Maternal serum soluble fms-like tyrosine kinase-1-to-placental growth factor ratio distinguishes growth-restricted from non-growth-restricted small-for-gestational-age fetuses.

BACKGROUND: Fetal growth restriction secondary to chronic placental insufficiency is a major cause of perinatal morbidity and mortality. A significant proportion of fetuses with fetal growth restriction are small for gestational age, defined as a birthweight of ≤10th percentile. However, not all small-for-gestational-age fetuses are growth restricted. Some are constitutionally small and otherwise healthy. It is important to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction to ensure appropriate interventions in small-for-gestational-age fetuses with fetal growth restriction and to minimize unnecessary interventions in healthy small-for-gestational-age fetuses. The maternal serum ratio of soluble fms-like tyrosine kinase-1 and placental growth factor is an indicator of placental insufficiency in the latter half of pregnancy. As such, the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio may be a clinically useful tool to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction. OBJECTIVE: This study aimed to determine whether the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio can distinguish between small-for-gestational-age fetuses with and without fetal growth restriction with a birthweight of ≤10th percentile. STUDY DESIGN: A retrospective audit of 233 singleton pregnancies delivering an infant with a birthweight of ≤10th percentile corrected for gestational age with an antenatal maternal serum soluble fms-like tyrosine kinase-1-to-placental growth factor result was performed. Fetal growth restriction was defined as a birthweight of ≤10th percentile with an umbilical artery pulsatility index of >95th percentile, fetal middle cerebral artery pulsatility index of <5th percentile, amniotic fluid index of <6 cm, and/or cerebroplacental ratio of <1st percentile. The soluble fms-like tyrosine kinase-1-to-placental growth factor ratios before delivery between fetuses with and without fetal growth restriction (121 [fetal growth restriction] vs 112 [no fetal growth restriction]) were compared. The Student t test and Fisher exact test were used to compare cases and controls. The Mann-Whitney U test, linear regression analysis, and Spearman correlation coefficient (Rho) were used to examine associations between the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio and fetal outcomes to determine whether the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio served as a prognostic marker of fetal growth restriction severity. RESULTS: The mean soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was increased in fetal growth restriction cases compared with non-fetal growth restriction controls (234.3±25.0 vs 67.4±7.7, respectively; P<.0001). When controlling for preeclampsia, which is associated with placental insufficiency, fetal growth restriction cases still demonstrated an independent increase in the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio (effect size, 0.865; 95% confidence interval, 0.509-1.220; P<.001). The soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was negatively correlated with birthweight percentiles in pregnancies delivering an infant with a birthweight of ≤10th percentile (r=-0.3565; P<.0001). This association was maintained for fetuses with fetal growth restriction (r=-0.2309; P<.05), whereas fetuses without fetal growth restriction had no significant correlation between the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio and neonatal birthweight percentiles. CONCLUSION: The soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was significantly higher in small-for-gestational-age fetuses with fetal growth restriction than small-for-gestational-age fetuses without fetal growth restriction, independent of preeclampsia. Furthermore, the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was negatively correlated with fetal growth restriction birthweight percentiles, suggesting that it may be a clinical measure of fetal growth restriction severity. Therefore, the ratio may usefully delineate fetal growth restriction from constitutionally small but otherwise healthy fetuses antenatally, allowing for timely interventions in small-for-gestational-age cases with fetal growth restriction and unnecessary interventions to be minimized in small-for-gestational-age cases without fetal growth restriction.

The Impact of Health Geography on Public Health Research, Policy, and Practice in Canada.

The link between geography and health means that the places we occupy-where we are born, where we live, where we work, and where we play-have a direct impact on our health, including our experiences of health. A subdiscipline of human geography, health geography studies the relationships between our environments and the impact of factors that operate within those environments on human health. Researchers have focused on the social and physical environments, including spatial location, patterns, causes of disease and related outcomes, and health service delivery. The work of health geographers has adopted various theories and philosophies (i.e., positivism, social interactionism, structuralism) and methods to collect and analyze data (i.e., quantitative, qualitative, spatial analysis) to examine our environments and their relationship to health. The field of public health is an organized effort to promote the health of its population and prevent disease, injury, and premature death. Public health agencies and practitioners develop programs, services, and policies to promote healthy environments to support and enable health. This commentary provides an overview of the recent landscape of health geography and makes a case for how health geography is critically important to the field of public health, including examples from the field to highlight these links in practice.

Evidence-based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review.

