Search

To synthesize and appraise economic evaluations of vision screening to detect vision impairment in children.Literature searches were conducted on seven electronic databases, grey literature, and websites of agencies conducting health technology assessments. Studies were included if they (1) were full, comparative economic evaluations that used cost-utility, cost-benefit, cost-effectiveness, cost-consequence, or cost-analysis methods; (2) described screening services designed to detect amblyopia, strabismus, or uncorrected refractive errors in children under 6 years of age; and (3) published after 1994. High-quality studies were synthesized descriptively. Currencies were reported in 2019 Canadian dollars. Quality was assessed with the Pediatric Quality Appraisal Questionnaire (PQAQ).Vision screening services were conducted by paid staff, volunteers, or health care professionals in schools or clinics. Thirteen studies were published from five countries: China (n = 1), United States (n = 4), United Kingdom (n = 1), Canada (n = 1), and Germany (n = 6). Analytical techniques included cost-utility/cost-effectiveness combination (n = 2), cost-effectiveness analysis (n = 7), cost-utility analysis (n = 1), cost-benefit analysis (n = 1), cost-consequence analysis (n = 1), and cost analysis (n = 1). Incremental cost-effectiveness ratios ranged from C$1,056 to C$151,274 per additional case detected/prevented and from C$9,429 to C$30,254,703 per additional QALY gained, depending on the type of screening service and comparator. Six studies were determined to be of high quality.Vision screening to detect amblyopia for young children may be cost-effective compared with no screening if amblyopia reduced quality of life. Studies varied significantly in the type of screening services and comparators used. Methodological limitations were common. Future studies would be aided immensely by prospective studies on the impact of amblyopia on the health-related quality of life of young children and guidelines on the effective conduct of vision screening.RéSUMé: OBJECTIF: Synthétiser et évaluer des évaluations économiques de dépistages visuels visant à détecter la déficience visuelle chez les enfants. MéTHODE: Nous avons interrogé sept bases de données électroniques, la littérature grise et les sites Web d’organismes effectuant des évaluations des technologies de la santé. Nous avons inclus les études correspondant aux critères suivants : (1) évaluations économiques comparatives exhaustives utilisant l’analyse coûts-utilité, coûts-bénéfices, coûts-efficacité ou coûts-conséquences ou l’analyse des coûts; (2) décrivant des services de dépistage visant à détecter l’amblyopie, le strabisme ou les anomalies de la réfraction non corrigées chez les enfants de moins de six ans; et (3) publiées après 1994. Nous avons fait la synthèse descriptive des études de haute qualité. Les devises ont été converties en dollars canadiens de 2019. Nous avons évalué la qualité des études à l’aide de l’outil PQAQ (Pediatric Quality Appraisal Questionnaire). RéSULTATS: Les services de dépistage visuel étaient offerts par du personnel rémunéré, des bénévoles ou des professionnels de santé dans des écoles ou des cliniques. Treize études ont été publiées dans cinq pays : Chine (n = 1), États-Unis (n = 4), Royaume-Uni (n = 1), Canada (n = 1) et Allemagne (n = 6). Les techniques d’analyse employées étaient la combinaison analyse coûts-utilité/analyse coûts-efficacité (n = 2), l’analyse coûts-efficacité (n = 7), l’analyse coûts-utilité (n = 1), l’analyse coûts-avantages (n = 1), l’analyse coûts-conséquences (n = 1) et l’analyse des coûts (n = 1). Les rapports coût-efficacité différentiels s’échelonnaient entre 1 056 $ CA et 151 274 $ CA par cas supplémentaire détecté/prévenu et entre 9 429 $ CA et 30 254 703 $ CA par année de vie pondérée par la qualité (AVPQ) supplémentaire gagnée, selon le type de service de dépistage et le comparateur. Six études ont été jugées être de haute qualité. CONCLUSION: Comparativement à l’absence de dépistage, les dépistages visuels pour détecter l’amblyopie chez les jeunes enfants peuvent être efficaces par rapport à leur coût lorsque l’amblyopie réduit la qualité de vie. Le type de services de dépistage et les comparateurs utilisés variaient considérablement d’une étude à l’autre. Les contraintes méthodologiques étaient courantes. Les études futures seraient grandement favorisées par des études prospectives des incidences de l’amblyopie sur la qualité de vie liée à la santé chez les jeunes enfants et par des lignes directrices sur l’exécution efficace des dépistages visuels.

Background The extent to which heightened distress during the COVID-19 pandemic translated to increases in severe mental health outcomes is unknown. We examined trends in psychiatric presentations to acute care settings in the first 12 months after onset of the pandemic. Methods This was a trends analysis of administrative population data in Ontario, Canada. We examined rates of hospitalizations and emergency department visits for mental health diagnoses overall and stratified by sex, age and diagnostic grouping (e.g., mood disorders, anxiety disorders, psychotic disorders), as well as visits for intentional self-injury for people aged 10 to 105 years, from January 2019 to March 2021. We used Joinpoint regression to identify significant inflection points after the onset of the pandemic in March 2020. Results Among the 12 968 100 people included in our analysis, rates of mental health-related hospitalizations and emergency department visits declined immediately after the onset of the pandemic (peak overall decline of 30% [hospitalizations] and 37% [emergency department visits] compared to April 2019) and returned to near prepandemic levels by March 2021. Compared to April 2019, visits for intentional self-injury declined by 33% and remained below prepandemic levels until March 2021. We observed the largest declines in service use among adolescents aged 14 to 17 years (55% decline in hospitalizations, 58% decline in emergency department visits) and 10 to 13 years (56% decline in self-injury), and for those with substance-related disorders (33% decline in emergency department visits) and anxiety disorders (61% decline in hospitalizations). Interpretation Contrary to expectations, the abrupt decline in acute mental health service use immediately after the onset of the pandemic and the return to near prepandemic levels that we observed suggest that changes and stressors in the first 12 months of the pandemic did not translate to increased service use. Continued surveillance of acute mental health service use is warranted.

Purpose Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic. Methods Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3–17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates. Results In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41–1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25–1.50) increase in risk for emergency department visit and hospitalization, respectively. Conclusions Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization.

Background The World Health Organization recommends mothers and infants be in direct skin-to-skin contact immediately after birth and initiate breastfeeding as soon as possible. Little is known in women with schizophrenia. Methods We conducted a population-based cohort study using administrative health data from Ontario, Canada (2012–2014), comparing women with (n = 471) and without schizophrenia (n = 218 435), and their infants, on the primary outcomes of any skin-to-skin contact and opportunity to initiate breastfeeding within the first 2 h after birth. For dyads with available data, secondary outcomes of intention to breastfeed, breastfeeding support, any breastmilk, and exclusive breastmilk at discharge were assessed. Modified Poisson regression was used to generate relative risks (aRR) and 95% confidence intervals (CI), adjusted for maternal age, parity, neighbourhood income, region of residence, smoking in pregnancy, and maternal medical and non-psychotic psychiatric comorbidity for all outcomes. Results Maternal schizophrenia was associated with lower likelihood of skin-to-skin contact (65.2% vs 78.1%; aRR 0.88, 95% CI: 0.82–0.94), and breastfeeding initiation post-delivery (38.9% vs 52.6% aRR 0.80, CI: 0.71–0.90) compared to dyads unexposed to maternal schizophrenia. Secondary outcomes followed a similar pattern. The magnitude of the effect was slightly less when restricting the cohort to full-term, vaginal deliveries, not admitted to NICU, and infant not discharged to social services. Conclusions Reduced maternal-infant skin-to-skin contact and breastfeeding initiation immediately after birth may significantly impact maternal–child bonding and the establishment breastfeeding in this population. Mothers with schizophrenia may require individualized support to promote these WHO recommended hospital practices in the early post-natal period.

