An Outbreak of Salmonella Typhimurium Infections Linked to Ready-To-Eat Tofu in Multiple Health Districts - Ontario, Canada, May-July 2021.

From May to mid-August 2021, the Ontario, Canada provincial public health agency, Public Health Ontario, in collaboration with local public health authorities and federal food safety partners, investigated a spatiotemporal cluster of 38 patients with Salmonella Typhimurium infections across multiple public health districts in Ontario. Five (13%) patients were hospitalized; no deaths were reported. The outbreak was linked to consumption of ready-to-eat seasoned tofu from one manufacturer that was distributed to multiple Ontario restaurants. Isolates from the seasoned tofu were within one or fewer allele differences to the outbreak strain by whole genome sequencing. Evidence from food safety investigations conducted by local public health authorities and the Canadian Food Inspection Agency (CFIA) revealed that unsanitary conditions could have led to cross-contamination of the tofu, and insufficient heating of the tofu at the production level likely resulted in failure to eliminate the pathogen. The CFIA issued a food recall for the tofu at hotel, restaurant, and institution levels. Tofu was identified as a novel outbreak-associated food vehicle for S. Typhimurium in this outbreak. Interventions that target the production level and all parts of the supply chain and include additional safeguarding steps that minimize microbial growth are important.

Hospital-acquired infections in a tertiary hospital in Iran before and during the COVID-19 pandemic.

Infection prevention protocols are the accepted standard to control nosocomial infections. These protective measures intensified after the coronavirus 2019 (COVID-19) pandemic to reduce the risk of viral transmission. It is the rationale that this practice reduces nosocomial infections. We evaluated the impact of these protective measures on nosocomial infections in our center with more than 20,000 records of annual patient admission. In a retrospective study, we evaluated the incidence of nosocomial infections in Sina hospital for 9 months (April-December 2020) during the COVID-19 period and compared it with the 8 months in the pre-COVID period (April-November 2019). Despite decreasing the number of admissions during the COVID era (hospitalizations showed a reduction of 43.79%), the total hospital nosocomial infections remained unchanged; 4.73% in the pre-COVID period versus 4.78% during the COVID period. During the COVID period the infection percentages increased in the cardiovascular care unit (p-value = 0.002) and intensive care units (p-value = 0.045), and declined in cardiology (p-value = 0.046) and neurology (p-value = 0.019) wards. This study showed that intensifying the infection prevention protocols is important in decreasing the nosocomial infections in some wards (cardiology and neurology). Still, we saw increased nosocomial infection in some wards, e.g., the intensive care unit (ICU) and coronary care unit (CCU). Thus, enhanced infection prevention protocols implemented in hospitals to prevent the spread of a pandemic infection may not always decrease rates of other hospital-acquired infections during a pandemic. Due to limited resources, transfer of staff, and staff shortage due to quarantine measures may prohibit improved prevention procedures from effectively controlling nosocomial infections.

An outbreak of Salmonella Infantis linked to shredded pork products from an unlicensed source in multiple health districts, Ontario, Canada, 2021.

Background: An outbreak of Salmonella Infantis was associated with the consumption of shredded pork products at multiple restaurants in Ontario between July 2021 and October 2021. The outbreak involved 36 case-patients from six public health units. The implicated shredded pork products were obtained from an unlicensed source. This is the largest reported outbreak of Salmonella Infantis linked to restaurant food exposures in Ontario, with complexities related to the investigation of unlicensed foods. This article aims to describe the epidemiological, food safety and laboratory investigations that led to the identification and removal of the source of the outbreak from implicated restaurants, including the challenges encountered while investigating an outbreak related to an unlicensed source of food. Methods: Epidemiological and laboratory analyses were conducted to identify the source of the outbreak. Food safety investigations were conducted to ascertain the origin and distribution of the implicated food. Results: Whole-genome sequencing identified the outbreak strain from the isolates of 36 case-patients across six public health units in Ontario. Seven case-patients (19%) were hospitalized. No deaths were reported. The outbreak was linked to shredded pork products (i.e., rinds or skins) that were distributed by an unlicensed meat processor and consumed at various restaurants that served Southeast Asian fusion cuisine concentrated in the Greater Toronto Area. The product was removed from implicated restaurants. Conclusion: Historically, foods from unlicensed sources have been implicated in multiple large outbreaks and continue to be of significant public health risk. The outbreak investigation emphasized the threat of food from unlicensed sources to the public's health and the importance of additional public health interventions to prevent outbreaks linked to unlicensed sources.