BACKGROUND: Evidence-based practice and decision-making have been consistently linked to improved quality of care, patient safety, and many positive clinical outcomes in isolated reports throughout the literature. However, a comprehensive summary and review of the extent and type of evidence-based practices (EBPs) and their associated outcomes across clinical settings are lacking. AIMS: The purpose of this scoping review was to provide a thorough summary of published literature on the implementation of EBPs on patient outcomes in healthcare settings. METHODS: A comprehensive librarian-assisted search was done with three databases, and two reviewers independently performed title/abstract and full-text reviews within a systematic review software system. Extraction was performed by the eight review team members. RESULTS: Of 8537 articles included in the review, 636 (7.5%) met the inclusion criteria. Most articles (63.3%) were published in the United States, and 90% took place in the acute care setting. There was substantial heterogeneity in project definitions, designs, and outcomes. Various EBPs were implemented, with just over a third including some aspect of infection prevention, and most (91.2%) linked to reimbursement. Only 19% measured return on investment (ROI); 94% showed a positive ROI, and none showed a negative ROI. The two most reported outcomes were length of stay (15%), followed by mortality (12%). LINKING EVIDENCE TO ACTION: Findings indicate that EBPs improve patient outcomes and ROI for healthcare systems. Coordinated and consistent use of established nomenclature and methods to evaluate EBP and patient outcomes are needed to effectively increase the growth and impact of EBP across care settings. Leaders, clinicians, publishers, and educators all have a professional responsibility related to improving the current state of EBP. Several key actions are needed to mitigate confusion around EBP and to help clinicians understand the differences between quality improvement, implementation science, EBP, and research.

Urban design and adolescent mental health: A qualitative examination of adolescent emotional responses to pedestrian- and transit-oriented design and cognitive architecture concepts.

With the continued migration of people into cities, urban environments are becoming increasingly important determinants of health. However, the study of how precise environmental designs are linked to mental health are generally lacking, especially among adolescent populations. Using a qualitative approach featuring 23 go-along interviews with adolescents, we investigated the relationships between specific urban designs as outlined in pedestrian- and transit-oriented design (imageability, enclosure, scale, transparency, complexity) and cognitive architecture (biophilic architecture, symmetries, fractals) concepts and adolescent mental health indicators (i.e., emotional responses). Central findings from the subsequently undertaken framework analysis include considerably different perceptions regarding natural versus built enclosure and landmarks, significantly more expressed emotional engagement with visually rich and transparent urban designs relative to grey/concrete and windowless designs, and strong positive reactions to the three cognitive architecture concepts. Additional exploratory gender-based analyses were conducted and found potential differences in perceptions of design concepts between boys and girls. We note the broader relevance of these findings by discussing their implications for practitioners and suggesting how they can advance certain UN Sustainable Development Goals.

Successful pregnancy outcomes following intravenous immunoglobulin treatment in a woman with a previous fetal death in utero due to gestational alloimmune liver disease: A case report.

Gestational alloimmune liver disease resulting in neonatal haemochromatosis is a rare but often lethal neonatal and fetal condition and is the leading cause of fetal and neonatal liver injury. Chelation-antioxidant treatment, intravenous immunoglobulin therapy and exchange transfusions, as well as liver transplantation have been used as treatments for the affected newborn at birth. In the reported case, a woman with previous neonatal death at 34 weeks of gestation due to gestational alloimmune liver disease commenced weekly doses of intravenous immunoglobulin (1 mg/kg) from 15 weeks in a subsequent pregnancy. A healthy baby boy was delivered following induction of labour at 36 weeks and 5 days of gestation. Following the same protocol, another healthy baby boy was delivered at 37 weeks of gestation. This case report emphasises the clinical utility of antenatal prophylaxis with intravenous immunoglobulin in women at high risk of recurrent gestational alloimmune liver disease.

An Integrative Review of Team Nursing and Delegation: Implications for Nurse Staffing during COVID-19.

BACKGROUND: During the COVID-19 pandemic, providing care for critically ill patients has been challenging due to the limited number of skilled nurses, rapid transmission of the virus, and increased patient acuity in relation to the virus. These factors have led to the implementation of team nursing as a model of nursing care out of necessity for resource allocation. Nurses can use prior evidence to inform the model of nursing care and reimagine patient care responsibilities during a crisis. PURPOSE: To review the evidence for team nursing as a model of patient care and delegation and determine how it affects patient, nurse, and organizational outcomes. METHODS: We conducted an integrative review of team nursing and delegation using Whittemore and Knafl's (2005) methodology. RESULTS: We identified 22 team nursing articles, 21 delegation articles, and two papers about U.S. nursing laws and scopes of practice for delegation. Overall, team nursing had varied effects on patient, nursing, and organizational outcomes compared with other nursing care models. Education regarding delegation is critical for team nursing, and evidence indicates that it improves nurses' delegation knowledge, decision-making, and competency. LINKING EVIDENCE TO ACTION: Team nursing had both positive and negative outcomes for patients, nurses, and the organization. Delegation education improved team nursing care.

