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Hetherington E, Darling E, Harper S, Nguyen F, Schummers L, Norman WV. Inequalities in access to prenatal care during the COVID-19 pandemic: Analysis of a population-based cohort. Paediatr Perinat Epidemiol 2024. [PMID: 38339962 DOI: 10.1111/ppe.13050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Before the COVID-19 pandemic, access to prenatal care was lower among some socio-demographic groups. This pandemic caused disruptions to routine preventative care, which could have increased inequalities. OBJECTIVES To investigate if the COVID-19 pandemic increased inequalities in access to prenatal care among those who are younger, live in rural areas, have a lower socio-economic situation (SES) and are recent immigrants. METHODS We used linked administrative datasets from ICES to identify a population-based cohort of 455,245 deliveries in Ontario from January 2018 to December 2021. Our outcomes were first-trimester prenatal visits, first-trimester ultrasound and adequacy of prenatal care. We used joinpoint analysis to examine outcome time trends and identify trend change points. We stratified analyses by age, rural residence, SES and recent immigration, and examined risk differences (RD) with 95% confidence intervals (CI) between groups at the beginning and end of the study period. RESULTS For all outcomes, we noted disruptions to care beginning in March or April 2020 and returning to previous trends by November 2020. Inequalities were stable across groups, except recent immigrants. In July 2017, 65.0% and 69.8% of recent immigrants and non-immigrants, respectively, received ultrasounds in the first trimester (RD -4.8%, 95% CI -8.0, -1.5). By October 2020, this had increased to 75.4%, with no difference with non-immigrants (RD 0.4%, 95% CI -2.4, 3.2). Adequacy of prenatal care showed more intensive care as of November 2020, reflecting a higher number of visits. CONCLUSIONS We found no evidence that inequalities between socio-economic groups that existed prior to the pandemic worsened after March 2020. The pandemic may be associated with increased access to care for recent immigrants. The introduction of virtual visits may have resulted in a higher number of prenatal care visits.
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Affiliation(s)
- Erin Hetherington
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Quebec, Canada
- ICES McMaster, Hamilton, Ontario, Canada
| | - Elizabeth Darling
- ICES McMaster, Hamilton, Ontario, Canada
- McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Sam Harper
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Quebec, Canada
| | | | - Laura Schummers
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
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Murray-Davis B, Grenier LN, Mattison C, Malott AM, Cameron C, Li J, Darling E, Hutton EK. Mediating expectations and experiences that influence birth experiences in Canada's first Alongside Midwifery Unit. Birth 2023; 50:968-977. [PMID: 37485759 DOI: 10.1111/birt.12744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 10/28/2022] [Accepted: 06/24/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Globally, midwifery-led birthing units are associated with excellent maternal and neonatal outcomes, and positive childbirth experiences. However, little is known about what aspects of midwife-led units contribute to favorable experiences and overall satisfaction. Our aim was to explore and describe midwifery service user experiences at Canada's first Alongside Midwifery Unit (AMU). METHODS We used a qualitative, grounded theory approach using semi-structured interviews with recipients of midwifery care at the AMU. FINDINGS Data were collected from twenty-eight participants between September 2018 and March 2020. Our generated theory explains how birth experiences and satisfaction were influenced by how well the AMU aligned with expectations or desired experiences related to the following four themes: (1) maintaining the midwifery model of care, (2) emphasizing control and choice, (3) facilitating interprofessional relationships, and (4) appreciating the unique AMU birthing environment. CONCLUSION Canada's first AMU met or exceeded service-user expectations, resulting in high levels of satisfaction with their birth experience. Maintaining core elements of the midwifery model of care, promoting high levels of autonomy, and facilitating positive interprofessional interactions are crucial elements contributing to childbirth satisfaction in the AMU environment.
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Affiliation(s)
- Beth Murray-Davis
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
| | - Lindsay N Grenier
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
| | - Cristina Mattison
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
| | - Anne M Malott
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
- Markham Stouffville Alongside Midwifery Unit, Markham, Ontario, Canada
| | - Carol Cameron
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
- Markham Stouffville Alongside Midwifery Unit, Markham, Ontario, Canada
| | - Jenifer Li
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth Darling
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
| | - Eileen K Hutton
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Center, McMaster University, Hamilton, Ontario, Canada
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Vanstone M, Correia RH, Howard M, Darling E, Bayrampour H, Carruthers A, Davis A, Hadid D, Hetherington E, Jones A, Kandasamy S, Kuyvenhoven C, Liauw J, McDonald SD, Mniszak C, Molinaro ML, Pahwa M, Patel T, Sadik M, Sanya N, Shen K, Greyson D. How do perceptions of Covid-19 risk impact pregnancy-related health decisions? A convergent parallel mixed-methods study protocol. PLoS One 2023; 18:e0288952. [PMID: 37561748 PMCID: PMC10414672 DOI: 10.1371/journal.pone.0288952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Pregnant people have a higher risk of severe COVID-19 disease. They have been disproportionately impacted by COVID-19 infection control policies, which exacerbated conditions resulting in intimate partner violence, healthcare access, and mental health distress. This project examines the impact of accumulated individual health decisions and describes how perinatal care and health outcomes changed during the COVID-19 pandemic. OBJECTIVES Quantitative strand: Describe differences between 2019, 2021, and 2022 birth groups related to maternal vaccination, perinatal care, and mental health care. Examine the differential impacts on racialized and low-income pregnant people.Qualitative strand: Understand how pregnant people's perceptions of COVID-19 risk influenced their decision-making about vaccination, perinatal care, social support, and mental health. METHODS AND ANALYSIS This is a Canadian convergent parallel mixed-methods study. The quantitative strand uses a retrospective cohort design to assess birth group differences in rates of Tdap and COVID-19 vaccination, gestational diabetes screening, length of post-partum hospital stay, and onset of depression, anxiety, and adjustment disorder, using administrative data from ICES, formerly the Institute for Clinical Evaluative Sciences (Ontario) and PopulationData BC (PopData) (British Columbia). Differences by socioeconomic and ethnocultural status will also be examined. The qualitative strand employs qualitative description to interview people who gave birth between May 2020- December 2021 about their COVID-19 risk perception and health decision-making process. Data integration will occur during design and interpretation. ETHICS AND DISSEMINATION This study received ethical approval from McMaster University and the University of British Columbia. Findings will be disseminated via manuscripts, presentations, and patient-facing infographics. TRIAL REGISTRATION Registration: Clinicaltrials.gov registration number: NCT05663762.
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Affiliation(s)
- Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Rebecca H. Correia
- Health Research Methodology Graduate Program, McMaster University, Hamilton, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Elizabeth Darling
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - Hamideh Bayrampour
- Department of Family Practice, Midwifery Program, University of British Columbia, University Endowment Lands, Canada
| | - Andrea Carruthers
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Amie Davis
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Dima Hadid
- Health Policy PhD Program, McMaster University, Hamilton, Canada
| | - Erin Hetherington
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sujane Kandasamy
- Department of Child and Youth Health, Brock University, St. Catharines, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Jessica Liauw
- Department of Obstetrics and Gynecology, University of British Columbia, University Endowment Lands, Canada
| | - Sarah D. McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Radiology, McMaster University, Hamilton, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada
| | - Caroline Mniszak
- School of Population and Public Health, University of British Columbia, University Endowment Lands, Canada
| | | | - Manisha Pahwa
- Health Policy PhD Program, McMaster University, Hamilton, Canada
| | - Tejal Patel
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Marina Sadik
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Njideka Sanya
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Katrina Shen
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Devon Greyson
- School of Population and Public Health, University of British Columbia, University Endowment Lands, Canada
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Robinson C, Schlorff M, Chanchlani R, Gayowsky A, Darling E, Mondal T, Seow H, Batthish M. Cardiovascular Outcomes During Index Hospitalization in Children with Kawasaki Disease in Ontario, Canada. Pediatr Cardiol 2023; 44:681-688. [PMID: 36074151 DOI: 10.1007/s00246-022-02997-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
Kawasaki disease (KD) is a common childhood vasculitis associated with coronary artery aneurysms (CAA). However, there is limited published data on other cardiovascular events diagnosed during acute KD hospitalizations. Our objectives were to determine the incidence of cardiovascular events during acute KD hospitalizations, stratified by age at admission, CAA status, and pediatric intensive care unit (PICU) admission status. We identified all children (0-18 year) hospitalized with a new KD diagnosis in Ontario, between 1995 and 2018, through validated algorithms using population health administrative databases. We excluded children previously diagnosed with KD and non-Ontario residents. We evaluated for cardiovascular events that occurred during the acute KD hospitalizations, defined by administrative coding. Among 4597 children hospitalized with KD, 3307 (71.9%) were aged 0-4 years, median length of stay was 3 days (IQR 2-4), 113 children (2.5%) had PICU admissions, and 119 (2.6%) were diagnosed with CAA. During acute hospitalization, 75 children were diagnosed with myocarditis or pericarditis (1.6%), 47 with arrhythmias (1.0%), 25 with heart failure (0.5%), and ≤ 5 with acute MI (≤ 0.1%). Seven children underwent cardiovascular procedures (0.2%). Older children (10-18 years), children with CAA, and children admitted to the PICU were more likely to experience cardiovascular events, compared with children aged 0-4 years, without CAA or non-PICU admissions, respectively. The frequency of non-CAA cardiovascular events during acute KD hospitalizations did not change significantly between 1995 and 2018. During acute KD hospitalizations, older children, children with CAA, and PICU admissions are at higher risk of cardiovascular complications, justifying closer monitoring of these high-risk individuals.
