Healing journey: Experiences of First Nations individuals with recovery from opioid use.

OBJECTIVE: To understand experiences of recovery from opioid use among First Nations individuals living in a small remote community. DESIGN: Qualitative phenomenologic study. SETTING: Northwestern Ontario. PARTICIPANTS: Sixteen First Nations individuals living in a remote community who had participated in or completed the community opioid agonist therapy program. METHODS: Extensive community consultation took place to ensure local acceptance of the study and permission for publication. Semistructured telephone interviews with consenting participants were audiorecorded between November and December 2021 and transcribed. Transcripts were reviewed and discussed in meetings with Indigenous and non-Indigenous research team members who conducted thematic analysis using immersion and crystallization. MAIN FINDINGS: Participants described their opioid use as a form of self-management of trauma. Their recovery processes were multifaceted and included developing cultural and self-awareness. Motivation for change often arose from concerns about family well-being and finances. Traditional cultural practices and time spent on the land were identified as important wellness experiences. Barriers to healing included limited clinical and holistic addiction services, particularly around dose weaning and opioid agonist therapy discontinuation. CONCLUSION: Community-based addiction programming for First Nations patients needs to be robust. It requires resources for trauma-informed clinical and addiction care, culturally appropriate addictions education, aftercare support, and land-based activities.

Progression From Gestational Diabetes Mellitus to Type 2 Diabetes Mellitus Among First Nations Women in Northwest Ontario: A Retrospective Cohort Study.

OBJECTIVE: Our aim in this study was to identify the incidence of type 2 diabetes mellitus among First Nations women in northwest Ontario with a history of gestational diabetes mellitus (GDM). METHODS: This work was a retrospective cohort study of women diagnosed with GDM using a 50-gram oral glucose challenge test or a 75-gram oral glucose tolerance test from January 1, 2010, to December 31, 2017, at the Sioux Lookout Meno Ya Win Health Centre. Outcomes were assessed based on glycated hemoglobin (A1C) measurements performed between January 1, 2010, and December 31, 2019. RESULTS: The cumulative incidence of T2DM among women with a history of GDM was 18% (42 of 237) at 2 years and 39% (76 of 194) at 6 years. Women with GDM who developed T2DM were of similar age and parity and had equivalent C-section rates (26%) compared to those who did not develop T2DM. They had higher birth weights (3,866 grams vs 3,600 grams, p=0.006) and rates of treatment with insulin (24% vs 5%, p<0.001) and metformin (16% vs 5%, p=0.005). CONCLUSIONS: GDM confers a significant risk for the development of T2DM in First Nations women. Broad community-based resources, food security, and social programming are required.

Skin morbidity in Indigenous children in relation to housing conditions in remote communities in Northwestern Ontario, Canada.

BACKGROUND: Elevated rates of eczema and skin infections in Canadian First Nation (FN) communities are of concern to families, community leaders and healthcare professionals. AIM: To determine whether skin morbidity was associated with indoor environmental quality factors in Canadian FN children living in remote communities. METHODS: We quantified indoor environmental quality (IEQ) in the homes of FN children aged < 4 years of age living in four remote communities in the Sioux Lookout region of Northwestern Ontario, Canada. We conducted a quantitative housing inspection, including measuring surface area of mould (SAM), and monitored air quality for 5 days in each home, including carbon dioxide and relative humidity and quantified endotoxin in settled floor dust. We reviewed the medical charts of participating children for skin conditions and administered a health questionnaire. Relationships between IEQ and skin infections or eczema were evaluated using multivariable regression. RESULTS: In total, 98 children were included in the descriptive analyses, of whom 86 had complete data and were evaluated in multivariate analyses for dermatological outcomes (mean age 1.6 years). Of these 86 children, 55% had made ≥ 1 visits to the local health centre (HC) for skin and soft tissue infections and 25.5% for eczema. Unexpectedly, annualized eczema visits were inversely associated with SAM (RR = 0.14; 95% CI 0.01-0.93). There was a trend suggesting an inverse relationship between endotoxin and HC encounters for eczema and skin and soft tissue infections. CONCLUSION: Skin infections were common in this population of FN children. IEQ did not appear to be associated with skin infections or eczema. Mould exposure appeared to be inversely associated with HC encounters for eczema, possibly related to complex microorganism-host interactions occurring early in life.