Thinking relationally about built environments and walkability: A study of adult walking behavior in Waterloo, Ontario.

The majority of research on built form and walking has been approached from a deterministic perspective and does not address the theoretical underpinnings of individual walking behaviour. This paper interrogates the relationship between individual walkers and their local environment in order to illuminate how and why people walk through/with space. Specifically, the paper reports on findings from 20 adult participants in Waterloo, Canada who took part in a participatory walking interview accompanied by a member of the research team. A relational interpretation of the data revealed that the relationship between built form and walking extends beyond the correlates of residential density, mix of land uses and street networks. Our findings reveal that there are blurred boundaries between utilitarian and recreational walking behavior, and that walking decisions were influenced by desires to avoid discomfort, seek pleasure, foster social connection and more-than-human encounters. We conclude with the argument that a relational perspective better captures the dynamics between people and place, and ultimately guides practitioners to design built environments that accommodate the realities of human activity in general and walking behavior in particular.

Holding the keys to health? A scoping study of the population health impacts of automated vehicles.

BACKGROUND: Automated Vehicles (AVs) are central to the new mobility paradigm that promises to transform transportation systems and cities across the globe. To date, much of the research on AVs has focused on technological advancements with little emphasis on how this emerging technology will impact population-level health. This scoping study examines the potential health impacts of AVs based on the existing literature. METHODS: Using Arksey and O'Malley's scoping protocol, we searched academic and 'grey' literature to anticipate the effects of AVs on human health. RESULTS: Our search captured 43 information sources that discussed a least one of the five thematic areas related to health. The bulk of the evidence is related to road safety (n = 37), followed by a relatively equal distribution between social equity (n = 24), environment (n = 22), lifestyle (n = 20), and built environment (n = 18) themes. There is general agreement that AVs will improve road safety overall, thus reducing injuries and fatalities from human errors in operating motorized vehicles. However, the relationships with air quality, physical activity, and stress, among other health factors may be more complex. The broader health implications of AVs will be dependent on how the technology is adopted in various transportation systems. Regulatory action will be a significant determinant of how AVs could affect health, as well as how AVs influence social and environmental determinants of health. CONCLUSION: To support researchers and practitioners considering the health implications of AVs, we provide a conceptual map of the direct and indirect linkages between AV use and health outcomes. It is important that stakeholders, including public health agencies work to ensure that population health outcomes and equitable distribution of health impacts are priority considerations as regulators develop their response to AVs. We recommend that public health and transportation officials actively monitor trends in AV introduction and adoption, regulators focus on protecting human health and safety in AV implementation, and researchers work to expand the body of evidence surrounding AVs and population health.

Double Burden of Rural Migration in Canada? Considering the Social Determinants of Health Related to Immigrant Settlement Outside the Cosmopolis.

There is a large and growing body of research acknowledging the existence of health disparities between foreign-born and native-born populations in many high immigrant-receiving countries. Significant attention has been paid to the role of physical and social environments in the changing health status of immigrants over time. However, very limited attention has been given to these issues within the context of rural geographies, despite global evidence that immigrants are increasingly settling outside of traditional gateway cities and into rural communities. This paper presents the results of a scoping review aimed at assessing the state of knowledge on the health impacts of immigrant migration into rural communities in Canada. Guided by Arksey and O'Malley's scoping protocol, we conduct a review of academic literature in Canada related to rural migration. A total of 25 articles met inclusion criteria which included access to the social determinants of health. Findings identified a paucity of research directly connecting rural settlement to health but the literature did emphasize five distinct social determinants of health for rural residing immigrants: social inclusion, culturally-appropriate services, gender, employment, and housing. This paper concludes with an identification of research gaps and opportunities for future research into whether rural-residing immigrants face a double burden with respect to health inequity.

Challenges to evidence-based health promotion: a case study of a Food Security Coalition in Ontario, Canada.

