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Mifepristone medication abortion was first approved in China and France more than 30 years ago and is now used in more than 60 countries worldwide. It is a highly safe and effective method that has the potential to increase population access to abortion in early pregnancy, closer to home. In both Canada and the United States, the initial regulations for distribution, prescribing, and dispensing of mifepristone were highly restricted. However, in Canada, where mifepristone was made available in 2017, most restrictions on the medication were removed in the first year of its availability. The Canadian regulation of mifepristone as a normal prescription makes access possible in community primary care through a physician or nurse practitioner prescription, which any pharmacist can dispense. In this approach, people decide when and where to take their medication. We explore how policy-maker-engaged research advanced reproductive health policy and facilitated this rapid change in Canada. We discuss the implications of these policy advances for self-management of abortion and demonstrate how in Canada patients "self-manage" components of the abortion process within a supportive health care system. [ABSTRACT FROM AUTHOR]

Background: Patient-centered care (PCC) is one approach for ameliorating persistent gendered disparities in health care quality, yet no prior research has studied how to achieve patient-centred care for women (PCCW). The purpose of this study was to explore how clinicians deliver PCCW, challenges they face, and the strategies they suggest are needed to support PCCW.Methods: We conducted semi-structured qualitative interviews (25-60 min) with clinicians. Thirty-seven clinicians representing 7 specialties (family physicians, cardiologists, cardiac surgeons, obstetricians/gynecologist, psychiatrists, nurses, social workers) who manage depression (n = 16), cardiovascular disease (n = 11) and contraceptive counseling (n = 10), conditions that affect women across the lifespan. We used constant comparative analysis to inductively analyze transcripts, mapped themes to a 6-domain PCC conceptual framework to interpret findings, and complied with qualitative research reporting standards.Results: Clinicians said that women don't always communicate their health concerns and physicians sometimes disregard women's health concerns, warranting unique PCC approaches.. Clinicians described 39 approaches they used to tailor PCC for women across 6 PCC domains: foster a healing relationship, exchange information, address emotions/concerns, manage uncertainty, make decisions, and enable self-management. Additional conditions that facilitated PCCW were: privacy, access to female clinicians, accommodating children through onsite facilities, and flexible appointment formats and schedules. Clinicians suggested 7 strategies needed to address barriers of PCCW they identified at the: patient-level (online appointments, transport to health services, use of patient partners to plan and/or deliver services), clinician-level (medical training and continuing professional development in PCC and women's health), and system-level (funding models for longer appointment times, multidisciplinary teamwork to address all PCC domains).Conclusions: Our research revealed numerous strategies that clinicians can use to optimize PCCW, and health care managers and policy-makers can use to support PCCW through programs and policies. Identified strategies addressed all domains of an established PCC conceptual framework. Future research should evaluate the implementation and impact of these strategies on relevant outcomes such as perceived PCC among women and associated clinical outcomes to prepare for broad scale-up. [ABSTRACT FROM AUTHOR]

Background: Considerable research shows that women experience gendered disparities in healthcare access and quality. Patient-centred care (PCC) could reduce inequities by addressing the patient's clinical and personal needs. Healthcare policies can influence service delivery to optimise patient outcomes. This study assessed whether and how government policies recognise and promote PCC for women (PCCW).Methods: We analysed the content of English-language policies published in Canada from 2010 to 2018 on depression and cardiac rehabilitation - conditions featuring known gendered inequities - that were identified on government websites. We extracted data and used summary statistics to enumerate mentions of PCC and women's health.Results: We included 30 policies (20 depression, 10 cardiac rehabilitation). Of those, 20 (66.7%) included any content related to PCC (median 1.0, range 0.0 to 5.0), most often exchanging information (14, 46.7%) and making decisions (13, 43.3%). Less frequent domains were enabling self-management (8, 26.7%), addressing emotions (6, 20.0%) and fostering the relationship (4, 13.3%). No policies included content for the domain of managing uncertainty. A higher proportion of cardiac rehabilitation guidelines included PCC content. Among the 30 policies, 7 (23.3%) included content related to at least one women's health domain (median 0.0, range 0.0 to 3.0). Most frequently included were social determinants of health (4, 13.3%). Fewer policies mentioned any issues to consider for women (2, 28.6%), issues specific to subgroups of women (2, 28.6%) or distinguished care for women from men (2, 28.6%). No policies included mention of abuse or violence, or discrimination or stigma. The policies largely pertained to depression. Despite mention of PCC or women's health, policies offered brief, vague guidance on how to achieve PCCW; for example, "Patients value being involved in decision-making" and "Women want care that is collaborative, woman- and family-centered, and culturally sensitive."Conclusions: Despite considerable evidence of need and international recommendations, most policies failed to recognise gendered disparities or promote PCC as a mitigating strategy. These identified gaps represent opportunities by which government policies could be developed or strengthened to support PCCW. Future research should investigate complementary strategies such as equipping policy-makers with the evidence and tools required to develop PCCW-informed policies. [ABSTRACT FROM AUTHOR]

Introduction: Marginalized populations such as immigrants and refugees are less likely to receive cancer screening. Cancer Awareness: Ready for Education and Screening (CARES), a multifaceted community-based program in Toronto, Canada, aimed to improve breast and cervical screening among marginalized women. This matched cohort study assessed the impact of CARES on cervical and mammography screening among under-screened/never screened (UNS) attendees.Methods: Provincial administrative data collected from 1998 to 2014 and provided in 2015 were used to match CARES participants who were age eligible for screening to three controls matched for age, geography, and pre-education screening status. Dates of post-education Pap and mammography screening up to June 30, 2014 were determined. Analysis in 2016 compared screening uptake and time to screening for UNS participants and controls.Results: From May 15, 2012 to October 31, 2013, a total of 1,993 women attended 145 educational sessions provided in 20 languages. Thirty-five percent (118/331) and 48% (99/206) of CARES participants who were age eligible for Pap and mammography, respectively, were UNS on the education date. Subsequently, 26% and 36% had Pap and mammography, respectively, versus 9% and 14% of UNS controls. ORs for screening within 8 months of follow-up among UNS CARES participants versus their matched controls were 5.1 (95% CI=2.4, 10.9) for Pap and 4.2 (95%=CI 2.3, 7.8) for mammography. Hazard ratios for Pap and mammography were 3.6 (95% CI=2.1, 6.1) and 3.2 (95% CI=2.0, 5.3), respectively.Conclusions: CARES' multifaceted intervention was successful in increasing Pap and mammography screening in this multiethnic under-screened population. [ABSTRACT FROM AUTHOR]