Background The general health check, which includes the periodic health visit and annual physical exam, is not recommended to maintain the health of asymptomatic adults with no risk factors. Different funding mechanisms for primary care may be associated with the provision of service delivery according to recommended guidelines. We sought to determine how use of the periodic health visit for healthy individuals without comorbidities, despite evidence against its use, differed by primary care model. Methods Population-based cross-sectional study using linked health and administrative datasets in Ontario, Canada, where most residents are insured for physician services through Ontario’s single payer, provincially funded Ontario Health Insurance Plan. Participants included all living adults (> 19 years) in Ontario on January 1st, 2014, eligible for the Ontario Health Insurance Plan. Primary care enrollment model was the main exposure and included traditional fee-for-service, enhanced fee-for-service, capitation, team-based care, other (including salaried), and unenrolled. The main outcome measure was receipt of a periodic health visit during 2014. Age-sex standardized rates of periodic health visits performed during the one-year study period were analyzed by number of comorbid conditions. Results Of 10,712,804 adults in Ontario, 2,350,386 (21.9%) had a periodic health visit in 2014. The age-sex standardized rate was 6.1% (95% confidence interval [CI] 6.0, 6.1%) for healthy individuals. In the traditional fee-for-service model, the periodic health visit was performed for 55.3% (95% CI 54.4, 56.3%) of healthy individuals versus 10.2% (95% CI 10.0, 10.3%) in team-based care. Periodic health visit rates varied by primary care provider models. Traditional and enhanced fee-for-service models had higher rates across all comorbidity groups. Conclusions Patients whose primary care physicians are funded exclusively through fee-for-service had the highest rates of periodic health visits in healthy individuals. Primary care reform initiatives must consider the influence of remuneration on providing evidence-based primary care.

Key Points Question What proportion of individuals aged 16 years and older seeking care at an emergency department (ED) for mental health or addiction-related reasons have had no access to outpatient services in the preceding 2 years? Findings In this cohort study, 659 084 adults had a first ED visit, among whom 298 924 (45.4%) had no prior outpatient contact. Characteristics associated with poor access to mental health care generally, such as male sex, living in a rural area, presenting with a substance use disorder, and no usual primary care clinician, were associated with a first ED visit for mental health or addiction-related reasons with no prior outpatient contact. Meaning Nearly half of incident psychiatric ED visits were first-contact visits, which may have been avoidable with better access to outpatient mental health and addiction services., This cohort study estimates the proportion of individuals aged 16 years and older in Ontario, Canada, with incident psychiatric emergency department (ED) visits who have not previously accessed outpatient mental health or addiction services in the prior 2 years., Importance Psychiatric emergency department (ED) visits may be avoidable if individuals have access to adequate outpatient care, but the extent to which individuals use the ED itself as a key point of access is largely unknown. Objective To describe the extent to which the ED is a first point of contact for mental health care among adults, and identify key factors associated with this outcome. Design, Setting, and Participants This cohort study was conducted from 2010 to 2018 in Ontario, Canada. Using health care administrative data, all individuals aged 16 years and older with an incident psychiatric ED visit were included. Statistical analysis was performed from September 2019 to February 2021. Main Outcomes and Measures The primary outcome was no outpatient mental health or addictions contact in the 2 years preceding the incident ED visit. The study also measured predisposing (age, sex, immigrant status, comorbidity), enabling (neighborhood income, rurality, continuity of primary care), and need factors (diagnosis from incident ED visit) associated with the so-called first-contact ED visits, generating adjusted odds ratios (aORs) and 95% CIs. Results The cohort included 659 084 patients who visited the ED. Among these patients, 340 354 were female individuals (51.6%), and the mean (SD) age was 39.1 (18.5) years. The incident ED visit was a first contact for 298 924 individuals (45.4%). Patients who had increased odds of first-contact ED visits included older individuals (aged 65-84 years vs 16-24 years; aOR, 1.13; 95% CI, 1.12-1.14), male individuals (aOR, 1.14; 95% CI, 1.13-1.15), immigrants (eg, economic class immigrant vs nonimmigrant status: aOR, 1.20; 95% CI, 1.18-1.21), rural residents (aOR, 1.21; 95% CI, 1.20-1.21), and in those with minimal primary care (aOR, 1.68; 95% CI, 1.67-1.69). All diagnoses had a higher likelihood of first-contact ED visits than mood disorders, particularly substance and alcohol use disorders (aOR, 1.66; 95% CI, 1.65-1.68). Conclusions and Relevance This study’s results suggest that nearly half of incident psychiatric ED visits were first-contact visits, which may be avoidable. Targeted efforts to improve outpatient access should focus on populations with risk factors for first-contact ED presentations, including men, older adults, rural residents, those with poor primary care connectivity, and those with substance-related diagnoses.

OBJECTIVE We aimed to compare the risk for injury overall and by intent (accidental injury, self-injury, and assault) among children born to women with versus without schizophrenia. METHODS Using health administrative data from Ontario, Canada, children born from 2003 to 2017 to mothers with (n = 3769) and without (n = 1,830,054) schizophrenia diagnosed prior to their birth were compared on their risk for child injury, captured via emergency department, hospitalization, and vital statistics databases up to age 15 years. Cox proportional hazard models generated hazard ratios for time to first injury event (overall and by intent), adjusted for potential confounders (aHR). We stratified by child sex and age at follow-up: 0-1 (infancy), 2-5 (pre-school), 6-9 (primary school), and 10-15 (early adolescence) planning to collapse age categories as needed to obtain stable and reportable estimates. RESULTS Maternal schizophrenia was associated with elevated risk for child injury overall (105.4 vs. 89.4/1000 person-years (py), aHR 1.08, 95% CI 1.03-1.14), accidental injury (104.7 vs. 88.1/1000py, 1.08, 1.03-1.14), for self-injury (0.4 vs. 0.2/1000py, 2.14 1.18-3.85), and assault (1.0 vs. 0.3/1000py, 2.29, 1.45-3.62). By child sex, point estimates were of similar magnitude and direction, though not all remained statistically significant. For accidental injury and self-injury, the risk associated with maternal schizophrenia was most elevated in 10-15-year-olds. For assault, the risk associated with maternal schizophrenia was most elevated among children in the 0-1 and 2-5-year-old age groups. CONCLUSION The elevated risk of child injury associated with maternal schizophrenia, especially for self-injury and assault, suggests that targeted monitoring and preventive interventions are warranted.

Introduction Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options. Methods A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology – head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology. Results Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care. Conclusions This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

BACKGROUND: Firearm-related injury is an important and preventable cause of death and disability. We describe the burden, baseline characteristics and regional rates of firearm-related injury and death in Ontario. METHODS: We conducted a population-based cross-sectional study using linked data from health administrative data sets held at ICES. We identified residents of Ontario of all ages who were injured or died as a result of a firearm discharge between Apr. 1, 2002, and Dec. 31, 2016. We included injuries classified as assault, unintentional, self-harm or undetermined intent secondary to handguns, rifles, shotguns and larger firearms. The primary outcome was the incidence of nonfatal and fatal injuries resulting in an emergency department visit, hospital admission or death. We also describe regional and temporal rates. RESULTS: We identified 6483 firearm-related injuries (annualized injury rate 3.54 per 100 000 population), of which 2723 (42.3%) were fatal. Assault accounted for 40.2% (1494/3715) of nonfatal injuries and 25.5% (694/2723) of deaths. Young men, predominantly in urban neighbourhoods, within the lowest income quintile were overrepresented in this group. Injuries secondary to self-harm accounted for 68.0% (1366/2009) of injuries and occurred predominantly in older men living in rural Ontario across all income quintiles. The case fatality rate of injuries secondary to self-harm was 91.7%. Self-harm accounted for 1842 deaths (67.6%). INTERPRETATION: We found that young urban men were most likely to be injured in firearm-related assaults and that more than two-thirds of self-harm–related injuries occurred in older rural-dwelling men, most of whom died from their injuries. This highlights a need for suicide-prevention strategies in rural areas targeted at men aged 45 or older.

Background Gender inequality varies across countries and is associated with poor outcomes including violence against women and depression. Little is known about the relationship of source county gender inequality and poor health outcomes in female immigrants. Methods We used administrative databases to conduct a cohort study of 299,228 female immigrants ages 6–29 years becoming permanent residence in Ontario, Canada between 2003 and 2017 and followed up to March 31, 2020 for severe presentations of suffering assault, and selected mental health disorders (mood or anxiety, self-harm) as measured by hospital visits or death. Poisson regression examined the influence of source-country Gender Inequality Index (GII) quartile (Q) accounting for individual and country level characteristics. Results Immigrants from countries with the highest gender inequality (GII Q4) accounted for 40% of the sample, of whom 83% were from South Asia (SA) or Sub-Saharan Africa (SSA). The overall rate of assault was 10.9/10,000 person years (PY) while the rate of the poor mental health outcome was 77.5/10,000 PY. Both GII Q2 (Incident Rate Ratio (IRR): 1.48, 95% Confidence Interval (CI): 1.08, 2.01) and GII Q4 (IRR: 1.58, 95%CI: 1.08, 2.31) were significantly associated with experiencing assault but not with poor mental health. For females from countries with the highest gender inequality, there were significant regional differences in rates of assault, with SSA migrants experiencing high rates compared with those from SA. Relative to economic immigrants, refugees were at increased risk of sustaining assaults (IRR: 2.96, 95%CI: 2.32, 3.76) and poor mental health (IRR: 1.73, 95%CI: 1.50, 2.01). Higher educational attainment (bachelor’s degree or higher) at immigration was protective (assaults IRR: 0.64, 95%CI: 0.51, 0.80; poor mental health IRR: 0.69, 95% CI: 0.60, 0.80). Conclusion Source country gender inequality is not consistently associated with post-migration violence against women or severe depression, anxiety and self-harm in Ontario, Canada. Community-based research and intervention to address the documented socio-demographic disparities in outcomes of female immigrants is needed.

