Acute Respiratory Infection Incidence and Outpatient Antibiotic Prescription Patterns in People With or Without Human Immunodeficiency Virus Infection: A Virtual Cohort Study

Background

Inappropriate antibiotic use in acute respiratory infections (ARIs) is a major public health concern; however, data for people with human immunodeficiency virus (PWH) are limited.

Methods

The HIV Virtual Cohort Study is a retrospective cohort of adult Department of Defense beneficiaries. Male PWH cases (n = 2413) were matched 1:2 to controls without HIV (n = 4826) by age, gender, race/ethnicity, and beneficiary status. Acute respiratory infection encounters between 2016 and 2020 and corresponding antibiotic prescriptions were characterized as always, sometimes, or never appropriate based on International Classification of Diseases, Tenth Revision coding. Incidence of ARI encounters and antibiotic appropriateness were compared between PWH and controls. Subgroup analyses were assessed by CD4 count and viral load suppression on antiretroviral therapy.

Results

Mean rates of ARI encounters were similar for PWH (1066 per 1000 person-years) and controls (1010 per 1000 person-years); however, the rate was double among PWH without viral load (VL) suppression (2018 per 1000 person-years). Antibiotics were prescribed in 26% of encounters among PWH compared to 34% for controls (P ≤ .01); antibiotic use was "never" appropriate in 38% of encounters with PWH and 36% in controls. Compared to controls, PWH received more sulfonamides (5.5% vs 2.7%; P = .001), and variation existed among HIV subgroups in the prescription of sulfonamides, fluoroquinolones, and β-lactams.

Discussion

Acute respiratory infection encounters were similar for PWH and those without HIV; however, PWH with lower CD4 counts and/or nonsuppressed VL had more frequent ARI visits. Inappropriate antibiotic use for ARIs was high in both populations, and focused interventions to improve antibiotic appropriateness for prescribers caring for PWH should be pursued.

Technology Complements Physical Examination and Facilitates Skills Development among Health Sciences Clerkship Students: An Integrative Literature Review

Background

Technology is increasingly present in the clinical environment. There is a dearth of investigation of the relationship between technology and touch concerning student learning of physical examination practices.

Method

Integrative review methods were used to synthesise empirical literature to provide a comprehensive understanding of the relationship between physical examination, learning and technology in the context of health professional student clerkships.

Results

Three databases including MEDLINE, CINAHL and Eric were searched for all articles published from 2014 to 2021 using terms relating to (i) physical examination, (ii) technology, and (iii) student clerkships. Thirty-three studies met the inclusion criteria. From the analysis, it is evident that technologies that intersect with learning of physical examination may broadly be apportioned into two categories: 1) technologies that mediate physical examination practices; and 2) technologies that mediate the learning of physical examination.

Conclusions

This review indicates that technologies may have multiple roles in the student learning of physical examination, including technology mediating increased diagnostic accuracy and access to supplementary learning material relating to physical examination that is integrated for the clinical clerkship environment. It highlights a need to further understand the touch versus technology relationship and explore the dynamic intersection.

Development of a tool to measure holistic reflection in midwifery students and midwives

BACKGROUND

Holistic reflection encompasses reflection as a continuum, incorporating critical reflection, reflexivity, critical thinking and a whole-of-person approach. The development of holistic reflection in midwifery students and midwives is rarely measured in a standardised way.

AIM

To develop and test a tool to measure holistic reflection in midwifery students and midwives, for use in pre-registration and post-graduate education, and research.

DESIGN

The eight-step approach to tool development by DeVellis was followed with psychometric testing of data from a cross-sectional survey.

PARTICIPANTS

Midwifery students (pre-registration and postgraduate), and midwifery alumni of an Australian university.

METHODS

Draft items (n = 84) were generated from review of the literature, qualitative research, and a theoretical model. An expert panel (n = 19) reviewed draft items resulting in 39 items. The survey included demographic details, the draft Holistic Reflection Assessment Tool, emotional intelligence subscale, and a social desirability scale. Participants repeated the online survey at two weeks to confirm test-retest reliability.

RESULTS

The 187 responses were received. Exploratory factor analysis with varimax rotation revealed three factors accounting for 49% of variance. Internal consistency of the tool was high (α = .91) and test-retest reliability at two weeks (α = .93) demonstrated stability. There were low correlations between social desirability (r = .22, p < .001) and emotional intelligence (r = .21, p < .001) with the new holistic reflection scale.

CONCLUSIONS

The Holistic Reflection Assessment Tool is the first for midwifery. The tool was reliable, stable, and valid. Further research is warranted for criterion validity.

