BACKGROUND:Little is known about health or service use outcomes for residents of Canadian assisted living facilities. Our objectives were to estimate the incidence of admission to hospital over 1 year for residents of designated (i.e., publicly funded) assisted living (DAL) facilities in Alberta, to compare this rate with the rate among residents of long-term care facilities, and to identify individual and facility predictors of hospital admission for DAL residents.METHODS:Participants were 1066 DAL residents (mean age ± standard deviation 84.9 ± 7.3 years) and 976 longterm care residents (85.4 ± 7.6 years) from the Alberta Continuing Care Epidemiological Studies (ACCES). Research nurses completed a standardized comprehensive assessment for each resident and interviewed family caregivers at baseline (2006 to 2008) and 1 year later. We used standardized interviews with administrators to generate facility- level data. We determined hospital admissions through linkage with the Alberta Inpatient Discharge Abstract Database. We used multivariable Cox proportional hazards models to identify predictors of hospital admission.RESULTS:The cumulative annual incidence of hospital admission was 38.9% (95% confidence interval [CI] 35.9%- 41.9%) for DAL residents and 13.7% (95% CI 11.5%-15.8%) for long-term care residents. The risk of hospital admission was significantly greater for DAL residents with greater health instability, fatigue, medication use (11 or more medications), and 2 or more hospital admissions in the preceding year. The risk of hospital admission was also significantly higher for residents from DAL facilities with a smaller number of spaces, no licensed practical and/ or registered nurses on site (or on site less than 24 hours a day, 7 days a week), no chain affiliation, and from select health regions.INTERPRETATION:The incidence of hospital admission was about 3 times higher among DAL residents than among long-term care residents, and the risk of hospital admission was associated with a number of potentially modifiable factors. These findings raise questions about the complement of services and staffing required within assisted living facilities and the potential impact on acute care of the shift from long-term care to assisted living for the facility-based care of vulnerable older people.
BACKGROUND:Important knowledge gaps exist in our understanding of migration medicine practice and the impact of pathogens imported by Canadian travellers. We present here a comprehensive, Canada-specific surveillance summary of illness in a cohort of returned Canadian travellers and new immigrants.METHODS:We extracted and analyzed (using standard parametric and nonparametric techniques) data from the Canadian Travel Medicine Network (CanTravNet) database for ill returned Canadian travellers and new immigrants who presented to a Canadian GeoSentinel Surveillance Network site between September 2009 and September 2011.RESULTS:During the study period, 4365 travellers and immigrants presented to a CanTravNet site, 3943 (90.3%) of whom were assigned a travel-related diagnosis. Among the 3115 non-immigrant travellers with a definitive travel-related diagnosis, arthropod bite (n = 127 [4.1%]), giardiasis (n = 91 [2.9%]), malaria (n = 77 [2.5%]), latent tuberculosis (n = 73 [2.3%]), and strongyloidiasis (n = 66 [2.1%]) were the most common specific etiologic diagnoses. Among the 828 immigrants with definitive travel-related diagnoses, the most frequent etiologies were latent tuberculosis (n = 229 [27.7%]), chronic hepatitis B (n = 182 [22.0%]), active tuberculosis (n = 97 [11.7%]), chronic hepatitis C (n = 89 [10.7%]), and strongyloidiasis (n = 41 [5.0%]). Potentially serious infections, such as dengue fever (61 cases) and enteric fever due to Salmonella enterica serotype Typhi or Paratyphi (36 cases), were common. Individuals travelling for the purpose of visiting friends and relatives (n = 500 [11.6% of those with known reason for travel]) were over-represented among those diagnosed with malaria and enteric fever, compared with other illnesses (for malaria 34/94 [36.2%] v. 466/4221 [11.0%]; for enteric fever, 17/36 [47.2%] v. 483/4279 [11.3%]) (both p < 0.001). For cases of malaria, there was also overrepresentation (compared with other illnesses) from business travellers (22/94 [23.4%] v. 337/4221 [8.0%]) and males (62/94 [66.0%] v. 1964/4269 [46.0%]) (both p < 0.001). Malaria was more likely than other illnesses to be acquired in sub-Saharan Africa (p < 0.001), whereas dengue was more likely than other illnesses to be imported from the Caribbean and South East Asia (both p = 0.003) and enteric fever from South Central Asia (24/36 [66.7%]) (p < 0.001).INTERPRETATION:This analysis of surveillance data on ill returned Canadian travellers has detailed the spectrum of imported illness within this cohort. It provides an epidemiologic framework for Canadian practitioners encountering ill returned travellers. We have confirmed that travel to visit friends and relatives confers particularly high risks, which underscores the need to improve pretravel intervention for a population that is unlikely to seek specific pretravel advice. Potentially serious and fatal illnesses such as malaria and enteric fever were common, as were illnesses of public health importance, such as tuberculosis and hepatitis B.
