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Microcystins are natural hepatotoxic metabolites secreted by cyanobacteria in aquatic ecosystems. When present at elevated concentrations, microcystins can affect water quality aesthetics; contaminate drinking water reservoirs and recreational waters; disrupt normal ecosystem functioning; and cause health hazards to animals, plants, and humans. Animal and human exposures to microcystins generally result from ingesting contaminated drinking water or physically contacting tainted water. Much research has identified a multitude of liver problems from oral exposure to microcystins, varying from hepatocellular damage to primary liver cancer. Provisional guidelines for microcystins in drinking and recreational water have been established to prevent toxic exposures and protect public health. With increasing occurrences of eutrophication in freshwater systems, microcystin contamination in groundwater and surface waters is growing, posing threats to aquatic and terrestrial plants and agricultural soils used for crop production. These microcystins are often transferred to crops via irrigation with local sources of water, such as bloom-forming lakes and ponds. Microcystins can survive in high quantities in various parts of plants (roots, stems, and leaves) due to their high chemical stability and low molecular weight, increasing health risks for consumers of agricultural products. Studies have indicated potential health risks associated with contaminated fruits and vegetables sourced from irrigated water containing microcystins. This review considers the exposure risk to humans, plants, and the environment due to the presence of microcystins in local water reservoirs used for drinking and irrigation. Additional studies are needed to understand the specific health impacts associated with the consumption of microcystin-contaminated agricultural plants.

To conduct a systematic review of studies of social media platforms used by young people to discuss and view deliberate self-harm. 11 electronic databases were searched from January 2000 to January 2012 for primary research; in June 2014 an updated search of Medline was conducted. Grey literature sources were also searched. Search results were screened by two reviewers. Data were extracted by one reviewer and verified by another. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Due to heterogeneity in study objectives and outcomes, results were not pooled; a narrative analysis is presented. 26 studies were included. Most were conducted in Canada or the UK (30.8% each), used qualitative designs (42.3%), and evaluated discussion forums (73.1%). Participants were most often aged 19-21 years (69.2%), female (mean 68.6%), and 19.2% had a documented history of depression. The social media platforms evaluated were commonly supportive and provided a sense of community among users. Support included suggestions for formal treatment, advice on stopping self-harming behavior, and encouragement. Harms included normalizing and accepting self-harming behavior; discussion of motivation or triggers, concealment, suicidal ideation or plans; and live depictions of self-harm acts. Although this evidence is limited by its descriptive nature, studies identify beneficial and detrimental effects for young people using social media to discuss and view deliberate self-harm. The connections users make online may be valuable to explore for therapeutic benefit. Prospective, longitudinal investigations are needed to identify short- and long-term potential harms associated with use.

Background While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. Methods This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model—capability, opportunity, and motivation—of the Behaviour Change Wheel. Results Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. Conclusions Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. Trial registration ClinicalTrials.gov, NCT01815710 .

The authors wish to make the following corrections to their paper [...]

Background In 2012, the Saskatchewan Ministry for Health mandated a system-wide Lean transformation. Research has been conducted on the implementation processes of this system-wide Lean implementation. However, no research has been done on the sustainability of these Lean efforts. We conducted a realist evaluation on the sustainability of Lean in pediatric healthcare. We used the context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare. Methods We employed a case study research design. Guided by a realist evaluation framework, we conducted qualitative realist interviews with various stakeholder groups across four pediatric hospital units ‘cases’ at one acute hospital. Interview data was analyzed using an integrated approach of CMOc categorization coding, CMOc connecting and pattern matching. Results We conducted thirty-two interviews across the four cases. Five CMOcs emerged from our realist interview data. These configurations illustrated a ‘ripple-effect’ from implementation outcomes to contexts for sustainability. Sense-making and staff engagement were prominent mechanisms to the sustainment of Lean efforts. Failure to trigger these mechanisms resulted in resistance. The implementation approach used influenced mechanisms and outcomes for sustainability, more so than Lean itself. Specifically, the language, messaging and training approaches used triggered mechanisms of innovation fatigue, poor ‘sense-making’ and a lack of engagement for frontline staff. The mandated, top-down, externally led nature of implementation and lack of customization to context served as potential pitfalls. Overall, there was variation between leadership and frontline staff’s perceptions on how embedded Lean was in their contexts, and the degree to which participants supported Lean sustainability. Conclusions This research illuminates important contextual factors and mechanisms to the process of Lean sustainment that can be applicable to those implementing systems changes. Future work is needed to continue to develop the science on the sustainability of interventions for healthcare improvement.

