to introduce breed specific legislation (BSL) by banning pit-bull type dogs in 1990. The objective of the present work was to study the effectiveness of BSL in Manitoba. Methods Temporal differences in incidence of dog-bite injury hospitalisations (DBIH) within and across Manitoba jurisdictions with and without BSL were compared. Incidence was calculated as the number of unique cases of DBIH divided by the total person-years at risk and expressed as the number per 100 000 person-years. Year of implementation determined the pre-BSL and post-BSL period for jurisdictions with BSL; for jurisdictions without BSL to date, the entire study period (1984--2006) was considered as the preimplementation period. The annual number of DBIH, adjusted for total population at risk, was modelled in a negative binomial regression analysis with repeated measures. Year, jurisdiction and BSL implementation were independent variables. An interaction term between jurisdiction and BSL was introduced. Results A total of 16 urban and rural jurisdictions with pit-bull bans were identified. At the provincial level, there was a significant reduction in DBIH rates from the pre- BSL to post-BSL period (3.47 (95% CI 3.17 to 3.77) per 100 000 person-years to 2.84 (95% CI 2.53 to 3.15); p=0.005). In regression restricted to two urban jurisdictions, DBIH rate in Winnipeg relative to Brandon (a city without BSL) was significantly (p<0.001) lower after BSL (rate ratio (RR)=1.10 in people of all ages and 0.92 in those aged <20 years) than before (RR=1.29 and 1.28, respectively). Conclusions BSL may have resulted in a reduction of DBIH in Winnipeg, and appeared more effective in protecting those aged <20 years. [ABSTRACT FROM AUTHOR]

Purpose/Objectives: To test the effects of different perspective-taking instructional sets, gender, caregivers' personal histories with cancer, and caregiving relationship factors on family caregiver and patient perceptual agreement of symptom experiences of patients with lung cancer. Design: Counterbalanced. Setting: Thoracic oncology outpatient clinical setting in Canada. Sample: 98 dyads consisting of patients with lung cancer and their family caregivers. Methods: Data were collected on a one-time basis by employing an abbreviated version of the Memorial Symptom Assessment Scale targeting lack of energy and worrying. Caregivers were randomized to one of six counterbalanced conditions of perspective-taking instructions. Main Research Variables: Caregiver discrepancy scores, instructional sets (i.e., neutral, self-report, and imagine-self and imagine-patient perspective-taking), order effects, gender, caregivers' personal history with cancer, and caregiving relationship factors. Findings: No order effects were found for the instructional sets. Instructions to imagine the patient's perspective over imagining how the caregiver would feel if he or she had cancer were most effective in enhancing the caregiver's ability to estimate the patient's lack of energy and worrying. Gender had no significant effects. The amount of patient-caregiver communication had a positive impact on the accuracy of caregivers' perspectives. Conclusions: The patient-oriented instructions had a limited impact on enhancing patient-caregiver congruence on patient symptoms. This likely is related to the study's convenience sample of caregivers who appear to naturally engage in empathic processes of patient-oriented perspective-taking when they assessed and reported on patient symptom conditions. Implications for Nursing: Further exploratory work should identify interpersonal conditions that negatively hamper the effects of caregiver perspective-taking on their reasonable understanding of patient symptoms. [ABSTRACT FROM AUTHOR]

