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.

Systematic review of the use of metformin compared to insulin for the management of gestational diabetes: Implications for low-resource settings.

Introduction: This systematic review examines the effectiveness of metformin treatment compared to insulin treatment for gestational diabetes within the context of a low-resource environment. Methods: Electronic data searches of Medline, EMBASE, Scopus and Google scholar databases from 1 January, 2005 to 30 June, 2021 were performed using medical subject headings: 'gestational diabetes or pregnancy diabetes mellitus' AND 'Pregnancy or pregnancy outcomes' AND 'Insulin' AND 'Metformin Hydrochloride Drug Combination/or Metformin/or Hypoglycemic Agents' AND 'Glycemic control or blood glucose'. Randomized controlled trials were included if: participants were pregnant women with gestational diabetes mellitus (GDM); the interventions were metformin and/or insulin. Studies among women with pre-gestational diabetes, non-randomised control trials or studies with a limited description of the methodology were excluded. Outcomes included adverse maternal outcomes: weight gain, C-section, pre-eclampsia and glycaemic control and adverse neonatal outcomes: birth weight, macrosomia, pre-term birth and neonatal hypoglycaemia. The revised Cochrane Risk of Bias Assessment for randomised trials was used for the evaluation of bias. Results: We screened 164 abstracts and 36 full-text articles. Fourteen studies met the inclusion criteria. The studies provide moderate to high-quality evidence demonstrating the effectiveness of metformin as an alternative therapy to insulin. Risk of bias was low; multiple countries and robust sample sizes improved external validity. All studies were from urban centres with no rural data. Conclusion: These recent high quality studies comparing metformin to insulin for the treatment of GDM generally found either improved or equivalent pregnancy outcome and good glycaemic control for most patients, although many required insulin supplementation. Its ease of use, safety and efficacy suggest metformin may simplify the management of gestational diabetes, particularly in rural and other low-resource environments.

Résumé Introduction: Cette revue systématique examine l'efficacité du traitement par metformine par rapport au traitement par insuline pour le diabète gestationnel dans le contexte d'un environnement à faibles ressources. Méthodes: Des recherches de données électroniques ont été effectuées dans les bases de données Medline, Embase, Scopus et Google scholar du 1er janvier 2005 au 30 juin 2021 en utilisant les termes MeSH: 'gestational diabetes or pregnancy diabetes mellitus' AND 'Pregnancy or pregnancy outcomes' AND 'Insulin' AND 'Metformin Hydrochloride Drug Combination/or Metformin/or Hypoglycemic Agents' AND 'Glycemic control or blood glucose'. Les essais contrôlés randomisés ont été inclus si: les participantes étaient des femmes enceintes atteintes de diabète gestationnel (DG); les interventions étaient la metformine et/ou l'insuline. Les études portant sur des femmes atteintes de diabète prégestationnel, les essais contrôlés non randomisés ou les études dont la description de la méthodologie était limitée ont été exclus. Les résultats comprenaient des résultats maternels défavorables: prise de poids, césarienne, prééclampsie, contrôle glycémique et des résultats néonatals défavorables: poids de naissance, macrosomie, naissance prématurée et hypoglycémie néonatale. La version révisée de l'évaluation du risque de biais de Cochrane pour les essais randomisés a été utilisée pour l'évaluation du biais. Résultats: Nous avons examiné 164 résumés et 36 articles complets. Quatorze études répondaient aux critères d'inclusion. Les études fournissent des preuves modérées à de haute qualité démontrant l'efficacité de la metformine comme thérapie alternative à l'insuline. Le risque de biais était faible; la multiplicité des pays et la taille robuste des échantillons ont amélioré la validité externe. Toutes les études provenaient de centres urbains, sans données rurales. Conclusion: Ces études récentes de haute qualité comparant la metformine à l'insuline pour le traitement du DG ont généralement constaté une amélioration ou une équivalence de l'issue de la grossesse et un bon contrôle glycémique pour la plupart des patientes, bien que beaucoup d'entre elles aient eu besoin d'un supplément d'insuline. Sa facilité d'utilisation, son innocuité et son efficacité suggèrent que la metformine pourrait simplifier la prise en charge du diabète gestationnel, notamment en milieu rural et dans d'autres environnements à faibles ressources. Mots clés: Diabète gestationnel, traitement, metformine, rural.