Objective This study compared adherence to follow-up and clinical outcomes between standard in-clinic and remote follow-up after methotrexate/misoprostol abortion. Study design This nonrandomized trial recruited women requesting medical abortion at two sexual health clinics in Toronto, Canada. Women received methotrexate 50 mg/m 2 followed 3–7 days later by 800 mcg of misoprostol self-administered vaginally. For Day 15, follow-up participants could choose standard in-clinic follow-up with ultrasound and assessment or remote telephone follow-up with serum β-hCG performed at a community laboratory and symptom checklist. Standard and remote follow-up groups were compared for adherence, defined as completing follow-up within 7 days of the scheduled time, and clinical outcomes. Characteristics associated with adherence were assessed using multivariable logistic regression. Results Of 129 women, 86 (67%) chose remote follow-up. Nonadherence rates for remote (28%) and standard (23%) follow-up groups did not differ in univariate (p=.57) or multivariable analysis (odds ratio: 1.09, 95% confidence interval: 0.39–3.01). Rates of emergency/hospital visits were 3% and 9% for remote and standard groups, respectively (p=.22), and complete loss to follow was 6% and 14% in remote and standard groups (p=.18). Nonadherent women were more likely to be undecided about their contraception (65% vs. 28%; p=.002), and this difference persisted in the multivariable analysis. Conclusion Given a choice of remote or in-clinic follow-up after methotrexate/misoprostol abortion, most women chose remote follow-up. Rates of adherence to follow-up, adverse outcomes and complete loss to follow-up were similar for women choosing remote and standard follow-up. Implications statement Since standard and remote follow-up after methotrexate/misoprostol abortion are associated with similar adherence to follow-up and similar safety profiles, women should be offered their choice of follow-up method. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting. Options: The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed. Outcomes: Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception. Evidence: Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. Values: The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1). Benefits, Harms, and Costs: These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC. Sponsor: The Society of Obstetricians and Gynecologists of Canada. [Copyright &y& Elsevier]

Abstract: Background: Intrauterine device (IUD) use is low in Canada and declined between 1985 and 1995. This study examines temporal and regional trends in IUD insertion in Ontario, Canada, from 1996 to 2006. Study Design: We used physician billing data to determine annual age-adjusted IUD insertion rates for women aged 15–55 years and proportions inserted by gynecologists and family physicians (FPs). We used small area variation statistics to analyze variation in rates across the province. Results: Annual insertion rates followed a U-shaped distribution and were lowest in 2001 and highest in 2006. From 1996 to 2006, the proportion inserted by FPs fell from 38.2% to 31.6% (p<.001). In 2006, women in regions with the highest rates were twice as likely to have an IUD inserted as those in the lowest-rate regions. Conclusions: IUD insertion rates began to increase in 2001, the year of introduction of the levonorgestrel-releasing intrauterine system. Regional variation in rates suggests that access is not equal across the province and that strategies to support FPs to insert IUDs may be important to ensure adequate access. [Copyright &y& Elsevier]

Emergency contraception (EC) is used to decrease the risk of pregnancy after unprotected sexual intercourse. There are two types of EC: emergency contraceptive pills (ECPs), and the post- coital copper intrauterine device (IUD). ECPs are more commonly used and can reduce the risk of pregnancy by 75- 89%. Although they may be effective if used up to 5 days after intercourse, ECPs are more effective the sooner they are used. This medication is extremely safe and will not harm an existing pregnancy. Repeated use of ECPs poses no known health risks; however, ongoing forms of birth control will be more effective. ECPs do not provide protection against sexually transmitted infections. Improving access to ECPs is a priority for health care advocates. In Canada in 2005, the regulatory status of Plan B®, the most commonly used ECP, changed to enable access without a prescription. As a Schedule II medication, a woman needs only to request it from a pharmacist. Although this has removed one barrier, in some provinces it has resulted in a new barrier; increased cost due to the addition of a fee for counselling by a pharmacist. Some have advocated further deregulation to "on the shelf" (which would not require consultation with a pharmacist), while others maintain that the assessment and counselling by a pharmacist are essential for safe and appropriate use. To further promote appropriate use of emergency contraception, strategies are needed to eliminate barriers to use, increase emergency contraception knowledge and awareness, and assist women to identify their risk for pregnancy. [ABSTRACT FROM AUTHOR]

To compare the effectiveness, side effects, and acceptability of medical abortions induced by methotrexate and misoprostol with abortions induced by mifepristone and misoprostol.This was a multicenter, randomized, non-blinded, controlled trial comparing 50 mg/m2 of methotrexate followed 4-6 days later by 800 μg of vaginal misoprostol with 600 mg of oral mifepristone followed 36-48 hours by 400 μg of oral misoprostol.There were 518 women in the methotrexate group and 524 women in the mifepristone group. In the methotrexate group, 21 women required suction curretage, two for continuing pregnancy, eight because of physician request (usually for excessive bleeding), and 11 because of patient request. In the mifepristone group, 22 women needed surgical termination, 17 because of physician request, and five because of patient request. By day 8, only 386 (74.5%) in the methotrexate group had completed the abortion compared with 474 (90.5%) in the mifepristone group, and the mean number of days from beginning to completion was 7.1 for methotrexate and 3.3 for mifepristone (P ≤ .001). There were no differences in complications, and side effects were similar. Acceptance was slightly higher with mifepristone (88.0%) than with methotrexate (83.2%).Abortions induced with mifepristone completed faster than those induced with methotrexate, but the overall success rates, side effects, and complications were similar. Acceptance rates were slightly higher with mifepristone than methotrexate (P = .03). [ABSTRACT FROM AUTHOR]

Discusses the management of end-stage renal disease through the use of dialysis. Hemodialysis; Continuous ambulatory peritoneal dialysis; Systematic analysis; Letting the patient help; Postdialysis complications; Negotiating medications and meals; Keeping the patient comfortable.

Background: In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017.Methods: Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020).Results: A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval [CI], 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10).Conclusions: After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.). [ABSTRACT FROM AUTHOR]

The article offers information on mifepristone, a medication typically used in combination with misoprostol, to bring about an abortion. Topics discussed include information on the contraindications for using mifepristone; usage of ultrasonography to assess gestational age and rule out ectopic pregnancy; and the information on the Interim Federal Health Program.