Background: We studied the relationships among psychiatrist supply, practice patterns, and access to psychiatrists in Ontario Local Health Integration Networks (LHINs) with differing levels of psychiatrist supply. Methods: We analyzed practice patterns of full-time psychiatrists (n = 1379) and postdischarge care to patients who had been admitted to hospital for psychiatric care, according to LHIN psychiatrist supply in 2009. We measured the characteristics of psychiatrists' patient panels, including sociodemographic characteristics, outpatient panel size, number of new patients, inpatient and outpatient visits per psychiatrist, and percentages of psychiatrists seeing fewer than 40 and fewer than 100 unique patients. Among patients admitted to hospital with schizophrenia, bipolar disorder, or major depression (n = 21,123), we measured rates of psychiatrist visits, readmissions, and visits to the emergency department within 30 and 180 days after discharge. Results: Psychiatrist supply varied from 7.2 per 100 000 residents in LHINs with below-average supply to 62.7 per 100 000 in the Toronto Central LHIN. Population-based outpatient and inpatient visit rates and psychiatric admission rates increased with LHIN psychiatrist supply. However, as the supply of psychiatrists increased, outpatient panel size for full-time psychiatrists decreased, with Toronto psychiatrists having 58% smaller outpatient panels and seeing 57% fewer new outpatients relative to LHINs with the lowest psychiatrist supply. Similar patterns were found for inpatient practice. Moreover, as supply increased, annual outpatient visit frequency increased: the average visit frequency was 7 visits per outpatient for Toronto psychiatrists and 3.9 visits per outpatient in low-supply LHINs. One-quarter of Toronto psychiatrists and 2% of psychiatrists in the lowest-supply LHINs saw their outpatients more than 16 times per year. Of full-time psychiatrists in Toronto, 10% saw fewer than 40 unique patients and 40% saw fewer than 100 unique patients annually; the corresponding proportions were 4% and 10%, respectively, in the lowest-supply LHINs. Overall, follow-up visits after psychiatric discharge were low, with slightly higher rates in LHINs with a high psychiatrist supply. Interpretation: Full-time psychiatrists who practised in Ontario LHINs with high psychiatrist supply saw fewer patients, but they saw those patients more frequently than was the case for psychiatrists in low-supply LHINs. Increasing the supply of psychiatrists while funding unlimited frequency and duration of psychotherapy care may not improve access for patients who need psychiatric services.
In October 2012, Canada became negotiating member of the Trans-Pacific Partnership (TPP) agreement along with 11 other Pacific Rim countries. Widely touted as a model for 21st-century trade agreements,1 it extends well beyond traditional trade issues into domestic policy, creating number of concerns about its implications for public health. These concerns include potential increases in pharmaceutical costs, the undermining of Canadian law, and strengthened investor rights over public health regulations to limit the consumption of products harmful to health. The Comprehensive Economic and Trade Agreement (CETA) currently being negotiated between Canada and the European Union has already been forecast to increase Canadian drug costs by between $850 million and $1.6 billion annually by extending protection; leaked text of the TPP suggests that its provisions would increase these costs further.2 (See also Box 1.) The TPP's draft chapter on intellectual property rights goes beyond CETA, allowing the patenting of new forms and uses of old drugs regardless of efficacy, and introducing the patenting of diagnostic, therapeutic, and surgical methods. Although the rationale for extending patents is that it will lead to increased research and development spending in Canada, brand-name pharmaceutical companies have failed to comply with similar commitments in the past.2 Box 1 Other resources on the Trans-Pacific Partnership agreement Council of Canadians www.canadians.org/tpp infojustice.org http://infojustice.org/resource-library/tpp Knowledge Ecology International http://keionline.org/tpp Public Knowledge http://tppinfo.org/resources/leaked-texts-country-info/ A second concern is the inclusion of investor–state dispute settlement (ISDS) mechanisms in the TPP. Unlike most trade treaties, in which only governments can dispute perceived violations, ISDS treaties permit private foreign investors to launch arbitration against state if they believe government action has devalued their investment. Using these provisions, investors have challenged everything from environmental laws to financial regulations to public health and safety. ISDS awards involving US investors alone (often corporations) have already cost the taxpayers of losing countries as much as $3 billion, and claims worth an additional $15 billion are still pending.3–5 The cases themselves cost governments $8 million on average to defend, although the legal costs of single cases have exceeded $50 million, and the overlapping roles of arbitrators as board members of corporations, corporate lobbyists, and even counsel in