Objective To examine discharge and post-discharge outcomes for psychiatric inpatients with a history of exposure to physical, sexual, or emotional trauma. Methods In this population-based cohort study using health-administrative data, adult psychiatric inpatients in Ontario, Canada (2009–2016) with and without self-reported lifetime exposure to interpersonal trauma were compared on their likelihood of: discharge against medical advice; post-discharge outpatient follow-up; and post-discharge emergency department (ED) visits, rehospitalization, deliberate self-harm and suicide. Modified Poisson regressions generated relative risks (aRR) and 95% confidence intervals (CI), adjusted for age, sex, income, medical comorbidities, and psychiatric diagnosis. Results Psychiatric inpatients with a history of interpersonal trauma (n = 50,832/160,436, 31.7%) were at elevated risk for discharge against medical advice (5.6% vs. 4.6%; aRR = 1.27, 1.21–1.33), and for 1-year post-discharge psychiatric ED visits (31.0% vs. 28.3%, aRR = 1.04, 1.02–1.06), and deliberate self-harm (5.5% vs. 3.7%, aRR = 1.30, 1.23–1.36). Post-discharge 30-day follow-up with primary care was slightly more common among those with a trauma history (37.6% vs. 34.5%, aRR = 1.06, 1.04–1.08); psychiatrist follow-up was less common (35.1% vs. 37.1%, aRR = 0.87, 0.86–0.89). Elevations in risk were observed for those with primary diagnoses of psychotic, mood and anxiety disorders, but not for those with a primary diagnosis of substance-related disorders. Risk elevations were specifically observed in those without a diagnosis of post-traumatic stress disorder. Conclusion Implementing supports and services during and after inpatient hospitalization that take into account a history of interpersonal trauma may help reduce certain undesirable discharge and post-discharge outcomes in this slightly higher-risk group.

Objective To test the association of material deprivation and the utilization of vision care services for young children. Study design We conducted a population-based, repeated measures cohort study using linked health and administrative datasets. All children born in Ontario in 2010 eligible for provincial health insurance were followed from birth until their 7th birthday. The main exposure was neighborhood-level material deprivation quintile, a proxy for socioeconomic status. The primary outcome was receipt of a comprehensive eye examination (not to include a vision screening) by age 7 years from an eye care professional, or family physician. Results Of 128,091 children included, females represented 48.7% of the cohort, with 74.4% living in major urban areas and 16.2% living in families receiving income assistance. Only 65% (n=82,833) had at least one comprehensive eye examination, with the lowest uptake (56.9%; n= 31,911) in the most deprived and the highest uptake (70.5%; n =19,860) in the least deprived quintiles. After adjusting for clinical and demographic variables, children living in the least materially deprived quintile had a higher odds of receiving a comprehensive eye examination (aOR 1.43; 95%CI 1.36, 1.51) compared with children in the most material deprived areas. Conclusions Uptake of comprehensive eye examinations is poor, especially for children living in the most materially deprived neighbourhoods. Strategies to improve uptake and reduce inequities are warranted.

Improved survival of children with life-threatening conditions has resulted in more children in need of caregiving support. For example, a child assisted by medical technology may need constant monitoring of a tracheostomy at home, often a role taken on by parents. Increased caregiving is also required for children with certain developmental or psychiatric conditions that have self-injurious or high-risk behaviours. Caregiving for a child with high needs can be a fulfilling experience, but can also pose substantial risks of burnout as well as poor mental and physical health. Caregivers face increased stress, financial burden and sometimes stigma and social isolation. Those stressors may increase the likelihood of depression and anxiety, as well as of premature maternal cardiovascular disease and mortality.1 Even if caregivers do not meet criteria for a mental illness but are struggling with high emotional distress, their parenting skills and ability to promote secure attachment may be affected. Children of parents with mental illness have elevated risk for poor growth, feeding difficulties, depression, behavioural challenges and poor learning.2 A child with a disability and high needs may be even more susceptible to these detrimental effects. Some adverse outcomes may be reversible with support for the caregiver. For example, therapy for depressed mothers has been reported to improve the child’s mental health, social and academic functioning and the mother–child interaction.3 4 Likewise, children exposed to adverse experiences—most commonly parental mental illness—have been shown to have improved language and behaviour, decreased injuries and more uptake of immunisation …

Background and objectiveDespite firearms contributing to significant morbidity and mortality globally, firearm injury epidemiology is seldom described outside of the USA. We examined firearm injuries among youth in Canada, including weapon type, and intent.DesignPopulation-based, pooled cross-sectional study using linked health administrative and demographic databases.SettingOntario, Canada.ParticipantsAll children and youth from birth to 24 years, residing in Ontario from 1 April 2003 to 31 March 2018.ExposureFirearm injury intent and weapon type using the International Classification of Disease-10 CM codes with Canadian enhancements. Secondary exposures were sociodemographics including age, sex, rurality and income.Main outcomesAny hospital or death record of a firearm injury with counts and rates of firearm injuries described overall and stratified by weapon type and injury intent. Multivariable Poisson regression stratified by injury intent was used to calculate rate ratios of firearm injuries by weapon type.ResultsOf 5486 children and youth with a firearm injury (annual rate: 8.8/100 000 population), 90.7% survived. Most injuries occurred in males (90.1%, 15.5/100 000 population). 62.3% (3416) of injuries were unintentional (5.5/100 000 population) of which 1.9% were deaths, whereas 26.5% (1452) were assault related (2.3/100 00 population) of which 18.7% were deaths. Self-injury accounted for 3.7% (204) of cases of which 72.0% were deaths. Across all intents, adjusted regression models showed males were at an increased risk of injury. Non-powdered firearms accounted for half (48.6%, 3.9/100 000 population) of all injuries. Compared with handguns, non-powdered firearms had a higher risk of causing unintentional injuries (adjusted rate ratio (aRR) 14.75, 95% CI 12.01 to 18.12) but not assault (aRR 0.84, 95% CI 0.70 to 1.00).ConclusionsFirearm injuries are a preventable public health problem among youth in Ontario, Canada. Unintentional injuries and those caused by non-powdered firearms were most common and assault and self-injury contributed to substantial firearm-related deaths and should be a focus of prevention efforts.

BackgroundUnintentional injuries are a leading reason for seeking emergency care. Refugees face vulnerabilities that may contribute to injury risk. We aimed to compare the rates of unintentional injuries in immigrant children and youth by visa class and region of origin.MethodsPopulation-based, cross-sectional study of children and youth (0–24 years) from immigrant families residing in Ontario, Canada, from 2011 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by immigration visa class and region of origin. Poisson regression models estimated rate ratios for injuries.ResultsThere were 6596.0 and 8122.3 emergency department visits per 100 000 non-refugee and refugee immigrants, respectively. Hospitalisation rates were 144.9 and 185.2 per 100 000 in each of these groups. The unintentional injury rate among refugees was 20% higher than among non-refugees (adjusted rate ratio (ARR) 1.20, 95% CI 1.16, 1.24). In both groups, rates were lowest among East and South Asians. Young age, male sex, and high income were associated with injury risk. Compared with non-refugees, refugees had higher rates of injury across most causes, including for motor vehicle injuries (ARR 1.51, 95% CI 1.40, 1.62), poisoning (ARR 1.40, 95% CI 1.26, 1.56) and suffocation (ARR 1.39, 95% CI 1.04, 1.84).InterpretationThe observed 20% higher rate of unintentional injuries among refugees compared with non-refugees highlights an important opportunity for targeting population-based public health and safety interventions. Engaging refugee families shortly after arrival in active efforts for injury prevention may reduce social vulnerabilities and cultural risk factors for injury in this population.

