Seropositivity to SARS-CoV-2 in Alberta, Canada in a post-vaccination period (March 2021-July 2021).

BACKGROUND: The COVID-19 pandemic has necessitated the need to rapidly make public health decisions. We systematically evaluated SARS-CoV-2 seropositivity to understand local COVID-19 epidemiology and support evidence-based public health decision making. METHODS: Residual blood samples were collected for SARS-CoV-2 receptor binding domain (RBD) IgG testing over a 1-5 day period monthly from 26 February 2021-9 July 2021 from six clinical laboratories across the province of Alberta, Canada. Monthly crude and adjusted (for age and gender) seropositivity were calculated. Results were linked to provincial administrative, laboratory, and vaccine databases. RESULTS: 60,632 individual blood samples were tested. Vaccination data were available for 98.8% of samples. Adjusted RBD IgG positivity rose from 11.9% (95% confidence interval [CI] 11.9-12.0%) in March 2021 to 70.2% (95% CI 70.2-70.3%) in July 2021 (p < .0001). Seropositivity rose from 9.4% (95% CI 9.3-9.4%) in March 2021 to 20.2% (95% CI 20.1-20.2%) in July 2021 in unvaccinated Albertans. Unvaccinated seropositive individuals were from geographic areas with significantly (p < .001) lower median household income, lower proportion of married/common-law relationships, larger average household size and higher proportions of visible minorities compared to seronegative unvaccinated individuals. In July 2021, the age groups with the lowest and highest seropositivity in unvaccinated Albertans were those ≥80 years (12.0%, 95% CI 5.3-18.6%) and 20-29 years (24.2%, 95% CI 19.6-28.8%), respectively. Of seropositive unvaccinated individuals, 50.2% (95% CI 45.9-54.5%) had no record of prior SARS-CoV-2 molecular testing. CONCLUSIONS: Longitudinal surveillance of SARS-CoV-2 seropositivity with data linkage is valuable for decision-making during the pandemic.

Meaning-Making of Motherhood Among Mothers With Substance Abuse Problems.

Previous literature has documented the unique challenges encountered by mothers with substance abuse problems, which may hinder the ability to fulfill parenting responsibilities. Since there is evidence suggesting the engagement in meaning-making processes can help individuals reinterpret their transitions into parenthood and cope with parental stress, this study examined the meaning-making processes of motherhood among mothers with substance abuse problems. Sixteen Hong Kong Chinese mothers with a history of substance abuse were purposively selected and invited to narrate their life and maternal experiences in individual interviews. Based on the meaning-making model in the context of stress and coping, whereby global meaning refers to orienting system of an individual and situational meaning refers to the meaning one attributes to a particular situation, the global and situational meanings of participants related to motherhood and substance use, and their reappraised meanings in response to the discrepancies between global and situational meanings were analyzed. Using thematic analysis, the results showed that when faced with an internal conflict between global and situational meanings induced by substance abuse, most participants engaged in the meaning-making process of assimilation. Rather than changing their inherent parental beliefs and values, most participants adjusted their appraisals toward the situation, and hence made changes in their cognitions or behaviors such as making efforts to quit substance use or reprioritizing their parenting responsibilities. The analysis further revealed that being a mother provided a significant source of meaning to the participants in confronting highly stressful mothering experiences induced by substance abuse. Altogether, the findings suggest that a meaning-making approach may have benefits and implications for helping this population reorganize their self-perceptions, gain a clearer sense of future direction in motherhood, and achieve more positive life and parenting outcomes.

Pre-Vaccine Positivity of SARS-CoV-2 Antibodies in Alberta, Canada during the First Two Waves of the COVID-19 Pandemic.