Background: Evidence-based guidelines for antibiotic use are well established, but nonadherence to these guidelines continues. This study was undertaken to determine child, household and physician factors predictive of nonadherence to evidence-based antibiotic prescribing in children. Methods: The prescription and health care records of 20 000 Manitoba children were assessed for 2 criteria of nonadher-ence to evidence-based antibiotic prescribing during the pe-riod from fiscal year 1996 (April 1996 to March 1997) to fis-cal year 2000: receipt of an antibiotic for a viral respiratory tract infection (VRTI) and initial use of a second-line agent for acute otitis media, pharyngitis, pneumonia, urinary tract infection or cellulitis. The likelihood of nonadherence to evi-dence- based prescribing, according to child demographic characteristics, physician factors (specialty and place of training) and household income, was determined from hier-archical linear modelling. Child visits were nested within physicians, and the most parsimonious model was selected at p< 0.05. Results: During the study period, 45% of physician visits for VRTI resulted in an antibiotic prescription, and 20% of antibiotic prescriptions were for second-line antibiotics. Relative to gen-eral practitioners, the odds ratio for antibiotic prescription for a VRTI was 0.51 (95% confidence interval [CI] 0.42--0.62) for pediatricians and 1.58 (95% CI 1.03--2.42) for other special-ists. The likelihood that an antibiotic would be prescribed for a VRTI was 0.99 for each successive $10 000 increase in house-hold income. Pediatricians and other specialists were more likely than general practitioners to prescribe second-line anti-biotics for initial therapy. Both criteria for nonadherence to ev-idence- based prescribing were 40% less likely among physi-cians trained in Canada or the United States than among physicians trained elsewhere. Interpretation: The links that we... [ABSTRACT FROM AUTHOR]

Background: The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades.Methods: We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods.Results: Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI -36% to -30%) for ambulatory primary care visits, by 22% (95% CI -27% to -16%) for mammography and by 27% (95% CI -40% to -23%) for injury hospitalizations.Interpretation: Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations. [ABSTRACT FROM AUTHOR]

Purpose: The interplay between critical illness and mental disorders is poorly understood. The purpose of this study is to measure both the treated prevalence of mental disorders and psychotropic medication use before and after hospitalization and the impact of intensive care unit (ICU) admission on these outcomes. Methods: Using a population-based administrative database in Manitoba, Canada, 49,439 ICU patients admitted between 2000 and 2012 were compared to two matched comparison groups (hospitalized; n = 146,968 and general population; n = 141,937). Treated prevalence of mental disorders and psychotropic medication prescriptions were measured in the 5-year periods before and after the hospitalization. Multivariable models compared adjusted prevalence ratios (APRs) between populations. Results: The 5-year treated mental disorder prevalence in the ICU population increased from 41.5% pre-hospitalization to 55.6% post-hospitalization. Compared to non-ICU hospitalized patients, the adjusted treated mental disorder prevalence in ICU patients was lower prior to hospitalization (1-year APR 0.94, 95% CI 0.92–0.97, p < 0.0001; 5-year APR 0.99, 95% CI 0.98–1.00, p = 0.1), but higher following discharge (1-year APR 1.08, 95% CI 1.05–1.11, p < 0.0001, 5-year APR 1.03, 95% CI 1.01–1.05, p < 0.0001). A high proportion of ICU patients received antidepressant, anxiolytic and sedative-hypnotic prescriptions before and after their hospitalization. In multivariable analyses, ICU exposure was associated with an increase in mood, anxiety and psychotic disorders, and sedative-hypnotics use (p < 0.0001 for all Time × Group interactions). Conclusions: During the 5 years after admission to ICU, there is a significant increase in treated prevalence of mental disorders and psychotropic medication use compared to the 5 years prior to ICU and compared to general population and hospital cohorts. Prevention and intervention programs that identify and treat mental disorders among survivors of critical illness warrant further study. [ABSTRACT FROM AUTHOR]