Background Immigrants typically arrive in good health. This health benefit can decline as immigrants adopt behaviours similar to native-born populations. Risk of injury is low in immigrants but it is not known whether this changes with increasing time since migration. We sought to examine the association between duration of residence in Canada and risk of unintentional injury. Methods Population-based cross-sectional study of children and youth 0 to 24 years in Ontario, Canada (2011-2012), using linked health and administrative databases. The main exposure was duration of Canadian residence (recent: 0–5 years, intermediate: 6–10 years, long-term: >10 years). The main outcome measure was unintentional injuries. Cause-specific injury risk by duration of residence was also evaluated. Poisson regression models estimated rate ratios (RR) for injuries. Results 999951 immigrants were included with 24.2% recent and 26.4% intermediate immigrants. The annual crude injury rates per 100000 immigrants were 6831 emergency department visits, 151 hospitalizations, and 4 deaths. In adjusted models, recent immigrants had the lowest risk of injury and risk increased over time (RR 0.79; 95% CI 0.77, 0.81 recent immigrants, RR 0.90; 95% CI 0.88, 0.92 intermediate immigrants, versus long-term immigrants). Factors associated with injury included young age (0-4 years, RR 1.30; 95% CI 1.26, 1.34), male sex (RR 1.52; 95% CI 1.49, 1.55), and high income (RR 0.93; 95% CI 0.89, 0.96 quintile 1 versus 5). Longer duration of residence was associated with a higher risk of unintentional injuries for most causes except hot object/scald burns, machinery-related injuries, non-motor vehicle bicycle and pedestrian injuries. The risk of these latter injuries did not change significantly with increasing duration of residence in Canada. Risk of drowning was highest in recent immigrants. Conclusions Risk of all-cause and most cause-specific unintentional injuries in immigrants rises with increasing time since migration. This indicates the need to develop strategies for maintaining the immigrant health advantage over time while balancing the desire to support integration, active living, and healthy child development. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4612-1) contains supplementary material, which is available to authorized users.

BACKGROUND Unintentional injury is the leading cause of childhood death. Injury is associated with a number of sociodemographic characteristics, but little is known about risk in immigrants. Our objective was to examine the association between family immigrant status and unintentional injury in children and youth. METHODS We performed a population-based, cross-sectional study involving children and youth (age 0-24 yr) residing in Ontario from 2008 to 2012. Multiple linked health and administrative databases were used to describe unintentional injuries by family immigrant status. Unintentional injury events (e.g., emergency department visits, admissions to hospital, deaths) were analyzed using Poisson regression models to estimate rate ratios (RRs) for injury by immigrant status. RESULTS Annualized injury rates were 11 749 emergency department visits per 100 000 population, 267 hospital admissions per 100 000 population and 12 deaths per 100 000 population. Injury rates were lower among immigrants across all causes of unintentional injury (adjusted RR 0.56, 95% confidence interval [CI] 0.54-0.59). Among nonimmigrants, lowest neighbourhood income quintile was associated with the highest rates (RR 1.13, 95% CI 1.08-1.18, quintile 5 v. 1); among immigrants, lowest income quintile was associated with the lowest rates of injury (RR 0.88, 95% CI 0.82-0.94, quintile 5 v. 1). Highest rates of injury for nonimmigrants were among adolescents (age 10-14 yr, RR 1.23, 95% CI 1.18-1.28; v. 20-24 yr), but for immigrants, was highest among young children (0-4 yr RR 1.23, 95% CI 1.16-1.31; v. 20-24 yr). INTERPRETATION Rates of unintentional injury are lower among immigrant than among Canadian-born children, supporting a healthy immigrant effect. Socioeconomic status and age have different associations with injury risk, suggesting alternative causal pathways for injuries in immigrant children and youth.

Objectives To evaluate factors associated with uptake of a financial incentive for developmental screening at an enhanced 18-month well-child visit (EWCV) in Ontario, Canada. Study design Population-based cohort study using linked administrative data of children (17-24 months of age) eligible for EWCV between 2009 and 2017. Logistic regression modeled associations of EWCV receipt by provider and patient characteristics. Results Of 910 976 eligible children, 54.2% received EWCV (annually, 39.2%-61.2%). The odds of assessment were lower for socially vulnerable children, namely, those from the lowest vs highest neighborhood income quintile (aOR, 0.84; 95% CI, 0.83-0.85), those born to refugee vs nonimmigrant mothers (aOR, 0.90; 95% CI, 0.88-0.93), and to teenaged mothers (aOR, 0.70; 95% CI, 0.69-0.71)). Children were more likely to have had developmental screening if cared for by a pediatrician vs family physician (aOR, 1.28; 95% CI, 1.13-1.44), recently trained physician (aOR, 1.38; 95% CI, 1.29-1.48 for ≤5 years in practice vs ≥21 years) and less likely if the physician was male (aOR, 0.64; 95% CI, 0.61-0.66). For physicians eligible for a pay-for-performance immunization bonus, there was a positive association with screening. Conclusions In the context of a universal healthcare system and a specific financial incentive, uptake of the developmental assessment increased over time but remains moderate. The implementation of similar interventions or incentives needs to account for physician factors and focus on socially vulnerable children to be effective.

Maternal schizophrenia is associated with adverse birth outcomes, but the reasons for this remain unclear. In a population-based cohort of infants born to women with schizophrenia, we determined the occurrence of key perinatal outcomes and explored whether factors identifiable in our datasets explained any elevated risk. Using population-level health administrative data linked to clinical birth-registry data in Ontario, Canada (2006–2011), we examined the relative risk (RR) of preterm birth (

To examine the relationship between family immigrant status and unscheduled 7-day revisits to the emergency department (ED) and to test this relationship within subgroups of immigrants by visa class (family, economic, refugee), native tongue on landing in Canada, and region of origin.Population-based cohort study that used multiple linked health administrative and demographic datasets of landed immigrant and nonimmigrant children (18 years) in urban Ontario who visited an ED and were discharged between April 2003 and March 2010. Logistic regression was used to model the odds of 7-day ED revisits with family immigrant status, with adjustment for patient and ED characteristics.Of 3,322,901 initial visits to the ED, 249,648 (7.5%) resulted in a 7-day revisit. There was no significant association of immigrant status with either ED revisits or poor revisit outcomes (greater acuity visit or need for admission) in the adjusted models. Within immigrants, the odds of revisit were not associated with immigrant classes or region of origin; however, immigrants whose native tongue was not English or French had a slightly greater odds of revisiting the ED (aOR 1.05; 95% CI 1.01, 1.09). Significant predictors of revisits included younger age, greater triage acuity score, greater predilection for using an ED, daytime shifts, and greater deprivation index.Immigrant children are not more likely to have short-term revisits to the ED, but there may be barriers to care related to language fluency that need to be addressed. These findings may be relevant for improving translation services in EDs.

Introduction/Background Paediatric overweight and obesity are important public health problems worldwide. Children with autism spectrum disorder (ASD) may be at increased risk compared to their typically-developing peers; however, prevalence estimates in ASD have varied widely and existing studies have largely been limited by use of an external comparison group. Objectives To compare prevalence of overweight and obesity in children and youth ( Design/Methods This was a cross-sectional analysis of EMRPC (Electronic Medical Records Primary Care) data, representing 385 family physicians in 43 clinics in Ontario, Canada. Age- and sex-standardized body mass index (BMI) z-scores were calculated using abstracted heights and weights from the most recent visit between January 2011 and December 2015. Weight status was determined using World Health Organization growth reference standards. ASD was defined using a previously-validated algorithm in EMRPC, based on an ASD-related term in the ‘Cumulative Patient Profile.’ Chi-square test statistics and multinomial logistic regression were used to compare weight status of those with and without ASD. Results In total, 44,625 children and youth were included, 632 [1.42%] with ASD. Distribution of weight status was significantly different between those with and without ASD (p Conclusion Data from a large primary care database suggest that children with ASD are at substantially increased risk of overweight, obesity and severe obesity. Findings support the need for anticipatory guidance, prevention and management strategies specific to this clinical population. Future work will aim to better understand at what age differences in weight status emerge, and what nutritional, behavioural, or medical factors differentially affect weight status in the ASD population.

