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Horn A, Adgent MA, Osmundson SS, Wiese AD, Phillips SE, Patrick SW, Griffin MR, Grijalva CG. Risk of Death at 1 Year Following Postpartum Opioid Exposure. Am J Perinatol 2024; 41:949-960. [PMID: 35640619 PMCID: PMC9708936 DOI: 10.1055/s-0042-1745848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births. METHODS In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007-2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis. RESULTS Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings. CONCLUSION Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers. KEY POINTS · Opioid prescribing in the postpartum period is common.. · Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events.. · > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death..
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Affiliation(s)
- Arlyn Horn
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Margaret A. Adgent
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah S. Osmundson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew D. Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Sharon E. Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Stephen W. Patrick
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Marie R. Griffin
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Veterans’ Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - Carlos G. Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Veterans’ Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
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Aflaki K, Vigod SN, Sprague AE, Cook J, Berger H, Aoyama K, Jhirad R, Ray JG. Maternal Deaths Using Coroner's Data: A Latent Class Analysis. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102349. [PMID: 38190888 DOI: 10.1016/j.jogc.2024.102349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Knowledge regarding the antecedent clinical and social factors associated with maternal death around the time of pregnancy is limited. This study identified distinct subgroups of maternal deaths using population-based coroner's data, and that may inform ongoing preventative initiatives. METHODS A detailed review of coroner's death files was performed for all of Ontario, Canada, where there is a single reporting mechanism for maternal deaths. Deaths in pregnancy, or within 365 days thereafter, were identified within the Office of the Chief Coroner for Ontario database, 2004-2020. Variables related to the social and clinical circumstances surrounding the deaths were abstracted in a standardized manner from each death file, including demographics, forensic information, nature and cause of death, and antecedent health and health care factors. These variables were then entered into a latent class analysis (LCA) to identify distinct types of deaths. RESULTS Among 273 deaths identified in the study period, LCA optimally identified three distinct subgroups, namely, (1) in-hospital deaths arising during birth or soon thereafter (52.7% of the sample); (2) accidents and unforeseen obstetric complications also resulting in infant demise (26.3%); and (3) out-of-hospital suicides occurring postpartum (21.0%). Physical injury (22.0%) was the leading cause of death, followed by hemorrhage (16.8%) and overdose (13.3%). CONCLUSION Peri-pregnancy maternal deaths can be classified into three distinct sub-types, with somewhat differing causes. These findings may enhance clinical and policy development aimed at reducing pregnancy mortality.
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Affiliation(s)
- Kayvan Aflaki
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Simone N Vigod
- Department of Psychiatry, Women's College Hospital, Toronto, Canada
| | - Ann E Sprague
- Better Outcomes Registry and Network - Ontario, Ottawa, Canada
| | - Jocelynn Cook
- Society of Obstetricians and Gynecologists of Canada, Ottawa, Canada
| | - Howard Berger
- Departments of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Canada
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Reuven Jhirad
- Office of the Chief Coroner for Ontario/Ontario Forensic Pathology Service, Toronto, Canada
| | - Joel G Ray
- Departments of Medicine and Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Canada.
