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Persons with mental illnesses may experience stigma from their immediate family members in addition to other forms of stigma. Using semi-structured interviews, we investigated experiences of familial mental illness stigma among 15 people diagnosed with mental illnesses in a mid-sized city in Canada. We identified five themes that speak to participants' experiences of familial mental illness stigma and ways to reduce it. The themes include the following: diagnosis as a 'double-edged sword,' potential familial isolation, familial stigma as societal stigma localized, stories of acceptance, and confronting potential familial mental illness stigma. Participants' narratives indicate that familial mental illness stigma is rooted in the broader social or public stigma, which sees its way into familial relations as well. This stigma takes various forms, including relationship bias or unfair treatment, breakdown in romantic relationships, loss of status, verbal and emotional abuse, exclusion from decision-making, and alienation within their immediate and extended families. Familial mental illness stigma experiences negatively impact participant's psychological well-being and personal empowerment. However, participants also shared ways that family members create supportive environments or actively confront or prevent stigma. Overall, this study has contributed to knowledge on mental illness stigma, particularly familial mental illness stigma from the perspective of participants living with a mental illness in a high-income country. Suggestions for future research include a focus on strategies to prevent ongoing familial mental illness stigma and large-scale studies to explore familial mental illness stigma to understand why families might perpetrate stigma.

Objective: To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic., Design: In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents., Setting: Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170)., Main Outcome Measures: Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs., Results: The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses., Conclusions: COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A number of societies produce heart failure (HF) management guidelines, comprising official recommendations on the basis of recent research discoveries, but their applicability to specific situations encountered in daily practice might be difficult. In this clinical practice update we aim to provide responses to fundamental questions that face health care providers, like appropriate timing for the introduction and optimization of different classes of medication according to specific patient phenotypes, when second-line therapies and valvular interventions should be considered, and management of difficult clinical scenarios such as cardiorenal syndrome and frailty. A consensus-based methodology was used. Approaches to 5 different phenotypes are presented: (1) The wet HF phenotype is the easiest to manage, decongestion being performed alongside introduction of guideline-directed medical therapy (GDMT); (2) The de novo HF phenotype requires the introduction of the 4 pillars of GDMT, personalizing the order on the basis of the individuals' biological and physiological characteristics; (3) The worsening HF phenotype is a marker of poor prognosis, and therefore should motivate optimization of GDMT, start second-line therapies, and/or reevaluate goals of care/advanced HF therapies; (4) The cardiorenal phenotypes require correct volume assessment, because renal function usually improves with decongestion; and (5) The frail HF phenotype require special attention, careful drug titration, and consideration of cardiac rehabilitation programs. In conclusion, specific common HF phenotypes call for a personalized approach to improve adoption of the HF guidelines into clinical practice., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Indigenous-led, culturally safe health research and infrastructure are essential to address existing inequities and disparities for Indigenous Peoples globally. Biobanking, genomic research, and self-governance could reduce the existing divide and increase Indigenous participation in health research. While genomic research advances medicine, barriers persist for Indigenous patients to benefit. In northern BC, Canada, the Northern Biobank Initiative (NBI), with guidance from a Northern First Nations Biobank Advisory Committee (NFNBAC), has engaged in consultations with First Nations on biobanking and genomic research. Key informant interviews and focus groups conducted with First Nations leaders, Elders, Knowledge Keepers, and community members established culturally safe ways of biobanking and exploring genomic research. Strong support for a Northern British Columbia First Nations Biobank (NBCFNB) that will promote choice, inclusion, and access to health research opportunities emerged. The acceptance and enthusiasm for the development of this NBCFNB and its governance table highlight the shift towards Indigenous ownership and support of health research and its benefits. With engagement and partnership, community awareness, multigenerational involvement, and support from diverse and experienced healthcare leaders, the NBCFNB will establish this culturally safe, locally driven, and critically important research priority that may serve as an example for diverse Indigenous groups when designing their unique biobanking or genomic research opportunities.