BACKGROUND: Emergency department visits as a first point of contact for people with mental illness may reflect poor access to timely outpatient mental health care. We sought to determine the extent to which immigrants use the emergency department as an entryway into mental health services. METHODS: We used linked health and demographic administrative data sets to design a population-based cohort study. We included youth (aged 10–24 yr) with an incident mental health emergency department visit from 2010 to 2014 in Ontario, Canada (n = 118 851). The main outcome measure was an emergency department visit for mental health reasons without prior mental health care from a physician on an outpatient basis. The main predictor of interest was immigrant status (refugee, non-refugee immigrant and non-immigrant). Immigrant-specific predictors included time since migration, and region and country of origin. We used Poisson models to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (CIs). RESULTS: The cohort included 2194 (1.8%) refugee, 6680 (5.6%) non-refugee immigrant and 109 977 (92.5%) nonimmigrant youth. Rates of first mental health contact in the emergency department were higher among refugee (61.3%) and non-refugee immigrant youth (57.6%) than non-immigrant youth (51.3%) (refugee aRR 1.17, 95% CI 1.13–1.21; non-refugee immigrant aRR 1.10, 95% CI 1.08–1.13). Compared with non-refugee immigrants, refugees had a higher rate of first mental health contact in the emergency department (aRR 1.06, 95% CI 1.02–1.11). We also observed higher rates among recent versus longer-term immigrants (aRR 1.10, 95% CI 1.05–1.16) and immigrants from Central America (aRR 1.17, 95% CI 1.08–1.26) and Africa (aRR 1.15, 95% CI 1.06–1.24) versus from North America and Western Europe. INTERPRETATION: Immigrant youth are more likely to present with a first mental health crisis to the emergency department than non-immigrants, with variability by region of origin and time since migration. Immigrants may face barriers to access and use of outpatient mental health services from a physician. Efforts are needed to reduce stigma and identify mental health problems early, before crisis, among immigrant populations.

ObjectiveTo describe trends in mental health service use of youth by immigration status and characteristics.DesignPopulation-based longitudinal cohort study from 1996 to 2012 using linked health and administrative datasets.SettingOntario, Canada.ParticipantsYouth 10–24 years, living in Ontario, Canada.ExposureThe main exposure was immigration status (recent immigrants vs long-term residents). Secondary exposures were region of origin and refugee status.Main outcome measureMental health hospitalisations, emergency department (ED) visits and outpatient visits within consecutive 3-year time periods. Poisson regression models estimated rate ratios (RR).ResultsOver 2.5 million person years per period were included. Rates of recent immigrant mental health service utilisation were at least 40% lower than long-term residents (pMental health hospitalisation and ED visit rates increased in long-term residents (hospitalisations, RR 1.09 (95% CI 1.08 to 1.09); ED visits, RR 1.15 (1.14 to 1.15)) and recent immigrants (hospitalisations RR 1.05 (1.03 to 1.07); ED visits, RR 1.08 (1.05 to 1.11)). Mental health outpatient visit rates increased in long-term residents (RR 1.03 (1.03 to 1.03)) but declined in recent immigrant (RR 0.94 (0.93 to 0.95)). Comparable divergent trends in acute care and outpatient service use were observed among refugees and across most regions of origin. Recent immigrant acute care use was driven by longer-term refugees (hospitalisations RR 1.12 (1.03 to 1.21); ED visits RR 1.11 (1.02 to 1.20)).ConclusionsMental health service utilisation was lower among recent immigrants than long-term residents. While acute care use is increasing at a faster rate among long-term residents than recent immigrants, the decrease in outpatient mental health visits in immigrants highlights a potential emerging disparity in access to preventative care.

IntroductionOpioid-use during pregnancy is indicative of future adversity for mothers and children. We aimed to investigate neonatal abstinence syndrome (NAS) as a marker of drug-use in pregnancy and to compare maternal all-cause mortality relative to those with infants born without NAS in two high prevalence jurisdictions; England and Ontario. Objectives and ApproachWe developed two parallel cohorts using linked mother-baby records for all births in hospitals in England and Ontario between 2002 and 2013. Mothers with opioid-use were identified based on NAS recorded in the baby’s record. Maternal mortality within 10 years of delivery was compared for mothers with and without a NAS-pregnancy. The association between opioid-use in pregnancy and all-cause mortality was modelled using Cox regression. In addition, we estimated the unadjusted cumulative incidence of cause-specific mortality within a competing risks framework. Harmonised clinical codes were used to define all exposures, outcomes and comorbidities. ResultsThe study population comprised 13,581 and 4,966 NAS mothers in England and Ontario, respectively. Controls totalled 4,205,941 for England and 929,985 for Ontario. The crude hazard ratios for all-cause mortality were 12.1 (95% CI; 11.1-13.2) for England and 11.4 (9.7, 13.4) for Ontario, which were attenuated to 9.8 (9.0-10.6) and 9.0 (7.6, 10.7) respectively, after adjustment for maternal age at delivery and Charlson comorbidity index. The cumulative incidence of death was much higher among NAS mothers than controls for all causes except cancer in the English cohort, where estimates were similar. The majority of deaths within the NAS group were attributable to avoidable causes, particularly reflecting unintentional injuries (cumulative incidence of 19.6 (16.6-23.1) for England and 13.9 (9.7-19.3) for Ontario). Conclusion/ImplicationsOur approach demonstrates the utility of mother-baby record linkage to examine long-term health outcomes of vulnerable families. We identified similarly high mortality rates among the mothers of NAS babies in both England and Ontario, indicating a need for public health programs to target support to mothers as well and infants.

Objective:Although evidence suggests that treatment seeking for mental illness has increased over time, little is known about how the health system is meeting the increasing demand for services. We examined trends in physician-based mental health service use across multiple sectors.Method:In this population-based study, we used linked health-administrative databases to measure annual rates of mental health–related outpatient physician visits to family physicians and psychiatrists, emergency department visits, and hospitalizations in adults aged 16+ from 2006 to 2014. We examined absolute and relative changes in visit rates, number of patients, and frequency of visits per patient, and assessed temporal trends using linear regressions.Results:Among approximately 11 million Ontario adults, age- and sex-standardized rates of mental health–related outpatient physician visits declined from 604.8 to 565.5 per 1000 population over the study period ( Ptrend= 0.04). Over time, the rate of visits to family physicians/general practitioners remained stable ( Ptrend= 0.12); the number of individuals served decreased, but the number of visits per patient increased. The rate of visits to psychiatrists declined ( Ptrend< 0.001); the number of individuals served increased, but the number of visits per patient decreased. Concurrently, visit rates to emergency departments and hospitals increased (16.1 to 19.7, Ptrend< 0.001 and 5.6 to 6.0, Ptrend= 0.01, per 1000 population, respectively). Increases in acute care service use were greatest for anxiety and addictions.Conclusions:The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.

Subcutaneous fat necrosis of the newborn (SFNN) is a rare disorder characterised by indurated plaques or nodules with or without erythema, typically distributed over the cheeks, extremities, posterior trunk, buttocks, and thighs, and appears during the first 2 weeks of life. It is commonly associated with perinatal asphyxia and, while usually self-limited, can lead to severe hypercalcemia. There is no known familial association. The present article describes a neonate with extensive disease, counterintuitive hypocalcemia, and a family history of SFNN and reviews the existing literature on SFNN.

ObjectiveTo describe the trends in suicide and emergency department (ED) visits for self-harm in youth by immigration status and immigrant characteristics.DesignPopulation-based longitudinal cohort study from 1996 to 2012 using linked health and administrative datasets.SettingOntario, Canada.ParticipantsYouth 10 to 24 years, living in Ontario, Canada.ExposureThe main exposure was immigrant status (recent immigrant (RI) versus long-term residents (LTR)). Secondary exposures included region of birth, duration or residence, and refugee status.Main outcome measureTrends over time in suicide and ED self-harm were modelled within consecutive 3-year time periods. Rate ratios were estimated using Poisson regression models.Results2.5 to 2.9 million individuals were included per cohort period. LTR suicide rates ranged from 7.4 to 9.4/100 000 male person-years versus 2.2–3.4/100 000 females. RI’s suicide rates were 2.7–7.2/100,000 male versus 1.9–2.7/100 000 female person-years. Suicide rates were lower among RI compared with LTR (adjusted relative rate (aRR)=0.70, 95% CI=0.57 to 0.85) with different mechanisms of suicide. No significant time trend in suicide rates was observed (p=0.40). ED self-harm rates for LTR and RI were highest in females (2.6–3.4/1000 LTR females versus 1.1–1.5/1000 males, 1.2–1.8/1000 RI females versus 0.4–0.6/1000 males). RI had lower rates of self-harm compared with LTR (aRR=0.60, 95% CI=0.56 to 0.65). Stratum-specific rates showed a steeper decline per period in RI compared with LTR (RI: aRR=0.85, 95% CI=0.81 to 0.89; LTR: aRR=0.91, 95% CI=0.90 to 0.93). Observed trends were not universal across region of origin and by refugee status.InterpretationSuicide rates have been stable and ED self-harm rates are declining over time among RI youth. These trends by important subgroups should continue to be monitored to allow for early identification of subpopulations of immigrant youth in need of targeted and culturally appropriate public health interventions.

