SETD2 mutations do not contribute to clonal fitness in response to chemotherapy in childhood B cell acute lymphoblastic leukemia.

Mutations in genes encoding epigenetic regulators are commonly observed at relapse in B cell acute lymphoblastic leukemia (B-ALL). Loss-of-function mutations in SETD2, an H3K36 methyltransferase, have been observed in B-ALL and other cancers. Previous studies on mutated SETD2 in solid tumors and acute myelogenous leukemia support a role in promoting resistance to DNA damaging agents. We did not observe chemoresistance, an impaired DNA damage response, nor increased mutation frequency in response to thiopurines using CRISPR-mediated knockout in wild-type B-ALL cell lines. Likewise, restoration of SETD2 in cell lines with hemizygous mutations did not increase sensitivity. SETD2 mutations affected the chromatin landscape and transcriptional output that was unique to each cell line. Collectively our data does not support a role for SETD2 mutations in driving clonal evolution and relapse in B-ALL, which is consistent with the lack of enrichment of SETD2 mutations at relapse in most studies.

Permutations in pacer wire implantation in patients evaluated for transcatheter tricuspid valve interventions.

Pacer wire induced tricuspid regurgitation is not well-understood. The mechanisms behind pacer wired induced tricuspid regurgitation have not been clearly defined. This clinical vignette sets to identify different technical mechanisms behind cardiac lead induced tricuspid regurgitation to help optimize cardiac lead implantation strategies for future device implantation.

Demand-Side Factors in Maternal Health Outcomes: Evidence from a Community Health Worker Programme in Uganda.

While community health workers (CHWs) are a core feature of many low-resource healthcare systems, evidence on both their health impacts and the mechanisms behind these impacts remains limited. Using a difference-in-differences design with a control and treatment group, this study evaluated a CHW programme in southwestern Uganda aimed at improving maternal health outcomes. We found relatively little evidence of an overall programme effect on health behaviours, including antenatal care attendance and delivery under skilled supervision. Analysis of heterogeneity by gestational age at first antenatal visit - which should have modulated exposure to the intervention - provided suggestive evidence that treatment effects varied predictably with gestational age. Altogether, the absence of strong programme effects may have been due to suboptimal performance by CHWs, thus highlighting the importance of studying and instituting appropriate monitoring and incentive schemes for such programmes. Additionally, in contrast to the weak treatment effect findings, analysis of the entire study sample between the pre- and post-intervention periods showed large improvements in healthcare-seeking behaviour across both the treatment and control groups. These changes may have arisen from concurrent supply-side health facility improvements affecting the entire study population, spillover effects from the CHWs, or background health trends.

Outcomes of Patients Undergoing Elective Bowel Resection Before and After Implementation of an Anemia Screening and Treatment Program.