Indigenous children and young people (hereafter youth) across CANZUS nations embody a rich diversity of cultures and traditions. Despite the immense challenges facing these youth, many harness cultural and personal strengths to protect and promote their wellbeing. To support this for all youth, it is critical to understand what contributes to their wellbeing. This review aims to identify components contributing to wellbeing for Indigenous youth in CANZUS nations. Five databases were searched from inception to August 2022. Papers were eligible if they: focused on Indigenous youth in CANZUS nations; included views of youth or proxies; and focused on at least one aspect of wellbeing. We identified 105 articles for inclusion (Canada n = 42, Australia n = 27, Aotearoa New Zealand n = 8, USA n = 28) and our analysis revealed a range of thematic areas within each nation that impact wellbeing for Indigenous youth. Findings highlight the unique challenges facing Indigenous youth, as well as their immense capacity to harness cultural and personal strengths to navigate into an uncertain future. The commonalities of Indigenous youth wellbeing across these nations provide valuable insights into how information and approaches can be shared across borders to the benefit of all Indigenous youth and future generations., Competing Interests: The authors declare no conflict of interest.

Objective: To compare end-of-life in-person family presence, patient-family communication and healthcare team-family communication encounters in hospitalised decedents before and during the COVID-19 pandemic., Design: In a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group., Setting: One quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada., Participants: Decedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170)., Main Outcome Measures: End-of-life (last 48 hours) in-person family presence and virtual (video) patient-family communication, and end-of-life (last 5 days) virtual team-family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team-family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs., Results: End-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2-0.73) and 0.09 (0.04-0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team-family communication encounters: IRRs=0.76 (0.64-0.9) and 0.61 (0.47-0.79) for in-person, and IRRs=2.6 (2.1-3.3) and 4.8 (3.7-6.1) for telephone communications, respectively. Virtual team-family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51-8.95)., Conclusions: In hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team-family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team-family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There are collective movements of Indigenous food sovereignty (IFS) initiatives taking up place and space within urban environments across the Grand River Territory, within southern Ontario, Canada. Indigenous Peoples living within urban centres are often displaced from their home territories and are seeking opportunities to reconnect with culture and identity through Land and food. This research was guided by Indigenous research methodologies and applied community-based participatory research to highlight experiences from seven Indigenous community members engaged in IFS programming and practice. Thematic analysis revealed four inter-related themes illustrated by a conceptual model: Land-based knowledge and relationships; Land and food-based practices; relational principles; and place. Participants engaged in five Land and food-based practices (seed saving; growing and gathering food; hunting and fishing; processing and preserving food; and sharing and distributing), guided by three relational principles (responsibility, relationality, and reciprocity), framed by the social and physical environments of the place. Key findings revealed that employing self-determined processes to grow, harvest, and share food among the Indigenous community provide pathways towards IFS. This study is the first to explore urban IFS initiatives within this region, offering a novel understanding of how these initiatives are taking shape within urban environments.

Despite the health improvements afforded to non-Indigenous peoples in Canada, Aotearoa (New Zealand) and the United States, the Indigenous peoples in these countries continue to endure disproportionately high rates of mortality and morbidity. Indigenous peoples' concepts and understanding of health and wellbeing are holistic; however, due to their diverse social, political, cultural, environmental and economic contexts within and across countries, wellbeing is not experienced uniformly across all Indigenous populations. We aim to identify aspects of wellbeing important to the Indigenous people in Canada, Aotearoa and the United States. We searched CINAHL, Embase, PsycINFO and PubMed databases for papers that included key Indigenous and wellbeing search terms from database inception to April 2020. Papers that included a focus on Indigenous adults residing in Canada, Aotearoa and the United States, and that included empirical qualitative data that described at least one aspect of wellbeing were eligible. Data were analysed using the stages of thematic development recommended by Thomas and Harden for thematic synthesis of qualitative research. Our search resulted in 2669 papers being screened for eligibility. Following full-text screening, 100 papers were deemed eligible for inclusion (Aotearoa (New Zealand) n = 16, Canada n = 43, United States n = 41). Themes varied across countries; however, identity , connection , balance and self-determination were common aspects of wellbeing. Having this broader understanding of wellbeing across these cultures can inform decisions made about public health actions and resources.

