Healing journey: Experiences of First Nations individuals with recovery from opioid use.

OBJECTIVE: To understand experiences of recovery from opioid use among First Nations individuals living in a small remote community. DESIGN: Qualitative phenomenologic study. SETTING: Northwestern Ontario. PARTICIPANTS: Sixteen First Nations individuals living in a remote community who had participated in or completed the community opioid agonist therapy program. METHODS: Extensive community consultation took place to ensure local acceptance of the study and permission for publication. Semistructured telephone interviews with consenting participants were audiorecorded between November and December 2021 and transcribed. Transcripts were reviewed and discussed in meetings with Indigenous and non-Indigenous research team members who conducted thematic analysis using immersion and crystallization. MAIN FINDINGS: Participants described their opioid use as a form of self-management of trauma. Their recovery processes were multifaceted and included developing cultural and self-awareness. Motivation for change often arose from concerns about family well-being and finances. Traditional cultural practices and time spent on the land were identified as important wellness experiences. Barriers to healing included limited clinical and holistic addiction services, particularly around dose weaning and opioid agonist therapy discontinuation. CONCLUSION: Community-based addiction programming for First Nations patients needs to be robust. It requires resources for trauma-informed clinical and addiction care, culturally appropriate addictions education, aftercare support, and land-based activities.

Skin morbidity in Indigenous children in relation to housing conditions in remote communities in Northwestern Ontario, Canada.

BACKGROUND: Elevated rates of eczema and skin infections in Canadian First Nation (FN) communities are of concern to families, community leaders and healthcare professionals. AIM: To determine whether skin morbidity was associated with indoor environmental quality factors in Canadian FN children living in remote communities. METHODS: We quantified indoor environmental quality (IEQ) in the homes of FN children aged < 4 years of age living in four remote communities in the Sioux Lookout region of Northwestern Ontario, Canada. We conducted a quantitative housing inspection, including measuring surface area of mould (SAM), and monitored air quality for 5 days in each home, including carbon dioxide and relative humidity and quantified endotoxin in settled floor dust. We reviewed the medical charts of participating children for skin conditions and administered a health questionnaire. Relationships between IEQ and skin infections or eczema were evaluated using multivariable regression. RESULTS: In total, 98 children were included in the descriptive analyses, of whom 86 had complete data and were evaluated in multivariate analyses for dermatological outcomes (mean age 1.6 years). Of these 86 children, 55% had made ≥ 1 visits to the local health centre (HC) for skin and soft tissue infections and 25.5% for eczema. Unexpectedly, annualized eczema visits were inversely associated with SAM (RR = 0.14; 95% CI 0.01-0.93). There was a trend suggesting an inverse relationship between endotoxin and HC encounters for eczema and skin and soft tissue infections. CONCLUSION: Skin infections were common in this population of FN children. IEQ did not appear to be associated with skin infections or eczema. Mould exposure appeared to be inversely associated with HC encounters for eczema, possibly related to complex microorganism-host interactions occurring early in life.

Housing conditions and respiratory morbidity in Indigenous children in remote communities in Northwestern Ontario, Canada.

BACKGROUND: Rates of lower respiratory tract infection (LRTI) among First Nations (FN) children living in Canada are elevated. We aimed to quantify indoor environmental quality (IEQ) in the homes of FN children in isolated communities and evaluate any associations with respiratory morbidity. METHODS: We performed a cross-sectional evaluation of 98 FN children (81 with complete data) aged 3 years or younger, living in 4 FN communities in the Sioux Lookout region of Northern Ontario. We performed medical chart reviews and administered questionnaires. We performed a housing inspection, including quantifying the interior surface area of mould (SAM). We monitored air quality for 5 days in each home and quantified the contaminant loading of settled floor dust, including endotoxin. We analyzed associations between IEQ variables and respiratory conditions using univariable and multivariable analyses. RESULTS: Participants had a mean age of 1.6 years and 21% had been admitted to hospital for respiratory infections before age 2 years. Houses were generally crowded (mean occupancy 6.6 [standard deviation 2.6, range 3-17] people per house). Serious housing concerns were frequent, including a lack of functioning controlled ventilation. The mean SAM in the occupied space was 0.2 m2. In multivariable modelling, there was evidence of an association of LRTI with log endotoxin (p = 0.07) and age (p = 0.02), and for upper respiratory tract infections, with SAM (p = 0.07) and age (p = 0.03). Wheeze with colds was associated with log endotoxin (p = 0.03) and age (p = 0.04). INTERPRETATION: We observed poor housing conditions and an association between endotoxin and wheezing in young FN children living in Northern Ontario.

Early Gestational Diabetes Mellitus Screening With Glycated Hemoglobin: A Systematic Review.