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Dayan N, Shapiro GD, Luo J, Guan J, Fell DB, Laskin CA, Basso O, Park AL, Ray JG. Development and internal validation of a model predicting severe maternal morbidity using pre-conception and early pregnancy variables: a population-based study in Ontario, Canada. BMC Pregnancy Childbirth 2021; 21:679. [PMID: 34615477 PMCID: PMC8496026 DOI: 10.1186/s12884-021-04132-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 09/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improvement in the prediction and prevention of severe maternal morbidity (SMM) - a range of life-threatening conditions during pregnancy, at delivery or within 42 days postpartum - is a public health priority. Reduction of SMM at a population level would be facilitated by early identification and prediction. We sought to develop and internally validate a model to predict maternal end-organ injury or death using variables routinely collected during pre-pregnancy and the early pregnancy period. METHODS We performed a population-based cohort study using linked administrative health data in Ontario, Canada, from April 1, 2006 to March 31, 2014. We included women aged 18-60 years with a livebirth or stillbirth, of which one birth was randomly selected per woman. We constructed a clinical prediction model for the primary composite outcome of any maternal end-organ injury or death, arising between 20 weeks' gestation and 42 days after the birth hospital discharge date. Our model included variables collected from 12 months before estimated conception until 19 weeks' gestation. We developed a separate model for parous women to allow for the inclusion of factors from previous pregnancy(ies). RESULTS Of 634,290 women, 1969 experienced the primary composite outcome (3.1 per 1000). Predictive factors in the main model included maternal world region of origin, chronic medical conditions, parity, and obstetrical/perinatal issues - with moderate model discrimination (C-statistic 0.68, 95% CI 0.66-0.69). Among 333,435 parous women, the C-statistic was 0.71 (0.69-0.73) in the model using variables from the current (index) pregnancy as well as pre-pregnancy predictors and variables from any previous pregnancy. CONCLUSIONS A combination of factors ascertained early in pregnancy through a basic medical history help to identify women at risk for severe morbidity, who may benefit from targeted preventive and surveillance strategies including appropriate specialty-based antenatal care pathways. Further refinement and external validation of this model are warranted and can support evidence-based improvements in clinical practice.
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Affiliation(s)
- Natalie Dayan
- Department of Medicine and Research Institute, McGill University Health Centre, 5252 de Maisonneuve West, 2B.40, Montreal, QC, H4A 3S5, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Ave West, Montreal, QC, H3A 1A2, Canada.
| | - Gabriel D Shapiro
- Department of Medicine and Research Institute, McGill University Health Centre, 5252 de Maisonneuve West, 2B.40, Montreal, QC, H4A 3S5, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Ave West, Montreal, QC, H3A 1A2, Canada
| | - Jin Luo
- ICES, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Jun Guan
- ICES, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Deshayne B Fell
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Centre for Practice-Changing Research Building, Room L-1154, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Carl A Laskin
- Departments of Medicine and Obstetrics and Gynecology, University of Toronto, 123 Edward St., suite 1200, Toronto, ON, M5G 1E2, Canada.,TRIO Fertility, 655 Bay St, Toronto, ON, M5G 2K4, Canada
| | - Olga Basso
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Ave West, Montreal, QC, H3A 1A2, Canada
| | - Alison L Park
- ICES, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Joel G Ray
- ICES, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Departments of Medicine and Obstetrics and Gynecology, University of Toronto, 123 Edward St., suite 1200, Toronto, ON, M5G 1E2, Canada
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Kong F, Wang A, Su J, He J, Xie D, Xiong L, Sheng X, Liu Z. Accidental death during pregnancy and puerperium from 2009 to 2019 in Hunan, China: a cross-sectional study. BMJ Open 2021; 11:e047660. [PMID: 34593489 PMCID: PMC8487173 DOI: 10.1136/bmjopen-2020-047660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Few studies have analysed accidental maternal deaths. This study analysed the basic situation and classification of maternal accidental deaths and compared the differences between urban and rural areas. DESIGN A cross-sectional study on accidental deaths during pregnancy and puerperium from 2009 to 2019 in Hunan Province. SETTING Hunan Province, with a population of 74 million, has an area of 210 000 km2 and 123 counties/districts. PARTICIPANTS A collection of 239 cases of accidental death during pregnancy and puerperium in Hunan Province from 2009 to 2019, including 181 cases of rural pregnancy and puerperium and 58 cases of urban pregnancy and puerperium. MAIN OUTCOME MEASURE Classification of accidental mortality of pregnant women. RESULTS A total of 239 accidental deaths occurred in Hunan Province, with an accidental mortality rate of 2.8 per 100 000 live births. The accidental mortality rate in rural areas (3.2 per 100 000 live births) was higher than in urban areas (2.0 per 100 000 live births). The proportion of accidental deaths among pregnancy-related deaths showed an upward trend. The main types of accidental deaths were suicide (1.0 per 100 000 live births), traffic accidents (0.8 per 100 000 live births), accidental poisoning/overdose and assault/homicide (0.2 per 100 000 live births), and other accidents (0.6 per 100 000 live births). Maternal accidental deaths were mainly concentrated in low-income families, in rural areas and in those with low level of education. 74.5% of accidental deaths occurred before childbirth. 49.2% of pregnant women gave birth by caesarean section. CONCLUSION In response to the different causes of accidental maternal death, public health programmes and policy interventions should pay special attention to maternal suicide and traffic injuries.