In this update of the Canadian Cardiovascular Society heart failure (HF) guidelines, we provide comprehensive recommendations and practical tips for the pharmacologic management of patients with HF with reduced ejection fraction (HFrEF). Since the 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of HF, substantial new evidence has emerged that has informed the care of these patients. In particular, we focus on the role of novel pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitors, sinus node inhibitors, sodium glucose transport 2 inhibitors, and soluble guanylate cyclase stimulators in conjunction with other long established HFrEF therapies. Updated recommendations are also provided in the context of the clinical setting for which each of these agents might be prescribed; the potential value of each therapy is reviewed, where relevant, for chronic HF, new onset HF, and for HF hospitalization. We define a new standard of pharmacologic care for HFrEF that incorporates 4 key therapeutic drug classes as standard therapy for most patients: an angiotensin receptor-neprilysin inhibitor (as first-line therapy or after angiotensin converting enzyme inhibitor/angiotensin receptor blocker titration); a β-blocker; a mineralocorticoid receptor antagonist; and a sodium glucose transport 2 inhibitor. Additionally, many patients with HFrEF will have clinical characteristics for which we recommended other key therapies to improve HF outcomes, including sinus node inhibitors, soluble guanylate cyclase stimulators, hydralazine/nitrates in combination, and/or digoxin. Finally, an approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The phase 3 FIRST trial demonstrated significant improvement in progression-free survival (PFS) and overall survival (OS) with an immune-stimulatory agent, lenalidomide, in combination with low-dose dexamethasone until disease progression (Rd continuous) vs melphalan +prednisone + thalidomide (MPT) in transplant-ineligible patients with newly diagnosed multiple myeloma (NDMM). Rd continuous similarly extended PFS vs fixed-duration Rd for 18 cycles (Rd18). Outcomes in the Canadian/US subgroup (104 patients per arm) are reported in this analysis. Rd continuous demonstrated a significant improvement in PFS vs MPT (median, 29.3 vs 20.2 months; HR, 0.69 [95% CI, 0.49-0.97]; p = 0.03326) and an improvement vs Rd18 (median, 21.9 months). Median OS was 56.9 vs 46.8 months with Rd continuous vs MPT (p = 0.15346) and 59.5 months with Rd18. The overall response rate was higher with Rd continuous and Rd18 (78.8% and 79.8%) vs MPT (65.4%). In the 49.0%, 52.9%, and 29.8% of patients with at least very good partial response in the Rd continuous, Rd18, and MPT arms, respectively, the median PFS was 56.0, 30.9, and 40.2 months, respectively. The most common grade 3/4 treatment-emergent adverse events were neutropenia (28.4%, 30.1%, and 52.0%), anemia (23.5%, 21.4%, and 23.5%), and infections (37.3%, 30.1%, and 24.5%) with Rd continuous, Rd18, and MPT, respectively. These results were consistent with those in the intent-to-treat population, confirming the benefit of Rd continuous vs MPT in the Canadian/US subgroup and supporting the role of Rd continuous as a standard of care for transplant-ineligible patients with NDMM., (© 2020 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Leeches of the family Erpobdellidae are important members of benthic freshwater environments, where they are voracious predators of other invertebrates and an important source of nutrition for several species of vertebrates. Beset by a lack of reliable diagnostic morphological characters and destructive identification processes, molecular approaches have, in recent years, been employed to illuminate the relationships within this family, and DNA barcoding has been employed for identification purposes. However, an understanding of the levels of genetic variation across the geographic distributions of members of the genus is still lacking. Herein, we sequence the mitochondrial COI locus for 249 newly collected North American individuals, representing 5 species, as well as mitochondrial 12S rDNA, nuclear 18S rDNA, and nuclear 28S rDNA for a select subset of these. Our COI dataset was leveraged to detect potential cryptic species, and to calculate genetic distances as a proxy for the degree of gene flow between populations. Augmented by numerous sequences from GenBank, the multilocus dataset was used to reconstruct a phylogenetic hypothesis for worldwide members of the genus. Beyond corroborating previous overarching phylogenetic frameworks, our results show that an undescribed species that is morphologically and genetically similar to Erpobdella punctata exists in sympatry with this species - the new species has likely been overlooked in previous studies due to its morphological similarity with Erpobdella punctata. Erpobdella bucera is reported from Canada for the first time; and Erpobdella microstoma is newly reported from Saskatchewan and placed in a phylogeny for the first time. Finally, we find evidence for genetic structure in both E. cf. punctata and Erpobdella obscura that is correlated with major river drainage basin boundaries in North America., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The torsion balance, an instrument that was first developed to demonstrate the high precision of physical science in the laboratory became a different sort of demonstration instrument in its brief vogue in the 1920s. This article considers intersecting stories of acquiring and testing the torsion balance as a field instrument in Canada, Britain and Australia. It examines the purchasing trip and fieldwork of A. H. Miller of the Dominion Observatory in 1928-1931, testing conducted by the British Geological Survey in 1926-1930, and finally the Imperial Geophysical Experimental Survey of 1928-1930 in Australia. These different stories produce a kind of collective biography, illustrating well the variety of material and textual records that accrete around instruments, especially expensive ones. But the trials and travels of the torsion balance also point to large themes. By comparing the different ways an instrument becomes valuable, and to whom, these micro-histories reveal significant features of the developing identity of geophysics. They also show the interaction of different forms of scientific internationalism in the inter-war period.

