A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity.

OBJECTIVE: To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. DESIGN: We used the Delphi method. SETTING: A multiquestion electronic survey. PARTICIPANTS: Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. INTERVENTIONS: After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. MAIN OUTCOME MEASURES: Not applicable. RESULTS: When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. CONCLUSIONS: These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.

Smoking, smoking cessation and heart disease risk: A 16-year follow-up study.

BACKGROUND: Smoking is a major risk factor for heart disease. Over the past decade, the prevalence of smoking and the number of cigarettes smoked per day have decreased in Canada. Using a contemporary cohort of Canadian men and women, this study measured associations between smoking, smoking cessation and heart disease. METHODS: The study is based on nine cycles of data (1994/1995 through 2010/2011) from the National Population Health Survey, which collected information on smoking status every two years. The study sample consists of 4,712 men and 5,715 women aged 25 or older and free from heart disease in 1994/1995. Heart disease was determined by self-report of diagnosis, medication for, or death from heart disease. Relative risks of incident heart disease were compared among current daily smokers, former daily smokers, and those who never smoked daily. RESULTS: Compared with those who had never smoked daily, current daily smokers had a 60% higher risk of incident heart disease during the follow-up period. The risks were lower among current daily smokers who consumed fewer cigarettes. Although smoking cessation was associated with a lower risk of heart disease, 20 or more years of continuous cessation were required for the risk to approach that of people who never smoked daily. INTERPRETATION: Smoking cessation and cutting down the number of cigarettes smoked per day reduce the risk of heart disease.

Dynamics of smoking cessation and health-related quality of life among Canadians.

BACKGROUND: People who smoke are at increased risk of lung and other cancers, heart attack, stroke, chronic lung disease and premature death. After smoking cessation, these risks diminish, but little is known about the time required to regain the level of health of people who have never smoked. This analysis describes trajectories of health-related quality of life (HRQL) in relation to smoking status, focusing on the time required for former smokers to achieve an HRQL level similar to that of never-smokers. METHODS: Data were from nine cycles (1994/1995 through 2010/2011) of the National Population Health Survey. Analyses were based on longitudinal data for 3,341 men and 4,143 women aged 40 or older in 1994/1995. Multi-level growth modelling was used to describe HRQL trajectories over the 16-year follow-up period in relation to smoking status, which was updated every two years. RESULTS: Across all ages and for both sexes, persistent smokers had lower HRQL than did never-smokers. Among men, HRQL improved after 5 years of quitting; after 20 years, HRQL was similar to that of never-smokers. Among women, after 10 years of cessation, the HRQL of former smokers was clinically similar to that of those who had never smoked. INTERPRETATION: At any age, and for both men and women, long-term smoking cessation results in improvements in HRQL.

Employer-provided support services and job dissatisfaction in Canadian registered nurses.

BACKGROUND: Previous research indicates that nurses' job dissatisfaction relates to their work organization and environment; rarely has the contribution of employer provided support services been examined while controlling for the influence of other factors. OBJECTIVE: The objective of this study was to examine job dissatisfaction among Canadian registered nurses in relation to employer-provided programs for child care and fitness or recreation. METHODS: Data are from 2,993 respondents to the 2005 National Survey of the Work and Health of Nurses, weighted to represent Canada's 91,600 registered nurses in full-time, permanent positions who deliver direct care in hospitals or long-term care facilities. Multivariate modeling was used to examine job dissatisfaction in relation to employer-provided support programs, controlling for personal characteristics and variables reflecting work organization and the work environment. RESULTS: Employer-provided child care assistance programs were available to 16% of nurses, and fitness or recreation programs were available to 38%. An estimated 13% of nurses were dissatisfied with their jobs. Even when controlling for personal characteristics, overtime, shift work, shift length, weekly hours, overload, staffing inadequacy, autonomy, nurse-physician relations, and coworker respect, inverse associations with job dissatisfaction emerged for employer-supported child care (odds ratio = 0.49, 95% confidence interval = 0.27-0.88) and fitness programs (odds ratio = 0.65, 95% confidence interval = 0.42-0.99). DISCUSSION: This study provides new information suggesting that employer-provided support programs are protective against nurses' job dissatisfaction. This is a key finding in view of nursing shortages and the importance of job satisfaction to retention.

Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades.

BACKGROUND: Analyses of medication databases indicate marked increases in prescribing of antihypertensive drugs in Canada over the past decade. This study was done to examine the trends in the prevalence of hypertension and in control rates in Canada between 1992 and 2009. METHODS: Three population-based surveys, the 1986-1992 Canadian Heart Health Surveys, the 2006 Ontario Survey on the Prevalence and Control of Hypertension and the 2007-2009 Canadian Health Measures Survey, collected self-reported health information from, and measured blood pressure among, community-dwelling adults. RESULTS: The population prevalence of hypertension was stable between 1992 and 2009 at 19.7%-21.6%. Hypertension control improved from 13.2% (95% confidence interval [CI] 10.7%-15.7%) in 1992 to 64.6% (95% CI 60.0%-69.2%) in 2009, reflecting improvements in awareness (from 56.9% [95% CI 53.1%-60.5%] in 1992 to 82.5% [95% CI 78.5%-86.0%] in 2009) and treatment (from 34.6% [95% CI 29.2%-40.0%] in 1992 to 79.0% [95% CI 71.3%-86.7%] in 2009) among people with hypertension. The size of improvements in awareness, treatment and control were similar among people who had or did not have cardiovascular comorbidities Although systolic blood pressures among patients with untreated hypertension were similar between 1992 and 2009 (ranging from 146 [95% CI 145-147] mm Hg to 148 [95% CI 144-151] mm Hg), people who did not have hypertension and patients with hypertension that was being treated showed substantially lower systolic pressures in 2009 than in 1992 (113 [95% CI 112-114] v. 117 [95% CI 117-117] mm Hg and 128 [95% CI 126-130] v. 145 [95% CI 143-147] mm Hg). INTERPRETATION: The prevalence of hypertension has remained stable among community-dwelling adults in Canada over the past two decades, but the rates for treatment and control of hypertension have improved markedly during this time.

Employer-provided support services and job dissatisfaction in Canadian registered nurses.

BACKGROUND: Previous research indicates that nurses' job dissatisfaction relates to their work organization and environment; rarely has the contribution of employer provided support services been examined while controlling for the influence of other factors. OBJECTIVE: The objective of this study was to examine job dissatisfaction among Canadian registered nurses in relation to employer-provided programs for child care and fitness or recreation. METHODS: Data are from 2,993 respondents to the 2005 National Survey of the Work and Health of Nurses, weighted to represent Canada's 91,600 registered nurses in full-time, permanent positions who deliver direct care in hospitals or long-term care facilities. Multivariate modeling was used to examine job dissatisfaction in relation to employer-provided support programs, controlling for personal characteristics and variables reflecting work organization and the work environment. RESULTS: Employer-provided child care assistance programs were available to 16% of nurses, and fitness or recreation programs were available to 38%. An estimated 13% of nurses were dissatisfied with their jobs. Even when controlling for personal characteristics, overtime, shift work, shift length, weekly hours, overload, staffing inadequacy, autonomy, nurse-physician relations, and coworker respect, inverse associations with job dissatisfaction emerged for employer-supported child care (odds ratio = 0.49, 95% confidence interval = 0.27-0.88) and fitness programs (odds ratio = 0.65, 95% confidence interval = 0.42-0.99). DISCUSSION: This study provides new information suggesting that employer-provided support programs are protective against nurses' job dissatisfaction. This is a key finding in view of nursing shortages and the importance of job satisfaction to retention.

Nurse-physician relations and quality of nursing care: findings from a national survey of nurses.

