Changes in Children and Youth's Mental Health Presentations during COVID-19: A Study of Primary Care Practices in Northern Ontario, Canada.

Recent research suggests that children and youth are at increased risk of anxiety and depression due to the indirect effects of the COVID-19 pandemic. In Canada, children and youths may face additional hurdles in accessing mental health services in rural areas due to socioeconomic disadvantages and healthcare provider shortages worsened by the pandemic. Our study aimed to assess changes in primary healthcare utilization related to depression and anxiety among children and youth aged 10-25 years in Northern Ontario, Canada. We analyzed de-identified electronic medical record data to assess primary healthcare visits and prescriptions for depression and anxiety among children and youth aged 10-25 years. We used provider billing data and reasons for visits and antidepressant/antianxiety prescriptions compared with 21 months pre-pandemic (1 June 2018 to 28 February 2020) and 21 months during the pandemic (1 April 2020 to 31 December 2021). Our interrupted time series analysis showed an average increase in visits by 2.52 per 10,000 person-months and in prescriptions by 6.69 per 10,000 person-months across all ages and sexes. Females aged 10 to 14 years were found to have the greatest relative change in visits across all age-sex groups. The greatest relative increases in antianxiety and antidepression prescriptions occurred among females and males aged 10 to 14 years, respectively. These findings indicate that there were increased anxiety and depression presentations in primary healthcare among children and youths living in northern and rural settings during the COVID-19 pandemic. The increased primary healthcare presentations of anxiety and depression by children and youths suggest that additional mental health resources should be allocated to northern rural primary healthcare to support the increased demand. Adequate mental health professionals, accessible services, and clinical recommendations tailored to northern rural populations and care settings are crucial.

Arthroscopic management of recurrent synovial chondromatosis of the hip: a case report.

Synovial chondromatosis is a rare condition characterized by the chondral proliferation of synovium forming loose bodies which can lead to pain, swelling, and decreased range of movement of the affected joint. Case presentation: Here the authors report a case of eighteen years lady with recurrent hip synovial chondromatosis who was treated previously with hip arthrotomy and loose bodies removal and now she underwent arthroscopic loose bodies removal with partial synovectomy. Clinical discussion: In comparison to arthrotomy of the hip, arthroscopic management is a minimally invasive surgery that is associated with decreased postoperative pain, earlier improvement in range of motion, a shorter course of rehabilitation, and overall lower morbidity. Conclusion: Thus, the authors recommend arthroscopic removal of the loose bodies and partial synovectomy for the management of synovial chondromatosis of the hip.

Anterior Cruciate Ligament Tear Using Magnetic Resonance Imaging among Patients Undergoing Arthroscopy in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Magnetic Resonance Imaging is the preferred imaging modality in patients having anterior cruciate ligament tears. The aim of this study was to find out the prevalence of anterior cruciate ligament tears using magnetic resonance imaging among patients undergoing arthroscopy in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted in the Department of Orthopaedics and Traumatology of a tertiary care centre. Data from 17 November 2017 to 17 October 2022 were collected between 26 December 2022 and 30 December 2022 from the hospital records. Ethical approval was obtained from Institutinal Review Committee of the same institute (Reference number: 233/22). All patients with a knee injury who received arthroscopy were included in the study. Magnetic resonance imaging reports, arthroscopic findings and relevant data of each case were retrieved from the medical case records of patients. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among patients with arthroscopy confirmed anterior cruciate ligament tear, 138 (91.39%) (86.92 to 95.86, 95% Confidence Interval) had anterior cruciate ligament tear diagnosed with magnetic resonance imaging. The mean age of the patients who had anterior cruciate ligament tear in the magnetic resonance imaging was 32.35±11.31 years. Out of them, 87 (63%) were males and 51 (37%) were females. The mean duration of the injury was 11.60±18.47 months. Conclusions: The prevalence of anterior cruciate ligament tear using magnetic resonance imaging among patients undergoing arthroscopy in tertiary care centres was similar when compared to other similar studies when conducted in similar settings. Keywords: anterior cruciate ligament tears; arthroscopy; cross-sectional studies; MRI.

A geographic-location-based medical school admissions process does not influence pre-clerkship and licensing examination academic performance.