Social Inequities Contributing to Gestational Diabetes in Indigenous Populations in Canada: A Scoping Review.

The prevalence of gestational diabetes mellitus (GDM) is dramatically higher in Indigenous compared with non-Indigenous populations in Canada. In this scoping review, we synthesize the existing literature regarding GDM among Indigenous peoples in Canada, including social and structural determinants that contribute to its higher prevalence in this population. Seven themes related to GDM in Indigenous populations emerged from a synthesis of the 44 included articles. The themes were GDM prevalence and trends; risk factors; screening; diagnosis and treatment; maternal outcomes; child outcomes; systemic barriers; and Indigenous perceptions, concerns and health behaviours. The findings from this review suggest culturally appropriate health care and improved screening practices may help to mitigate the high prevalence and poor health outcomes associated with GDM in Indigenous communities across Canada. More community-driven, participatory research that includes the social determinants of health and a culturally safe lens is required to assess the effects and reduce the impact of GDM in this population.

Demographics of mental healthcare presentations in a northwest Ontario emergency department.

OBJECTIVES: Providing emergency mental health services for populations in remote rural areas of Canada is challenging. Program needs are distinct. We describe the emergency mental health workload and service needs at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) in northwest Ontario. METHODS: Emergency department (ED) data were collected for mental health, addiction and self-harm diagnoses (MHA) in 2018/2019. Comparisons were made to similar sized provincial hospitals and EDs. Mental health admissions data from Oct 1, 2018 to Dec 31, 2019 were manually collected from hospital medical charts for demographics, suicide attempts/ideation and frequency of applications for Form 1 psychiatric assessment. RESULTS: The volume of MHA ED visits as a percentage of total ED visits was 4 times higher at SLMHC when compared to both the 67 other Ontario level C hospitals (< 100 beds) and the 15 level C hospital with a similar volume of ED visits (15,000-20,000), (15% vs 4%). Self-harm presentations were 308 at SLMHC versus an average of 42 ± 37 at the 15 level C hospitals with a similar ED volume. From Oct 1, 2019 to Dec 31, 2019, there were 49 patients requiring a Form 1, with an average wait time of 55 h before transfer to a schedule 1 facility. CONCLUSION: There is an increased level of mental health, addiction and self-harm presentations in this northern ED. Lack of alternative resources indicate the need for the development of an integrated model of mental health care service. Reliance on the ED for crisis management indicates the need for the development of more regionally relevant models of care.

RéSUMé: OBJECTIFS: Fournir des services de santé mentale d'urgence aux populations des régions rurales éloignées du Canada est un défi. Les besoins du programme sont distincts. Nous décrivons la charge de travail d'urgence en santé mentale et les besoins en services au Sioux Lookout Meno Ya Win Health Centre (SLMHC) dans le nord-ouest de l'Ontario. MéTHODES: Des données sur les urgences ont été recueillies pour les diagnostics de santé mentale, de toxicomanie et d'automutilation (MHA) en 2018/2019. Des comparaisons ont été faites avec des hôpitaux provinciaux et des services d'urgence de taille similaire. Les données sur les admissions en santé mentale du 1er octobre 2018 au 31 décembre 2019 ont été collectées manuellement à partir des dossiers médicaux des hôpitaux pour les données démographiques, les tentatives/idées de suicide et la fréquence des demandes d'évaluation psychiatrique du formulaire 1. RéSULTATS: Le volume de visites aux urgences du MHA en pourcentage du total des visites aux urgences était 4 fois plus élevé au SLMHC par rapport aux 67 autres hôpitaux de niveau C de l'Ontario (< 100 lits) et aux 15 hôpitaux de niveau C avec un volume similaire de visites aux urgences (15 000­20 000), (15% contre 4%). Les présentations d'automutilation étaient de 308 au SLMHC contre une moyenne de 42 ± 37 dans les 15 hôpitaux de niveau C avec un volume d'urgence similaire. Du 1er octobre 2019 au 31 décembre 2019, 49 patients ont nécessité un formulaire 1, avec un temps d'attente moyen de 55 heures avant le transfert vers un établissement de l'annexe 1. CONCLUSION: Le nombre de cas de santé mentale, de toxicomanie et d'automutilation est en augmentation dans cette urgence du nord. Le manque de ressources alternatives indique la nécessité de développer un modèle intégré de service de soins de santé mentale. Le recours aux services d'urgence pour la gestion des crises indique la nécessité d'élaborer des modèles de soins plus adaptés au niveau régional.