Objective: We aimed to determine the impact of a primary treatment consultation recording on perception of being informed, satisfaction with cancer care, satisfaction with the oncologist, and psychological distress in patients with brain tumors. Methods: This was a prospective, double-blind, parallel, randomized controlled trial conducted in 3 Canadian cities, in which patients who had their initial treatment consultation recorded were assigned to either receive their digital recording or not. It was hypothesized that patients who received their recording would realize statistically significant benefit on the outcomes of interest at 1 week, 3 months, and 6 months post-consultation in comparison to patients who did not receive their recording. Outcome measures included the following: Patient Satisfaction with Cancer Scale, Hospital Anxiety and Depression Scale, PrestMan Satisfaction with Doctor Scale, and Perception of Being Informed Scale. Results: Of the 246 eligible patients, 133 participated (60.9% male; age M=52.4 years; 53.4% grade IV disease). Of these, 63 received their consultation recording and 70 did not. Intention-to-treat analysis showed that, compared to baseline, patients who received their consultation recording reported being more fully informed about their disease and treatment at 1 week post-consultation than patients who did not receive their recording (p = 0.007), but this finding was no longer significant at 3 and 6 months. There were no statistically significant differences observed between the two groups on the measures of satisfaction with cancer care, satisfaction with the doctor, and depression or anxiety at any assessment time point, though the study was under-powered. Conclusion: The study findings show that primary treatment consultation recordings may provide limited benefit beyond brain tumor patients' perception of being informed, despite being highly valued by these patients, and high listening rates among their significant others. The lack of statistical power should be considered when interpreting the findings. Trial registration: ClinicalTrials.gov - NCT01866228 [ABSTRACT FROM AUTHOR]

Background: In Manitoba, Canada, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit, an unconditional income supplement of up to CAD $81/month, during their latter two trimesters. Our objective was to determine the impact of the Healthy Baby Prenatal Benefit on birth and early childhood outcomes among Manitoba First Nations women and their children.Methods: We used administrative data to identify low-income First Nations women who gave birth 2003-2011 (n = 8209), adjusting for differences between women who received (n = 6103) and did not receive the Healthy Baby Prenatal Benefit (n = 2106) with using propensity score weighting. Using multi-variable regressions, we compared rates of low birth weight, preterm, and small- and large-for-gestational-age births, 5-min Apgar scores, breastfeeding initiation, birth hospitalization length of stay, hospital readmissions, complete vaccination at age one and two, and developmental vulnerability in Kindergarten.Results: Women who received the benefit had lower risk of low birth weight (adjusted relative risk [aRR] 0.74; 95% CI 0.62-0.88) and preterm (aRR 0.77; 0.68-0.88) births, and were more likely to initiate breastfeeding (aRR 1.05; 1.01-1.09). Receipt of the Healthy Baby Prenatal Benefit was also associated with higher rates of child vaccination at age one (aRR 1.10; 1.06-1.14) and two (aRR 1.19; 1.13-1.25), and a lower risk that children would be vulnerable in the developmental domains of language and cognitive development (aRR 0.88; 0.79-0.98) and general knowledge/communication skills (aRR 0.87; 0.77-0.98) in Kindergarten.Conclusions: A modest unconditional income supplement of CAD $81/month during pregnancy was associated with improved birth outcomes, increased vaccination rates, and better developmental health outcomes for First Nations children from low-income families. [ABSTRACT FROM AUTHOR]

Background: Pregnancy loss is common and several factors (e.g. chromosomal anomalies, parental age) are known to increase the risk of occurrence. However, much existing research focuses on recurrent loss; comparatively little is known about the predictors of a first miscarriage. Our objective was to estimate the population-level prevalence of miscarriages and to assess the contributions of clinical, social, and health care use factors as predictors of the first detected occurrence of these losses.Methods: In this population-based cohort study, we used linked administrative health data to estimate annual rates of miscarriage in the Manitoba population from 2003 to 2014, as a share of identified pregnancies. We compared the unadjusted associations between clinical, social, and health care use factors and first detected miscarriage compared with a live birth. We estimated multivariable generalized linear models to assess whether risk factors were associated with first detected miscarriage controlling for other predictors.Results: We estimated an average annual miscarriage rate of 11.3%. In our final sample (n = 79,978 women), the fully-adjusted model indicated that use of infertility drugs was associated with a 4 percentage point higher risk of miscarriage (95% CI 0.02, 0.06) and a past suicide attempt with a 3 percentage point higher risk (95% CI -0.002, 0.07). Women with high morbidity were twice as likely to experience a miscarriage compared to women with low morbidity (RD = 0.12, 95% CI 0.09, 0.15). Women on income assistance had a 3 percentage point lower risk (95% CI -0.04, -0.02).Conclusions: We estimate that 1 in 9 pregnant women in Manitoba experience and seek care for a miscarriage. After adjusting for clinical factors, past health care use and morbidity contribute important additional information about the risk of first detected miscarriage. Social factors may also be informative. [ABSTRACT FROM AUTHOR]