Background: Students are selected for admission to the Northern Ontario School of Medicine University (NOSM U) MD degree program using criteria aiming to maximize access of persons thought most likely to practice in the region, including use of a geographic context score (GCS) which ranks those with lived experience in northern Ontario and/or rurality most highly. This study investigates the effect of this admissions process upon medical school academic performance. Methods: We used a retrospective cohort design combined with multiple linear regression analysis to investigate the relationship between admission scores and performance on pre-clerkship courses, and the Medical Council of Canada Qualifying Exam Part 1 (MCCQE1).The GCS did not significantly explain performance variance on any pre-clerkship course, nor on the MCCQE1, while the undergraduate Grade Point Average correlated with most assessment scores. The number of prior undergraduate biomedical courses predicted science and clinical skills performance, particularly in Year 1, but not with MCCQE1 scores. Performance on Year 2 courses, particularly foundational sciences and clinical skills, significantly predicted MCCQE1 scores. Results: Our data suggest that admission geographic context scoring is unrelated to future academic performance. Further, students with fewer prior undergraduate biomedical courses may benefit from increased support and/or a modified program during the early years.

Contexte: La sélection étudiants à l'École de médecine du Nord de l'Ontario est fondée sur des critères visant à faciliter l'admission de candidats qu'on estime susceptibles de pratiquer dans la région. Un de ces critères est le score de contexte géographique (SCG) qui classe au premier rang les personnes ayant déjà vécu dans le Nord de l'Ontario ou en milieu rural. Cette étude examine l'effet de ce processus d'admission sur les résultats académiques des étudiants en médecine. Méthodes: Nous avons utilisé un modèle de cohorte rétrospective et une analyse par régression linéaire multiple pour étudier la relation entre les scores d'admission et les résultats obtenus aux cours avant l'externat et à l'examen d'aptitude du Conseil médical du Canada (EACMC), partie 1.Le SCG n'explique pas de manière significative la variance des résultats dans les cours pré-cliniques, ni à l'EACMC1, tandis que la moyenne pondérée cumulative au premier cycle est en corrélation avec la plupart des scores d'évaluation. Le nombre de cours en sciences biomédicales suivis dans un programme de premier cycle ont permis de prédire les résultats en sciences et en compétences cliniques, en particulier en première année, mais pas les résultats à l'EACMC1. Les résultats aux cours de deuxième année, en particulier de sciences fondamentales et de compétences cliniques, ont permis de prédire de manière significative les résultats à l'EACMC1. Résultats: Nos données portent à croire que le score de contexte géographique au moment de l'admission est sans lien avec les résultats académiques subséquents. En outre, les étudiants ayant suivi moins de cours en sciences biomédicales au premier cycle pourraient bénéficier d'un soutien plus important ou d'un programme adapté au cours des premières années.

A Clinical Competency Framework for the Basic Package of Oral Care: Perceptions of Primary Oral Health Providers in Rural Nepal.

Introduction: The basic package of Oral Care (BPOC) was developed to improve oral health care for underserved populations worldwide. However, systematic delivery of the BPOC has been difficult to achieve, and training efforts have in some cases contributed to proliferation of malpractice. Standard Competency Frameworks (CF), increasingly used in dental and medical education to improve quality assurance, have not been established to date for the BPOC. Methods: To evaluate provider perceptions of a BPOC-specific CF, in-depth interviews were conducted with 7 Primary Oral Health Providers (POHPs) and 5 Clinic Assistants working in the Jevaia Oral Health Care project (Jevaia) in Nepal. Participants were limited to providers who have used the CF. Interviews were audio recorded, transcribed in Nepali, and translated into English. A qualitative thematic analysis was applied through a multi-stage review process, and emergent themes were further grouped and categorized to draw final conclusions. Results: Findings were categorized into four groups: (1) "What is the CF to Me": Respondents frequently conflated the CF with professional development training. These activities together were essentially felt to offer clear performance guidance and a pathway for learning. (2) "Relationship to the Work": Respondents reported that the CF's guidelines increased confidence, peer accountability, and job satisfaction. (3) "Practical Improvements": Providers felt the CF improved their clinical skills, communication, crowd management, and teamwork. (4) "Community Impact": Many participants felt that improved skills had led to a more efficient workflow, greater community acceptance, and increased utilization of services. Conclusions: Clinicians broadly felt that the CF improved both their professional satisfaction and the quality of patient care. CFs should be considered integral to BPOC implementation, along with opportunities for continuous professional learning, and these activities will likely be most meaningful and impactful when recognized by government and other licensing bodies.