The development of a community-based public health response to an outbreak of post-streptococcal glomerulonephritis in a First Nations community.

BACKGROUND: Post-streptococcal glomerulonephritis (PSGN) is a rare immune-mediated condition that typically occurs in children as a result of group A streptococcus (GAS) infection. PSGN is not considered a disease of public health significance, or reportable, in Canada. Higher incidence of PSGN has been described among Indigenous people in Canada. No national or provincial guidance exists to define or manage PSGN outbreaks. OBJECTIVE: To describe an outbreak of seven paediatric cases of PSGN in a remote First Nations community in northwestern Ontario and the development of a community-wide public health response. METHODS: Following a literature review, an intervention was developed involving screening of all children in the community for facial or peripheral edema or skin sores, and treatment with antibiotics if noted. Case, contact and outbreak definitions were also developed. The purpose of the response was to break the chain of transmission of a possible nephritogenic strain of streptococcus circulating in the community. Relevant demographic, clinical and laboratory data were collected on all cases. OUTCOME: Seven paediatric cases of PSGN presented to the community nursing station between September 25 and November 29, 2017. Community-wide screening for skin sores was completed for 95% of the community's children, including 17 household contacts, and as a result, the last of the cases was identified. Nineteen adult household contacts were also screened. Ten paediatric contacts and two adult contacts with skin sores were treated with one dose of intramuscular penicillin, and six paediatric contacts received oral cephalexin. No further cases were identified following the screening. CONCLUSION: PSGN continues to occur in Indigenous populations worldwide at rates higher than in the overall population. In the absence of mandatory reporting in Canada, the burden of PSGN remains underappreciated and could undermine upstream and downstream public health interventions. Evidence-based public health guidance is required to manage outbreaks in the Canadian context. The community-based response protocol developed to contain the PSGN outbreak in this First Nations community can serve as a model for the management of future PSGN outbreaks.

Intravenous iron therapy in a rural hospital: A retrospective chart review.

INTRODUCTION: Intravenous iron infusion therapy is commonly delivered in rural hospitals, but there are no common guidelines for dosing or choice of agent. The objective of the study was to understand present practice and alternate therapies and develop practical recommendations for small hospital use. METHODS: This was a retrospective chart review of all non-dialysis patients aged 15 years or older who received iron replacement therapy at Sioux Lookout Meno Ya Win Health Centre from May 2013 to May 2019 and a literature review of available iron preparations. RESULTS: Of the 147 patients who received intravenous iron replacement, 75 were administered a single dose of 200 mg or 500 mg iron sucrose. Commonly used in pregnant patients, an increase in haemoglobin by an average of 9.2 g/L followed a 200 mg dose and 12.5 g/L after 500 mg. The 3-h infusion time for the 500 mg dose consumed considerably more nursing resources. Non-pregnant patients can be transfused more effectively with iron maltoside which can efficiently deliver larger doses of iron. CONCLUSION: We recommend iron maltoside for efficient intravenous iron replacement in non-pregnant patients and single or multiple doses of 200 mg iron sucrose during pregnancy.

