Hospitalization With Clostridioides difficile in Pediatric Inflammatory Bowel Disease: a Population-Based Study

OBJECTIVES

Several studies have demonstrated higher rates of Clostridioides difficile infection (CDI) in adults with inflammatory bowel disease (IBD). We conducted a population-based study comparing the risk of hospitalization with CDI in children with and without IBD.

METHODS

Using health administrative data and validated algorithms, we identified all children (<16 years) diagnosed with IBD in 5 Canadian provinces, then age and sex matched to 5 children without IBD. Province-specific 5-year incidence rates of hospitalization with CDI were pooled and generalized linear mixed-effects models were used to estimate the crude incidence rate ratio (IRR) comparing (1) children with and without IBD and (2) children with Crohn disease and ulcerative colitis. Hazard ratios (HR) from Cox proportional hazards models adjusting for age, sex, rural/urban household, and income were pooled using fixed-effects models.

RESULTS

The incidence rate of CDI identified during hospitalization was 49.06 [95% confidence interval (CI), 39.40-61.08] per 10,000 person-years (PY) in 3593 children with IBD compared to 0.39 (95% CI, 0.13-1.21) per 10,000 PY in 16,284 children without IBD (crude IRR, 133.4, 95% CI, 42.1-422.7; adjusted HR, 68.2, 95% CI, 24.4-190.4). CDI was identified less often in children with Crohn disease than ulcerative colitis (crude IRR, 0.51, 95% CI, 0.32-0.82; adjusted HR, 0.69, 95% CI, 0.46-1.05).

CONCLUSIONS

Children with IBD have a markedly higher incidence of CDI identified during a hospitalization relative to children without IBD. Consequently, symptomatic children with IBD who are hospitalized should be screened for CDI.

The Canadian Alliance for Healthy Hearts and Minds: How Well Does It Reflect the Canadian Population?

BACKGROUND

The intent of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to understand the early determinants of subclinical cardiac and vascular disease and progression in adults selected from existing cohorts-the Canadian Partnership for Tomorrow's Health, the Prospective Urban and Rural Evaluation (PURE) cohort, and the Montreal Heart Institute Biobank. We evaluated how well the CAHHM-Health Services Research (CAHHM-HSR) subcohort reflects the Canadian population.

METHODS

A cross-sectional design was used among a prospective cohort of community-dwelling adults aged 35-69 years who met the CAHHM inclusion criteria, and a cohort of adults aged 35-69 years who responded to the 2015 Canadian Community Health Survey-Rapid Response module. The INTERHEART risk score was calculated at the individual level with means and proportions reported at the overall and provincial level.

RESULTS

There are modest differences between CAHHM-HSR study participants and the 2015 Canadian Community Health Survey-Rapid Response respondents in age (56.3 vs 51.7 mean years), proportion of men (44.9% vs 49.3%), and mean INTERHEART risk score (9.7 vs 10.1). Larger differences were observed in postsecondary education (86.8% vs 70.2%), Chinese ethnicity (11.0% vs 3.3%), obesity (23.2% vs 29.3%), current smoker status (6.1% vs 18.4%), and having no cardiac testing (30.4% vs 55.9%).

CONCLUSIONS

CAHHM-HSR participants are older, of higher socioeconomic status, and have a similar mean INTERHEART risk score, compared with participants in the Canadian Community Health Survey. Differing sampling strategies and missing data may explain some differences between the CAHHM-HSR cohort and Canadian community-dwelling adults and should be considered when using the CAHHM-HSR for scientific research.

Reduced Cognitive Assessment Scores Among Individuals With Magnetic Resonance Imaging–Detected Vascular Brain Injury

Background and Purpose—

Little is known about the association between covert vascular brain injury and cognitive impairment in middle-aged populations. We investigated if scores on a cognitive screen were lower in individuals with higher cardiovascular risk, and those with covert vascular brain injury.