School‐based healthy living interventions are widely promoted as strategies for preventing obesity. The peer‐led Healthy Buddies™ curriculum has been shown to improve obesity‐related outcomes in school‐aged children. We examined whether these improvements existed among subgroups of children stratified by sex, income level and urban/rural geography. In a cluster‐randomized controlled trial, elementary schools in Manitoba, Canada, were randomly allocated to Healthy Buddies™ (10 schools, 340 students) or standard curriculum (10 schools, 347 students). Healthy Buddies™ participants had 21weekly lessons on healthy eating, physical activity and self‐efficacy, delivered by children age 9–12 to children age 6–8. We assessed pre‐ and post‐intervention body mass index (BMI) z‐scores, waist circumference, healthy living knowledge, dietary intake and self‐efficacy among the younger children. Compared to standard curriculum (n = 154), Healthy Buddies™ participants (n = 157) experienced a greater reduction in waist circumference (−1.7 cm; 95% confidence interval [CI][−2.8, −0.5 cm]) and improved dietary intake (4.6; 95% CI [0.9, 8.3]), healthy living knowledge (5.9; 95% CI [2.3, 9.5]) and self‐efficacy (5.3; 95% CI [1.0, 9.5]) scores. In subgroup analyses, effects for waist circumference (−2.0 cm; 95% CI [−3.6, −0.5]), healthy living knowledge (9.1; 95% CI [4.4, 13.8]) and self‐efficacy (8.3; 95% CI [3.3, 13.3]) were significant among boys. Dietary intake (10.5; 95% CI [5.5, 15.4]), healthy living knowledge (9.8; 95% CI [4.5, 15.0]) and self‐efficacy (6.7; 95% CI [0.7, 12.7]) improved among urban‐dwelling but not rural‐dwelling children. Healthy Buddies™ was effective for boys and children living in urban settings. Enhanced curricula may be needed to improve program effectiveness for select subgroups of school‐aged children. [ABSTRACT FROM AUTHOR]