Quitting Behaviors Among Dual Cigarette and E-Cigarette Users and Cigarette Smokers Enrolled in the Tobacco User Adult Cohort

PURPOSE

We examined quitting behaviors among a cohort of dual users (cigarettes and electronic cigarettes [e-cigarettes]) and exclusive cigarette smokers for: (1) cigarette smoking reduction, (2) quit attempts, (3) abstinence from cigarettes, and (4) abstinence from all tobacco products.

METHODS

Participants enrolled in the Tobacco User Adult Cohort and categorized as "daily" user of cigarettes and "daily" or "some days per week" use of e-cigarettes (ie, dual users; n = 88) or "daily" user of cigarettes only (ie, cigarette smokers; n = 617) served as the analytic sample. Participants were interviewed face to face every 6 months, through 18 months. Data on self-reported current product(s) used, cessation interest, quit attempts and abstinence from cigarettes, and all tobacco products were collected.

RESULTS

No difference in reduction of cigarette consumption over time was noted between groups. Rates of reporting an attempt to quit all tobacco products (≥ 24 hours of not using any tobacco in an attempt to quit) also did not differ by group. Compared to cigarette smokers, dual users were more likely to report abstinence from cigarettes at 6 months (OR = 2.54, p = .045) but not at 12 or 18 months. There was no significant difference in abstinence from all tobacco products by group at 6, 12, or 18 months.

CONCLUSIONS

Although dual use of e-cigarettes has been cited as a potential cessation tool for cigarette smokers, our findings indicated that this association was only observed in the short term. We also found no evidence of any association between dual use and eventual abstinence from all tobacco products.

IMPLICATIONS

Our study observed that, in the natural environment, dual users of cigarettes and e-cigarettes were more likely than cigarette smokers to quit cigarettes in the short term but no more likely to quit using cigarettes and all tobacco products over time.

Are medical students influenced by preceptors in making career choices, and if so how? A systematic review

INTRODUCTION

Increasingly medical students undertake clinical training in distributed learning environments. The driving factor for this is predominantly to address medical workforce shortages. In these environments students are often taught by private practitioners, residents, house staff and registrars, as well as faculty. Through a mix of short- and long-term preceptorships, clerkships and rotations, medical students are exposed to a wider range of preceptors, mentors and role models than has traditionally been the case. The aim of this systematic review was to understand if and how medical students' career choices are influenced by their interactions with preceptors.

METHOD

A search of Ovid Medline, Scopus, ISI Web of Science, PubMed, Eric and CIHNAL was undertaken. The search was structured around the key terms: Medical Student, Career Choice and Preceptor, and variants of these terms. Search limits were set to English-language publications between 1995 and 2010.

RESULTS

A total of 36 articles met the selection criteria from the 533 citations sourced from the search. Required preceptorships as short as 3 weeks' duration influence the career choice of students when they rate the preceptor as a high quality teacher. Preceptors who are judged (by students) as high quality teachers have the greatest influence on student career choice by up to four-fold. When students judged a preceptor as being a negative role model, a poor teacher or lacking discipline specific knowledge they will turn away from that field. The positive influence of relationships between preceptors and students on career choice is strongest where there is continuity of preceptors, continuity of care, and continuity of patient interactions. The longer the duration of the preceptorship the greater the influence on student career choice, particularly in primary cares environments.

CONCLUSION

This review adds to the literature by identifying how differing components and combinations of components of a preceptorship influence medical student career choices. Multiple components of the preceptorship combined have a greater influence. In free choice, longitudinal integrated clerkships' duration of placement and continuity relationships with preceptors have the greatest influence on medical students in pursuing a primary care career. This information informs medical schools, curriculum designers and policy-makers in reforming medical education to address workforce shortages.

Impact of an urban healthy homes intervention

In the study described in this article, the authors evaluated the impact of an urban Healthy Homes intervention that included educational home visits. Their one-group, pre-post design used a structured interview at baseline and postintervention. The sample (N = 84) was comprised of low-income children younger than 18 years of age with an asthma diagnosis or with an asthmatic mother. Children were primarily male (62%), < or =10 years old (74%), and lived in a single family home (69%) with moisture (61%). Interventions included a personalized action plan, education, demonstrations, and home remediation as needed. Significant post-intervention decreases occurred in reported asthma symptoms for the child, school days missed, caregiver work days missed, and emergency department/urgent care center visits. Caregiver self-efficacy and quality of life increased significantly. The comprehensive home visitation intervention program effectively impacted asthma symptoms, lost school and work days, emergency use of the health care system, and improved caregiver quality of life and self-efficacy.

