Two cases of tularemia in hunters from rural Newfoundland.

BACKGROUND: Tularemia is a rare zoonosis caused by Francisella tularensis, a small gram-negative intracellular coccobacillus. Transmission occurs through direct contact with small mammals such as hares and rabbits, exposure to ticks, or ingestion or inhalation of aerosolized particles. It is a highly variable disease with six subtypes based on clinical features. Tularemia is a very rare disease in Canada, with only 0.01 cases per 100,000 people reported in 2017. METHODS: In this case report, we describe two cases of tularemia affecting hunters from rural Newfoundland and Labrador. RESULTS: The first case describes a patient with glandular tularemia diagnosed with serology; the second describes a patient with typhoidal tularemia diagnosed on blood culture. Both patients recovered after treatment with gentamicin. DISCUSSION: These cases highlight the importance of eliciting a careful social history from patients presenting with an unexplained febrile illness. Tularemia should be considered in the differential diagnosis of fever after hunting in rural areas.

HISTORIQUE: La tularémie est une zoonose rare causée par le Francisella tularensis, un petit coccobacille intracellulaire à Gram négatif. La transmission se produit par contact direct avec des petits mammifères comme des lièvres et des lapins, l'exposition aux tiques, l'ingestion ou l'inhalation de particules aérosolisées. C'est une maladie extrêmement variable possédant six sous-types en fonction des caractéristiques cliniques. La tularémie est une maladie très rare au Canada; seulement 0,01 cas sur 100 000 habitants a été signalé en 2017. MÉTHODOLOGIE: Dans le présent rapport de cas, les auteurs décrivent deux cas de tularémie chez des chasseurs de régions rurales de Terre-Neuve-et-Labrador. RÉSULTATS: Le premier cas décrit un patient atteint de tularémie glandulaire diagnostiquée par sérologie et le deuxième, un patient atteint d'une tularémie typhoïde diagnostiquée par culture sanguine. Les deux patients se sont rétablis après avoir été traités à la gentamicine. DISCUSSION: Ces cas font ressortir l'importance d'une histoire sociale attentive des patients qui ont consulté à cause d'une maladie fébrile inexpliquée. Il faut envisager une tularémie lors du diagnostic différentiel de fièvre chez des personnes qui ont chassé dans des régions rurales.

Paying for Prescription Drugs Around the World: Why Is the U.S. an Outlier?

Issue: Compared with other high-income countries, the United States spends the most per capita on prescription drugs. Goal: To compare drug spending levels and trends in the U.S. and nine other high-income countries ­ Australia, Canada, France, Germany, the Netherlands, Norway, Sweden, Switzerland, and the United Kingdom; consider potential explanations for higher U.S. spending; and explore patients' exposure to pharmaceutical costs. Method: Analysis of health data from the Organisation for Economic Co-operation and Development, the 2016 Commonwealth Fund International Health Policy Survey, and other sources. Findings and Conclusions: Various factors contribute to high per capita drug spending in the U.S. While drug utilization appears to be similar in the U.S. and the nine other countries considered, the prices at which drugs are sold in the U.S. are substantially higher. These price differences appear to at least partly explain current and historical disparities in spending on pharmaceutical drugs. U.S. consumers face particularly high out-of-pocket costs, both because the U.S. has a large uninsured population and because cost-sharing requirements for those with coverage are more burdensome than in other countries. Most Americans support reducing pharmaceutical costs. International experience demonstrates that policies like universal health coverage, insurance benefit design that restricts out-of-pocket spending, and certain price control strategies, like centralized price negotiations, can be effective.

In New Survey Of Eleven Countries, US Adults Still Struggle With Access To And Affordability Of Health Care.

Surveys of patients' experiences with health care services can reveal how well a country's health system is meeting the needs of its population. Using data from a 2016 survey conducted in eleven countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-we found that US adults reported poor health and well-being and were the most likely to experience material hardship. The United States trailed other countries in making health care affordable and ranked poorly on providing timely access to medical care (except specialist care). In all countries, shortfalls in patient engagement and chronic care management were reported, and at least one in five adults experienced a care coordination problem. Problems were often particularly acute for low-income adults. Overall, the Netherlands performed at the top of the eleven-country range on most measures of access, engagement, and coordination.

The Impact of a Concussion-U Educational Program on Knowledge of and Attitudes about Concussion.

