Emission rates of bio-based building materials, a method description for qualifying and quantifying VOC emissions.

Biobased insulation materials offer opportunities to use vapor-open building constructions. Such constructions allow direct interaction between the biobased material and the indoor environment. This interaction raises questions about indoor air quality concerning volatile organic compounds (VOCs). This study presents results for the VOC emissions from biobased materials. It consists of two parts: 1) qualification of VOC emissions (compounds) from several biobased and non-biobased building materials, and 2) quantification of VOC emissions (emission rate) from expanded cork (biobased), particle board (semi-biobased), and EPS insulation. By quantifying the emission rate, the exposure to the released VOC emissions at room temperature in a standardized room can be compared to health limit requirements. Gas chromatography and mass spectroscopy (GC-MS) is used to derive the individual VOC emissions and the Total Volatile Organic Compounds (TVOC) from these materials. For qualification, two different sampling techniques are used in which temperature is introduced as a variable to investigate its effect on the type of compounds emitted. For quantification, the toluene equivalent approach is compared to the group equivalent approach. From the analyses it is concluded that temperature has an effect on the type of VOC compounds emitted from (biobased) materials. Results from the quantification indicate that expanded cork and particle board emit no harmful substances at a level that can affect human health. For EPS insulation, elevated levels of benzene were found to exceed healthy limits. The toluene equivalent approach for quantifying the emission, generally, underestimates the rate as compared to the more accurate group equivalent approach.

Evidence brief: supporting rapid learning and improvement across Ontario's health system

Ontario has both a health system and a research system that are increasingly aiming to support rapid learning and improvement. Yet, Ontario's health system still faces complex challenges, such as reducing emergency-room wait times, ending hallway medicine, improving support for people with mental health and substance-use problems, and providing optimal care to a growing aging population. To contend with these challenges, the government recently introduced The People's Health Care Act, which will enact the Connecting Care Act and amend and repeal a number of existing acts and regulations.This redesign provides a unique opportunity to take stock of the health and research system assets that exist within each of these agencies, at each level of health system and across the different parts of the health system to determine how they can best be joined up to maximize their value. The redesign also provides an opportunity to ask how a rapid-learning health-system approach if 'baked into' the redesign and its implementation from the beginning, could assist with ensuring that the redesign (and course corrections based on rapid feedback and real-time learning) continually 'moves the needle' in ways that matter most to patients and families.

Incidence of hypotension and acute hypotensive transfusion reactions following platelet concentrate transfusions.

BACKGROUND AND OBJECTIVES: Platelet concentrates (PCs) are associated with transfusion reactions involving hypotension, particularly bradykinin-mediated acute hypotensive transfusion reactions. This study aims to determine the incidence of hypotensive events and more specifically acute hypotensive transfusion reaction associated with PC transfusions. We also sought to ascertain whether these reactions are associated with elevated bradykinin levels. MATERIALS AND METHODS: This is a prospective descriptive study of PCs administered at Sainte-Justine Hospital over 28 months. All PCs administered during this period were screened for hypotension through review of all transfusion-associated reaction reports (TARRs) sent to the blood bank. All residual PC bags were returned to the blood bank. TARRs associated with hypotension were reviewed by adjudicators that established the imputability of the PC transfusion to the reaction. Bradykinin levels were sampled in the first 168 PC bags returned to the blood bank. Levels were compared between PCs associated with hypotension and control PCs not associated with hypotension. RESULTS: A total of 3672 PC bags were returned to the blood bank; 25 PCs were associated with hypotension. Adjudicators ascertained that five hypotensive events were imputable to PCs of which one was an acute hypotensive transfusion reaction (incidence: 0·03%). Bradykinin level in the latter PC was 10 pg/ml, whereas levels were 226·2 ± 1252 pg/ml in the 143 control PCs. CONCLUSION: Our results show a low incidence of hypotension after PC transfusion. We identified only one acute hypotensive transfusion reaction. No correlation between bradykinin level and the occurrence of acute hypotensive reactions could be observed given that only one event was identified.

Evidence brief: strengthening public and patient engagement in health technology assessment in Ontario

This evidence brief and the stakeholder dialogue it was prepared to inform were designed to guide the actions of those involved in strengthening public and patient engagement in HTA in Ontario. In this section of the brief, we propose key definitions to ensure a common conceptual understanding. We also highlight key goals for public and patient engagement in HTA, as well as describe the health policy and HTA context in Ontario. The second section focuses on the key challenges associated with strengthening public and patient engagement in HTA, with an emphasis on the Ontario context. In the third section we propose three elements of a potentially comprehensive approach to address the problem. Lastly, we highlight key implementation considerations for moving forward.