BACKGROUND: Patients with anemia undergoing elective colorectal cancer surgery are known to have significantly higher rates of postoperative complications and worse outcomes. OBJECTIVE: This study aimed to improve rates of anemia screening and treatment in patients undergoing elective colon and rectal resections through a quality improvement initiative. DESIGN: We compared a historical cohort of patients before implementation of our anemia screening and treatment quality improvement program to a prospective cohort after implementation. SETTINGS: This study was conducted at a tertiary care hospital. PATIENTS: This study included all adult patients with a new diagnosis of colon or rectal cancer without evidence of metastatic disease between 2017 and 2019. INTERVENTIONS: The interventions include the anemia screening and treatment quality improvement program. MAIN OUTCOME MEASURES: The primary outcome was hospital cost per admission. RESULTS: This study includes a total of 84 patients who underwent elective colon or rectal resection before implementation of our anemia quality improvement project and 88 patients who underwent surgery after. In the preimplementation cohort 44 of 84 patients (55.9%) were anemic compared to 47 of 99 patients (54.7%) in the postimplementation cohort. Rates of screening (25%-86.4%) and treatment (27.8%- 63.8%) were significantly increased in the postimplementation cohort. Mean total cost per admission was significantly decreased in the postimplementation cohort (mean cost $16,827 vs $25,796; p = 0.004); this significant reduction was observed even after adjusting for relevant confounding factors (ratio of means: 0.74; 95% CI, 0.65-0.85). The mechanistic link between treatment of anemia and reductions in cost remains unknown. No significant difference was found in rates of blood transfusion, complications, or mortality between the groups. LIMITATIONS: The study limitation includes before-after design subjected to selection and temporal biases. CONCLUSIONS: We demonstrate the successful implementation of an anemia screening and treatment program. This program was associated with significantly reduced cost per admission. This work demonstrates possible value and benefits of implementation of an anemia screening and treatment program. See Video Abstract at http://links.lww.com/DCR/C15 .RESULTADOS DE LOS PACIENTES SOMETIDOS A RESECCIÓN INTESTINAL ELECTIVA ANTES Y DESPUÉS DE LA IMPLEMENTACIÓN DE UN PROGRAMA DE DETECCIÓN Y TRATAMIENTO DE ANEMIA. ANTECEDENTES: Se sabe que los pacientes anémicos que se someten a una cirugía electiva de cáncer colorrectal tienen tasas significativamente más altas de complicaciones posoperatorias y peores resultados. OBJETIVO: Mejorar las tasas de detección y tratamiento de la anemia en pacientes sometidos a resecciones electivas de colon y recto a través de una iniciativa de mejora de calidad. DISEO: Comparamos una cohorte histórica de pacientes antes de la implementación de nuestro programa de detección de anemia y mejora de la calidad del tratamiento con una cohorte prospectiva después de la implementación. ENTORNO CLINICO: Hospital de atención terciaria. PACIENTES: Todos los pacientes adultos con un nuevo diagnóstico de cáncer de colon o recto sin evidencia de enfermedad metastásica entre 2017 y 2019. INTERVENCIONES: Detección de anemia y programa de mejora de la calidad del tratamiento. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue el costo hospitalario por ingreso. RESULTADOS: Un total de 84 pacientes se sometieron a resección electiva de colon o recto antes de la implementación de nuestro proyecto de mejora de calidad de la anemia y 88 pacientes se sometieron a cirugía después. En la cohorte previa a la implementación, 44/84 (55,9 %) presentaban anemia en comparación con 47/99 (54,7 %) en la cohorte posterior a la implementación. Las tasas de detección (25 % a 86,4 %) y tratamiento (27,8 % a 63,8 %) aumentaron significativamente en la cohorte posterior a la implementación. El costo total medio por admisión se redujo significativamente en la cohorte posterior a la implementación (costo medio $16 827 vs. $25 796, p = 0,004); esta reducción significativa se observó incluso después de ajustar los factores de confusión relevantes (proporción de medias: 0,74, IC del 95 %: 0,65 a 0,85). El vínculo mecánico entre el tratamiento de la anemia y la reducción de costos sigue siendo desconocido. No hubo diferencias significativas en las tasas de transfusión de sangre, complicaciones o mortalidad entre los grupos. LIMITACIONES: El diseño de antes y después está sujeto a sesgos temporales y de selección. CONCLUSIONES: Demostramos la implementación exitosa de un programa de detección y tratamiento de anemia. Este programa se asoció con un costo por admisión significativamente reducido. Este trabajo demuestra el valor y los beneficios posibles de la implementación de un programa de detección y tratamiento de la anemia. Consulte Video Resumen en http://links.lww.com/DCR/C15 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking.

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

Diffuse B Cell Lymphoma Leading to Complete Heart Block: Is This Transient or Permanent?

BACKGROUND Cardiac lymphomas can lead to heart block through tumor disruption of the cardiac conduction system. It is reported that with cardiac tumor treatment, conduction abnormalities can resolve. We present a case of cardiac lymphoma resulting in complete heart block requiring a pacemaker, followed by reduction of the pacing burden after chemotherapy. CASE REPORT A 72-year-old woman with a medical history of hypertension, hypothyroidism, and persistent atrial fibrillation presented with dyspnea on exertion and fatigue for 2 weeks. Electrocardiography revealed complete heart block with junctional bradycardia of 48 beats per min. Transthoracic echocardiography demonstrated preserved left ventricular systolic function along with a large mass (3.6×3.7 cm). An endomyocardial biopsy was consistent with diffuse large B cell lymphoma, and the cardiac involvement was thought to be secondary based on positron emission tomography scan findings. Her clinical course was complicated by an episode of syncope deemed to be due to transient asystole, and an urgent single-chamber permanent pacemaker was implanted. Chemotherapy was initiated with R-CHOP, and, following the second cycle of chemotherapy, a positron emission tomography scan revealed no increased radiotracer uptake and thus resolution of all tumors. An echocardiogram 6 weeks after chemotherapy showed complete resolution of the cardiac mass. Subsequent serial pacemaker checks demonstrated improvement of atrioventricular nodal function as manifested by reduced pacing burden. CONCLUSIONS Lymphoma with cardiac involvement can lead to conduction abnormalities, including CHB, and heart block in the setting of these tumors may be reversible with appropriate therapy; however, implantation of a pacemaker remains inevitable is some cases.

