Community-associated methicillin-resistant Staphylococcus aureus infection: Literature review and clinical update.

OBJECTIVE: To provide information on the prevalence and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections and the distinction between community-associated MRSA and health care-associated MRSA. QUALITY OF EVIDENCE: The MEDLINE and EMBASE databases were searched from 2005 to 2016. Epidemiologic studies were summarized and the relevant treatment literature was based on level I evidence. MAIN MESSAGE: The incidence of community-associated MRSA infection is rising. Certain populations, including indigenous Canadians and homeless populations, are particularly affected. Community-associated MRSA can be distinguished from health care-associated MRSA based on genetic, epidemiologic, or microbiological profiles. It retains susceptibility to some oral agents including trimethoprim-sulfamethoxazole, clindamycin, and tetracyclines. Community-associated MRSA typically presents as purulent skin and soft tissue infection, but invasive infection occurs and can lead to severe, complicated disease. Treatment choices and the need for empiric MRSA coverage are influenced by the type and severity of infection. CONCLUSION: Community-associated MRSA is a common cause of skin and soft tissue infections and might be common in populations where overcrowding and limited access to clean water exist.

Opioid use disorder and type 2 diabetes mellitus: Effect of participation in buprenorphine-naloxone substitution programs on glycemic control.

OBJECTIVE: To measure the effect of buprenorphine-naloxone as opioid substitution therapy on glycemic control in patients with type 2 diabetes mellitus and opioid use disorder. DESIGN: Retrospective cohort study and secondary data analysis. SETTING: Northwestern Ontario. PARTICIPANTS: Patients with diabetes receiving opioid substitution therapy, as well as patients with diabetes only, who live in 6 remote First Nations communities. MAIN OUTCOME MEASURES: Glycated hemoglobin A1c values during a 2-year time period in the 2 groups. RESULTS: Over a 2-year period, there was an absolute decrease of 1.20% in mean glycated hemoglobin A1c values in patients with diabetes who also received opioid substitution therapy, compared with patients with diabetes who were not being treated for opioid dependence, whose values rose by 0.02%. CONCLUSION: Patients with diabetes who also suffer from opioid use disorder achieve significant (P = .011) improvement in glycemic control when treated with buprenorphine-naloxone substitution therapy compared with other patients with diabetes. Treating opioid use disorder with buprenorphine-naloxone substitution therapy has an unintended positive effect on diabetes management.

Alzheimer's Disease and Related Dementia in Indigenous Populations: A Systematic Review of Risk Factors.

BACKGROUND: There remains a lack of information and understanding of the prevalence and incidence of Alzheimer's disease and related dementia in Indigenous populations. Little evidence available suggests that Indigenous peoples may have disproportionately high rates of Alzheimer's disease and related dementia (ADRD). OBJECTIVE: Given this information, this study systematically explores what risk factors may be associated with ADRD in Indigenous populations. METHODS: A search of all published literature was conducted in October 2016, March 2018, and July 2019 using Medline, Embase, and PsychINFO. Subject headings explored were inclusive of all terms related to Indigenous persons, dementia, and risk. All relevant words, phrases, and combinations were used. To be included in this systematic review, articles had to display an association of a risk factor and ADRD. Only studies that reported a quantifiable measure of risk, involved human subjects, and were published in English were included. RESULTS: Of 237 articles originally identified through database searches, 45 were duplicates and 179 did not meet a priori inclusion criteria, resulting in 13 studies eligible for inclusion in this systematic review. CONCLUSION: The large number of potentially modifiable risk factors reported relative to non-modifiable risk factors illustrates the importance of socioeconomic context in the pathogenesis of ADRD in Indigenous populations. The tendency to prioritize genetic over social explanations when encountering disproportionately high disease rates in Indigenous populations can distract from modifiable proximal, intermediate, and distal determinants of health.

Epidemiologic features of invasive group A Streptococcus infection in a rural hospital: 6-year retrospective report and literature review.

INTRODUCTION: High rates of invasive group A Streptococcus disease were suspected by clinicians in northwestern Ontario. Patients with sepsis were being encountered with bacteremia positive for group A Streptococcus. This study was designed to assess the incidence of invasive group A Streptococcus infection in the region and provide best-practice treatment information. METHODS: We performed a retrospective chart review at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) from 2009 to 2014 to examine rates of infection due to invasive group A Streptococcus and outcomes. All blood cultures from 2015 were also examined to calculate the relative rates of distinct pathogens responsible for cases of bacteremia. A literature review on this topic was performed, with attention to rural incidence where available and clinical practice guidelines. RESULTS: Invasive group A Streptococcus disease was diagnosed in 65 patients during the study period. Most (37 [57%]) had bacteremia without a clinical focus. Type 2 diabetes mellitus was a comorbid condition in 27 (42%) and skin conditions in 30 (46%). The case fatality rate was 4.6%. In 2015, group A Streptococcus accounted for 8% of all positive blood cultures from in- and outpatients in the catchment area. The calculated annual incidence rate of invasive group A Streptococcus infection was 37.2 cases per 100 000 population. CONCLUSION: Rural physicians may encounter group A Streptococcus bacteremia in their practice. The death rate associated with these infections can be as high as 20%, and patients require urgent treatment, typically with intravenous penicillin and clindamycin therapy. The rate of invasive group A Streptococcus infection in the predominantly First Nations population served by the SLMHC exceeded the Canadian rate eightfold and is comparable to rates observed in low-income countries and among Indigenous populations in Australia. This disparity may result from inadequate housing, overcrowding or limited access to clean water.