Economic sanctions and spread of infectious diseases.

Economic sanctions can induce economic crises and compromise the determinants of health. In the literature, economic crises have been found to increase the risk of infectious disease outbreaks. Presumably, sanctions can increase the risk of infectious disease spreads, indirectly. However, non-economic factors can fuel the adverse impact of sanctions, including political consequences of sanctions and civil war. We performed a systematic literature review of articles in Embase, MEDLINE, Scopus, Web of Science, Cochrane Library, and the grey literature to assess empirically the impact of economic sanctions on the spread of infectious diseases within and beyond the borders of sanctioned countries. Our review did not identify any study meeting our inclusion criteria. Most of the studies did not control for major socio-political events, particularly armed conflicts in the sanctioned countries. This discovery underscores a notable gap in the examination of the impact of economic sanctions on the propagation of infectious diseases, presenting a threat to global health. Using the social-ecological model, we hypothesize how the economic crisis resulting from economic sanctions affects determinants of health, increases the risk of the spread of infectious diseases and hinders the response capacity of health systems.

An Outbreak of Salmonella Typhimurium Infections Linked to Ready-To-Eat Tofu in Multiple Health Districts - Ontario, Canada, May-July 2021.

From May to mid-August 2021, the Ontario, Canada provincial public health agency, Public Health Ontario, in collaboration with local public health authorities and federal food safety partners, investigated a spatiotemporal cluster of 38 patients with Salmonella Typhimurium infections across multiple public health districts in Ontario. Five (13%) patients were hospitalized; no deaths were reported. The outbreak was linked to consumption of ready-to-eat seasoned tofu from one manufacturer that was distributed to multiple Ontario restaurants. Isolates from the seasoned tofu were within one or fewer allele differences to the outbreak strain by whole genome sequencing. Evidence from food safety investigations conducted by local public health authorities and the Canadian Food Inspection Agency (CFIA), revealed that unsanitary conditions could have led to cross-contamination of the tofu, and insufficient heating of the tofu at the production level likely resulted in failure to eliminate the pathogen. The CFIA issued a food recall for the tofu at hotel, restaurant, and institution levels. Tofu was identified as a novel outbreak-associated food vehicle for S. Typhimurium in this outbreak. Interventions that target the production level and all parts of the supply chain and include additional safeguarding steps that minimize microbial growth are important.

One-year test-retest reliability of ten vision tests in Canadian athletes.

Background: Vision tests are increasingly being suggested for use in concussion management and baseline testing. Concussions, however, often occur months after baseline testing and reliability studies generally examine intervals limited to days or one week. Therefore, our objective was to determine the one-year test-retest reliability of these tests. Methods: We assessed one-year test-retest reliability of ten vision tests in elite Canadian athletes followed by the Institut National du Sport du Quebec. We included athletes who completed two baseline (preseason) annual evaluations by one clinician within 365±30 days. We excluded athletes with any concussion or vision training in between the annual evaluations or presented with any factor that is believed to affect the tests (e.g. migraines, etc.). Data were collected from clinical charts. We evaluated test-retest reliability using Intraclass Correlation Coefficient (ICC) and 95% limits of agreement (LoA). Results: We examined nine female and seven male athletes with a mean age of 22.7 (SD 4.5) years. Among the vision tests, we observed excellent test-retest reliability in Positive Fusional Vergence at 30cm (ICC=0.93) but this dropped to 0.55 when an outlier was excluded in a sensitivity analysis. There was good to moderate reliability in Negative Fusional Vergence at 30cm (ICC=0.78), Phoria at 30cm (ICC=0.68), Near Point of Convergence break (ICC=0.65) and Saccade (ICC=0.56). The ICC for Positive Fusional Vergence at 3m (ICC=0.56) also decreased to 0.21 after removing one outlier. We found poor reliability in Near Point of Convergence (ICC=0.47), Gross Stereoscopic Acuity (ICC=0.03) and Negative Fusional Vergence at 3m (ICC=0.0). ICC for Phoria at 3m was not appropriate because scores were identical in 14/16 athletes. 95% LoA of the majority of tests were ±40% to ±90%. Conclusions: Four tests had moderate one-year test-retest reliability. The remaining tests had poor reliability. The tests would therefore be useful only if concussion has a moderate-large effect on scores.