Evidence of Increased Age and Sex Standardized Death Rates Among Individuals Who Accessed Opioid Agonist Treatment Before the Era of Synthetic Opioids in Ontario, Canada.

Objective The objective of this study was to evaluate age-sex standardized death rates (ASDR) from all causes from 2011 to 2015 among people who have accessed opioid agonist treatment (OAT) and compare rates living in the Northern and Southern areas of Ontario. Methods Routinely collected administrative health data was used to calculate crude death rates and age-sex standardized death rates (ASDRs) per 1,000,000 population of individuals who accessed OAT and compared the rates geographically from 2011 to 2015. The weighted ASDRs for each year were calculated by using the mid-year population of these regions. The rate ratios were calculated considering the base year as 2011.  Results A total of 55,924 adults who accessed OAT were included between January 1, 2011, and December 31, 2015. The majority of patients in the cohort - 52.3% - were between 15 and 34 years old, 32.5% were female, 11.3% were in the lowest income group, 71.1% lived in Southern areas. Overall, the ASDR steadily increased during the study period and spiked in 2015. We found that among individuals who had accessed OAT, living in Southern Ontario was associated with a lower risk of all-cause mortality than those living in Northern Ontario. ASDR for Northern Ontario was 20.0 (95% confidence interval (CI)= 10.2-34.2) in 2011, and 103.5(95%CI=78.5-133.5) in 2015, which was a five-fold increase from 2011. Whereas in Southern Ontario, ASDR in 2011 was 13.8 (95% CI= 11.5-16.5), and in 2015 ASDR was 60.8 (95%CI=55.8-66.1), which was only a 4-fold increase from 2011 Conclusion Our findings demonstrate evidence of a steadily increasing ASDR among individuals who accessed OAT with higher rates in Northern areas of the province before the era of synthetic opioids in Ontario, Canada.

Scar Pregnancy a Diagnostic Conundrum: A Case Report.

Cesarean scar pregnancy is a rare form of ectopic pregnancy which may lead to uterine rupture and catastrophic hemorrhage. We report a case of cesarean scar pregnancy in a 35-year-old female with the past history of cesarean section presented with complaints of amenorrhoea for 6 weeks and non-specific  pain. Two Transvaginal sonography was done 48 hours apart which suggested a cesarean scar pregnancy in one and cervical pregnancy on the other. Magnetic Resonace Imaging showed a well-defined cystic lesion of (21x19)mm2 embedded within the previous cesarean scar which confirmed the diagnosis of cesarean scar pregnancy. Laparotomy unveiled uterus around 6 weeks size and a (3x3)cm2 bulge was noted at the site of previous scar in lower uterine segment, where a small incision was given and the gestational sac was removed following which the uterine incision was closed with 2-0 polyglactin suture. High index of suspicion and prompt diagnosis is ofparamount for reducing morbidity and mortality.

Evidence of increased Fentanyl use during the COVID-19 pandemic among opioid agonist treatment patients in Ontario, Canada.

BACKGROUND: Amid the opioid crisis, the health care system is restructuring to prevent and treat COVID-19. Individuals in opioid agonist treatment (OAT) are uniquely challenged because of disruption to treatment, medication diversion, and isolation during the pandemic. METHODS: Between January and September 2020, we utilized the electronic medical record from a chain of 67 opioid agonist treatment clinics in Ontario, Canada, to examine routinely collected urine drug screen results of patients in opioid agonist treatment by Public Health Units. RESULTS: We present evidence of a 108% increase in the percentage of fentanyl positive urine drug screens from April to September (p< 0.001). During the same period, health regions in northern and southwestern Ontario, areas with a high concentration of rural communities, have seen the most notable increase in the percent of fentanyl positive urine drug screen results. CONCLUSION: The use of fentanyl increased by 108% among OAT patients in Ontario during the COVID 19 pandemic. We argue that the persistent increase of fentanyl exposure over time, specifically in the OAT population, suggests that reduced monitoring may decrease OAT's effectiveness and negatively impact patient outcomes.

Negative Impact of Amphetamine-Type Stimulant Use on Opioid Agonist Treatment Retention in Ontario, Canada.