We systematically evaluated SARS-CoV-2 IgG positivity in a provincial cohort to understand the local epidemiology of COVID-19 and support evidence-based public health decisions. Residual blood samples were collected for serology testing over 5-day periods monthly from June 2020 to January 2021 from six clinical laboratories across the province of Alberta, Canada. A total of 93,993 individual patient samples were tested with a SARS-CoV-2 nucleocapsid antibody assay with positives confirmed using a spike antibody assay. Population-adjusted SARS-CoV-2 IgG seropositivity was 0.92% (95% confidence interval [CI]: 0.91 to 0.93%) shortly after the first COVID-19 wave in June 2020, increasing to 4.63% (95% CI: 4.61 to 4.65%) amid the second wave in January 2021. There was no significant difference in seropositivity between males and females (1.39% versus 1.27%; P = 0.11). Ages with highest seropositivity were 0 to 9 years (2.71%, 95% CI: 1.64 to 3.78%) followed by 20 to 29 years (1.58%, 95% CI: 1.12 to 2.04%), with the lowest rates seen in those aged 70 to 79 (0.79%, 95% CI: 0.65 to 0.93%) and >80 (0.78%, 95% CI: 0.60 to 0.97%). Compared to the seronegative group, seropositive patients inhabited geographic areas with lower household income ($87,500 versus $97,500; P < 0.001), larger household sizes, and higher proportions of people with education levels of secondary school or lower, as well as immigrants and visible minority groups (all P < 0.05). A total of 53.7% of seropositive individuals were potentially undetected cases with no prior positive COVID-19 nucleic acid test (NAAT). Antibodies were detectable in some patients up to 9 months post positive NAAT result. This seroprevalence study will continue to inform public health decisions by identifying at-risk demographics and geographical areas. IMPORTANCE Using SARS-CoV-2 serology testing, we assessed the proportion of people in Alberta, Canada (population 4.4 million) positive for COVID-19 antibodies, indicating previous infection, during the first two waves of the COVID-19 pandemic (prior to vaccination programs). Linking these results with sociodemographic population data provides valuable information as to which groups of the population are more likely to have been infected with the SARS-CoV-2 virus to help facilitate public health decision-making and interventions. We also compared seropositivity data with previous COVID-19 molecular testing results. Absence of antibody and molecular testing were highly correlated (95% negative concordance). Positive antibody correlation with a previous positive molecular test was low, suggesting the possibility of mild/asymptomatic infection or other reasons leading individuals from seeking medical attention. Our data highlight that the true estimate of population prevalence of COVID-19 is likely best informed by combining data from both serology and molecular testing.

Dataset of test volume and tests repeated for complete blood count and electrolyte panels from hospitals in a Canadian province in 2018.

All laboratory tests performed within the province of Alberta in Canada are captured by three Laboratory Information Systems (LIS; Millennium, Sunquest and Meditech), which comprise the provincial Consolidated Laboratory Data Repository (CLDR). The following secondary laboratory data for electrolyte panel (EP) and complete blood count (CBC) test panels performed in emergency room (ER) and inpatient settings were collected from January 1 - December 31, 2018: total test panel volume, total number of test panels repeated, number of test panels repeated within the 24 hour period, test result, date of testing, time of test, and patient Provincial Health Number (PHN). Patient PHN were used as a linking variable to match subsequent tests performed on the same patient. The first time a test was recorded per patient was defined as the "index test". If the same test panel was performed within a 24-h period following the index test for the patient, data for the repeated test panel was also collected. The index test was defined as "normal" or "abnormal" according to established laboratory normal values and laboratory test reference ranges. For CBCs, we considered the panel to be abnormal if any of the hematocrit (Hct), hemoglobin (Hgb), mean corpuscular hemoglobin concentration (MCHC), mean corpuscular volume (MCV), platelet (PLT), red blood cell (RBC), red cell distribution width (RDW) or white blood cell (WBC) values were outside the normal laboratory reference range. For electrolyte panels, we considered the panel to be abnormal if any of the chloride (Cl), potassium (K), and sodium (Na) were outside of the normal laboratory reference range. All EP results were from clinical chemistry analyzers only. The reuse potential of this dataset can allow other jurisdictions in Canada to compare their redundant repeat testing in their hospital settings with this dataset as a benchmark. This article was submitted via another Elsevier journal as a co-submission ("Inappropriate repeat testing of complete blood count (CBC) and electrolytes in inpatients from Alberta, Canada" [1]), and readers should refer to the co-submission article for interpretation of the results.

Inappropriate repeat testing of complete blood count (CBC) and electrolyte panels in inpatients from Alberta, Canada.