Issue brief (student-led): addressing student mental health needs at McMaster University

McMaster University has many excellent programs and services in place to address student mental health needs. These services are offered through the Student Affairs office that is responsible for presenting McMaster students with opportunities to "discover, learn, and grow."(4) Mental health services on campus are primarily delivered through the Student Wellness Centre, which provides a wide range of services and resources for McMaster students, including medical and other health services, counselling services, and wellness education. The centre offers personal, psychological and group counselling to help students through emotional, personal or interpersonal problems. Additionally, the Student Wellness Centre helps students connect to relevant campus, community and online resources for further support.(5) Student Accessibility Services assists current and prospective McMaster students with academic and disability-related needs, including mental health disabilities.(6) Program coordinators at the office work with faculty and students to determine the appropriate accommodations to best meet the unique needs of the students seeking support.(

Issue brief: designing integrated approaches to support people with multimorbidity in Ontario

Managing multiple medical conditions is part of the daily life of a growing number of Ontarians. As Fortin et al. observed, "patients with multiple conditions are the rule rather than the exception in primary care."(2) Multimorbidity (living with three or more medical conditions) has attracted significant attention among health system policymakers and stakeholders in Ontario, in part because adults with multimorbidity account for more than two-thirds of healthcare costs.(3) Multimorbidity not only has a significant impact on healthcare utilization and costs, but affects quality of life, ability to work, employability, disability, processes of care and mortality.(4) Despite the burden of multimorbidity, patients often receive care that is "fragmented, incomplete, inefficient, and ineffective."(4) Thus, there have been growing calls for changes to health systems and clinical decision-making processes to more effectively and efficiently provide the complex care required by those with multimorbidity.(5;6) One such response in Ontario has been Health Links, which was launched in December 2012 and now includes 26 'early adopters'. Health Links are designed to support local patient-care networks, led by a coordinating partner, and attempt to coordinate and optimize access to needed services, initially with a particular focus on the 5% of patients who consume about 66% of healthcare costs.(3;7) However, primary care, community care and other providers, whether working as part of or separate from Health Links, need support to achieve measurable successes in caring for patients with multimorbidity and preventing multimorbidity in those at risk, and to achieve health system transformation more broadly for this patient group.

Issue brief: strengthening national health systems' capacity to respond to future global pandemics

Effective pandemic governance is more important now than ever as pandemic risk factors like urbanization, the hypermobility of persons, trans-border trade, rapid population growth and changes to the environment and food systems all increase in tandem with the demands of globalization.(1) These transformative global shifts have fundamentally changed the way pathogens are spread around the world.(2) The World Health Organization (WHO) estimates that newly emerging infectious disease outbreaks in one country are now only hours away from affecting many others.(3) Pandemics previously spread over years (e.g., bubonic plague in the 14th century), months (e.g., cholera epidemics in 19th century) or weeks (e.g., Spanish influenza of 1918-1919), but in today's globalized world, Severe Acute Respiratory Syndrome (SARS) took only 17 hours to spread half-way around the world from China to Canada. Future disease outbreaks are expected to take similarly short periods before they affect multiple countries across geographically distinct regions.(3) The current outbreak of H7N9 bird influenza in China (which spreads more easily from infected fowl to humans than the H5N1 strain did in 2003, according to Dr. Keiji Fukuda, WHO's top influenza expert) is a stark reminder that the threat of a pandemic exists as an imminent threat to human health and international security.(4) Of notable concern is the fact that more than 30 unexpected outbreaks of previously unknown pathogens and re-emerging diseases were observed in the past two decades alone.(2) Although the great majority of new and re-emerging diseases have not caused pandemics, national health systems that can respond adequately to pandemic threats are fundamental to controlling pandemic-prone local disease outbreaks within a country or a region

Citizen brief: Improving access to palliative care in Ontario

For concerned citizens and influential thinkers and doers, the McMaster Health Forum strives to be a leading hub for improving health outcomes through collective problem solving. Operating at the regional/provincial level and at national levels, the Forum harnesses information, convenes stakeholders and prepares action-oriented leaders to meet pressing health issues creatively. The Forum acts as an agent of change by empowering stakeholders to set agendas, take well-considered actions and communicate the rationale for actions effectively.

