Health Care Utilization in the First 7 Years in Children with Fetal Growth Abnormalities: A Retrospective Cohort Study.

OBJECTIVE: To investigate the relationship between birth weight for gestational age and health care utilization of term offspring from birth to 7 years. STUDY DESIGN: We used a population-based retrospective cohort study of infants (≥37 weeks' gestational age) born between 2003 and 2007 in the Canadian province of Nova Scotia (n = 42 050). Perinatal records were linked to provincial administrative health data from birth to age 7 years. The primary outcome was health care utilization (physician visits and hospital admissions) and costs. Birth weight was categorized as small for gestational age (SGA, <10th percentile), appropriate for gestational age (AGA), or large for gestational age (LGA, >90th percentile). Regression models adjusted for potential confounders were used to investigate the associations. RESULTS: Children born SGA had a higher number of specialist visits and hospital admissions, a longer length of stay for the birth admission, and, as a result, higher physician and hospital costs amounting to a cost differential of Can $1222 during the first 7 years of life compared with children born AGA. By contrast, health care use and costs did not differ between children born LGA and AGA. CONCLUSION: Former SGA term infants have a moderate increase in health care use and costs in early childhood compared with former AGA infants, and LGA birth at term is not associated with higher health care utilization.

Cesarean Delivery and Healthcare Utilization and Costs in the Offspring: A Retrospective Cohort Study.

OBJECTIVE: To examine the association between cesarean delivery and healthcare utilization and costs in offspring from birth until age 7 years. STUDY DESIGN: A retrospective cohort study of singleton term births in the Canadian province of Nova Scotia between 2003 and 2007 followed until age 7 years was conducted using data from the Nova Scotia Atlee Perinatal Database and administrative health data. The main exposure was mode of delivery (cesarean delivery vs vaginal birth); the outcome was healthcare utilization and costs during the first 7 years of life. Associations were modeled using multiple regression adjusting for maternal prepregnancy weight and sociodemographic factors. RESULTS: In total, 32 464 births were included in the analysis. Compared with children born by vaginal birth, children born by cesarean delivery had more physician visits (incidence rate ratio 1.06, 95% CI 1.05-1.08) and longer hospital stays (incidence rate ratio 1.12, 95% CI 1.03-1.21) and were more likely to be high utilizers of physician visits (OR 1.23, 95% CI 1.10-1.37). Physician and hospital costs were $775 higher for children born by cesarean delivery compared with vaginal birth. CONCLUSIONS: Cesarean delivery compared with vaginal birth is associated with small but statistically significant increases in healthcare utilization and costs during the first 7 years of life.

The Atlantic blue crab Callinectes sapidus in southern European coastal waters: Distribution, impact and prospective invasion management strategies.

The native distribution of the blue crab Callinectes sapidus in the western Atlantic extends from Nova Scotia to Argentina. Introduced to Europe at the beginning of the 20th century, it is currently recorded almost ubiquitously in the Mediterranean and in the Black Sea. An overview of the occurrence, abundance, and ecological impact of the species in southern European waters is provided; additionally, we present a pragmatic assessment of its management scenarios, explicitly considering the dual nature of C. sapidus as both an invasive species and a fishery resource. We emphasise that the ongoing expansion of C. sapidus in the region may represent a stimulating challenge for the identification and implementation of future strategies in the management of invasive crustaceans. The impact of the invader could be converted into an enhancement of the services delivered by southern European coastal ecosystems, while mitigation costs could be transformed into profits for local populations.

Polychlorinated biphenyls and organochlorine pesticides as intrinsic tracer tags of foraging grounds of bluefin tuna in the northwest Atlantic Ocean.