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Affiliation(s)
- Cal Robinson
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Megan Schlorff
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Elizabeth Darling
- McMaster Midwifery Research Centre, McMaster University, Hamilton, ON, Canada
| | - Tapas Mondal
- Division of Cardiology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Michelle Batthish
- Division of Rheumatology, Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
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Ricci C, Otterman V, Bennett TL, Metcalfe S, Darling E, Semenic S, Dzakpasu S. Rates of and factors associated with exclusive and any breastfeeding at six months in Canada: an analysis of population-based cross-sectional data. BMC Pregnancy Childbirth 2023; 23:56. [PMID: 36690995 PMCID: PMC9869293 DOI: 10.1186/s12884-023-05382-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/16/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Breastfeeding has many health, economic and environmental benefits for both the infant and pregnant individual. Due to these benefits, the World Health Organization and Health Canada recommend exclusive breastfeeding for the first six months of life. The purpose of this study is to examine the prevalence of exclusive and any breastfeeding in Canada for at least six months, and factors associated with breastfeeding cessation prior to six months. METHODS We performed a secondary analysis of breastfeeding-related questions asked on the cross-sectional 2017-2018 Canadian Community Health Survey. Our sample comprised 5,392 females aged 15-55 who had given birth in the five years preceding the survey. Descriptive statistics were carried out to assess the proportion of females exclusively breastfeeding and doing any breastfeeding for at least six months by demographic and behavioural factors. We also assessed, by baby's age, trends in the introduction of solids and liquids, breastfeeding cessation and the reasons females stopped breastfeeding. Multivariate log binominal regression was used to examine the association between breastfeeding at six months and selected maternal characteristics hypothesized a priori to be associated with breastfeeding behaviour. RESULTS Overall, for at least six months, 35.6% (95% confidence interval (CI): 33.3%-37.8%) of females breastfed exclusively and 62.2% (95% CI: 60.0%-64.4%) did any breastfeeding. The largest decline in exclusive breastfeeding occurred in the first month. Factors most strongly associated with breastfeeding for at least six months were having a bachelor's or higher degree, having a normal body mass index, being married and daily co-sleeping. Insufficient milk supply was given as the most common reason for breastfeeding cessation irrespective of when females stopped breastfeeding. CONCLUSION Six-month exclusive breastfeeding rates in Canada remain below targets set by the World Health Assembly. Continued efforts, including investment in monitoring of breastfeeding rates, are needed to promote and support exclusive breastfeeding, especially among females vulnerable to early cessation.
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Affiliation(s)
- Christina Ricci
- grid.415368.d0000 0001 0805 4386Lifespan Chronic Disease and Conditions Division, Public Health Agency of Canada, Ottawa, ON Canada
| | - Victoria Otterman
- grid.415368.d0000 0001 0805 4386Lifespan Chronic Disease and Conditions Division, Public Health Agency of Canada, Ottawa, ON Canada
| | - Terri-Lyn Bennett
- grid.415368.d0000 0001 0805 4386Lifespan Chronic Disease and Conditions Division, Public Health Agency of Canada, Ottawa, ON Canada
| | - Stephanie Metcalfe
- grid.415368.d0000 0001 0805 4386Lifespan Chronic Disease and Conditions Division, Public Health Agency of Canada, Ottawa, ON Canada
| | - Elizabeth Darling
- grid.25073.330000 0004 1936 8227Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON Canada
| | - Sonia Semenic
- grid.14709.3b0000 0004 1936 8649Ingram School of Nursing, McGill University, Montreal, QC Canada
| | - Susie Dzakpasu
- grid.415368.d0000 0001 0805 4386Lifespan Chronic Disease and Conditions Division, Public Health Agency of Canada, Ottawa, ON Canada
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Bourret K, Mattison C, Hebert E, Kabeya A, Simba S, Crangle M, Darling E, Robinson J. Evidence-informed framework for gender transformative continuing education interventions for midwives and midwifery associations. BMJ Glob Health 2023; 8:bmjgh-2022-011242. [PMID: 36634981 PMCID: PMC9843202 DOI: 10.1136/bmjgh-2022-011242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Continuing education for midwives is an important investment area to improve the quality of sexual and reproductive health services. Interventions must take into account and provide solutions for the systemic barriers and gender inequities faced by midwives. Our objective was to generate concepts and a theoretical framework of the range of factors and gender transformative considerations for the development of continuing education interventions for midwives. METHODS A critical interpretive synthesis complemented by key informant interviews, focus groups, observations and document review was applied. Three electronic bibliographic databases (CINAHL, EMBASE and MEDLINE) were searched from July 2019 to September 2020 and were again updated in June 2021. A coding structure was created to guide the synthesis across the five sources of evidence. RESULTS A total of 4519 records were retrieved through electronic searches and 103 documents were included in the critical interpretive synthesis. Additional evidence totalled 31 key informant interviews, 5 focus groups (Democratic Republic of Congo and Tanzania), 24 programme documents and field observations in the form of notes. The resulting theoretical framework outlines the key considerations including gender, the role of the midwifery association, political and health systems and external forces along with key enabling elements for the design, implementation and evaluation of gender transformative continuing education interventions. CONCLUSION Investments in gender transformative continuing education for midwives, led by midwifery associations, can lead to the improvement of midwifery across all United Nations' target areas including governance, health workforce, health system arrangements and education.
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Affiliation(s)
- Kirsty Bourret
- Women and Children's Health, Karolinska Institute, Stockholm, Sweden .,McMaster Midwifery Research Center, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Cristina Mattison
- Women and Children's Health, Karolinska Institute, Stockholm, Sweden,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Emmanuelle Hebert
- Bureau des relations internationales, Université du Québec à Trois-Rivières, Trois-Rivieres, Quebec, Canada
| | - Ambrocckha Kabeya
- Société Congolaise de la Pratique Sage-femme, Kinshasa, Democratic Republic of the Congo
| | - Stephano Simba
- Tanzania Midwives Association (TAMA), Dar es Salaam, United Republic of Tanzania
| | - Moya Crangle
- Canadian Association of Midwives, Montreal, Quebec, Canada
| | - Elizabeth Darling
- Obstetrics and Gynecology, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Jamie Robinson
- Canadian Association of Midwives, Montreal, Quebec, Canada
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7
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Popoola A, Panday J, Taneja S, Greyson D, McDonald SD, Patel T, Darling E, Vanstone M. Pregnant and lactating people's strategies to mitigate the risk of cannabis consumption. Womens Health (Lond) 2023; 19:17455057231202406. [PMID: 37776037 PMCID: PMC10541750 DOI: 10.1177/17455057231202406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Multiple studies have demonstrated that pregnant and lactating people who use cannabis perceive a variety of benefits from that use, offering some explanation of why rates of use continue to increase. OBJECTIVES The aim of this study was to explore pregnant and lactating people's perceptions of the risks of cannabis use and understand what steps, if any, they take to mitigate these risks. DESIGN Qualitative description. METHODS We analyzed semi-structured interviews with 52 Canadians who made the decision to start, stop, or continue using cannabis during pregnancy or lactation between 2019 and 2021. Data collection iterated with analysis. We used a conventional (inductive) approach to content analysis. RESULTS Perception of risk was found to be an essential component of decision-making about cannabis use. We identified a cycle of "risk identification," "management," and "observation" of effects. First, the pregnant or lactating person assesses the risks and weighs them against the perceived benefits of cannabis use. Second, they take action to minimize risks, with some choosing abstinence. Others, often those who were using cannabis to manage symptoms, continued cannabis use but devised a variety of other risk mitigation strategies such as, decreasing the amount or frequency of their use, changing the form of cannabis, and strategically timing their use with caregiving responsibilities. The final stage of the cycle involves seeking information about whether or not the initial perceived risk has manifested after implementing mitigation strategies, through observations and clinical information about the pregnancy or child. CONCLUSION Participants consistently engaged in deliberation about the risks and benefits associated with their perinatal cannabis use. Nearly all implemented strategies intended to minimize risk. Our results highlight the need for more research to inform clear public health messaging about risk mitigation to minimize the potential harms of perinatal cannabis use. This work informs clinicians about patient-perceived risks and mitigation strategies which could in turn help inform shared decision-making conversations.
