A single-entry model and wait time for hip and knee replacement in eastern health region of Newfoundland and Labrador 2011-2019.

BACKGROUND: A single-entry model in healthcare consolidates waiting lists through a central intake and allows patients to see the next available health care provider based on the prioritization. This study aimed to examine whether and to what extent the prioritization reduced wait times for hip and knee replacement surgeries. METHOD: The survival regression method was used to estimate the effects of priority levels on wait times for consultation and surgery for hip and knee replacements. The sample data included patients who were referred to the Orthopedic Central Intake clinic at the Eastern Health region of Newfoundland and Labrador and had surgery of hip and knee replacements between 2011 and 2019. RESULT: After adjusting for covariates, the hazard of having consultation booked was greater in patients with priority 1 and 2 than those in priority 3 when and at 90 days after the referral was made for both hip and knee replacements. Regarding wait time for surgery after the decision for surgery was made, while the hazard of having surgery was lower in priority 2 than in priority 3 when and indifferent at 182 days after the decision was made, it was not significantly different between priority 1 and priority 3 among hip replacement patients. Priority levels were not significantly related to the hazard of having surgery for a knee replacement after the decision for surgery was made. Overall, the hazard of having surgery after the referral was made by a primary care physician was greater for patients in high priority than those in low priority. Preferring a specific surgeon indicated at referral was found to delay consultation and it was not significantly related to the total wait time for surgery. Incomplete referral forms prolonged wait time for consultation and patients under age 65 had a longer total wait time than those aged 65 or above. CONCLUSION: Patients with high priority could have a consultation booked earlier than those with low priority and prioritization in a single entrance model shortens the total wait time for surgery. However, the association between priority levels and wait for surgery after the decision for surgery was made has not well-established.

Strengthening collaborations at the public health system-academic interface: a call to action.

In Canada and globally, the COVID-19 pandemic has highlighted the importance of reliable and responsive public health systems. The pandemic has required decisive leadership and collaboration across all sectors of society informed by the best available evidence. In this commentary, we argue that in order to create a robust public health system equipped to address current and future public health challenges, we must prioritize and invest in stronger relationships between public health practice and academia. We briefly review key recommendations following the SARS outbreak, particularly those calling for stronger linkages between public health academia and practice settings in Canada. We then propose key actions for strengthening these linkages. Echoing other COVID-19-related calls, which request long-term reinvestment in public health education and training, we recommend the following actions: (1) Improve collaboration between education programs and public health agencies to address system needs (e.g., surge capacity) and persisting health inequities; (2) Fund a pan-Canadian public health training initiative that builds on a renewed set of public health competencies to address priority training needs (e.g., equity-oriented leadership); and (3) Prepare a cadre of certified public health leaders who can progress along public health career pathways, including those already in practice.

RéSUMé: Au Canada et ailleurs dans le monde, la pandémie de COVID-19 a montré qu'il est important d'avoir des systèmes de santé publique fiables et réactifs. La pandémie nécessite un leadership décisif et une collaboration entre tous les secteurs de la société, éclairés par les meilleures preuves disponibles. Dans ce commentaire, nous faisons valoir que pour créer un système de santé publique robuste capable de relever les défis actuels et futurs, il faut privilégier des liens plus forts entre les praticiens de la santé publique et les milieux universitaires et y consacrer les investissements nécessaires. Nous passons brièvement en revue les principales recommandations qui ont suivi la crise du SRAS, en particulier celles qui réclamaient le renforcement des liens entre les facultés de santé publique et les milieux de pratique au Canada. Nous proposons ensuite des mesures clés pour renforcer ces liens. Faisant écho à d'autres appels à l'action liés à la COVID-19, qui préconisent un réinvestissement à long terme dans l'enseignement et la formation en santé publique, nous recommandons les mesures suivantes: 1) Améliorer la collaboration entre les programmes d'enseignement et les organismes de santé publique pour aborder les besoins des systèmes (p. ex. leur capacité d'appoint) et les inégalités persistantes en santé; 2) Financer une initiative pancanadienne de formation en santé publique qui s'appuie sur un ensemble renouvelé de compétences en santé publique pour répondre aux besoins prioritaires en matière de formation (p. ex. le leadership axé sur l'équité); et 3) Préparer un groupe de dirigeants de santé publique agréés pouvant progresser dans les carrières de la santé publique, y compris des personnes qui exercent déjà la profession.