A collaborative approach to hepatitis C testing in two First Nations communities of northwest Ontario.

Background: Two remote First Nations communities each collaborated with an urban-based liver clinic to organize wide-spread testing, followed by linkage to care for hepatitis C virus (HCV). Method: Involvement of community members was central to planning and conduct of the programs. Samples were obtained using dry blood spot cards (DBS). A week-long pilot study in Community 1 investigated the effectiveness of the program, using DBS. Community 2, being larger, more remote, and known to be endemic for HCV was more challenging. Three-week-long testing drives plus a stand-alone testing day were used to collect samples over 5 months. Public Health Agency (PHAC)'s National Laboratory for HIV Reference Services (NLHRS) received and tested the DBS samples for HCV and other blood-borne infections. Outcomes were measured by number of people tested, the quality of the tests, and community members' satisfaction with the program and retained knowledge about HCV, based on interviews. Results: In Community 1, 226 people were tested for HCV over 4 days. 85% agreed to human immunodeficiency virus (HIV) testing as well. In Community 2, 484 people, one-half of the adult population, were tested. Surveys of participants showed food was the most significant draw, and Facebook the most effective way to inform people of the events. Interviews with staff and participants showed a high level of satisfaction. Conclusion: The results suggest this is an effective approach to testing for HCV in unusually challenging settings. Lessons from the program include the power of community involvement; and the effectiveness of a highly targeted health initiative when developed through collaboration.

Traditional Medicine and Type 2 Diabetes in First Nations Patients.

BACKGROUND: Diabetes may be a cultural experience for many First Nations patients. In this study, we explore the potential role for traditional medicine in the treatment of diabetes. METHODS: A responsive interviewing qualitative methodology was used for 10 First Nations key informant interviews. The first objective was to accurately "re-tell" participants' stories. The second was to develop an overview of traditional medicine and its role in health and diabetes management by synthesizing academic literature, pre-existing local knowledge and perspectives, and stories shared by elders and traditional healers. The traditional medicine healers gave specific permission for this study and its publication. RESULTS: There is a strong cultural and historic context for the experience of diabetes in First Nations. Political and cultural suppression, lifestyle change and ongoing social determinants of health place diabetes in a unique context and generate a sense of fatalism. Traditional medicine can facilitate individual empowerment by connecting a patient with the lessons of previous generations and traditional beliefs and practices. CONCLUSIONS: Traditional medicine can be a valuable resource for First Nations patients living with diabetes and should be considered as a therapeutic modality.

Diabetes prevalence and complication rates: In individual First Nations communities in the Sioux Lookout region of Ontario.

OBJECTIVE: To test the feasibility of reporting diabetes indicators at a regional and community level in order to provide feedback to local leaders on health system performance. DESIGN: Analysis of administrative data from hospital discharges and physician billings. SETTING: Sioux Lookout region of Ontario. PARTICIPANTS: Residents from 30 remote communities served by the Sioux Lookout First Nations Health Authority. MAIN OUTCOME MEASURES: Incidence and prevalence of diabetes and incidence of diabetes complications, including heart attack, stroke, retinopathy, amputations, end-stage kidney disease, diabetes-related hospitalizations, and death. RESULTS: Data were available for 18 542 residents from the 30 remote communities. Residents were almost entirely of First Nations descent. The prevalence of diabetes was 12.9%, the annual incidence was 1.0%, and the annual rate of complications was 5.4% in 2015-2016. Prevalence increased slightly over time. We had sufficient data to report prevalence in 25 of 30 communities (average population 738; range 234 to 2626). We reported statistically significant differences in prevalence by community; 8 were above average and 2 were below average. For diabetes complications, data were pooled over 5 years, and while community-level results could be reported, the variance was too high to allow detection of significant differences. Using 2-tailed t tests for difference of proportions, we determined that grouping communities into subregions of approximately 2000 persons would permit the detection of differences of 30% from the average 5-year complication rate. CONCLUSION: This study demonstrates the possibility of reporting diabetes prevalence by individual First Nations reserve communities. Complication rates can be reported by individual community, but estimates are more useful for comparison if the smallest communities are grouped together. Such studies could be replicated across Canada to promote local use of these data for resource planning and monitoring long-term progress of diabetes programs and services.