The Affordability of a Thrifty Food Plan-based Market Basket in the United States-affiliated Pacific Region.

In an effort to characterize food costs in the United States (US)-affiliated Pacific Region, a first-time food cost survey was conducted in March 2014. A market basket survey was developed using an adaptation of the US Department of Agriculture Thrifty Food Plan. Surveys were conducted in the states of Alaska and Hawai'i; Portland, Oregon; the US-affiliated Pacific Islands of American Samoa (American Samoa); Commonwealth of the Northern Mariana Islands; the island of Pohnpei within the Federated States of Micronesia; Guam; Republic of the Marshall Islands; and Republic of Palau. Urban and rural communities were included. Multiple stores in multiple communities were surveyed in each jurisdiction. Food retailers (N = 74) ranged from convenience markets to supermarkets. Not all foods in the market basket survey were available in each of the communities. Inspection of available income data also showed that food costs represented a higher percentage of household income for American Samoa than those of Alaska, Hawai'i, and Portland. Thrifty Food Plan weighted weekly totals for the region ranged from $181.90 to $264.30. Weighting was based on the amount of the item converted to grams required for the Thrifty Food Plan menu. These food costs are significantly higher than those of Portland ($142.00) for the survey period. Protein foods, grains, vegetables, fruit, and dairy were the 5 most costly components, in descending order. Food affordability was assessed by comparing food costs across jurisdictions and examining estimated food costs to reported average jurisdiction incomes. The survey is intended to help inform public health policy and educational programs in the region. A locally adapted food survey would benefit future analyses, regional policy, and educational efforts.

Hospital cost associated with anemia in elective colorectal surgery: a historical cohort study.

PURPOSE: Anemia is highly prevalent in the colorectal surgery population, affecting 30-70% of patients. Anemia is associated with significant morbidity and mortality; however, there is a lack of evidence on how much anemia impacts healthcare costs. This study aims to determine the hospital cost of index surgical admission, postoperative length of stay, and transfusion rate associated with preoperative anemia in elective major colorectal surgery. METHODS: This historical cohort study included 851 adult inpatients having elective colorectal surgery at a tertiary care academic health sciences network between April 2010 and February 2016. Anemia was defined as hematocrit ≤ 39%. The primary outcome was total hospital costs standardized to 2016 CAD. Secondary outcomes were postoperative length of stay and transfusion. Multivariable regression analyses and propensity score methods were used to measure adjusted associations between anemia and outcomes. RESULTS: Before surgery, 381/851 (45%) patients were anemic. The mean (standard deviation [SD]) cost of index admission for an elective colorectal surgery was 20,040 (23,219) CAD. Anemia was associated with an adjusted 14% relative increase in costs (95% confidence interval [CI], 6 to 23; P < 0.001). The total hospitalization cost attributable to anemia was 3,027 CAD (95% CI, 2,670 to 3,388). Hospital costs and length of stay were highly associated; anemia was associated with an 18% increase in length of stay (95% CI, 7 to 30; P < 0.001) and increased transfusion rates (risk ratio, 4.7; 95% CI, 2.71 to 8.33; P < 0.001). CONCLUSION: Over 2,600 CAD per index surgical admission is attributable to preoperative anemia. Preoperative interventions with per patient cost of less than 2,600 CAD could be cost effective at the hospital level. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03476707); registered 26 March, 2018.

