BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial.

BACKGROUND: Nursing home (NH) residents should have the opportunity to consider, discuss and document their healthcare wishes. However, such advance care planning (ACP) is frequently suboptimal. OBJECTIVE: Assess a comprehensive, person-centred ACP approach. DESIGN: Unblinded, cluster randomised trial. SETTING: Fourteen control and 15 intervention NHs in three Canadian provinces, 2018-2020. SUBJECTS: 713 residents (442 control, 271 intervention) aged ≥65 years, with elevated mortality risk. METHODS: The intervention was a structured, $\sim$60-min discussion between a resident, substitute decision-maker (SDM) and nursing home staff to: (i) confirm SDMs' identities and role; (ii) prepare SDMs for medical emergencies; (iii) explain residents' clinical condition and prognosis; (iv) ascertain residents' preferred philosophy to guide decision-making and (v) identify residents' preferred options for specific medical emergencies. Control NHs continued their usual ACP processes. Co-primary outcomes were: (a) comprehensiveness of advance care planning, assessed using the Audit of Advance Care Planning, and (b) Comfort Assessment in Dying. Ten secondary outcomes were assessed. P-values were adjusted for all 12 outcomes using the false discovery rate method. RESULTS: The intervention resulted in 5.21-fold higher odds of respondents rating ACP comprehensiveness as being better (95% confidence interval [CI] 3.53, 7.61). Comfort in dying did not differ (difference = -0.61; 95% CI -2.2, 1.0). Among the secondary outcomes, antimicrobial use was significantly lower in intervention homes (rate ratio = 0.79, 95% CI 0.66, 0.94). CONCLUSIONS: Superior comprehensiveness of the BABEL approach to ACP underscores the importance of allowing adequate time to address all important aspects of ACP and may reduce unwanted interventions towards the end of life.

Decision tree-based rules outperform risk scores for childhood asthma prognosis.

BACKGROUND: There are no widely accepted prognostic tools for childhood asthma; this is in part due to the multifactorial and time-dependent nature of mechanisms and risk factors that contribute to asthma development. Our study objective was to develop and evaluate the prognostic performance of conditional inference decision tree-based rules using the Pediatric Asthma Risk Score (PARS) predictors as an alternative to the existing logistic regression-based risk score for childhood asthma prediction at 7 years in a high-risk population. METHODS: The Canadian Asthma Primary Prevention Study data were used to develop, compare, and contrast the prognostic performance (area under the curve [AUC], sensitivity, and specificity) of conditional inference tree-based decision rules to the pediatric asthma risk score for the prediction of childhood asthma at 7 years. RESULTS: Conditional inference decision tree-based rules have higher prognostic performance (AUC: 0.85; 95% CI: 0.81, 0.88; sensitivity = 47%; specificity = 93%) than the pediatric asthma risk score at an optimal cutoff of ≥6 (AUC: 0.71; 95% CI: 0.67, 0.76; sensitivity = 60%; specificity = 74%). Moreover, the pediatric asthma risk score is not linearly related to asthma risk, and at any given pediatric asthma risk score value, different combinations of its pediatric asthma risk score clinical variables differentially predict asthma risk. CONCLUSION: Conditional inference tree-based decision rules could be a useful childhood asthma prognostic tool, providing an alternative way to identify unique subgroups of at-risk children, and insights into associations and effect mechanisms that are suggestive of appropriate tailored preventive interventions. However, the feasibility and effectiveness of such decision rules in clinical practice is warranted.

Wheeze trajectories are modifiable through early-life intervention and predict asthma in adolescence.