Geographical variations in the prevalence of atopic sensitization in six study sites across Canada

BACKGROUND

Geographical variations in atopic sensitization in Canada have not been described previously. This study used the standardized protocol of the European Community Respiratory Health Survey-1 (ECRHS-1) to investigate the distribution and predictors of atopic sensitization in six sites across Canada and to compare the results with some ECRHS-1 centers.

METHODS

Adults aged 20-44 years in six study sites across Canada underwent allergy skin testing using 14 allergens (Dermatophagoides pteronyssinus, Dermatophagoides farinae) cat, cockroach, grasses (Timothy grass, Kentucky grass), molds (Cladosporium herbarium, Alternaria alternata, Aspergillus fumigatus, Penicillium), trees (tree mix, birch, Olea europea), and common ragweed.

RESULTS

The overall prevalence of atopy (skin test over 0 mm to any allergen) was 62.7%. There was significant geographical variation in the prevalence of atopy in the six study sites (lowest 55.6% [95% C.I.51.3-59.9] in Prince Edward Island, highest 66.0 [61.7-70.3] in Montreal) and of sensitization to each of the allergens tested even after adjustment for confounders. When the first eight of the nine allergens in the ECRHS were used to estimate the prevalence of atopic sensitization, the prevalence of atopy in Canada was 57% compared with 35.2% overall for centers in the ECRHS. The prevalence of atopy in Vancouver (57% [52.3-61.8]) was close to that of Portland, Oregon (52.1% [46.2-58.0]).

CONCLUSION

There was a significant variation in atopic sensitization among different study sites across Canada. The prevalence of atopic sensitization is relatively high in Canada compared with sites in the ECRHS and this may, in part, account for the high prevalence of asthma and asthma symptoms in Canada.

Prince Edward Island Heart Health Dissemination Research Project: establishing a sustainable community mobilization initiative

This paper provides an overview of the Prince Edward Island Heart Health Program (PEIHHP) Dissemination Research Project. Prince Edward Island (PEI) is a small province in the Atlantic region of Canada with a population of 137,980. The Island's economy is dependent on the fishery, agriculture, and tourism industries. Although unemployment rates are high (14.4%), Prince Edward Island has the lowest poverty rate in the country at 15.2%, high levels of social support (86%), and the second lowest rate of high chronic stress (Report on the Health of Canadians, 1996, 1999).

Prevalence of asthma symptoms among adults aged 20-44 years in Canada

BACKGROUND

Reported prevalence rates of asthma vary within and between countries around the world. These differences suggest environmental factors in addition to genetic factors in the cause of the disease and may provide clues for preventive strategies. We examined the variability of asthma-related symptoms and medication use among adults in 6 sites across Canada (Vancouver, Winnipeg, Hamilton, Montreal, Halifax and Prince Edward Island) and compared our findings with those from sites that had participated in a recent European survey.

METHODS

We used the same sampling strategy and standardized questionnaire as those used in the European Community Respiratory Health Survey (ECRHS). The 6 Canadian sites were selected to represent different environments with respect to climate, air pollution and occupational exposure. Community-based samples of 3000 to 4000 people aged 20-44 years were randomly selected in each site. Subjects were asked to complete the questionnaire by mail between March 1993 and November 1994. Prevalence rates (and 95% confidence intervals [CIs]) of asthma symptoms, self-reported asthma attacks and use of asthma medication were compared across the Canadian sites and with sites that had participated in the ECRHS.

RESULTS

The overall response rate of those selected to receive the questionnaire was 86.5% (range 74.5%-92.8%). The prevalence rates of most asthma symptoms varied significantly among the Canadian sites. For instance, 21.9% (Montreal) to 30.4% (Halifax) of the men and 24.0% (Vancouver) to 35.2% (Halifax) of the women reported wheezing in the year before the survey. Depending on the site, 4.4% to 6.3% of the men and 5.2% to 9.5% of the women reported an asthma attack in the last year, and 4.0% to 6.1% of the men and 4.9% to 9.7% of the women were currently using asthma medication. Prevalence rates of symptoms, asthma attacks and medication use did not change with age, but they were higher among women than among men. Compared with the results from the ECRHS sites, those from the Canadian sites were among the highest.

INTERPRETATION

Significant variation in the prevalence of asthma symptoms, asthma attacks and use of asthma medication between Canadian sites and international sites suggests environmental influences. Different combinations of factors in different sites may be responsible for the high prevalence rates and should be the subject of further research to guide clinical management and public health intervention.