Researchers have utilized chemical fingerprints in the determination of habitat utilization and movements of the aquatic animals. In the present effort, we analyzed polychlorinated biphenyl (PCB) congeners and organochlorine pesticides in the samples of juvenile bluefin tuna caught offshore of Virginia, and in larger bluefin tuna from the Gulf of Maine and near Nova Scotia. For a given specimen, or a given location, PCB concentrations were highest, followed by DDTs, and chlordanes. Average contaminant concentrations from fish captured from the three locations were not significantly different; and PCBs, DDTs, and chlordanes correlated well with each other. Trans-nonachlor/PCB 153 ratios in bluefin tuna of eastern Atlantic (i.e., Mediterranean) origin are low compared to the corresponding ratios in fish in the western Atlantic. As the former migrate to the western Atlantic, these ratios gradually turnover due to the accumulation of biomass from forage contaminated with higher trans-nonachlor/PCB 153 ratio reflecting dissimilar use of chlordane pesticides on two sides of the Atlantic Ocean. The trans-nonachlor/PCB 153 ratio indicated that one juvenile bluefin tuna from offshore of Virginia and one large bluefin tuna from Gulf of Maine in the present study originated from foraging grounds in the Mediterranean Sea, and that they have made the trans-Atlantic migrations. The remaining individuals were determined to be either spawned in the Gulf of Mexico or the trans-nonachlor/PCB 153 ratio for the putative Mediterranean bluefin tuna was completely turned over to resemble the ratio characteristic to the western Atlantic. Based on the turnover time for trans-nonachlor/PCB 153 ratio previously determined, the residence time of juvenile bluefin tuna offshore Virginia was estimated to be at least 0.8 to 1.6years. A discriminant function analysis (DFA) plot of total PCB normalized signatures of PCB congeners showed three separate clusters, which suggested that bluefin tuna from offshore Virginia, Gulf of Maine, and Nova Scotia could have had extended residences and foraging within the areas of capture to be able to sustain the stable signatures of PCB congeners. The DFA cluster results supported the concept of metapopulation theory of spatial ecology comprising discrete aggregates of local populations of bluefin tuna where the desired prey species are likely to be abundant. Despite their highly migratory trait and endothermic advantage of foraging in broader and colder habitats, the movements and mixing across the aggregation ranges related to feeding did not appear to be extensive. Advancement in the understanding of bluefin tuna population dynamics beyond the coarse concept of trans-Atlantic migrations to the metapopulation hypothesis provides a novel exploratory tool in the stock assessment and resource management. As the chemical tracer tags are fortified naturally and document the time- and space-integrated foraging history, they promise to serve as the low-cost alternatives to the high-cost electronic data recording tags employed for addressing the migratory movements of bluefin tuna. Between the different potential chemical tracer tags, a distinct advantage of PCB/pesticide analysis over the otolith micro-constituent analysis is that the muscle tissue of a given individual bluefin tuna can be sampled repeatedly for PCB/pesticide analysis over different spatial and temporal scales in a non-lethal manner.

Do We Need an Intubation-Skilled Person at All High-Risk Deliveries?

OBJECTIVE: To evaluate the significance and predictive value of each of the Neonatal Resuscitation Program (NRP)-listed ante- and intrapartum risk factors for the need of neonatal intubation at birth. STUDY DESIGN: In this population-based study, perinatal data of all infants born at ≥ 35 weeks gestation in the province of Nova Scotia between 1994 and 2014, were identified and reviewed from the Nova Scotia Atlee Database. The frequency of occurrence of risk factors, incidence of neonatal intubation at birth, and its relationship with the different NRP-listed risk factors, were examined. Variables that were significant (P < .05) in univariate analyses were entered into the regression model. RESULTS: During the 20-year study period, 176,365 infants ≥ 35 weeks gestation were born. In presence of any of the listed risk factors, 0.3% of infants received intubation at birth compared with 0.08% in absence of any risk factor (P < .001). On logistic regression analysis, only 16 of the NRP-listed risk factors had a significant relationship with intubation at birth (P < .001). Delivery in a tertiary care center did not have an impact. CONCLUSIONS: The presence of an intubation-skilled person at birth may not be indicated in all the NRP-listed ante- and intrapartum risk factors. Stratification of the relative significance of different risk factors may be of importance for the less-resourced health care units providing maternal and newborn care.

Pleated turtle escapes the box--shape changes in Dermochelys coriacea.

Typical chelonians have a rigid carapace and plastron that form a box-like structure that constrains several aspects of their physiology and ecology. The leatherback sea turtle, Dermochelys coriacea, has a flexible bony carapace strengthened by seven longitudinal ridges, whereas the plastron is reduced to an elliptical outer bony structure, so that the ventrum has no bony support. Measurements of the shell were made on adult female leatherbacks studied on the feeding grounds of waters off Nova Scotia (NS) and on breeding beaches of French Guiana (FG) to examine whether foraging and/or breeding turtles alter carapace size and/or shape. NS turtles exhibited greater mass and girth for a given curved carapace length (CCL) than FG turtles. Girth:CCL ratios rose during the feeding season, indicating increased girth. Measurements were made of the direct (straight) and surface (curved) distances between the medial longitudinal ridge and first right-hand longitudinal ridge (at 50% CCL). In NS turtles, the ratio of straight to curved inter-ridge distances was significantly higher than in FG turtles, indicating distension of the upper surfaces of the NS turtles between the ridges. FG females laid 11 clutches in the breeding season; although CCL and curved carapace width remained stable, girth declined between each nesting episode, indicating loss of mass. Straight to curved inter-ridge distance ratios did not change significantly during the breeding season, indicating loss of dorsal blubber before the onset of breeding. The results demonstrate substantial alterations in size and shape of female D. coriacea over periods of weeks to months in response to alterations in nutritional and reproductive status.