Thank you for your comments and questions of clarification[1][1] pertaining to our article in CMAJ .[2][2] Our definition of a firearm injury was based on the International Statistical Classification of Diseases and Related Health Problems, 10th rev, Clinical Modification (ICD-10-CM) codes for

BACKGROUND: With increasing rates of opioid use during pregnancy, the incidence of neonatal abstinence syndrome (NAS) is rising across North America. While perinatal outcomes for infants born with NAS have been well-described, little is known about long-term maternal health outcomes in this vulnerable population.

BACKGROUND: Firearm injuries contribute to substantial morbidity and mortality. The immigrant paradox suggests that, despite being more socially disadvantaged, immigrants are less likely than nonimmigrants to have poor outcomes. We tested the association of immigrant characteristics with firearm injuries among children and youth. METHODS: We conducted a population-based cohort study involving residents of Ontario aged 24 years and younger from 2008–2012 using health and administrative databases. We estimated rate ratios of unintentional and assault-related firearm injuries by immigrant status using Poisson regression models with Generalized Estimating Equations. RESULTS: We included 15 866 954 nonimmigrant and 4 551 291 immigrant person-years in our analysis. Nonimmigrant males had 1032 unintentional (12.4 per 100 000, 95% confidence interval [CI] 11.7–13.2) and 304 assault-related (3.6 per 100 000, 95% CI 3.2–4.0) firearm injuries. Immigrant males had 148 unintentional (7.2 per 100 000, 95% CI 6.1–8.5) and 113 assault-related (5.5 per 100 000, 95% CI 4.5–6.6) firearm injuries. Compared with nonimmigrants, immigrants had a lower rate of unintentional firearm injury (adjusted rate ratio 0.5, 95% CI 0.4–0.6) but a similar rate of assault-related firearm injury. Among immigrants, refugees had a 43% higher risk of assault-related firearm injury compared with nonrefugees (adjusted rate ratio 1.4, 95% CI 1.0–2.0). Immigrants from Central America and Africa accounted for 68% of immigrants with assault-related firearm injuries. INTERPRETATION: Compared with nonimmigrants, immigrant children and youth had a lower risk of unintentional firearm injury, although the risk of assault-related firearm injury was higher among refugees and immigrants from Central America and Africa. The results suggest that prevention strategies for firearm safety should target nonimmigrant youth as well as these newly identified high-risk immigrant populations.

Background Opioid addiction is a major public health issue, but little is known about long-term mortality for mothers with opioid use in pregnancy. The prevalence of neonatal abstinence syndrome is high in England and Ontario (Canada). We aimed to compare maternal mortality among mothers of infants with and without neonatal abstinence syndrome in these regions. Methods In this population-based study, we used administrative data to obtain parallel cohorts of linked mother–child records from singleton hospital births in England and Ontario between April 1, 2002, and Dec 31, 2012. Death records captured maternal mortality up to 10 years after delivery. We used neonatal abstinence syndrome as a marker of opioid-use during pregnancy. We modelled the association between neonatal abstinence syndrome and all-cause maternal mortality using Cox regression, and the cumulative incidence of cause-specific mortality within a competing risks framework. The primary exposure was neonatal abstinence syndrome among all mothers (aged 12–49 years) who had a live birth during the study period; mothers of infants without neonatal abstinence syndrome were controls. The main outcome was all deaths among mothers following index delivery. We estimated all-cause mortality rates, 10-year cumulative incidence risk of death, and crude and adjusted hazard ratios (HRs). Findings The study included 13 577 and 4 205 675 mothers of infants with neonatal abstinence syndrome in England and Ontario, respectively, and 4966 and 929 985 mothers of infants without neonatal abstinence syndrome in England and Ontario, respectively. 10-year mortality among mothers of infants with neonatal abstinence syndrome was 5·1% in England and 4·6% in Ontario compared with 0·4% in controls (both p Interpretation Approximately one in 20 mothers of infants with neonatal abstinence syndrome died within 10 years of delivery in both England and Canada. Our study was limited by the paucity of direct measures of maternal opioid use and treatment. Policy responses to the current opioid epidemic require effective strategies for long-term support to improve the health and welfare of mothers who use opioids and their children. Funding Institute for Clinical Evaluative Sciences, Ontario Ministry of Health and Long-Term Care.

Objective: Small clinical samples suggest that psychiatric inpatients report a lifetime history of interpersonal trauma. Since past experiences of trauma may complicate prognosis and treatment trajectories, population-level knowledge is needed about its prevalence and correlates among inpatients. Methods: Using health-administrative databases comprising all adult psychiatric inpatients in Ontario, Canada (2009 to 2016, n = 160,436, 49% women), we identified those who reported experiencing physical, sexual, and/or emotional trauma in their lifetime, 1 year, and 30 days preceding admission. We described the prevalence of each type of trauma, comparing women and men using modified Poisson regression, and identified individual-level characteristics associated with lifetime trauma history using multivariable logistic regression. Results: 31.7% of inpatients reported experiencing trauma prior to admission. Lifetime prevalence was higher in women (39.6% vs. 24.1%; age-adjusted prevalence ratio [aPR] = 1.68; 95% CI, 1.65 to 1.71), including sexual (22.7% vs. 8.4%; aPR = 2.81; 95% CI, 2.73 to 2.89), emotional (33.3% vs. 19.4%; aPR = 1.76; 95% CI, 1.72 to 1.79), and physical trauma (24.2% vs. 14.8%; aPR = 1.68; 95% CI, 1.65 to 1.72). Factors most prominently associated with lifetime trauma were witnessing parental substance use (adjusted odds ratio [aOR] = 8.68; 95% CI, 8.39 to 8.99), female sex (aOR = 2.29; 95% CI, 2.23 to 2.35), and number of recent stressful life events (aOR = 1.62; 95% CI, 1.59 to 1.65). Conclusions: These results suggest that trauma-informed approaches are essential to consider in the design and delivery of inpatient psychiatric services for both women and men.

Assisted reproductive technologies have been widely used over the past 30 years, and 1% to 4% of births worldwide are products of these technologies. However, adverse health outcomes related to assisted reproductive technologies, including cerebral palsy, have been reported. We extracted and reviewed all relevant studies cited by Medline from 1996 to 2010 evaluating the role of assisted reproductive technologies as a causative factor for cerebral palsy and poor long-term neurologic outcome. The research suggests that multiple pregnancy, preterm delivery, and babies small for gestational age are factors in the development of cerebral palsy. The vanishing embryo syndrome may also play a role. We review the evidence for these potentially causative factors, as well as their implications for embryo transfer policies.

BACKGROUND: As Ewing sarcoma (EWS) can affect children and adults, these patients can be treated at either a pediatric or an adult institution. This study investigated whether differences in therapeutic strategy undertaken in pediatric and adult specialty sarcoma centers correlated with clinical outcome. METHODS: Data from patients with localized EWS treated between 1990 and 2005 at tertiary care pediatric and adult institutions were reviewed. RESULTS: Fifty-three patients (24 adult and 29 pediatric) were treated. Pediatric patients received a median of 16 cycles of chemotherapy comprised of doxorubicin, vincristine, cyclophosphamide, ifosfamide, and etoposide. Adult patients received a median of 10 cycles of treatment, and a significantly lower total cumulative dose of ifosfamide and cyclophosphamide (P < .0001). There was no difference noted with regard to the total dose of doxorubicin, or in the type of local therapy offered (surgery or radiotherapy, vs both). However, local therapy occurred earlier in pediatric patients compared with adults (3.7 months vs 7.4 months; P = .0003). The 3-year event-free survival (EFS) rate in pediatric and adult patients was 70% ± 9% and 43% ± 13% (P = 0.1), respectively. The 3-year overall survival rate was 81% ± 7.7% and 59% ± 12% (P = .02) for pediatric and adult patients, respectively. Factors found to be significantly associated with EFS on univariate analysis included pelvic site, cyclophosphamide dose, and time to local therapy. On multivariate analysis, only pelvic disease (hazard ratio [HR] 4.26; P = .018) and time to local therapy (HR, 1.19; P = .002) were found to be significant. CONCLUSIONS: Adults with localized EWS have an inferior outcome compared with pediatric patients. This difference may be related to lower doses of alkylating agents and the timing of local therapy. Cancer 2010. © 2010 American Cancer Society.