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Affiliation(s)
- Anuoluwa Popoola
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Janelle Panday
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Shipra Taneja
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Devon Greyson
- Department of Communication, University of Massachusetts Amherst, Amherst, MA, USA
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Sarah D. McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Radiology and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Tejal Patel
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Elizabeth Darling
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
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Norman WV, Darling E, Kaczorowski J, Dunn S, Schummers L, Law M, McGrail K. P031Mifepristone as a normal prescription rapidly increased rural and urban providers. Contraception 2022. [DOI: 10.1016/j.contraception.2022.09.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Panday J, Taneja S, Popoola A, Pack R, Greyson D, McDonald SD, Black M, Murray-Davis B, Darling E, Vanstone M. Correction to: Clinician responses to cannabis use during pregnancy and lactation: a systematic review and integrative mixed-methods research synthesis. Fam Pract 2022; 39:1000. [PMID: 35348677 PMCID: PMC9508872 DOI: 10.1093/fampra/cmac021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Janelle Panday
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Shipra Taneja
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Anuoluwa Popoola
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Rachael Pack
- Center for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Devon Greyson
- Department of Communication, University of Massachusetts Amherst, Amherst, United States.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Sarah D McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada.,Department of Radiology, McMaster University, Hamilton, Canada
| | - Morgan Black
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Beth Murray-Davis
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.,Department of Obstetrics and Gynecology, McMaster Midwifery Research Centre, McMaster University, Hamilton, Canada
| | - Elizabeth Darling
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada.,Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.,Department of Obstetrics and Gynecology, McMaster Midwifery Research Centre, McMaster University, Hamilton, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Canada
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Panday J, Taneja S, Popoola A, Pack R, Greyson D, McDonald SD, Black M, Murray-Davis B, Darling E, Vanstone M. Clinician responses to cannabis use during pregnancy and lactation: a systematic review and integrative mixed-methods research synthesis. Fam Pract 2022; 39:504-514. [PMID: 34791187 PMCID: PMC9155166 DOI: 10.1093/fampra/cmab146] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Perinatal cannabis use is increasing, and clinician counselling is an important aspect of reducing the potential harm of cannabis use during pregnancy and lactation. To understand current counselling practices, we conducted a systematic review and integrative mixed-methods synthesis to determine "how do perinatal clinicians respond to pregnant and lactating patients who use cannabis?" METHODS We searched 6 databases up until 2021-05-31. Eligible studies described the attitudes, perceptions, or beliefs of perinatal clinician about cannabis use during pregnancy or lactation. Eligible clinicians were those whose practice particularly focusses on pregnant and postpartum patients. The search was not limited by study design, geography, or year. We used a convergent integrative analysis method to extract relevant findings for inductive analysis. RESULTS Thirteen studies were included; describing perspectives of 1,366 clinicians in 4 countries. We found no unified approach to screening and counselling. Clinicians often cited insufficient evidence around the effects of perinatal cannabis use and lacked confidence in counselling about use. At times, this meant clinicians did not address cannabis use with patients. Most counselled for cessation and there was little recognition of the varied reasons that patients might use cannabis, and an over-reliance on counselling focussed on the legal implications of use. CONCLUSION Current approaches to responding to cannabis use might result in inadequate counselling. Counselling may be improved through increased education and training, which would facilitate conversations to mitigate the potential harm of perinatal cannabis use while recognizing the benefits patients perceive.
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Affiliation(s)
- Janelle Panday
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Shipra Taneja
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Anuoluwa Popoola
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Rachael Pack
- Center for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Devon Greyson
- Department of Communication, University of Massachusetts Amherst, Amherst, United States.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Sarah D McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada.,Department of Radiology, McMaster University, Hamilton, Canada
| | - Morgan Black
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Beth Murray-Davis
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.,Department of Obstetrics and Gynecology, McMaster Midwifery Research Centre, McMaster University, Hamilton, Canada
| | - Elizabeth Darling
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada.,Department of Obstetrics and Gynecology, McMaster University, Hamilton, Canada.,Department of Obstetrics and Gynecology, McMaster Midwifery Research Centre, McMaster University, Hamilton, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Canada
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11
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Norman W, Darling E, Dunn S, Law M, Kaczorowski J, Schummers L, McGrail K. Mifepristone’s Effect on the Abortion Workforce and Rural Services in Ontario. Journal of Obstetrics and Gynaecology Canada 2022. [DOI: 10.1016/j.jogc.2022.02.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Vanstone M, Panday J, Popoola A, Taneja S, Greyson D, McDonald SD, Pack R, Black M, Murray-Davis B, Darling E. Pregnant People's Perspectives On Cannabis Use During Pregnancy: A Systematic Review and Integrative Mixed-Methods Research Synthesis. J Midwifery Womens Health 2022; 67:354-372. [PMID: 35445514 PMCID: PMC9324983 DOI: 10.1111/jmwh.13363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 11/28/2022]
Abstract
Introduction Rates of perinatal cannabis use are rising, despite clinical evidence about the potential for harm. Accordingly, pregnant and lactating people who perceive a benefit from cannabis use may have a difficult time making informed decisions about cannabis use. Methods We conducted a systematic review of mixed‐methods research to synthesize existing knowledge on the perspectives of pregnant people and their partners about cannabis use in pregnancy. Six health and social science databases were searched up until May 30, 2021. There were no methodological, time, or geographic limits applied. We employed a convergent integrative approach to the inductive analysis of findings from all studies. Results We identified 26 studies describing views of 17,781 pregnant and postpartum people about cannabis use in pregnancy. No studies describing the views of partners were identified, and only one study specifically addressed the perspectives of lactating people. Comparative analysis revealed that whether cannabis was studied alone or grouped with other substances resulted in significant diversity in descriptions of participant decision‐making priorities and perceptions of risks and benefits. Studies of cannabis alone demonstrated a complex decision‐making process whereby perceived benefits are balanced against the available information about risk, which is often unclear and uncertain. Clear and helpful information was difficult to identify, and health care providers were not described as a helpful and trusted resource for decision‐making. Discussion Decision‐making about cannabis use is difficult for pregnant and lactating people who perceive a benefit from this use, although this decisional difficulty is seldom reflected in studies that examine cannabis as one of multiple substances that pregnant or lactating people may use. Our review suggests several approaches clinicians may take to encourage open and supportive conversations to facilitate informed decisions about cannabis use during the perinatal period.
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Affiliation(s)
- Meredith Vanstone
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Janelle Panday
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anuoluwa Popoola
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shipra Taneja
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Devon Greyson
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Communication, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Sarah D McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Department of Radiology, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rachael Pack
- Center for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Morgan Black
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Beth Murray-Davis
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth Darling
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada.,McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
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13
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Robinson C, Chanchlani R, Gayowsky A, Darling E, Seow H, Batthish M. Health care utilization and costs following Kawasaki disease. Paediatr Child Health 2022; 27:160-168. [PMID: 35712030 PMCID: PMC9191915 DOI: 10.1093/pch/pxab092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/23/2021] [Indexed: 12/17/2022] Open
Abstract
Objectives Kawasaki disease (KD) is a common childhood vasculitis with increasing incidence in Canada. Acute KD hospitalizations are associated with high health care costs. However, there is minimal health care utilization data following initial hospitalization. Our objective was to determine rates of health care utilization and costs following KD diagnosis. Methods We used population-based health administrative databases to identify all children (0 to 18 years) hospitalized for KD in Ontario between 1995 and 2018. Each case was matched to 100 nonexposed comparators by age, sex, and index year. Follow-up continued until death or March 2019. Our primary outcomes were rates of hospitalization, emergency department (ED), and outpatient physician visits. Our secondary outcomes were sector-specific and total health care costs. Results We compared 4,597 KD cases to 459,700 matched comparators. KD cases had higher rates of hospitalization (adjusted rate ratio 2.07, 95%CI 2.00 to 2.15), outpatient visits (1.30, 95%CI 1.28 to 1.33), and ED visits (1.22, 95%CI 1.18 to 1.26) throughout follow-up. Within 1 year post-discharge, 717 (15.6%) KD cases were re-hospitalized, 4,587 (99.8%) had ≥1 outpatient physician visit and 1,695 (45.5%) had ≥1 ED visit. KD cases had higher composite health care costs post-discharge (e.g., median cost within 1 year: $2466 CAD [KD cases] versus $234 [comparators]). Total health care costs for KD cases, respectively, were $13.9 million within 1 year post-discharge and $54.8 million throughout follow-up (versus $2.2 million and $23.9 million for an equivalent number of comparators). Conclusions Following diagnosis, KD cases had higher rates of health care utilization and costs versus nonexposed children. The rising incidence and costs associated with KD could place a significant burden on health care systems.