Tracking progress in suicide prevention in Indigenous communities: a challenge for public health surveillance in Canada.

Indigenous peoples in Canada experience disproportionate rates of suicide compared to non-Indigenous populations. Indigenous communities and organizations have designed local and regional approaches to prevention, and the federal government has developed a national suicide prevention framework. However, public health systems continue to face challenges in monitoring the population burden of suicide and suicidal behaviour. National health data systems lack Indigenous identifiers, do not capture data from some regions, and do not routinely engage Indigenous communities in data governance. These challenges hamper efforts to detect changes in population-level outcomes and assess the impact of suicide prevention activities. Consequently, this limits the ability to achieve public health prevention goals and reduce suicide rates and rate inequities.This paper provides a critical analysis of the challenges related to suicide surveillance in Canada and assesses the strengths and limitations of existing data infrastructure for monitoring outcomes in Indigenous communities. To better understand these challenges, we discuss the policy context for suicide surveillance and examine the survey and administrative data sources that are commonly used in public health surveillance. We then review recent data on the epidemiology of suicide and suicidal behaviour among Indigenous populations, and identify challenges related to national surveillance.To enhance capacity for suicide surveillance, we propose strategies to better track progress in Indigenous suicide prevention. Specifically, we recommend establishing an independent community and scientific governing council, integrating Indigenous identifiers into population health datasets, increasing geographic coverage, improving suicide data quality, comprehensiveness, and timeliness, and developing a platform for making suicide data accessible to all stakeholders. Overall, the strategies we propose can build on the strengths of the existing national suicide surveillance system by adopting a collaborative and inclusive governance model that recognizes the stake Indigenous communities have in suicide prevention.

Diabetes and the occurrence of infection in primary care: a matched cohort study.

BACKGROUND: People with diabetes may be at higher risk for acquiring infections through both glucose-dependent and biologic pathways independent of glycemic control. Our aim was to estimate the association between diabetes and infections occurring in primary care. METHODS: Using the Newfoundland and Labrador Sentinel of the Canadian Primary Care Sentinel Surveillance Network, patients with diabetes ≥18 years between 1 January 2008 and 31 March 2013 were included with at least 1-year of follow-up. We randomly matched each patient with diabetes on the date of study entry with up to 8 controls without diabetes. Primary outcome was the occurrence of ≥1 primary care physician visits for any infectious disease. Secondary outcomes included primary visits for head & neck, respiratory, gastrointestinal, genitourinary, skin and soft tissue, musculoskeletal, and viral infections. Using multivariable conditional logistic regression analysis, we measured the independent association between diabetes and the occurrence of infections. RESULTS: We identified 1779 patients with diabetes who were matched to 11,066 patients without diabetes. Patients with diabetes were older, had a higher prevalence of comorbidities, and were more often referred to specialists. After adjusting for potential confounders, patients with diabetes had an increased risk of any infection compared to patients without diabetes (adjusted odds ratio = 1.21, 95% confidence interval 1.07-1.37). Skin and soft tissue infections had the strongest association, followed by genitourinary, gastrointestinal, and respiratory infections. Diabetes was not associated with head and neck, musculoskeletal, or viral infections. CONCLUSION: Patients with diabetes appear to have an increased risk of certain infections compared to patients without diabetes.

Association between perceptions of public drinking water quality and actual drinking water quality: A community-based exploratory study in Newfoundland (Canada).

