Len Kelly

Invasive Haemophilus influenzae Disease Caused by Non-Type b Strains in Northwestern Ontario, Canada, 2002–2008

A high incidence of invasive non-type b Haemophilus influenzae disease was found in Northwestern Ontario, Canada; H. influenzae type a was the most prevalent serotype (42%). Clinical and demographic analyses indicate that aboriginal children aged <5 years and adults with predisposing medical conditions are the most affected by invasive H. influenzae disease in the post-H. influenzae vaccine era.

Invasive disease caused by Haemophilus influenzae type a in Northern Ontario First Nations communities.

Seven epidemiologically unrelated cases of invasive Haemophilus influenzae type a (Hia) disease were identified in First Nations communities of Northwestern Ontario, Canada, in 2004-2008. In all cases, Hia was isolated from blood. The clinical presentation in most of the cases was moderately severe and all patients responded to antibiotic therapy. Laboratory analysis of Hia isolates from Northwestern Ontario indicated striking similarities in their phenotypic and genotypic characteristics. The findings are discussed in the context of current epidemiology of invasive Hia disease. Our data along with some published studies by others suggest an increased susceptibility to this infection among North American indigenous populations.

Community-based Medical Education: Is Success a Result of Meaningful Personal Learning Experiences?

Background: Community-based medical education (CBME) is the delivery of medical education in a specific social context. Learners become a part of social and medical communities where their learning occurs. Longitudinal integrated clerkships (LICs) are year-long community-based placements where the curriculum and clinical experience is typically delivered by primary care physicians. These programs have proven to be robust learning environments, where learners develop strong communication skills and excellent clinical reasoning. To date, no learning model has been offered to describe CBME. Methods: The characteristics of CBME are explored by the authors who suggest that the social and professional context provided in small communities enhances medical education. The authors postulate that meaningfulness is engendered by the authentic context, which develops over time. These relationships with preceptors, patients and the community provide meaningfulness, which in turn enhances learning. Results and Discussion: The authors develop a novel learning model. They propose that the context-rich environment of CBME allows for meaningful relationships and experiences for students and that such meaningfulness enhances learning.

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population

Objectives To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population. Setting A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada. Participants A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities. Outcomes The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres. Results No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy. Conclusions Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

Community-associated methicillin-resistant Staphylococcus aureus in northwest Ontario: A five-year report of incidence and antibiotic resistance

BACKGROUND The incidence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is traditionally high in remote areas of Canada with large Aboriginal populations. Northwestern Ontario is home to 28,000 First Nations people in more than 30 remote communities; rates of CA-MRSA are unknown. OBJECTIVE To determine the CA-MRSA rates and antibiotic susceptibilities in this region. METHODS A five-year review of laboratory and patient CA-MRSA data and antibiotic susceptibility was undertaken. RESULTS In 2012, 56% of S aureus isolates were CA-MRSA strains, an increase from 31% in 2008 (P=0.06). Reinfection rates have been increasing faster than new cases and, currrently, 25% of infections are reinfections. CA-MRSA isolates continue to be susceptible to many common antibiotics (nearly 100%), particularly trimethoprim/sulfamethoxazole, clindamycin and tetracycline. Erythromycin susceptibility stands at 58%. DISCUSSION Rates of CA-MRSA, as a percentage of all S aureus isolates, were higher than those reported in other primary care series. The infection rate per 100,000 is one the highest reported in Canada. Antibiotic susceptibilities were unchanged during the study period; the 99% susceptibility rate to clindamycin differs from a 2010 Vancouver (British Columbia) study that reported only a 79% susceptibility to this antibiotic. CONCLUSION There are very high rates of CA-MRSA infections in northwestern Ontario. Disease surveillance and ongoing attention to antibiotic resistance is important in understanding the changing profile of MRSA infections. Social determinants of health, specifically improved housing and sanitation, remain important regional issues.

Traditional First Nations Birthing Practices: Interviews With Elders in Northwestern Ontario

OBJECTIVES Traditionally, First Nations maternity care was provided by community-based midwives trained through apprenticeship. Obstetrical practices and beliefs were integrated to provide holistic care. The Sioux Lookout Meno Ya Win Health Centre has a mandate to be a centre of excellence for Aboriginal health care. We undertook a literature review and performed a qualitative research study to understand some of the traditional practices in maternity care. METHODS We conducted qualitative semi-structured interviews in English and Oji-Cree with 12 elders who had knowledge and experience of historical birthing practices in their home communities. Research team members included nursing and medical personnel and Anishinabe First Nation members. Interviews were analyzed and themes developed and verified by member checking and triangulation. RESULTS The hands-on training for a community-based midwife often began in her teenage years with observation of childbirth practices. Practices were handed down by oral tradition and included prescriptions for healthy diet and moderate exercise during pregnancy; intrapartum care with preparation of clean cloths, moss, and scissors; the involvement of certain supportive family and community members; careful attention to the sacred handling of the placenta and umbilical cord; and careful wrapping of the newborn in fur. Complications, sometimes fatal, included retained placentas and stillbirths. CONCLUSION The provision of modern maternity care to Aboriginal patients should include acknowledgement of, and respect for, traditional birthing practices. Facilities providing care for these patients should consult with the relevant Aboriginal communities to understand their needs and initiate appropriate programming.

Bronchiolitis and pneumonia requiring hospitalization in young first nations children in Northern Ontario, Canada.

