This review article explores the legislative differences across Canadian jurisdictions with respect to involuntary admission and treatment pending appeal. Some jurisdictions restrict involuntary admission for mental illness to when there is a risk for serious bodily harm or physical impairment. However, the majority of jurisdictions recognize non-bodily harms or substantial mental or physical deterioration as grounds for involuntary admission when other criteria are met. Once a person is involuntarily admitted, jurisdictions differ on how treatment is authorized and whether treatment can commence while a person contests a finding of incapacity to treatment to the courts. Some jurisdictions permit treatment pending appeal while others do not. This article compares Canadian jurisdictions’ mental health legislation and addresses discrepancies through the lens of the Canadian Charter of Rights and Freedoms and the Canada Health Act.

Early adversity increases risk for child mental health difficulties. Stressors in the home environment (e.g., parental mental illness, household socioeconomic challenges) may be particularly impactful. Attending out-of-home childcare may buffer or magnify negative effects of such exposures. Using a longitudinal observational design, we leveraged data from the NIH Environmental influences on Child Health Outcomes Program to test whether number of hours in childcare, defined as 1) any type of nonparental care and 2) center-based care specifically, was associated with child mental health, including via buffering or magnifying associations between early exposure to psychosocial and socioeconomic risks (age 0–3 years) and later internalizing and externalizing symptoms (age 3–5.5 years), in a diverse sample of N = 2,024 parent–child dyads. In linear regression models, childcare participation was not associated with mental health outcomes, nor did we observe an impact of childcare attendance on associations between risk exposures and symptoms. Psychosocial and socioeconomic risks had interactive effects on internalizing and externalizing symptoms. Overall, the findings did not indicate that childcare attendance positively or negatively influenced child mental health and suggested that psychosocial and socioeconomic adversity may need to be considered as separate exposures to understand child mental health risk in early life.

Background: Combating antibiotic resistance, exacerbated by widespread unnecessary outpatient antibiotic prescriptions, necessitates innovative stewardship solutions. Audit and feedback reports are effective but often resource heavy. We introduced a free, open-source system, Outpatient Automated Stewardship Information System (OASIS©), for automating the creation and distribution of recurring audit and feedback reports to clinicians to improve antibiotic prescribing. Methods: We used mixed methods to evaluate implementation of OASIS© across 11 clinics at Denver Health and Hospital Authority (DHHA) and Children’s Hospital Colorado (CHCO) from July 2022 to August 2023. Both sites host their own Epic® electronic healthcare and enterprise data warehouse systems. R statistical software was utilized to retrieve and process the data needed to create individual[HCM1] clinician audit and feedback reports with peer comparison. Reports were provided for 1) antibiotics prescribed for respiratory diagnoses, 2) antibiotics prescribed for respiratory diagnoses where antibiotics are never indicated, 3) first-line antibiotic prescribing for acute otitis media (AOM), and 4) five-day duration of antibiotics for children two years and older with AOM. Feedback reports for each metric were emailed to clinicians for three consecutive months. The primary outcome was adaptations needed to implement OASIS©. Secondary outcomes included fidelity (measured by email readership), time to set up and maintain the program, and barriers and facilitators to implementation (assessed by four qualitative interviews with OASIS© stakeholders). Results: The most significant adaptations made pertained to the automation of OASIS© reports for organizations not using R for data retrieval and reporting, setting up OASIS© specific email addresses, and validating clinician fidelity via read receipts. Fidelity was higher at DHHA (91-100%) compared to CHCO (10-30%). When interviewed, data analysts expressed that time for initial setup ranged from 1-6 hours. After reporting was automated, the estimated monthly time to send reports was 10 minutes. Views on setup complexity were split, but all recognized the readability of the reports and OASIS©’s value for improving prescribing behaviors. The greatest barriers to implementation included obtaining analytic resources for initial setup and the need to download additional R packages. No interviewee had prior experience creating audit and feedback reports. Conclusions: Implementing OASIS© requires addressing system diversity and knowledge gaps in outpatient informatics and antibiotic stewardship. Despite these challenges, the tool proved efficient and beneficial for monitoring and reporting antimicrobial prescribing. This free tool could likely be effectively disseminated to other health systems given the limited time and resources required for adaptations, setup, and monitoring. [HCM1]I