INTRODUCTION: The avoidance of repeat chemistry testing such as Complete Blood Count (CBC) and Electrolyte Panel (EP) on clinically stable patients was identified as important utilization goals by Choosing Wisely Canada. The purpose of this study was to assess the volume of overutilization of CBC and EP in an inpatient setting in Alberta, Canada, and provide an estimated cost assessment of unnecessary testing. METHODS: The total laboratory testing volumes of two common test panels were collected retrospectively for one-year from January to December 2018. Data was collected on test panels performed in an emergency room (ER) and inpatient setting from three separate Laboratory Information Systems covering the provincial population in Alberta, Canada. Total initial test panel instances, total repeated panels, repeated panels that were previously normal or abnormal, and estimated costs were examined. Cost assessment was completed based on Reference Median Cost (RMC) analysis for each of these two common test panels. RESULTS: During the study period, 2,020,467 (CBC) and 1,455,983 (EP) initial test panel instances were recorded, of which 67.7% and 73.5% were repeated for the CBC and EP, respectively. There was a higher proportion of EP repeated inappropriately (previously normal; 35.6%) compared to CBCs (5.4%). The cost to the province for inappropriately repeating CBC and EP were estimated to be RMC $0.52 million and RMC $1.90 million CAD, respectively. CONCLUSION: Results from this study can assist policy makers in implementing utilization management initiatives and update clinical practice guidelines to reduce costs to healthcare without compromising patient care.

Implementation of an educational province-wide intervention to reduce redundant vitamin B12 testing: A cross-sectional study.

INTRODUCTION: We describe the implementation of an Alberta-wide intervention aimed at educating clinicians about redundant vitamin B12 testing. We hypothesized that the introduction of an educational comment outlining recommended vitamin B12 test intervals would reduce the annual number of vitamin B12 tests performed. MATERIALS AND METHODS: We performed a cross-sectional observational study that included all vitamin B12 tests ordered in Alberta between May 1, 2017 and April 30, 2018. An educational comment was appended to all vitamin B12 test results in Alberta beginning May 2, 2017. Using a simple seasonal model, we compared predicted versus observed vitamin B12 test volumes for the 12-month period following the introduction of the educational comment. The sole outcome measured was the monthly change in volume of vitamin B12 testing. A cost-analysis of the effects of the intervention on test volumes was also performed. RESULTS: Over the sum of the first 12 months of the intervention, 18,000 more vitamin B12 tests were ordered compared to the predicted value in Alberta. With an estimated cost of $7 per test, this resulted in a $126,000 increase in costs for vitamin B12 testing provincially. CONCLUSIONS: An educational intervention aimed at limiting inappropriate vitamin B12 testing in Alberta did not alter testing as desired. Multiple utilization management strategies and a longer observation period may be needed to reduce redundant vitamin B12 testing.

Vitamin B12 test volume data before and after the implementation of an educational province-wide intervention to reduce redundant testing in Alberta.

The data presented in this article is the provincial vitamin B12 test volume data for Alberta, Canada per month between April 1, 2015 and April 30, 2018. This data set was collected from the three different Alberta Public Laboratories Laboratory Information Systems: Cerner Millennium for Calgary, Sunquest for Edmonton, and MediTech for the remaining rural zones of Alberta (Bonnyville, Grand Prairie, Camrose, Red Deer, and Medicine Hat). An educational province-wide intervention aimed at reducing redundant testing was implemented on April 11, 2017 in Calgary, Alberta and Edmonton, Alberta and on May 2, 2017 in rural Alberta sites. All vitamin B12 test results in Alberta were appended with the educational comment "A normal test result indicates adequate stores and should not be repeated. However, if specific clinical situations require re-testing, the interval should not be sooner than 1 year." Provincial monthly test volumes prior to this intervention ranged from 54,182 to 73,522 tests per month and after this intervention ranged from 59,116 to 74,006 tests per month. The total number of vitamin B12 tests ordered over the 37 months in Alberta was 2,444,724; 690,448 tests were ordered in Calgary, 1,029,315 tests were ordered in Edmonton, and 724,961 tests were ordered in rural sites. This data article was submitted as a companion paper to the related research article, "Implementation of an educational province-wide intervention to reduce redundant vitamin B12 testing: a cross-sectional study"[1].

Test volume data for 51 most commonly ordered laboratory tests in Calgary, Alberta, Canada.