Résumé Introduction: La perfusion intraveineuse de fer est fréquente dans les hôpitaux ruraux, mais il n'existe pas de lignes directrices courantes sur la posologie ou le choix de l'agent. Cette étude visait à comprendre la pratique actuelle, et les autres options thérapeutiques et d'émettre des recommandations pratiques à l'intention des petits hôpitaux. Méthodologie: Revue rétrospective des dossiers de tous les patients de 15 ans et plus non sous dialyse qui avaient reçu une supplémentation en fer à l'Hôpital SLMHC entre les mois de mai 2013 et mai 2019 et revue de la littérature sur les préparations de fer commercialisées. Résultats: Sur les 147 patients ayant reçu une perfusion de supplémentation en fer, 75 ont reçu une dose unique de 200 mg ou de 500 mg de fer-saccharose. Fréquemment utilisées chez les femmes enceintes, les doses de 200 et de 500 mg ont augmenté le taux d'Hb d'en moyenne 9,2 g/L et de 12.5 g/L, respectivement. La perfusion de 3 heures nécessaire à la dose de 500 mg a utilisé considérablement plus de ressources infirmières. Le fer-isomaltoside, qui administre efficacement des doses supérieures de fer, est perfusé plus efficacement chez les patients, à l'exclusion des femmes enceintes. Conclusion: Nous recommandons le fer-isomaltoside pour la supplémentation en fer efficace chez les patients, à l'exclusion des femmes enceintes et une dose unique ou multiple de 200 mg de fer-saccharose durant la grossesse. Mots-clés: Fer-isomaltoside, médecine rurale, perfusion intraveineuse de fer.

Demographics, prevalence and outcomes of diabetes in pregnancy in NW Ontario.

INTRODUCTION: Diabetes in pregnancy confers increased risk. This study examines the prevalence and birth outcomes of diabetes in pregnancy at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) and other small Ontario hospitals. METHODS: This was a retrospective study of maternal profile: age, parity, comorbidities, mode of delivery, neonatal birth weight, APGARS and complications. Data were compared to other Ontario hospitals offering an equivalent level of obstetrical services. RESULTS: Type 2 diabetes mellitus in pregnancy is far more prevalent in mothers who deliver at SLMHC (relative risk [RR]: 20.9, 95% confidence interval [CI]: 16.0-27.2); the rates of gestational diabetes (GDM) are double (RR: 2.0, 95% CI: 1.7-2.3). SLMHC mothers with diabetes were on average 5 years younger and of greater parity with increased substance use. Neonates largely had equivalent outcomes except for increased macrosomia, neonatal hypoglycaemia and hyperbilirubinaemia in GDM pregnancies. CONCLUSION: Patients with diabetes in pregnancy at SLMHC differ substantially from mothers delivering at Ontario hospitals with a comparable level of service. Programming and resources must meet the service needs of these patients.

Résumé Introduction: Le diabète durant la grossesse élève le risque. Cette étude s'est penchée sur la prévalence des issues liées à l'accouchement causées par le diabète durant la grossesse au centre de santé SLMHC (Sioux Lookout Meno Ya Win Health Centre) et dans d'autres petits hôpitaux ontariens. Méthodologie: Il s'agissait d'une étude rétrospective du profil de la mère: âge, parité, comorbidités, méthode d'accouchement, poids du bébé à la naissance, score APGAR et complications. Les données ont été comparées à celles d'autres hôpitaux ontariens qui offrent un niveau équivalent de services obstétriques. Résultats: Le diabète de type 2 durant la grossesse est beaucoup plus répandu chez les femmes qui accouchent au SLMHC (risque relatif [RR]: 20,9; intervalle de confiance [CI] à 95 %: 16,0­27,2); le taux de diabète gestationnel est deux fois plus élevé (RR: 2,0; IC à 95 %: 1,7­2,3). Les femmes diabétiques ayant accouché au SLMHC étaient en moyenne 5 ans plus jeunes, avaient eu plus de naissances et elles consommaient des drogues en plus grand nombre. L'état des nouveau-nés était grandement équivalent, à l'exception d'un plus grand nombre de macrosomies, d'hypoglycémies néonatales et d'hyperbilirubinémies dans les cas de diabète gestationnel. Conclusion: Les patientes diabétiques durant la grossesse vues au SLMHC diffèrent substantiellement des femmes qui accouchent dans les hôpitaux ontariens offrant un niveau comparable de services. La programmation et les ressources doivent répondre aux besoins en matière de services de ces patientes. Mots-clés: Diabete, Premieres Nations, grossesse.