Background: Cancer 'patients' are increasingly using traditional indigenous and complementary medicines (T&CM) alongside conventional medical treatments to both cure and cope with their cancer diagnoses. To date T&CM use among Indigenous cancer patients from Australia, Canada, New Zealand, and the United States has not been systematically reviewed., Methods: We systematically searched bibliographic databases to identify original research published between January 2000 and October 2017 regarding T&CM use by Indigenous cancer patients in Australia, Canada, New Zealand, and the United States. Data from records meeting eligibility criteria were extracted and appraised for quality by 2 independent reviewers., Results: Twenty-one journal articles from 18 studies across all 4 countries met our inclusion criteria. T&CM use ranged from 19% to 57.7% (differing across countries). T&CM was mostly used concurrently with conventional cancer treatments to meet their spiritual, emotional, social, and cultural needs; however, bush, traditional, and herbal medicines were used in a minority of cases as an alternative., Conclusions: Our findings highlight the importance of T&CM use to Indigenous cancer patients across these 4 countries; we identified multiple perceived spiritual, emotional and cultural benefits to its use. The patient's perception of their health professional's attitudes toward T&CM in some cases hindered or encouraged the patient's disclosure. Additional research is required to further explore the use and disclosure of T&CM among Indigenous cancer patients to help inform and ensure effective, safe, coordinated care for Indigenous cancer patients that relies on shared open decision making and communication across patients, communities, and providers.