cases they are not arbitrating raise questions about their capacity for impartiality.5 Canada has already shown its vulnerability under ISDS as result of the first-ever intellectual property rights challenge by patent-holding pharmaceutical company.3 Brought by Eli Lilly in 2012 under NAFTA (which has an ISDS chapter), the company is claiming $500 million in damages for court decisions that revoked Canadian patents on two drugs for failing to satisfy the promise of the patent requirement,6 provision unique to Canadian law that requires patentees to demonstrate or soundly predict any promised benefit of the pharmaceutical product by the filing date.7 Leaked text of the TPP's draft intellectual property chapter would allow for theoretical and speculative utility instead, resulting in watered-down requirement and precisely what Canada is attempting to defend against in the Eli Lilly NAFTA challenge. Because of the leaked IP chapter, pharmaceuticals are one area where the health implications of the TPP are easier to project. The treaty and its probable ISDS provisions, however, also have the potential to open up foreign investor litigation on broad range of public health issues, including efforts to reduce noncommunicable diseases through regulatory policies related to tobacco, alcohol, and food products. Many countries are currently reconsidering both the value of including ISDS mechanisms in trade and investment agreements and the threat these mechanisms may present to public health and national sovereignty.8 The EU has recently frozen the negotiation of free trade agreement with the US to seek public consultation on investor protections.9 Canada has postponed signing off on CETA, in large part because of concerns about intellectual property rights and the implications for future litigation similar to the Eli Lilly case.10 A well-publicized and transparent process for public scrutiny over controversial matters within the TPP is urgently needed in Canada and has been called for by legislators from most of the negotiating countries (see www.tppmpsfortransparency.org/). Such call warrants the support of every Canadian concerned about health and the health care system.
BACKGROUND:Most Canadian newcomers are admitted in the economic, family, or refugee class, each of which has its own selection criteria and experiences. Evidence has shown various risks for mental health disorders across admission classes, but the respective service-use patterns for people in these classes are unknown. In this study, we compared service use for nonpsychotic mental health disorders by newcomers in various admission classes with that of long-term residents (i.e., Canadian-born persons or immigrants before 1985) in urban Ontario.METHODS:In this population-based matched cross-sectional study, we linked health service databases to the Ontario portion of the Citizenship and Immigration Canada database. Outcomes were mental health visits to primary care physicians, mental health visits to psychiatrists, and emergency department visits or hospital admissions. We measured service use for recent immigrants (those who arrived in Ontario between 2002 and 2007; n = 359 673). We compared service use by immigrants in each admission class during the first 5 years in Canada with use by age- and sex-matched long-term residents. We measured likelihood of access to each service and intensity of use of each service using conditional logistic regression and negative binomial models.RESULTS:Economic and family class newcomers were less likely than long-term residents to use primary mental health care. The use of primary mental health care by female refugees did not differ from that of matched long-term residents, but use of such care by male refugees was higher (odds ratio 1.14, 95% confidence interval 1.09-1.19). Immigrants in all admission classes were less likely to use psychiatric services and hospital services for mental health care. Exceptions were men in the economic and family classes, whose intensity of hospital visits was similar to that of matched long-term residents.INTERPRETATION:Immigrants in all admission classes generally used less care for nonpsychotic disorders than longterm residents, although male refugees used more primary care. Future research should examine how mental health needs align with service use, particularly for more vulnerable groups such as refugees.
0 false 18 pt 18 pt 0 0 false false false /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0pc .45pc 0pc .45pc; mso-para-margin:0pc; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; mso-bidi-font-size:10.0pt; font-family:Cambria; color:black;} This is our final editorial in Open Medicine . We are closing Open Medicine knowing that we have made a meaningful contribution to something bigger than ourselves, and that our efforts have helped to change the landscape of medical publishing. We are especially thankful to the many authors who entrusted their work to us, and we are proud to see their articles archived in PubMed Central, on MEDLINE and on the Open Medicine website. They are the reason we embarked on this journey, and we will continue to advocate for accessibility, transparency, and accountability in health care publishing in Canada.