Diabetes prevalence and demographics in 25 First Nations communities in northwest Ontario (2014-2017).

INTRODUCTION: First Nations communities are known to have high rates of diabetes. The rural First Nations communities in northwest (NW) Ontario are particularly affected. Regional studies in 1985 and 1994 found a high prevalence of diabetes. More recently, they are estimated to have the highest prevalence in Ontario at 19%, double the provincial norm. The purpose of this study is to examine the epidemiology and prevalence of diabetes in the total population and cardiovascular comorbidities in the adult population of 25 First Nations communities in NW Ontario. METHODS: This retrospective diabetes prevalence study used primary care electronic medical record data for a 3-year period, 1 August 2014-31 July 2017. Diabetes prevalence was calculated for both the total and the adult (18+) populations and comorbid hypertension and dyslipidaemia were identified in adults. RESULTS: The age-adjusted diabetes prevalence for the total population was 15.1% versus a Canadian prevalence of 8.8%. The age-adjusted adult prevalence was 14.1%, double Canada's average of 7.1%. The average age of adults with diabetes was 52 years (±14.9); 57% were female. Comorbid hypertension (58%) and dyslipidaemia (73%) were common. Metformin was the most commonly used medication (58%), followed by insulin/analogues (23%) and sulphonylureas (13%). CONCLUSION: The diabetes prevalence in the First Nations population of NW Ontario is double Canada's norm. Addressing it will require addressing relevant social determinants of health, including poverty and food security.

Résumé Introduction : Les communautés des Premières nations sont reconnues pour leur taux élevé de diabète, particulièrement les communautés rurales des Premières nations du Nord-Ouest de l'Ontario. Des études régionales réalisées en 1985 et 1994 ont révélé une forte prévalence de diabète. Plus récemment, on a estimé que la prévalence dans ces communautés s'élevait à 19 %, la plus forte en Ontario et le double de la norme provinciale. Cette étude visait à examiner l'épidémiologie et la prévalence du diabète auprès de la population totale et les comorbidités cardiovasculaires auprès de la population adulte de 25 communautés des Premières nations du Nord-Ouest de l'Ontario. Méthodologie : Cette étude rétrospective visant à évaluer la prévalence du diabète a eu recours aux données sur 3 ans des dossiers médicaux électroniques des cliniques de première ligne, soit du 1er août 2014 au 31 juillet 2017. La prévalence du diabète a été calculée dans les populations totale et d'adultes (18 ans et plus) et l'hypertension et la dyslipidémie ont été dépistées en concomitance chez les adultes. Résultats: La prévalence du diabète ajustée en fonction de l'âge dans la population totale était de 15,1 % par rapport à la prévalence canadienne de 8,8 %. La prévalence ajustée en fonction de l'âge chez les adultes était de 14,1 %, soit le double de la prévalence canadienne de 7,1 %. L'âge moyen des adultes diabétiques était de 52 (±14,9) ans; et 57 % des participants étaient de sexe féminin. L'hypertension (58 %) et la dyslipidémie (73 %) étaient courantes en concomitance. La metformine était le médicament le plus fréquemment utilisé (58 %), suivie de l'insuline/analogues (23 %) et des sulfonylurées (13 %). Conclusion: La prévalence du diabète dans les populations des Premières nations du Nord-Ouest de l'Ontario est le double de celle du Canada. Pour régler la situation, il faudra se pencher sur les déterminants sociaux de la santé pertinents tels que la pauvreté et l'insécurité alimentaire. Mots-clés: Diabète, Premières nations, prévalence.