BACKGROUND: The diagnosis of a sports-related concussion is often dependent on the athlete self-reporting their symptoms. It has been suggested that improving youth athlete knowledge and attitudes toward concussion may increase self-reporting behaviour. The objective of this study was to determine if a novel Concussion-U educational program improves knowledge of and attitudes about concussion among a cohort of elite male Bantam and Midget AAA hockey players. METHODS: Fifty-seven male Bantam and Midget AAA-level hockey players (mean age=14.52±1.13 years) were recruited from the local community. Each participant completed a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey-Student Version immediately before and after a Concussion-U educational presentation. Follow-up sessions were arranged 4 to 6 months after the presentation, and assessed retention of knowledge and attitude changes. RESULTS: Forty-three players completed all three surveys. Concussion knowledge and attitude scores significantly (p<0.01) increased from pre- to post-presentation by 12.79 and 8.41%, respectively. At long-term follow-up, knowledge levels remained significantly (p<0.01) higher than baseline by 8.49%. Mean attitude scores were also increased at follow-up; however, this increase was not statistically significant. CONCLUSIONS: A Concussion-U educational program led to an immediate improvement in concussion knowledge and attitudes among elite male Bantam and Midget AAA hockey players. Increased knowledge was maintained at long-term follow-up, but improved attitude was not. Future studies should investigate whether similar educational programs influence symptom reporting and concussion incidence. In addition, they should focus on how to maintain improved concussion attitudes.

Mortality Trends Among Working-Age Whites: The Untold Story.

Recent research has called attention to an unexpected rise in death rates among middle-aged, white Americans between 1999 and 2014. The full extent of the phenomenon may be underappreciated, however. If one assumes, based on historical trends, that mortality rates should have declined by 1.8 percent per year, then whites in 2014 had higher-than-expected mortality rates from age 19 to age 65. Furthermore, while increased substance abuse and suicides explain the elevated mortality rates for younger adults, middle-aged whites also seem to be experiencing stalled or rising mortality rates for most ailments and diseases. While a national phenomenon, middle-aged whites face much more adverse mortality trends in certain states and regions. The especially broad reach of these negative mortality trends suggests there is an urgent need for further investigation of its causes and potential remedies.

Arm-cycling sprints induce neuromuscular fatigue of the elbow flexors and alter corticospinal excitability of the biceps brachii.

We examined the effects of arm-cycling sprints on maximal voluntary elbow flexion and corticospinal excitability of the biceps brachii. Recreationally trained athletes performed ten 10-s arm-cycling sprints interspersed with 150 s of rest in 2 separate experiments. In experiment A (n = 12), maximal voluntary contraction (MVC) force of the elbow flexors was measured at pre-sprint 1, post-sprint 5, and post-sprint 10. Participants received electrical motor point stimulation during and following the elbow flexor MVCs to estimate voluntary activation (VA). In experiment B (n = 7 participants from experiment A), supraspinal and spinal excitability of the biceps brachii were measured via transcranial magnetic and transmastoid electrical stimulation that produced motor evoked potentials (MEPs) and cervicomedullary motor evoked potentials (CMEPs), respectively, during a 5% isometric MVC at pre-sprint 1, post-sprint 1, post-sprint 5, and post-sprint 10. In experiment A, mean power output, MVC force, potentiated twitch force, and VA decreased 13.1% (p < 0.001), 8.7% (p = 0.036), 27.6% (p = 0.003), and 5.6% (p = 0.037), respectively, from pre-sprint 1 to post-sprint 10. In experiment B, (i) MEPs decreased 42.1% (p = 0.002) from pre-sprint 1 to post-sprint 5 and increased 40.1% (p = 0.038) from post-sprint 5 to post-sprint 10 and (ii) CMEPs increased 28.5% (p = 0.045) from post-sprint 1 to post-sprint 10. Overall, arm-cycling sprints caused neuromuscular fatigue of the elbow flexors, which corresponded with decreased supraspinal and increased spinal excitability of the biceps brachii. The different post-sprint effects on supraspinal and spinal excitability may illustrate an inhibitory effect on supraspinal drive that reduces motor output and, therefore, decreases arm-cycling sprint performance.

Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs.

Industrialized countries face a daunting challenge in providing high-quality care for aging patients with increasingly complex health care needs who will need ongoing chronic care management, community, and social services in addition to episodic acute care. Our international survey of primary care doctors in the United States and nine other countries reveals their concern about how well prepared their practices are to manage the care of patients with complex needs and about their variable experiences in coordinating care and communicating with specialists, hospitals, home care, and social service providers. While electronic information exchange remains a challenge in most countries, a positive finding was the significant increase in the adoption of electronic health records by primary care doctors in the United States and Canada since 2012. Finally, feedback on job-related stress, perceptions of declining quality of care, and administrative burden signal the need to monitor front-line perspectives as health reforms are conceived and implemented.