Objective: Reports of amputations associated with sodium-glucose cotransporter 2 (SGLT2) inhibitors have been inconsistent. We aimed to compare the risk of below-knee amputation with SGLT2 inhibitors versus dipeptidyl peptidase 4 (DPP-4) inhibitors among patients with type 2 diabetes.Research Design and Methods: This multicenter observational study used administrative health care databases from seven Canadian provinces and the U.K. Incident SGLT2 inhibitor users were matched to DPP-4 inhibitor users using a prevalent new-user design and time-conditional propensity scores. Cox proportional hazards models were used to estimate site-specific adjusted hazard ratios (HR) and corresponding 95% CIs of incident below-knee amputation for SGLT2 inhibitor versus DPP-4 inhibitor users. Random effects meta-analyses were used to pool the site-specific results.Results: The study cohort included 207,817 incident SGLT2 inhibitor users matched to 207,817 DPP-4 inhibitor users. During a mean exposed follow-up time of 11 months, the amputation rate was 1.3 per 1,000 person-years among SGLT2 inhibitor users and 1.5 per 1,000 person-years among DPP-4 inhibitor users. The adjusted HR of below-knee amputations associated with SGLT2 inhibitor use compared with DPP-4 inhibitor use was 0.88 (95% CI 0.71-1.09). Similar results were obtained in stratified analyses by specific SGLT2 inhibitor molecule.Conclusions: In this large multicenter observational study, there was no association between SGLT2 inhibitor use and incident below-knee amputations among patients with type 2 diabetes compared with DPP-4 inhibitor use. While these findings provide some reassurance, studies with a longer duration of follow-up are needed to assess potential long-term effects. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether intrauterine exposure to maternal diabetes is associated with risk factors for cardiovascular disease and related end points in adulthood. We examined this potential association in a population-based birth cohort followed up to age 35 years.Methods: We performed a cohort study of offspring born between 1979 and 2005 (n = 293 546) and followed until March 2015 in Manitoba, Canada, using registry-based administrative data. The primary exposures were intrauterine exposure to gestational diabetes and type 2 diabetes mellitus. The primary outcome was a composite measure of incident cardiovascular disease events, and the secondary outcome was a composite of risk factors for cardiovascular disease in offspring followed up to age 35 years.Results: The cohort provided 3 628 576 person-years of data (mean age at latest follow-up 20.5 [standard deviation 6.4] years, 49.3% female); 2765 (0.9%) of the offspring experienced a cardiovascular disease end point, and 12 673 (4.3%) experienced a cardiovascular disease risk factor. After propensity score matching, the hazard for cardiovascular disease end points was elevated in offspring exposed to gestational diabetes (adjusted hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.12-1.79) but not type 2 diabetes (adjusted HR 1.40, 95% CI 0.98-2.01). A similar association was observed for cardiovascular disease risk factors (gestational diabetes: adjusted HR 1.92, 95% CI 1.75-2.11; type 2 diabetes: adjusted HR 3.40, 95% CI 3.00-3.85).Interpretation: Intrauterine exposure to maternal diabetes was associated with higher morbidity and risk related to cardiovascular disease among offspring up to 35 years of age. [ABSTRACT FROM AUTHOR]

Objective: To estimate incidence of newly diagnosed mental disorders among ICU patients.Design: Retrospective-matched cohort study using a population-based administrative database.Setting: Manitoba, Canada.Participants: A total of 49,439 ICU patients admitted between 2000 and 2012 were compared with two control groups (hospitalized: n = 146,968 and general population: n = 141,937), matched on age (± 2 yr), sex, region of residence, and hospitalization year.Intervention: None.Measurements and Main Results: Incident mental disorders (mood, anxiety, substance use, personality, posttraumatic stress disorder, schizophrenia, and psychotic disorders) not diagnosed during the 5-year period before the index ICU or hospital admission date (including matched general population group), but diagnosed during the subsequent 5-year period. Multivariable survival models adjusted for sociodemographic variables, Charlson comorbidity index, admission diagnostic category, and number of ICU and non-ICU exposures. ICU cohort had a 14.5% (95% CI, 14.0-15.0) and 42.7% (95% CI, 42.0-43.5) age- and sex-standardized incidence of any diagnosed mental disorder at 1 and 5 years post-ICU exposure, respectively. In multivariable analysis, ICU cohort had increased risk of any diagnosed mental disorder at all time points versus the hospitalized cohort (year 5: adjusted hazard ratio, 2.00; 95% CI, 1.80-2.23) and the general population cohort (year 5: adjusted hazard ratio, 3.52; 95% CI, 3.23-3.83). A newly diagnosed mental disorder was associated with younger age, female sex, more recent admitting years, presence of preexisting comorbidities, and repeat ICU admission.Conclusions: ICU admission is associated with an increased incidence of mood, anxiety, substance use, and personality disorders over a 5-year period. [ABSTRACT FROM AUTHOR]