Background: High rates of lower respiratory tract infection (LRTI), including bronchiolitis and pneumonia, have been reported in Inuit infants living in arctic Canada. We examined rates of LRTI in First Nations Canadian infants living in the Sioux Lookout Zone, in Northern Ontario. Methods: A retrospective review of hospital admissions for LRTI during a 5-year period, in patients <1 year of age was carried out at the Sioux Lookout Meno Ya Win Health Centre, an acute-care hospital that provides secondary care to 31 mainly isolated communities and the town of Sioux Lookout. Admission rates were compared with those in the province of Ontario, as a whole. Results: One-hundred and seventeen subjects were identified. The annualized rate of admission for nonbacterial LRTI was 44 per 1000 infants <1 year of age per year. This rate was significantly higher than for the whole province (P = 0.011). Admission rates also varied significantly between communities (P < 0.001).Thirteen percent of subjects required transfer to a tertiary care center. A virus was identified in 55% (36/65) of subjects tested for respiratory viruses, and respiratory syncytial virus and parainfluenza virus were identified most often. Of patients who had a blood culture performed, bacteria were found in 10% (6/59) of subjects. Many patients had radiographic evidence of consolidation, consistent with pneumonia. Conclusions: Rates of LRTI are significantly elevated in First Nations infants living in the Sioux Lookout Zone. Varying rates between communities suggest that environmental factors may be contributing to rates of LRTI in this population.

Epidemiology of invasive pneumococcal and Haemophilus influenzae diseases in Northwestern Ontario, Canada, 2010–2015

INTRODUCTION North American indigenous populations experience a high burden of invasive bacterial infections. Because Streptococcus pneumoniae and Haemophilus influenzae have multiple antigenic variants, the existing vaccines cannot prevent all cases. This study addresses the current epidemiology of invasive H. influenzae and pneumococcal disease (IPD) in a region of Northwestern Ontario, Canada with a relatively high (82%) indigenous population. METHODS Data were retrieved from a retrospective chart review at a hospital servicing a population of 29000 (82% indigenous), during January 2010-July 2015. RESULTS Ten cases of invasive H. influenzae disease and 37 cases of IPD were identified. The incidence of both in the study population (6.3 and 23.1/100000/year, respectively) exceeded national rates (1.6 and 9.0/100000/year). H. influenzae serotype a (Hia) was the most common (50%), followed by non-typeable H. influenzae (20%). In adults, 77% of IPD cases were caused by serotypes included in the 23-valent pneumococcal polysaccharide vaccine. All paediatric IPD cases were caused by serotypes not included in the 13-valent pneumococcal conjugate vaccine. The case-fatality rate was 10% for invasive H. influenzae and 2.7% for IPD. Most cases exhibited substantial co-morbidity. CONCLUSIONS In Northwestern Ontario, the incidence of invasive Hia disease exceeds that of H. influenzae type b (Hib) in the pre-Hib vaccine era. This provides strong support for the development of a new Hia vaccine. Improved pneumococcal vaccination of high-risk adults in the region is warranted.

Nonpharmacological management of neonatal abstinence syndrome: a review of the literature

Abstract Background: Infants with neonatal abstinence syndrome (NAS) experience withdrawal that occurs as a result of termination of placental opioid supply following delivery. Common symptoms include restlessness, tremors, agitation and gastrointestinal disturbances. Severe NAS is often treated using opioids and/or sedatives. Although commonly employed effectively in neonatal care, there is a lack of published information regarding nonpharmacological management of the NAS infant. Objective: The purpose of this review was to summarize the current literature on nonpharmacological management of NAS. Methods: A literature search of Medline and EMBASE was performed for articles published between 2000 and June 2107. Results: Nonpharmacological management encompasses “environmental control”, “feeding methods”, “social integration”, “soothing techniques” and “therapeutic modalities”. Several interventions, including: breastfeeding, swaddling, rooming-in, environmental control and skin to skin contact have proven to be effective in managing NAS and should be incorporated into standard of care for this population (Level I–III Evidence). These interventions can be effective when offered in combination with pharmacological therapy, or as stand-alone therapy for less severe cases of NAS (Finnegan score <8). Conclusions: Given the increasing body of evidence on its efficacy and ease of implementation, nonpharmacological treatment should universally be incorporated into standard of care for NAS.

A 5 year retrospective study of emergency department use in Northwest Ontario: a measure of mental health and addictions needs

OBJECTIVE The main objective of this study was to understand the five-year trend in total emergency department (ED) visits, frequency of use, and diagnoses and disposition of patients. Since the region has experienced a profound increase in opioid use disorder since 2009, we were particularly interested in changes in the volume of mental health and addiction (MHA) ED presentations. METHODS Retrospective aggregate data analysis of ED visits to the Sioux Lookout Meno Ya Win Health Centre 2010-2014. RESULTS ED visit volume increased 29% over the five-year study period, while MHA ED visits increased 73%. The admission rate remained stable at 6.9% of ED visits. Five-year trends in clinically grouped diagnostic categories identified respiratory, MHA, and abdominal/pelvic complaints as the three most common ED presentations. In 2014, MHA presentations accounted for 10.3% of ED visits, 8.7% of admissions, and 20.0% of inter-hospital transfers. CONCLUSION The dramatic increase in MHA ED visits mirrors the opioid epidemic the region is experiencing. MHA may soon become the commonest ED presentation. If reasons for ED visits serve as a proxy for unmet outpatient needs, increased efforts at developing community MHA services and addressing the related social determinants of health are required.