ObjectivesChildren from immigrant families may be at risk for iron deficiency (ID) due to differences in pre-migration and post-migration exposures. Our objectives were to determine whether there is an association between family immigrant status and iron stores and to evaluate whether known dietary, environmental or biological determinants of low iron status influence this relationship.DesignThis was a cross-sectional study of healthy urban preschool children (12–72 months) recruited from seven primary care practices in Toronto. Laboratory assessment of serum ferritin and haemoglobin and standardised parent-completed surveys were completed between 2008 and 2013 during routine health maintenance visits. Multiple regression analyses were used to evaluate the association between family immigrant status and serum ferritin, ID (ferritin ResultsOf 2614 children included in the analysis, 47.6% had immigrant family status. The median serum ferritin was 30 μg/L and 10.4% of all children had ID and 1.9% had IDA. After adjusting for maternal ethnicity and education, age, sex, income quintile, cow's milk intake, breastfeeding duration and bottle use, there were no significant associations between immigrant status and ferritin, ID or IDA. Significant predictors of low iron status included age, sex, cow's milk intake and breastfeeding duration.ConclusionsWe found no association between family immigrant status and iron status after including clinically important covariates in the models. These data suggest immigrant children may not need enhanced screening for iron status or targeted interventions for iron supplementation.

Common approaches to understanding control of muscle blood flow in exercise focus on the contributions of various putative vasoregulatory mechanisms to the magnitude of the steady-state response. The application of systems-control principles offers a unique approach to characterizing and quantifying the non-steady-state adaptation of muscle blood flow with exercise onset. Information gained from this approach provides novel insight into the nature of control mechanisms governing physiological responses to exercise. This review is intended to provide the reader with an understanding of 1) exercise models, methodology for measuring muscle blood flow, and analysis approaches for quantifying muscle blood-flow dynamics; 2) what is currently known about the dynamic response of muscle blood-flow control mechanisms in humans; and 3) the similarities and differences in exercising muscle blood-flow control in the upper versus the lower limbs in humans.

For the current issue of the Journal, we asked Drs Natasha Saunders and Jeremy Friedman to comment on and put into context the recent Cochrane Review on avoiding or reducing intake of lactose-containing milk or milk products for reducing the duration and severity of acute diarrhea in children. Background Young children with acute diarrhea, typically due to infectious gastroenteritis, may temporarily stop producing lactase, the intestinal enzyme that digests lactose. Thus, they may not digest lactose, the main sugar in milk, and this may worsen or prolong the diarrheal illness. However, there is uncertainty regarding whether avoiding lactose-containing milk or milk products helps young children recover from acute diarrhea more quickly. Methods Search strategy: The authors performed a search of the Cochrane Infectious Diseases Group Specialized Register (May 14, 2013), Cochrane Central Register of Controlled Trials (CENTRAL) published in The Cochrane Library (Issue 4, 2013), MEDLINE (1996 to May 14, 2013), EMBASE (1974 to May 14, 2013), LILACS (1982 to May 14, 2013) and the reference lists of potentially relevant trials and key conference proceedings, and wrote to individuals and organizations in the field. Selection criteria: Randomized or quasi-randomized controlled trials that assessed the effects of avoiding or reducing exposure to lactose in young children

We tested the hypothesis that nitric oxide (NO) and prostaglandins (PGs) contribute to the rapid vasodilation that accompanies a transition from mild to moderate exercise. Nine healthy volunteers (2 women and 7 men) lay supine with forearm at heart level. Subjects were instrumented for continuous brachial artery infusion of saline (control condition) or combined infusion of NG-nitro-l-arginine methyl ester (l-NAME) and ketorolac (drug condition) to inhibit NO synthase and cyclooxygenase, respectively. A step increase from 5 min of steady-state mild (5.4 kg) rhythmic, dynamic forearm handgrip exercise (1 s of contraction followed by 2 s of relaxation) to moderate (10.9 kg) exercise for 30 s was performed. Steady-state forearm blood flow (FBF; Doppler ultrasound) and forearm vascular conductance (FVC) were attenuated in drug compared with saline (control) treatment: FBF = 196.8 ± 30.8 vs. 281.4 ± 34.3 ml/min and FVC = 179.3 ± 29.4 vs. 277.8 ± 34.8 ml·min−1·100 mmHg−1 (both P < 0.01). FBF and FVC increased from steady state after release of the initial contraction at the higher workload in saline and drug conditions: ΔFBF = 72.4 ± 8.7 and 52.9 ± 7.8 ml/min, respectively, and ΔFVC = 66.3 ± 7.3 and 44.1 ± 7.0 ml·min−1·100 mmHg−1, respectively (all P < 0.05). The percent ΔFBF and ΔFVC were not different during saline infusion or combined inhibition of NO and PGs: ΔFBF = 27.2 ± 3.1 and 28.1 ± 3.8%, respectively ( P = 0.78) and ΔFVC = 25.7 ± 3.2 and 26.0 ± 4.0%, respectively ( P = 0.94). The data suggest that NO and vasodilatory PGs are not obligatory for rapid vasodilation at the onset of a step increase from mild- to moderate-intensity forearm exercise. Additional vasodilatory mechanisms not dependent on NO and PG release contribute to the immediate and early increase in blood flow in an exercise-to-exercise transition.

Controversy exists regarding the contribution of a rapid vasodilatory mechanism(s) to immediate exercise hyperemia. Previous in vivo investigations have exclusively examined rest-to-exercise (R-E) transitions where both the muscle pump and early vasodilator mechanisms may be activated. To isolate vasodilatory onset, the present study investigated the onset of exercise hyperemia in an exercise-to-exercise (E-E) transition, where no further increase in muscle pump contribution would occur. Eleven subjects lay supine and performed a step increase from rest to 3 min of mild (10% maximal voluntary contraction), rhythmic, dynamic forearm handgrip exercise, followed by a further step to moderate exercise (20% maximal voluntary contraction) in each of arm above ( condition A) or below ( condition B) heart level. Beat-by-beat measures of brachial arterial blood flow (Doppler ultrasound) and blood pressure (arterial tonometry) were performed. We observed an immediate increase in forearm vascular conductance in E-E transitions, and the magnitude of this increase matched that of the R-E transitions within each of the arm positions ( condition A: E-E, 52.8 ± 10.7 vs. R-E, 60.3 ± 11.7 ml·min−1·100 mmHg−1, P = 0.66; condition B: E-E, 43.2 ± 12.8 vs. R-E, 33.9 ± 8.2 ml·min−1·100 mmHg−1, P = 0.52). Furthermore, changes in forearm vascular conductance were identical between R-E and E-E transitions over the first nine contraction-relaxation cycles in condition A. The immediate and identical increase in forearm vascular conductance in R-E and E-E transitions within arm positions provides strong evidence that rapid vasodilation contributes to immediate exercise hyperemia in humans. Specific vasodilatory mechanisms responsible remain to be determined.

Objective To characterize youth who use the emergency department (ED) as a “first contact” for mental health (MH) problems. Method This was a population-based cross-sectional cohort study using linked health and demographic administrative datasets of youth 10 to 24 years of age with an incident MH ED visit from April 1, 2010, to March 31, 2014, in Ontario, Canada. We modeled the association of demographic, clinical, and health service use characteristics with having no prior outpatient MH care in the preceding 2-year period (“first contact”) using modified Poisson models. Results Among 118,851 youth with an incident mental health ED visit, 14.0% were admitted. More than half (53.5%) had no prior outpatient MH care, and this was associated with younger age (14−17 versus 22−24 years old: risk ratio [RR] = 1.09, 95% CI = 1.07−1.10), rural residence (RR = 1.16, 95% CI = 1.14−1.18), lowest versus highest income quintile (RR = 1.04, 95% CI = 1.03−1.06), and refugee immigrants (RR = 1.17, 95% CI = 1.13−1.21) and other immigrants (RR = 1.10, 95% CI = 1.08−1.13) versus nonimmigrants. The 5.1% of the cohort without a usual provider of primary care had the highest risk of first contact (RR = 1.78, 95% CI = 1.77−1.80). A history of low-acuity ED use and individuals whose primary care physicians were in the lowest tertile for mental health visit volumes were associated with higher risk. Conclusion More than half of youth requiring ED care had not previously sought outpatient MH care. Associations with multiple markers of primary care access characteristics suggest that timely primary care could prevent some of these visits.