Unlabelled: Environment and Climate Change Canada's FireWork air quality (AQ) forecast system for North America with near-real-time biomass burning emissions has been running experimentally during the Canadian wildfire season since 2013. The system runs twice per day with model initializations at 00 UTC and 12 UTC, and produces numerical AQ forecast guidance with 48-hr lead time. In this work we describe the FireWork system, which incorporates near-real-time biomass burning emissions based on the Canadian Wildland Fire Information System (CWFIS) as an input to the operational Regional Air Quality Deterministic Prediction System (RAQDPS). To demonstrate the capability of the system we analyzed two forecast periods in 2015 (June 2-July 15, and August 15-31) when fire activity was high, and observed fire-smoke-impacted areas in western Canada and the western United States. Modeled PM2.5 surface concentrations were compared with surface measurements and benchmarked with results from the operational RAQDPS, which did not consider near-real-time biomass burning emissions. Model performance statistics showed that FireWork outperformed RAQDPS with improvements in forecast hourly PM2.5 across the region; the results were especially significant for stations near the path of fire plume trajectories. Although the hourly PM2.5 concentrations predicted by FireWork still displayed bias for areas with active fires for these two periods (mean bias [MB] of -7.3 µg m(-3) and 3.1 µg m(-3)), it showed better forecast skill than the RAQDPS (MB of -11.7 µg m(-3) and -5.8 µg m(-3)) and demonstrated a greater ability to capture temporal variability of episodic PM2.5 events (correlation coefficient values of 0.50 and 0.69 for FireWork compared to 0.03 and 0.11 for RAQDPS). A categorical forecast comparison based on an hourly PM2.5 threshold of 30 µg m(-3) also showed improved scores for probability of detection (POD), critical success index (CSI), and false alarm rate (FAR)., Implications: Smoke from wildfires can have a large impact on regional air quality (AQ) and can expose populations to elevated pollution levels. Environment and Climate Change Canada has been producing operational air quality forecasts for all of Canada since 2009 and is now working to include near-real-time wildfire emissions (NRTWE) in its operational AQ forecasting system. An experimental forecast system named FireWork, which includes NRTWE, has been undergoing testing and evaluation since 2013. A performance analysis of FireWork forecasts for the 2015 wildfire season shows that FireWork provides significant improvements to surface PM2.5 forecasts and valuable guidance to regional forecasters and first responders.

Background: The Selenium and Vitamin E Cancer Prevention Trial (SELECT) was a randomized, double-blind, placebo-controlled prostate cancer prevention study funded by the National Cancer Institute (NCI) and conducted by the Southwest Oncology Group (SWOG). A total of 35,533 men were assigned randomly to one of the four treatment groups (vitamin E + placebo, selenium + placebo, vitamin E + selenium, and placebo + placebo). The independent Data and Safety Monitoring Committee (DSMC) recommended the discontinuation of study supplements because of the lack of efficacy for risk reduction and because futility analyses demonstrated no possibility of benefit of the supplements to the anticipated degree (25% reduction in prostate cancer incidence) with additional follow-up. Study leadership agreed that the randomized trial should be terminated but believed that the cohort should be maintained and followed as the additional follow-up would contribute important information to the understanding of the biologic consequences of the intervention. Since the participants no longer needed to be seen in person to assess acute toxicities or to be given study supplements, it was determined that the most efficient and cost-effective way to follow them was via a central coordinated effort., Purpose: A number of changes were necessary at the local Study Sites and SELECT Statistical Center to transition to following participants via a Central Coordinating Center. We describe the transition process from a randomized clinical trial to the observational Centralized Follow-Up (CFU) study., Methods: The process of transitioning SELECT, implemented at more than 400 Study Sites across the United States, Canada, and Puerto Rico, entailed many critical decisions and actions including updates to online documents such as the SELECT Workbench and Study Manual, a protocol amendment, reorganization of the Statistical Center, creation of a Transition Committee, development of materials for SELECT Study Sites, development of procedures to close Study Sites, and revision of data collection procedures and the process by which to contact participants., Results: At the time of the publication of the primary SELECT results in December 2008, there were 32,569 men alive and currently active in the trial. As of 31 December 2011, 17,761 participants had been registered to the CFU study. This number is less than had been anticipated due to unforeseen difficulties with local Study Site institutional review boards (IRBs). However, from this cohort, we estimate that an additional 580 prostate cancer cases and 215 Gleason 7 or higher grade cancers will be identified. Over 109,000 individual items have been mailed to participants. Active SELECT ancillary studies have continued. The substantial SELECT biorepository is available to researchers; requests to use the specimens are reviewed for feasibility and scientific merit. As of April 2012, 12 proposals had been approved., Limitations: The accrual goal of the follow-up study was not met, limiting our power to address the study objectives satisfactorily. The CFU study is also dependent on a number of factors including continued funding, continued interest of investigators in the biorepository, and the continued contribution of the participants. Our experience may be less pertinent to investigators who wish to follow participants in a treatment trial or participants in prevention trials in other medical areas., Conclusions: Extended follow-up of participants in prevention research is important to study the long-term effects of the interventions, such as those used in SELECT. The approach taken by SELECT investigators was to continue to follow participants centrally via an annual questionnaire and with a web-based option. The participants enrolled in the CFU study represent a large, well-characterized, generally healthy cohort. The CFU has enabled us to collect additional prostate and other cancer endpoints and longer follow-up on the almost 18,000 participants enrolled. The utility of the extensive biorepository that was developed during the course of the SELECT is enhanced by longer follow-up.