Objective: Patient-centred care (PCC) is one approach for mitigating gendered inequities in health care quality. Little is known about how to implement PCC for women (PCCW). This study explored women's views about PCCW implementation.Methods: Descriptive analysis of semi-structured qualitative telephone interviews with diverse women about PCC using an established 6-domain PCC framework.Results: Participants were 33 women who varied in health care experience, age, education and setting. Themes were consistent across these characteristics. Women said that clinicians often dismissed their healthcare concerns. We transformed desired PCC elements into strategies to implement PCCW, 27 at the point-of-care (i.e. assume a non-judgmental disposition, demonstrate active listening, elicit questions, acknowledge emotions, explore preferences for treatment, and offer self-care information) and 3 at the system level (education for women/girls and clinicians about PCCW, widespread access to women's-only services or women clinicians).Conclusion: Many women experienced suboptimal PCC. By sharing their PCC experiences, women identified PCC elements of importance to them, and insight on actionable point-of-care and system-level strategies to implement PCCW.Practice Implications: This study revealed numerous ways that clinicians can foster PCCW, and insight on how healthcare managers and policy-makers can support PCCW implementation. [ABSTRACT FROM AUTHOR]

Background: Gendered disparities in health care delivery and outcomes are an international problem. Patient-centred care (PCC) improves patient and health system outcomes, and is widely advocated to reduce inequities. The purpose of this study was to review published research for frameworks of patient-centred care for women (PCCW) that could serve as the basis for quality improvement.Methods: A scoping review was conducted by searching MEDLINE, EMBASE, CINAHL, SCOPUS, Cochrane Library, and Joanna Briggs index for English-language quantitative or qualitative studies published from 2008 to 2018 that included at least 50% women aged 18 years or greater and employed or generated a PCCW framework. Findings were analyzed using a 6-domain PCC framework, and reported using summary statistics and narrative descriptions.Results: A total of 9267 studies were identified, 6670 were unique, 6610 titles were excluded upon title/abstract screening, and 11 were deemed eligible from among 60 full-text articles reviewed. None were based on or generated a PCCW framework, included solely women, or analyzed or reported findings by gender. All studies explored or described PCC components through qualitative research or surveys. None of the studies addressed all 6 domains of an established PCC framework; however, additional PCC elements emerged in 9 of 11 studies including timely responses, flexible scheduling, and humanized management, meaning tailoring communication and treatment to individual needs and preferences. There were no differences in PCC domains between studies comprised primarily of women and other studies.Conclusions: Given the paucity of research on PCCW, primary research is needed to generate knowledge about PCCW processes, facilitators, challenges, interventions and impacts, which may give rise to a PCCW framework that could be used to plan, deliver, evaluate and improve PCCW. [ABSTRACT FROM AUTHOR]

Objectives: Patient-centred care (PCC) improves multiple patient and health system outcomes. However, many patients do not experience PCC, particularly women, who are faced with disparities in care and outcomes globally. The purpose of this study was to identify if and how guidelines address PCC for women (PCCW). Methods: We searched MEDLINE, EMBASE, National Guideline Clearing House, and guideline developer websites for publicly-available, English-language guidelines on depression and cardiac rehabilitation, conditions with known gendered inequities. We used summary statistics to report guideline characteristics, clinical topic, mention of PCC according to McCormack's framework, and mention of women's health considerations. We appraised guideline quality with the AGREE II instrument. Results: A total of 27 guidelines (18 depression, 9 cardiac rehabilitation) were included. All 27 guidelines mentioned at least one PCC domain (median 3, range 1 to 6), most frequently exchanging information (20, 74.1%), making decisions (20, 74.1%), and enabling patient self-management (21, 77.8%). No guidelines fully addressed PCC: 9 (50.0%) of 18 depression guidelines and 3 (33.3%) of 9 cardiac rehabilitation guidelines addressed 4 or more PCC domains. Even when addressed, guidance was minimal and vague. Among 14 (51.9%) guidelines that mentioned women's health, most referred to social determinants of health; none offered guidance on how to support women impacted by these factors, engage women, or tailor care for women. These findings pertained even to women-specific guidelines. Reported use or type of guideline development process/system did not appear to be linked with PCCW content. Based on quality appraisal with AGREE II, guidelines were either not recommended or recommended with modifications. In particular, the stakeholder involvement AGREE II domain was least addressed, but guidelines that scored higher for stakeholder involvement also appeared to better address PCCW. Implications: This research identified opportunities to generate guidelines that achieve PCCW. Strategies include employing a PCC framework, considering gender issues, engaging women on guideline-writing panels, and including patient-oriented tools in guidelines. Primary research is needed to establish what constitutes PCCW. [ABSTRACT FROM AUTHOR]

Objective: Individuals with psychosis are at elevated risk of adverse sexual and reproductive health (SRH) outcomes, and not receiving adequate SRH care. SRH is important for youth, yet little is known about SRH care access and experiences among those with early psychosis. This study explored SRH care experiences among women and nonbinary individuals with early psychosis. Method: We conducted semistructured qualitative interviews with 19 service users (cisgender and transgender women, nonbinary individuals) receiving care in 2 early psychosis programs in Ontario, Canada. We also conducted semistructured interviews and focus groups with 36 clinicians providing SRH or mental health care to this population. Participants were asked about SRH care access/provision experiences and the interplay with psychosis. Using a social interactionist orientation, a thematic analysis described and explained service user and clinician perspectives regarding SRH care. Results: Amongst both service users and clinician groups, common themes developed: (a) diversity of settings: SRH services are accessed in a large range of spaces across the health care system, (b) barriers in nonpsychiatric SRH care settings: psychosis impacts the ability to engage with existing SRH services, (c) invisibility of SRH in psychiatric settings: SRH is rarely addressed in psychiatric care, (d) variability of informal SRH-related conversations and supports, and cutting across all of the above themes, (e) intersecting social and cultural factors impacted SRH services access. Conclusions: SRH is important for health and wellbeing; improvements are urgently needed across the healthcare system and within early psychosis programs to meet this population's multifaceted SRH needs. [ABSTRACT FROM AUTHOR]

Résumé: Contexte: Au Canada, plus de 2 millions de personnes vivent avec l'ostéoporose, une maladie qui accroît le risque de fracture, ce qui fait augmenter la morbidité et la mortalité, et entraîne une perte de qualité de vie et d'autonomie. La présente actualisation des lignes directrices vise à accompagner les professionnelles et professionnels de la santé au Canada dans la prestation de soins visant à optimiser la santé osseuse et à prévenir les fractures chez les femmes ménopausées et les hommes de 50 ans et plus. Méthodes: Le présent document fournit une actualisation des lignes directrices de pratique clinique de 2010 d'Ostéoporose Canada sur le diagnostic et la prise en charge de l'ostéoporose au pays. Nous avons utilisé l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) et effectué l'assurance de la qualité conformément aux normes de qualité et de présentation des rapports de la grille AGREE II (Appraisal of Guidelines for Research & Evaluation). Les médecins de premier recours et les patientes et patients partenaires ont été représentés à tous les niveaux des comités et des groupes ayant participé à l'élaboration des lignes directrices, et ont participé à toutes les étapes du processus pour garantir la pertinence des informations pour les futurs utilisateurs et utilisatrices. Le processus de gestion des intérêts concurrents a été entamé avant l'élaboration des lignes directrices et s'est poursuivi sur toute sa durée, selon les principes du Réseau international en matière de lignes directrices. Dans la formulation des recommandations, nous avons tenu compte des avantages et des risques, des valeurs et préférences de la patientèle, des ressources, de l'équité, de l'acceptabilité et de la faisabilité; la force de chacune des recommandations a été déterminée en fonction du cadre GRADE. Recommandations: Les 25 recommandations et les 10 énoncés de bonne pratique sont répartis en sections : activité physique, alimentation, évaluation du risque de fracture, instauration du traitement, interventions pharmacologiques, durée et séquence du traitement, et monitorage. La prise en charge de l'ostéoporose devrait se fonder sur le risque de fracture, établi au moyen d'une évaluation clinique réalisée avec un outil d'évaluation du risque de fracture validé. L'activité physique, l'alimentation et la pharmacothérapie sont des éléments essentiels à la stratégie de prévention des fractures, qui devraient être personnalisés. Interprétation: Les présentes lignes directrices ont pour but d'outiller les professionnelles et professionnels de la santé et la patientèle afin qu'ensemble ils puissent parler de l'importance de la santé osseuse et du risque de fracture tout au long de la vie adulte avancée. La détection et la prise en charge efficace de la fragilité osseuse peuvent contribuer à réduire les fractures et à préserver la mobilité, l'autonomie et la qualité de vie. [ABSTRACT FROM AUTHOR]