BACKGROUND:Studying drugs withdrawn from the market for safety reasons can help in evaluating the strengths and weaknesses of the pre- and post-market safety evaluation systems. This study considered 2 questions: Has there been a change over time in the percentage of new drugs that are eventually withdrawn because of safety reasons? How long are new drugs on the market before their serious safety problems are recognized?METHODS:All drugs approved between 1 January 1990 and 31 December 2009 and subsequently withdrawn for safety reasons (until 1 October 2013) were identified, and the generic name, date of approval, and date of withdrawal were recorded. The total number of drugs approved over the same period was obtained from annual Health Canada reports. The percentages of new active substances approved in the 5-year periods 1990-1994, 1995-1999, 2000-2004, and 2005-2009 and eventually withdrawn were compared using the χ(2) test. The time between approval and withdrawal was calculated in days.RESULTS:Of the 528 new drugs approved over the period of interest, a total of 22 (4.2%) were eventually withdrawn. Between 3.9% and 4.4% of the drugs approved in each 5-year period were eventually withdrawn (χ(2) = 0.04, p = 0.99 for difference among 5-year periods). The median time between approval and withdrawal was 1271 days (interquartile range 706-2876).INTERPRETATION:One explanation for the finding of no difference in the percentage of drugs approved in the four 5-year periods that were eventually withdrawn is the lack of any change in the rigour of the premarket evaluation system and the postmarket surveillance systems. The 1271-day median time between Notice of Compliance and withdrawal emphasizes the need to be particularly cautious in prescribing new drugs early in their life cycle.
On 1 April 2013, Canada’s Council of the Federation (a body of provincial and territorial premiers) launched a pan-Canadian pricing scheme to improve the affordability of 6 generic medicines (amlodipine, atorvastatin, omeprazole, rabeprazole, ramipril, and venlafaxine), which represent about 20% of publicly funded spending on generic drugs. The Council set a price ceiling on these drugs at 18% of the equivalent innovator medicine’s price, which was predicted to save an estimated $100 million for government drug plans. To test whether the Council’s price ceiling will result in generic drug prices comparable to those in other countries, we obtained data on the pan-provincial reimbursement prices of the 6 medicines and compared them with prices in the United States, New Zealand, Sweden, the United Kingdom, and Germany. In 69 pairwise comparisons of the newly reduced prices on these generic products, we found that 55 (80%) were still more expensive in Canada than in the 5 other countries studied . The Council’s new approach does reduce the cost of generic medicines, but even with this imposed price ceiling, Canadians continue to overpay for generic medicines. We conclude that much more money could be saved, were it not for the fact that the Council’s approach is inferior to that of other countries. We suggest that the Council of the Federation better could harness competition or negotiation by returning to its initial but unfulfilled plan of instituting a national competitive bidding process for generic medicines. Normal 0 false false false EN-US JA X-NONE
Despite its popularity in medical circles, Wikipedia endures skepticism. Often used to gather information, it is rarely considered accurate or complete enough to guide treatment decisions In the face of this, clinicians and trainees turn to resources like UpToDate with greater frequency and confidence because in clinical medicine, a small error can make a big difference. In this issue of Open Medicine, we've published the first ever formally peer-reviewed, and edited, Wikipedia article. The clinical topic is Dengue Fever. Though there may be a need for shorter, more focused clinical articles published elsewhere as this one expands, it is anticipated that the Wikipedia page on Dengue will be a reference against which all others can be compared. Though it might be decades before we see an end to Dengue, perhaps the end to exhaustive or expensive searches about what yet needs to be done, can bring it sooner.