Discourse in popular media, public policy, and academic literature contends that people who are homeless frequently make inappropriate use of hospital emergency department (ED) services. Although researchers have investigated the ED experiences of people who are homeless, no previous studies have examined how this population understands the role of the ED in their health care and in their day-to-day lives. In the present study, 16 individuals participated in semistructured interviews regarding their ED experiences, and narrative analysis was applied to their responses. Within the context of narratives of disempowerment and discrimination, participants viewed the ED in differing ways, but they generally interpreted it as a public, accessible space where they could exert agency. ED narratives were also paradoxical, depicting it as a fixed place for transient care, or a place where they were isolated yet felt a sense of belonging. Implications for policy and practice are discussed. [ABSTRACT FROM AUTHOR]

Background: Canadian medical student and residents’ severity ratings of professionalism vignettes were examined to identify the differences in ratings by the level of training and by sex. Methods: Eight hundred and thirty‑five medical learners (400 medical students and 435 residents) were invited to participate in an online survey measuring medical professionalism. The survey was composed of questions about descriptive information and professionalism vignettes. The tool consists of 16 vignettes examining respondent’s ability to recognize the professional and unprofessional behaviors. For each vignette, participants were asked to rate the severity of the infraction as “not a problem” to “severe.” Wilcoxon rank sum tests and Fischer’s Chi‑square tests were used to examine the differences in perceptions of professionalism by the level of training and sex, and logistic regression models were created with the level of training and sex to examine their association with binary vignette responses (not a severe infraction and severe infraction); controlling for the effect of the other variable. Results: Overall response rate for the completed survey was 30% (n = 253). Significant differences between males and females were found for lapse in excellence (P ≤ 0.039), inappropriate dress (P ≤ 0.003), lack of altruism (P ≤ 0.033), disrespect (P ≤ 0.013), shirking duty (P ≤ 0.028), and abuse of power (P ≤ 0.006). Females rated all six vignettes as more severe as compared to males. Shirking duty (P ≤ 0.002) was found to have the differences between learner responses. Regressions found sex to be associated with severity of professionalism infractions on seven vignettes. Discussion: Future work is needed in the area of professionalism and sex to understand why female and male learners may perceive professionalism differently. [ABSTRACT FROM AUTHOR]

Objective: This qualitative study explores teens’ perspectives on facilitators and barriers to accessing school-based clinics, emphasizing the importance of youth self-report. Methods: We conducted in-person interviews with teens (N = 25) at 2 high schools that had school-based clinics in Winnipeg, Manitoba (Canada). We supplemented the interviews with a brief questionnaire administered to a sample of teens at both schools (N = 105). Data were iteratively coded and analyzed using NVivo. Results: Teens framed 5 clinic attributes that facilitated access: confidential, welcoming, judgment-free, validating and understanding, and fast/easy/convenient. Teens identified judgment from peers, fear and anxiety, hours/wait times, lack of privacy, and teens who gather at the clinic to socialize as factors that made the clinic hard to access or inhibited access entirely. Conclusions: School-based clinics were highly regarded by teens who used them. The most important factors underlying ease of use were assurance of confidentiality and a positive client-provider relationship that made teens feel safe and comfortable. However, considerable individual and structural barriers remain to ensuring the clinics are teen-friendly and accessible. [ABSTRACT FROM AUTHOR]

Objective: To examine health services, social services, education, and justice system outcomes among First Nations children and youth with fetal alcohol spectrum disorder (FASD).Methods: In this retrospective cohort study, health and social services, education, and justice data were linked with clinical records on First Nations (FN) individuals aged 1 to 25 and diagnosed with FASD between 1999 and 2010 (n = 743). We compared the FN FASD group to non-FN individuals with FASD (non-FN FASD; n = 315) and to First Nations individuals (matched on age, sex, and income) not diagnosed with FASD (FN non-FASD; n = 2229). Rates and relative risks (RRs) were calculated using generalized linear models.Results: FN FASD individuals had similar health services use to non-FN FASD individuals but had greater involvement with child welfare (RR, 1.20; 95% confidence interval [CI], 1.02 to 1.41) and the justice system (RR, 1.37; 95% CI, 1.07 to 1.74) and were more likely to be charged with a crime (RR, 1.40; 95% CI, 1.05 to 1.86). There were no suicides/suicide attempts among the non-FN FASD individuals during the study, but the crude rate/100 person-years of suicides among FN FASD individuals (0.22 for females; 1.06 for males) was substantially higher than for FN non-FASD individuals (0.08 for females; 0.32 for males). There were no significant differences between groups in the education outcomes we measured.Conclusions: Young people with FASD are at risk for poor health, education, and social outcomes, but First Nations young people with FASD face comparably higher risks, particularly with child welfare and justice system involvement. The study emphasizes a critical need for appropriate resources for First Nations children with FASD. [ABSTRACT FROM AUTHOR]