INTRODUCTION: Des cliniciens soupçonnaient des taux élevés d'infections invasives à streptocoque du groupe A dans le Nord-Ouest de l'Ontario. Les patients infectés présentaient une bactériémie positive pour les streptocoques du groupe A. Notre étude visait à évaluer l'incidence des infections invasives à streptocoque du groupe A dans la région et à offrir des renseignements sur les meilleures pratiques de traitement. METHODS: Nous avons mené une étude rétrospective des dossiers de patients du Centre de santé Meno Ya Win de Sioux Lookout (SLMHC) entre 2009 et 2014 afin d'étudier les taux d'infections invasives à streptocoque du groupe A et les résultats. Nous avons également examiné toutes les hémocultures effectuées en 2015 afin de déterminer les taux relatifs de pathogènes distincts responsables des cas de bactériémie. Nous avons procédé à une analyse documentaire sur le sujet, en portant attention à l'incidence en milieu rural lorsque les données étaient disponibles ainsi qu'aux guides de pratique clinique. RESULTS: Soixante-cinq patients ont reçu un diagnostic d'infection invasive à streptocoque du groupe A pendant la période à l'étude. La plupart d'entre eux (37 [57 %]) présentait une bactériémie sans manifestation clinique. Vingt-sept (42 %) patients présentaient également un diabète de type 2 et 30 (46 %) patients présentaient des affections cutanées. Le taux de mortalité clinique était de 4,6 %. En 2015, les infections à streptocoque du groupe A comptaient pour 8 % de la totalité des hémocultures positives provenant des patients hospitalisés et des patients externes dans la région à l'étude. On a calculé un taux d'incidence annuel d'infections invasives à streptocoque du groupe A de 37,2 cas par 100 000 personnes. CONCLUSION: Les médecins en milieu rural peuvent rencontrer des cas de bactériémie à streptocoque du groupe A dans le cadre de leur pratique. Le taux de mortalité associé à ces infections peut atteindre 20 %. Les patients ont besoin d'un traitement urgent, reposant généralement sur l'administration de pénicilline et de clindamycine par voie intraveineuse. Le taux d'infections invasives à streptocoque du groupe A dans la population majoritairement autochtone desservie par le SLMHC était 8 fois plus élevé que le taux observé dans la population canadienne et est comparable aux taux observés dans les pays à faible revenu et chez les populations aborigènes d'Australie. Cette disparité pourrait être attribuable au logement inadéquat, au surpeuplement ou à l'accès limité à de l'eau potable.

High Incidence of Invasive Group A Streptococcal Infections in Remote Indigenous Communities in Northwestern Ontario, Canada.

BACKGROUND: Worldwide, indigenous populations appear to be at increased risk for invasive group A streptococcal (iGAS) infections. Although there is empirical evidence that the burden of iGAS disease is significant among remote First Nations communities in Northwestern Ontario, Canada, the epidemiology of iGAS infections in the area remains poorly characterized. METHODS: Individuals that met case definition for iGAS disease and whose laboratory specimens were processed by Meno Ya Win Health Centre in Sioux Lookout, Canada or who were reported to Thunder Bay District Health Unit, Canada were identified for the period 2009 to 2014. Case demographics, clinical severity, comorbidities, and risk factors were collected through chart review. Strain typing and antibiotic susceptibility were determined when possible. Basic descriptive statistics were calculated. RESULTS: Sixty-five cases of iGAS disease were identified, for an annualized incidence of 56.2 per 100 000. Primary bacteremia was present in 26.2% of cases, and cellulitis was identified in 55.4% of cases. The most common comorbidities identified were diabetes (38.5%) and skin conditions (38.5%). Prevalent risk factors included alcohol dependence (25%). Fourteen different emm types were identified among 42 isolates, with the most common being emm114 (17.4%), emm11 (15.2%), and emm118 (13.0%). Resistance to erythromycin and clindamycin was found in 24.6% of isolates. CONCLUSIONS: Rural and remote First Nations communities in Northwestern Ontario experience iGAS infections at a rate 10 times the provincial and national average. Compared with other North American series, a lower proportion of isolates causing infection were of emm types included in candidate GAS vaccines.

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.

Interlaminar epidural steroid injections for low back pain in rural Ontario.

INTRODUCTION: We sought to document the efficacy of interlaminar epidural steroid injections (ESIs) for the relief of low back pain in a rural population. METHODS: We conducted a prospective observational cohort study with brief follow-up telephone interviews at 1, 3 and 6 months after interlaminar ESI. RESULTS: A total of 47 ESIs were administered to the 24 participants. In an intention-to-treat analysis, pain relief was achieved in 78.7%, 55.3% and 27.7% of participants at 1, 3 and 6 months. CONCLUSION: Interlaminar ESIs, without fluoroscopic guidance, were effective for up to 3 months of symptom relief.

INTRODUCTION: Nous avons cherché à déterminer l'efficacité des infiltrations épidurales interlaminaires de stéroïdes pour réduire la lombalgie chez une population rurale. METHODS: Pour ce faire, nous avons mené une étude de cohorte observationnelle prospective au moyen de brèves entrevues téléphoniques de suivi après 1, 3 et 6 mois. RESULTS: Au total, 47 infiltrations épidurales ont été administrées à 24 participants. Dans le cadre d'une analyse par intention de traiter, 78,7 %, 55,3 % et 27,7 % des participants ont rapporté un soulagement de la douleur à 1, 3 et 6 mois, respectivement. CONCLUSION: Les infiltrations épidurales interlaminaires sans guidage fluoroscopique peuvent procurer un soulagement des symptômes pendant jusqu'à 3 mois.