BACKGROUND: The objectives of this study were to identify developmental trajectories of wheezing using data-driven methodology, and to examine whether trajectory membership differentially impacts the effectiveness of primary preventive efforts that target modifiable asthma risk factors. METHODS: Secondary analysis of the Canadian Asthma Primary Prevention Study (CAPPS), a multifaceted prenatal intervention among children at high risk of asthma, followed from birth to 15 years. Wheezing trajectories were identified by latent class growth analysis. Predictors, intervention effects, and asthma diagnoses were examined between and within trajectory groups. RESULTS: Among 525 children, 3 wheeze trajectory groups were identified: Low-Progressive (365, 69%), Early-Transient (52, 10%), and Early-Persistent (108, 21%). The study intervention was associated with lower odds of Early-Transient and Early-Persistent wheezing (P < .01). Other predictors of wheeze trajectories included, maternal asthma, maternal education, city of residence, breastfeeding, household pets, infant sex and atopy at 12 months. The odds of an asthma diagnosis were three-fold to six-fold higher in the Early-Persistent vs Low-Progressive group at all follow-up assessments (P = .03), whereas Early-Transient wheezing (limited to the first year) was not associated with asthma. In the Early-Persistent group, the odds of wheezing were lower among intervention than control children (adjusted odds ratio: 0.67; 95% CI: 0.48; 0.93) at 7 years. CONCLUSIONS: Using data-driven methodology, children can be classified into clinically meaningful wheeze trajectory groups that appear to be programmed by modifiable and non-modifiable factors, and are useful for predicting asthma risk. Early-life interventions can alter some wheeze trajectories (ie, Early-Persistent) in infancy and reduce wheezing prevalence in mid-childhood.

Reassessing access to intensive care using an estimate of the population incidence of critical illness.

BACKGROUND: The consistently observed male predominance of patients in intensive care units (ICUs) has raised concerns about gender-based disparities in ICU access. Comparing rates of ICU admission requires choosing a normalizing factor (denominator), and the denominator usually used to compare such rates between subpopulations is the size of those subpopulations. However, the appropriate denominator is the number of people whose medical condition warranted ICU care. We devised an estimate of the number of critically ill people in the general population, and used it to compare rates of ICU admission by gender and income. METHODS: This population-based, retrospective analysis included all adults in the Canadian province of Manitoba, 2004-2015. We created an estimate for the number of critically ill people who warrant ICU care, and used it as the denominator to generate critical illness-normalized rates of ICU admission. These were compared to the usual population-normalized rates of ICU care. RESULTS: Men outnumbered women in ICUs for all age groups; population-normalized male:female rate ratios significantly exceed 0 for every age group, ranging from 1.15 to 2.10. Using critical-illness normalized rates, this male predominance largely disappeared; critically ill men and women aged 45-74 years were admitted in equivalent proportions (critical-illness normalized rate ratios 0.96-1.01). While population-normalized rates of ICU care were higher in lower income strata (p < 0.001), the gradient for critical illness-based rates was reversed (p < 0.001). CONCLUSIONS: Across a 30-year adult age span, the male predominance of ICU patients was accounted for by higher estimated rates of critical illness among men. People in lower income strata had lower critical-illness normalized rates of ICU admission. Our methods highlight that correct inferences about access to healthcare require calculating rates using denominators appropriate for this purpose.

NIAID, NIEHS, NHLBI, and MCAN Workshop Report: The indoor environment and childhood asthma-implications for home environmental intervention in asthma prevention and management.

Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases; National Institute of Environmental Health Sciences; National Heart, Lung, and Blood Institute; and Merck Childhood Asthma Network sponsored a joint workshop to discuss the current state of science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included US and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment, and exposure reduction techniques. This informed a primary focus of the workshop: to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in scientific methodologies and knowledge and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications?

BACKGROUND: Obstructive sleep apnea (OSA) is associated with increased risk of postoperative complications. The authors investigated whether preoperative diagnosis and prescription of continuous positive airway pressure therapy reduces these risks. METHODS: Matched cohort analysis of polysomnography data and Manitoban health administrative data (1987 to 2008). Postoperative outcomes in adult OSA patients up to 5 yr before (undiagnosed OSA, n = 1,571), and any time after (diagnosed OSA, n = 2,640) polysomnography and prescription of continuous positive airway pressure therapy for a new diagnosis of OSA, were compared with controls at low risk of having sleep apnea (n = 16,277). Controls were matched by exact procedure, indication, and approximate date of surgery. Procedures used to treat sleep apnea were excluded. Follow-up was at least 7 postoperative days. Results were reported as odds ratio (95% CI) for OSA or subgroup versus controls. RESULTS: In multivariate analyses, the risk of respiratory complications (2.08 [1.35 to 3.19], P < 0.001) was similarly increased for both undiagnosed and diagnosed OSA. The risk of cardiovascular complications, primarily cardiac arrest and shock, was significantly different (P = 0.009) between undiagnosed OSA (2.20 [1.16 to 4.17], P = 0.02) and diagnosed OSA patients (0.75 [0.43 to 1.28], P = 0.29). For both outcomes, OSA severity, type of surgery, age, and other comorbidities were also important risk modifiers. CONCLUSIONS: Diagnosis of OSA and prescription of continuous positive airway pressure therapy were associated with a reduction in postoperative cardiovascular complications. Despite limitations in the data, these results could be used to justify and inform large efficacy trials of perioperative continuous positive airway pressure therapy in OSA patients.