Fetal exposure to prenatal stress can increase risk for psychopathology but postnatal caregiving may offset risk. This study tests whether maternal sensitivity and the home environment during early childhood modify associations of prenatal stress with offspring behavior in a sample of 127 mother–child pairs (n = 127). Mothers reported on perceived stress during pregnancy. Maternal sensitivity was rated by coders during a parent–child free play task when children were 4 years old. One year later, mothers reported on the home environment, child internalizing and externalizing behaviors, and children completed an assessment of inhibitory control. As hypothesized, the early childhood caregiving environment modified associations of prenatal stress with child behavior. Specifically, prenatal stress was associated with more internalizing behaviors at lower levels of maternal sensitivity and in home environments that were lower in emotional support and cognitive stimulation, but not at mean or higher levels. Furthermore, prenatal stress was associated with lower inhibitory control only at lower levels of maternal sensitivity, but not at higher levels. Maternal sensitivity and an emotionally supportive and cognitively stimulating home environment in early childhood may be important factors that mitigate risk for mental health problems among children exposed to prenatal stress.

Oral anticoagulation (OAC) prevents stroke in atrial fibrillation, yet a residual stroke risk remains. In this single-center retrospective analysis of acute ischemic stroke patients despite OAC, suboptimal OAC treatment is common (30%: inappropriate dosing (17%); patient non-adherence (13%)). Other causes of stroke included OAC interruption (14.5%), a competing stroke mechanism (11.0%), and undetermined breakthrough stroke in 44.5%. Overall, easily modifiable causes of ischemic stroke despite OAC are common. Accordingly, strategies to improve treatment compliance, including appropriate dosing along with guideline-based risk factor and periprocedural OAC management, should be emphasized to improve secondary stroke prevention in this patient population.

Human activities are increasingly impacting our oceans and the focus tends to be on their environmental impacts, rather than consequences for animal welfare. Global shipping density has quadrupled since 1992. Unsurprisingly, increased levels of vessel collisions with cetaceans have followed this global expansion of shipping. This paper is the first to attempt to consider the severity of ship-strike on individual whale welfare. The methodology of the ‘Welfare Assessment Tool for Wild Cetaceans’ (WATWC) was used, which is itself based upon the Five Domains model. Expert opinion was sought on six hypothetical but realistic case studies involving humpback whales (Megaptera novaeangliae) struck by ships. Twenty-nine experts in the cetacean and welfare sector took part. They were split into two groups; Group 1 first assessed a case we judged to be the least severe and Group 2 first assessed the most severe. Both groups then additionally assessed the same four further cases. This was to investigate whether the severity of the first case influenced judgements regarding subsequent cases (i.e. expert judgements were relative) or not (i.e. judgements were absolute). No significant difference between the two groups of assessors was found; therefore, the hypothesis of relative scoring was rejected. Experts judged whales may suffer some level (>1) of overall (Domain 5) harm for the rest of their lives following a ship-strike incident. Health, closely followed by Behaviour were found to be the welfare aspects most affected by ship-strikes. Overall, the WATWC shows a robust potential to aid decision-making on wild cetacean welfare.

High-quality evidence from prospective longitudinal studies in humans is essential to testing hypotheses related to the developmental origins of health and disease. In this paper, the authors draw upon their own experiences leading birth cohorts with longitudinal follow-up into adulthood to describe specific challenges and lessons learned. Challenges are substantial and grow over time. Long-term funding is essential for study operations and critical to retaining study staff, who develop relationships with participants and hold important institutional knowledge and technical skill sets. To maintain contact, we recommend that cohorts apply multiple strategies for tracking and obtain as much high-quality contact information as possible before the child’s 18th birthday. To maximize engagement, we suggest that cohorts offer flexibility in visit timing, length, location, frequency, and type. Data collection may entail multiple modalities, even at a single collection timepoint, including measures that are self-reported, research-measured, and administrative with a mix of remote and in-person collection. Many topics highly relevant for adolescent and young adult health and well-being are considered to be private in nature, and their assessment requires sensitivity. To motivate ongoing participation, cohorts must work to understand participant barriers and motivators, share scientific findings, and provide appropriate compensation for participation. It is essential for cohorts to strive for broad representation including individuals from higher risk populations, not only among the participants but also the staff. Successful longitudinal follow-up of a study population ultimately requires flexibility, adaptability, appropriate incentives, and opportunities for feedback from participants.