Emotional and personality changes following cingulotomy

The effects of bilateral anterior cingulate cortex (ACC) lesions on emotional and personality functioning were studied. Patients undergoing cingulotomy for chronic intractable pain were assessed on the Minnesota Multiphasic Personality Inventory (MMPI), the Profile of Mood States (POMS), cognitive tests, and pain ratings, pre- and postsurgically. Patients with intractable pain, not treated with cingulotomy, served as controls. Cingulotomy patients experienced reductions in POMS-Tension, POMS-Anger, and MMPI Scale 7 (Psychasthenia) compared with baseline and the controls. POMS-Tension was significantly correlated with attention-intention performance. The results indicate that the ACC modulates emotional experience, related to self-perceived tension, and that there is relationship between the emotional and the attentional effects of cingulotomy.

Occupational asthma in adults in six Canadian communities

We examined the prevalence, population attributable risk (PAR), and clinical characteristics of occupational asthma (OA) in a randomly selected population in six communities in Canada. Our study followed the European Community Respiratory Health Survey protocol. A randomly selected population of 18,701 (87% response rate) persons from the study communities, ranging in age from 20 to 44 yr, completed an initial questionnaire, of whom 2,974 (39% response rate) attended the laboratory and completed supplementary questionnaires. Of these latter individuals, 383 had asthma. Asthma was defined as physician-diagnosed asthma, and adult-onset asthma was defined as a first attack at age 15 yr or older. We used several methods for estimating OA as follows: (1) reporting of a high-risk job (occupation and industry) for OA at the time of asthma onset (Probable OA); (2) reporting of exposure to a substance that may cause OA (Possible OA) while not in a high-risk job at the time of asthma onset; and (3) combination of the PAR for high-risk jobs and exposures. The prevalence (95% confidence interval [CI]) of Probable OA and Possible OA combined was 36.1% (31.3 to 41.0%) among subjects with adult-onset asthma. The occupations most commonly reported in association with OA were nursing in the Probable OA group and clerical and food preparation in the Possible OA group. The clinical characteristics and exposures reported by both groups were similar. The PAR for adult-onset asthma in high-risk jobs and exposures was 18.2%. The assessment of occupation and industry alone, rather than of exposures, may underestimate the contribution of occupational exposures to asthma prevalence.

Comparative evaluation of procedures with a Baxter CS-3000 cell separator for collecting peripheral blood cells from children

The safety and efficacy of apheresis using a newly developed procedure with a small volume separation container holder (SVSCH, Baxter) for the collection of PBSC from children with cancer were retrospectively compared with our historical experience with other procedures using different equipment and the CS-3000 plus cell separator. The procedures tested included the application of (a) specialized collection protocol 4 using the combination of an SVSCH and a small volume collection chamber (SVCC) (group A: 6 collections in 4 patients), (b) standard lymphocyte collection protocol 3 with GRANULO separation (G) and A-35 collection chambers (group B: 9 collections in 5 patients), and (c) modified collection procedure 1-120 with G and SVCC (group C: 7 collections in 3 patients). Although the retrospective nature of this study and the differences in the cohorts tested prevent a reliable analysis, the percent decrease in the peripheral platelet count after collection tended to be minimum in group A (11% +/- 5% versus 23% +/- 4% [B] or 17% +/- 4% [C]). Moreover, the largest number of CD34+ cells was collected in group A (8.7 +/- 9.4 x 10(5)/100 ml processed blood) compared with groups B (5.5 +/- 7.5 x 10(5)/100 ml processed blood) and C (4.0 +/- 2.8 x 10(5)/100 ml processed blood). These data suggest that a procedure incorporating SVSCH can be safely and effectively applied to small children and enables the selective collection of PBSC with less contamination by platelets, which is useful for subsequent cell processing.

Childbirth and the illness focus

Childbirth is essentially women's business, a natural female act being performed since the beginning of mankind. However, as Western society has evolved, so too has the management of childbirth. It is the medical profession that has gained control of providing care for childbearing women, to the detriment of many women's experiences. The societal expectations on childbearing women, the iatrogenic effects of pregnancy being treated as an illness under the medical model, and the implications for the profession of midwifery will be discussed.

Hepatitis C in Prince Edward Island: a descriptive review of reported cases, 1990-1995

INTRODUCTION

The prevalence of hepatitis C in Canada is not known. There is limited information on most small area populations such as Prince Edward Island.

METHODS

A retrospective approach was used to obtain detailed information on all cases of hepatitis C identified in Prince Edward Island from December 1990 to September 1995. Cases were reviewed for demographic, clinical and risk factor information, including blood donation and transfusion histories.