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Affiliation(s)
- Cal Robinson
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada,Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada,ICES McMaster, Hamilton, Ontario, Canada
| | | | - Elizabeth Darling
- McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Michelle Batthish
- Correspondence: Michelle Batthish, Division of Rheumatology, Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada. Telephone 905-521-2100, fax 905-521-4968, e-mail
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14
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Robinson C, Chanchlani R, Gayowsky A, Brar S, Darling E, Demers C, Klowak J, Knight B, Kuenzig E, Mondal T, Parekh R, Seow H, Jimenez-Rivera C, Webster R, Fung S, Benchimol EI, Batthish M. Incidence and short-term outcomes of Kawasaki disease. Pediatr Res 2021; 90:670-677. [PMID: 33785879 DOI: 10.1038/s41390-021-01496-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/04/2021] [Accepted: 03/07/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Kawasaki disease (KD) is a childhood vasculitis with conflicting reported North American trends in incidence and patient characteristics. OBJECTIVES (1) determine KD incidence between 1995 and 2017; (2) compare patient characteristics by era and age group; (3) determine complication and cardiovascular follow-up rates. METHODS We used population-based health administrative data to identify children (0-18 yr) hospitalized with KD in Ontario, Canada between 1995 and 2017. We excluded children with prior KD diagnosis or incomplete records. We determined the annualized incidence and follow-up trends. RESULTS KD was diagnosed in 4,346 children between 1995 and 2017. Annual KD incidence was 22.0 (<5 yr), 6.1 (5-9 yr), and 0.6 (10-18 yr) per 100,000 children. KD incidence increased significantly for all age groups, including from 18.4 to 25.0 cases per 100,000 children <5 yr. Ninety-day mortality occurred in ≤5 children (≤0.1%). Coronary artery aneurysm (CAA) occurred in 106 children (2.4%, 95% confidence interval 2.0-2.9) during admission and 151 (3.5%, 95% confidence interval 3.0-4.1) during 11-year median follow-up. Children 10-18 yr had longer hospitalizations (4.3 vs. 3.5 days, p = 0.003) and more CAA (7.4% vs. 3.4%, p = 0.007). By 1-year post-diagnosis, 3970 (91.3%) and 2576 (59.3%) children had echocardiography and cardiology follow-up, respectively. CONCLUSIONS KD incidence is increasing in Ontario, with greater healthcare utilization from hospitalizations and subsequent follow-up. IMPACT 4346 children were hospitalized for Kawasaki disease over 22 years in Ontario, and Kawasaki disease incidence increased significantly for all age groups, males and females. Older children (10-18 years) had longer hospital length of stay, more PICU admissions and more frequent coronary artery aneurysms. Nearly all children with Kawasaki disease had follow-up echocardiography within 1 year.
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Affiliation(s)
- Cal Robinson
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,ICES McMaster, Hamilton, ON, Canada
| | | | - Sandeep Brar
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Elizabeth Darling
- McMaster Midwifery Research Centre, McMaster University, Hamilton, ON, Canada
| | - Catherine Demers
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, ON, Canada
| | - Jennifer Klowak
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Braden Knight
- ICES Ottawa, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Ellen Kuenzig
- ICES Ottawa, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Tapas Mondal
- Division of Pediatric Cardiology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Rulan Parekh
- Division of Pediatric Nephrology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Carolina Jimenez-Rivera
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Richard Webster
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Stephen Fung
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Eric I Benchimol
- ICES Ottawa, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Michelle Batthish
- Division of Pediatric Rheumatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
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15
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Robinson C, Lao F, Chanchlani R, Gayowsky A, Darling E, Batthish M. Long-term hearing and neurodevelopmental outcomes following Kawasaki disease: A population-based cohort study. Brain Dev 2021; 43:735-744. [PMID: 33824025 DOI: 10.1016/j.braindev.2021.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Kawasaki disease (KD) incidence is increasing in Ontario. Cardiovascular sequelae following KD are well-described. However, there are limited data on non-cardiovascular outcomes. OBJECTIVES To determine the risk of hearing loss, anxiety, developmental disorders, intellectual disabilities and attention-deficit/hyperactivity disorder (ADHD) among KD survivors vs. non-exposed children. METHODS We included all Ontario children (≤18 yr) surviving hospitalization with a KD diagnosis between 1995 and 2018, using population-based health administrative databases. We excluded children with prior KD diagnoses and non-residents. KD cases were matched with 100 non-exposed children by age, sex and year. Follow-up continued until death or March 2019. We calculated the prevalence, incidence and adjusted hazard ratios (aHR [95%CI]) of outcomes between 0-1 yr, 1-5 yr, 5-10 yr and >10 yr follow-up. RESULTS Among 4597 KD survivors, 364 (7.9%) were diagnosed with hearing loss, 1213 (26.4%) anxiety disorders, 398 (8.7%) developmental disorders, 51 (1.1%) intellectual disability and 21 (0.5%) ADHD, during median 11 year follow-up. Compared to 459,700 non-exposed children, KD survivors were not at increased risk of hearing loss after adjustment for potential confounders. KD survivors were at increased risk of anxiety disorders between 0-1 yr (aHR 1.75 [1.46-2.10]), 1-5 yr (aHR 1.13 [1.01-1.28]), 5-10 yr (aHR 1.14 [1.03-1.28]) and >10 yr (aHR 1.11 [1.02-1.22]); developmental disorders between 0-1 yr (aHR 1.49 [1.28-1.74]) and 1-5 yr (aHR 1.19 [1.02-1.40]); intellectual disabilities >10 yr (aHR 2.36 [1.36-4.10]); and ADHD >10 yr (aHR 2.01 [1.14-3.57]). CONCLUSIONS KD survivors are at increased risk of being diagnosed with anxiety disorders sooner, being diagnosed with developmental disorders between 0 and 5 yr and being diagnosed with intellectual disabilities or ADHD >10 yr after KD diagnosis. This may justify enhanced developmental and audiological surveillance of KD survivors.
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Affiliation(s)
- Cal Robinson
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada; Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Francis Lao
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; ICES McMaster, Hamilton, Ontario, Canada
| | | | - Elizabeth Darling
- McMaster Midwifery Research Centre, McMaster University, Hamilton, ON, Canada
| | - Michelle Batthish
- Division of Rheumatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
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16
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Mattison C, Bourret K, Hebert E, Leshabari S, Kabeya A, Achiga P, Robinson J, Darling E. Health systems factors impacting the integration of midwifery: an evidence-informed framework on strengthening midwifery associations. BMJ Glob Health 2021; 6:bmjgh-2020-004850. [PMID: 34083246 PMCID: PMC8174493 DOI: 10.1136/bmjgh-2020-004850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/08/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Midwifery associations are organisations that represent midwives and the profession of midwifery. They support midwives to reduce maternal and newborn mortality and morbidity by promoting the overall integration of midwifery in health systems. Our objective was to generate a framework for evidence-informed midwifery association strengthening. Methods A critical interpretive synthesis complemented by key informant interviews, focus groups, observations, and document review was used to inform the development of concepts and theory. Three electronic bibliographical databases (CINAHL, EMBASE and MEDLINE) were searched through to 2 September 2020. A coding structure was created to guide the synthesis across the five sources of evidence. Results A total of 1634 records were retrieved through electronic searches and 57 documents were included in the critical interpretive synthesis. Thirty-one (31) key informant interviews and five focus groups were completed including observations (255 pages) and audio recordings. Twenty-four (24) programme documents were reviewed. The resulting theoretical framework outlines the key factors by context, describes the system drivers that impact the sustainability of midwifery associations and identifies the key-enabling elements involved in designing programmes that strengthen midwifery associations. Conclusion Midwifery associations act as the web that holds the profession together and are key to the integration of the profession in health systems, supporting enabling environments and improving gender inequities. Our findings highlight that in order to strengthen midwifery (education, regulation and services), we have to lead with association strengthening. Building strong associations is the foundation necessary to create formal quality midwifery education systems and to support midwifery regulation and accreditation mechanisms.
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Affiliation(s)
- Cristina Mattison
- Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Kirsty Bourret
- Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Emmanuelle Hebert
- University of Quebec at Trois-Rivières, Trois-Rivieres, Quebec, Canada.,Congolese Society of Midwifery Practice, Kinshasa, Democratic Republic of Congo
| | - Sebalda Leshabari
- Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ambrocckha Kabeya
- Congolese Society of Midwifery Practice, Kinshasa, Democratic Republic of Congo
| | - Patrick Achiga
- Vice-secretary, South Sudan Nurses and Midwives Association, Juba, South Sudan
| | - Jamie Robinson
- Global Programs Manager, Canadian Association of Midwives, Montreal, Quebec, Canada
| | - Elizabeth Darling
- Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
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17
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MacDonald T, Dorcely O, Ewusie J, Darling E, Greene S, Moll S, Mbuagbaw L. Maternal-newborn outcomes in rural Haiti: an interrupted time series study. Journal of Obstetrics and Gynaecology Canada 2021. [DOI: 10.1016/j.jogc.2021.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Schlorff M, Robinson C, Mondal T, Demers C, Darling E, Brar S, Parekh R, Seowh H, Chanchlani R, Batthish M. 111 Kawasaki disease in Ontario children from 1995-2017: A population-based descriptive analysis. Paediatr Child Health 2020. [DOI: 10.1093/pch/pxaa068.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Kawasaki disease (KD) is a common pediatric vasculitis with rising global incidence. Associated coronary artery aneurysms (CAA) can result in significant long-term morbidity and mortality. However, our understanding of the trends in incidence along with patient and disease characteristics for North American children over the past two decades remains limited, particularly in universal health care systems. This understanding can inform healthcare resource planning and identify knowledge gaps for educational initiatives.
Objectives
The objectives of this study were to: 1) compare patient, hospital and disease characteristics for children diagnosed with KD between two eras (1995-2001 and 2002-2017) and three age groups (0-4yr, 5-9yr, 10-18yr) and 2) determine trends in KD incidence across Ontario, Canada between 1995 to 2017.
Design/Methods
We used healthcare administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) to identify a population-based cohort of Ontario children (0-18 years) diagnosed with KD during hospital admission between April 1995 and March 2017. We excluded children with previous KD diagnosis. We compared eras and age groups by Chi-squared test. We determined the annual incidence of KD in Ontario, compared by Cochrane-Armitage test.