Methods—

Seven thousand five hundred forty-seven adults, aged 35 to 69 years, free of cardiovascular disease underwent a cognitive assessment using the Digital Symbol Substitution test and Montreal Cognitive Assessment, and magnetic resonance imaging (MRI) to detect covert vascular brain injury (high white matter hyperintensities, lacunar, and nonlacunar brain infarctions). Cardiovascular risk factors were quantified using the INTERHEART (A Global Study of Risk Factors for Acute Myocardial Infarction) risk score. Multivariable mixed models tested for independent determinants of reduced cognitive scores. The population attributable risk of risk factors and MRI vascular brain injury on low cognitive scores was calculated.

Results—

The mean age of participants was 58 (SD, 9) years; 55% were women. Montreal Cognitive Assessment and Digital Symbol Substitution test scores decreased significantly with increasing age ( P <0.0001), INTERHEART risk score ( P <0.0001), and among individuals with high white matter hyperintensities, nonlacunar brain infarction, and individuals with 3+ silent brain infarctions. Adjusted for age, sex, education, ethnicity covariates, Digital Symbol Substitution test was significantly lowered by 1.0 (95% CI, −1.3 to −0.7) point per 5-point cardiovascular risk score increase, 1.9 (95% CI, −3.2 to −0.6) per high white matter hyperintensities, 3.5 (95% CI, −6.4 to −0.7) per nonlacunar stroke, and 6.8 (95% CI, −11.5 to −2.2) when 3+ silent brain infarctions were present. No postsecondary education accounted for 15% (95% CI, 12–17), moderate and high levels of cardiovascular risk factors accounted for 19% (95% CI, 8–30), and MRI vascular brain injury accounted for 10% (95% CI, −3 to 22) of low test scores.

Conclusions—

Among a middle-aged community-dwelling population, scores on a cognitive screen were lower in individuals with higher cardiovascular risk factors or MRI vascular brain injury. Much of the population attributable risk of low cognitive scores can be attributed to lower educational attainment, higher cardiovascular risk factors, and MRI vascular brain injury.

Lead in drinking water: a response from the Atlantic PATH study

Exposure to lead through drinking water is an issue of increasing concern, particularly with recent high-profile cases of lead-contaminated water. The maximum acceptable concentration level for drinking water in Canada is 10 µg/L, whereas the current blood intervention level is 10 µg/dL. The health effects related to lead exposure are well established and there is evidence that blood lead levels as low as <5 µg/dL are associated with adverse health effects in both children and adults. We analyzed water and toenail samples for lead concentrations from the Atlantic Partnership for Tomorrow’s Health (Atlantic PATH) project, a cohort of the general population in Nova Scotia. Approximately 46% of Nova Scotia residents use well water as their primary source of drinking water. Water from dug wells had higher lead concentrations compared to drilled wells, and the lowest lead levels were found in water from municipal supplies. Although the majority of the lead levels in the drinking water provided by Atlantic PATH participants were below the Canadian maximum acceptable concentration level, there were outliers, particularly among unregulated private well water sources. Given the health effects that are linked to low-level exposures, any exposure to lead in primary water sources remains a concern.

Changing health in China: re-evaluating the epidemiological transition model

This paper reviews the changing health situation in China, which has shown remarkable improvement in the 50 years since the founding of the People's Republic of China (PRC) in 1949. At first sight this improving health situation follows the classical epidemiological transition model. Just three decades ago health in China was characterised by high rates of infectious disease and early mortality (diseases of poverty) in a mainly peasant society. More recently infectious disease rates have decreased, with corresponding and extended morbidity and mortality associated with an aging population in a rapidly urbanising society. This process has given rise to new health problems, including chronic and degenerative diseases (diseases of affluence). Nonetheless, while there is some validity in the application of the epidemiological transition concept, further analysis demonstrates that China faces a new epidemiological phase, characterised by increasing life expectancy and diseases of affluence coupled with the emergence and re-emergence of infectious diseases. We demonstrate that China's state policy plays a major role in defining the parameters of health in a Chinese context. We conclude that, today, China is faced with a new set of health issues, including the impact of smoking, hypertension, the health effects of environmental pollution and the rise of HIV/AIDS; however, state policy remains vital to the health of China's vast population. The challenge for policy is to maintain health reform whilst tackling the problems associated with rapid urbanisation, widening social and spatial inequalities and the emergence of HIV/AIDS and other infectious diseases.