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study.

BACKGROUND: Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death. METHODS: In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice. RESULTS: Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18-2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99-2.21; between-person OR 3.04, CI 2.79-3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge. INTERPRETATION: Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.

Epidemiology of critically ill patients in intensive care units: a population-based observational study.

INTRODUCTION: Epidemiologic assessment of critically ill people in Intensive Care Units (ICUs) is needed to ensure the health care system can meet current and future needs. However, few such studies have been published. METHODS: Population-based analysis of all adult ICU care in the Canadian province of Manitoba, 1999 to 2007, using administrative data. We calculated age-adjusted rates and trends of ICU care, overall and subdivided by age, sex and income. RESULTS: In 2007, Manitoba had a population of 1.2 million, 118 ICU beds in 21 ICUs, for 9.8 beds per 100,000 population. Approximately 0.72% of men and 0.47% of women were admitted to ICUs yearly. The age-adjusted, male:female rate ratio was 1.75 (95% CI 1.64 to 1.88). Mean age was 64.5 ± 16.4 years. Rates rose rapidly after age 40, peaked at age 75 to 80, and declined for the oldest age groups. Rates were higher among residents of lower income areas, for example declining from 7.9 to 4.4 per 100,000 population from the poorest to the wealthiest income quintiles (p <0.0001). Rates of ICU admission slowly declined over time, while cumulative yearly ICU bed-days slowly rose; changes were age-dependent, with faster declines in admission rates with older age. There was a high rate of recidivism; 16% of ICU patients had received ICU care previously. CONCLUSIONS: These temporal trends in ICU admission rates and cumulative bed-days used have significant implications for health system planning. The differences by age, sex and socioeconomic status, and the high rate of recidivism require further research to clarify their causes, and to devise strategies for reducing critical illness in high-risk groups.

A population-based analysis of leaving the hospital against medical advice: incidence and associated variables.

BACKGROUND: Prior studies of patients leaving hospital against medical advice (AMA) have been limited by not being population-based or assessing only one type of patient. METHODS: We used administrative data at the Manitoba Centre for Health Policy to evaluate all adult residents of Manitoba, Canada discharged alive from acute care hospitals between April 1, 1990 and February 28, 2009. We identified the rate of leaving AMA, and used multivariable logistic regression to identify socio-demographic and diagnostic variables associated with leaving AMA. RESULTS: Of 1,916,104 live hospital discharges, 21,417 (1.11%) ended with the patient leaving AMA. The cohort contained 610,187 individuals, of whom 12,588 (2.06%) left AMA once and another 2986 (0.49%) left AMA more than once. The proportion of AMA discharges did not change over time. Alcohol and drug abuse was the diagnostic group with the highest proportion of AMA discharges, at 11.71%. Having left AMA previously had the strongest association with leaving AMA (odds ratio 170, 95% confidence interval 156-185). Leaving AMA was more common among men, those with lower average household incomes, histories of alcohol or drug abuse or HIV/AIDS. Major surgical procedures were associated with a much lower chance of leaving the hospital AMA. CONCLUSIONS: The rate of leaving hospital AMA did not systematically change over time, but did vary based on patient and illness characteristics. Having left AMA in the past was highly predictive of subsequent AMA events.

Genome-wide association study of the age of onset of childhood asthma.