RéSUMé: OBJECTIF: La prévalence de l'anémie est très élevée dans la population subissant une chirurgie colorectale, touchant 30­70 % des patients. L'anémie est associée à une morbidité et une mortalité importantes; toutefois, nous manquons de données probantes pour estimer les coûts des soins de santé associés à l'anémie. Cette étude avait pour but de déterminer les coûts hospitaliers de l'admission chirurgicale initiale, la durée de séjour postopératoire et le taux de transfusion associés à une anémie préopératoire lors de chirurgie colorectale majeure non urgente. MéTHODE: Cette étude de cohorte historique a inclus 851 patients adultes hospitalisés et subissant une chirurgie colorectale non urgente dans un réseau hospitalier universitaire de soins tertiaires entre avril 2010 et février 2016. L'anémie était définie comme un hématocrite ≤ 39 %. Le critère d'évaluation principal était les coûts hospitaliers totaux standardisés à la valeur du dollar canadien en 2016. Les critères d'évaluation secondaires étaient la durée de séjour postopératoire et les transfusions. Des analyses de régression multivariée et des évaluations par score de propension ont été utilisées pour mesurer les associations ajustées entre l'anémie et nos critères d'évaluation. RéSULTATS: Avant la chirurgie, 381/851 (45 %) patients étaient anémiques. Le coût moyen (écart type [ÉT]) de l'admission initiale pour une chirurgie colorectale non urgente était de 20 040 (23 219) CAD. L'anémie a été associée à une augmentation relative ajustée de 14 % des coûts (intervalle de confiance [IC] 95 %, 6 à 23; P < 0,001). Les coûts d'hospitalisation totaux attribuables à l'anémie étaient de 3027 CAD (IC 95 %, 2670 à 3388). Les coûts hospitaliers et la durée de séjour étaient très fortement associés; l'anémie a été associée à une augmentation de 18 % de la durée de séjour (IC 95 %, 7 à 30; P < 0,001) et des taux de transfusion (risque relatif, 4,7; IC 95 %, 2,71 à 8,33; P < 0,001). CONCLUSION: Plus de 2600 CAD pour l'admission chirurgicale initiale sont attribuables à l'anémie préopératoire. Des interventions préopératoires ayant un coût par patient de moins de 2600 CAD pourraient être rentables au niveau hospitalier. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03476707); enregistrée le 26 mars 2018.

Improving Communication Between Nurses and Resident Physicians: A 3-Year Quality Improvement Project.

Breakdown in communication is a predictor of both nursing and surgical errors. In a 2013 survey at our institution, staff on the general surgery unit identified nurse-resident communication as the most important issue related to patient safety. The general surgery Comprehensive Unit-based Safety Program sought to improve nurse-resident communication through a 3-year quality improvement initiative. A multidisciplinary working group conducted a root-cause analysis and developed initiatives addressing priority issues in nurse-resident communication. Two main interventions were developed: structured face-to-face interaction at discharge rounds and notebooks to transfer nonurgent messages. Compliance was evaluated. The primary outcomes of percieved communication and collaboration were assessed using a validated survey distributed to residents and unit nurses before the intervention, 9 months after, and 2.5 years after the intervention. The interventions were associated with improvements in perceived communication and team function. Survey scores, on average, were significant higher at 9 months postintervention and remained significant compared with preintervention after 2.5 years (from 57% to 74%, P = .01, then 72%, P = .02, among residents; and from 63% to 80%, P = .01, then 77% among nurses). Our framework and initiatives addressing nurse-resident communication may be useful for other teams interested in addressing this critical patient safety issue.

Impact of group practices on patients, physicians and healthcare systems: protocol for a scoping review.

INTRODUCTION: Group practices have potential benefits for patients, physicians and healthcare systems. Although group practices have been around for many years, research in this area is lacking and generally is centred around the economic benefits that may be realised from group practice. The aim of this scoping review is to identify the impact that group practices have on patients, physicians and healthcare systems to guide further research in this area. METHODS AND ANALYSIS: A scoping review will be performed based on the methodology proposed by Arksey and O'Malley and refined by Levac and colleagues. MEDLINE, EMBASE, Cochrane Central and Cochrane Economic Database will be searched from inception to present day to identify relevant studies that assess the impact of group practices on patient care, satisfaction and outcomes; physician quality of life, satisfaction and income and healthcare systems. Titles and abstracts will be screened by two members and the abstraction results charted and verified. Qualitative and quantitative analyses will be performed to identify key themes. ETHICS AND DISSEMINATION: Research ethics board approval is not required for this scoping review. A consultation phase will be used to discuss the results with key stakeholders followed by dissemination at local and national levels. We will also publish the results in a peer-reviewed journal.

Chronic intestinal pseudo-obstruction due to Strongyloides stercoralis.

We report a case of chronic intestinal pseudo-obstruction due to a generalized visceral autonomic neuropathy in an immune-competent patient infected with Strongyloides stercoralis. The patient had immigrated to the United States from Sierra Leone in childhood but had not returned for decades. His symptoms resolved with ivermectin treatment. Clinicians should have a high index of suspicion for strongyloidiasis in any patient with abdominal complaints and a history of travel to endemic areas, even if the travel history is remote.

Effect of the Children's Healthy Living Program on Young Child Overweight, Obesity, and Acanthosis Nigricans in the US-Affiliated Pacific Region: A Randomized Clinical Trial.

