The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study.

AIMS: People with diabetes and poor glycaemic control are at higher risk of diabetes-related complications and incur higher healthcare costs. An understanding of the sociodemographic and clinical characteristics associated with poor glycaemic control is needed to overcome the barriers to achieving care goals in this population. METHODS: We used linked administrative and laboratory data to create a provincial cohort of adults with prevalent diabetes, and a measure of HbA1c that occurred at least 1 year following the date of diagnosis. The primary outcome was poor glycaemic control, defined as at least two consecutive HbA1c measurements ≥ 86 mmol/mol (10%), not including the index measurement, spanning a minimum of 90 days. We used multivariable Cox proportional hazards models to evaluate the association between baseline sociodemographic and clinical factors and poor glycaemic control. RESULTS: In this population-based cohort of 169 890 people, younger age was significantly associated with sustained poor glycaemic control, with a hazard ratio (HR) of 3.08, 95% CI (2.79-3.39) for age 18-39 years compared with age ≥ 75 years. Longer duration of diabetes, First Nations status, lower neighbourhood income quintile, history of substance abuse, mood disorder, cardiovascular disease, albuminuria and high LDL cholesterol were also associated with poor glycaemic control. CONCLUSIONS: Although our results may be limited by the observational nature of the study, the large geographically defined sample size, longitudinal design and robust definition of poor glycaemic control are important strengths. These findings demonstrate the complexity associated with poor glycaemic control and indicate a need for tailored interventions.

Non-linear relationship between serum 25-hydroxyvitamin D concentration and subsequent hip fracture.

UNLABELLED: Serum 25-OH vitamin D levels were compared in 254 hip fracture subjects and 2,402 matched control subjects. There was a significant inverse association between 25-OH vitamin D and hip fracture only between 0 and 70 nmol/L. INTRODUCTION: Vitamin D is integral to bone metabolism, however the utility of serum 25-OH vitamin D as a risk marker for hip fractures is controversial. METHODS: We conducted a case-control study of patients admitted to the hospitals with hip fractures in Calgary, Alberta, (catchment population 1.4 million) between January 1, 2007 and August 31, 2011. We searched the laboratory information system of Calgary Laboratory Services for serum 25-OH vitamin D levels within 6 months prior to admission on patients admitted to hospital with hip fractures. Cases were identified through the Calgary Laboratory Services laboratory information system and were matched to controls for age, sex, and month of testing. The hip fracture-25-OH vitamin D association was examined using multiple linear and spline regression. RESULTS: Of 305 subjects initially identified with hip fractures, serum 25-OH vitamin D levels were available for 254 (83 %). These were matched to 2,402 control subjects. We observed a significant (p < 0.01) non-linear relationship such that 25-OH vitamin D was inversely associated with hip fracture only below 70 nmol/L (odds ratio = 0.81 per 10 nmol/L increase; 95 % CI 0.86-0.93). CONCLUSIONS: The utility of 25-OH vitamin D level as a risk marker for hip fracture depends on the cut-off level used and was of potential use only for lower levels of 25-OH vitamin D.

Molecular epidemiology of Escherichia coli causing bloodstream infections in a centralized Canadian region: a population-based surveillance study.

OBJECTIVES: Escherichia coli is a leading cause of bloodstream infections worldwide, and is responsible for substantial patient morbidity, mortality and healthcare expenditure. Understanding the molecular epidemiology of E. coli will aid in designing superior treatment and prevention strategies. METHODS: We undertook a population-based surveillance study describing the clinical factors, susceptibility patterns, incidence rates and geographical distribution of sequence types (STs) among E. coli isolates (n = 686) causing incident bloodstream infections in a centralized Canadian region during 2016. STs were identified using a seven-single-nucleotide-polymorphism quantitative PCR (n = 422) and sequencing of certain house-keeping genes (n = 249). RESULTS: The annual population incidence rate of E. coli bloodstream infections was 48.8/100 000 patient years, and five dominant clones (ST131, ST73, ST69, ST95 and ST1193) accounting for 55% (378/686) of the population were identified, each with a specific geographical distribution within Calgary. ST131 was the most common (overall incidence rate of 10.4/100 000 patient years), an antimicrobial-resistant (AMR) clone affecting mainly the elderly and the very young. ST131 was common among residents in long-term care with an incidence rate of 312.5/100 000 patient years. ST73 was associated with community infections in the elderly, while ST69 and ST95 had increased incidence rates among females. ST1193 was the second most AMR clone and was associated with bloodstream infections in elderly males. CONCLUSIONS: This study showed that E. coli clones have unique characteristics in a well-defined human population. The elimination of ST131 would substantially decrease the overall incidence rate and AMR burden among E. coli bloodstream infections in the Calgary region, leading to considerable public health benefits.