BACKGROUND: Childhood asthma is a complex disease with known heritability and phenotypic diversity. Although an earlier onset has been associated with more severe disease, there has been no genome-wide association study of the age of onset of asthma in children. OBJECTIVE: We sought to identify genetic variants associated with earlier onset of childhood asthma. METHODS: We conducted the first genome-wide association study of the age of onset of childhood asthma among participants in the Childhood Asthma Management Program (CAMP) and used 3 independent cohorts from North America, Costa Rica, and Sweden for replication. RESULTS: Two single nucleotide polymorphisms (SNPs) were associated with earlier onset of asthma in the combined analysis of CAMP and the replication cohorts: rs9815663 (Fisher P= 2.31 × 10(-8)) and rs7927044 (P= 6.54 × 10(-9)). Of these 2 SNPs, rs9815663 was also significantly associated with earlier asthma onset in an analysis including only the replication cohorts. Ten SNPs in linkage disequilibrium with rs9815663 were also associated with earlier asthma onset (2.24 × 10(-7)

A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning.

OBJECTIVE: Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families. DESIGN: Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts. SETTING AND PARTICIPANTS: A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP. METHODS: Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis. RESULTS: Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises. CONCLUSION AND IMPLICATIONS: Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.

Aeroallergen-related Diseases Predate the Diagnosis of Inflammatory Bowel Disease.

OBJECTIVE: This study aimed to determine whether having a diagnosis of asthma or allergic rhinitis (AR) increased the risk of being diagnosed with inflammatory bowel disease (IBD) and whether there was increased incidence of these diseases after a diagnosis of IBD. DESIGN: This is a retrospective, historical cohort-based study. We used the administrative data of Manitoba Health and the population-based University of Manitoba IBD Epidemiology Database. We used numbers of prescriptions for drugs used to treat asthma and to treat AR to identify diagnoses of asthma and AR, respectively.We calculated relative risks (RRs) to assess incidence of IBD compared with matched controls after diagnoses of asthma and AR and hazard ratios to determine the incidence of asthma and AR after IBD diagnosis. RESULTS: Compared with controls, a diagnosis of asthma or AR preceding a diagnosis of IBD was increased in cases (RR, 1.62; 95% confidence interval [CI], 1.50-1.75; and RR, 2.10; 95% CI, 1.97-2.24) with a similar outcome by subtype of IBD (Crohn's disease vs ulcerative colitis) and by sex. On sensitivity analysis, diagnoses of asthma or AR were comparable when considering at least 5, 10, 15 or 20 drug prescriptions. Persons with IBD were more likely to develop asthma or AR than controls after being diagnosed with IBD (hazard ratio for asthma, 1.31, 95% CI, 1.18-1.45; and hazard ratio for AR, 2.62, 95% CI, 2.45-2.80). CONCLUSIONS: The association between asthma, AR, and IBD suggest the possibility that whatever triggers the onset of these atopic diseases may trigger the onset of IBD as well, and aeroallergens are plausible culprits.

This study demonstrates that a preexisting diagnosis of asthma or allergic rhinitis is associated with an increased risk of subsequently developing IBD. These data reinforce the importance of considering that gastrointestinal complaints in patients with asthma and allergic rhinitis may reflect a possible diagnosis of IBD. It also raises the possibility that aeroallergens may be environmental cause(s) of IBD.

Constructing episodes of inpatient care: data infrastructure for population-based research.

BACKGROUND: Databases used to study the care of patients in hospitals and Intensive Care Units (ICUs) typically contain a separate entry for each segment of hospital or ICU care. However, it is not uncommon for patients to be transferred between hospitals and/or ICUs, and when transfers occur it is necessary to combine individual entries to accurately reconstruct the complete episodes of hospital and ICU care. Failure to do so can lead to erroneous lengths-of-stay, and rates of admissions, readmissions, and death. METHODS: This study used a clinical ICU database and administrative hospital abstracts for the adult population of Manitoba, Canada from 2000-2008. We compared five methods for identifying patient transfers and constructing hospital episodes, and the ICU episodes contained within them. Method 1 ignored transfers. Methods 2-5 considered the time gap between successive entries (≤1 day vs. ≤2 days), with or without use of data fields indicating inter-hospital transfer. For the five methods we compared the resulting number and lengths of hospital and ICU episodes. RESULTS: During the study period, 48,551 hospital abstracts contained 53,246 ICU records. For Method 1 these were also the number of hospital and ICU episodes, respectively. Methods 2-5 gave remarkably similar results, with transfers included in approximately 25% of ICU-containing hospital episodes, and 10% of ICU episodes. Comparison with Method 1 showed that failure to account for such transfers resulted in overestimating the number of episodes by 7-10%, and underestimating mean or median lengths-of-stay by 9-30%. CONCLUSIONS: In Manitoba is it not uncommon for critically ill patients to be transferred between hospitals and between ICUs. Failure to account for transfers resulted in inaccurate assessment of parameters relevant to researchers, clinicians, and policy-makers. The details of the method used to identify transfers, at least among the variations tested, made relatively little difference. In addition, we showed that these methods for constructing episodes of hospital and ICU care can be implemented in a large, complex dataset.