Studying public perception on drinking water quality is crucial for managing of water resources, generation of water quality standards, and surveillance of the drinking-water quality. However, in policy discourse, the reliability of public perception concerning drinking water quality and associated health risks is questionable. Does the public perception of water quality equate with the actual water quality? We investigated public perceptions of water quality and the perceived health risks and associated with the actual quality of public water supplies in the same communities. The study was conducted in 45 communities of Newfoundland (Canada) in 2012. First, a telephone survey of 100 households was conducted to examine public perceptions of drinking water quality of their respective public sources. Then we extracted public water quality reports of the same communities (1988-2011) from the provincial government's water resources portal. These reports contained the analysis of 2091 water samples, including levels of Disinfection By-Products (DBPs), nutrients, metals, ions and physical parameters. The reports showed that colour, manganese, total dissolved solids, iron, turbidity, and DBPs were the major detected parameters in the public water. However, the majority of the respondents (>56%) were either completely satisfied or very satisfied with the quality of drinking water. Older, higher educated and high-income group respondents were more satisfied with water quality than the younger, less educated and low-income group respondents. The study showed that there was no association with public satisfaction level and actual water quality of the respective communities. Even, in the communities, supplied by the same water system, the respondents had differences in opinion. Despite the effort by the provincial government to make the water-test results available on its website for years, the study showed existing disconnectedness between public perception of drinking water quality and actual quality. We had little scope to explore the possible explanations, and hence further studies are required to verify the age, gender educational status and income differential about the satisfaction of public service like water supply.

Spine bone mineral density increases after 6 months of exclusive lactation, even in women who keep breastfeeding.

This pilot study enrolled 31 women who had breastfed exclusively for 6 months. Lumbar and thoracic BMD increased 4 and 5%, respectively. Femoral neck and total body BMD did not change. Return of menses and progestin-only pill use were two potential signals that predicted a greater increase in BMD. PURPOSE/INTRODUCTION: The skeleton is resorbed during lactation to provide much of the calcium content of milk. After lactation ceases, these deficits in skeletal mineral content are largely restored, such that lactation has a neutral or protective effect against the long-term risk of low bone mineral density (BMD), osteoporosis, and fragility fractures. We hypothesized that a large observational study may identify the factors that predict a greater increase in BMD after lactation ceases. A pilot study was first needed to test feasibility and the magnitude of expected BMD change. METHODS: We undertook Factors Affecting Bone formation after Breastfeeding Pilot (FABB Pilot), which enrolled women who had breastfed exclusively for 6 months and planned to wean soon. The main outcome was change in BMD between enrolment and 6 months later. RESULTS: Thirty-one women were recruited and completed both time points. Lumbar and thoracic spine BMD increased 4 and 5%, respectively; there was no significant change in femoral neck and total body BMD. Most women did not wean their babies as planned but continued to breastfeed multiple times per day. Despite this, a significant increase in BMD was seen in the subsequent 6 months. Return of spontaneous menses and use of a progestin-only pill at recruitment were two potential signals that predicted a greater increase in BMD during the 6 months after exclusive lactation. CONCLUSIONS: Spine BMD increased significantly during 6 months following exclusive lactation and despite continued lactation. The factors that stimulate skeletal recovery remain to be identified.

The association between diabetes mellitus and incident infections: a systematic review and meta-analysis of observational studies.

OBJECTIVE: To quantify the association between diabetes and the risk of incident infections by conducting a systematic review and meta-analysis. RESEARCH DESIGN AND METHODS: Two reviewers independently screened articles identified from PubMed, EMBASE, Cochrane Library, IPA, and Web of Science databases. Cohort studies (CS) or case-control studies (CCS) evaluating the incidence of infections in adults with diabetes were included. Infections were classified as: skin and soft tissue, respiratory, blood, genitourinary, head and neck, gastrointestinal, bone, viral, and non-specified infections. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Summary crude and adjusted OR with 95% CIs were calculated using random effects models, stratified by study design. Heterogeneity was measured using the I2statistic and explored using subgroup analyses. RESULTS: A total of 345 (243 CS and 102 CCS) studies were included. Combining adjusted results from all CS, diabetes was associated with an increased incidence of skin (OR 1.94, 95% CI 1.78 to 2.12), respiratory (OR 1.35, 95% CI 1.28 to 1.43), blood (OR 1.72, 95% CI 1.48 to 2.00), genitourinary (OR 1.61, 95% CI 1.42 to 1.82), head and neck (OR 1.17, 95% CI 1.13 to 1.22), gastrointestinal (OR 1.48, 95% CI 1.40 to 1.57), viral (OR 1.29, 95% CI 1.13 to 1.46), and non-specified (OR 1.84, 95% CI 1.66 to 2.04) infections. A stronger association was observed among CCS: skin (OR 2.64, 95% CI 2.20 to 3.17), respiratory (OR 1.62, 95% CI 1.37 to 1.92), blood (OR 2.40, 95% CI 1.68 to 3.42), genitourinary (OR 2.59, 95% CI 1.60 to 4.17), gastrointestinal (OR 3.61, 95% CI 2.94 to 4.43), and non-specified (OR 3.53, 95% CI 2.62 to 4.75). CONCLUSION: Diabetes is associated with an increased risk of multiple types of infections. A high degree of heterogeneity was observed; however, subgroup analysis decreased the amount of heterogeneity within most groups. Results were generally consistent across types of infections.