The isolation of human coronavirus NL63 (HCoV-NL63) in The Netherlands raised questions about its contribution to respiratory illness. In this study, a total of 525 respiratory specimens, collected in Canada primarily during the winter months of 2001-2002, were tested for HCoV-NL63; 19 tested positive for HCoV-NL63, demonstrating virus activity during January-March 2002. Patients with HCoV-NL63 were 1 month-100 years old (median age, 37 years). The main clinical presentations were fever (15/19), sore throat (5/19), and cough (9/19), and 4 patients were hospitalized. These results provide evidence for the worldwide distribution of HCoV-NL63.

Changes in health services and care needs have created high demand for case management of in-home services. To address this challenge, several models of case management have been used. Evaluations to date suggest that clients need different approaches for different circumstances at different times to optimize cost-effectiveness. Accordingly, one Canadian home care program adopted flexible client-driven case management engaging clients as partners in flexibly selecting either an integrated team, consumer-managed or brokerage model of case management in keeping with their preferences and abilities. Using an exploratory, multimeasure quasi-experimental design, a generic model of program evaluation, and both quantitative and qualitative methods, researchers identified challenges in implementing this intervention, policy impediments the clients characteristically in each of the three case management models, and client, provider, and caregiver outcomes of flexible, client-driven care. While further longitudinal investigation is needed findings suggest several important considerations for those interested in this option for care management. Alternative case management models do attract different client groups, and having a choice does not alter care costs or outcomes. Flexible client-driven case management may be experienced positively by case managers and other providers.

The issue of gestational diabetes mellitus within disadvantaged communities is being addressed by Healthy Start for Mom & Me, a highly collaborative and multi-faceted prenatal nutrition program targeting at-risk women and teens in Winnipeg, Manitoba. The program s kitchen table approach focuses on the core concepts of education, community participation, and capacity-building to develop effective methods for community-based practice in this population. A qualitative case study of the program was conducted in 1999. This study showed that health education practices in the program are sensitive to marginalized women s needs and enhance service providers understanding of the context of participants lives. Community dietitians roles in this prenatal program are evolving, and are significant for other dietitians charting a new course of community-based practice.

Objective: To estimate the incidence and prevalence of type I diabetes among Manitoba children aged 0-14 years from 1985-1993., Research Design and Methods: The Manitoba Diabetes Database (a population-based database of individuals diagnosed with diabetes based on Manitoba's health insurance system) was used to estimate the annual incidence of diabetes for the years 1985-1993 and the point prevalence of diabetes at 31 March 1993 for Manitoba children aged 0-14 years. The Diabetes Education Resource for Children and Adolescents program database was used to correct incidence and prevalence rates for ascertainment using the two-source capture-recapture method., Results: The overall ascertainment rate of the Manitoba Diabetes Database was 95% for incident cases and 93% for prevalent cases. The average annual incidence was 20.4 per 100,000 for children aged 0-14 years. The annual incidence appears to be stable for all age-groups 0-14 years over the past decade. The point prevalence of diabetes among children was 120.4 per 100,000., Conclusions: The incidence of type I diabetes in children aged 0-14 years in Manitoba is higher than reported previously in other urban regions of Canada, but similar to population-based estimates from Prince Edward Island. The incidence appears stable in Manitoba over the past decade even in the 0-4 year age-group. The Manitoba Diabetes Database appears to be a highly accurate population-based source of data on the epidemiology of diabetes in children.