Sedation and analgesia usage in severe pandemic H1N1 (2009) infection: a comparison to respiratory failure secondary to other infectious pneumonias.

BACKGROUND: During the 2009 H1N1 pandemic (pH1N1), patients requiring mechanical ventilation for respiratory failure received high doses of sedation and analgesia. OBJECTIVE: To examine sedation and analgesia use among patients with respiratory failure due to severe pH1N1 infection compared to other infectious pneumonias. METHODS: In this observational cohort study of intensive care unit (ICU) patients with respiratory failure, we compared doses of sedatives and analgesics administered to patients with pH1N1, non-pH1N1 viral pneumonia, and adult respiratory distress syndrome (ARDS) secondary to bacterial pneumonia, on days 1, 3, 7, 14, and 28 of ICU admission. Cumulative drug use, daily drug use, and weight-adjusted medication doses were examined. RESULTS: The study population consisted of 37 patients with pH1N1 infection, 22 patients with non-pH1N1 viral pneumonia, and 46 patients with ARDS secondary to bacterial pneumonia. To achieve similar levels of sedation using the Richmond Agitation Sedation Scale, patients with pH1N1 were administered the highest cumulative median doses of fentanyl (11,230 µg; interquartile range [IQR] 3240-21,000), compared to 2400 µg (IQR 130-7130) in viral pneumonia and 2880 µg (IQR 600-6950) in ARDS (p < 0.001). Patients with pH1N1 were also administered the highest cumulative median doses of midazolam at 820 mg (IQR 330-1160), compared to 160 mg (IQR 20-390) in viral pneumonia and 160 mg (IQR 20-480 mg) in ARDS (p < 0.001). The pH1N1 group received the highest median daily fentanyl and midazolam doses on all study days. The pH1N1 group did not differ significantly in cumulative propofol dose compared with the other 2 study groups. CONCLUSIONS: Sedative and analgesic use may be uniquely higher in critically ill patients with pH1N1 infection compared to patients with other infectious pneumonias. This finding may be important for resource planning in future pandemics. Further study is required to explore the underlying mechanisms for potentially higher sedative and analgesic requirements in this patient population.

High screen time is associated with asthma in overweight Manitoba youth.

OBJECTIVE: Low physical activity and high sedentary behavior are associated with adverse health outcomes, including asthma. The purposes were to (1) determine if low physical activity and/or high screen time increase the risk of asthma and airway hyperresponsiveness (AHR) in youth and (2) determine if weight status modifies these associations. METHODS: This is a prospective cohort study of healthy weight and overweight Canadian youth. In 2003-2005, 723 youth (8.6 ± 0.5 years; 34.0% asthma, 55.9% boys) were recruited from the 1995 Manitoba Prospective Cohort Study. In 2008-2010, 489 returned for follow-up measures (30.9% asthma, 56.6% boys). The primary exposure variables were parent-reported physical activity and screen time at 8-10 years of age. The primary outcome measures were pediatric allergist-defined asthma and AHR defined as the provocative concentration of methacholine required to induce a 20% fall in forced expiratory volume in 1 second (FEV(1)). RESULTS: Low physical activity (≤2 times weekly) was not associated with asthma or AHR. However, high screen time (≥1 hour/day) was associated with a greater odds of asthma at baseline (odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.20-3.37, p < .01) and follow-up (OR = 2.11, 95% CI = 1.14-3.89, p < .02) versus low screen time. This association was more pronounced among overweight youth (baseline: OR = 3.95, 95% CI = 1.70-9.12, p < .0001; follow-up: OR = 3.22, 95% CI = 1.17-8.86, p < .02). Screen time was not associated with AHR at baseline or follow-up. CONCLUSIONS: High screen time increases the risk of asthma, particularly among overweight youth. Screen time, in addition to physical activity, should be included in clinical assessments of youth with asthma.