Results
We identified 4346 Ontario children diagnosed with KD between 1995-2017. The mean (SD) age at diagnosis was 3.4 years (± 2.9) and male:female ratio was 1.5:1. Median (IQR) length of hospital admission was 3 days (2-4) and 104 children (2.4%) required PICU admission. No child died within 90 days of diagnosis. Baseline CAA were observed in 106 children (2.4%). There was no difference in baseline CAA by era (2.3% [1995-2001] vs 2.5% [2002-2017], p=0.72). CAA were significantly more common in children aged 10-18 years (5.3% vs 2.4% [0-4yr] and 2.2% [5-9yr], p=0.03). Myo-/pericarditis occurred in 71 children (1.6%). Red blood cell transfusions were administered to 51 children (1.2%) and were significantly more common during 2002-2017 (≤0.5% vs 1.5%, p<0.001). The standardized incidence of KD increased significantly over the study period (p<0.0001), from 6.5 cases per 100,000 person-years (1995-2000) to 8.4 cases (2012-2017). Significant seasonal variation was observed; incidence was highest from November to March (OR 1.7 – 2.1, using August as reference month) and peaked in January (OR 2.1).
Conclusion
The incidence of KD has increased significantly over the past 20 years in Ontario, Canada which may reflect increased awareness and improved diagnosis. However, the frequency of baseline CAA has not changed. Baseline CAA are more common in children 10-18 years. This may suggest delayed diagnosis in this age group.
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Affiliation(s)
- Megan Schlorff
- Department of Pediatrics, McMaster University, Hamilton ON, Canada
| | - Cal Robinson
- Department of Pediatrics, McMaster University, Hamilton ON, Canada
| | - Tapas Mondal
- Department of Pediatrics, McMaster University, Hamilton ON, Canada
| | - Catherine Demers
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton ON, Canada
| | | | - Sandeep Brar
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
| | - Rulan Parekh
- Department of Pediatrics, University of Toronto, Toronto ON, Canada
| | - Hsien Seowh
- Department of Oncology, McMaster University, Hamilton ON, Canada
| | - Rahul Chanchlani
- Department of Pediatrics, McMaster University, Hamilton ON, Canada
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19
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Malhi R, Nussey L, Krueger S, Darling E, Giglia L, Seigel S, Simpson S, Wasser R, Hunter A. 153 Neonatal Outcomes of Inadequate Prenatal Care. Paediatr Child Health 2019. [DOI: 10.1093/pch/pxz066.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ranu Malhi
- Department of Pediatrics, McMaster University
| | | | | | | | | | | | - Sarah Simpson
- St. Joseph’s Healthcare Hamilton, Women’s and Infants Program
| | - Rebecca Wasser
- St. Joseph’s Healthcare Hamilton, Women’s and Infants Program
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20
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Deluce S, Darling E. NON-INDICATED TRANSFERS OF CARE FROM MIDWIVES TO PHYSICIANS IN ONTARIO. Journal of Obstetrics and Gynaecology Canada 2019. [DOI: 10.1016/j.jogc.2019.02.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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21
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Weiss D, Dunn SI, Sprague AE, Fell DB, Grimshaw JM, Darling E, Graham ID, Harrold J, Smith GN, Peterson WE, Reszel J, Lanes A, Walker MC, Taljaard M. Effect of a population-level performance dashboard intervention on maternal-newborn outcomes: an interrupted time series study. BMJ Qual Saf 2018; 27:425-436. [PMID: 29175856 PMCID: PMC5965347 DOI: 10.1136/bmjqs-2017-007361] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To assess the effect of the Maternal Newborn Dashboard on six key clinical performance indicators in the province of Ontario, Canada. DESIGN Interrupted time series using population-based data from the provincial birth registry covering a 3-year period before implementation of the Dashboard and 2.5 years after implementation (November 2009 through March 2015). SETTING All hospitals in the province of Ontario providing maternal-newborn care (n=94). INTERVENTION A hospital-based online audit and feedback programme. MAIN OUTCOME MEASURES Rates of the six performance indicators included in the Dashboard. RESULTS 2.5 years after implementation, the audit and feedback programme was associated with statistically significant absolute decreases in the rates of episiotomy (decrease of 1.5 per 100 women, 95% CI 0.64 to 2.39), induction for postdates in women who were less than 41 weeks at delivery (decrease of 11.7 per 100 women, 95% CI 7.4 to 16.0), repeat caesarean delivery in low-risk women performed before 39 weeks (decrease of 10.4 per 100 women, 95% CI 9.3 to 11.5) and an absolute increase in the rate of appropriately timed group B streptococcus screening (increase of 2.8 per 100, 95% CI 2.2 to 3.5). The audit and feedback programme did not significantly affect the rates of unsatisfactory newborn screening blood samples or formula supplementation at discharge. No statistically significant effects were observed for the two internal control outcomes or the four external control indicators-in fact, two external control indicators (episiotomy and postdates induction) worsened relative to before implementation. CONCLUSION An electronic audit and feedback programme implemented in maternal-newborn hospitals was associated with clinically relevant practice improvements at the provincial level in the majority of targeted indicators.
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Affiliation(s)
- Deborah Weiss
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario — Ottawa Children’s Treatment Centre (CHEO-OCTC), Ottawa, Ontario, Canada
| | - Sandra I Dunn
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario — Ottawa Children’s Treatment Centre (CHEO-OCTC), Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Ann E Sprague
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario — Ottawa Children’s Treatment Centre (CHEO-OCTC), Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Deshayne B Fell
- Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Elizabeth Darling
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - JoAnn Harrold
- Division of Neonatology, Children’s Hospital of Eastern Ontario (CHEO) and The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Graeme N Smith
- Department of Obstetrics and Gynecology, Queen’s University and Kingston General Hospital, Kingston, Ontario, Canada
| | - Wendy E Peterson
- School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | - Jessica Reszel
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario — Ottawa Children’s Treatment Centre (CHEO-OCTC), Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario (CHEO) Research Institute, Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Andrea Lanes
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario — Ottawa Children’s Treatment Centre (CHEO-OCTC), Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Obstetrics, Maternal and Newborn Investigations (OMNI) Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mark C Walker
- Better Outcomes Registry & Network (BORN) Ontario, Children’s Hospital of Eastern Ontario — Ottawa Children’s Treatment Centre (CHEO-OCTC), Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Obstetrics, Maternal and Newborn Investigations (OMNI) Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Darling E, Corsi RL. Field-to-laboratory analysis of clay wall coatings as passive removal materials for ozone in buildings. Indoor Air 2017; 27:658-669. [PMID: 27859627 DOI: 10.1111/ina.12345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 10/07/2016] [Indexed: 06/06/2023]
Abstract
Ozone reacts readily with many indoor materials, as well as with compounds in indoor air. These reactions lead to lower indoor than outdoor ozone concentrations when outdoor air is the major contributor to indoor ozone. However, the products of indoor ozone reactions may be irritating or harmful to building occupants. While active technologies exist to reduce indoor ozone concentrations (i.e, in-duct filtration using activated carbon), they can be cost-prohibitive for some and/or infeasible for dwellings that do not have heating, ventilating, and air-conditioning systems. In this study, the potential for passive reduction of indoor ozone by two different clay-based interior surface coatings was explored. These coatings were exposed to occupied residential indoor environments and tested bimonthly in environmental chambers for quantification of ozone reaction probabilities and reaction product emission rates over a 6-month period. Results indicate that clay-based coatings may be effective as passive removal materials, with relatively low by-product emission rates that decay rapidly within 2 months.
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Affiliation(s)
- E Darling
- Department of Civil, Architectural and Environmental Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA
| | - R L Corsi
- Department of Civil, Architectural and Environmental Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA
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Aldred JR, Darling E, Morrison G, Siegel J, Corsi RL. Benefit-cost analysis of commercially available activated carbon filters for indoor ozone removal in single-family homes. Indoor Air 2016; 26:501-512. [PMID: 25952610 DOI: 10.1111/ina.12220] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/02/2015] [Indexed: 06/04/2023]
Abstract
This study involved the development of a model for evaluating the potential costs and benefits of ozone control by activated carbon filtration in single-family homes. The modeling effort included the prediction of indoor ozone with and without activated carbon filtration in the HVAC system. As one application, the model was used to predict benefit-to-cost ratios for single-family homes in 12 American cities in five different climate zones. Health benefits were evaluated using disability-adjusted life-years and included city-specific age demographics for each simulation. Costs of commercially available activated carbon filters included capital cost differences when compared to conventional HVAC filters of similar particle removal efficiency, energy penalties due to additional pressure drop, and regional utility rates. The average indoor ozone removal effectiveness ranged from 4 to 20% across the 12 target cities and was largely limited by HVAC system operation time. For the parameters selected in this study, the mean predicted benefit-to-cost ratios for 1-inch filters were >1.0 in 10 of the 12 cities. The benefits of residential activated carbon filters were greatest in cities with high seasonal ozone and HVAC usage, suggesting the importance of targeting such conditions for activated carbon filter applications.