Data presented in this article include the top 51 ordered laboratory tests in Calgary and surrounding area, Alberta, from January to December 2017. This data set was collected from Calgary Laboratory Service's Laboratory Information System, and included top 51 tests ordered from community (n = 11, 224, 330), inpatient (n = 2,340,594) and emergency (n = 1,670,062) settings. Test order mnemonic that were not true laboratory tests (eg: "extra PST tube", "extra tube", etc.) were excluded in the analysis. The top test ordered in all 3 test encounters was the complete blood count test (community encounter, n = 921, 873; inpatient setting, n = 357, 375; and emergency setting, n = 276, 954). This data article was submitted as a companion paper to the related research article, "Estimated costs of 51 commonly ordered laboratory tests in Canada" [1].

Estimated costs of 51 commonly ordered laboratory tests in Canada.

INTRODUCTION: Test cost display has been shown to reduce inappropriate laboratory test ordering practices in the United States. Unfortunately, such a system is limited in the Canadian publically funded healthcare environment. Many Canadian physicians inaccurately estimate the cost of laboratory tests, which may contribute to mis-utilization. Here, we provide an estimated cost of over 50 commonly ordered laboratory tests in Canada as an educational tool for physicians. METHODS: Test volume data was collected from Calgary Laboratory Services' Laboratory Information System in order to determine which laboratory and diagnostic tests are most commonly ordered in Calgary and its surrounding area. Reference median cost (RMC) of fifty one commonly ordered test was calculated by determining the price list of all-inclusive indirect costs from six different clinical laboratories across Canada. RESULTS: Of the 51 laboratory tests included, the minimum RMC was $5 CAD (eg: albumin, calcium, urea), and the maximum RMC was $300 (surgical pathology report). CONCLUSIONS: A caveat to the provided list of test costs is that it is only an estimate and may differ from what each individual clinical laboratories charges to third parties or for research purposes. However, this list can serve as an educational tool and raise awareness for Canadian physicians on the relative costs of laboratory tests.

Severe ischemic cytomegalovirus proctocolitis with multiple perforation.

Cytomegalovirus (CMV) typically causes gastrointestinal infections in immunocompetent patients. Colonic perforations secondary to CMV are exceeding rare. We describe a 88-year-old male presenting with a week-long history of intractable abdominal discomfort, bloating, nausea and diarrhea. Flexible sigmoidoscopy revealed significant ulceration with yellowish slough. Emergency surgery was performed subsequently in view of multiple perforations in the rectosigmoid junction. CMV gastrointestinal infections demonstrated an ischemic process secondary to vasculitis, which accelerated the pathway to colonic perforation. CMV gastrointestinal infection should be considered as a differential diagnosis in patients with colonoscopy findings similar to ischemic colitis and Clostridium difficile infections.

Canadian family physician knowledge and attitudes toward laboratory utilization management.

OBJECTIVES: Mitigation of unnecessary and redundant laboratory testing is an important quality assurance priority for laboratories and represents an opportunity for cost savings in the health care system. Family physicians represent the largest utilizers of laboratory testing by a large margin. Engagement of family physicians is therefore key to any laboratory utilization management initiatives. Despite this, family physicians have been largely excluded from the planning and implementation of such initiatives. Our purposes were to (1) assess the importance of lab management issues to family physicians, and (2) attempt to define the types of initiatives most acceptable to family physicians. DESIGN AND METHODS: We invited all Alberta family practice residents and practicing physicians to participate in a self-administered online electronic survey. Survey questions addressed the perceived importance of lab misutilization, prevalence of various types of misutilization, acceptability of specific approaches to quality control, and responsibility of various parties to address this issue. RESULTS: Of 162 respondents, 95% considered lab misutilization to be either important or very important. Many physicians placed the responsibility for addressing lab misutilization issues on multiple parties, including patients, but most commonly the ordering physician (97%). Acceptability for common strategies for quality improvement in lab misutilization showed a wide range (35%-98%). CONCLUSIONS: These responses could serve as a framework for laboratories to begin discussions on this important topic with primary care groups.

Morning colonoscopies are associated with improved adenoma detection rates.