This article investigates the association between nurse-physician working relations and nurse-rated quality of nursing team care.The analysis is based on a nationally representative sample of registered nurses working in Canadian hospitals. Multiple logistic regression was used to examine the association between the quality of nurse-physician working relations and nurses' reports of fair or poor nursing team care on the last shift worked. Unfavourable quality of nurse-physician working relations was significantly related to lower quality of nursing team care, controlling for other potential influences. These influences included low nurse co-worker support, job dissatisfaction, and self-rated poor general health, each of which was also related to lower care quality.The analysis highlights the importance of interprofessional working relations to nurse-perceived quality of patient care in Canadian hospitals.

Employer-provided support services and job dissatisfaction in Canadian registered nurses.

BACKGROUND: Previous research indicates that nurses' job dissatisfaction relates to their work organization and environment; rarely has the contribution of employer-provided support services been examined while controlling for the influence of other factors. OBJECTIVE: The objective of this study was to examine job dissatisfaction among Canadian registered nurses in relation to employer-provided programs for child care and fitness or recreation. METHODS: Data are from 2,993 respondents to the 2005 National Survey of the Work and Health of Nurses, weighted to represent Canada's 91,600 registered nurses in full-time, permanent positions who deliver direct care in hospitals or long-term care facilities. Multivariate modeling was used to examine job dissatisfaction in relation to employer-provided support programs, controlling for personal characteristics and variables reflecting work organization and the work environment. RESULTS: Employer-provided child care assistance programs were available to 16% of nurses, and fitness or recreation programs were available to 38%. An estimated 13% of nurses were dissatisfied with their jobs. Even when controlling for personal characteristics, overtime, shift work, shift length, weekly hours, overload, staffing inadequacy, autonomy, nurse-physician relations, and coworker respect, inverse associations with job dissatisfaction emerged for employer-supported child care (odds ratio = 0.49, 95% confidence interval = 0.27-0.88) and fitness programs (odds ratio = 0.65, 95% confidence interval = 0.42-0.99). DISCUSSION: This study provides new information suggesting that employer-provided support programs are protective against nurses' job dissatisfaction. This is a key finding in view of nursing shortages and the importance of job satisfaction to retention.

Problem gambling in bipolar disorder: results from the Canadian Community Health Survey.

OBJECTIVE: This investigation was undertaken to explore the prevalence and associated features of problem gambling amongst individuals with bipolar I disorder. METHODS: The data for this analysis were procured from the Canadian Community Health Survey: Mental Health and Well-being (CCHS 1.2) conducted by Statistics Canada. Individuals screening positive for a lifetime (World Mental Health- Composite International Diagnostic Interview) WMH-CIDI-defined manic episode (i.e. bipolar I disorder) or depressive episode (i.e. major depressive disorder) and current (i.e. past 12-month) problem gambling were compared to the general population without these disorders. Past year problem gambling was operationalized with the Canadian Problem Gambling Index (CPGI). RESULTS: The sample consisted of 36,984 individuals (> or = 15 years old); the weighted prevalence of problem gambling was significantly higher (6.3%) amongst the population with bipolar disorder as compared to the general population (2.0%, p<0.001) and those with major depressive disorder (2.5%, p<0.01). Compared to those without bipolar disorder, the odds of problem gambling for bipolar individuals were over twice as high (OR=2.3; 95% CI 1.4-3.7), even when controlling for potential confounders. Males also had higher odds of problem gambling (OR=1.8; 95% CI 1.4-2.3), as did individuals without post-secondary education (OR=1.4; 95% CI 1.1-1.8). Persons who were married/cohabiting had lowered odds of problem gambling, compared with those who were unmarried (OR=0.6; 95% CI 0.5-0.8). Comorbid alcohol dependence (OR=3.4; 95% CI 2.3-5.0) and illicit drug dependence (OR=2.6; 95% CI 1.1-6.2) each conferred an increased risk for problem gambling. Physical activity level (moderate to active) was associated with a decreased risk for problem gambling (OR=0.8; 95% CI 0.6-0.9). CONCLUSIONS: Individuals with bipolar I disorder are differentially affected by problem gambling. Opportunistic screening for problem gambling is warranted, particularly in persons with comorbid alcohol or substance dependence.

Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization.

OBJECTIVE: This is the first cross-national population-based investigation exploring the prevalence and functional implications of comorbid general medical disorders in bipolar disorder. METHODS: Data were extracted from the Canadian Community Health Survey (N = 36,984). Analyses were conducted to ascertain the prevalence and prognostic implications of predetermined comorbid general medical disorders among persons who screened positive for a lifetime manic episode (indicative of a diagnosis of bipolar disorder). Within the subpopulation of people who screened positive for a manic episode, the effect of medical comorbidity on employment, functional role, psychiatric care, and medication use was examined. RESULTS: When the data were weighted to be representative of the household population of the ten provinces in 2002, an estimated 2.4 percent of respondents screened positive for a lifetime manic episode. Rates of chronic fatigue syndrome, migraine, asthma, chronic bronchitis, multiple chemical sensitivities, hypertension, and gastric ulcer were significantly higher in the bipolar disorder group (all p < .05). Chronic medical disorders were associated with a more severe course of bipolar disorder, increased household and work maladjustment, receipt of disability payments, reduced employment, and more frequent medical service utilization. CONCLUSIONS: Comorbid medical disorders in bipolar disorder are associated with several indices of harmful dysfunction, decrements in functional outcomes, and increased utilization of medical services.

Canadian trends in cancer prevalence.

BACKGROUND: Cancer prevalence trends are rarely reported in the published literature, and until now, have not been reported for Canada. DATA AND METHODS: Based on incidence data from the Canadian Cancer Registry linked with mortality data from the Canadian Vital Statistics Death Database, trends in prevalence proportions overtime were calculated by time since diagnosis for a large number of the most common cancers. RESULTS: Statistically significant increases in prevalence proportions were observed for most individual cancers, and most prevalence durations studied. Aging of the population contributed to these increases. Relatively large increases were observed for liver and thyroid cancer, while decreases occurred for cancers of the larynx and cervix uteri. INTERPRETATION: Information on how and why trends vary by cancer can inform resource allocation planning.

The difference in hypertension control between older men and women.

BACKGROUND: In Canada, as elsewhere, control of hypertension in older persons who are using antihypertensive medication is more likely in men than in women. The reasons for the observed difference are not known. DATA AND METHODS: Data are from cycle 1 of the 2007 to 2009 Canadian Health Measures Survey (CHMS). The CHMS includes a comprehensive questionnaire, automated blood pressure (BP) measures, and a variety of biological and anthropometric assessments. Frequencies, means, cross-tabulations and multivariate models were produced to study differences between the sexes in hypertension control in a weighted sample representative of the household population aged 60 to 79. RESULTS: The prevalence of hypertension was nearly equal among older men (60%) and women (59%), and the percentage of those with hypertension who were receiving pharmaceutical treatment was not statistically different (84% and 89%, respectively). However, despite current treatment, hypertension was uncontrolled in a substantially higher percentage of women (30%) than men (17%). The difference persisted when age, socio-economic status, co-morbidity, category of medication, anthropometry, and other correlates of hypertension were taken into account. INTERPRETATION: The factors considered in the analysis do not account for the advantage to older men in hypertension control. The findings underscore the importance of efforts to control blood pressure in older women.

An update on cancer survival.

Statistics Canada routinely produces cohort-based estimates for cancer survival; the most recent were based on cases diagnosed from 1992-2000. This report provides predicted survival estimates for cases diagnosed more recently. Using records from the Canadian Cancer Registry linked to the Canadian Vital Statistics Death Data Base, cancer- and age-specific estimates of relative survival have been calculated for 2004-2006. The five-year relative survival ratio (RSR) for all cancers combined was 62%, and ranged from 6% for pancreatic cancer to 98% for cancer of the thyroid. The RSR was typically higher at younger than older ages, with exceptions for some common cancers. From 1992-1994 to 2004-2006, the five-year RSR for a number of cancers increased--usually slightly, but in some cases, appreciably (for example, the age-standardized RSR for non-Hodgkin lymphoma rose from 51% to 63%; for leukemia, from 44% to 54%; and for liver, 9% to 17%).