RESULTS

There were 54 RIBA confirmed cases of hepatitis C infection included in the Prince Edward Island Hepatitis C Database, of which 38 (70%) were males. Age ranged from 18 to 76 years, with a mean age of 38 years. Twenty-eight (52%) of the cases had a history of injection drug use, and 24 (44%) had received blood or blood products in the past. There were five cases with neither of these risk factors identified.

DISCUSSION

The results suggest that, in this small, primarily rural population, injection drug use is the most common means of hepatitis C transmission, followed by receipt of blood or blood products.

Regional and rural-urban differences in obesity in Canada. Canadian Heart Health Surveys Research Group

OBJECTIVE

To describe regional and rural-urban differences in weight and weight loss patterns in Canadian adults.

DESIGN

Population-based, cross-sectional surveys.

SETTING

Nine Canadian provinces (excluding Nova Scotia) from 1986 to 1992.

PARTICIPANTS

A probability sample of 27,120 men and women aged 18 to 74 years was selected using the health insurance registration files in each province. Anthropometry was performed on 18,043 participants (67%).

OUTCOME MEASURES

Region of Canada (Atlantic, central, western); rural or urban residence (rural if participant resided in a community whose population was < 10,000, urban if population > or = 10,000); body mass index (BMI, kg/m2); percentage of participants trying to lose weight; reasons for trying to lose weight; level of leisure-time physical activity.

RESULTS

Overall, mean BMI values in rural men (26.1 kg/m2) and women (25.3 kg/m2) were not significantly different from urban counterparts (25.7 kg/m2 and 24.8 kg/m2, respectively). Similarly, obesity (BMI > or = 27 kg/m2) was as prevalent in rural men (37%) and women (30%) as in urban participants (34% and 28%, respectively). However, a difference was observed in western Canada where 41% of rural and 34% of urban men were obese (odds ratio [OR], adjusted for age and education = 1.29; 95% confidence interval [CI] 1.06, 1.57), as were 35% of rural and 25% of urban women (OR, adjusted for age and education = 1.47; 95% CI 1.17, 1.84). Among men in western Canada, the rural-urban differences were greatest in the 25-64 year age group, whereas in women the differences were present at all ages. Overall, in Canada, urban men (26%) are more likely than rural men (23%) to be trying to lose weight; the reverse was true for women (39% and 42%, respectively).

CONCLUSION

Considerable regional and rural-urban differences are seen in the patterns of weight and weight loss in Canada. A fuller understanding of the underlying behavioural determinants of these differences is needed. On the basis of such an understanding, effective programs to promote healthy weights for individuals and communities in these areas might be developed.

The membrane-associated 40 KD fatty acid binding protein (Berk's protein), a putative fatty acid transporter is present in human skeletal muscle

Muscle tissue (1.1 +/- 0.1 grams) was obtained from seven healthy individuals (3 males, 4 females) using an open incision approach before and after ingestion of either 75 grams of dextrose (N=5) or water (N=2). Purified sarcolemmal membranes from the muscle were prepared using a sucrose step gradient. A polyclonal antibody raised against the purified (99%) rat hepatocyte 40 KD membrane fatty acid binding protein (mFABP-L) was used to probe for this putative transporter in the muscle membranes using Western blot. A single band at the 40 KD MW band was identified which reacted antigenically with the protein purified from rat livers. These response of Berk's protein 60-75 minutes after dextrose ingestion (or water) was erratic and no specific trend could be identified. Our data demonstrate that the 40 KD mFABP-L originally isolated from rat liver is also present in human skeletal muscle membrane. This protein may be involved in transport of fatty acids across the membrane of skeletal muscle, however its physiological role in human fatty acid metabolism remains to be established.

Decreased DNA repair in familial Alzheimer's disease

Alterations in the capacity of a cell to repair DNA lesions play an important role in a number of human diseases. We and others have demonstrated defective DNA repair of alkylation damage in cells from patients with Alzheimer's disease. It has been hypothesized that this defect is related to the cause of Alzheimer's disease and results in the accumulation of lesions in the central nervous system neurons. One prediction of this hypothesis is that in dominantly inherited Alzheimer's disease, the repair defect will be present in half of the offspring of affected patients long before they develop symptoms of the disease. In order to test the hypothesis that decreased DNA repair is responsible for familial Alzheimer's disease and their at-risk offspring we have studied DNA repair in these individuals after exposure of lymphoblasts to alkylating agents. Our results indicate that cell lines from affected patients repair significantly less damage in 3 h than cell lines from healthy controls. A small number of at-risk individuals were also studied and some of these had lower levels of repair, although more cell lines from individuals in this group must be studied. These findings provide further support for defective DNA repair playing a role in the pathogenesis of Alzheimer's disease.