Prevalence of chronic kidney disease and cardiovascular comorbidities in adults in First Nations communities in northwest Ontario: a retrospective observational study.

BACKGROUND: The prevalence of adult chronic kidney disease and cardiovascular comorbidities in Canadian Indigenous communities is largely unknown. We conducted a study to document the prevalence of chronic kidney disease and concurrent diabetes mellitus, hypertension and dyslipidemia in a First Nations population in northwest Ontario. METHODS: In this observational study, we used retrospective data collected from regional electronic medical records of 16 170 adults (age ≥ 18 yr) from 26 First Nations communities in northwest Ontario from May 2014 to May 2017. Demographic and laboratory data included age, gender, prescribed medications, estimated glomerular filtration rate, urine albumin:creatinine ratio, low-density lipoprotein cholesterol (LDL-C) level and glycated hemoglobin (HbA1c) concentration. We identified patients with diabetes by an HbA1c concentration of 6.5% or higher, or the use of a diabetic medication, those with dyslipidemia by an elevated LDL-C level (≥ 2.0 mmol/L) or use of lipid-lowering medication, and those with hypertension by use of antihypertensive medication. RESULTS: Of the 16 170 adults residing in the communities, 5224 unique patients (32.3%) had renal testing (albumin:creatinine ratio and/or estimated glomerular filtration rate). The age-adjusted prevalence of chronic kidney disease was 14.5%, and the prevalence of stage 3-5 chronic kidney disease (estimated glomerular filtration rate < 60 mL/min) was 7.0%. Most patients with chronic kidney disease (1487 [80.0%]) had at least 1 cardiovascular comorbidity. A total of 1332 patients (71.6%) had diabetes, 1313 (70.6%) had dyslipidemia, and 1098 (59.1%) had hypertension; all 3 comorbidities were present in 716 patients (38.5%). INTERPRETATION: We document a high prevalence of advanced chronic kidney disease in this First Nations population, 7.0%, double the rate in the general population. High rates of cardiovascular comorbidities were also common in these patients with chronic kidney disease, which places them at increased risk for cardiovascular disease.

Opioid use in pregnancy and parenting: An Indigenous-based, collaborative framework for Northwestern Ontario.

Opioid use affects up to 30% of pregnancies in Northwestern Ontario. Health care providers in Northwestern Ontario have varying comfort levels providing care to substance-involved pregnant women. Furthermore, health care practitioners, social service agencies and community groups in Northwestern Ontario often work in isolation with little multidisciplinary communication and collaboration. This article describes two workshops that brought together health and social service providers, community organizations, as well as academic institutions and professional organizations involved in the care of substance-involved pregnant and parenting women. The initial workshop presented best practices and local experience in the management of opioid dependence in pregnancy while the second workshop asked participants to apply a local Indigenous worldview to the implementation of clinical, research and program priorities that were identified in the first workshop. Consensus statements developed by workshop participants identified improved transitions in care, facilitated access to buprenorphine treatment, stable funding models for addiction programs and a focus on Indigenous-led programming. Participants identified a critical need for a national strategy to address the effects of opioid use in pregnancy from a culturally safe, trauma-informed perspective that takes into account the health and well-being of the woman, her infant, her family and her community.

First Nations hepatitis C virus infections: Six-year retrospective study of on-reserve rates of newly reported infections in northwestern Ontario.