The article discusses right of Canadian women to have access to safe, effective and preferred method of early abortion based on the internationally-recognized standard of combined mifepristone and misoprostol. In contrast to abortion-related services to women in Europe and the U.S., Canadian women use the cytotoxic drug methotrexate. The World Health Organization (WHO) does not recommend methotrexate because it can cause serious deformities in the infant if the abortion fails.

In 2005 the emergency contraception formulation of levonorgestrel (Plan B) became available in Ontario pharmacies without a prescription. We surveyed 239 pharmacies 1 month before the regulatory change and 14–17 months after the change to determine whether availability of the drug increased. The response rates were 79% and 70% before and after the change in status. The proportion of pharmacies that had an in-stock supply of Plan B increased from 78% to 92% (p < 0.001). After the regulatory change, 87% of the surveyed pharmacies (95% confidence interval 82%–92%) reported that they had the drug in stock and were willing to dispense it behind the counter. Availability was similar for urban and rural pharmacies, but rural pharmacies had more restricted hours (e.g., 15% closed on weekends). Thus, as a result of the regulatory change, emergency contraception is more widely available, but access in rural areas is still limited by restricted pharmacy hours. [ABSTRACT FROM AUTHOR]

Background: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older. Methods: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework. Recommendations: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized. Interpretation: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine has the potential to improve abortion access disparities in Canada. We aimed to explore the provision of telemedicine for first-trimester medical abortion and related barriers in 2019. Methods: We conducted a national, cross-sectional, anonymized, web-based survey of clinicians who provided abortion care in 2019 in Canada. We distributed our survey through professional health organizations to maximize identification of possible eligible respondents and used a modified Dillman technique to foster responses. Questions elicited provider demographics, clinical characteristics, including telemedicine first-trimester medical abortion and perceived related barriers. Descriptive statistics were analyzed using R software. Results: Among 465 respondents, 388 reported providing first-trimester medical abortion across Canada; 44.0% reported experience using telemedicine for some components of care: 49.3% of primary care clinicians and 28.7% of specialists. Telemedicine was used for initial consultation (86.0%), prescription (82.2%), or follow-up (92.2%). The median percentage of telemedicine providers' patients who underwent a dating ultrasound was 90.0. The majority usually followed up with patients through quantitative human chorionic gonadotropin (hCG) (84.2%). Seventy-eight percent perceived barriers to telemedicine; the most common being inability to confirm gestational age with ultrasound (43.0%), and lack of provincial telemedicine abortion fee code to pay practitioners (30.2%), timely access to serum hCG testing (24.6%), and nearby emergency services (23.3%). Discussion: In 2019, fewer than half of respondents reported providing some aspects of first-trimester medical abortion through telemedicine and the majority perceived barriers. Our results can inform knowledge translation activities to reduce barriers and increase telemedicine abortion care in Canada. [ABSTRACT FROM AUTHOR]

Background: Substantial changes in abortion care regulations, available medications and national clinical practice guidelines have occurred since a 2012 national Canadian Abortion Provider Survey (CAPS). We developed and piloted the CAPS 2019 survey instrument to explore changes of the abortion provider workforce, their clinical care as well as experiences with stigma and harassment. Methods: We undertook development and piloting in three phases: (1) development of the preliminary survey sections and questions based on the 2012 survey instrument, (2) content validation and feasibility of including certain content aspects via a modified Delphi Method with panels of clinical and research experts, and (3) pilot testing of the draft survey for face validity and clarity of language; assessing usability of the web-based Research Electronic Data Capture platform including the feasibility of complex skip pattern functionality. We performed content analysis of phase 2 results and used a general inductive approach to identify necessary survey modifications. Results: In phase 1, we generated a survey draft that reflected the changes in Canadian abortion care regulations and guidelines and included questions for clinicians and administrators providing first and second trimester surgical and medical abortion. In phase 2, we held 6 expert panel meetings of 5–8 participants each representing clinicians, administrators and researchers to provide feedback on the initial survey draft. Due to the complexity of certain identified aspects, such as interdisciplinary collaboration and interprovincial care delivery differences, we revised the survey sections through an iterative process of meetings and revisions until we reached consensus on constructs and questions to include versus exclude for not being feasible. In phase 3, we made minor revisions based on pilot testing of the bilingual, web-based survey among additional experts chosen to be widely representative of the study population. Demonstrating its feasibility, we included complex branching and skip pattern logic so each respondent only viewed applicable questions based on their prior responses. Conclusions: We developed and piloted the CAPS 2019 survey instrument suitable to explore characteristics of a complex multidisciplinary workforce, their care and experience with stigma on a national level, and that can be adapted to other countries. [ABSTRACT FROM AUTHOR]

Background: In previous work in young women aged 15–30 years we measured breast water and fat using MR and obtained blood for hormone assays on the same day in the follicular phase of the menstrual cycle. Only serum growth hormone levels and sex hormone binding globulin (SHBG) were significantly associated with percent breast water after adjustment for covariates. The sex hormones estradiol, progesterone and testosterone were not associated with percent water in the breast in the follicular phase of the menstrual cycle. In the present study we have examined the association of percent breast water with serum levels of sex hormones in both follicular and luteal phase of the menstrual cycle. Methods: In 315 healthy white Caucasian young women aged 15–30 with regular menstrual cycles who had not used oral contraceptives or other hormones in the previous 6 months, we used MR to determine percent breast water, and obtained blood samples for hormone assays within 10 days of the onset of the most recent menstrual cycle (follicular phase) of the cycle on the same day as the MR scan, and a second blood sample on days 19–24 of the cycle. Serum progesterone levels of > = 5 mmol/L in days 19–24 were used to define the 225 subjects with ovulatory menstrual cycles, whose data are the subject of the analyses shown here. Results: SHBG was positively associated with percent water in both follicular and luteal phases of the menstrual cycle. Total and free estradiol and total and free testosterone were not associated with percent water in the follicular phase, but in young women with ovulatory cycles, were all negatively associated with percent water in the luteal phase. Conclusions: Our results from young women aged 15–30 years add to the evidence that the extent of fibroglandular tissue in the breast that is reflected in both mammographic density and breast water is associated positively with higher serum levels of SHBG, but not with higher levels of sex hormones. [ABSTRACT FROM AUTHOR]