The developmental origins of psychopathology begin before birth and perhaps even prior to conception. Understanding the intergenerational transmission of psychopathological risk is critical to identify sensitive windows for prevention and early intervention. Prior research demonstrates that maternal trauma history, typically assessed retrospectively, has adverse consequences for child socioemotional development. However, very few prospective studies of preconception trauma exist, and the role of preconception symptoms of posttraumatic stress disorder (PTSD) remains unknown. The current study prospectively evaluates whether maternal preconception PTSD symptoms predict early childhood negative affectivity, a key dimension of temperament and predictor of later psychopathology. One hundred and eighteen women were recruited following a birth and prior to conception of the study child and were followed until the study child was 3–5 years old. Higher maternal PTSD symptoms prior to conception predicted greater child negative affectivity, adjusting for concurrent maternal depressive symptoms and sociodemographic covariates. In exploratory analyses, we found that neither maternal prenatal nor postpartum depressive symptoms or perceived stress mediated this association. These findings add to a limited prospective literature, highlighting the importance of assessing the mental health of women prior to conception and providing interventions that can disrupt the intergenerational sequelae of trauma.

Background: Peritoneal dialysis is a type of dialysis performed by patients in their homes; patients receive training from dialysis clinic staff. Peritonitis is a serious complication of peritoneal dialysis, most commonly caused by gram-positive organisms. During March‒April 2019, a dialysis provider organization transitioned ~400 patients to a different manufacturer of peritoneal dialysis equipment and supplies (from product A to B). Shortly thereafter, patients experienced an increase in peritonitis episodes, caused predominantly by gram-negative organisms. In May 2019, we initiated an investigation to determine the source. Methods: We conducted case finding, reviewed medical records, observed peritoneal dialysis procedures and trainings, and performed patient home visits and interviews. A 1:1 matched case–control study was performed in 1 state. A case had ≥2 of the following: (1) positive peritoneal fluid culture, (2) high peritoneal fluid white cell count with ≥50% polymorphonuclear cells, or (3) cloudy peritoneal fluid and/or abdominal pain. Controls were matched to cases by week of clinic visit. Conditional logistic regression was used to estimate univariate matched odds ratios (mOR) and 95% confidence intervals (CIs). We conducted microbiological testing of peritoneal dialysis fluid bags to rule out product contamination. Results: During March‒September 2019, we identified 157 cases of peritonitis across 15 clinics in 2 states (attack rate≍39%). Staphylococcus spp (14%), Serratia spp (12%) and Klebsiella spp (6.3%) were the most common pathogens. Steps to perform peritoneal dialysis using product B differed from product A in several key areas; however, no common errors in practice were identified to explain the outbreak. Patient training on transitioning products was not standardized. Outcomes of the 73 cases in the case–control study included hospitalization (77%), peritoneal dialysis failure (40%), and death (7%). The median duration of training prior to product transition was 1 day for cases and controls (P = .86). Transitioning to product B (mOR, 18.00; 95% CI, 2.40‒134.83), using product B (mOR, 18.26; 95% CI, 3.86‒∞), drain-line reuse (mOR, 4.67; 95% CI, 1.34‒16.24) and performing daytime exchanges (mOR, 3.63; 95% CI, 1.71‒8.45) were associated with peritonitis. After several interventions, including transition of patients back to product A (Fig. 1), overall cases declined. Sterility testing of samples from 23 unopened product B peritoneal dialysis solution bags showed no contamination. Conclusions: Multiple factors may have contributed to this large outbreak, including a rapid transition in peritoneal dialysis products and potentially inadequate patient training. Efforts are needed to identify and incorporate best training practices, and product advances are desired to improve the safety of patient transitions between different types of peritoneal dialysis equipment.

Funding: None

Disclosures: None