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Affiliation(s)
- Fanjuan Kong
- Information Management Section, Hunan Province, Changsha, Hunan, China
| | - Aihua Wang
- Information Management Section, Hunan Province, Changsha, Hunan, China
| | - Jinping Su
- Information Management Section, Hunan Province, Changsha, Hunan, China
| | - Jian He
- Information Management Section, Hunan Province, Changsha, Hunan, China
| | - Donghua Xie
- Information Management Section, Hunan Province, Changsha, Hunan, China
| | - Lili Xiong
- Information Management Section, Hunan Province, Changsha, Hunan, China
| | - Xiaoqi Sheng
- Psychology Department, Hunan Province, Changsha, Hunan, China
| | - Zhiyu Liu
- Information Management Section, Hunan Province, Changsha, Hunan, China
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5
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Aoyama K, Park AL, Davidson AJF, Ray JG. Severe Maternal Morbidity and Infant Mortality in Canada. Pediatrics 2020; 146:peds.2019-3870. [PMID: 32817396 DOI: 10.1542/peds.2019-3870] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe maternal morbidity (SMM) comprises an array of conditions and procedures denoting an acutely life-threatening pregnancy-related condition. SMM may further compromise fetal well-being. Empirical data are lacking about the relation between SMM and infant mortality. METHODS This population-based cohort study included 1 892 857 singleton births between 2002 and 2017 in Ontario, Canada, within a universal health care system. The exposure was SMM as an overall construct arising from 23 weeks' gestation up to 42 days after the index delivery. The primary outcome was infant mortality from birth to 365 days. Multivariable modified Poisson regression generated relative risks and 95% confidence intervals (CIs), adjusted for maternal age, income, rurality, world region of origin, diabetes mellitus, and chronic hypertension. RESULTS Infant mortality occurred among 174 of 19 587 live births with SMM (8.9 per 1000) vs 5289 of 1 865 791 live births without SMM (2.8 per 1000) (an adjusted relative risk of 2.93 [95% CI 2.51-3.41]). Of 19 587 pregnancies with SMM, 4523 (23.1%) had sepsis. Relative to births without SMM, the adjusted odds ratio for infant death from sepsis was 1.95 (95% CI 1.10-3.45) if SMM occurred without maternal sepsis and 6.36 (95% CI 3.50-11.55) if SMM included sepsis. CONCLUSIONS SMM confers a higher risk of infant death. There is also coupling tendency (concurrent event of interest) between SMM with sepsis and infant death from sepsis. Identification of preventable SMM indicators, as well as the development of strategies to limit their onset or progression, may reduce infant mortality.