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Affiliation(s)
- J R Aldred
- Department of Civil, Architectural, and Environmental Engineering, University of Texas, Austin, TX, USA
| | - E Darling
- Department of Civil, Architectural, and Environmental Engineering, University of Texas, Austin, TX, USA
| | - G Morrison
- Department of Civil, Architectural, and Environmental Engineering, Missouri University of Science and Technology, Rolla, MO, USA
| | - J Siegel
- Department of Civil Engineering, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - R L Corsi
- Department of Civil, Architectural, and Environmental Engineering, University of Texas, Austin, TX, USA
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Dunn S, Sprague AE, Grimshaw JM, Graham ID, Taljaard M, Fell D, Peterson WE, Darling E, Harrold J, Smith GN, Reszel J, Lanes A, Truskoski C, Wilding J, Weiss D, Walker M. A mixed methods evaluation of the maternal-newborn dashboard in Ontario: dashboard attributes, contextual factors, and facilitators and barriers to use: a study protocol. Implement Sci 2016; 11:59. [PMID: 27142655 PMCID: PMC4855363 DOI: 10.1186/s13012-016-0427-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022] Open
Abstract
Background There are wide variations in maternal-newborn care practices and outcomes across Ontario. To help institutions and care providers learn about their own performance, the Better Outcomes Registry & Network (BORN) Ontario has implemented an audit and feedback system, the Maternal-Newborn Dashboard (MND), for all hospitals providing maternal-newborn care. The dashboard provides (1) near real-time feedback, with site-specific and peer comparison data about six key performance indicators; (2) a visual display of evidence-practice gaps related to the indicators; and (3) benchmarks to provide direction for practice change. This study aims to evaluate the effects of the dashboard, dashboard attributes, contextual factors, and facilitation/support needs that influence the use of this audit and feedback system to improve performance. The objectives of this study are to (1) evaluate the effect of implementing the dashboard across Ontario; (2) explore factors that potentially explain differences in the use of the MND among hospitals; (3) measure factors potentially associated with differential effectiveness of the MND; and (4) identify factors that predict differences in hospital performance. Methods/design A mixed methods design includes (1) an interrupted time series analysis to evaluate the effect of the intervention on six indicators, (2) key informant interviews with a purposeful sample of directors/managers from up to 20 maternal-newborn care hospitals to explore factors that influence the use of the dashboard, (3) a provincial survey of obstetrical directors/managers from all maternal-newborn hospitals in the province to measure factors that influence the use of the dashboard, and (4) a multivariable generalized linear mixed effects regression analysis of the indicators at each hospital to quantitatively evaluate the change in practice following implementation of the dashboard and to identify factors most predictive of use. Discussion Study results will provide essential data to develop knowledge translation strategies for facilitating practice change, which can be further evaluated through a future cluster randomized trial.
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Affiliation(s)
- Sandra Dunn
- Better Outcomes Registry & Network (BORN Ontario), Children's Hospital of Eastern Ontario (CHEO) Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada.
| | - Ann E Sprague
- Better Outcomes Registry & Network (BORN Ontario), Children's Hospital of Eastern Ontario (CHEO) Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Jeremy M Grimshaw
- Department of Medicine, Ottawa Hospital Research Institute (OHRI), Clinical Epidemiology Program, University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8 L6, Canada
| | - Ian D Graham
- Ottawa Hospital Research Institute (OHRI), School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8 L6, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute (OHRI), School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Deshayne Fell
- Better Outcomes Registry & Network (BORN Ontario), 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Wendy E Peterson
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8 M5, Canada
| | - Elizabeth Darling
- Laurentian University, 935 Ramsey Lake Road, Sudbury, ON, P3E 2C6, Canada
| | - JoAnn Harrold
- Children's Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Graeme N Smith
- Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2 V7, Canada
| | - Jessica Reszel
- Better Outcomes Registry & Network (BORN Ontario), Children's Hospital of Eastern Ontario (CHEO) Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Andrea Lanes
- Better Outcomes Registry & Network (BORN Ontario), 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Carolyn Truskoski
- Better Outcomes Registry & Network (BORN Ontario), School of Nursing, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Jodi Wilding
- Better Outcomes Registry & Network (BORN Ontario), 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Deborah Weiss
- Better Outcomes Registry & Network (BORN Ontario), 401 Smyth Road, Ottawa, ON, K1H 8 L1, Canada
| | - Mark Walker
- Ottawa Hospital Research Institute (OHRI), University of Ottawa, Better Outcomes Registry & Network (BORN Ontario), 501 Smyth Road, Ottawa, ON, K1H 8 L6, Canada
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Kelting T, Searles B, Darling E. A survey on air bubble detector placement in the CPB circuit: a 2011 cross-sectional analysis of the practice of Certified Clinical Perfusionists. Perfusion 2012; 27:345-51. [PMID: 22730348 DOI: 10.1177/0267659112446526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ideal location of air bubble detector (ABD) placement on the cardiopulmonary bypass (CPB) circuit is debatable. There is, however, very little data characterizing the prevalence of specific ABD placement preferences by perfusionists. Therefore, the purpose of this study was to survey the perfusion community to collect data describing the primary locations of air bubble detector placement on the CPB circuit. In June 2011, an 18-question on-line survey was conducted. Completed surveys were received from 627 participants. Of these, analysis of the responses from the 559 certified clinical perfusionists (CCP) was performed. The routine use of ABD during CPB was reported by 96.8% of CCPs. Of this group, specific placement of the bubble detector is as follows: distal to the venous reservoir outlet (35.6%), between the arterial pump and oxygenator (3.8%), between the oxygenator and arterial line filter (35.1%), distal to the arterial line filter (ALF) (23.6%), and other (1.8%). Those placing the ABD distal to the venous reservoir predominately argued that an emptied venous reservoir was the most likely place to introduce air into the circuit. Those who placed the ABD between the oxygenator and the arterial line filter commonly reasoned that this placement protects against air exiting the membrane. Those placing the ABD distal to the ALF (23.6%) cited that this location protects from all possible entry points of air. A recent false alarm event from an ABD during a case was reported by 36.1% of CCPs. This study demonstrates that the majority of CCPs use an ABD during the conduct of CPB. The placement of the ABD on the circuit, however, is highly variable across the perfusion community. A strong rationale for the various ABD placements suggests that the adoption of multiple ABD may offer the greatest comprehensive protection against air emboli.
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Affiliation(s)
- T Kelting
- Department of Cardiovascular Perfusion, College of Health Professions, SUNY Upstate Medical University, Syracuse, NY 13210, USA
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Abstract
Cell phone use in the U.S. has increased dramatically over the past decade and text messaging among adults is now mainstream. In professions such as perfusion, where clinical vigilance is essential to patient care, the potential distraction of cell phones may be especially problematic. However, the extent of this as an issue is currently unknown. Therefore, the purpose of this study was to (1) determine the frequency of cell phone use in the perfusion community, and (2) to identify concerns and opinions among perfusionists regarding cell phone use. In October 2010, a link to a 19-question survey (surveymonkey.com) was posted on the AmSECT (PerfList) and Perfusion.com (PerfMail) forums. There were 439 respondents. Demographic distribution is as follows; Chief Perfusionist (30.5%), Staff Perfusionist (62.0%), and Other (7.5%), with age ranges of 20-30 years (14.2%), 30-40 years (26.5%), 40-50 years (26.7%), 50-60 years (26.7%), >60 years (5.9%). The use of a cell phone during the performance of cardiopulmonary bypass (CPB) was reported by 55.6% of perfusionists. Sending text messages while performing CPB was acknowledged by 49.2%, with clear generational differences detected when cross-referenced with age groups. For smart phone features, perfusionists report having accessed e-mail (21%), used the internet (15.1%), or have checked/posted on social networking sites (3.1%) while performing CPB. Safety concerns were expressed by 78.3% who believe that cell phones can introduce a potentially significant safety risk to patients. Speaking on a cell phone and text messaging during CPB are regarded as "always an unsafe practice" by 42.3% and 51.7% of respondents, respectively. Personal distraction by cell phone use that negatively affected performance was admitted by 7.3%, whereas witnessing another perfusionist distracted with phone/text while on CPB was acknowledged by 33.7% of respondents. This survey suggests that the majority of perfusionists believe cell phones raise significant safety issues while operating the heart-lung machine. However, the majority also have used a cell phone while performing this activity. There are clear generational differences in opinions on the role and/or appropriateness of cell phones during bypass. There is a need to further study this issue and, perhaps, to establish consensus on the use of various communication modes within the perfusion community.
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Affiliation(s)
- T Smith
- SUNY Upstate Medical University in Syracuse, NY, USA.
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Abstract
BACKGROUND Many publications have examined the reasons behind the rising cesarean delivery rate around the world. Women's responses to the Maternity Experiences Survey of the Canadian Perinatal Surveillance System were examined to explore correlates of having a cesarean section on other experiences surrounding labor, birth, mother-infant contact, and breastfeeding. METHODS A randomly selected sample of 8,244 estimated eligible women stratified primarily by province and territory was drawn from the May 2006 Canadian Census. Completed responses were obtained from 6,421 women (78%). RESULTS Three-quarters of the women (73.7%) gave birth vaginally and 26.3 percent by cesarean section, including 13.5 percent with a planned cesarean and 12.8 percent with an unplanned cesarean. In addition to more interventions in labor, women who had a cesarean birth after attempting a vaginal birth had less mother-infant contact after birth and less optimal breastfeeding practices. CONCLUSION Findings from the Maternity Experiences Survey indicated that women who have cesarean births experience more interventions during labor and birth and have less optimal birthing and early parenting outcomes.