Evidence brief: creating community-based specialty clinics in Ontario

Ontario's Action Plan for Health Care called for "right care, right time, right place" (p. 10) and specifically for "moving procedures into the community" (p. 13).(1) To support the implementation of this commitment, the ministry of health has taken several steps. The ministry has supported one midwifery-led birth centre in Ontario (on Six Nations of the Grand River territory) and announced in March 2012 plans for two more. The ministry may also announce another type of community-based specialty clinic in the coming months.

Evidence brief: Improving end-of-life communication, decision-making and care in Ontario

Improving end-of-life communication, decision-making and care has been identified as a pressing health issue in Ontario (and in Canada more generally), as evidenced by recent research,(1;2) public opinion polls,(3) expert panels and commissions,(4-6) and a high-profile legal case,(7) which have revealed many challenges in this area. The importance of this issue is also reflected by a strong push from various organizations to support citizens in having informed conversations about end-oflife issues and engaging in formalized advance care planning,(8) large advocacy coalitions dedicated to quality end-of-life care,(9;10) numerous initiatives to support high-quality integrated palliative and end-of-life care, including implementation of the 2011 Declaration of Partnership and Commitment to Action,(11) as well as an active research community dedicated to this issue.

Issue brief: building momentum in using the avoidable mortality indicators in Canada

Over the past three decades, Canada has made substantial progress in reducing the national rate of avoidable mortality (deaths that could potentially have been avoided through disease prevention or healthcare services). In fact, the national avoidable mortality rate has decreased by half ­ from 373 per 100,000 in 1979 to 185 per 100,000 in 2008.(1) During this period, avoidable mortality attributed to preventable causes decreased by 47%, while avoidable mortality attributed to treatable causes decreased by 56%. Additionally, Canada is faring well from an international standpoint, ranking the third lowest amongst G7 nations in rates of avoidable mortality, after Japan and France.(1) However, despite the significant gains that Canada has made in reducing avoidable mortality rates, there still exist variations in the distribution of avoidable mortality across provinces and territories, and across different population groups.(1) Additional efforts are needed to reduce avoidable mortality rates both among the jurisdictions and groups being 'left behind', as well as overall.

Evidence brief: coordinating the use of genetic tests and related services in British Columbia

Rapid technological advances in genetics and genomics hold promise for the diagnosis, treatment and even prevention of common and rare diseases. Nevertheless, they also raise concerns regarding their potential impacts on health systems, which has led many countries to reflect on the optimal models to coordinate genetic testing and related services,(1-5) as well as the optimal frameworks to guide policy and coverage decisions that could help embrace opportunities offered by new and emerging technologies while minimizing the use of harmful and ineffective ones.

Naloxone for shock.

BACKGROUND: There is pre-clinical evidence, involving several animal species, suggesting that opioid peptides play a role in the physiopathology of shock (endotoxic, hypovolemic, cardiogenic, spinal, anaphylactic). Many case reports have suggested that naloxone (an opiate antagonist) might be an effective treatment for shock in humans, but others have not supported such a point of view. This controversy led us to undertake a meta-analysis of the available evidence on the efficacy of naloxone as a treatment measure of shock in humans. OBJECTIVES: To evaluate the effectiveness and safety of naloxone in human shock and to estimate the methodological quality of the clinical trials. SEARCH STRATEGY: Computerized bibliographic search up to December 2002, review of references of all papers found on the subject and contact with primary investigators of eligible studies. SELECTION CRITERIA: Randomized controlled trials evaluating naloxone in human shock, regardless of the patient's age (adult, child or neonate). DATA COLLECTION AND ANALYSIS: Three independent reviewers extracted data on study design, intervention, outcome and methodological quality. MAIN RESULTS: Three independent readers reviewed 80 human publications and selected six clinical trials. Overall agreement on study selection was perfect (concordance: 100%). This meta-analysis includes six studies involving 126 patients with septic, cardiogenic, hemorrhagic or spinal shock. Naloxone therapy was associated with statistically significant hemodynamic improvement (odds ratio 0.24; 95% confidence interval [95%CI] 0.09-0.68). The mean arterial pressure was significantly higher in the naloxone groups than in the placebo groups (weighted mean difference: +9.33 mmHg; 95%CI 7.07-11.59). No heterogeneity was found for this outcome. The death rate was lower in the naloxone group (odds ratio 0.59; 95%CI 0.21-1.67) but this was consistent with the play of chance. A significant heterogeneity for the latter outcome was detected (p<0.05). REVIEWER'S CONCLUSIONS: Naloxone improves blood pressure, especially mean arterial blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined, and additional randomized controlled trials are needed to assess its usefulness.