The COVID-19 pandemic had profound effects on the mental wellbeing of adolescents. We sought to evaluate pandemic-related changes in health care use for suicidal ideation, self-poisoning and self-harm. We obtained data from the Canadian Institute for Health Information on emergency department visits and hospital admissions from April 2015 to March 2022 among adolescents aged 10–18 years in Canada. We calculated the quarterly percentage of emergency department visits and hospital admissions for a composite outcome comprising suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits and hospital admissions. We used interrupted time-series methods to compare changes in levels and trends of these outcomes between the prepandemic (Apr. 1, 2015–Mar. 1, 2020) and pandemic (Apr. 1, 2020–Mar. 31, 2022) periods. The average quarterly percentage of emergency department visits for suicidal ideation, self-poisoning and self-harm relative to all-cause emergency department visits was 2.30% during the prepandemic period and 3.52% during the pandemic period. The level (0.08%, 95% confidence interval [CI] −0.79% to 0.95%) or trend (0.07% per quarter, 95% CI −0.14% to 0.28%) of this percentage did not change significantly between periods. The average quarterly percentage of hospital admissions for the composite outcome relative to all-cause admissions was 7.18% during the prepandemic period and 8.96% during the pandemic period. This percentage showed no significant change in level (−0.70%, 95% CI −1.90% to 0.50%), but did show a significantly increasing trend (0.36% per quarter; 95% 0.07% to 0.65%) during the pandemic versus prepandemic periods, specifically among females aged 10–14 years (0.76% per quarter, 95% CI 0.22% to 1.30%) and females aged 15–18 years (0.56% per quarter, 95% CI 0.31% to 0.81%). The quarterly change in the percentage of hospital admissions for suicidal ideation, self-poisoning and self-harm increased among adolescent females in Canada during the first 2 years of the COVID-19 pandemic. This underscores the need to promote public health policies that mitigate the impact of the pandemic on adolescent mental health.

Background Overviews of reviews of healthcare interventions (overviews) integrate information from multiple systematic reviews (SRs) to provide a single synthesis of relevant evidence for decision-making. Overviews may identify multiple SRs that examine the same intervention for the same condition and include some, but not all, of the same primary studies. Different researchers use different approaches to manage these “overlapping SRs,” but each approach has advantages and disadvantages. This study aimed to develop an evidence-based decision tool to help researchers make informed inclusion decisions when conducting overviews of healthcare interventions. Methods We used a two-stage process to develop the decision tool. First, we conducted a multiple case study to obtain empirical evidence upon which the tool is based. We systematically conducted seven overviews five times each, making five different decisions about which SRs to include in the overviews, for a total of 35 overviews; we then examined the impact of the five inclusion decisions on the overviews’ comprehensiveness and challenges, within and across the seven overview cases. Second, we used a structured, iterative process to transform the evidence obtained from the multiple case study into an empirically based decision tool with accompanying descriptive text. Results The resulting decision tool contains four questions: (1) Do Cochrane SRs likely examine all relevant intervention comparisons and available data? (2) Do the Cochrane SRs overlap? (3) Do the non-Cochrane SRs overlap? (4) Are researchers prepared and able to avoid double-counting outcome data from overlapping SRs, by ensuring that each primary study’s outcome data are extracted from overlapping SRs only once? Guidance is provided to help researchers answer each question, and empirical evidence is provided regarding the advantages, disadvantages, and potential trade-offs of the different inclusion decisions. Conclusions This evidence-based decision tool is designed to provide researchers with the knowledge and means to make informed inclusion decisions in overviews. The tool can provide practical guidance and support for overview authors by helping them consider questions that could affect the comprehensiveness and complexity of their overviews. We hope this tool will be a useful resource for researchers conducting overviews, and we welcome discussion, testing, and refinement of the proposed tool.

Background We explored the performance of three machine learning tools designed to facilitate title and abstract screening in systematic reviews (SRs) when used to (a) eliminate irrelevant records (automated simulation) and (b) complement the work of a single reviewer (semi-automated simulation). We evaluated user experiences for each tool. Methods We subjected three SRs to two retrospective screening simulations. In each tool (Abstrackr, DistillerSR, RobotAnalyst), we screened a 200-record training set and downloaded the predicted relevance of the remaining records. We calculated the proportion missed and workload and time savings compared to dual independent screening. To test user experiences, eight research staff tried each tool and completed a survey. Results Using Abstrackr, DistillerSR, and RobotAnalyst, respectively, the median (range) proportion missed was 5 (0 to 28) percent, 97 (96 to 100) percent, and 70 (23 to 100) percent for the automated simulation and 1 (0 to 2) percent, 2 (0 to 7) percent, and 2 (0 to 4) percent for the semi-automated simulation. The median (range) workload savings was 90 (82 to 93) percent, 99 (98 to 99) percent, and 85 (85 to 88) percent for the automated simulation and 40 (32 to 43) percent, 49 (48 to 49) percent, and 35 (34 to 38) percent for the semi-automated simulation. The median (range) time savings was 154 (91 to 183), 185 (95 to 201), and 157 (86 to 172) hours for the automated simulation and 61 (42 to 82), 92 (46 to 100), and 64 (37 to 71) hours for the semi-automated simulation. Abstrackr identified 33–90% of records missed by a single reviewer. RobotAnalyst performed less well and DistillerSR provided no relative advantage. User experiences depended on user friendliness, qualities of the user interface, features and functions, trustworthiness, ease and speed of obtaining predictions, and practicality of the export file(s). Conclusions The workload savings afforded in the automated simulation came with increased risk of missing relevant records. Supplementing a single reviewer’s decisions with relevance predictions (semi-automated simulation) sometimes reduced the proportion missed, but performance varied by tool and SR. Designing tools based on reviewers’ self-identified preferences may improve their compatibility with present workflows. Systematic review registration Not applicable.