BACKGROUND:Diagnosis and treatment for venous thromboembolic disease (VTE) have evolved considerably through diagnostic and therapeutic innovations. Despite their considerable potential for enhancing care, however, the extent to which these innovations are being adopted in usual practice is unknown. We documented the infrastructure available in hospitals and health regions across Canada for provision of optimal diagnosis and therapy for VTE disease.METHODS:Over the period January 2008 through October 2009, we studied health system infrastructure for care of VTE disease in Canada's 10 provinces and 3 territories and all 94 health regions therein. We interviewed health system managers and/or clinical leaders from all 658 acute care hospitals in Canada and documented key elements of health system infrastructure at the hospital level for these institutions.RESULTS:There was considerable variation across Canada in the availability of key infrastructure for the diagnosis and management of VTE disease. Provinces with higher populations tended to have a large proportion of hospitals with capability to measure d-dimer levels, whereas less populated provinces were more likely to send samples to centralized analysis facilities for d-dimer testing. All provinces and territories had some facilities offering advanced diagnostic imaging, but the number of institutions and the availability of imaging were highly variable (with the proportion offering at least limited availability ranging from 0% to 90%). Only 6 provinces had regions with availability of dedicated early and/or long-term outpatient clinics for VTE disease.CONCLUSIONS:Infrastructure in Canada for optimal care of patients with VTE disease was suboptimal during the study period and was not entirely in step with the evidence. Such shortfalls in health system infrastructure limit the extent to which health care providers can deliver optimal, evidence-based care to their patients. Nationwide evaluations of health system infrastructure such as this one should be undertaken internationally to better characterize quality of care and potential for improvement.
BACKGROUND:Patients with cancer consistently report conflict and anxiety when making decisions about complementary and alternative medicine (CAM) treatment. To design evidence-informed decision-support strategies, a better understanding is needed of how the decision-making process unfolds for these patients during their experience with cancer. We undertook this study to review the research literature regarding CAM-related decision-making by patients with cancer within the context of treatment, survivorship, and palliation. We also aimed to summarize emergent concepts within a preliminary conceptual framework.METHODS:We conducted an integrative literature review, searching 12 electronic databases for articles published in English that described studies of the process, context, or outcomes of CAM-related decision-making. We summarized descriptive data using frequencies and used a descriptive constant comparative method to analyze statements about original qualitative results, with the goal of identifying distinct concepts pertaining to CAM-related decision-making by patients with cancer and the relationships among these concepts.RESULTS:Of 425 articles initially identified, 35 met our inclusion criteria. Seven unique concepts related to CAM and cancer decision-making emerged: decision-making phases, information-seeking and evaluation, decision-making roles, beliefs, contextual factors, decision-making outcomes, and the relationship between CAM and conventional medical decision-making. CAM decision-making begins with the diagnosis of cancer and encompasses 3 distinct phases (early, mid, and late), each marked by unique aims for CAM treatment and distinct patterns of information-seeking and evaluation. Phase transitions correspond to changes in health status or other milestones within the cancer trajectory. An emergent conceptual framework illustrating relationships among the 7 central concepts is presented.INTERPRETATION:CAM-related decision-making by patients with cancer occurs as a nonlinear, complex, dynamic process. The conceptual framework presented here identifies influential factors within that process, as well as patients' unique needs during different phases. The framework can guide the development and evaluation of theory-based decision-support programs that are responsive to patients' beliefs and preferences.
The article examines the recent Physician Sunshine Act in the Unites States and assesses its efficacy in tackling the issue of commericial conflicts of interest in medicine.
Dengue fever, also known as breakbone fever, is a mosquito-borne infectious tropical disease caused by the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles. In a small proportion of cases, the disease develops into life-threatening dengue hemorrhagic fever, which results in bleeding, thrombocytopenia, and leakage of blood plasma, or into dengue shock syndrome, in which dangerously low blood pressure occurs. Treatment of acute dengue fever is supportive, with either oral or intravenous rehydration for mild or moderate disease and use of intravenous fluids and blood transfusion for more severe cases. Along with attempts to eliminate the mosquito vector, work is ongoing to develop a vaccine and medications targeted directly at the virus.
The authors present and describe a decision tree to provide guidance to clinicians who are administering medications to or prescribing for lactating (i.e., producing milk) and breastfeeding patients. It also applies to any patients who are expressing or pumping their milk to be used for feeding immediately or to be stored for future use or donation. Breastfeeding initiation rates and the duration of breastfeeding have increased dramatically in Canada over the past decades. As a result, lactating and breastfeeding patients are increasingly seen in many nonobstetric areas of health care, including emergency departments, radiology suites, and surgical departments. The decision tree has been designed for decision-making about any medication, including diagnostic agents, hormones, vaccines, herbs, over-the-counter products, and chemotherapeutic agents. The decision tree prompts clinicians to consider whether a medication can be deferred or, if it is required, how to make decisions about compatible or contraindicated medications. Given the benefits of breastfeeding to patients and their babies and children, clinicians should ensure that they promote, support, and protect breastfeeding when administering and prescribing medications.