Background: As children with diabetes transition to adulthood, they may be especially vulnerable to diabetic ketoacidosis (DKA). Cross-national comparisons may inform efforts to avoid this complication.Objective: To compare DKA hospitalization rates in the USA and Manitoba, Canada, during the vulnerable years known as "emerging adulthood."Design: Cross-sectional study using inpatient administrative databases in the USA (years 1998-2014) and Manitoba, Canada (years 2003-2013).Participants: Individuals aged 12-30 years hospitalized with DKA, identified using ICD-9 (USA) or ICD-10 codes (Manitoba).Main Measures: DKA hospitalization rates per 10,000 population by age (with a focus on those aged 15-17 vs. 19-21). Admissions were characterized by gender, socioeconomic status, year of hospitalization, and mortality during hospitalization.Key Results: The DKA rate was slightly higher in the USA among those aged 15-17: 4.8 hospitalizations/10,000 population vs. 3.7/10,000 in Manitoba. Among those aged 19-21, the DKA hospitalization rate rose 90% in the USA to 9.2/10,000, vs. 23% in Manitoba, to 4.5/10,000. In both the USA and Manitoba, rates were higher among those from poorer areas, and among adolescent girls compared with adolescent boys. DKA admissions rose gradually during the period under study in the USA, but not in Manitoba.Conclusions: In years of "emerging adulthood," the Canadian healthcare system appears to perform better than that of the USA in preventing hospitalizations for DKA. Although many factors likely contribute to this difference, universal and seamless coverage over the lifespan in Canada may contribute. [ABSTRACT FROM AUTHOR]

Background: Few studies have investigated prenatal care use among women who use alcohol during pregnancy. The objective of this study was to investigate rates of prenatal care usage of women who have given birth to children with fetal alcohol spectrum disorder (FASD). Methods: We conducted a case–control study of women with children born in Manitoba between Apr. 1, 1984, and Mar. 31, 2012, with follow-up until 2013, using linkable administrative data. The study group included women whose child(ren) was (were) diagnosed with FASD (n = 702) between Apr. 1, 1999, and Mar. 31, 2012, at a centralized diagnostic clinic. The comparison group included women whose child(ren) did not have an FASD diagnosis (n = 2097), exact matched on the index child's birthdate, postal code and socioeconomic status. Adequacy of prenatal care was defined using the Revised Graduated Prenatal Care Utilization Index. Results: Women in the study group had lower socioeconomic status than women in the comparison group and were more likely to have mental disorders and involvement with the child welfare system. Rates of inadequate prenatal care were higher among women in the study group (adjusted relative risk 2.47, 95% confidence interval [CI] 2.08–2.94), as were rates of no prenatal care (adjusted relative risk 3.55, 95% CI 2.42–5.22). In the study group, 41% of women accessed inadequate or no prenatal care, and 59% received intermediate, adequate or intensive prenatal care. Interpretation: Women who give birth to children with FASD have higher rates of inadequate prenatal care and significant social complexities. Socioeconomic disparities in the use of prenatal care should be addressed; multisector interventions are needed that facilitate the uptake of prenatal care by high-risk women who use alcohol. [ABSTRACT FROM AUTHOR]