BACKGROUND: Higher adenoma detection rates are associated with decreased risks for subsequent colorectal cancers. Studies have suggested that adenoma detection rate (ADR) may be affected by timing of colonoscopy due to endoscopist fatigue later in the day. The aim of our study is to assess the influence of the timing variables on ADR. METHODS: Univariate analysis and multivariate logistic regression analysis were performed on a prospective colonoscopy database, comparing ADR for colonoscopies performed in the morning shift (AM) and in the afternoon shift (PM) over a 1-year period. Each shift lasted 4 h. Only elective outpatient completed colonoscopies with adequate bowel preparation, performed by four certified staff endoscopists, were included. Surveillance colonoscopies for cancers were excluded. ADR was defined as the detection of at least one histologically confirmed polyp during colonoscopy. RESULTS: A total of 533 colonoscopies were included. ADR was 25 % in the cohort. Mean age was 59 (SD 14.1). Two hundred and seventy (50.6 %) were done in the AM and 263 (49.4 %) were done in the PM. ADR was 29 % in the AM group compared to 21 % in the PM group (p = 0.03). Excluding time needed for polypectomy, the mean time taken for scope withdrawal was significantly longer in the morning group (12 min) compared with the afternoon group (10 min) (p = 0.002). The longer withdrawal time in the morning was significantly associated with increased ADRs (OR 1.104, 95 % CI 1.063-1.147) (p < 0.0001). CONCLUSION: Timing of colonoscopy is an independent predictor for ADR. Colonoscopies performed in the morning have a longer mean withdrawal time, thus leading to a significantly higher ADR. As endoscopists concentration decreases as the day progresses, this may account for the shorter time spent on colonoscopies on the afternoon.

Bacterial ferrous iron transport: the Feo system.

To maintain iron homeostasis within the cell, bacteria have evolved various types of iron acquisition systems. Ferric iron (Fe(3+)) is the dominant species in an oxygenated environment, while ferrous iron (Fe(2+)) is more abundant under anaerobic conditions or at low pH. For organisms that must combat oxygen limitation for their everyday survival, pathways for the uptake of ferrous iron are essential. Several bacterial ferrous iron transport systems have been described; however, only the Feo system appears to be widely distributed and is exclusively dedicated to the transport of iron. In recent years, many studies have explored the role of the FeoB and FeoA proteins in ferrous iron transport and their contribution toward bacterial virulence. The three-dimensional structures for the Feo proteins have recently been determined and provide insight into the molecular details of the transport system. A highly select group of bacteria also express the FeoC protein from the same operon. This review will provide a comprehensive look at the structural and functional aspects of the Feo system. In addition, bioinformatics analyses of the feo operon and the Feo proteins have been performed to complement our understanding of this ubiquitous bacterial uptake system, providing a new outlook for future studies.

The impact of preoperative serum anti-TNFα therapy levels on early postoperative outcomes in inflammatory bowel disease surgery.

OBJECTIVE: Assess the impact of preoperative serum antitumor necrosis factor-α (anti-TNFα) drug levels on 30-day postoperative morbidity in inflammatory bowel disease (IBD) patients. BACKGROUND: Studies on the association of anti-TNFα drugs and postoperative outcomes in IBD are conflicting due to variable pharmacokinetics of anti-TNFα drugs. It remains to be seen whether preoperative serum anti-TNFα drug levels correlate with postoperative morbidity. METHODS: Thirty-day postoperative outcomes of consecutive IBD surgical patients with serum drawn within 7 days preoperatively were studied. The total serum level of 3 anti-TNFα drugs (infliximab, adalimumab, and certolizumab) was measured, with ≥ 0.98 µg/mL considered as detected. Data were also reviewed according to a clinical cutoff value of 3 µg/mL. RESULTS: A total of 217 patients [123 with Crohn disease (CD) and 94 with ulcerative colitis (UC)] were analyzed; 75 of 150 (50%) treated with anti-TNFα therapy did not have detected levels at the time of surgery. In the UC cohort, adverse postoperative outcome rates between the undetectable and detectable groups were similar when stratified according to type of UC surgery. In the CD cohort, there was a higher but statistically insignificant rate of adverse outcomes in the detectable versus undetectable groups. Using a cut off level of 3 µg/mL, postoperative morbidity (odds ratio [OR] = 2.5, P = 0.03) and infectious complications (OR = 3.0, P = 0.03) were significantly higher in the ≥ 3 µg/mL group. There were higher rates of postoperative morbidity (P = 0.047) and hospital readmissions (P = 0.04) in the ≥ 8 µg/mL compared with <3 µg/mL group. CONCLUSIONS: Increasing preoperative serum anti-TNFα drug levels are associated with adverse postoperative outcomes in CD but not UC patients.