Hospitalizations for pediatric intoxication in Washington State, 1987-1997.

BACKGROUND: Intoxication (or poisoning) that necessitates hospitalization remains an important source of morbidity in children. OBJECTIVE: To determine changes, during an 11-year period (1987-1997), in the incidence of hospitalization due to intoxication among children in Washington State and circumstances of ingestion, agents used, hospital length of stay, charges, and mortality. METHODS: A computerized database of all hospital discharges (Comprehensive Hospital Abstract Reporting System [CHARS] database) in Washington was used. Cases included all children younger than 19 years with a primary or secondary diagnosis for an intoxication or with an external cause of injury code (E code) for an intoxication from 1987 to 1997. RESULTS: There were 7322 hospitalizations (45 per 100 000 children per year); the annual rate significantly decreased during the study period. Most patients (75%) were teenagers. Sixty-five percent were female. Pharmaceutical agents were used in 80% of cases. Analgesics were the most commonly used (34%), followed by antidepressants (12%) and psychotropic drugs (8%). Nonpharmaceutical agents were more prevalent in children younger than 12 years than in teenagers. Self-inflicted intoxication was the most frequent cause identified by E codes (47%). Median length of stay was 1 day, and median hospital charges were $2096. Mortality was low (0.2%) and did not change significantly over time. CONCLUSIONS: Acute intoxication continues to be an important cause of hospitalization in children. The type of agent involved did not change significantly over time. Teenage girls continue as the highest risk group for suicide attempt from ingestions. Self-inflicted intoxications were associated with higher costs, length of stay, and readmissions. Although preventive measures and development of poison centers have contributed to decrease mortality from acute intoxication in children in the last 50 years, efforts need to be targeted toward suicide prevention, especially among teenage girls.

The impact of clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit.

OBJECTIVE: To determine the clinical and economic impact attributable to upper gastrointestinal bleeding (UGIB) acquired in a pediatric intensive care unit (PICU). DESIGN: Prospective case-control-within-cohort study. SETTING: PICU at a university hospital. PATIENTS: All consecutive patients over a 1-yr period. METHODS: All UGIB (hematemesis or blood in gastric tube) were reported. A UGIB was qualified as clinically significant (CS-UGIB) if a panel of reviewers assessed that a complication (decreased hemoglobin concentration, transfusion, multiple organ dysfunction syndrome, surgery, or death) was attributed to it. A UGIB was qualified as clinically nonsignificant (NS-UGIB) if none of these complications was attributed to it. The Ø-UGIB group comprised patients without UGIB. Pairing between the three groups was done according to these criteria: death or survival, Pediatric Risk of Mortality Score on admission, respiratory failure, coagulopathy, and age. Data considered for the impact analysis was prospectively monitored during the stay in PICU. Costs were estimated in Canadian dollars (1999) as follows: costs of stay + medical staff + ventilation + red blood cell transfusions. RESULTS: The cohort included 1006 admissions. Sixteen cases of CS-UGIB were paired to 13 cases of NS-UGIB and 32 cases of Ø-UGIB. Compared with the Ø-UGIB group and the NS-UGIB group, the CS-UGIB group showed a significantly (p < 0.05) higher rate of red blood cell transfusions, duration of ventilation, length of stay in PICU, and a lower hemoglobin level. There was no difference between the NS-UGIB group and the Ø-UGIB group. The cost analysis demonstrated a significant difference (p < 0.05) between the CS-UGIB group (20,062.67 Can dollars/patient per stay) and the other groups (NS-UGIB, 6104.77 Can dollars/patient per stay; Ø-UGIB, 5457.25 Can dollars/patient per stay). CONCLUSION: This study demonstrates a significant clinical and economic impact of CS-UGIB in PICU, although no impact was detected for NS-UGIB. Further studies on the benefit of UGIB prophylaxis for critically ill children with risk factors for CS-UGIB are needed.

Reactive hemophagocytic syndrome presenting as a component of multiple organ dysfunction syndrome.