OBJECTIVE: To document rates of newly reported hepatitis C virus (HCV) cases from 2010 to 2015 in remote First Nations communities. DESIGN: Retrospective analysis of aggregate data of newly reported HCV antibody-positive (Ab+) cases. SETTING: Northwestern Ontario. PARTICIPANTS: A total of 31 First Nations communities (an on-reserve population of 20 901) supported in health care by the Sioux Lookout First Nations Health Authority. MAIN OUTCOME MEASURES: The aggregate characteristic data included year of notification, age range, and sex for a 6-year period (2010 to 2015). RESULTS: There were 267 HCV Ab+ cases in the 6-year study period. The incidence in 2015 was 324.2 per 100 000 population. This is 11 times the rate for all of Ontario. The most common associated risk factor was sharing of intravenous drug use equipment. Women made up 52% of patients with newly reported HCV Ab+ cases. More than 45% of cases were in patients between 20 and 29 years of age. CONCLUSION: This high burden of newly reported HCV Ab+ cases in geographically remote First Nations communities is concerning, and prevention and treatment resources are needed. This burden of disease might pose more urgent health and social challenges than can be generalized from the experience of the rest of Canada.

High Incidence of Invasive Group A Streptococcal Infections in Remote Indigenous Communities in Northwestern Ontario, Canada.

BACKGROUND: Worldwide, indigenous populations appear to be at increased risk for invasive group A streptococcal (iGAS) infections. Although there is empirical evidence that the burden of iGAS disease is significant among remote First Nations communities in Northwestern Ontario, Canada, the epidemiology of iGAS infections in the area remains poorly characterized. METHODS: Individuals that met case definition for iGAS disease and whose laboratory specimens were processed by Meno Ya Win Health Centre in Sioux Lookout, Canada or who were reported to Thunder Bay District Health Unit, Canada were identified for the period 2009 to 2014. Case demographics, clinical severity, comorbidities, and risk factors were collected through chart review. Strain typing and antibiotic susceptibility were determined when possible. Basic descriptive statistics were calculated. RESULTS: Sixty-five cases of iGAS disease were identified, for an annualized incidence of 56.2 per 100 000. Primary bacteremia was present in 26.2% of cases, and cellulitis was identified in 55.4% of cases. The most common comorbidities identified were diabetes (38.5%) and skin conditions (38.5%). Prevalent risk factors included alcohol dependence (25%). Fourteen different emm types were identified among 42 isolates, with the most common being emm114 (17.4%), emm11 (15.2%), and emm118 (13.0%). Resistance to erythromycin and clindamycin was found in 24.6% of isolates. CONCLUSIONS: Rural and remote First Nations communities in Northwestern Ontario experience iGAS infections at a rate 10 times the provincial and national average. Compared with other North American series, a lower proportion of isolates causing infection were of emm types included in candidate GAS vaccines.

Evaluation of 6 remote First Nations community-based buprenorphine programs in northwestern Ontario: Retrospective study.

OBJECTIVE: To evaluate established opioid addiction treatment programs that use traditional healing in combination with buprenorphine-naloxone maintenance treatment in 6 First Nations communities in the Sioux Lookout region of northwestern Ontario. DESIGN: Retrospective cohort study. SETTING: Six First Nations communities in northwestern Ontario. PARTICIPANTS: A total of 526 First Nations participants in opioid-dependence treatment programs. INTERVENTION: Buprenorphine-naloxone substitution therapy and First Nations healing programming. MAIN OUTCOME MEASURES: Retention rates and urine drug screening (UDS) results. RESULTS: Treatment retention rates at 6, 12, and 18 months were 84%, 78%, and 72%, respectively. We estimate that the rate at 24 months will also be more than 70%. The UDS programming varied and was implemented in only 1 community. Initially urine testing was voluntary and it then became mandatory. Screening with either method found the proportion of urine samples with negative results for illicit opioids ranged between 84% and 95%. CONCLUSION: The program's treatment retention rates and negative UDS results were higher than those reported for most methadone and buprenorphine-naloxone programs, despite a patient population where severe posttraumatic stress disorder is endemic, and despite the programs' lack of resources and addiction expertise. Community-based programs like these overcome the initial challenge of cultural competence. First Nations communities in other provinces should establish their own buprenorphinenaloxone programs, using local primary care physicians as prescribers. Sustainable core funding is needed for programming, long-term aftercare, and trauma recovery for such initiatives.