Early Gestational Diabetes Mellitus Screening With Glycated Hemoglobin: A Systematic Review.

OBJECTIVE: This review sought to examine the association of HbA1c levels <6.5% in early pregnancy with the subsequent development of gestational diabetes mellitus (GDM) and adverse pregnancy outcomes. METHODS: A search of Medline and EMBASE was conducted for the period of January 1, 2000 to July 9, 2019 and the terms: "gestational diabetes or pregnancy diabetes mellitus" and "glycosylated hemoglobin or glycated hemoglobin A" and "pregnancy trimester, first, or first-trimester pregnancy," "screening or prenatal screening," "prenatal diagnosis or early diagnosis or prediction," "retrospective studies or prospective studies." Quality of evidence was assessed using the Newcastle-Ottawa scale. Inclusion criteria were: measurement of HbA1c <20 weeks gestation, the absence of pre-gestational diabetes mellitus, and analysis of HbA1c levels below 6.5%. The primary outcome evaluated was the development of GDM. Secondary outcomes were adverse pregnancy outcomes, including large-for-gestational-age birth weight, macrosomia, preterm birth, neonatal and perinatal death, congenital anomaly, preeclampsia, shoulder dystocia, and cesarean section. RESULTS: We screened 121 relevant abstracts. Thirty-two studies qualified for a full review, of which 11 met the eligibility criteria. All studies were assessed as high quality and found an increased risk of GDM with HbA1c levels >5.7. Levels >6.0 identified all patients who developed GDM. Adverse pregnancy outcomes were associated with elevated HbA1c levels in 4 of 6 studies and included preeclampsia, induced labour, shoulder dystocia, cesarean section, large-for-gestational-age birth weight, macrosomia, congenital anomalies, and perinatal death. Two studies found no association with adverse events. CONCLUSION: HbA1c levels between 5.7% and 6.4% in early pregnancy consistently identified patients who went on to develop GMD. The evidence that particular levels are associated with adverse outcomes is less robust.

Screening for gestational diabetes in pregnancy in Northwestern Ontario.

INTRODUCTION: We estimate the screening and prevalence of gestational diabetes mellitus (GDM) in a primarily first nations obstetrical population in Northwestern Ontario. METHODS: The study is an 8-year retrospective analysis of all gestational glucose challenge and tolerance tests performed at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) laboratory from 1 January, 2010 to 31 December, 2017. Test, gestational timing and completion rate of screening were recorded, and GDM prevalence was calculated on the tested population. Screening completion rates were recorded for the subset of women who delivered at SLMHC from 2014 to 2017. RESULTS: The average annual GDM prevalence was 12%, double the Ontario rate. Over the 8-year period, 513 patients were diagnosed with GDM among the 4298 patients screened. Patients were screened with the 2-step (90%) or the 1-step (10%) protocol. Screening occurred <20 weeks in 3%; 54% occurred in <28 weeks and 40% >28 weeks. Seventy percent of the tests were from remote nursing stations. The screening completion rate for women delivering at SLMHC in 2017 was 80.8%. CONCLUSION: The prevalence of GDM in Northwestern Ontario is twice the provincial rate. Most screening used the 2-step protocol; early screening was underused. Improvements in screening programming are underway and future research may match surveillance rates and results to GDM outcomes.