Prevalance and associations of food insecurity in children with diabetes mellitus.

OBJECTIVES: To examine the prevalence of food insecurity in households with a child with insulin-requiring diabetes mellitus (DM), investigate whether food insecurity is associated with poorer DM control, and describe the household characteristics and coping strategies of food-insecure families with a child with DM. STUDY DESIGN: Telephone interviews were conducted with consecutive consenting families over a 16-month period. Food insecurity was assessed through a validated questionnaire; additional questions elicited demographic information and DM management strategies. Charts were reviewed for hemoglobin A1c (HbA1c). Univariate and logistic regression analyses were performed. RESULTS: A total of 183 families were interviewed. Food insecurity was present in 21.9% (95% confidence interval, 15.87%-27.85%), significantly higher than the overall prevalences in Nova Scotia (14.6%) and Canada (9.2%). Food insecurity was associated with higher HbA1c level; however, in multivariate analysis, only child's age and parents' education were independent predictors of HbA1c. Children from food-insecure families had higher rates of hospitalization, for which food security status was the only independent predictor. Common characteristics and coping strategies of food-insecure families were identified. CONCLUSIONS: Food insecurity was more common in families with a child with DM, and the presence of food insecurity was predictive of the child's hospitalization. Risk factors identified in this study should be used to screen for this problem in families with a child with DM.

Renal tumors and the risk of malignancy based on size.

PURPOSE: To determine the incidence of malignancy in resected renal tumors in a subpopulation of Canadian patients and the significance of tumor size, patient's demographics, and whether the tumor was an incidental finding. METHODS: Medical records of 168 consecutive nephrectomies performed between March 2003 and June 2008 at our institution were reviewed retrospectively. RESULTS: Average age of the patients was 61 years old (SD 11, range 28-89) and male to female ratio was 1.3:1. Total of 180 masses were resected in 168 nephrectomies (128 radical, 40 partial) during the study period. Of the 180 masses, 20 (11%) were benign and 160 (89%) were malignant lesions. Fifty-five percent of the resected renal masses were incidentally found on preoperative imaging. Based on the pathology reports, the average size of the masses was 5.5 cm (SD 4.0, range 0.3-25.0). The larger masses were more likely to be malignant than the smaller masses (Pearson's chi-square test, p = 0.040). CONCLUSION: The present study assists us to adequately assess the risk of malignancy of a renal mass in a Canadian population based on size which allows us to properly advise the patients and suggest best possible treatment options. We recommend more aggressive therapies for masses larger than 4 cm and parenchymal sparing procedures for masses smaller than 4 cm as large proportion of these are benign.

Immunological responses, histopathological finding and disease resistance of blue mussel (Mytilus edulis) exposed to treated and untreated municipal wastewater.