Objectives This study examines whether mothers involved with child protection services (CPS) at the birth of their first child had higher rates of postpartum depression and anxiety. Methods A retrospective cohort of mothers whose first child was born in Manitoba, Canada between April 1, 1995 and March 31, 2015 is used. Postpartum depression and anxiety among mothers whose first child was placed in care at birth (n = 776) was compared with mothers who received services from CPS (but whose children were not placed in care) (n = 4,270), and a 3:1 matched group of mothers who had no involvement with CPS in the first year of their firstborn’s life (n = 2,328). Adjusted odds ratios (AOR) of depression and anxiety diagnoses in the first year postpartum were obtained from logistic regression models. Adjusted rate ratios (ARR) of antidepressant use obtained using Poisson models. Results Mothers whose children were taken into care have greater odds of having a postpartum depression or anxiety diagnosis than mothers receiving services (AOR = 1.31; 95% CI 1.08-1.59) and those not involved with CPS (AOR = 2.13; 95% CI 1.67-2.73). Among mothers who had a postpartum depression or anxiety diagnosis, mothers whose children were placed in care had significantly higher rates of antidepressant use than mothers receiving services only (ARR = 2.00; 1.82, 2.19) and mothers who were not involved with CPS (ARR = 2.42; 95% CI 1.94-3.51). Conclusions for Practice Targeted programs should be implemented to address postpartum mental illness among mothers who are involved with CPS at the birth of their child. [ABSTRACT FROM AUTHOR]

This study examines whether mothers who had a child taken into care by child protection services have higher mortality rates compared with rates seen in their biological sisters who did not have a child taken into care. We conducted this retrospective cohort study using linkable administrative data from 3,948 mothers whose oldest child was born in Manitoba, Canada, between April 1, 1992, and March 31, 2015. These mothers were from 1,974 families in which one sister had a child taken into care and one sister did not. We computed rate differences and hazard ratios of all-cause, avoidable, and unavoidable mortality. There were an additional 24 deaths per 10,000 person-years among mothers who had had a child taken into care. Mothers who had a child taken into care had higher rates of mortality due to avoidable causes (hazard ratio = 3.46; 95%c onfidence interval: 1.41, 8.48) and unavoidable causes (hazard ratio = 2.92; 95% confidence interval: 1.01, 8.44). The number of children taken into care did not affect mortality rates among mothers with at least 1 child taken into care. The higher mortality rates--particularly avoidable mortality--among mothers who had a child taken into care indicate a need for more specific interventions for these mothers. [ABSTRACT FROM AUTHOR]

Objective: The objective was to compare mental illness diagnoses and treatment use among mothers who lost custody of their child through involvement with child protection services and those seen in mothers dealing with the death of a child.Methods: We studied mental health outcomes of a cohort of women whose first child was born in Manitoba, Canada between 1 April 1997 and 31 March 2015. Of these women, 5,792 had a child taken into care, and 1,143 mothers experienced the death of a child (<18 y old) before 31 March 2015. Adjusted relative rates (ARR) of 3 mental health diagnoses and 3 mental health treatment use outcomes between these 2 groups were examined.Results: Mothers with a child taken into care had significantly greater ARR of depression (ARR = 1.90; 95% CI, 1.82 to 1.98), anxiety (ARR = 2.51; 95% CI, 2.40 to 2.63), substance use (ARR = 8.54; 95% CI, 7.49 to 9.74), physician visits for mental illness (ARR = 3.01; 95% CI, 2.91 to 3.12), and psychotropic medication use (ARR = 4.95; 95% CI, 4.85 to 5.06) in the years after custody loss compared with mothers who experienced the death of a child.Conclusion: Losing custody of a child to child protection services is associated with significantly worse maternal mental health than experiencing the death of a child. Greater acknowledgement and supportive services should be provided to mothers experiencing the loss of a child through the involvement of child protection services. [ABSTRACT FROM AUTHOR]