Suicide Rates in Aboriginal Communities in Labrador, Canada.

OBJECTIVES: To compare suicide rates in Aboriginal communities in Labrador, including Innu, Inuit, and Southern Inuit, with the general population of Newfoundland, Canada. METHODS: In partnership with Aboriginal governments, we conducted a population-based study to understand patterns of suicide mortality in Labrador. We analyzed suicide mortality data from 1993 to 2009 from the Vital Statistics Death Database. We combined this with community-based methods, including consultations with Elders, youths, mental health and community workers, primary care clinicians, and government decision-makers. RESULTS: The suicide rate was higher in Labrador than in Newfoundland. This trend persisted across all age groups; however, the disparity was greatest among those aged 10 to 19 years. Males accounted for the majority of deaths, although suicide rates were elevated among females in the Inuit communities. When comparing Aboriginal subregions, the Innu and Inuit communities had the highest age-standardized mortality rates of, respectively, 165.6 and 114.0 suicides per 100 000 person-years. CONCLUSIONS: Suicide disproportionately affects Innu and Inuit populations in Labrador. Suicide rates were high among male youths and Inuit females.

A descriptive analysis of the spatio-temporal distribution of enteric diseases in New Brunswick, Canada.

BACKGROUND: Enteric diseases affect thousands of Canadians annually and several large outbreaks have occurred due to infection with enteric pathogens. The objectives of this study were to describe the spatial and temporal distributions of reportable Campylobacter, Escherichia coli, Giardia, Salmonella and Shigella from 1994 to 2002 in New Brunswick, Canada. By examining the spatial and temporal distributions of disease incidence, hypotheses as to potential disease risk factors were formulated. METHODS: Time series plots of monthly disease incidence were examined for seasonal and secular trends. Seasonality of disease incidence was evaluated using the temporal scan statistic and seasonal-trend loess (STL) decomposition methods. Secular trends were evaluated using negative binomial regression modeling. The spatial distribution of disease incidence was examined using maps of empirical Bayes smoothed estimates of disease incidence. Spatial clustering was examined by multiple methods, which included Moran's I and the spatial scan statistic. RESULTS: The peak incidence of Giardia infections occurred in the spring months. Salmonella incidence exhibited two peaks, one small peak in the spring and a main peak in the summer. Campylobacter and Escherichia coli O157 disease incidence peaked in the summer months. Moran's I indicated that there was significant positive spatial autocorrelation for the incidence of Campylobacter, Giardia and Salmonella. The spatial scan statistic identified clusters of high disease incidence in the northern areas of the province for Campylobacter, Giardia and Salmonella infections. The incidence of Escherichia coli infections clustered in the south-east and north-east areas of the province, based on the spatial scan statistic results. Shigella infections had the lowest incidence rate and no discernable spatial or temporal patterns were observed. CONCLUSIONS: By using several different spatial and temporal methods a robust picture of the spatial and temporal distributions of enteric disease in New Brunswick was produced. Disease incidence for several reportable enteric pathogens displayed significant geographic clustering indicating that a spatially distributed risk factor may be contributing to disease incidence. Temporal analysis indicated peaks in disease incidence, including previously un-reported peaks.

A randomized controlled study of manikin simulator fidelity on neonatal resuscitation program learning outcomes.