Importance: Pacific Islanders have among the highest rates of obesity and type 2 diabetes in the world. Targeting children is critical for primary prevention. Objectives: To prevent young child overweight and obesity and to improve health in the US-Affiliated Pacific region via the Children's Healthy Living Program. Design, Setting, and Participants: In this multijurisdictional, multilevel, multicomponent community randomized clinical trial, where all evaluable children were analyzed according to the random assignment of their community, hierarchical difference-in-difference models accounted for the community randomization, community clustering with jurisdictions, and these models were adjusted for the age and sex distribution of the community. The setting was 27 communities in 5 jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and Hawaii). Participants were 4329 children (time 1) and 4042 children (time 2) aged 2 to 8 years in 27 selected communities from October 7, 2012, to October 25, 2015. Data analysis was completed in June 2018. Interventions: Nineteen activities addressed policy, environment, messaging, training, and 6 target behaviors (sleep time, screen time, physical activity, fruits and vegetables, water, and sugar-sweetened beverages). Main Outcomes and Measures: Primary outcomes were body size measurements. Secondary outcomes were acanthosis nigricans, sleep quality and duration, dietary intake, physical activity, and other questionnaire reponses. Results: The study included 27 communities and 8371 evaluable children (mean [SD] age, 5.4 [1.8] years; 50.9% male [n = 4264]). Data analysis included 952 children in the intervention group and 930 children in the control group aged 2 to 5 years at time 1; 825 children in the intervention group and 735 children in the control group aged 2 to 5 years at time 2; 565 children in the intervention group and 561 children in the control group aged 6 to 8 years at time 1; and 517 children in the intervention group and 560 children in the control group aged 6 to 8 years at time 2. The intervention communities showed significant improvement compared with control communities in overweight and obesity prevalence (effect size [d] = -3.95%; 95% CI, -7.47% to -0.43%), waist circumference (d = -0.71 cm; 95% CI, -1.37 to -0.05 cm), and acanthosis nigricans prevalence (d = -2.28%; 95% CI, -2.77% to -1.57%). Age and sex subgroup analysis revealed greater difference among the intervention communities in acanthosis nigricans prevalence in the group aged 2 to 5 years (-3.99%) vs the group aged 6 to 8 years (-3.40%), and the interaction was significant (d = 0.59%, P < .001), as well as the smaller difference in the group aged 2 to 5 years (-0.10%) vs the group aged 6 to 8 years (-1.07%) in screen time (d = -0.97 hour per day, P = .01). Conclusions and Relevance: The intervention reduced the prevalence of young child overweight and obesity and acanthosis nigricans. Comprehensive, effective, and sustainable interventions are needed to improve child health in the US-Affiliated Pacific region. Trial Registration: ClinicalTrials.gov Identifier: NCT01881373.

Association of Donor Tricuspid Valve Repair With Outcomes After Cardiac Transplantation.

BACKGROUND: Tricuspid regurgitation after cardiac transplantation is associated with worse clinical outcomes. This study sought to determine the association of donor tricuspid valve repair (dTVR) with outcomes after cardiac transplantation. METHODS: Patients who underwent cardiac transplantation between January 20, 2002, and December 31, 2016, were included. Multivariable Cox regression modeling was performed to determine the association between dTVR and the composite outcome of death, posttransplant TVR, kidney transplant after cardiac transplant, or chronic dialysis, and included propensity scoring to control for baseline differences in likelihood of undergoing dTVR. RESULTS: The analysis included 330 patients, with 173 (52.4%) undergoing dTVR. dTVR performance varied by surgeon and also increased over time, with 71 (83.5%) performed during January 1, 2011, to November 30, 2013. Transplant year and surgeon were significantly associated with the baseline likelihood of undergoing dTVR. Although fewer composite outcomes occurred in the dTVR vs no dTVR group (39 [22.5%] vs 56 [36.4%], p = 0.006), dTVR was not significantly associated with the composite outcome in multivariable modeling. Lower risk for the composite outcome was associated with greater number of biopsies during the first posttransplant year, whereas higher risk was associated with more high-grade biopsy specimens and higher creatinine. CONCLUSIONS: There was no significant benefit or harm with regards to the composite of death, posttransplant TVR, or dialysis associated with dTVR.

Reduced Myocardial Flow Reserve Is Associated With Diastolic Dysfunction and Decreased Left Atrial Strain in Patients With Normal Ejection Fraction and Epicardial Perfusion.