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Affiliation(s)
- Beverley Chalmers
- Department of Obstetrics and Gynaecology and Affiliate Investigator at the Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
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Montori VM, Devereaux PJ, Adhikari NKJ, Burns KEA, Eggert CH, Briel M, Lacchetti C, Leung TW, Darling E, Bryant DM, Bucher HC, Schünemann HJ, Meade MO, Cook DJ, Erwin PJ, Sood A, Sood R, Lo B, Thompson CA, Zhou Q, Mills E, Guyatt GH. Randomized trials stopped early for benefit: a systematic review. JAMA 2005; 294:2203-9. [PMID: 16264162 DOI: 10.1001/jama.294.17.2203] [Citation(s) in RCA: 499] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Randomized clinical trials (RCTs) that stop earlier than planned because of apparent benefit often receive great attention and affect clinical practice. Their prevalence, the magnitude and plausibility of their treatment effects, and the extent to which they report information about how investigators decided to stop early are, however, unknown. OBJECTIVE To evaluate the epidemiology and reporting quality of RCTs involving interventions stopped early for benefit. DATA SOURCES Systematic review up to November 2004 of MEDLINE, EMBASE, Current Contents, and full-text journal content databases to identify RCTs stopped early for benefit. STUDY SELECTION Randomized clinical trials of any intervention reported as having stopped early because of results favoring the intervention. There were no exclusion criteria. DATA EXTRACTION Twelve reviewers working independently and in duplicate abstracted data on content area and type of intervention tested, reporting of funding, type of end point driving study termination, treatment effect, length of follow-up, estimated sample size and total sample studied, role of a data and safety monitoring board in stopping the study, number of interim analyses planned and conducted, and existence and type of monitoring methods, statistical boundaries, and adjustment procedures for interim analyses and early stopping. DATA SYNTHESIS Of 143 RCTs stopped early for benefit, the majority (92) were published in 5 high-impact medical journals. Typically, these were industry-funded drug trials in cardiology, cancer, and human immunodeficiency virus/AIDS. The proportion of all RCTs published in high-impact journals that were stopped early for benefit increased from 0.5% in 1990-1994 to 1.2% in 2000-2004 (P<.001 for trend). On average, RCTs recruited 63% (SD, 25%) of the planned sample and stopped after a median of 13 (interquartile range [IQR], 3-25) months of follow-up, 1 interim analysis, and when a median of 66 (IQR, 23-195) patients had experienced the end point driving study termination (event). The median risk ratio among truncated RCTs was 0.53 (IQR, 0.28-0.66). One hundred thirty-five (94%) of the 143 RCTs did not report at least 1 of the following: the planned sample size (n = 28), the interim analysis after which the trial was stopped (n = 45), whether a stopping rule informed the decision (n = 48), or an adjusted analysis accounting for interim monitoring and truncation (n = 129). Trials with fewer events yielded greater treatment effects (odds ratio, 28; 95% confidence interval, 11-73). CONCLUSIONS RCTs stopped early for benefit are becoming more common, often fail to adequately report relevant information about the decision to stop early, and show implausibly large treatment effects, particularly when the number of events is small. These findings suggest clinicians should view the results of such trials with skepticism.
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Affiliation(s)
- Victor M Montori
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Angona R, Searles B, Nasrallah F, Darling E. Status of pediatric perfusion education: 2000 survey. J Extra Corpor Technol 2001; 33:233-8. [PMID: 11806435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
In recent years, studies have raised questions about pediatric perfusion training, minimum proficiency requirements, and specialization. To understand these questions better, a survey was undertaken to investigate the status of pediatric/neonatal perfusion training in the United States. Three groups were surveyed: program directors (PD), recent graduates of perfusion programs (RG), and pediatric cardiac anesthesiologists (PCA). Program directors and recent graduates were queried about didactic curriculum and clinical experiences. All three groups were asked core questions regarding minimum proficiency, specialization, and need for a postgraduate style program. Didactically, 65% of program directors believed that perfusion programs provided a solid introductory knowledge base in infant perfusion. Clinically, students performed an average of 124 +/- 42.5 adult and 17 +/- 12.9 pediatric cases during their education. Program directors cited numerous limitations to clinical pediatric education, including access to pediatric cases and allocation of resources. The PD (69%) and RG (96%) both believed graduates were less prepared to perform infant/pediatric cardio-pulmonary bypass (CPB) at graduation as compared to adult CPB. The opinions of all three groups were divided when asked whether the essentials and guidelines requirement for minimum pediatric caseload is too low (yes response: PD 52%, RG 73%, PCA 47%). The PD and RG were against pediatric subspecialization/certification (87%, 57% respectively); whereas, the PCA were unanimously in favor (100%) of pediatric subspecialization/certification for perfusionist. All three groups felt a postgraduate-style program in infant perfusion would benefit the community (78%, 82%, 100%). Finally, 64% of RG said that, if available, they would have considered entering a training program in pediatric/neonatal perfusion after graduation. Our results indicate that there are still limitations to pediatric perfusion education. A postgraduate-style program in infant perfusion is one possible solution to this problem.
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Affiliation(s)
- R Angona
- Department of Cardiovascular Perfusion, Upstate Medical University, Syracuse, New York 13210, USA
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Darling E. 'Enriching and enlarging the whole sphere of human activities': the work of the voluntary sector in housing reform in inter-war Britain. Clio Med 2001; 60:149-78. [PMID: 11142144 DOI: 10.1163/9789004333345_006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- E Darling
- School of Art and Design History, Kingston University
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Darling E, Harris-Holloway S, Kern FH, Ungerleider R, Jaggers J, Lawson S, Shearer I. Impact of modifying priming components and fluid administration using miniaturized circuitry in neonatal cardiopulmonary bypass. Perfusion 2000; 15:3-12. [PMID: 10676862 DOI: 10.1177/026765910001500102] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Following a succession of changes in circuitry and priming additives between 1993 and 1998, a comprehensive re-evaluation of neonatal cardiopulmonary bypass (CPB) practice was undertaken. Samples from 10 infants (Group 1) undergoing CPB were evaluated for osmolality, oncotic pressure, total protein, hematocrit, glucose, and electrolytes (Na+, K+, iCa2+). These samples were tested at six measurement points: (1) after priming, (2) patient pre-CPB, (3) CPB-start, (4) CPB-mid, (5) CPB-end, and (6) post-modified ultrafiltration (MUF). Prime volumes were also carefully measured as well as the type and amount of volume given during CPB. After evaluating the initial data, changes in protocol regarding mannitol, calcium correction, and oncotic strength on CPB were made. Following implementation of these protocol changes, a second set (Group 2) of 10 infants was identically evaluated. Group 1 prime osmolality was 379 +/- 44 mOsm/kg, while Group 2 prime osmolality was 324 +/- 14 mOsm/kg (p = 0.003). There were no differences in osmolality between groups during bypass and osmolality was unaffected by modified ultrafiltration. Ionized calcium levels were significantly different at the end of bypass between Group 1, 0.6 +/- 0.1 mmol/l; and Group 2, 1.17 +/- 0.24 mmol/l (p < 0.001). In Group 1, there was a 40% drop (p = 0.001) in colloid osmotic pressure (COP) levels from pre-CPB (13.3 +/- 3.4 mmHg) to CPB-end (8.8 +/- 1.2 mmHg). In Group 2, there were no differences in COP during CPB. COP levels of Group 1 and Group 2 at CPB-end were 8.8 +/- 1.2 mmHg and 14 +/- 1.9, respectively (p < 0.0001). Total volume addition during bypass for Group 1 was 363.5 +/- 148.7 ml and for Group 2 was 245.1 +/- 92.2 ml (p < 0.05). In conclusion, progressive changes in neonatal circuits and techniques can have potentially wide-ranging effects on electrolyte and osmotic/oncotic homeostasis. An audit of perfusion management through expanded laboratory tests is recommended, especially in periods of change.
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Affiliation(s)
- E Darling
- Department of Perfusion Services, Duke University Health Systems, Durham, North Carolina 27710, USA
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Darling E, Kaemmer D, Lawson S, Smigla G, Collins K, Shearer I, Jaggers J. Experimental use of an ultra-low prime neonatal cardiopulmonary bypass circuit utilizing vacuum-assisted venous drainage. J Extra Corpor Technol 1998; 30:184-9. [PMID: 10537579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
In adult cardiopulmonary bypass surgery, vacuum assisted venous drainage has become a popular technique to augment venous return to the bypass circuit. The application of this technique in neonatal cardiopulmonary bypass surgery could be beneficial to the further miniaturization of neonatal circuitry by coupling radical respositioning of the oxygenator and pump console with decreasing line length. This report communicates the use of an investigational, vacuum assisted venous drainage neonatal circuit that is positioned at patient level utilizing a modified pump console with elevated double head twin roller pumps. The circuit, including the oxygenator, arterial line, venous line, raceway tubing, and a functional level in the venous reservoir has a priming volume of 107 ml. Initial bench and animal tests have demonstrated that this technique may be clinically feasible in CPB applications. With vacuum assisted venous drainage, the goal of asanguinous neonatal cardiac surgery could become a reality. Safety issues must be adequately addressed to ensure that this technique does not impose unacceptable risks.