Developing the evidence base for health promotion can be challenging because interventions often have to target competing determinants of health, including social, structural, environmental and political determinants; all of which are difficult to measure and thus evaluate. Drawing on a case study of food insecurity, which refers to inadequate access to food due to financial constraints, we illustrate the challenges faced by community-based organizations in collecting data to form an evidence base for the development and evaluation of collective programmes aimed at addressing food insecurity. Interviews were conducted with members of a multi-stakeholder coalition (n = 22 interviewees; n = 10 organizations) who collectively work to address food insecurity in their community through a range of community-based programmes and services. Member organizations also provided a list of measures currently used to inform programme and service development and evaluation. Data were collected in a city in Southern Ontario, Canada between May and September 2015. Participants identified four barriers to collecting data: Organizational needs and philosophies; concerns surrounding clientele wellbeing and dignity; issues of feasibility; and restrictive requirements imposed by funding bodies. Participants also discussed their previous successes in collecting meaningful data for identifying impact. Our results point to the challenge of generating data suitable for developing and evaluating programmes aimed at broader determinants of health, while maintaining the primary goal of meeting clients' needs. Documenting change at intermediate- and macro-levels would provide evidence for the collective effectiveness of current programmes and services offered. However, appropriate resources need to be invested to allow for scientific evaluation.

Exploring experiences of the food environment among immigrants living in the Region of Waterloo, Ontario.

OBJECTIVES: This exploratory study aimed to shed light on the role of the food environment in shaping food access among immigrants living in the Region of Waterloo, Ontario. METHODS: In this qualitative case study, in-depth interviews aided by photovoice were conducted with nine immigrants, and key informant (KI) interviews were conducted with nine community stakeholders (e.g., settlement workers, planners) who held expert knowledge of the local context with respect to both the food system and experiences of immigrants in interacting with this system. In this paper, we focus specifically on insights related to the food environment, applying the Analysis Grid for Environments Linked to Obesity Framework to assess economic, physical, socio-cultural and political aspects. RESULTS: Economic features of the food environment, including food prices and differential costs of different types of food, emerged as factors related to food access. However, interactions with the food environment were shaped by broader economic factors, such as limited employment opportunities and low income. Most immigrants felt that they had good geographic access to food, though KIs expressed concerns about the types of outlet and food that were most accessible. Immigrants discussed social networks and cultural food practices, whereas KIs discussed political issues related to supporting food security in the Region. CONCLUSION: This exploratory case study is consistent with prior research in highlighting the economic constraints within which food access exists but suggests that there may be a need to further dissect food environments.

Disclosing food allergy status in schools: health-related stigma among school children in Ontario.

In 2006, 3 years after the tragic death of 13-year-old Sabrina Shannon, the Province of Ontario (Canada) passed Sabrina's Law ushering in a new era of focus and concern for severe food allergic children at risk of anaphylaxis. Questions were raised at the time regarding the potential of doing more harm than good with the new legislation. This paper reports the experiences of health-related stigma among food allergic children at risk of anaphylaxis who were required to disclose their health status under this new legislation. In 2008, in-depth interviews were conducted with 20 children and youth and their parents in order to explore the experiences living with a severe food allergy. This particular study explores their experiences of felt and enacted stigma in the school setting as a result of the disclosure process. Interviews were tape recorded with permission and transcribed for subsequent thematic analysis using NVIVO, a qualitative analysis software package. Results indicate that participants were stigmatised as a result of protective school policies under the law, and that created tension between their physical safety and social well-being. Sabrina's Law also led to a cultural shift in awareness of food allergies that resulted in some participants normalising their health status, offering promising directions for the future.

"We don't have such a thing, that you may be allergic": Newcomers' understandings of food allergies in Canada.

Food allergies are emerging as important public health risks in Canada, affecting 3-4% of adults and 6-7% of children. Despite much lower prevalence rates among recent immigrants (i.e. in the country less than 10 years), evidence has shown this population to be more concerned about the risks of food allergies than the general population and have unique experiences around purchasing foods for allergen-free environments. As a substantial and growing segment of the Canadian population, it is important to understand newcomers' perceptions and knowledge of food allergies and related policies developed to protect allergic children (e.g. nut-free schools and or classrooms). This paper draws upon the results of focus groups conducted with newcomers from food allergic households (i.e. directly affected), as well as those with school-aged children who have to prepare or buy foods for allergen-controlled classrooms or schools (i.e. indirectly affected) living in Mississauga, Ontario. Results indicate unique challenges and understandings of food allergies as a new and unfamiliar risk for most newcomers, particularly as the indirectly affected participants negotiate the policy landscape. The directly affected group highlights the supportive environment in Canada resulting from the same policies and increased awareness in the general population.

Plant dependence on rhizobia for nitrogen influences induced plant defenses and herbivore performance.