Unusual cause of pneumomediastinum in a laparoscopic extraperitoneal inguinal hernia repair.

Pneumomediastinum is an extremely rare complication after laparoscopic inguinal hernia repair. Very few cases have been reported in the surgical literature to date and most reports indicate pneumoperitoneum from the transabdominal preperitoneal approach as a causative factor. This case report describes a patient in whom an elective total extraperitoneal inguinal hernia repair was complicated by a pneumomediastinum without concomitant pneumoperitoneum, and identifies the tracking of air along the anterior extraperitoneal space and endothoracic fascia as a cause. Previous case reports were reviewed and possible etiologies are discussed.

Early use of low residue diet is superior to clear liquid diet after elective colorectal surgery: a randomized controlled trial.

OBJECTIVE: Compare the feasibility and patient tolerance to either a clear fluid (CF) or low residue diet (LRD) started on postoperative day (POD) 1 after elective colorectal surgery. BACKGROUND: Diet advancement after surgery traditionally starts gradually with liquids, on the basis of fears that early solid intake may increase nausea, vomiting, and overall complications. A randomized controlled trial comparing LRD and CF on POD 1 was performed. METHODS: 111 elective colorectal surgery patients were randomized to CF (n = 57) or LRD (n = 54). The primary end point was vomiting on POD 2. Secondary endpoints included nausea score, days to flatus, length of hospital stay (LOS), and postoperative morbidity. RESULTS: Patient characteristics, surgical technique, intraoperative characteristics, and postoperative opioid use were similar between study arms. CF versus LRD results were as follows: POD2 vomiting (28% vs 14%; P = 0.09), and significant increase in mean nausea score (4.7 vs 3.5; P = 0.01), days to flatus (4.8 vs 3.7 days; P = 0.04), and LOS (7.0 vs 5.0 days; P = 0.01). LOS remained significantly shorter even after adjusting for significant covariates (laparoscopic technique, surgical site, postoperative comorbidity, stoma, and nasogastric tube) with LRD patients having an adjusted 1.4-day decrease in LOS (P < 0.01). There was no significant difference in postoperative morbidity between study arms. Multivariate analysis of all secondary endpoints confirmed an overall significant improvement in outcomes for LRD vs CF (P < 0.01). CONCLUSIONS: LRD, rather than CF, on POD1 after colorectal surgery is associated with less nausea, faster return of bowel function, and a shorter hospital stay without increasing postoperative morbidity.

Delivery of bioactive lipids from composite microgel-microsphere injectable scaffolds enhances stem cell recruitment and skeletal repair.

In this study, a microgel composed of chitosan and inorganic phosphates was used to deliver poly(lactic-co-glycolic acid) (PLAGA) microspheres loaded with sphingolipid growth factor FTY720 to critical size cranial defects in Sprague Dawley rats. We show that sustained release of FTY720 from injected microspheres used alone or in combination with recombinant human bone morphogenic protein-2 (rhBMP2) improves defect vascularization and bone formation in the presence and absence of rhBMP2 as evaluated by quantitative microCT and histological measurements. Moreover, sustained delivery of FTY720 from PLAGA and local targeting of sphingosine 1-phosphate (S1P) receptors reduces CD45+ inflammatory cell infiltration, promotes endogenous recruitment of CD29+CD90+ bone progenitor cells and enhances the efficacy of rhBMP2 from chitosan microgels. Companion in vitro studies suggest that selective activation of sphingosine receptor subtype-3 (S1P3) via FTY720 treatment induces smad-1 phosphorylation in bone-marrow stromal cells. Additionally, FTY720 enhances stromal cell-derived factor-1 (SDF-1) mediated chemotaxis of CD90+CD11B-CD45- bone progenitor cells in vitro after stimulation with rhBMP2. We believe that use of such small molecule delivery formulations to recruit endogenous bone progenitors may be an attractive alternative to exogenous cell-based therapy.