The neonatal resuscitation program (NRP) has been developed to educate physicians and other health care providers about newborn resuscitation and has been shown to improve neonatal resuscitation skills. Simulation-based training is recommended as an effective modality for instructing neonatal resuscitation and both low and high-fidelity manikin simulators are used. There is limited research that has compared the effect of low and high-fidelity manikin simulators for NRP learning outcomes, and more specifically on teamwork performance and confidence. The purpose of this study was to examine the effect of using low versus high-fidelity manikin simulators in NRP instruction. A randomized posttest-only control group study design was conducted. Third year undergraduate medical students participated in NRP instruction and were assigned to an experimental group (high-fidelity manikin simulator) or control group (low-fidelity manikin simulator). Integrated skills station (megacode) performance, participant satisfaction, confidence and teamwork behaviour scores were compared between the study groups. Participants in the high-fidelity manikin simulator instructional group reported significantly higher total scores in overall satisfaction (p = 0.001) and confidence (p = 0.001). There were no significant differences in teamwork behaviour scores, as observed by two independent raters, nor differences on mandatory integrated skills station performance items at the p < 0.05 level. Medical students' reported greater satisfaction and confidence with high-fidelity manikin simulators, but did not demonstrate overall significantly improved teamwork or integrated skills station performance. Low and high-fidelity manikin simulators facilitate similar levels of objectively measured NRP outcomes for integrated skills station and teamwork performance.

Effects of chronic in-vivo treatments with protease-activated receptor 2 agonist on endothelium function and blood pressures in mice.

Short-term treatments with protease-activated receptor 2-activating peptides (PAR2-AP) induce endothelium-dependent vasodilation and decrease blood pressure. In this study, we tested the effect of chronic in-vivo treatment with PAR2-AP on the blood pressure and endothelium function of mice. Male PAR2 wild-type (WT) and par2-deficient (KO) mice received subcutaneous infusions of either saline, low (PAR2-LD), or high (PAR2-HD) doses of 2-furoyl-LIGRLO-amide for 1 or 2 weeks. In each treatment group, endothelium function was assessed in isolated arteries. Blood pressure, heart rate, and locomotor activity were recorded by radiotelemetry, and levels of tumour nercrosis factor α (TNF-α) and interkeukin 1ß (IL-1ß) were measured in plasma samples by ELISA. The relaxation of WT aortas and mesenteric arteries induced by PAR2-AP was decreased by PAR2-LD and PAR2-HD. In mesenteric arteries, PAR2-LD and PAR2-HD decreased the relaxation induced by acetylcholine, but not by nitroprusside; in aortas, PAR2-LD and PAR2-HD caused differential decreases in the relaxations induced by acetylcholine and nitroprusside. Only PAR2-HD lowered systolic arterial pressures in WT, when compared with all of the other groups. TNF-α and IL-1ß plasma concentrations were not different among the groups. We conclude that the systolic blood pressure of unrestrained mice can be lowered by chronic in-vivo activation of PAR2; however, this effect is countered by receptor desensitization and the concomitant development of endothelium and vascular dysfunction.

Effects of injectable anesthetic combinations on left ventricular function and cardiac morphology in Sprague-Dawley rats.

Novel anesthetic agents or combinations may provide superior general anesthesia for echocardiography in rodents with the potential for reduced adverse effects. This study sought to characterize the effects of 3 injectable anesthetics on left ventricular (LV) systolic function and cardiac morphology in healthy male and female rats. Rats underwent echocardiographic assessment after general anesthesia via pentobarbital or combinations of ketamine and medetomidine (KME) and ketamine and midazolam (KMI) according to a crossover Latin-square design. Blood samples for serum estradiol measurements were obtained from all females after echocardiography with each anesthetic. Rats given KMI showed superior LV systolic function with the highest values for fractional shortening (FS), ejection fraction (EF) and stroke volume, whereas heart rate was greatest with pentobarbital, followed by KMI and then KME. KME produced the greatest effects on cardiac morphology, most notably during systole, including reduced septal and posterior wall thickness and increased LV chamber dimensions and volumes. In addition, KME had the greatest cardiac-depressing effects on LV systolic function, including reduced FS, EF, and heart rate values. Compared with male rats, female rats had superior LV function with greater EF and FS values, whereas male rats showed higher heart rate. Significant negative correlations were noted between serum estradiol levels and FS and EF values in female rats receiving KME. We conclude that the combination of KMI may be a superior anesthetic for use in male and female rats undergoing echocardiography.