Résumé Introduction: Nous estimons le dépistage et la prévalence du diabète gestationnel au sein d'une population obstétrique composée principalement de femmes des Premières Nations du Nord-Ouest de l'Ontario. Méthodologie: Il s'agissait d'une analyse rétrospective de 8 ans de toutes les épreuves d'hyperglycémie gestationnelle provoquée et de tous les tests de tolérance au glucose effectués au laboratoire Sioux Lookout Meno Ya Win Health Centre (SLMHC) entre le 1er janvier 2010 et le 31 décembre 2017. Le nombre de tests, le moment de la grossesse et le taux d'achèvement des tests de dépistage ont été consignés, et la prévalence du diabète gestationnel a été calculée dans la population testée. Le taux d'achèvement des tests de dépistage du sous-groupe de femmes ayant accouché au SLMHC entre 2014 et 2017 a aussi été consigné. Résultats: La prévalence annuelle moyenne de diabète gestationnel était de 12 %, soit le double de celle de l'Ontario. Durant les 8 ans qu'a duré l'étude, 513 patientes ont reçu un diagnostic de diabète gestationnel parmi les 4298 patientes soumises au dépistage. Le protocole à 2 étapes ou à 1 étape a servi au dépistage chez les patientes, à raison de respectivement 90 et 10 %. Le dépistage a eu lieu à < 20 semaines chez 3 %; à < 28 semaines chez 54 % et à > 28 semaines chez 40 % des patientes. Soixante-dix pour cent des tests ont été effectués dans des postes éloignés de soins infirmiers. Le taux d'achèvement du dépistage chez les femmes ayant accouché au SLMHC en 2017 était de 80,8 %. Conclusion: La prévalence de diabète gestationnel dans le Nord-Ouest de l'Ontario est le double du taux provincial. La plupart des tests effectués ont eu recours au protocole à 2 étapes; le dépistage précoce était sous-utilisé. L'on tente actuellement d'améliorer les programmes de dépistage, et de plus amples recherches pourraient documenter le taux de surveillance et approfondir notre compréhension des issues liées au diabète gestationnel.

Outcomes of Pregnancies Affected by Gestational Diabetes and Type 2 Diabetes in a Rural First Nations Obstetrical Program in Northwest Ontario.

OBJECTIVES: In this work, we describe diabetes prevalence and birth outcomes in a primarily First Nations obstetrical population in northwest Ontario. METHODS: This retrospective, observational study of maternal and neonatal characteristics and birth outcomes was performed at the Sioux Lookout Meno Ya Win Health Centre between April 1, 2012 and March 31, 2017. RESULTS: The prevalence of pre-existing type 2 diabetes mellitus was 3.7% and gestational diabetes mellitus was 7.9%. Mothers with diabetes, compared to those without diabetes, were, on average, 5 years older and were of greater parity. Average prepregnancy weight was higher, with an increased incidence of hypertension, inductions and caesarean sections. Neonates had increased incidence of macrosomia, hypoglycemia and hyperbilirubinemia. All maternal cohorts had high rates of alcohol, tobacco and illicit opioid use. CONCLUSIONS: We have identified a high prevalence of diabetes in this First Nations obstetrical population, with associated adverse maternal and neonatal outcomes.

Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario.

OBJECTIVE: To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice. METHODS: Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores. RESULTS: The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average. CONCLUSION: The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

Women and Their Microbes: The Unexpected Friendship.

Communities of microbiota have been associated with numerous health outcomes, and while much emphasis has been placed on the gastrointestinal niche, there is growing interest in the microbiome specific for female reproductive health and the health of their offspring. The vaginal microbiome plays an essential role not only in health and dysbiosis, but also potentially in successful fertilization and healthy pregnancies. In addition, microbial communities have been isolated from formerly forbidden sterile niches such as the placenta, breast, uterus, and Fallopian tubes, strongly suggesting an additional microbial role in women's health. A combination of maternally linked prenatal, birth, and postnatal factors, together with environmental and medical interventions, influence early and later life through the microbiome. Here, we review the role of microbes in female health focusing on the vaginal tract and discuss how male and female reproductive microbiomes are intertwined with conception and how mother-child microbial transfer is a key determinant in infant health, and thus the next generation.

[An unusual cause of sinusitis]. / Een ongewone oorzaak van sinusitis.

BACKGROUND: Larvae of the sheep botfly (Oestrus ovis) normally have sheep or goats as host. In humans the larvae can survive for a short time in the nose or under the eyelids, after which they die or are sneezed out. CASE DESCRIPTION: We describe a 47-year-old woman who during a stay in the Cape Verde Islands developed symptoms of sneezing, a swollen face and an itchy feeling in her nose. These symptoms were due to an infestation of three fully-developed larvae of the O. ovis species in her sinus maxillaries which were later evacuated by endoscopy. CONCLUSION: In exceptional cases larvae of the O. ovis species can fully mature in a healthy person after a visit to an endemic area. Development into the mature stage has only been described in patients with a poor mucosal immune response.