Introduction This study aimed to evaluate the early population impact of Ontario’s school-based human papillomavirus (HPV) vaccination program, implemented in September 2007 for grade 8 females, by comparing anogenital wart (AGW) health care utilization before and after vaccine program implementation, in program-eligible and program-ineligible cohorts, focusing on 15–26 year olds. Methods Using a retrospective longitudinal population-based study design, health administrative data were used to identify incident AGWs and total health service utilization (HSU) for AGWs for Ontario residents 15 years and older between April 1 2004 and March 31 2014. The study period was divided into two eras: the pre-vaccine program era and the vaccine program era. Negative binomial models were generated to analyze trends across time by age group and sex. We adjusted female rates for routine Papanicolaou (Pap) testing to address spillover effects of Pap smear policy changes on AGW diagnosis. Results Between fiscal years 2004 and 2013, AGW incidence decreased 2.6% on average per year in 15–17 year old females, and total HSU for AGWs decreased an average of 4.8% and 2.2% per year in 15–17 and 18–20 year old females. Comparing the vaccine era to the pre-vaccine era, AGW incidence decreased 6.5% in 18–20 year old females, and AGW HSU decreased 13.8%, 11.1%, and 10.0% in 15–17, 18–20, and 21–23 year old females respectively. In contrast, male AGW incidence rates increased an average of 4.1%, 2.8%, and 0.9% per year in 15–17, 21–23, and 24–26 year old males respectively. AGW incidence rates increased 12.2% in 15–17 year old males from the pre-vaccine to vaccine era. Conclusion The decline in AGW incidence and HSU in program-eligible females suggests the school-based HPV vaccination program has had an early population impact in Ontario. The increasing AGW incidence in males suggests no early evidence of herd effects in males. [ABSTRACT FROM AUTHOR]

Objective: To explore the Canadian first-trimester medication abortion (MA) workforce and their clinical care following the introduction of mifepristone in 2017, updated national clinical practice guidelines and government approval of nurse practitioners (NPs) as first-trimester MA providers.Study Design: We conducted a national, self-administered, cross-sectional survey of abortion providers in 2019. Our bilingual (French/English) survey collected information on demographics, abortion number, and clinical care characteristics. The true number of abortion providers is unknown thus we cannot calculate a survey response rate. To maximize identification of possibly eligible respondents, we widely distributed the survey between July and December 2020 through health professional organizations, using a modified Dillman technique. We used descriptive statistics to characterize the workforce and clinical practices.Results: Four-hundred-sixty-five clinicians responded, of whom 388 provided first-trimester MA. Physicians (n = 358) and NPs (n = 30) reported providing 13,429 first-trimester MAs in 2019 which represented 27.7% of all reported abortions in the survey. The majority of first-trimester MA respondents were primary care physicians (n = 245, 63.1%), had less than five years' experience (n = 223, 61.3%) and practiced outside of hospitals (n = 228, 66.5%). Forty-three percent (n = 165) practiced rurally, and 44.0% (n = 136) used telemedicine for some abortion care. Ninety-nine percent (n = 350) used a guideline-recommended mifepristone/misoprostol regimen while 14.5% (n = 51) sometimes used methotrexate. Patients most commonly received mifepristone/misoprostol at community pharmacies (median 100.0%; interquartile range 50.0%-100.0%).Conclusion: Our results suggest that there are many new first-trimester MA providers, an increase in the proportion of MAs since 2012 and a shift to primary care settings. Respondents widely adopted mifepristone.Implications Statement: Our results highlight that, following mifepristone introduction, many new primary care practitioners started providing first-trimester medication abortion throughout Canada, including the first non-physicians. This increased access to abortion particularly in rural and underserved communities. These results could inform future directions in policy, guidelines, and abortion access initiatives. [ABSTRACT FROM AUTHOR]

Background: Preliminary evidence suggests that individuals living in lower income neighbourhoods are at higher risk of COVID-19 infection. The relationship between sociodemographic characteristics and COVID-19 risk warrants further study. Methods: We explored the association between COVID-19 test positivity and patients' socio-demographic variables, using neighborhood sociodemographic data collected retrospectively from two COVID-19 Assessment Centres in Toronto, ON. Results: Eighty-three thousand four hundred forty three COVID-19 tests completed between April 5–September 30, 2020, were analyzed. Individuals living in neighbourhoods with the lowest income or highest concentration of immigrants were 3.4 (95% CI: 2.7 to 4.9) and 2.5 (95% CI: 1.8 to 3.7) times more likely to test positive for COVID-19 than those in highest income or lowest immigrant neighbourhoods, respectively. Testing was higher among individuals from higher income neighbourhoods, at lowest COVID-19 risk, compared with those from low-income neighbourhoods. Conclusions: Targeted efforts are needed to improve testing availability in high-risk regions. These same strategies may also ensure equitable COVID-19 vaccine delivery. [ABSTRACT FROM AUTHOR]

Background: Preliminary evidence suggests that individuals living in lower income neighbourhoods are at higher risk of COVID-19 infection. The relationship between sociodemographic characteristics and COVID-19 risk warrants further study.Methods: We explored the association between COVID-19 test positivity and patients' socio-demographic variables, using neighborhood sociodemographic data collected retrospectively from two COVID-19 Assessment Centres in Toronto, ON.Results: Eighty-three thousand four hundred forty three COVID-19 tests completed between April 5-September 30, 2020, were analyzed. Individuals living in neighbourhoods with the lowest income or highest concentration of immigrants were 3.4 (95% CI: 2.7 to 4.9) and 2.5 (95% CI: 1.8 to 3.7) times more likely to test positive for COVID-19 than those in highest income or lowest immigrant neighbourhoods, respectively. Testing was higher among individuals from higher income neighbourhoods, at lowest COVID-19 risk, compared with those from low-income neighbourhoods.Conclusions: Targeted efforts are needed to improve testing availability in high-risk regions. These same strategies may also ensure equitable COVID-19 vaccine delivery. [ABSTRACT FROM AUTHOR]