Examining Chlamydia trachomatis and Neisseria gonorrhoeae rates between 2010 and 2015: a population-based observational study.

Bacterial sexually transmitted infections including Chlamydia trachomatis and Neisseria gonorrhoeae remain an important public health concern. We aimed to assess the population-based incidence of C. trachomatis and N. gonorrhoeae in an age-standardized cohort over time. A retrospective study of a large Canadian health region was undertaken between 2010 and 2015 using linked census and digital laboratory data. C. trachomatis and N. gonorrhoeae tests were linked to patient data. Sex and age-standardized incidence rates (IR) and ratios (IRR) were calculated for cases and testing rates. The annual mean population was 1,150,556 individuals (50.1% female). A total of 15,109 cases of chlamydia and 981 cases of gonorrhoea occurred. The overall IR for chlamydia ranged from 18.81 to 25.63 cases per 10,000 person-years. The IRR was 1.27 (95% CI 1.20-1.34, p < 0.001) for the comparison of 2015 and 2010 rates. For gonorrhoea, overall rates ranged from 0.92 to 1.86 cases per 10,000 person-years. The IRR for gonorrhoea was 2.02 (95% CI 1.56-2.59, p < 0.001) for 2015 and 2010 rates. In our large population-based study spanning six years, we observed increasing rates of C. trachomatis and N. gonorrhoeae with low testing rates.

A case-control study of fluctuating dermatoglyphic asymmetry as a risk marker for developmental delay.

In traits which are normally bilaterally symmetrical, asymmetries may arise as a result of genomic or environmental stress. Such asymmetries are called fluctuating asymmetry. Symmetry is known to be decreased in a variety of disorders of developmental origin, and thus could potentially serve as a risk marker for disorders with a developmental component. We examined this idea by conducting a case-control study of 49 developmentally delayed children and 51 controls. Using two dermatoglyphic characters as a measure of symmetry (finger print concordance and A-B triradial ridge count difference), we found odds ratios of 2.32 (95% CI 0.65-3.17) and 2.11 (95% CI 0.57-3.27); depending on which character was measured. These results suggest that fluctuating asymmetry may have potential as a risk marker for developmental disorders, and that this area of research warrants further research.

Fluctuating asymmetry and disorders of developmental origin.

Environmental and/or genetic stresses may cause a breakdown in developmental homeostasis, resulting in increased bilateral asymmetry of morphological traits. The degree of these deviations (termed "fluctuating asymmetry") is thought to correlate with the severity of the stress. If these stresses also play a role in the appearance of developmental disorders, then increased morphological asymmetry may serve as a risk marker for disorders of developmental origin. This would be possible if 1) the environmental stress that caused a breakdown in developmental stability also contributed to the appearance of the disorder, and/or 2) the genetic predisposition (liability) to the disorder and increased susceptibility to fluctuating asymmetry have a common cause. Although a number of authors have reported associations between increased fluctuating asymmetry and disorders of presumed developmental origin, the usefulness of fluctuating asymmetry as a risk marker has not been established. One obstacle to this assessment is the lack of odds ratios reported by previous authors.

Development and validation of an improving prescribing in the elderly tool.

OBJECTIVE: To apply recently published consensus panel guidelines to a series of hospital inpatient charts to develop and validate a brief screening tool for potentially inappropriate prescriptions in the elderly. SETTING: A 400-bed acute care hospital in London, Ontario. METHODS: Three hundred and sixty-one consecutive inpatient charts, 185 from a clinical teaching unit (CTU) and 176 from a geriatric assessment unit (GAU) were examined for potentially inappropriate prescriptions as listed by McLeod et al. The potentially inappropriate prescribing practices detected were used to develop the Improving Prescribing in the Elderly Tool (IPET). Construct validity was examined by looking for a predicted difference in the rate of potentially inappropriate prescriptions between the CTU and the GAU. Interrater reliability was determined by applying the IPET to a new series of 100 charts. RESULTS: Forty-two of 361 individuals (12.5%) had 45 potentially inappropriate prescriptions representing 14 different potential drug/disease interactions; these were used to construct the IPET. A demonstrated difference in the rate of potentially inappropriate prescriptions between the CTU and GAU indicated construct validity. The interrater reliability of the IPET (kappa) when applied to a new series of 100 charts was 1.0. INTERPRETATION: The IPET is a brief, reliable and valid tool based on the published literature that may be used to screen for potentially inappropriate prescriptions in the elderly.