Probiotic yogurt consumption may improve gastrointestinal symptoms, productivity, and nutritional intake of people living with human immunodeficiency virus in Mwanza, Tanzania.

The gut-associated lymphoid tissue is a major site of human immunodeficiency virus (HIV) activity and significantly influences disease prognosis. Reducing immune activation due to gastroenteritis may thus help slow disease progression. Probiotic microorganisms have considerable immunomodulatory effects at the level of the gut-associated lymphoid tissue. A probiotic yogurt initiative was thus established in Mwanza, Tanzania, to improve gastrointestinal (GI) integrity and reduce the incidence and severity of opportunistic infections among people with HIV. The research objective was to retrospectively evaluate the effects of yogurt supplemented with Lactobacillus rhamnosus as an adjunct to the diet of people living with HIV on systemic and GI symptoms, daily routine activities, and nutritional intake. Eighty-five people with HIV consuming probiotic yogurt and 86 controls were interviewed. Demographics and HIV disease stage were comparable between groups. Probiotic yogurt consumers reported an ability to work a median of 2 hours more daily (P = .01), experienced a lower fever incidence (P = .01), and were more likely to achieve daily nutrient requirements for vitamin A, several B complex vitamins, and calcium (P = .02). Antiretroviral users experienced less drug-induced stomach pain (P = .02) and a lower overall impact of GI symptoms on routine activities (P = .03). The results of this study need be further substantiated because of limits imposed by the observational, retrospective study design; however, results suggest that yogurt supplemented with L rhamnosus may effectively alleviate GI symptoms and improve productivity, nutritional intake, and tolerance to antiretroviral treatment among people with HIV in Mwanza.

Vaginal microbiome and epithelial gene array in post-menopausal women with moderate to severe dryness.

After menopause, many women experience vaginal dryness and atrophy of tissue, often attributed to the loss of estrogen. An understudied aspect of vaginal health in women who experience dryness due to atrophy is the role of the resident microbes. It is known that the microbiota has an important role in healthy vaginal homeostasis, including maintaining the pH balance and excluding pathogens. The objectives of this study were twofold: first to identify the microbiome of post-menopausal women with and without vaginal dryness and symptoms of atrophy; and secondly to examine any differences in epithelial gene expression associated with atrophy. The vaginal microbiome of 32 post-menopausal women was profiled using Illumina sequencing of the V6 region of the 16S rRNA gene. Sixteen subjects were selected for follow-up sampling every two weeks for 10 weeks. In addition, 10 epithelial RNA samples (6 healthy and 4 experiencing vaginal dryness) were acquired for gene expression analysis by Affymetrix Human Gene array. The microbiota abundance profiles were relatively stable over 10 weeks compared to previously published data on premenopausal women. There was an inverse correlation between Lactobacillus ratio and dryness and an increased bacterial diversity in women experiencing moderate to severe vaginal dryness. In healthy participants, Lactobacillus iners and L. crispatus were generally the most abundant, countering the long-held view that lactobacilli are absent or depleted in menopause. Vaginal dryness and atrophy were associated with down-regulation of human genes involved in maintenance of epithelial structure and barrier function, while those associated with inflammation were up-regulated consistent with the adverse clinical presentation.

Probiotics and prebiotics to combat enteric infections and HIV in the developing world: a consensus report.