Background: COVID-19 has significant impact on long-term care (LTC) residents and staff. The purpose of this paper is to report the data gathered during a COVID-19 outbreak in a Canadian LTC home regarding staff experiences, challenges, and needs, to offer lessons learned and implications. Methods: A total of 30 staff from multiple disciplines participated in the study, including nurses, care workers, recreational staff, and a unit clerk. Focus groups (n = 20) and one-on-one interviews (n = 10) were conducted as part of a larger participatory action research (PAR) study in a Canadian LTC home. All data collection was conducted virtually via Zoom, and thematic analysis was performed to identify themes. Results: Four main themes were identified: We are Proud, We Felt Anxious, We Grew Closer to Residents and Staff Members, and The Vaccines Help. Conclusions: This research details the resilience that characterizes staff in LTC, while highlighting the emotional toll of the pandemic, particularly during an outbreak. LTC staff in this study found innovative ways to connect and support residents and this resulted in stronger connections and relationships. Leadership and organizational support are pivotal for supporting team resilience to manage crisis and adapt positively in times of COVID-19 pandemic, especially during the period of outbreak. [ABSTRACT FROM AUTHOR]

Describes the effectiveness of a multifocus recruitment strategy to a pilot project allowing direct provision of emergency contraception in a community pharmacy through collaborative agreements between pharmacists and physicians. Recruitment of pharmacies to the project.

Background: Reports have suggested that anosmia is strongly associated with SARS-CoV-2 infection, but patients were often asked about this symptom after their diagnosis. This study assessed associations between prospectively reported anosmia and other symptoms related to SARS-CoV-2 infection, and SARS-CoV-2 positivity in community testing centres in Toronto, Ontario. Methods: We conducted a retrospective cross-sectional study in which data were collected from 2 COVID-19 assessment centres affiliated with 2 hospitals in Toronto, Ontario, from Apr. 5 to Sept. 30, 2020. We included symptomatic profiles of all people who underwent a SARS-CoV-2 test at either clinic within the study period. We used generalized estimating equations to account for repeat visits and to assess associations between anosmia and other symptoms and SARS-CoV-2 positivity. Results: A total of 83 443 SARS-CoV-2 tests were conducted across the 2 sites for 72 692 participants during the study period. Of all tests, 1640 (2.0%) were positive; 837 (51.0%) of people who tested positive were asymptomatic. The adjusted odds ratio for the association between anosmia and test positivity was 5.29 (95% confidence interval [CI] 4.50–6.22), with sensitivity of 0.138 (95% CI 0.121–0.154), specificity of 0.980 (95% CI 0.979–0.981), a positive predictive value of 0.120 (95% CI 0.106–0.135) and a negative predictive value of 0.983 (95% CI 0.982–0.984). Interpretation: Anosmia had high specificity and a positive predictive value of 12% for SARS-CoV-2 infection in this community population with low prevalence of SARS-CoV-2 positivity. The presence of anosmia should increase clinical suspicion of SARS-CoV-2 infection, and our findings suggest that people presenting with this symptom should be tested. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic and pandemic response created novel challenges for abortion services. Canada was uniquely positioned to transition to telemedicine because internationally common restrictions on abortion medication were removed before the pandemic.Objective: We sought to characterize the experiences of abortion health care professionals in Canada during the COVID-19 pandemic and the impact of the pandemic response on abortion services.Methods: We conducted a sequential mixed methods study between July 2020 and January 2021. We invited physicians, nurse practitioners and administrators to participate in a cross-sectional survey containing an open-ended question about the impact of the pandemic response on abortion care. We employed an inductive codebook thematic analysis, which informed the development of a second, primarily quantitative survey.Results: Our initial survey had 307 respondents and our second had 78. Fifty-three percent were family physicians. Our first survey found respondents considered abortion access essential. We identified three key topicss: access to abortion care was often maintained despite pandemic-related challenges (e.g. difficulty obtaining tests, additional costs); change of practice to low-touch medication abortion care and provider perceptions of patient experience, including shifting demand, telemedicine acceptability and increased rural access. The second survey indicated uptake of telemedicine medication abortion among 89% of participants except in Quebec, where regulations meant procedures were nearly exclusively surgical. Restrictions did not delay care according to 76% of participants.Conclusions: Canadian health care professionals report their facilities deemed abortion an essential service. Provinces and territories, except Quebec, described a robust pandemic transition to telemedicine to ensure access to services.Podcast: An accompanying podcast is available in the Supplementary Data, in which the authors Dr Madeleine Ennis and Kate Wahl discuss their research on how family planning care and access to abortion services have changed during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Examines the characteristics of sexual assaults committed by unknown and known assailants. Partner sexual assault; Friends and acquaintances as perpetrators of sexual assaults; Variables related to coercion, violence and physical trauma; Four identified assailant groups.

Purpose: Access to family planning health services in Canada has been historically inadequate and inequitable. A potential solution appeared when Health Canada approved mifepristone, the gold standard for medical abortion, in July 2015. We sought to investigate the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems, and service access throughout Canada.Methods: We conducted 1-on-1 semistructured interviews with a national sample of abortion-providing and nonproviding physicians and health system stakeholders in Canadian health care settings. Our data collection, thematic analysis, and interpretation were guided by Diffusion of Innovation theory.Results: We conducted interviews with 90 participants including rural practitioners and those with no previous abortion experience. In the course of our study, Health Canada removed mifepristone restrictions. Our results suggest that Health Canada's initial restrictions discouraged physicians from providing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. Once deregulated, remaining factors were primarily related to local and regional implementation processes. Participants held strong perceptions that mifepristone was the new standard of care for medical abortion in Canada and within the scope of primary care practice.Conclusion: Health Canada's removal of mifepristone restrictions facilitated the implementation of abortion care in the primary care setting. Our results are unique because Canada is the first country to facilitate provision of medical abortion in primary care via evidence-based deregulation of mifepristone. [ABSTRACT FROM AUTHOR]

Objectives: Mifepristone for first-trimester medical termination of pregnancy (MTOP) became available in Quebec in 2018, one year after the rest of Canada. Using the theory of the Diffusion of Innovation (DOI) and the transtheoretical model of change (TTM), we investigated factors influencing the implementation of mifepristone MTOP in Quebec.Material and Methods: Semi-structured interviews were conducted with 37 Quebec physicians in early 2018. Deductive thematic analysis guided by the theory of DOI explored facilitators and barriers to physicians' adoption of mifepristone MTOP. We then classified participants into five stages of mifepristone adoption based on the TTM. Follow-up data collection one year later assessed further adoption.Results: At baseline, three physicians provided mifepristone MTOP (Maintenance) and two were about to start (Action). Thirteen physicians at Preparation and Advanced Contemplation stages intended to start while, within the Slow Contemplation, two intended to start and ten were unsure. Seven had no intention to provide mifepristone MTOP (Pre-Contemplation). Major reported barriers were: complexity of local health care organisations, medical policy restrictions, lack of support, and general uncertainty. One year later, ten physicians provided mifepristone MTOP (including three at baseline) and nine still intended to, while seventeen did not intend to start provision. Seven of sixteen participants (44%) who worked in TOP clinics at baseline were still not providing MTOP with mifepristone one year later.Conclusion: Despite ideological support, mifepristone MTOP uptake in Quebec is slow and laborious, mainly due to restrictive medical policies, vested interests in surgical provision and administrative inertia. [ABSTRACT FROM AUTHOR]

