Canadian Refugee Women Are at Increased Risk of Postpartum Depression: How Can We Help?

Refugee women in Canada are at increased risk of postpartum depression (PPD) compared with Canadian-born women. Physicians specializing in women's health are in a unique position to intervene with refugee women experiencing PPD. Although there are common contributors to the development of PPD in both Canadian-born and refugee women, refugee women face a number of additional barriers to treatment. These can include factors unique to the refugee experience (e.g., family separation, uncertainty regarding legal status, social mores of the new country) as well as social determinants of health (e.g., poverty, language barriers, barriers to accessing health care). Some authors have argued that all recent immigrant women who are pregnant should be considered at risk for developing PPD and have stressed the importance of early intervention with this group. This commentary argues that effective strategies to address the needs of women refugees who are pregnant focus on the following areas: early identification of women at risk, advocacy efforts, and mitigation of broader relevant social factors (e.g., food insecurity, poverty, lack of social supports). In addition to these strategies, more research is needed to identify how factors interact to increase the risk of PDD in women refugees and to identify factors that protect against the development of PPD in this group.

Parasitic stool testing in newly arrived refugees in Calgary, Alta.

OBJECTIVE: To determine the prevalence of intestinal parasites and rates of stool testing compliance, as well as associated patient characteristics, among newly arrived refugees at the Mosaic Refugee Health Clinic in Calgary, Alta. DESIGN: Retrospective chart review. SETTING: Primary care clinic for refugee patients. PARTICIPANTS: A total of 1390 new refugee patients at the clinic from May 1, 2011, to June 30, 2013. MAIN OUTCOME MEASURES: Stool ova and parasite test completion and proportion of positive test results. RESULTS: Of 1390 patients, 74.1% (95% CI 71.7% to 76.4%) completed at least 1 stool ova and parasite test. Among those completing tests, 29.7% (95% CI 26.9% to 32.6%) had at least 1 positive result. Patients aged 6 to 18 years were more likely to have positive test results (38.5%, 95% CI 32.2% to 45.0%) than patients aged 19 to 39 were, as were those last residing in Asia (36.4%, 95% CI 30.4% to 42.8%) or sub-Saharan Africa (30.9%, 95% CI 26.8% to 35.1%), compared with those arriving from the Middle East. Giardia lamblia, Blastocystis hominis, Dientamoeba fragilis, and Entamoeba histolytica or Entamoeba dispar were the most prevalent parasites. If B hominis and D fragilis are excluded because of their lower potential to cause harm, the overall prevalence was 16.3%. CONCLUSION: Given the high compliance of patients submitting stool ova and parasite tests and a high prevalence of positive test results in some refugee groups, targeted screening should be considered in newly arrived refugees at greater risk of intestinal parasites.

Reducing malaria misdiagnosis: the importance of correctly interpreting Paracheck Pf® "faint test bands" in a low transmission area of Tanzania.

BACKGROUND: Although malaria rapid diagnostic tests (RDTs) have been extensively evaluated since their introduction in the early 1990's, sensitivity and specificity vary widely limiting successful integration into clinical practice. This paper reviews specific issues surrounding RDT use in field settings and presents results of research investigating how to interpret "faint test bands" on ParaCheck Pf® in areas of low transmission in order to reduce malaria misdiagnosis. METHODS: A multi-phase cross-sectional study was conducted at a remote hospital in the northern Tanzanian highlands. Capillary blood samples were taken from consenting participants (n = 319) for blood smear and ParaCheck Pf® testing. Primary outcome variables were sensitivity, specificity and proportion misdiagnosed by ParaCheck Pf® and local microscopy. ParaCheck Pf® "faint bands" were classified as both true positives or true negatives during evaluation to determine appropriate clinical interpretation. Multivariate logistic regression adjusted for age and gender was conducted to determine odds of misdiagnosis for local microscopy and ParaCheck Pf®. RESULTS: Overall, 23.71% of all ParaCheck Pf® tests resulted in a "faint band" and 94.20% corresponded with true negatives. When ParaCheck Pf® "faint bands" were classified as positive, specificity was 75.5% (95% CI = 70.3%-80.6%) as compared to 98.9% (95% CI = 97.0%-99.8%) when classified as negative. The odds of misdiagnosis by local microscopy for those > 5 years as compared to those ≤ 5 years are 0.370 (95% CI = 0.1733-0.7915, p = 0.010). In contrast, even when ParaCheck Pf® faint bands are considered positive, the odds of misdiagnosis by ParaCheck Pf® for those > 5 years as compared to those ≤ 5 years are 0.837 (95% CI = 0.459-1.547, p = 0.5383). CONCLUSIONS: We provide compelling evidence that in areas of low transmission, "faint bands" should be considered a negative test when used to inform clinical decision-making. Correct interpretation of RDT test bands in a clinical setting plays a central role in successful malaria surveillance, appropriate patient management and most importantly reducing misdiagnosis.

Acute corticospinal tract Wallerian degeneration is associated with stroke outcome.

BACKGROUND AND PURPOSE: In children with stroke, poor motor outcome is associated with early Wallerian degeneration of the corticospinal tract that is seen on diffusion-weighted MRI. In this study we test the hypothesis that early diffusion changes also occur in the corticospinal tract (CST) of adults after stroke and that these lesions are associated with poor outcome. METHODS: In this retrospective study, we assessed images from a serial MRI study of adults with acute middle cerebral/internal carotid artery stroke. MRI-negative TIA patients served as controls. Custom software measured signal along the CST on different sequences, including the apparent diffusion coefficient (ADC). Visual detection of abnormal signal by blinded neuroradiologists was also evaluated. We then determined associations between CST signal changes and 3-month motor outcome (NIHSS score). RESULTS: Thirty-eight patients (20 stroke/18 control) were included. ADC measures were much more accurate than other MRI sequences for detection of degeneration in the CST. The ADC decreased in a time-dependent fashion in the CST of patients with poor motor outcome but not in those with good outcome. Changes in ADC were maximal at 7 days. Neuroradiologists could visually detect these changes with accuracy comparable to the software method. CONCLUSION: CST ADC decreases after acute stroke in patients with poor motor outcome and may represent early Wallerian degeneration. Recognition of this imaging marker may improve early outcome prediction and patient selection for rehabilitation and neuroprotection trials.

Fluorescein angiographic findings in a male infant with incontinentia pigmenti.

Incontinentia pigmenti is a rare, X-linked dominant, genodermatosis and is almost always lethal in males. It is characterized by cutaneous, ocular, dental, and central nervous system (CNS) abnormalities and about 35% of patients develop some form of ocular abnormality, which may include retinal vascular abnormalities, ischemic retinal infarctions, retinal detachments, cataracts, uveitis, strabismus, and nystagmus. Incontinentia pigmenti has been linked to the NEMO gene, which is mapped to Xq28.