Infectious disease in the developing world continues to represent one of the greatest challenges facing humanity. Every year over a million children suffer and die from the sequela of enteric infections, while in 2008 it is estimated almost 2.7 million (UNAIDS 2009 update) adults and children became infected with human immunodeficiency virus (HIV). While oral rehydration therapy for diarrhea, and antiretrovirals (ARV) for HIV are critical, there is a place for adjunctive therapies to improve quality of life. The importance of the human microbiota in retaining health is now recognized, as is the concept of replenishing beneficial microbes through probiotic treatments. Studies have shown that probiotics can reduce the duration of diarrhea, improve gut barrier function, help prevent bacterial vaginosis (BV), and enhance immunity even in HIV-infected subjects. However, many issues remain before the extent of probiotic benefits can be verified, and their application to the developing world realised. This consensus report outlines the potential probiotic, and to a lesser extent prebiotic, applications in resource disadvantages settings, and recommends steps that could bring tangible relief to millions of people. The challenges to both efficacy and effectiveness studies in these settings include a lack of infrastructure and funding for scientists, students and research projects in developing countries; making available clinically proven probiotic and prebiotic products at affordable prices; and undertaking appropriately designed clinical trials. We present a roadmap on how efficacy studies may be conducted in a resource disadvantages setting among persons with chronic diarrhea and HIV. These examples and the translation of efficacy into effectiveness are described.

Effect of 25 weeks probiotic supplementation on immune function of HIV patients.

INTRODUCTION: Studies with a follow-up of < 8 weeks have indicated immune-preserving effects of yogurt probiotic supplementation among HIV patients. To evaluate the impact of 25 weeks use of probiotics, a randomized, double blind, controlled study was undertaken on 65 women who were naïve to anti-retroviral treatment. RESULTS: Ten participants were excluded post-randomization due to non-eligibility. Thirty participants were assigned placebo, of whom 25 completed the study versus 19 of 25 completing the study in the probiotics group (p = 0.5). From baseline to 10 weeks follow-up, the CD4 count declined on average 3 CD4 cells/µl (95% Confidence Interval: -97; 91) with placebo versus an increase of 50 cells/µl (95% CI: -61; 162) with probiotics (p = 0.5). From baseline to 25 weeks, the CD4 count increased with 19 cells/µl (95% CI: -90; 129) in the placebo group versus 46 cells/µl (95% CI: -100; 192) with probiotics (p = 0.8). No differences in immune markers, diarrhea incidence or adverse events were observed. DISCUSSION: Lactobacillus GR-1 and RC-14 may be safely consumed at 2 x 10(9) CFU/day by moderately immune compromised HIV patients but this did not universally preserve immune-function. PATIENTS AND METHODS: Women were randomized to receive oral capsules containing Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 (2 x 10(9) colony forming units) or placebo twice daily for 25 weeks. The CD4 count and immune markers (IgG, IgE, IFNγ and IL-10) were measured at baseline and during follow-up, the occurrence of diarrhea was reported daily.

Effect of micronutrient and probiotic fortified yogurt on immune-function of anti-retroviral therapy naive HIV patients.

BACKGROUND: Micronutrient supplementation has been shown to reduce the progression of HIV but does not have an effect on the intestinal barrier or the intestinal microbiota of HIV patients. Studies have suggested that probiotics could potentially complement micronutrients in preserving the immune-function of HIV patients. OBJECTIVE: Assess the impact of micronutrient supplemented probiotic yogurt on the immune function of HIV patients. DESIGN: We performed a randomized, double blind, controlled trial with CD4 count as primary outcome among HIV patients naïve to anti-retroviral treatment. Secondary outcomes included hematological parameters, incidence of diarrhea and clinical symptoms. A total of 112 HIV patients were randomized to receive a micronutrient fortified yogurt with (n = 55) or without additional probiotic Lactobacillus rhamnosus GR-1 (n = 57) for four weeks. RESULTS: An average decline in CD4 count of -70 cells/µL (95% CI: -154 to -15) was observed in the micronutrient, probiotic group versus a decrease of -63 cells/µL (95% CI: -157 to -30) in the micronutrient control group (p = 0.9). Additional probiotic supplementation was well tolerated and not associated with adverse events. No difference between groups was detected in incidence of diarrhea or clinical symptoms. An improvement of hemoglobin levels was observed for all subjects, based upon a mean difference from baseline of 1.4 g/L (SD = 6) (p = 0.02). CONCLUSION: The addition of probiotics to a micronutrient fortified yogurt was well tolerated by HIV patients but was not associated with a further increase in CD4 count after one month.