Background: Low socioeconomic status is one of many barriers that may limit access to family planning services. We aimed to examine the relation between household income and contraceptive methods among female youth in Canada. Methods: Our study population included sexually active females aged 15–24 who were trying to avoid pregnancy. We used cross-sectional data from the 2009–2010 and 2013–2014 cycles of the Canadian Community Health Survey to compare household income and other sociodemographic covariates for those using oral contraceptives, injectable contraceptives, condoms or a dual method (condoms plus oral or injectable contraceptives). Results: Of female youth at risk for unintended pregnancy, 59.2% reported using oral contraceptives, 29.0% used dual methods, 16.8% used condoms only, 2.5% used injectable contraceptives and 13.6% did not use contraception. In multiple regression models, lower annual household income (< $80 000) was associated with decreased use of oral contraceptives (relative risk [RR] 0.85, 95% confidence interval [CI] 0.80–0.91) and dual methods (RR 0.81, 95% CI 0.71–0.91), increased use of condoms (RR 1.36, 95% CI 1.11–1.67) and injectable contraceptives (RR 1.69, 95% CI 0.98–2.92), and a greater risk of contraceptive nonuse (RR 1.19, 95% CI 0.94–1.50). Interpretation: We found that lower household income was associated with decreased use of oral contraceptives and increased reliance on injectable contraceptives and condoms only. Young, low-income females may face barriers to accessing the full range of contraceptive methods available in Canada. Easier access to affordable contraception may decrease the number of female youth at risk for unintended pregnancy due to financial barriers. [ABSTRACT FROM AUTHOR]

Context: Prior to 2017, most abortions in Canada were surgical and provided by a small number of physicians, mainly in urban areas. The medical abortion pill mifepristone first became available in Jan 2017. By Nov 2017 the regulations were globally unique; mifepristone was treated as a normal prescription drug. Both physicians and nurse-practitioners (NPs) can prescribe, and any pharmacist can dispense the pill for self-administration by the patient at a convenient time and place. We hypothesized the unique regulation of mifepristone would increase the size and distribution of the abortion workforce, particularly in primary care, and thus reduce rural-urban access disparity. Objective: We investigated trends for abortion rate, method, and workforce. Setting and Dataset: Ontario, including 40% of Canada's residents, linked health administrative data. Study design and Analysis: We defined all abortions from Jan 1, 2012 to Mar 10, 2020, using practitioner visits, hospital, emergency and ambulatory care admissions, and dispensed pharmaceuticals. We used interrupted time series (ITS) analysis to compare temporal trends in abortion rate, method, and workforce composition. Population: All most responsible professionals providing abortion (MRP-A), defining one MRP-A per abortion. Intervention: We compared MRP-A prior to mifepristone (Jan 2012 to Jan 2017), to once it was available to prescribe normally (Nov 7, 2017 - Mar 10, 2020). Outcome measures: Trends and rates for the number and characteristics of MRP-A: age, specialty, rural vs urban, abortion method, service volume and rate of providers per 1000 female residents aged 15-49 years (1Kfem15-49) per health region. Results: Among all 315,447 abortions we identified an MRP-A for 311,742 (98.3%). The abortion rate was stable 2012-2020, approximately 11 per 1Kfem15-49 while the percent as medical abortion increased from 2.2% to 31.4%. The rate of MRP per 1Kfem15-49 tripled. The rate of rural MRP-A increased seven-fold while the rate of rural physicians did not change. Mean age of MRP-As fell 6.9 years. By the end of the study period most MRP-As were GPs (66.5%) with 23.2% OBGyns and 9.1% NPs. Conclusions: When regulatory change supported primary care friendly approaches to medical abortion, it was rapidly implemented in both urban and rural primary care. We observed a tripling of the overall number of abortion providers, including a seven-fold increase in rural areas, while the abortion rate was stable. [ABSTRACT FROM AUTHOR]

Background: Many tools exist to guide family physicians' impressions about frailty status of older adults, but no single tool, instrument, or set of criteria has emerged as most useful. The role of physicians' subjective impressions in frailty decisions has not been studied. This study explores how family physicians conceptualize frailty, and the factors that they consider when making subjective decisions about patients' frailty statuses. Methods: Descriptive qualitative study of family physicians who practice in a large urban academic family medicine center as they participated in one-on-one "think-aloud" interviews about the frailty status of their patients aged 80 years and over. Of 23 eligible family physicians, 18 shared their impressions about the frailty status of their older adult patients and the factors influencing their decisions. Interviews were audio-recorded, transcribed, and thematically analyzed. Results: Four themes were identified, the first of which described how physicians conceptualized frailty as a spectrum and dynamic in nature, but also struggled to conceptualize it without a formal definition in place. The remaining three themes described factors considered before determining patients' frailty statuses: physical characteristics (age, weight, medical conditions), functional characteristics (physical, cognitive, social) and living conditions (level of independence, availability of supports, physical environment). Conclusions: Family physicians viewed frailty as multifactorial, dynamic, and inclusive of functional and environmental factors. This conceptualization can be useful to make comprehensive and flexible evaluations of frailty status in conjunction with more objective frailty tools. [ABSTRACT FROM AUTHOR]

Engagement of community members to act as peer workers is a key feature of many community-centred health promotion programmes. However, little is known about their experiences beyond the commonly reported themes of fulfilment through helping people in need and improvement of personal confidence, self-esteem and self-care. This gap in the literature is of particular interest given increasing involvement of peer workers in community-centred programmes addressing health disparities, such as uptake of cancer screening. This paper aims to explore experiences of the peer leaders who worked for the Cancer Awareness: Ready for Education and Screening ( CARES) project to promote awareness, knowledge, and uptake of breast and cervical cancer screening among under-/never-screened women who belonged to ethnic minority, recent immigrant and low-income communities in Toronto, Canada. In 2013, three focus groups were conducted with 14 peer leaders to explore their experiences. All were immigrant women between 30 and 50 years of age. All discussions were audio recorded and transcribed verbatim. We used situational maps and analysis to create a visual representation of the data, and to investigate peer leaders experiences. Situational analysis was chosen to bring to light dominant and also silent underlying aspects which define the meaning of being a peer leader. The first level of analysis identified main themes that characterised peer leaders' experience: (i) Helping others (women, friends and family) and themselves by improved self-confidence, self-awareness and self-care and (ii) Redefining professional and social positions through their project activities leading to professional development and networking. The second level of analysis explored the redefining process and identified some peer leaders' negotiations in relation to knowledge (science vs. myth), beliefs (fear vs. assurance) and boundaries (private vs. work). Adding to the literature on the peer workers' experience, the findings are discussed in relation to empowerment of peer workers, training implications and theoretical contributions. [ABSTRACT FROM AUTHOR]