Quality of reporting in clinical trials of preharvest food safety interventions and associations with treatment effect.

Randomized controlled trials (RCTs) are the gold standard for evaluating treatment efficacy. Therefore, it is important that RCTs are conducted with methodological rigor to prevent biased results and report results in a manner that allows the reader to evaluate internal and external validity. Most human health journals now require manuscripts to meet the Consolidated Standards of Reporting Trials (CONSORT) criteria for reporting of RCTs. Our objective was to evaluate preharvest food safety trials using a modification of the CONSORT criteria to assess methodological quality and completeness of reporting, and to investigate associations between reporting and treatment effects. One hundred randomly selected trials were evaluated using a modified CONSORT statement. The majority of the selected trials (84%) used a deliberate disease challenge, with the remainder representing natural pathogen exposure. There were widespread deficiencies in the reporting of many trial features. Randomization, double blinding, and the number of subjects lost to follow-up were reported in only 46%, 0%, and 43% of trials, respectively. The inclusion criteria for study subjects were only described in 16% of trials, and the number of animals housed together was only stated in 52% of the trials. Although 91 trials had more than one outcome, no trials specified the primary outcome of interest. There were significant bivariable associations between the proportion of positive treatment effects and failure to report the number of subjects lost to follow-up, the number of animals housed together in a group, the level of treatment allocation, and possible study limitations. The results suggest that there are substantive deficiencies in reporting of preharvest food safety trials, and that these deficiencies may be associated with biased treatment effects. The creation and adoption of standards for reporting in preharvest food safety trials will help to ensure the inclusion of important trial details in all publications.

Cross-sectional relationship of pedometer-determined ambulatory activity to indicators of health.

OBJECTIVE: To describe the cross-sectional relationship between an objective measure of walking (pedometer-determined steps/day) and general indicators of health, a prior diagnosis of one or more components of the metabolic syndrome, and self-reported occupational activity in a generally sedentary working population. RESEARCH METHODS AND PROCEDURES: Steps/day were compared with previous diagnosis of one or more components of the metabolic syndrome (by self-administered questionnaire) and with general health indicators including BMI, waist circumference, resting heart rate, and blood pressure in 182 subjects in Prince Edward Island, Canada. Study participants were volunteer employees recruited from five workplaces where, in general, the job types were moderately or highly sedentary. RESULTS: Steps/day were 7230 +/- SD 3447 for women (n = 153) and 8265 +/- 2849 (n = 21) for men. Pedometer-determined steps/day were associated inversely with BMI (r = -0.4005, p < 0.0001) in all participants and waist circumference in females only (r = -0.4303, p < 0.0001). There was a low correlation between steps/day and diastolic blood pressure in the whole sample (r = -0.2140, p = 0.0383). Participants who reported a prior diagnosis of one or more components of the metabolic syndrome (hypertension, hypercholesterolemia, heart disease, or type 2 diabetes) took fewer steps/day than healthy participants (p = 0.0254). Pedometer-determined steps/day were positively associated with self-reported occupational activity (p = 0.0002). DISCUSSION: Fewer steps/day are associated with increased BMI, waist circumference, diastolic blood pressure, and components of the metabolic syndrome. Low occupational activity is a contributing factor to low total ambulatory activity.

Associations between indicators of livestock farming intensity and incidence of human Shiga toxin-producing Escherichia coli infection.

The impact of livestock farming on the incidence of human Shiga toxin-producing Escherichia coli (STEC) infection was assessed by using several livestock density indicators (LDI) that were generated in a systematic approach. A total of 80 LDI were considered suitable proxy measures for livestock density. Multivariate Poisson regression identified several LDI as having a significant spatial association with the incidence of human STEC infection. The strongest associations with human STEC infection were the ratio of beef cattle number to human population and the application of manure to the surface of agricultural land by a solid spreader and by a liquid spreader. This study demonstrates the value of using a systematic approach in identifying LDI and other spatial predictors of disease.