Racism and Oral Health Outcomes among Pregnant Canadian Aboriginal Women.

This study assessed links between racism and oral health outcomes among pregnant Canadian Aboriginal women. Baseline data were analyzed for 541 First Nations (94.6%) and Métis (5.4%) women in an early childhood caries preventive trial conducted in urban and on-reserve communities in Ontario and Manitoba. One-third of participants experienced racism in the past year determined by the Measure of Indigenous Racism Experience. In logistic regressions, outcomes significantly associated with incidents of racism included: wearing dentures, off-reserve dental care, asked to pay for dental services, perceived need for preventive care, flossing more than once daily, having fewer than 21 natural teeth, fear of going to dentist, never received orthodontic treatment and perceived impact of oral conditions on quality of life. In the context of dental care, racism experienced by Aboriginal women can be a barrier to accessing services. Programs and policies should address racism's insidious effects on both mothers' and children's oral health outcomes.

Potential role for interferon-γ release assays in tuberculosis screening in a remote Canadian community: a case series.

BACKGROUND: Current Canadian guidelines suggest that neonatal Bacille Calmette-Guérin (BCG) vaccination does not result in false-positive tuberculosis (TB) skin tests, despite a growing body of evidence that interferon-γ release assays may be a more specific alternative in identifying latent tuberculosis infections in vaccinated populations. We set out to evaluate the relationship between TB skin tests and interferon-γ release assays in patients who previously received neonatal BCG vaccine. METHODS: All children with a positive skin test at age 14 years in a remote community north of Sioux Lookout, Ontario, were considered for interferon-γ release assay testing. RESULTS: Of the 11 children who underwent routine screening at 14 years of age for latent TB infection, 7 had a positive TB skin test (≥ 10 mm). All 7 of these children had received the BCG vaccine as newborns and all had a negative TB skin test during their routine screening at 4 years of age. No potential exposure to active TB could be identified. Chest radiographs were normal, and none of the children had symptoms suggestive of active TB. The 7 children underwent interferon-γ release assay testing using QuantiFERON Gold. All 7 tests were negative. INTERPRETATION: With the addition of interferon-γ release assays to routine skin test screening, we provide evidence that neonatal BCG vaccination may contribute to a false-positive skin test in youth at 14 years of age. Consideration should be given to the possibility that neonatal BCG may contribute to false-positive TB skin tests.

Racism and Oral Health Outcomes among Pregnant Canadian Aboriginal Women.

This study assessed links between racism and oral health outcomes among pregnant Canadian Aboriginal women. Baseline data were analyzed for 541 First Nations (94.6%) and Métis (5.4%) women in an early childhood caries preventive trial conducted in urban and on-reserve communities in Ontario and Manitoba. One-third of participants experienced racism in the past year determined by the Measure of Indigenous Racism Experience. In logistic regressions, outcomes significantly associated with incidents of racism included: wearing dentures, off-reserve dental care, asked to pay for dental services, perceived need for preventive care, flossing more than once daily, having fewer than 21 natural teeth, fear of going to dentist, never received orthodontic treatment and perceived impact of oral conditions on quality of life. In the context of dental care, racism experienced by Aboriginal women can be a barrier to accessing services. Programs and policies should address racism's insidious effects on both mothers' and children's oral health outcomes.

Community-wide measures of wellness in a remote First Nations community experiencing opioid dependence: evaluating outpatient buprenorphine-naloxone substitution therapy in the context of a First Nations healing program.