The oral contraceptive pill (OCP) activates the renin-angiotensin-aldosterone system (RAAS) through first-pass hepatic metabolism. Although usually benign, RAAS activation may have detrimental effects on renal and hemodynamic function in some women. Since combined hormonal contraception with the transdermal patch (EVRA) does not undergo first-pass hepatic metabolism, we hypothesized that the RAAS response would be different from that of OCP subjects. Thirty-five nonsmoking, premenopausal women (15 control subjects, 10 OCP subjects, and 10 contraceptive patch subjects) without evidence of cardiovascular disease, renal disease, or diabetes were studied. Baseline angiotensinogen, renin, angiotensin II, aldosterone, and plasma renin activity were assessed along with hormonal and hemodynamic responses to simulated orthostatic stress using incremental lower body negative pressure (LBNP; --15, --25, and --40 mmHg). Baseline levels of angiotensinogen, angiotensin II, and plasma renin activity were significantly higher in OCP subjects compared with normotensive control and contraceptive patch subjects (P < 0.05), whereas aldosterone was significantly higher in OCP versus control subjects only (P < 0.05). Plasma renin levels were significantly lower at baseline in contraceptive patch subjects compared with normotensive control and OCP subjects (P < 0.05). In response to LBNP, increases in renin, angiotensin II, and aldosterone were attenuated in contraceptive patch subjects in conjunction with an exaggerated decline in mean arterial pressure (P < 0.05 vs. control and OCP subjects). The contraceptive patch in healthy premenopausal women is associated with an impaired ability to maintain blood pressure in response to LBNP, possibly due to insensitivity of the endogenous RAAS. Further evaluation may be beneficial in women with kidney disease. [ABSTRACT FROM AUTHOR]

Objective To evaluate patient predictors of good outcome following total joint arthroplasty (TJA). Methods A population cohort with hip/knee arthritis (osteoarthritis [OA] or inflammatory arthritis) ages ≥55 years was recruited between 1996 and 1998 (baseline) and assessed annually for demographics, troublesome joints, health status, and overall hip/knee arthritis severity using the Western Ontario and McMaster Universities OA Index (WOMAC). Survey data were linked with administrative databases to identify primary TJAs. Good outcome was defined as an improvement in WOMAC summary score greater than or equal to the minimal important difference (MID; 0.5 SD of the mean change). Logistic regression and Akaike's information criterion were used to determine the optimal number of predictors and the best model of that size. Log Poisson regression was used to determine the relative risk (RR) for a good outcome. Results Primary TJA was performed in 202 patients (mean age 71.0 years; 79.7% female; 82.7% with >1 troublesome hip/knee; 65.8% knee replacements). Mean improvement in WOMAC summary score was 10.2 points (SD 18.05; MID 9 points). Of these patients, 53.5% experienced a good outcome. Four predictors were optimal. The best 4-variable model included pre-TJA WOMAC, comorbidity, number of troublesome hips/knees, and arthritis type (C statistic 0.80). The probability of a good outcome was greater with worse (higher) pre-TJA WOMAC summary scores (adjusted RR 1.32 per 10-point increase; P < 0.0001), fewer troublesome hips/knees (adjusted RR 0.82 per joint; P = 0.002), OA (adjusted RR for rheumatoid arthritis versus OA 0.33; P = 0.009), and fewer comorbidities (adjusted RR per condition 0.88; P = 0.01). Conclusion In an OA cohort with a high prevalence of multiple troublesome joints and comorbidity, only half achieved a good TJA outcome, defined as improved pain and disability. A more comprehensive assessment of the benefits and risks of TJA is warranted. [ABSTRACT FROM AUTHOR]

Objective: To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.Options: The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed.Outcomes: Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception.Evidence: Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed.Values: The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1).Benefits, Harms, and Costs: These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC.Sponsor: The Society of Obstetricians and Gynecologists of Canada. [ABSTRACT FROM AUTHOR]

The article offers information on evidence-based clinical guidelines for refugees and immigrants in Canada. It mentions that the Canadian Collaboration for Immigrant and Refugee Health explicitly uses an evidence-based clinical preventive approach to improve patients' health. It adds that displaced refugees are at highest risk for past exposure to harmful living conditions, violence, and trauma.

Objective: To provide current and emerging evidence on oral contraceptives and the risk of venous thromboembolism.Evidence: Articles published in English from 2005 were retrieved through searches of PubMed and Medline, using the following terms: venous thromboembolism, VTE, contraception, oral contraceptives, hormonal contraception. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.Values: The quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). [ABSTRACT FROM AUTHOR]

Abstract: Objective: To provide current and emerging evidence on oral contraceptives and the risk of venous thromboembolism. Evidence: Articles published in English from 2005 were retrieved through searches of PubMed and Medline, using the following terms: venous thromboembolism, VTE, contraception, oral contraceptives, hormonal contraception. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values: The quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). [Copyright &y& Elsevier]

Abstract: Objectives: To review the etiology and incidence of and associative factors in the formation of adhesions following gynaecological surgery. To review evidence for the use of available means of adhesion prevention following gynaecological surgery. Options: Women undergoing pelvic surgery are at risk of developing abdominal and/or pelvic adhesive disease postoperatively. Surgical technique and commercial adhesion prevention systems may decrease the risk of postoperative adhesion formation. Outcomes: The outcomes measured are the incidence of postoperative adhesions, complications related to the formation of adhesions, and further intervention relative to adhesive disease. Evidence: Medline, EMBASE, and The Cochrane Library were searched for articles published in English from 1990 to March 2009, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, cohort studies, and meta-analyses specifically addressing postoperative adhesions, adhesion prevention, and adhesive barriers. Searches were updated on a regular basis and incorporated in the guideline to March 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. [ABSTRACT FROM AUTHOR]

Objectives: To review the etiology and incidence of and associative factors in the formation of adhesions following gynaecological surgery. To review evidence for the use of available means of adhesion prevention following gynaecological surgery.Options: Women undergoing pelvic surgery are at risk of developing abdominal and/or pelvic adhesive disease postoperatively. Surgical technique and commercial adhesion prevention systems may decrease the risk of postoperative adhesion formation.Outcomes: The outcomes measured are the incidence of postoperative adhesions, complications related to the formation of adhesions, and further intervention relative to adhesive disease.Evidence: Medline, EMBASE, and The Cochrane Library were searched for articles published in English from 1990 to March 2009, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, cohort studies, and meta-analyses specifically addressing postoperative adhesions, adhesion prevention, and adhesive barriers. Searches were updated on a regular basis and incorporated in the guideline to March 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. [ABSTRACT FROM AUTHOR]