This study provides new information on the response of the immune system of Mytilus edulis exposed to untreated and treated sewage, linking immune response to ecologically relevant endpoints, such as disease resistance. Our goal was to assess the potential effects of sewage on the immune system (phagocytic activity and production of cytotoxic metabolites, disease resistance) and gills (light microscope) of mussels through a bioassay and field study in an estuarine receiving environment (RE). A semi-static experiment was developed in a wastewater treatment plant in New Glasgow, NS Canada. Mussels were exposed for 21 days to 12.5%, 25%, 50% and 100% of untreated sewage influent and artificial seawater control. Sampling occurred after 7, 14 and 21 days of exposure. In the field study, eight sites were selected in East River and Pictou Harbour, NS, positioned upstream and downstream of sewage effluents outfalls. Caged mussels were exposed to the RE for 90 days (May-July 2005). Mussels were challenged to test their efficiency at eliminating the bacteria, Listonella anguillarium in the bioassay and field studies. The bioassay results showed that higher concentrations of untreated sewage could modulate the immune system of mussels through increased of phagocytic activity (PA), nitric oxide (NO) and hydrogen peroxide (H(2)O(2)) production during 14 days of exposure, and decreased activity and production at 21 days, with the exception of H(2)O(2) production which was high even at 21 days. Mussels exposed to untreated sewage RE also presented a high PA, NO and H(2)O(2) production and lower number of haemocytes compared to mussels from reference sites. In the bacterial challenge, mussels pre-exposed to 100% sewage died 24h after being infected with L. anguillarium, while mussels pre-exposed to 50% eliminated bacteria had a mortality rate of 30%. Mussels from the control, 12.5% and 25% groups eliminated bacteria and no mortality was observed. No significant difference was observed in bacterial clearance in mussels exposed to effluents in the RE. The lesions observed in gills in both studies were: infiltration of haemocytes in the tissue, epithelium proliferation, lamellar fusion and dilated haemolymphatic sinus. In summary, untreated municipal wastewater affected the immune system of blue mussels during 21 days of exposure and the effects were reflected in their capability to resist pathogens. And an immune modulation was observed in mussels exposed to untreated sewage in a RE, but this modulation was not reflected in the mussel's capability in eliminating pathogens.

Supplemental diagnosis of Kudoa funduli (Myxozoa) parasitizing Fundulus heteroclitus (Cyprinodontidae) from coastal northeastern North America.

The diagnosis of Kudoa funduli (Hahn, 1915) Meglitsch, 1948 (Myxozoa), is supplemented through study of new material collected from Fundulus heteroclitus (Cyprinodontidae) in coastal waters of Nova Scotia, Canada, and Connecticut. Plasmodia normally develop intracellularly in striated muscle of the flank and head, eventually rupturing and releasing spores. Spores disperse along adjacent epimysium, sometimes as far as the skin surface. Some plasmodia develop extracellularly within the bony cavities of vertebrae. Formalin-fixed spores viewed with a light microscope possess rounded edges, an inconspicuous apical region, thin sutural ridges, measure 6.6-7.4 microm wide, 4.3-5 microm thick, and 5.1-5.4 microm long, and have 4 equally sized polar capsules, 1.7-2.3 microm length by 1.4-1.7 microm width. Scanning electron microscopy revealed that spores are almost stellate, with inconspicuous uplifted tips, and that, within intracellular plasmodia, are embedded in an extensive honeycomb-like matrix. Prevalence of infection of K. funduli was 100% in host populations sampled in both Nova Scotia and Connecticut. Molecular sequence data of the 18S ribosomal DNA (737 base pairs) reveal that K. funduli is a valid species and a member of a clade that includes Kudoa dianae Dyková, Avila, and Fiala, 2002, Kudoa miniauriculata Whitaker, Kent, and Sakanari, 1996, and Kudoa paniformis Kabata and Whitaker, 1981.

Promoting social responsibility for health: health impact assessment and healthy public policy at the community level.

The 1997 Jakarta Declaration on Health Promotion into the 21st Century called for new responses to address the emerging threats to health. The declaration placed a high priority on promoting social responsibility for health, and it identified equity-focused health impact assessment as a high priority for action. This theme was among the foci at the 2000 Fifth Global Conference on Health Promotion held in Mexico. This paper, which is an abbreviation of a technical report prepared for the Mexico conference, advances arguments for focusing on health impact assessment at the local level. Health impact assessment identifies negative health impacts that call for policy responses, and identifies and encourages practices and policies that promote health. Health impact assessment may be highly technical and require sophisticated technology and expertise. But it can also be a simple, highly practical process, accessible to ordinary people, and one that helps a community come to grips with local circumstances that need changing for better health. To illustrate the possibilities, this paper presents a case study, the People Assessing Their Health (PATH) project from Eastern Nova Scotia, Canada. It places ordinary citizens, rather than community elites, at the very heart of local decision-making. Evidence from PATH demonstrates that low technology health impact assessment, done by and for local people, can shift thinking beyond the illness problems of individuals. It can bring into consideration, instead, how programmes and policies support or weaken community health, and illuminate a community's capacity to improve local circumstances for better health. This stands in contrast to evidence that highly technological approaches to community-level health impact assessment can be self-defeating. Further development of simple, people-centred, low technology approaches to health impact assessment at the local level is called for.

Absence of serotype-specific surface antigen and altered teichoic acid glycosylation among epidemic-associated strains of Listeria monocytogenes.