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Affiliation(s)
- Kazuyoshi Aoyama
- Program in Child Health Evaluative Sciences, SickKids Research Institute and .,Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada; and
| | - Alison L Park
- Institute for Clinical Evaluative Sciences Central, Toronto, Ontario, Canada
| | | | - Joel G Ray
- Institute for Clinical Evaluative Sciences Central, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada; and.,Departments of Obstetrics and Gynecology and Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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6
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Zipursky JS, Yaphe H, Hudson H, Wong A, Thompson M. Acute poisoning in pregnancy: a province-wide perspective from a poison center. Clin Toxicol (Phila) 2019; 58:736-741. [PMID: 31621422 DOI: 10.1080/15563650.2019.1676898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Poisoning in pregnancy can cause maternal and neonatal morbidity and mortality, but few data detail such events. Herein, we describe poisoning exposures in pregnant women identified by a large Canadian Poison Centre.Methods: This retrospective study evaluated poisoning exposures in pregnant women aged 12-60 years, reported to the Ontario Poison Centre from 2010 to 2017. Exposures were identified from the Poison Centre database by calls received, in which the patient was also reported to be pregnant. We collected patient demographics (age, trimester, and location), as well as information about the poisoning exposure (number and type of substances, route of exposure, reason for exposure, decontamination, and treatment recommendations).Results: There were 1716 cases of poisoning exposures during pregnancy over the eight-year study period, representing 0.28% of all 619,539 calls over the period. Median maternal age was 29 years (IQR 25-33), and exposures were most frequent in the second trimester of pregnancy (41%). Unintentional exposures (n = 1397) accounted for 81% of all calls. Of the 18% of calls (n = 305) for intentional exposures, 71% (n = 219) were suspected attempted suicides. Intentional exposures were more frequent in the first (OR 2.64, 95% CI 1.85-3.76) and second trimesters (OR 1.61, 95% CI 1.13-2.28), relative to third trimester. The associated risk of intentional exposures was more likely in women aged ≤19 years (OR 21.41, 95% CI 12.75-35.94) and 20-29 years (OR 3.72, 95% CI 2.70-5.14), relative to women ≥30 years old.Conclusions: Intentional poisoning exposures in pregnancy most commonly involve young women in the first two trimesters. Population-based studies are needed to further examine risk factors for overdose, poisoning, and self-harm in pregnancy, as well as perinatal outcomes.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, University of Toronto, Toronto, Canada.,Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Hannah Yaphe
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Canada
| | - Heather Hudson
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Canada
| | - Albert Wong
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Canada
| | - Margaret Thompson
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Canada.,Division of Emergency Medicine, St. Michael's Hospital, Toronto, Canada
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Vigod SN, Arora S, Urquia ML, Dennis CL, Fung K, Grigoriadis S, Ray JG. Postpartum self-inflicted injury, suicide, assault and homicide in relation to immigrant status in Ontario: a retrospective population-based cohort study. CMAJ Open 2019; 7:E227-E235. [PMID: 30979727 PMCID: PMC6461543 DOI: 10.9778/cmajo.20180178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Intentional injury, including suicide and assault, is a leading cause of maternal morbidity and mortality. We aimed to determine whether immigrant and nonimmigrant women differ in their 1-year risk of intentional injury after birth. METHODS This population-based retrospective cohort study used administrative data from Ontario from 2002 to 2012. Risk of self-inflicted injury (self-harm or suicide), and injury inflicted by others (assault or homicide), were each analyzed within 1 year after delivery of a live-born infant for immigrant and nonimmigrant mothers. Relative risks (RRs) were adjusted for maternal age, parity, income, resource utilization and psychiatric history. RESULTS The study included 327 279 immigrant and 942 502 nonimmigrant mothers. Risk of self-inflicted injury was similar among immigrants and nonimmigrants (adjusted RR 0.91, 95% confidence interval [CI] 0.78-1.04), with no variation by duration of residence or refugee status. Immigrants were at lower risk than nonimmigrants for injury inflicted by others (adjusted RR 0.57, 95% CI 0.51-0.64); that risk was higher among refugees than among nonrefugee immigrants (adjusted RR 1.79, 95% CI 1.33-2.41), and it was higher among long-term (adjusted RR 2.27, 95% CI 1.76-2.91) and medium-term (adjusted RR 1.58, 95% CI 1.19-2.11) immigrants than among recent immigrants. Variability by country of origin was observed for both injury types. INTERPRETATION Immigrant mothers have a reported risk for self-inflicted injury after birth similar to that of their Canadian-born counterparts. The extent to which selective underreporting of intentional injury in immigrant women might explain our findings is a key consideration for future research.
