There is a crack in everything — that’s how the light gets in Leonard Cohen, Anthem In an era often characterized as one of growing convergence of the laws governing criminal activities in different countries, the issue-area of cannabis policy undergoes processes of fragmentation and polarization. Some countries continue to criminalize all forms of medical and recreational uses of cannabis. Others have sought to “separate the market” for cannabis from that of other drugs by decriminalizing the possession of small amounts of marijuana, authorizing its use for medical purposes, and establishing administrative measures for taxing and regulating the commercial sale of the drug. This Article explores the causes and consequences of the decline of the transnational legal order of cannabis prohibition. It shows how the erosion of the regulatory capacities of this transnational legal order reflects deepseated political conflicts over the legitimacy of prohibition norms in this field. It analyzes the ways in which conflicting regulatory approaches become institutionalized as a consequence of the structural mismatch between the actors framing the meaning of cannabis prohibition norms at the international level and the actors implementing these norms in national and local contexts. Finally, the Article shows how this transnational legal order has created path-dependent trajectories of legal change that continue to shape domestic drug policies.

Childbirth is a necessary stressor. It prepares the infant for extrauterine life, and prepares the mother for lactation and safe return to the non-pregnant state. However, added stressors can have repercussions. This study aims to describe added stressors (including prenatal maternal socio-demographic and psychological factors) affecting mode of delivery (MOD), and the effect of MOD on mother-infant health at one month postpartum.

Approximately 150 first-time, English-speaking, expectant mothers, at least 18 years of age, recruited from San Francisco, California prenatal clinics, participated in a postpartum intervention sleep study. Women were excluded if they had a sleep or mood disorder, or worked nights. This is a secondary analysis of these data.

Prenatal maternal socio-demographic and risk factors (depression, anxiety, attitudes/adjustment, perceived stress) were evaluated by MOD outcome using analysis of variance (ANOVA), t-tests, Mann Whitney U, and Kruskall-Wallis. Labor induction/augmentation was evaluated by maternal report of non-reassuring fetal status (NRFS) with NRFS as the key outcome, analyzed by Chi-Square and

logistic regression. Lastly, MOD was evaluated for effect on maternal symptoms of depression and anxiety, infant temperament rating, infant sleep, and breastfeeding continuation at one month using ANOVA and Chi-Square statistics.

Prenatal depression and anxiety symptoms were not associated with MOD (normal vaginal, instrument vaginal, cesarean in labor, or scheduled cesarean). Mothers with a prenatal "attitude toward baby" score that was more positive were more likely to have an unplanned cesarean birth. A scheduled cesarean birth was more likely in older women and those with higher pre-pregnancy BMI. Maternal reports of NRFS were associated with induction/augmentation. One month postpartum measures of maternal symptoms, maternal adjustment, infant temperament, and breastfeeding did not differ by MOD. However, according to maternal diary entries, cesarean-born infants slept an average of one hour more during the day than infants born vaginally.

These findings provide preliminary indication that prenatal attitude toward baby plays a role in MOD, induction/augmentation is associated with increased NRFS, and cesarean birth is associated with increased infant sleep at one month. Nurses should develop and test interventions to minimize prenatal and labor factors that unnecessarily add to delivery stress.

Introduction: Morbidity and mortality conferences (M+M) are a traditional part of residency training and mandated by the Accreditation Counsel of Graduate Medical Education. This study’s objective was to determine the goals, structure, and the prevalence of practices that foster strong safety cultures in the M+Ms of U.S. emergency medicine (EM) residency programs.

Methods: The authors conducted a national survey of U.S. EM residency program directors. The survey instrument evaluated five domains of M+M (Organization and Infrastructure; Case Finding; Case Selection; Presentation; and Follow up) based on the validated Agency for Healthcare Research & Quality Safety Culture survey. 

Results: There was an 80% (151/188) response rate. The primary objectives of M+M were discussing adverse outcomes (53/151, 35%), identifying systems errors (47/151, 31%) and identifying cognitive errors (26/151, 17%). Fifty-six percent (84/151) of institutions have anonymous case submission, with 10% (15/151) maintaining complete anonymity during the presentation and 21% (31/151) maintaining partial anonymity. Forty-seven percent (71/151) of programs report a formal process to follow up on systems issues identified at M+M. Forty-four percent (67/151) of programs report regular debriefing with residents who have had their cases presented.

Conclusion: The structure and goals of M+Ms in EM residencies vary widely. Many programs lack features of M+M that promote a non-punitive response to error, such as anonymity. Other programs lack features that support strong safety cultures, such as following up on systems issues or reporting back to residents on improvements. Further research is warranted to determine if M+M structure is related to patient safety culture in residency programs.

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