OBJECTIVE: This review sought to examine the association of HbA1c levels <6.5% in early pregnancy with the subsequent development of gestational diabetes mellitus (GDM) and adverse pregnancy outcomes. METHODS: A search of Medline and EMBASE was conducted for the period of January 1, 2000 to July 9, 2019 and the terms: "gestational diabetes or pregnancy diabetes mellitus" and "glycosylated hemoglobin or glycated hemoglobin A" and "pregnancy trimester, first, or first-trimester pregnancy," "screening or prenatal screening," "prenatal diagnosis or early diagnosis or prediction," "retrospective studies or prospective studies." Quality of evidence was assessed using the Newcastle-Ottawa scale. Inclusion criteria were: measurement of HbA1c <20 weeks gestation, the absence of pre-gestational diabetes mellitus, and analysis of HbA1c levels below 6.5%. The primary outcome evaluated was the development of GDM. Secondary outcomes were adverse pregnancy outcomes, including large-for-gestational-age birth weight, macrosomia, preterm birth, neonatal and perinatal death, congenital anomaly, preeclampsia, shoulder dystocia, and cesarean section. RESULTS: We screened 121 relevant abstracts. Thirty-two studies qualified for a full review, of which 11 met the eligibility criteria. All studies were assessed as high quality and found an increased risk of GDM with HbA1c levels >5.7. Levels >6.0 identified all patients who developed GDM. Adverse pregnancy outcomes were associated with elevated HbA1c levels in 4 of 6 studies and included preeclampsia, induced labour, shoulder dystocia, cesarean section, large-for-gestational-age birth weight, macrosomia, congenital anomalies, and perinatal death. Two studies found no association with adverse events. CONCLUSION: HbA1c levels between 5.7% and 6.4% in early pregnancy consistently identified patients who went on to develop GMD. The evidence that particular levels are associated with adverse outcomes is less robust.

Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario.

OBJECTIVE: To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice. METHODS: Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores. RESULTS: The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average. CONCLUSION: The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

Intermittent fasting and weight loss: Systematic review.

OBJECTIVE: To examine the evidence for intermittent fasting (IF), an alternative to calorie-restricted diets, in treating obesity, an important health concern in Canada with few effective office-based treatment strategies. DATA SOURCES: A MEDLINE and EMBASE search from January 1, 2000, to July 1, 2019, yielded 1200 results using the key words fasting, time restricted feeding, meal skipping, alternate day fasting, intermittent fasting, and reduced meal frequency. STUDY SELECTION: Forty-one articles describing 27 trials addressed weight loss in overweight and obese patients: 18 small randomized controlled trials (level I evidence) and 9 trials comparing weight after IF to baseline weight with no control group (level II evidence). Studies were often of short duration (2 to 26 weeks) with low enrolment (10 to 244 participants); 2 were of 1-year duration. Protocols varied, with only 5 studies including patients with type 2 diabetes. SYNTHESIS: All 27 IF trials found weight loss of 0.8% to 13.0% of baseline weight with no serious adverse events. Twelve studies comparing IF to calorie restriction found equivalent results. The 5 studies that included patients with type 2 diabetes documented improved glycemic control. CONCLUSION: Intermittent fasting shows promise for the treatment of obesity. To date, the studies have been small and of short duration. Longer-term research is needed to understand the sustainable role IF can play in weight loss.

Effects of opioid use in pregnancy on pediatric development and behaviour in children older than age 2: Systematic review.

OBJECTIVE: To summarize information on the effects of opioid use in pregnancy on subsequent pediatric development and behaviour. DATA SOURCES: Searches were performed in EMBASE, MEDLINE, and PsycINFO for peer-reviewed, English articles, including a manual search of their references, that were published between January 1, 2000, and May 1, 2018. STUDY SELECTION: Of the 543 articles reviewed, 19 relevant articles that focused on developmental effects of opioid exposure in utero were identified. Most of the studies provided level II evidence. One level I meta-analysis and 1 level III expert committee report were included. SYNTHESIS: The literature was divided between documenting some level of impairment or normalization of early development deficits over time. Often no opioid effect was found once researchers controlled for socioenvironmental factors. The degree to which environmental factors, opioid exposure, or both affect pediatric development remains to be determined. CONCLUSION: The effect of maternal opioid use on pediatric development is unclear and the evidence is inconsistent. However, opioid exposure in pregnancy does define these children as a population at risk. They might experience developmental delays compared with their peers, yet remain within population norms in cognition, fine-motor skills, hand-eye coordination, executive function, and attention and impulsivity levels.

Maternal-Fetal Monitoring of Opioid-Exposed Pregnancies: Analysis of a Pilot Community-Based Protocol and Review of the Literature.

OBJECTIVES: To describe/analyse a novel, community-based prenatal monitoring protocol for opioid-exposed pregnancies developed by our centre in 2014 to optimize prenatal care for this population. A literature review of published monitoring protocols for this population is also presented. METHODS: Retrospective comparison of pre-protocol (n = 215) and post-protocol (n = 251) cohorts. Medline and Embase were searched between 2000-2016 using MeSH terms: [fetal monitoring OR prenatal care] AND [opioid-related disorders OR substance-related disorders] in Medline and [fetal monitoring OR prenatal care] AND [opiate addiction OR substance abuse] in Embase, producing 518 results. Thirteen studies included protocols for monitoring opioid-exposed pregnancies. No comprehensive monitoring protocols with high-quality supporting evidence were found. RESULTS: We evaluated 466 opioid-exposed pregnancies, 215 before and 251 after introduction of the protocol. Since implementation, there was a significant increase in the number of opioid-exposed patients who have underwent urine drug screening (72.6% to 89.2%, P < 0.0001); a significant reduction in the number of urine drug screenings positive for illicit opioids (50.2% to 29.1%, P < 0.0001); and a significant increase in the number of patients who discontinued illicit opioid use by the time of delivery (24.7% to 39.4%, P < 0.01). There was no difference in the CS rate (27.4% vs. 26.3%, P > 0.05). There were no observed differences in the rate of preterm birth, birth weight <2500 g, or Apgar score <7 (P > 0.05). CONCLUSIONS: Care of women with increased opioid use during pregnancy is an important but under-studied health issue. A novel protocol for focused antenatal care provision for women with opioid-exposed pregnancies improves standard of care and maternal/fetal outcomes.