Blood pressure in Canadian adults.

BACKGROUND: Hypertension is estimated to cause more than one-eighth of all deaths worldwide. In Canada, the last national surveys to include direct measures of blood pressure (BP) took place over the years 1985-1992; hypertension was estimated at 21%. DATA AND METHODS: Data are from cycle 1 of the Canadian Health Measures Survey, conducted from March 2007 through February 2009. The survey included direct BP measures using an automated device. Weighted frequencies, means and cross-tabulations were produced to estimate levels of hypertension awareness, treatment and control in the population aged 20 to 79 years. RESULTS: Among adults aged 20 to 79 years, hypertension (systolic BP higher than or equal to 140 or diastolic BP higher than or equal to 90 mm Hg, or self-reported recent medication use for high BP) was present in 19%. Another 20% had BP in the pre-hypertension range (systolic 120 to 139 or diastolic 80 to 89 mm Hg). Of those with hypertension, 83% were aware, 80% were taking antihypertensive drugs, and 66% were controlled. Uncontrolled hypertension was largely due to high systolic BP. INTERPRETATION: Hypertension prevalence is similar to that reported in 1992. Since then, the level of hypertension control has increased considerably.

Factors related to on-the-job abuse of nurses by patients.

BACKGROUND: Numerous studies indicate that health care providers, particularly nurses, face a high risk of on-the-job abuse from patients. This article examines physical and emotional abuse from patients in nurses working in hospitals or long-term care facilities. DATA AND METHODS: Data are from the 2005 National Survey of the Work and Health of Nurses. Cross-tabulations were used to examine abuse in relation to personal characteristics of the nurse, job characteristics, and workplace climate factors. Multiple logistic regression modeling was used to examine abuse in relation to staffing and resource adequacy and relations among colleagues, controlling for personal and job characteristics. RESULTS: In 2005, 34% of Canadian nurses providing direct care in hospitals or long-term care facilities reported physical assault by a patient in the previous year; 47% reported emotional abuse. Abuse was related to being male, having less experience, usually working non-day shifts, and perceiving staffing or resources as inadequate, nurse-physician relations as poor, and co-worker and supervisor support as low. Associations between abuse and staffing or resource inadequacy and poor working relations persisted when controlling for personal and job characteristics. INTERPRETATION: Modifiable factors are important to nurses' on-the-job safety.

An update on mammography use in Canada.

BACKGROUND: This article updates mammography use by Canadian women aged 50 to 69, and reports trends from 1990 to 2008 among the provinces. Characteristics of non-users are examined. DATA SOURCES AND METHODS: Data from the 2008 Canadian Community Health Survey (CCHS) were used to update mammography use and to examine factors associated with non-use. Historical estimates were produced using the 2000/2001,2003 and 2005 CCHS, the 1994/1995, 1996/1997 and 1998/1999 National Population Health Survey and the 1990 Health Promotion Survey. Frequency estimates, cross-tabulations and logistic regression analysis were used. RESULTS: In 2008, 72% of women aged 50 to 69 reported having had a mammogram in the past two years, up from 40% in 1990. The increase occurred from 1990 to 2000/2001; rates then stabilized. Between 1990 and 2000/2001, the difference in participation between women in the highest and lowest income quintiles gradually narrowed-from a 26- to a 12-percentage-point difference. In 2008, the disparity widened to 18 percentage points. Non-use was high in British Columbia, Prince Edward Island and Nunavut. Non-use was associated with being an immigrant, living in a lower income household, not having a regular doctor and smoking.

Colorectal cancer testing in Canada--2008.