BACKGROUND:Elevators are ubiquitous and active inside hospitals, potentially facilitating bacterial transmission. The objective of this study was to estimate the prevalence of bacterial colonization on elevator buttons in large urban teaching hospitals. METHODS:A total of 120 elevator buttons and 96 toilet surfaces were swabbed over separate intervals at 3 tertiary care hospitals on weekdays and weekends in Toronto, Ontario. For the elevators, swabs were taken from 2 interior buttons (buttons for the ground floor and one randomly selected upper-level floor) and 2 exterior buttons (the "up" button from the ground floor and the "down" button from the upper-level floor). For the toilet surfaces, swabs were taken from the exterior and interior handles of the entry door, the privacy latch, and the toilet flusher. Samples were obtained using standard bacterial collection techniques, followed by plating, culture, and species identification by a technician blind to sample source. RESULTS:The prevalence of colonization of elevator buttons was 61% (95% confidence interval 52%-70%). No significant differences in colonization prevalence were apparent in relation to location of the buttons, day of the week, or panel position within the elevator. Coagulase-negative staphylococci were the most common organisms cultured, whereas Enterococcus and Pseudomonas species were infrequent. Elevator buttons had a higher prevalence of colonization than toilet surfaces (61% v. 43%, p = 0.008). CONCLUSIONS:Hospital elevator buttons were commonly colonized by bacteria, although most pathogens were not clinically relevant. The risk of pathogen transmission might be reduced by simple countermeasures.
Background: Francophones who live outside the primarily French-speaking province of Quebec, Canada, risk being excluded from research by lack of a sampling frame. We examined the adequacy of random sampling, advertising, and respondent-driven sampling for recruitment of francophones for survey research. Methods: We recruited francophones residing in the city of Calgary, Alberta, through advertising and respondentdriven sampling. These 2 samples were then compared with a random subsample of Calgary francophones derived from the 2006 Canadian Community Health Survey (CCHS). We assessed the effectiveness of advertising and respondent-driven sampling in relation to the CCHS sample by comparing demographic characteristics and selected items from the CCHS (specifically self-reported general health status, perceived weight, and having a family doctor). Results: We recruited 120 francophones through advertising and 145 through respondent-driven sampling; the random sample from the CCHS consisted of 259 records. The samples derived from advertising and respondentdriven sampling differed from the CCHS in terms of age (mean ages 41.0, 37.6, and 42.5 years, respectively), sex (proportion of males 26.1%, 40.6%, and 56.6%, respectively), education (college or higher 86.7% , 77.9% , and 59.1%, respectively), place of birth (immigrants accounting for 45.8%, 55.2%, and 3.7%, respectively), and not having a regular medical doctor (16.7%, 34.5%, and 16.6%, respectively). Differences were not tested statistically because of limitations on the analysis of CCHS data imposed by Statistics Canada. Interpretation: The samples generated exclusively through advertising and respondent-driven sampling were not representative of the gold standard sample from the CCHS. Use of such biased samples for research studies could generate misleading results.
A noninferiority trial is designed to demonstrate that an experimental therapy is not worse than an active control. Although noninferiority trials are superficially similar to conventional superiority trials, there are fundamental differences. In particular, aspects of a study that make the therapies appear more similar than they actually are can falsely bias the study toward demonstrating noninferiority. This has important implications for methodologic techniques such as blinding and statistical analysis based on the intention-to-treat principle. When applying the results of noninferiority trials, clinicians should be judicious in determining whether the degree of noninferiority demonstrated is clinically acceptable and whether the ancillary benefits of the treatment justify its use.