OBJECTIVE: To report two cases of severe reactive hemophagocytic syndrome (RHS), to discuss their impact, and to present evidence that RHS may be a constitutive part of multiple organ dysfunction syndrome (MODS). DESIGN: Case-report. SETTING: Pediatric intensive care unit (PICU). PATIENTS: Two patients with RHS and MODS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Case #1: A 3 yr-old boy with Mucha-Haberman syndrome (pityriasis lichenoides) was admitted to the PICU for septic shock, acute respiratory distress syndrome, capillary leak, acute renal failure, liver dysfunction, and RHS (pancytopenia and hemophagocytosis on bone marrow aspirate). The pancytopenia was severe (white blood cell count, 0.9 x 10(9)/L; hemoglobin, 59 g/L; platelets, 36 x 10(9)/L), required many transfusions, and resolved 2 months later. The patient needed mechanical ventilation for 6 wks. Length of stay in PICU was 2 months. Case #2: A previously healthy 4 yr-old girl was admitted to the PICU for respiratory failure. She developed acute respiratory distress syndrome, cardiomyopathy with complete atrioventricular block, shock, capillary leak, liver dysfunction, and RHS (pancytopenia and hemophagocytosis on bone marrow aspirate). The pancytopenia was severe (white blood cell count, 1.92 x 10(9)/L; hemoglobin, 65 g/L; platelets, 58 x 10(9)/L) and necessitated transfusional support. Serology for respiratory syncytial virus was positive. RHS duration was 20 days; the patient recovered completely. Length of mechanical ventilation was 16 days and length of stay in PICU was 3 wks. CONCLUSIONS: These cases show that RHS may be a significant cause of pancytopenia in the PICU. It needs to be recognized as a clinical entity because it can be reversible and nonneoplastic. RHS and MODS share some pathophysiologic elements and could be related to each other.

Development of a pediatric multiple organ dysfunction score: use of two strategies.

BACKGROUND: An organ dysfunction (OD) scoring system for critically ill children is not yet available, and the method for developing such a system is not well defined. The aim of this study was to compare two developmental methods for assessing OD in critically ill children. METHODS: Consecutive admissions between January and May 1997 in three French and Canadian pediatric intensive care units (PICUs) were studied prospectively. Physiologic data were selected using a Delphi method; the most abnormal values during PICU stay were recorded. The outcome measure was the vital status at PICU discharge. Six organ systems were studied: hepatic, cardiovascular, renal, hematologic, respiratory, and neurologic. For each of the six organ systems, the PEdiatric Multiple OD (PEMOD) system included one variable and the PEdiatric Logistic OD (PELOD) system included several variables. Severity levels and relative weights of ODs were determined according to the mortality rate (PEMOD) or by logistic regression (PELOD). RESULTS: There were 594 admissions, including 51 deaths (9%). Severity levels and relative weights of ODs were: four levels graded from 1 to 4 for the PEMOD system and three levels with scores of 1, 10, and 20 for PELOD system. For both systems, calibrations were good (p = 0.23 and p = 0.44 respectively). The PELOD system was more discriminant than the PEMOD system (areas under the ROC curves 0.98 and 0.92, respectively, p < 10(-5)). Moreover, with the PEMOD system, four ODs did not contribute significantly to the prediction of PICU outcome. CONCLUSIONS: The PELOD system was more discriminant and had the advantage of taking into account both the relative severities among ODs and the degree of severity of each OD.

Therapy of shock with naloxone: a meta-analysis.

OBJECTIVES: To evaluate the effectiveness of naloxone in human shock; and to estimate the methodologic quality of the clinical trials. DATA SOURCES: Computerized bibliographic search on MEDLINE covering the period from January 1979 to July 1996, review of references of all papers found on the subject, and contact with primary investigators of eligible studies. STUDY SELECTION: To be included in this study, a paper should be a randomized, clinical trial published in a peer-reviewed journal evaluating naloxone in human shock, regardless of the patient's age (adult, child, neonate). Three independent readers reviewed 61 human publications and selected five clinical trials. Overall agreement on study selection was perfect (concordance: 100%). We excluded a posteriori two studies whose authors were unable to provide us with the raw data to complete contingency tables. This meta-analysis deals with three studies including 61 patients with septic shock. DATA EXTRACTION: Three independent reviewers extracted data on study design, intervention, outcome, and methodologic quality. The intraclass correlation coefficient was 0.7. The quality score of each study was 48, 60, and 61, on a scale of 104. DATA SYNTHESIS: Naloxone therapy was associated with statistically significant hemodynamic improvement (typical odds ratio: 0.241; 95% confidence interval: 0.08 to 0.68). The overall effect size was 0.89. However, a publication bias was possible. The case fatality rate was not decreased by naloxone (typical odds ratio: 0.60; 95% confidence interval: 0.21 to 1.67); a chi-square analysis detected significant heterogeneity for the latter outcome (p < .05). CONCLUSIONS: Naloxone improves blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined and additional randomized clinical trials are needed to assess its usefulness.