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Affiliation(s)
- E Darling
- Perfusion Services, Duke University Medical Center, Durham, North Carolina, USA
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Abstract
In September 1996, perfusionists from 50 paediatric open-heart surgery programmes were contacted to identify centres that are currently using the technique of modified ultrafiltration (MUF). Of the 50 centres contacted, 22 (44%) were utilizing the technique. These centres were surveyed on the following: neonatal circuit description, patient entry criteria, MUF circuit description, conduct of MUF, use of extracorporeal safety devices and/or modifications, and technical complications. All 22 centres used roller pumps and membrane oxygenators. In 19 centres, MUF was utilized exclusively in the arteriovenous mode (86%), while two centres (9%) used the venovenous mode and one centre (5%) used both methods. Most (82%) of the 22 MUF centres used a blood cardioplegia system for myocardial preservation. After cardiopulmonary bypass (CPB), these blood cardioplegia systems were often converted for use as MUF circuits in a variety of ways. Other methods of accessing the CPB circuit for MUF included utilizing either a recirculation line or a dedicated port added to the circuit specifically for MUF. Blood flow rates during MUF, pump strategies, haemoconcentrator vacuum levels and endpoints were variable from centre to centre. Technical complications related to MUF were reported by 82% of the surveyed MUF centres. The most common complication, air cavitating into the circuit, was reported by 15 centres. From these data, we propose recommendations on the integration of MUF into CPB circuits, the conduct of perfusion during MUF, and appropriate safety considerations to minimize technical complications.
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Affiliation(s)
- E Darling
- Perfusion Services, Duke University Medical Center, Durham, North Carolina 27710, USA
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Morrison RS, Ahronheim JC, Morrison GR, Darling E, Baskin SA, Morris J, Choi C, Meier DE. Pain and discomfort associated with common hospital procedures and experiences. J Pain Symptom Manage 1998; 15:91-101. [PMID: 9494307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To determine whether reliable and valid rankings of pain and discomfort resulting from hospital procedures encountered by advanced dementia patients could be developed from interviews with cognitively intact adults, rankings of pain and discomfort resulting from 16 common procedures were obtained from two samples of hospitalized, nondemented adults using ten- (N = 100) and five- (N = 35) point numeric rating scales (NRS). Reliability was assessed by having 30 additional subjects complete ten-point NRS representing the ten most frequent procedures in a re-arranged order. By repeated measure analysis of variance, the scales discriminated between procedures (F = 35.1, P < 0.001). Subjects could discriminate between pain and discomfort (F = 21.6, P < 0.001). The five-point NRS exhibited better subject discrimination between experiences. Reliability was also acceptable. A five-point NRS produced reliable and valid pain and discomfort rankings for 16 common hospital procedures and experiences. These rankings should prove useful in reducing suffering and can serve as surrogates for quantifying pain and discomfort in dementia patients.
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Affiliation(s)
- R S Morrison
- Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York, USA
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Darling E. Practical considerations in sedating the elderly. Crit Care Nurs Clin North Am 1997; 9:371-80. [PMID: 9355361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CS can safely be administered to the elderly population. The definition of elderly is a subjective term. That is, each patient should be considered as an individual person with different physiologic and psychologic needs. Special attention must be given to ensure a safe environment for induction of sedation. The patient should be fully assessed, keeping in mind the physiologic changes that accompany aging. Elderly patients have an increased variability of drug response. Elderly patients have a decreased requirement for most anesthetic drugs. Elderly patients have an increased redosing interval. Continuous monitoring for signs of intolerance and cautious administration of sedation will help reduce the risks associated with sedation in the elderly.
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Affiliation(s)
- E Darling
- Clinical Electrophysiology Krannert Institute of Cardiology, Indianapolis, Indiana, USA
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Abstract
Our objective was to review the quality of service delivered by a national cancer information service--the British Association of Cancer United Patients (BACUP)--and to consider the implications for future policy and practice. We used a sample of callers over a 10-day period, responding to a structured postal questionnaire. The sample included patients, relatives, friends, and general public who called the service with any concern relating to cancer. Of the 406 invited to take part, 282 responded (69%). The questionnaire was designed to evaluate the callers' perceptions of the information they received, their perceptions of the nurse's communication skills, the emotional impact of the call, and their overall satisfaction with the service. The results indicate that over 90% of callers evaluated the information they received and the nurse's communication skills positively, and there was no difference between the two major groups of callers, i.e. patients and relatives/friends. Both groups reported that the call had a positive emotional impact on them and that they were satisfied with the service. Emotional impact was predicted by quality of information for patients and nurse's communication skills for friends/relatives; overall satisfaction was predicted by nurse's communication skills for patients and both measures for relatives/friends. We conclude that the telephone is an effective medium for conveying information about cancer, and BACUP is meeting its needs. The needs of patients and relatives/friends are different--principally information for patients and support for relatives/friends--and it may be possible to improve training still further by focusing on those differences. The main challenge for cancer information services is to meet the ever-increasing demand.
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Arroyo MG, Darling E, Szudy B. Risk mapping for change:. New Solut 1995; 5:27-30. [PMID: 22911031 DOI: 10.2190/ns5.2.f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Herrmann-Frank A, Darling E, Meissner G. Functional characterization of the Ca(2+)-gated Ca2+ release channel of vascular smooth muscle sarcoplasmic reticulum. Pflugers Arch 1991; 418:353-9. [PMID: 1652123 DOI: 10.1007/bf00550873] [Citation(s) in RCA: 123] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The Ca(2+)-gated Ca2+ release channel of aortic sarcoplasmic reticulum (SR) was partially purified and reconstituted into planar lipid bilayers. Canine and porcine aorta microsomal protein fractions were solubilized in the detergent 3-[(3-cholamidopropyl)dimethyl-ammonio]-1-propane sulphonate (CHAPS) in the presence and absence of 3[H]-ryanodine and centrifuged through linear sucrose gradients. A single 3[H]-ryanodine receptor peak with an apparent sedimentation coefficient of 30 s was obtained. Upon reconstitution into planar lipid bilayers, the unlabelled 30 s protein fraction induced the formation of a Ca(2+)- and monovalent-ion-conducting channel (110 pS in 100 mM Ca2+, 360 pS in 250 mM K+). The channel was activated by micromolar Ca2+, modulated by millimolar adenosine triphosphate, Mg2+ and the Ca(2+)-releasing drug caffeine, and inhibited by micromolar ruthenium red. Micro- to millimolar concentrations of the plant alkaloid ryanodine induced a permanently closed state of the channel. Our results suggest that smooth muscle SR contains a Ca(2+)-gated Ca2+ release pathway, with properties similar to those observed for the skeletal and cardiac ryanodine receptor/Ca2+ release channel complexes.
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Affiliation(s)
- A Herrmann-Frank
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill 27599-7260
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Meissner G, Darling E, Eveleth J. Kinetics of rapid Ca2+ release by sarcoplasmic reticulum. Effects of Ca2+, Mg2+, and adenine nucleotides. Biochemistry 1986; 25:236-44. [PMID: 3754147 DOI: 10.1021/bi00349a033] [Citation(s) in RCA: 387] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A radioisotope flux-rapid-quench-Millipore filtration method is described for determining the effects of Ca2+, adenine nucleotides, and Mg2+ on the Ca2+ release behaviour of "heavy" sarcoplasmic reticulum (SR) vesicles. Rapid 45Ca2+ efflux from passively loaded vesicles was blocked by the addition of Mg2+ and ruthenium red. At pH 7 and 10(-9) M Ca2+, vesicles released 45Ca2+ with a low rate (k = 0.1 s-1). An increase in external Ca2+ concentration to 4 microM or the addition of 5 mM ATP or the ATP analogue adenosine 5'-(beta,gamma-methylenetriphosphate) (AMP-PCP) resulted in intermediate 45Ca2+ release rates. The maximal release rate was observed in media containing 4 microM Ca2+ and 5 mM AMP-PCP and had a first-order rate constant of 30-100 s-1. Mg2+ partially inhibited Ca2+- and nucleotide-induced 45Ca2+ efflux. In the absence of AMP-PCP, 45Ca2+ release was fully inhibited at 5 mM Mg2+ or 5 mM Ca2+. The composition of the release media was systematically varied, and the flux data were expressed in the form of Hill equations. The apparent n values of activation of Ca2+ release by ATP and AMP-PCP were 1.6-1.9. The Hill coefficient of Ca2+ activation (n = 0.8-2.1) was dependent on nucleotide and Mg2+ concentrations, whereas the one of Mg2+ inhibition (n = 1.1-1.6) varied with external Ca2+ concentration. These results suggest that heavy SR vesicles contain a "Ca2+ release channel" which is capable of conducting Ca2+ at rates comparable with those found in intact muscle. Ca2+, AMP-PCP (ATP), and Mg2+ appear to act at noninteracting or interacting sites of the channel.
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