Stillbirth risk with social class and deprivation: no evidence for increasing inequality

The objective of this study was to determine whether inequality in stillbirth risk between social strata has changed over time. Subjects were all 288,869 births in Cumbria, northwest England, 1950-1993 and all 8,039,269 births in England and Wales, 1981-1992. Social class of Cumbrian babies was ascertained from birth registrations. Community deprivation scores were calculated from census data for (i) enumeration districts in Cumbria and (ii) county districts in England and Wales. The relative index of inequality was used to measure inequality of stillbirth risk between social strata. Results indicate inequality in stillbirth risk in Cumbria has fallen significantly since 1966 (P< or =0.02) and was not evident in more recent time periods. In England and Wales, there was significant inequality in stillbirth risk in all time periods and no evidence that this has changed over time. Inequality in stillbirth risk has not increased and in some areas has attenuated in recent years.

Stillbirths in relation to the coastline of Cumbria, 1950-89

The nuclear installation at Sellafield, in west Cumbria in the north of England, has discharged radioactive waste into the Irish Sea since 1952. The objective of this paper was to investigate whether women living near to the coast in Cumbria had an increased risk of having stillborn children. A retrospective cohort analysis was carried out using all 259,050 births (4017 stillbirths) to women normally resident in Cumbria during 1950-89, allowing for year of birth, social class and birth order using (i) comparison of observed and expected numbers of stillbirths in distance bands relative to the coast, (ii) comparison of cumulative observed and expected numbers of stillbirths by distance from the coast, and (iii) logistic regression analysis of stillbirth risk in relation to distance from the coast. Comparison of observed and expected numbers of stillbirths in distance bands within 10 km of the coast did not provide evidence of an excess risk of stillbirth closer to the coast. The comparison of the cumulative observed and expected numbers of stillbirths within 10 km of the coast supported this result. Logistic regression analysis of all births in Cumbria showed that distance from the coast did not significantly influence stillbirth risk (P > 0.05). There was no evidence to suggest an increased risk of stillbirth in mothers resident nearer to the coast.

Stillbirth rates around the nuclear installation at Sellafield, North West England: 1950-1989

BACKGROUND

The aim of the study was to investigate whether proximity to the nuclear installation at Sellafield, in Cumbria, North West of England, increases the risk of stillbirth in the resident population. The cohort consisted of all 256066 live and 4034 stillbirths to mothers usually domiciled in Cumbria, 1950-1989.

METHODS

The study was a retrospective cohort analysis allowing for year of birth, social class and birth order using: (i) Poisson probability mapping, (ii) comparison of cumulative observed and expected numbers of stillbirths by distance from Sellafield, (iii) logistic regression of stillbirth risk in relation to distance and direction from Sellafield.

RESULTS

Poisson probability mapping of stillbirths within 25 km of Sellafield provided no evidence to suggest that proximity to Sellafield increased the risk of stillbirth, either overall or in any specific direction. Comparison of the cumulative observed and expected numbers of stillbirths also showed no increased risk with proximity to Sellafield. Logistic regression analysis of all Cumbrian births supported these results, showing, in particular, that distance from Sellafield did not significantly influence stillbirth risk (P = 0.30). Although there was significant variation in stillbirth risk with direction (P = 0.0004), this was due to stillbirths in areas much further than 25 km from Sellafield. There was no significant effect with distance from Sellafield within any of six directional sectors (P > 0.05).

CONCLUSIONS

There was no evidence to suggest that proximity to Sellafield increases the risk of stillbirth in the resident population.