U.S. health care from a global perspective: spending, use of services, prices, and health in 13 countries.

This analysis draws upon data from the Organization for Economic Cooperation and Development and other cross-national analyses to compare health care spending, supply, utilization, prices, and health outcomes across 13 high-income countries: Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. These data predate the major insurance provisions of the Affordable Care Act. In 2013, the U.S. spent far more on health care than these other countries. Higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions. In contrast, U.S. spending on social services made up a relatively small share of the economy relative to other countries. Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions.

Foam rolling for delayed-onset muscle soreness and recovery of dynamic performance measures.

CONTEXT: After an intense bout of exercise, foam rolling is thought to alleviate muscle fatigue and soreness (ie, delayed-onset muscle soreness [DOMS]) and improve muscular performance. Potentially, foam rolling may be an effective therapeutic modality to reduce DOMS while enhancing the recovery of muscular performance. OBJECTIVE: To examine the effects of foam rolling as a recovery tool after an intense exercise protocol through assessment of pressure-pain threshold, sprint time, change-of-direction speed, power, and dynamic strength-endurance. DESIGN: Controlled laboratory study. SETTING: University laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 8 healthy, physically active males (age = 22.1 ± 2.5 years, height = 177.0 ± 7.5 cm, mass = 88.4 ± 11.4 kg) participated. INTERVENTION(S): Participants performed 2 conditions, separated by 4 weeks, involving 10 sets of 10 repetitions of back squats at 60% of their 1-repetition maximum, followed by either no foam rolling or 20 minutes of foam rolling immediately, 24, and 48 hours postexercise. MAIN OUTCOME MEASURE(S): Pressure-pain threshold, sprint speed (30-m sprint time), power (broad-jump distance), change-of-direction speed (T-test), and dynamic strength-endurance. RESULTS: Foam rolling substantially improved quadriceps muscle tenderness by a moderate to large amount in the days after fatigue (Cohen d range, 0.59 to 0.84). Substantial effects ranged from small to large in sprint time (Cohen d range, 0.68 to 0.77), power (Cohen d range, 0.48 to 0.87), and dynamic strength-endurance (Cohen d = 0.54). CONCLUSIONS: Foam rolling effectively reduced DOMS and associated decrements in most dynamic performance measures.

Roller-massager application to the quadriceps and knee-joint range of motion and neuromuscular efficiency during a lunge.

CONTEXT: Roller massagers are used as a recovery and rehabilitative tool to initiate muscle relaxation and improve range of motion (ROM) and muscular performance. However, research demonstrating such effects is lacking. OBJECTIVE: To determine the effects of applying a roller massager for 20 and 60 seconds on knee-joint ROM and dynamic muscular performance. DESIGN: Randomized controlled clinical trial. SETTING: University laboratory. PATIENTS OR OTHER PARTICIPANTS: Ten recreationally active men (age = 26.6 ± 5.2 years, height = 175.3 ± 4.3 cm, mass = 84.4 ± 8.8 kg). INTERVENTION(S): Participants performed 3 randomized experimental conditions separated by 24 to 48 hours. In condition 1 (5 repetitions of 20 seconds) and condition 2 (5 repetitions of 60 seconds), they applied a roller massager to the quadriceps muscles. Condition 3 served as a control condition in which participants sat quietly. MAIN OUTCOME MEASURE(S): Visual analog pain scale, electromyography (EMG) of the vastus lateralis (VL) and biceps femoris during roller massage and lunge, and knee-joint ROM. RESULTS: We found no differences in pain between the 20-second and 60-second roller-massager conditions. During 60 seconds of roller massage, pain was 13.5% (5.7 ± 0.70) and 20.6% (6.2 ± 0.70) greater at 40 seconds and 60 seconds, respectively, than at 20 seconds (P < .05). During roller massage, VL and biceps femoris root mean square (RMS) EMG was 8% and 7%, respectively, of RMS EMG recorded during maximal voluntary isometric contraction. Knee-joint ROM was 10% and 16% greater in the 20-second and 60-second roller-massager conditions, respectively, than the control condition (P < .05). Finally, average lunge VL RMS EMG decreased as roller-massage time increased (P < .05). CONCLUSIONS: Roller massage was painful and induced muscle activity, but it increased knee-joint ROM and neuromuscular efficiency during a lunge.

International survey of older adults finds shortcomings in access, coordination, and patient-centered care.