Assessment of urology postgraduate trainees' competencies in flexible ureteroscopic stone extraction.

INTRODUCTION: We aimed to assess flexible ureteroscopic stone extraction skill of urology postgraduate trainees (PGTs) at an Objective Structured Clinical Examination (OSCE) and to determine whether previous experience in the operating theatre or practice on the simulator correlated with performance. METHODS: After obtaining ethics approval, PGTs from postgraduate years (PGYs) 3-5 were recruited from all four Quebec urology training programs during an OSCE. After a short orientation to the UroMentor™ simulator, PGTs were asked to perform Task 10 for 15 minutes, where two small stones from the left proximal ureter and renal pelvis were extracted using a basket. Competency of PGTs in performing the task was assessed using objective assessment from the simulator and subjective evaluations using Ureteroscopy-Global Rating Scale (URS-GRS). Simulator performance reports and URS-GRS scores were analyzed. RESULTS: Thirty PGTs (9 PGY-3, 11 PGY-4, 10 PGY-5) participated in this study. PGTs had performed a mean of 55.9 semi-rigid and 45.7 flexible ureteroscopies prior to the study. Mean URS-GRS score of the participants was 20.0±4.4. Using norm-referenced method with three experts, cutoff score of 19 on the URS-GRS was determined to indicate competency. Sixty percent (18/30) of PGTs were competent. All eight PGTs who had practiced on the simulator were competent. Previous experience in the operating theatre and PGY level did not correlate with performance. CONCLUSIONS: This study confirmed the feasibility of incorporating the UroMentor at OSCEs to assess competency of urology PGTs in ureteroscopic stone extraction skill. PGTs who practiced on the simulator scored significantly higher than those who did not practice; however, the software needs to be updated to improve its face validity and to include more complex tasks, such as holmium laser lithotripsy. Future studies with larger sample sizes and more complex cases are needed to confirm these results.

Birth control policies in Iran: a public health and ethics perspective.

In less than one generation, a unique demographic transition has taken place in Iran. A population growth rate of 4.06% in 1984 fell to 1.15% in 1993 and a total fertility rate of 6.4 births per woman in 1984 declined to 1.9 in 2010. In 2012, Iranian policymakers shifted away from a birth control policy towards a pro-natalist policy. At first glance, this may seem reasonable since its goal is to avoid the consequences of an aging population. However, we argue that the policy package raises serious public health, socioeconomic, environmental and ethical concerns and is likely to fail on its own terms.

Transfer of Flexible Ureteroscopic Stone-Extraction Skill from a Virtual Reality Simulator to the Operating Theatre: A Pilot Study.