BACKGROUND:Gestational diabetes mellitus is associated with an increased risk of incident type 2 diabetes and has deleterious effects on other cardiovascular risk factors. However, the effect of gestational diabetes on the risk of cardiovascular disease remains unclear. We conducted a scoping review of the literature to examine the association between these 2 conditions. METHODS:We systematically searched the PubMed and Embase databases for studies examining the association between gestational diabetes and cardiovascular disease. We restricted our search to studies involving humans that were published in English or French. Outcomes of interest included acute coronary syndromes, angina, arrhythmia, coronary artery disease, heart failure, myocardial infarction, stroke, and composite end points with these outcomes. RESULTS:A total of 11 publications (3 cohort studies [1 published as an abstract], 2 cross-sectional studies, 1 case-control study [published as an abstract], 4 narrative reviews, and 1 editorial) met our inclusion criteria. The 2 cohort studies published as full manuscripts were conducted in overlapping populations. The included studies reported a range of adjusted relative risks for incident cardiovascular disease, from not significant to 1.85 (95% confidence interval [CI] 1.21 to 2.82). Adjustment for subsequent type 2 diabetes mellitus attenuated the effects but with wide 95% CIs that spanned unity (range 1.13 [95% CI 0.67 to 1.89] to 1.56 [95% CI 1.00 to 2.43]). INTERPRETATION:Available data suggest that gestational diabetes is associated with an increased risk of cardiovascular disease. However, these data are limited, and evidence regarding this association independent of the increased risk due to subsequent type 2 diabetes and other risk factors for cardiovascular disease remains inconclusive.
Background: There is growing scientific evidence and public acknowledgment of the failure and harms of cannabis prohibition, and increasing support for cannabis legalization. What is missing is a discussion about the relative merits of different regulatory frameworks, including how a public health approach could be used to minimise the harms and maximise the benefits of cannabis. T he purpose of this paper is to inform the scientific and public dialogue by offering a proposal for cannabis regulation derived from evidence-based public health oriented recommendations for alcohol and tobacco. Methods: Since there is very limited evidence base for public health oriented cannabis regulation as an alternative to cannabis global cannabis prohibition, and there is a substantial body of knowledge regarding the public health oriented regulatory evidence base for alcohol and tobacco, we examined international syntheses of evidence based recommendations for public health oriented alcohol and tobacco regulation to identify options that have been shown to have public health benefits. Results : This paper describes a model of how cannabis could be regulated to control availability and accessibility (control structure, retail sales, price), purchase, consumption, use, supply (production, product) and demand drivers (promotion, packaging) that could be researched as part of evaluating a strategy of public health regulation of cannabis. Interpretation: As the public opinion supporting cannabis “legalization” is growing, proactive, rigorously evaluated action based on a public health approach needs to be taken. Otherwise a commercial exploitation model may result such that similar health and social problems as those associated with alcohol and tobacco may be repeated. Alcohol and tobacco evidence based recommendations suggest that a comprehensive public health approach to cannabis regulation could contain or reduce health and social problems that presently exist in the setting of cannabis prohibition, while allowing for benefits to accrue.
BACKGROUND:The Permanent Resident Database of Citizenship and Immigration Canada (CIC) contains sociodemographic information on immigrants but lacks ethnic group classifications. To enhance its usability for ethnicityrelated research, we categorized immigrants in the CIC database into one of Canada's official visible minority groups or a white category using their country of birth and mother tongue.METHODS:Using public data sources, we classified each of 267 country names and 245 mother tongues in the CIC data into 1 of 10 visible minority groups (South Asian, Chinese, black, Latin American, Filipino, West Asian, Arab, Southeast Asian, Korean, and Japanese) or a white group. We then used country of birth alone (method A) or country of birth plus mother tongue (method B) to classify 2.5 million people in the CIC database who immigrated to Ontario between 1985 and 2010 and who had a valid encrypted health card number. We validated the ethnic categorizations using linked selfreported ethnicity data for 6499 people who responded to the Canadian Community Health Survey (CCHS).RESULTS:Among immigrants listed in the CIC database, the 4 most frequent visible minority groups as classified by method B were South Asian (n = 582 812), Chinese (n = 400 771), black (n = 254 189), and Latin American (n = 179 118). Methods A and B agreed in 94% of the categorizations (kappa coefficient 0.94, 95% confidence interval [CI] 0.93-0.94). Both methods A and B agreed with self-reported CCHS ethnicity in 86% of all categorizations (for both comparisons, kappa coefficient 0.83, 95% CI 0.82-0.84). Both methods A and B had high sensitivity and specificity for most visible minority groups when validated using self-reported ethnicity from the CCHS (e.g., with method B, sensitivity and specificity were, respectively, 0.85 and 0.97 for South Asians, 0.93 and 0.99 for Chinese, and 0.90 and 0.97 for blacks).INTERPRETATION:The use of country of birth and mother tongue is a validated and practical method for classifying immigrants to Canada into ethnic categories.