Industrialized nations face the common challenge of caring for aging populations, with rising rates of chronic disease and disability. Our 2014 computer-assisted telephone survey of the health and care experiences among 15,617 adults age sixty-five or older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States has found that US older adults were sicker than their counterparts abroad. Out-of-pocket expenses posed greater problems in the United States than elsewhere. Accessing primary care and avoiding the emergency department tended to be more difficult in the United States, Canada, and Sweden than in other surveyed countries. One-fifth or more of older adults reported receiving uncoordinated care in all countries except France. US respondents were among the most likely to have discussed health-promoting behaviors with a clinician, to have a chronic care plan tailored to their daily life, and to have engaged in end-of-life care planning. Finally, in half of the countries, one-fifth or more of chronically ill adults were caregivers themselves.

Where are we on the diffusion curve? Trends and drivers of primary care physicians' use of health information technology.

OBJECTIVE: To describe trends in primary care physicians' use of health information technology (HIT) between 2009 and 2012, examine practice characteristics associated with greater HIT capacity in 2012, and explore factors such as delivery system and payment reforms that may affect adoption and functionality. DATA: We used data from the 2012 and 2009 Commonwealth Fund International Health Policy Surveys of Primary Care Physicians. The data were collected in both years by postal mail between March and July among a nationally representative sample of primary care physicians in the United States. STUDY DESIGN: We compared primary care physicians' HIT capacity in 2009 and 2012. We employed multivariable logistic regression to analyze whether participating in an integrated delivery system, sharing resources and support with other practices, and being eligible for financial incentives were associated with greater HIT capacity in 2012. PRINCIPAL FINDINGS: Primary care physicians' HIT capacity has significantly expanded since 2009, although solo practices continue to lag. Practices that are part of an integrated delivery system or share resources with other practices have higher rates of electronic medical record (EMR) adoption, multifunctional HIT, electronic information exchange, and electronic access for patients. Receiving or being eligible for financial incentives is associated with greater adoption of EMRs and information exchange. CONCLUSIONS: Federal efforts to increase adoption have coincided with a rapid increase in HIT capacity. Delivery system and payment reforms and federally funded extension programs could offer promising pathways for further diffusion.

Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries.

The United States is in the midst of the most sweeping health insurance expansions and market reforms since the enactment of Medicare and Medicaid in 1965. Our 2013 survey of the general population in eleven countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-found that US adults were significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity. Signaling the lack of timely access to primary care, adults in the United States and Canada reported long waits to be seen in primary care and high use of hospital emergency departments, compared to other countries. Perhaps not surprisingly, US adults were the most likely to endorse major reforms: Three out of four called for fundamental change or rebuilding. As US health insurance expansions unfold, the survey offers benchmarks to assess US progress from an international perspective, plus insights from other countries' coverage-related policies.

Exertional rhabdomyolysis in an acutely detrained athlete/exercise physiology professor.

The authors report a case of exercise-induced (exertional) rhabdomyolysis in a male athlete/exercise physiology professor who started a high-intensity resistance training program after a period of detraining. The subject performed 1 high-intensity resistance training session that consisted of 48 total sets of push-ups (24) and chin-ups (24) with no rest between the sets. Two days after the exercise session, the subject reported "Cola colored" urine. On arriving at the hospital, test results indicated elevated myoglobin and creatine kinase (CK) levels (59 159 U/L; normal is 20-200 U/L). Treatment included intravenous hydration with sodium bicarbonate to reduce myoglobin, blood work to monitor CK levels, and acupuncture from the shoulder to hand. Three weeks posttreatment, the subject started to exercise again. This case study illustrates that unaccustomed exercise in the form of high-intensity resistance training may be harmful (ie, severe delayed onset muscle soreness or even worse, as reported in this case, rhabdomyolysis) to detrained athletes.

A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas.

Health reforms in high-income countries increasingly aim to redesign primary care to improve the health of the population and the quality of health care services, and to address rising costs. Primary care improvements aim to provide patients with better access to care and develop more-integrated care systems through better communication and teamwork across sites of care, supported by health information technology and feedback to physicians on their performance. Our international survey of primary care doctors in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States found progress in the use of health information technology in health care practices, particularly in the United States. Yet a high percentage of primary care physicians in all ten countries reported that they did not routinely receive timely information from specialists or hospitals. Countries also varied notably in the extent to which physicians received information on their own performance. In terms of access, US doctors were the most likely to report that they spent substantial time grappling with insurance restrictions and that their patients often went without care because of costs. Signaling the need for reforms, the vast majority of US doctors surveyed said that the health care system needs fundamental change.