AIM: To assess the learning curve of flexible ureteroscopic stone extraction using the UroMentor™ simulator and transfer of flexible ureteroscopic stone extraction skills to the operating theatre. MATERIALS AND METHODS: After obtaining ethics approval, urology Post-Graduate Trainees (PGTs) from Post-Graduate Years (PGYs) 1 to 4 were recruited. During phase I, participants completed 3 weekly 1-hour training sessions on the UroMentor simulator practicing task 10, where two stones from the left proximal ureter and renal pelvis were extracted using a basket. Objective assessments by the simulator and subjective assessments using the validated Ureteroscopy-Global Rating Scale (URS-GRS) were used to establish the learning curve. During phase II, the URS-GRS tool was used to assess performance of participants in the operating theatre. URS-GRS scores obtained on the simulator and in the operating theatre were correlated. RESULTS: In phase I, eight urology PGTs (PGY1-4) with mean age of 27.8 ± 2 (25-31) years participated in the study. PGTs practiced a total of 52 times, with a mean operative time of 14.6 ± 4.3 minutes and a mean fluoroscopy time of 10.4 ± 12 seconds. Competency in task 10 was achieved after seven trials on the UroMentor simulator. In phase II, 5 PGTs were assessed during 55 consecutive flexible ureteroscopic stone extraction in the operating theatre. The mean operative time was 51.4 ± 15.2 minutes and the mean fluoroscopy time was 29 ± 6 seconds. There was a significant positive correlation between URS-GRS scores obtained on the simulator and in the operating theatre (r = 0.9, p = 0.03), thus establishing predictive validity of performance on the UroMentor simulator. CONCLUSIONS: Competency in task 10 on the UroMentor simulator (flexible ureteroscopic stone extraction) was achieved after seven trials. Since there was a strong positive correlation between URS-GRS scores on the simulator and in the operating theatre, the skills obtained on the simulator could be transferred to the operating theatre.

Objective Structured Assessment of Technical Skills for the Photoselective Vaporization of the Prostate Procedure: A Pilot Study.

INTRODUCTION AND OBJECTIVES: Photoselective vaporization of the prostate (PVP) is a frequently performed procedure by postgraduate trainees (PGTs). However, there is no PVP-specific objective assessment tool to evaluate the acquisition of PVP skills. The aim of the present study was to develop and validate an objective structured assessment of technical skills tool for the PVP procedure (PVP-OSATS). METHODS: This study was conducted in two phases. Phase I included the development of PVP-OSATS and assessment of its reliability and construct validity. Panel discussion among experts led to the development of the PVP-OSATS tool with 12 parameters, each scored from 1 (worst) to 5 (best) with a maximum score of 60. Laser prostatectomy experts and PGTs from postgraduate years (PGY) 4 and 5 were recruited. Inter-rater reliability, using Cohen's and Fleiss's kappa, was calculated for all parameters. To assess for construct validity, PGTs were compared with experts. Phase II included assessment of the concurrent validity of this novel tool. This was performed by recruiting Quebec urology PGTs between PGY-3 and -5 to test their PVP skills during the semiannual objective structured clinical examination using the validated GreenLight(™) simulator. RESULTS: During phase I,116 intraoperative PVP-OSATS assessments were collected; 102 for PGTs and 14 for experts. Cohen's and Fleiss's kappa was adequate (k ≥ 0.6) for all 12 parameters, confirming adequate inter-rater reliability. There was significant difference between PGTs and experts in all PVP-OSATS parameters (p ≤ 0.01) except in respect to anatomical landmarks and instrument damage. During phase II, there was significant positive correlation between PVP-OSATS scores inside the operating room and global scores obtained by the GreenLight simulator (r = 0.814; p < 0.001). CONCLUSION: This study reports inter-rater reliability, construct, and concurrent validity of PVP-OSATS as a novel PVP-specific objective assessment tool.

Isolated vertigo and possibility of brain ischemia.

BACKGROUND: In cases of isolated vertigo, physicians are unable to definitely distinguish between central or peripheral vertigo by history and physical examination. Some central causes of isolated vertigo such as cerebellar stroke can be life-threatening and require intervention. Brain infarction can be detected shortly after the onset of clinical symptoms by using diffusion-weighted MRI (DWI). We have conducted this study to perform DWI on isolated vertigo patients with a higher probability of brain infarction. METHODS: We enrolled 55 consecutive patients with isolated vertigo who had at least one cardiovascular risk factor. A questionnaire that consisted of cardiovascular risk factors was completed and DWI performed for each patient. We analyzed the association of cardiovascular risk factors with infarction as identified by DWI. RESULTS: Using DWI, 5 (9.1%) patients had an acute ischemic stroke. Among cardiovascular risk factors, analysis showed a significant relationship between diabetes mellitus (DM) and infarction. CONCLUSION: Isolated vertigo may occur due to the occlusion of a small artery in the area of brain circulated by the posterior inferior cerebellar artery. According to our results, DWI may be used in diabetic patients with isolated vertigo to locate a probable infarction.