"Asthma isn't an excuse, it's just a condition": youths' perceptions of physical activity and screen time.

OBJECTIVE: During puberty, physical activity patterns begin to decline, while sedentary time increases. These changes may be confounded by asthma. The purpose of this study was to gain insight into youths' perceptions of screen time and physical activity by asthma status. METHODS: Four interviews and seven focus groups with boys only or girls only were conducted with 15- to 16-year-old youth enrolled in either of two asthma-focused cohorts in Manitoba, Canada. Using a semi-structured interview guide, youth were asked about their perceptions of physical activity and screen time such as texting, watching television, electronic games, and Internet chatting and about their perceptions of the influence that asthma has on these behaviors. Data were analyzed using thematic coding. RESULTS: Two themes were common to youth with asthma and without asthma: (1) sports are an integral part of youths' lives and (2) screen time is important to youth. Two themes were identified among youth with asthma only: (1) physical activity used to be more difficult and (2) being active and living with asthma. Youth with asthma described physical activity as neither a hindrance to activity nor an excuse for inactivity, although asthma may still present some challenges. They also acknowledged their reliance on screen time for communication and for entertainment. CONCLUSIONS: Youth with asthma believe that physical activity has become increasingly easier as they become older and that being active with asthma, despite its challenges, is a key part of their lives.

Applying the Knowledge-to-Action Framework to Engage Stakeholders and Solve Shared Challenges with Person-Centered Advance Care Planning in Long-Term Care Homes.

As they near the end of life, long term care (LTC) residents often experience unmet needs and unnecessary hospital transfers, a reflection of suboptimal advance care planning (ACP). We applied the knowledge-to-action framework to identify shared barriers and solutions to ultimately improve the process of ACP and improve end-of-life care for LTC residents. We held a 1-day workshop for LTC residents, families, directors/administrators, ethicists, and clinicians from Manitoba, Alberta, and Ontario. The workshop aimed to identify: (1) shared understandings of ACP, (2) barriers to respecting resident wishes, and (3) solutions to better respect resident wishes. Plenary and group sessions were recorded and thematic analysis was performed. We identified four themes: (1) differing provincial frameworks, (2) shared challenges, (3) knowledge products, and 4) ongoing ACP. Theme 2 had four subthemes: (i) lacking clarity on substitute decision maker (SDM) identity, (ii) lacking clarity on the SDM role, (iii) failing to share sufficient information when residents formulate care wishes, and (iv) failing to communicate during a health crisis. These results have informed the development of a standardized ACP intervention currently being evaluated in a randomized trial in three Canadian provinces.

H1N1: viral pneumonia as a cause of acute respiratory distress syndrome.

PURPOSE OF REVIEW: To review the literature on novel swine origin influenza A (H1N1 2009) as a cause of respiratory failure and acute respiratory distress syndrome (ARDS). RECENT FINDINGS: H1N1 2009 was first recognized as a pathogen in March of 2009, when there was a spike in the number of cases of influenza-like illness leading to severe and at times fatal pneumonia. The etiologic agent was then identified as a novel H1N1 influenza A virus, which subsequent spread rapidly throughout the globe. Most countries reported cases of severe viral pneumonitis requiring intensive care unit (ICU) admission. Severe disease was noted to occur more commonly in younger patients than those typically affected by seasonal influenza and obesity and pregnancy were associated with severe disease. The majority of patients requiring ICU admission met criteria for ARDS and case fatality ratio was estimated at less than 0.5%. Chest radiographs and pathology resembled ARDS and most patients were treated with low tidal volume ventilation, high positive end expiratory pressure and at times, rescue therapies. Available evidence suggests that early antiviral treatment improves outcomes from H1N1 2009. SUMMARY: H1N1 2009 has emerged as an important cause of ARDS in 2009-2010. Prompt recognition and treatment with antivirals improves outcomes.