INTRODUCTION: Coronary microvascular dysfunction (MVD) may contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Using myocardial flow reserve (MFR) measured by positron emission tomography (PET) as an assessment of microvascular function, we hypothesized that abnormal MFR is associated with LV diastolic dysfunction (DD) and reduced LV and LA strain in patients with risk factors for HFpEF and normal epicardial perfusion on cardiac PET. METHODS AND RESULTS: Retrospective study of patients without heart failure who underwent cardiac rubidium-82 PET and echocardiography. Global MFR was calculated as the ratio of global stress to rest myocardial blood flow. Echocardiographic measures of diastolic function were recorded. Global longitudinal LA and LV strain were measured with a 2-dimensional speckle-tracking technique. Relationships among MFR and echocardiographic measures were assessed with linear regression, analysis of variance, and test for trend. Seventy-three patients (age 64 ± 11 years, 52% male) were identified with no epicardial perfusion defect on cardiac PET and an ejection fraction ≥50%. Decreased MFR was associated with LV DD (P = .02) and increased E/e', an estimation of LV filling pressure (low E/e' [<8] vs. high E/e' [>15], P < .001). MFR was associated with LA strain independent of age, gender, and common comorbidities (adjusted ß = 2.6% per unit MFR, P = 0.046); however, MFR was only marginally related to LV strain. CONCLUSIONS: In patients with risk factors for HFpEF, MVD assessed with MFR was associated with DD, increased estimated LV filling pressure, and abnormal LA strain.

Graft Infection Masquerading as Rheumatologic Disease: a Rare Case of Aortobifemoral Graft Infection Presenting as Hypertrophic Osteoarthropathy.

BACKGROUND: Prosthetic vascular graft procedures are a common treatment modality for peripheral vascular disease. A relatively common complication is graft infection, occurring at a rate of 0.5-5%. When they occur, graft infections are associated with significant morbidity and mortality. Vascular graft infections also represent a diagnostic and therapeutic challenge for the physician METHODS: Here, we report a case where the rare finding of secondary hypertrophic osteoarthropathy was an important indication of underlying aortic graft infection that was initially misdiagnosed. A review of the literature revealed 34 cases of vascular graft infection associated with hypertrophic osteoarthropathy. RESULTS: The mean interval from surgery to time of infection was approximately 5 years. Mortality was 35%. When combined with hypertrophic osteoarthropathy, vascular graft infection was complicated by an aortoenteric fistula in 53% of the cases. CONCLUSION: The complexity of this case highlights the challenges physicians face in order to diagnose and treat this condition.

Vaccine Hesitancy: In Search of the Risk Communication Comfort Zone.

INTRODUCTION: This paper reports the findings of a national online survey to parents of children aged 5 and younger. The objectives of the study were to assess parental understanding of childhood immunizations, identify sources of information that they trust for vaccine-related content, assess where parents with young children stand on the key issues in the public debate about vaccination, and identify which risk communication messages are most effective for influencing the behaviours of vaccine hesitant parents. METHODS: A total of 1,000 surveys (closed and open-ended questions) were administered in November 2015 using the Angus Reid Forum Panel, a key consumer panel consisting of approximately 150,000 Canadian adults aged 18 and older, spread across all geographic regions of Canada. RESULTS: Approximately 92% of the Canadian parents surveyed consider vaccines safe and effective, and trust doctors and public health officials to provide timely and credible vaccine-related information. However, a concerning number of them either believe or are uncertain whether there is a link between vaccines and autism (28%), worry that vaccines might seriously harm their children (27%), or believe the pharmaceutical industry is behind the push for mandatory immunization (33%). Moreover, despite the common assumption that social media are becoming the go-to source of health news and information, most parents still rely on traditional media and official government websites for timely and credible information about vaccines and vaccine preventable diseases, particularly during community-based disease outbreaks. Finally, parents reported high levels of support for pro-vaccine messaging that has been demonstrated in previous research to have little to no positive impact on behaviour change, and may even be counterproductive. DISCUSSION: The study's results are highly relevant in a context where public health officials are expending significant resources to increase rates of childhood immunization and combat vaccine hesitancy. The data offer insight into where parents stand on the political and public debate about mandatory vaccination, what aspects of vaccine science remain uncertain to them, which media and institutional sources they use and trust to navigate the health information environment, how they look for information and whom they trust during periods of health emergency or crisis, and which communication strategies are considered most effective in persuading vaccine hesitant parents to immunize their children.