Objective: The objective of this study was to evaluate epidemiological trends of co-use patterns of amphetamine-type stimulants and opioids and the impact of co-use patterns on Opioid Agonist Treatment (OAT) retention in Ontario, Canada. The secondary objective was to assess geographical variation in amphetamine-type stimulant use in Northern Rural, Northern Urban, Southern Rural and Southern Urban Areas of Ontario. Methods: A retrospective cohort study on 32,674 adults receiving OAT from ~70 clinics was conducted between January 1, 2014, and December 31, 2020, in Ontario, Canada. Patients were divided into four groups base on the proportion of positive urine drug screening results for amphetamine-type stimulants during treatment: group 1 (0-25%), group 2 (25-50%), group 3 (50-75%), and groups 4 (75-100%). A Fractional logistic regression model was used to evaluate differences over time in amphetamine-type stimulant use with urine drug screening results. A Cox Proportional Hazard Ratio model was used to calculate the impact of amphetamine-type stimulant use on retention in OAT and adjusted for sociodemographic characteristics, drug use and clinical factors. Lastly, a logistic regression model was used on a subgroup of patients to assess the impact of geography on amphetamine-type stimulant use in Northern Rural, Northern Urban, Southern Rural and Southern Urban Areas of Ontario. Results: There were significant differences in amphetamine-type stimulant positive urine drug screening results year-over-year from 2015 to 2020. Significant differences were observed between amphetamine-type stimulant groups with regards to sociodemographic, clinical and drug use factors. Compared to those with no amphetamine-type stimulant use, the number of days retained in OAT treatment for amphetamine-type stimulant users was reduced (hazard ratio 1.19; 95% confidence interval = 1.07-1.17; p < 0.001). Lastly, an adjusted logistic regression model showed a significant increase in the likelihood of amphetamine-type stimulant use in Northern Rural regions compared to Southern Urban areas. Conclusion: There was a significant increase in amphetamine-type stimulant use among individuals in OAT from 2014 to 2020, associated with decreased OAT retention. Research is required to determine if tailored strategies specific to individuals in OAT who use amphetamine-type stimulants can improve OAT outcomes.

Cotrimoxazole Induced Steven Johnson Syndrome: A Case Report.

Steven Johnson syndrome and toxic epidermal necrolysis are severe and rare adverse drug reactions usually caused by drugs like antiepileptics, penicillin and allopurinol and sometimes also due to infections, malignancy or idiopathic in some cases. Here we are reporting a case of a 50 years female who came with complaint of a burning sensation on the upper half of the body with atypical flat target lesion that later coalesced involving her face, chest and bilateral upper limbs. On examination, positive nikolsky sign and tenderness with <10% body surface area involvement was noticed. The diagnosis of cotrimoxazole induced Steven Johnson syndrome was made. Patient was shifted to ICU and given supportive care along with prophylactic teicoplanin, itraconazole and dexamethasone. The mechanism of eruptions in our patient was due to cotrimoxazole. Cotrimoxazole induced Steven Johnson syndrome is rare and the supportive management with broad spectrum antibiotic and the corticosteroid was enough to beat this life-threatening condition. Keywords: cotrimoxazole; pneumonia; Steven Johnson syndrome.

Left Chronic Otitis Media with Squamous Cell Carcinoma of the Middle Ear and Postauricular Mastoid Fistula: A Case Report.

Though squamous cell carcinoma is the commonest tumor, it rarely presents in the middle ear and follows a history of chronic ear discharge. Postauricular mastoid fistula is also a rare complication of chronic otitis media. These two pathological changes occurring simultaneously are even rarer. We report a rare case of a 37 years old male with a history of left-sided chronic ear discharge and conductive hearing loss. Squamous cell carcinoma along with postauricular mastoid fistula was diagnosed based on high-resolution computed tomography scan and histopathology. Left modified radical mastoidectomy with tympanic membrane grafting was done under general anesthesia. Often middle ear tumor is associated with long-standing ear discharge and this case is a very good example. The co-occurrence of the middle ear tumor with mastoid fistula is extremely rare as both the entities are rare in itself.

Full-time Studies and Volunteering.

Our volunteering began being a part of the editorial support team in the Journal of Nepal Medical Association. This has really built up our confidence to work as a team. During our days in Journal Office, a sudden knock of another opportunity stroke our door. The Administrative Officer of Nepal Medical Association asked us about volunteering in the Election of Nepal Medical Association which held from 17th to 21st Magh, 2076 and we accepted it. We also helped NMA during the pre-election procedure that needs to be done before going for the election. We think that was the work where we got the trust of NMA officers.

Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal.

INTRODUCTION: Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities. METHODS: A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23. RESULTS: Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method. CONCLUSIONS: The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Factors affecting the behavior outcomes on post-partum intrauterine contraceptive device uptake and continuation in Nepal: a qualitative study.

BACKGROUND: The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal. METHODS: This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework. RESULTS: The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women's intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband's preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions. CONCLUSION: As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD.

Prevalence and pattern of dyslipidemia in Nepalese individuals with type 2 diabetes.

BACKGROUND: Atherogenic dyslipidemia is an important modifiable risk factor for cardiovascular disease among patients of type 2 diabetes mellitus. Timely detection and characterization of this condition help clinicians estimate future risk of cardiovascular disease and take appropriate preventive measures. The aim of this study was to determine the prevalence, pattern and predictors of dyslipidemia in a cohort of Nepalese patients with type 2 diabetes. RESULTS: We found mixed dyslipidemia as the most prevalent (88.1%) and isolated dyslipidemia (10.1%) as the least prevalent forms of dyslipidemia in our patients. The most prevalent form of single dyslipidemia was high LDL-C (73.8%) and combined dyslipidemia was high TG, high LDL-C and low HDL-C (44.7%). Prevalence of all single and mixed dyslipidemia was higher in patients with poor glycemic control and hypertension. The glycemic status of patients correlated with their fasting serum lipid profile. Dyslipidemia was associated mainly with male gender, poor glycemic control and hypertension. CONCLUSIONS: Atherogenic dyslipidemia is associated mainly with male gender, poor glycemic control and hypertension. It is highly prevalent in Nepalese patients with type 2 diabetes. Urgent lifestyle modification, sustained glycemic control and aggressive lipid lowering treatment plans are necessary to minimize the future risk of cardiovascular disease in this population.

Prevalence of metabolic syndrome in Nepalese type 2 diabetic patients according to WHO, NCEP ATP III, IDF and Harmonized criteria.

BACKGROUND: Metabolic syndrome (MetS) present in type 2 diabetic patients greatly increases the risk of strokes and cardiovascular diseases. Timely detection and mapping of MetS facilitates appropriate preventive and therapeutic approaches to minimize these risks. Our study aimed to determine the prevalence of MetS among Nepalese type 2 diabetic patients using WHO (1999), NCEP ATP III (2001), IDF (2005) and Harmonized (2009) definitions and identify the diagnostic concordance and disparity resulting from these four definitions. METHODS: Clinical and biochemical data were collected for 1061 type 2 diabetic patients at Manipal Teaching Hospital, Pokhara, Nepal. The data was analyzed in order to identify prevalence of MetS in these patients. Statistical analysis included usage of Student's t- and Chi-square tests, kappa statistics and 95% confidence intervals. RESULTS: The total age adjusted prevalence rates of MetS were 80.3%, 73.9%, 69.9% and 66.8% according to Harmonized, NCEP ATP III, WHO and IDF definitions, respectively. Prevalence increased with the age and was higher in females (p <0.001) according to WHO, NCEP ATP III and Harmonized definitions. Patients of Dalit community had the highest prevalence (p<0.05) according to NCEP ATP III and Harmonized definitions while Mongoloid and Newar patients had the highest prevalence (p <0.05) according to WHO and IDF definitions, respectively. Prevalence was also highest among patient engaged in agriculture occupation. Central obesity and hypertension were respectively the most and the least prevalent components of MetS. The highest overall agreement was between Harmonized and NCEP ATP III definitions (κ =0.62, substantial) and the lowest between WHO & IDF definitions (κ=0.26, slight). The Harmonized definition had the highest sensitivity (99.9%) and negative predictive value (98.9%) while NCEP ATP III definition had the highest specificity (98.9%) and positive predictive values (99.9%) in identifying the cases of MetS. CONCLUSIONS: The prevalence of MetS among Nepalese type 2 diabetic patients was very high suggesting that these patients were at increased risk of strokes, cardiovascular diseases and premature death. The Harmonized definition was the most sensitive while NCEP ATP III and IDF definitions were the most specific in detecting the presence of MetS in Nepalese type 2 diabetic patients.