Symbiotic rhizobia induce many changes in legumes that could affect aboveground interactions with herbivores. We explored how changing the intensity of Bradyrhizobium japonicum, as modulated by soil nitrogen (N) levels, influenced the interaction between soybean (Glycine max) and herbivores of different feeding guilds. When we employed a range of fertilizer applications to manipulate soil N, plants primarily dependent on rhizobia for N exhibited increased root nodulation and higher levels of foliar ureides than plants given N fertilizer; yet all treatments maintained similar total N levels. Soybean podworm (Helicoverpa zea) larvae grew best on plants with the highest levels of rhizobia but, somewhat surprisingly, preferred to feed on high-N-fertilized plants when given a choice. Induction of the defense signaling compound jasmonic acid (JA) by H. zea feeding damage was highest in plants primarily dependent on rhizobia. Differences in rhizobial dependency on soybean did not appear to affect interactions with the phloem-feeding soybean aphid (Aphis glycines). Overall, our results suggest that rhizobia association can affect plant nutritional quality and the induction of defense signaling pathways and that these effects may influence herbivore feeding preferences and performance-though such effects may vary considerably for different classes of herbivores.

Prioritizing obesity in the city.

A decade ago, the World Health Organization declared obesity to be a global epidemic. Accordingly, there is a growing body of research examining how "obesogenic environments" contribute to the increasing prevalence of obesity. Using the ANGELO Framework, this research explores the role of municipal policies and practices in constructing obesogenic environments in two Southern Ontario cities in order to examine how socio-cultural and political environments shape excess body weight. Data was collected from municipal policy documents, public health websites, and key informants in Hamilton and Mississauga, Ontario, Canada. Results indicate that while the cities took different approaches to dealing with obesity, they both reflected the cities' overall prioritizing of health. Additionally, the findings reveal the pervasiveness of values and attitudes held in the socio-cultural environment in further shaping (and being shaped by) political as well as economic and physical environments in the cities. The importance of explicitly acknowledging the official discourse of the city, which this study demonstrates to be a significant factor in constructing obesogenic environments, is highlighted. Theoretical contributions and policy implications are also discussed.

"My health has improved because I always have everything I need here...": A qualitative exploration of health improvement and decline among immigrants.

Immigrants in Canada constitute approximately 20% of the total population and will continue to account for a significant portion of the country's population in the future. Accordingly, a growing body of research has focused on examining the disparity in health status between the increasing foreign-born and the Canadian-born populations. The healthy immigrant effect, in particular, acknowledges that immigrants have better health status than their Canadian-born counterparts upon arrival in the country. However, studies have shown that over time the health of immigrants declines to a level on par with the Canadian-born population. There is much speculation as to the reasons for this decline including acculturation (i.e., uptake of unhealthy lifestyles) and a lack of access to health care. Yet, there have been few studies to examine possible reasons for potential declines in health, especially from the perspective of immigrants themselves. This study is one of the first to qualitatively examine perceived changes in health status and reasons for health status change among immigrants. The paper presents the results of 23 in-depth interviews with adults with recent (less than 3 years of residency), mid-term (3-10 years), and long-term (more than 10 years) immigrants living in the Greater Toronto Area. The results reveal that the majority of the participants believed their health had remained stable or even improved over time due to improved living standards and lifestyle behaviours in Canada. Those who perceived their health to have worsened over time attributed the change to the stress associated with migration, and the aging process rather than the adoption of an unhealthy lifestyle. Additionally, while the vast majority of participants reported improved access to resources upon migration, there were mixed reviews in terms of how beneficial these resources were or could be for health. The findings highlight the need for research to incorporate mental health into studies on changing immigrant health status and to focus on those factors contributing to high levels of stress among more recent immigrants.

'Education? It is irrelevant to my job now. It makes me very depressed ...': exploring the health impacts of under/unemployment among highly skilled recent immigrants in Canada.

Immigrants account for 20% of the population and 60% of total population growth in Canada (Statistics Canada 2001). The majority of immigrants are accepted for entry to Canada under the Skilled Worker Program in order to fill employment shortages in the labour market (CIC 2007). Recent research has revealed that an increasing number of immigrants who gain entry under this programme face significant barriers to employment. As a result, many remain unemployed or accept employment outside of and below their field of education and training. However, the impacts such employment circumstances have on the health of immigrants have not yet been examined. This paper presents the results of a collaborative research project that explores the health impacts of under/unemployment among skilled immigrants in Mississauga, Ontario, Canada. In-depth interviews are used to examine the experiences of employment and perceptions of subsequent health impacts among 22 recent immigrants. The participants most frequently identified mental health impacts due to a lack of income, loss of employment-related skills, loss of social status and family pressures. These health concerns are also extended to family members. In addition to mental health, physical health is perceived to be affected by employment circumstances through high levels of stress and strenuous working conditions. These findings shed light on the nature of the links between employment and health relationship as well as determinants of immigrant health. Additional research is required to examine the long-term effects of under/unemployment.