OBJECTIVE: To document the development of unique opioid-dependence treatment in remote communities that combines First Nations healing strategies and substitution therapy with buprenorphine-naloxone. DESIGN: Quantitative measurements of community wellness and response to community-based opioid-dependence treatment. SETTING: Remote First Nations community in northwestern Ontario. PARTICIPANTS: A total of 140 self-referred opioid-dependent community members. INTERVENTION: Community-developed program of First Nations healing, addiction treatment, and substitution therapy. MAIN OUTCOME MEASURES: Community-wide measures of wellness: number of criminal charges, addiction-related medical evacuations, child protection agency cases, school attendance, and attendance at community events. RESULTS: The age-adjusted adult rate of opioid-dependence treatment was 41%. One year after the development of the in-community healing and substitution therapy program for opioid dependence, police criminal charges had fallen by 61.1%, child protection cases had fallen by 58.3%, school attendance had increased by 33.3%, and seasonal influenza immunizations had dramatically gone up by 350.0%. Attendance at community events is now robust, and sales at the local general store have gone up almost 20%. CONCLUSION: Community-wide wellness measures have undergone dramatic public health changes since the development of a First Nations healing program involving opioid substitution therapy with buprenorphine-naloxone. Funding for such programs is ad hoc and temporary, and this threatens the survival of the described program and other such programs developing in this region, which has been strongly affected by an opioid-dependence epidemic.

Acute rheumatic fever in First Nations communities in northwestern Ontario: Social determinants of health "bite the heart".

OBJECTIVE: To document a case series of 8 young First Nations patients diagnosed with acute rheumatic fever (ARF), a preventable disease that resulted in the death of 2 patients, in northwestern Ontario in the context of late diagnosis, overcrowded housing, and inadequate public health response. DESIGN: Retrospective case series over an 18-month period. SETTING: Remote First Nations communities in northwestern Ontario. PARTICIPANTS: Eight patients with ARF. MAIN OUTCOME MEASURES: Incidence, mortality, residual rheumatic heart disease, time to diagnosis, barriers to diagnosis and treatment, housing situation of patients, patient demographic characteristics (age, sex), and investigation results. RESULTS: The incidence of ARF in this population was 21.3 per 100,000, which is 75 times greater than the overall Canadian estimated incidence. The average patient age was 9.4 years. Most cases developed joint findings, and 5 of the surviving patients had rheumatic heart disease when they received echocardiography. The average time to diagnosis was 88 days. Two 4-year-old children died from ARF. Most patients lived in inadequate and crowded housing. CONCLUSION: This rare disease still exists in remote First Nations communities. These communities demonstrate an incidence equal to that in aboriginal communities in Australia and New Zealand, which have among the highest international incidence of ARF. Primordial prevention, including improved on-reserve housing, is urgently needed. Case detection and ongoing surveillance for primary and secondary prophylaxis requires a well resourced regional strategy.

The comprehensive geriatric assessment guide: an exploratory analysis of a medical trainee performance evaluation tool.

PURPOSE: Few opportunities exist for medical students and residents to receive feedback on specific geriatric skills because they are frequently unsupervised when assessing elderly patients. Patients and caregivers are currently an untapped source of clinical content feedback. The purpose of this study was to determine whether patients/caregivers could accurately complete a postassessment evaluation of trainees' clinical performance. METHOD: The authors developed the Comprehensive Geriatric Assessment Guide (CGAG) consisting of 36 yes/no/don't-remember questions that prompt the patient/caregiver to indicate what topics the trainee discussed during clinical assessment. In 2010, two raters independently listened to audio recordings of 10 trainee-administered clinical assessments, scoring them using the CGAG to determine interrater reliability. Next, 32 patients/caregivers completed a CGAG after a trainee-administered clinical assessment. Then, the authors compared the results with a "gold standard" CGAG of the encounter. RESULTS: Interrater reliability for the CGAG was high (90.4% agreement), indicating that the patients/caregivers were able to accurately complete the postassessment CGAG. Of 36 CGAG questions, 30 had patient/caregiver and gold standard agreement of over 80%; the remaining 6 had low agreement. CONCLUSIONS: Patients and caregivers were able to recall sufficient clinical assessment detail to potentially provide constructive feedback to medical trainees on their assessment skills via the CGAG. Six questions with low agreement will be reworded to improve clarity on future versions of the CGAG. Future investigations will help determine whether use of the CGAG during medical education may help trainees improve assessment performance and allow educators to track progress in geriatric competencies.