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Affiliation(s)
- Simone N Vigod
- Women's College Hospital and Research Institute (Vigod, Arora); ICES (Vigod, Urquia, Fung); Department of Psychiatry (Vigod, Grigoriadis, Ray), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Urquia), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Li Ka Shing Knowledge Institute (Dennis, Ray), St. Michael's Hospital; Faculty of Nursing (Dennis), University of Toronto; Department of Psychiatry (Grigoriadis), Sunnybrook Health Sciences Centre; Department of Medicine (Ray), University of Toronto, Toronto, Ont.
| | - Serena Arora
- Women's College Hospital and Research Institute (Vigod, Arora); ICES (Vigod, Urquia, Fung); Department of Psychiatry (Vigod, Grigoriadis, Ray), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Urquia), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Li Ka Shing Knowledge Institute (Dennis, Ray), St. Michael's Hospital; Faculty of Nursing (Dennis), University of Toronto; Department of Psychiatry (Grigoriadis), Sunnybrook Health Sciences Centre; Department of Medicine (Ray), University of Toronto, Toronto, Ont
| | - Marcelo L Urquia
- Women's College Hospital and Research Institute (Vigod, Arora); ICES (Vigod, Urquia, Fung); Department of Psychiatry (Vigod, Grigoriadis, Ray), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Urquia), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Li Ka Shing Knowledge Institute (Dennis, Ray), St. Michael's Hospital; Faculty of Nursing (Dennis), University of Toronto; Department of Psychiatry (Grigoriadis), Sunnybrook Health Sciences Centre; Department of Medicine (Ray), University of Toronto, Toronto, Ont
| | - Cindy-Lee Dennis
- Women's College Hospital and Research Institute (Vigod, Arora); ICES (Vigod, Urquia, Fung); Department of Psychiatry (Vigod, Grigoriadis, Ray), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Urquia), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Li Ka Shing Knowledge Institute (Dennis, Ray), St. Michael's Hospital; Faculty of Nursing (Dennis), University of Toronto; Department of Psychiatry (Grigoriadis), Sunnybrook Health Sciences Centre; Department of Medicine (Ray), University of Toronto, Toronto, Ont
| | - Kinwah Fung
- Women's College Hospital and Research Institute (Vigod, Arora); ICES (Vigod, Urquia, Fung); Department of Psychiatry (Vigod, Grigoriadis, Ray), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Urquia), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Li Ka Shing Knowledge Institute (Dennis, Ray), St. Michael's Hospital; Faculty of Nursing (Dennis), University of Toronto; Department of Psychiatry (Grigoriadis), Sunnybrook Health Sciences Centre; Department of Medicine (Ray), University of Toronto, Toronto, Ont
| | - Sophie Grigoriadis
- Women's College Hospital and Research Institute (Vigod, Arora); ICES (Vigod, Urquia, Fung); Department of Psychiatry (Vigod, Grigoriadis, Ray), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Urquia), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Li Ka Shing Knowledge Institute (Dennis, Ray), St. Michael's Hospital; Faculty of Nursing (Dennis), University of Toronto; Department of Psychiatry (Grigoriadis), Sunnybrook Health Sciences Centre; Department of Medicine (Ray), University of Toronto, Toronto, Ont
| | - Joel G Ray
- Women's College Hospital and Research Institute (Vigod, Arora); ICES (Vigod, Urquia, Fung); Department of Psychiatry (Vigod, Grigoriadis, Ray), University of Toronto, Toronto, Ont.; Department of Community Health Sciences (Urquia), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Li Ka Shing Knowledge Institute (Dennis, Ray), St. Michael's Hospital; Faculty of Nursing (Dennis), University of Toronto; Department of Psychiatry (Grigoriadis), Sunnybrook Health Sciences Centre; Department of Medicine (Ray), University of Toronto, Toronto, Ont
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