Focal epithelial hyperplasia is a benign, papulo-nodular disease of the oral cavity. It is rare, affecting primarily Native American populations during childhood. It is closely associated with human papillomavirus 13 and 32. This report describes the diagnosis of 2 cases of focal epithelial hyperplasia in children from southern Guyana. The diagnosis was made using clinical criteria, polymerase chain reaction, and DNA sequencing.

We tested the hypothesis that vasoregulatory mechanisms completely counteract the effects of sudden changes in arterial perfusion pressure on exercising muscle blood flow. Twelve healthy young subjects (7 female, 5 male) lay supine and performed rhythmic isometric handgrip contractions (2 s contraction/ 2 s relaxation 30% maximal voluntary contraction). Forearm blood flow (FBF; echo and Doppler ultrasound), mean arterial blood pressure (arterial tonometry), and heart rate (ECG) were measured. Moving the arm between above the heart (AH) and below the heart (BH) level during contraction in steady-state exercise achieved sudden ∼30 mmHg changes in forearm arterial perfusion pressure (FAPP). We analyzed cardiac cycles during relaxation (FBFrelax). In an AH-to-BH transition, FBFrelax increased immediately, in excess of the increase in FAPP (∼69% vs. ∼41%). This was accounted for by pressure-related distension of forearm resistance vasculature [forearm vascular conductance (FVCrelax) increased by ∼19%]. FVCrelax was restored by the second relaxation. Continued slow decreases in FVCrelax stabilized by 2 min without restoring FBFrelax. In a BH-to-AH transition, FBFrelax decreased immediately, in excess of the decrease in FAPP (∼37% vs. ∼29%). FVCrelax decreased by ∼14%, suggesting pressure-related passive recoil of resistance vessels. The pattern of FVCrelax was similar to that in the AH-to-BH transition, and FBFrelax was not restored. These data support rapid myogenic regulation of vascular conductance in exercising human muscle but incomplete flow restoration via slower-acting mechanisms. Local arterial perfusion pressure is an important determinant of steady-state blood flow in the exercising human forearm.

We tested the hypothesis that vasoregulatory mechanisms exist in humans that can rapidly adjust muscle blood flow to repeated increases and decreases in exercise intensity. Six men and seven women (age, 24.4 ± 1.3 yr) performed continuous dynamic forearm handgrip contractions (1- to 2-s contraction-to-relaxation duty cycle) during repeated step increases and decreases in contraction intensity. Three step change oscillation protocols were examined: Slow (7 contractions per contraction intensity × 10 steps); Fast (2 contractions per contraction intensity × 15 steps); and Very Fast (1 contraction per contraction intensity × 15 steps). Forearm blood flow (FBF; Doppler and echo ultrasonography), heart rate (ECG), and mean arterial pressure (arterial tonometry) were examined for the equivalent of a cardiac cycle during each relaxation phase (FBFrelax). Mean arterial pressure and heart rate did not change during repeated step changes ( P = 0.352 and P = 0.190). For both Slow and Fast conditions, relaxation phase FBFrelaxadjusted immediately and repeatedly to both increases and decreases in contraction intensity, and the magnitude and time course of FBFrelaxchanges were virtually identical. For the Very Fast condition, FBFrelaxincreased with the first contraction and thereafter slowly increased over the course of repeated contraction intensity oscillations. We conclude that vasoregulatory mechanisms exist in human skeletal muscle that are capable of rapidly and repeatedly adjusting muscle blood flow with ongoing step changes in contraction intensity. Importantly, they demonstrate symmetry in response magnitude and time course with increasing versus decreasing contraction intensity but cannot adjust to very fast exercise intensity oscillations.

We sought to understand the nature of control mechanisms involved in the adaptation of exercising muscle hyperemia. Seven subjects performed rhythmic dynamic forearm exercise under two exercise conditions: small step 1 [step increase from rest to 40% peak forearm vascular conductance (FVC), in ml·min−1·100 mmHg−1] for 5 min followed by small step 2 (further increase to 80% peak FVC for 5 min), and large step (step increase from rest to 80% peak FVC for 5 min). FVC data were fit with a two- (small step 1) and three-component (small step 2, large step) exponential as appropriate. For the rapid phase I response, FVC dynamic response characteristics (time delay, time constant) were not affected by the magnitude of the work intensity increase when the transition began from rest, but were slower in the 40–80% transition. Rest-80% gain was greater than either rest-40% or 40–80% transitions but represented the same proportion of the phase I + phase II gain across all transitions (57 vs. 56 vs. 57%, respectively, P = 0.975). For the slower phase II response, dynamic response characteristics were not affected by the magnitude of the work intensity increase when initiated from rest. The time constant was not altered when the transition began from exercise vs. rest. We conclude that 1) dynamic response characteristics of exercise hyperemia control mechanisms are not affected by the magnitude of work rate increase when forearm exercise is initiated from rest, 2) phase I but not phase II dynamic response characteristics are sensitive to baseline exercise intensity, and 3) the mechanisms contributing to phase I result in the same relative response magnitude, regardless of the size of the step increase in exercise intensity or the baseline from which it is initiated.

We tested the hypothesis that rapid vasodilation proportional to contraction intensity contributes to the immediate (first cardiac cycle after initial contraction) exercise hyperemia. Ten healthy subjects performed single 1-s isometric forearm contractions at 5, 10, 15, 20, 30, 50, and 70% maximal voluntary contraction intensity (MVC) in arm above heart (AH) and below heart (BH) positions. Forearm blood flow (FBF; brachial artery mean blood velocity, Doppler ultrasound), mean arterial pressure (arterial tonometry), and heart rate (electrocardiogram) were measured beat by beat. Venous emptying (measured with a forearm strain gauge) was already maximized at 5% MVC, indicating that increases in contraction intensity did not further empty the forearm veins. Immediate increases in FBF were linearly proportional to contraction intensity from 5 to 70% MVC in AH (slope = 4.4 ± 0.5%ΔFBF/%MVC). In BH, the immediate increase in FBF demonstrated a curvilinear relationship with increasing contraction intensity and was greater than AH at 15, 20, 30, and 50% MVC ( P < 0.05). Peak changes in FBF were greater in BH vs. AH from 10 to 50% MVC, even when venous refilling was complete ( P < 0.05). These data support the existence of a rapid-acting vasodilatory mechanism(s) at the onset of human forearm exercise.

Objective To identify clinical and laboratory features predictive of osteomyelitis in children with sickle cell disease and bony pain. Design Patients in the case group and participants in the control group were randomized in a 1:3 ratio. Setting The Hospital for Sick Children, Toronto, Ontario, Canada. Participants Patients with sickle cell disease and osteomyelitis (case patients) and patients with sickle cell disease and bony, vaso-occlusive crisis (control patients), 18 years or younger. Main Outcome Measures Five characteristics (number of painful sites, white blood cell count, swelling of the affected limb[s], and duration of pain and fever before presentation) at the time of presentation to hospital. Results Data were analyzed for 31 cases and 93 controls. Compared with controls, cases had more days of pain (5 vs 2 days; odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.4 days) and fever (1 vs 0 day; 1.7; 1.2-2.4 days) before presentation. Cases were also more likely to have swelling of the affected limb(s) (71% vs 17%; OR, 11.8; 95% CI, 4.6%-30.0%) and fewer painful sites (1 vs 2; 0.7; 0.5-1.0). On laboratory evaluation, cases had higher white blood cell counts (18.6 vs 15.6/μL; OR, 1.1; 95% CI, 1.0-1.1/μL). Multivariate logistic regression showed that the significant predictors of osteomyelitis were duration of fever (OR, 1.8; 95% CI, 1.2-2.6) and pain (1.2; 1.0-1.4) before presentation and swelling of the affected limb (8.4; 3.5-20.0). The risk of osteomyelitis was decreased if more than 1 painful site was present (OR, 0.7; 95% CI, 0.5-1.0). Conclusion In the clinical scenario of a child with sickle cell disease presenting with bony pain and swelling affecting a single site, with prolonged fever and pain, the physician should consider closer monitoring and investigations to exclude a diagnosis of osteomyelitis.