OBJECTIVES: This article provides estimates of the report level of colorectal cancer (CRC) testing in the Canadian population aged 50 or older in 2008. DATA SOURCES AND METHODS: The data are from the 2008 Canadian Community Health Survey. With weighted data, the percentage of people who had undergone CRC testing (fecal occult blood test in the past two years or endoscopy within the past five years) was estimated. Bivariate and multivariate analyses were used to examine testing status in relation to personal, socio-economic and other health-related characteristics. RESULTS: In 2008, an estimated 40% of Canadians aged 50 or older reported that they had had CRC testing. The percentage ranged from 28% in Quebec to 53% in Manitoba. Testing was associated with being 65 or older, higher income, having a regular doctor, being a non-smoker, and being physically active. INTERPRETATION: Organized CRC screening was limited in 2008, but may account for some of the differences in participation among the provinces.

Smokers' use of acute care hospitals--a prospective study.

BACKGROUND: Previous Canadian estimates of hospital use by smoking history have been derived by applying disease-specific "smoking-attributable fractions" to administrative data. For this analysis, health survey data were linked to hospitalization data at an individual level, permitting prospective measures of hospital use by smoking status and age. DATA AND METHODS: Data for 28,255 respondents (outside Quebec) to the 2000/2001 Canadian Community Health Survey (CCHS) were linked to the Hospital Person-Oriented Information Database. Days in hospital over four years were quantified for each respondent and examined in relation to smoking status in 2000/2001. Multiple logistic regression was used to examine the association between smoking and hospitalization, while controlling for confounders. RESULTS: During the four years after their CCHS interview, current daily smokers and former daily smokers who had quit in the past five years averaged more than twice as many days in hospital as did never-daily smokers. Altogether, excess hospital days for current and former smokers aged 45 to 74 numbered 7.1 million over four years, and accounted for 32% of all hospital days used by people in this age group.

Cancer prevalence in the Canadian population.

BACKGROUND: The rising numbers of cancer diagnoses, together with improvements in survival, have led to increases in the prevalence of cancer in Canada. This article provides more precise and detailed estimates of cancer prevalence than have been available previously. DATA AND METHODS: Based on incidence data from the Canadian Cancer Registry linked with mortality data from the Canadian Vital Statistics Death Database, direct estimates of cancer prevalence as of January 1, 2005 were calculated for an extensive list of cancers, by time since diagnosis, age and sex. RESULTS: Two-, five- and ten-year cancer prevalence counts were 217,089 (675 per 100,000), 454,149 (1,412 per 100,000) and 722,833 (2,248 per 100,000), respectively. Breast (20.6% of ten-year prevalent cases), prostate (18.7%) and colorectal cancer (12.9%) were the most prevalent, together accounting for just over half of all cases. Prevalence proportions for all cancers combined increased dramatically with age, peaking at ages 80 to 84; proportions were higher in females than in males before age 60, and higher in males thereafter. INTERPRETATION: Prevalence data tabulated according to type of cancer, age and time since diagnoses provide important information about the demand for cancer-related health care and social services.

Correlates of medication error in hospitals.

OBJECTIVES: This article examines associations between medication error and selected factors in the workplace of hospital-employed registered nurses (RNs) in Canada. DATA SOURCES AND METHODS: Data are from the 2005 National Survey of the Work and Health of Nurses, and were weighted to be representative of all RNs in Canada who deliver direct care to hospital patients. Correlates of medication error were considered in bivariate and multivariate analyses. Multiple logistic regression modeling was used to examine medication error in relation to work organization and workplace environment, while controlling for personal factors, including nurses' general and mental health, job dissatisfaction, education, years of experience in nursing, and clinical area of employment. RESULTS: Nearly one-fifth (19%) of hospital RNs reported that medication error involving patients in their care had occurred "occasionally" or "frequently" in the past year. In the fully adjusted multivariate model, medication error was positively associated with usually working overtime, role overload, perceived staffing or resource inadequacy, low co-worker support, and low job security. Usually working a 12-hour shift, compared with shorter shifts, was negatively associated with medication error.