ObjectivesDiverting patients away from the emergency department (ED) has been proposed as a solution for mitigating overcrowding. This systematic review examined the impact of interventions designed to either bypass the ED or direct patients to other alternative care after ED presentation.MethodsSeven electronic databases and the grey literature were searched. Eligible studies included randomised/controlled trials or cohort studies that assessed the effectiveness of pre-hospital or ED-based diversion interventions. Two reviewers independently screened the studies for relevance, inclusion and risk of bias. Pooled statistics were calculated as relative risks (RR) with 95% confidence intervals (CI) using a random effects model.ResultsFifteen studies were included evaluating pre-hospital (n=11) or ED-based (n=4) diversion interventions. The quality of the studies ranged from moderate to low. Patients deemed suitable for diversion among the pre-hospital studies (n=3) ranged from 19.2% to 90.4% and from 19% to 36% in ED-based studies (n=4). Of the eligible patients, the proportion of patients diverted via ED-based diversion tended to be higher (median 85%; IQR 76–93%) compared with pre-hospital diversion (median 40%; IQR 24–57%). Overall, pre-hospital diversion did not decrease the proportion of patients transferred to the ED compared with standard care (RR 0.92; 95% CI 0.80 to 1.06). There was no significant decrease in subsequent ED utilisation among patients diverted via pre-hospital diversion compared with non-diverted patients (RR 1.09; 95% CI 0.99 to 1.21). Of the three pre-hospital studies completing a cost analysis, none found a significant difference in total healthcare costs between diverted and non-diverted patients.ConclusionThere was no conclusive evidence regarding the impact of diversion strategies on ED utilisation and subsequent healthcare utilisation. The overall quality of the research limited the ability of this review to draw definitive conclusions and more research is required prior to widespread implementation.

Major depressive disorders are common among adolescents and can impact all aspects of their daily life. Traditional therapies, cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT) have been delivered face-to-face. However, Internet-based (online) delivery of these therapies is emerging as an option for adolescents. Internet-based CBT and IPT involve therapeutic content, interaction between the user and the system, and different technological features embedded into the online program (eg, multimedia). Studies of Internet-based CBT and IPT for adolescent depression differ on all three aspects, and variable, positive therapy effects have been reported. A better understanding of the treatment conditions that influence therapy outcomes is important to designing and evaluating these novel therapies. Our aim was to examine the technological and program delivery features of Internet-based CBT and IPT for adolescent depression and to document their potential relation to treatment outcomes and program use. We performed a realist synthesis. We started with an extensive search of published and gray literature. We included intervention studies that evaluated Internet-based CBT or IPT for adolescent depression. We included mixed-methods and qualitative studies, theoretical papers, and policy/implementation documents if they included a focus on how Internet-based psychological therapy is proposed to work for adolescents with depression/depressive symptoms. We used the Mixed-Methods Appraisal Tool to assess the methodological quality of studies. We used the Persuasive System Design (PSD) model as a framework for data extraction and analysis to examine how Internet-based CBT and IPT, as technology-based systems, influence the attitudes and behaviors of system users. PSD components described for the therapies were linked to reported outcomes using a cross-case comparison method and thematic synthesis. We identified 19 Internet-based CBT programs in 59 documents. Of those, 71% (42/59) were of moderate to high quality. The PSD features surface credibility (competent \"look and feel\"), dialogue support (online program + in-person support), liking and similarity (esthetics and content appeal to adolescent users), the reduction and tunneling of therapeutic content (reducing online content into simple tasks, guiding users), and use of self-monitoring were present in therapies that resulted in improved therapy engagement, satisfaction, and adherence, as well as symptom and functional impairments. When incorporated into Internet-based CBT for adolescent depression, PSD features may improve adolescent adherence, satisfaction, and depression-related outcomes. Testing of these features using hypothesis-driven dismantling approaches is recommended to advance our understanding of how these features contribute to therapy effectiveness.