Outbreaks of food-borne listeriosis have often involved strains of serotype 4b. Examination of multiple isolates from three different outbreaks revealed that ca. 11 to 29% of each epidemic population consisted of strains which were negative with the serotype-specific monoclonal antibody c74.22, lacked galactose from the teichoic acid of the cell wall, and were resistant to the serotype 4b-specific phage 2671.

Living with cerebral palsy and tube feeding: A population-based follow-up study.

OBJECTIVES: To assess the impact of surgically placed feeding tubes on children with severe cerebral palsy (CP) and their families and to determine the survival of these children after initiation of tube feeding (TF). METHODS: Virtually all children from Nova Scotia who had gastrostomy or jejunostomy procedures between the years 1980 and 1998 and who had been diagnosed with CP were identified. Caretakers of those children who had TF initiated in the last 8 years were evaluated by using a semi-structured interview. Names of children who had not had recent follow-up visits were submitted to the provincial Vital Statistics office to determine whether they had died. Data from patients who were tube-fed between 1980 and 1989 were then used in combination with data from the more recent cases to create a survival curve. RESULTS: A total of 61 children were identified; 16 had died. Forty of 45 eligible families were interviewed; 90% were pleased with the effect of TF on their child and family life. Negative reports were associated with increased stress related to feeding. Survival rates after gastrostomy and/or jejunostomy were 83% after 2 years and 75% after 7 years. CONCLUSIONS: In children with severe CF, initiation of TF improved the quality of life for both the child and family in 90% despite frequent minor complications.

If a first antiepileptic drug fails to control a child's epilepsy, what are the chances of success with the next drug?

OBJECTIVE: This study was carried out to determine how often a child's epilepsy is controlled and remits if a first antiepileptic drug (AED) fails to control seizures. STUDY DESIGN: We used the Nova Scotia population-based epilepsy study, which identified children between 1977 and 1985 who had two or more unprovoked seizures without progressive cause and followed them up for at least 4 years. Seizure types were partial, primary, and secondarily generalized (excluding absence seizures). The study documented success or failure of the initial AED in the first year of treatment, as well as long-term seizure control and remission. RESULTS: The number of eligible children was 417, with an average follow-up period of 8 years. The initial prescribed AEDs were phenobarbital (48%), carbamazepine (38%), and phenytoin (11%). Overall, 345 (83%) children received only one AED in the first year of treatment; 61% became free of seizures and no longer required AED treatment at the end of follow-up (remission). Only 4% of those treated with a single AED during the first year later experienced intractable epilepsy. In contrast, 72 of 417 (17%) had inadequate seizure control with their first AED and received a second AED, with only 42% having complete remission of their epilepsy. The 72 children in whom seizures were not controlled with the first AED were more likely to have neurologic deficits (p = 0.01) and complex partial seizures (p = 0.01), and 29% had intractable epilepsy (p < 0.0001). CONCLUSIONS: If the first AED is not efficacious, the outcome is less favorable, although many children will have remission of their epilepsy. Invasive or complex treatments for epilepsy with partial and generalized tonic-clonic seizures should not be used until at least two AEDs have failed to control seizures.

Persistence of pertussis in an immunized population: results of the Nova Scotia Enhanced Pertussis Surveillance Program.

An enhanced pertussis surveillance and laboratory diagnosis program was initiated in the Halifax metropolitan area of Nova Scotia to better delineate the epidemiology of pertussis. During the 28 months of the study, 526 cases of pertussis were identified (overall yearly incidence: 74 cases per 100,000 population). Laboratory confirmation was obtained in 168 (32%) cases, including 111 (21%) by culture. Peak incidence occurred among children 2 to 5 years of age; the highest morbidity rate was seen in children less than 1 year of age. Hospitalization was required for 22 (4.2%) patients; 14 (64%) of those hospitalized were less than 1 year of age. Most (91%) patients had received at least three doses of pertussis vaccine; vaccine efficacy was estimated at 45%. The surveillance program demonstrated that the incidence of pertussis in Nova Scotia, although among the highest in North America, is still underestimated. A ninefold increase in cases was identified over the comparable period of the previous year, largely because patients meeting clinical criteria were reported. By supplementing culture techniques with immunofluorescent staining and serologic methods, we increased the rate of laboratory confirmation from 17% to 65%, suggesting that strict clinical criteria accurately reflect accurately reflect incidence. We conclude that pertussis remains a significant health problem in Nova Scotia, despite nearly universal vaccination.