Current practices of adjunctive therapy for pertussis at six Canadian tertiary care pediatric hospitals.

OBJECTIVE: To document initial investigations and treatment used in the management of children hospitalized with pertussis. DESIGN: Retrospective chart review encompassing admissions from January 1, 1991 to June 1, 1995. SETTING: Six Canadian pediatric hospitals representing about 39% of the pediatric tertiary care beds in Canada. PATIENTS: Four hundred and forty children who met the inclusion criterion of a primary admitting diagnosis of pertussis and who did not meet the exclusion criterion of nosocomially acquired pertussis or a prior admission for pertussis during the study period. MAIN RESULTS: Most patients had cultures positive for Bordetella pertussis, although the proportion of positive tests varied widely among hospitals. Erythromycin was the most commonly used medication; however, only 47% of children received the recommended dosage. Salbutamol and corticosteroids were used most often in patients with reactive airways disease. Younger children and those with reactive airways disease had longer lengths of stay in hospital. CONCLUSIONS: Pertussis treatment varied widely among the six hospitals studied, and was often not consistent with current Canadian recommendations. The results will allow practitioners to place their practices in a national perspective and provide a baseline for further studies.

The association of warthin tumor with salivary ductal inclusions in intra and periparotid lymph nodes.

A predominant theory of the much debated histogenesis of Warthin tumor (WT) is that it arises from heterotopic salivary ductal inclusions (SDI) in parotid lymph nodes (LN). If this were the case, we might expect to see an increased number of SDI in the lymph nodes of patients with WT compared to controls. To test this, we compared the prevalence of SDI in patients with WT versus those with pleomorphic adenoma (PA). Cases of WT and PA were retrieved from the case files of the Department of Pathology at the QEII Health Science Centre, Halifax, NS, Canada. We then compared the prevalence of SDI in parotid LN between patients diagnosed with WT versus PA. 46 WT and 52 PA met our inclusion criteria. WT was significantly associated with an older age at surgery (62.5 years vs 50.2 years, p = 0.001). 71.7 % of WT and 32.7 % of PA had inclusions in any LN. The presence of inclusion is a significant predictor for WT versus PA (p = 0.019). Where smoking status was available, 92.5 % of WT patients were smokers/ex-smokers, versus. 55.1 % of PA (p = 0.034 for current smokers). Among PA, 44 % of smokers had inclusions compared with 22.7 % of non-smokers. SDIs are more frequent in parotid LN from patients with WT than PA. The high proportion of smokers among WT patients is consistent with prior studies. The results support the hypothesis that WT arises from SDIs. Individuals with more SDIs may be predisposed to WT.

The impact of hissy fits in primary care.

BACKGROUND: Hissy fits are experienced by physicians and patients alike, yet their full impact has never been studied before. METHODS: Specially trained researchers observed hissy fits at a clinic over 12 months. They interviewed perpetrators, victims and witnesses and recorded their comments because they had to. RESULTS: Hissy fits were common at the clinic and sometimes escalated to riots. Seasonal variations were endured. INTERPRETATION: Nobody likes this behaviour. Efforts should be made to counsel hissy fitters in channeling their angst in other, more positive ways.

Chlamydia trachomatis genital infection.

OBJECTIVE: To determine family physicians' approaches to detecting, managing, and preventing genital Chlamydia trachomatis infection and their perceptions of barriers to prevention. To determine whether sex of physician is associated with differences in clinical approach to chlamydia, with levels of effort aimed at its prevention, and with perceived barriers to preventive efforts. DESIGN: Questionnaires were sent to a random sample of family physicians. SETTING: All health regions in Nova Scotia. PARTICIPANTS: Two hundred fifty-seven Nova Scotia family physicians. MAIN OUTCOME MEASURES: Responses to survey questions analyzed for association of practice behaviours with sex of physician. RESULTS: Response rate was 60%. Most physicians performed diagnostic tests for chlamydia on all patients. Responses indicated that 17% would test for C trachomatis during an annual Papanicolaou test in a low-risk 30-year-old, 61% would test a high-risk 21-year-old man, and 89% would test a pregnant 17-year-old. Therapies physicians might use were judged appropriate in 96% of responses. Only 51% indicated they would ever discuss false-positive test results with patients. Men physicians were less likely than women to ask 75% or more of their adolescent patients about sexual activity or to educate them about prevention of sexually transmitted diseases. Women physicians saw time and the fee schedule as less serious barriers to prevention than men did. CONCLUSIONS: Some physicians are not managing C trachomatis well. We should explore situations where gaps in performance are associated with sex of physician.