The British Columbia Farmers' Market Nutrition Coupon Program Reduces Short-Term Household Food Insecurity Among Adults With Low Incomes: A Pragmatic Randomized Controlled Trial

BACKGROUND

The British Columbia Farmers' Market Nutrition Coupon Program (BC FMNCP) provides households with low incomes with coupons to purchase healthy foods from farmers' markets.

OBJECTIVE

To examine the impact of the BC FMNCP on the short-term household food insecurity, malnutrition risk, mental well-being, sense of community (secondary outcomes), and subjective social status (exploratory outcome) of adults with low incomes post-intervention and 16 weeks post-intervention.

DESIGN

Secondary analyses from a pragmatic randomized controlled trial conducted in 2019 that collected data at baseline, post-intervention, and 16 weeks post-intervention.

PARTICIPANTS/SETTING

Adults ≥18 years with low incomes were randomized to an FMNCP group (n = 143) or a no-intervention control group (n = 142).

INTERVENTION

Participants in the FMNCP group received 16 coupon sheets valued at $21 Canadian dollars (CAD)/sheet over 10 to 15 weeks to purchase healthy foods from farmers' markets and were eligible to participate in nutrition skill-building activities.

MAIN OUTCOME MEASURES

Outcomes included short-term household food insecurity (modified version of Health Canada's 18-item Household Food Security Survey Module), malnutrition risk (Malnutrition Universal Screening Tool), mental well-being (Warwick-Edinburgh Mental Well-Being Scale), sense of community (Brief Sense of Community Scale), and subjective social status (MacArthur Scale of Subjective Social Status community scale).

STATISTICAL ANALYSIS

Mixed-effects linear regression and multinomial logistic regression examined between-group differences in outcomes post-intervention and 16 weeks post-intervention.

RESULTS

The risk of marginal and severe short-term household food insecurity was lower among those in the FMNCP group compared with those in the control group (relative risk ratio [RRR] 0.15, P = 0.01 and RRR 0.16, P = 0.02) post-intervention, with sustained reductions in severe household food insecurity 16 weeks post-intervention (RRR 0.11, P = 0.01). No statistically significant differences were observed in malnutrition risk, mental well-being, sense of community, or subjective social status post-intervention or 16 weeks post-intervention.

CONCLUSIONS

The BC FMNCP reduced short-term household food insecurity but was not found to improve malnutrition risk or psychosocial well-being among adults with low incomes compared with a no-intervention control group.

Exploring the prospective acceptability of a healthy food incentive program from the perspective of people with type 2 diabetes and experiences of household food insecurity in Alberta, Canada

OBJECTIVE

FoodRx is a 12-month healthy food prescription incentive program for people with type 2 diabetes (T2DM) and experiences of household food insecurity. In this study, we aimed to explore potential users' prospective acceptability (acceptability prior to program use) of the design and delivery of the FoodRx incentive and identify factors influencing prospective acceptability.

DESIGN

We used a qualitative descriptive approach and purposive sampling to recruit individuals who were interested or uninterested in using the FoodRx incentive. Semi-structured interviews were guided by the theoretical framework of acceptability, and corresponding interview transcripts were analysed using differential qualitative analysis guided by the socioecological model.

SETTING

Individuals living in Alberta, Canada.

PARTICIPANTS

In total, fifteen adults with T2DM and experiences of household food insecurity.

RESULTS

People who were interested in using the FoodRx incentive (n 10) perceived it to be more acceptable than those who were uninterested (n 5). We identified four themes that captured factors that influenced users' prospective acceptability: (i) participants' confidence, views and beliefs of FoodRx design and delivery and its future use (intrapersonal), (ii) the shopping routines and roles of individuals in participants' social networks (interpersonal), (iii) access to and experience with food retail outlets (community), and (iv) income and food access support to cope with the cost of living (policy).

CONCLUSION

Future healthy food prescription programs should consider how factors at all levels of the socioecological model influence program acceptability and use these data to inform program design and delivery.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

A Healthy Food Prescription Incentive Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Longitudinal Qualitative Study

Objectives

Food insecurity is inadequate or insecure access to food due to financial constraints. Individuals experiencing food insecurity tend to have poorer diet quality compared to their food secure peers. Given the importance of maintaining healthful dietary patterns for optimal glycemic control, food insecurity is a considerable barrier to managing type 2 diabetes (T2DM). Healthy food prescription incentive programs aim to reduce such barriers by providing financial incentives to purchase healthy foods. The purpose of this study is to conduct longitudinal qualitative shop-along interviews among adults with T2DM who are experiencing food insecurity. We will explore experiences of redeeming healthy food incentives and factors influencing food purchasing patterns during participation in a healthy food prescription program in Alberta, Canada.

Methods

The healthy food prescription incentive program consists of two core elements: 1) A one-time healthy food prescription pamphlet outlining an evidence-based healthy dietary pattern; and 2) A healthy food incentive of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. Thirty participants aged 18–85 years will be purposefully recruited from primary care clinics. At baseline and 6-month follow-up, participants will take part in supermarket-based shop-along qualitative interviews. Participants will be asked to complete a usual grocery shop alongside a researcher. Using think-aloud principles, they will be asked to verbalize their thought processes for the shop's duration. Researchers will also collect naturalistic observations of participants, such as consulting nutrition labels. A post-shop interview will be completed to discuss experiences, decision-making rationale, and potential barriers and facilitators to food purchasing. Data will be analyzed iteratively and inductively at each time point. Further, a longitudinal analysis will compare emerging themes and identify changes occurring over time.

Results

N/A

Conclusions

This study will generate key data regarding if, how, and why such programs may address barriers to maintaining healthful dietary patterns. These findings will help to understand experiences of participating in healthy food incentive programs that can be used to improve future programs.

Funding Sources

Alberta Innovates.

Impact of the British Columbia Farmers’ Market Nutrition Coupon Program on the Diet Quality of Low-Income Adults: A Randomized Controlled Trial

Objectives

Improving diet quality among low-income populations remains a public health priority. In Canada, the British Columbia (BC) Farmers’ Market Nutrition Coupon Program (FMNCP) aims to improve the diet quality of low-income households by providing coupons to purchase healthy foods from BC farmers’ markets. This randomized controlled trial, conducted in 2019, examined the impact of the FMNCP on the diet quality of low-income adults.

Methods

Low-income adults ≥18 years were randomized to a FMNCP group (n = 143) that received 16 weeks’ worth of coupons valued at $21/week to purchase fruits, vegetables, dairy, meat, poultry, fish, eggs, and nuts from farmers’ markets, or to a no-intervention control group (n = 142). Participants completed data collection, including two 24-hour dietary recalls, at baseline (0 weeks), post-intervention (10–15 weeks), and 16 weeks post-intervention (26–31 weeks). Dietary intake data from the 24-hour dietary recalls were used to calculate Healthy Eating Index-2015 (HEI-2015) total scores (primary outcome) and subscores (secondary outcomes). Total scores can range from 0–100, with a higher score indicating higher diet quality. Between-group differences in HEI-2015 total scores and subscores at post-intervention and 16 weeks post-intervention were examined using linear mixed effect models. Subgroup analyses were conducted to examine differences in program impacts according to sex and age group (18–59 years, ≥60 years).

Results

Most participants were female (90.5%) and < 60 years of age (79.7%). HEI-2015 total scores did not significantly differ between the FMNCP and control groups at post-intervention (−0.07; 95% CI −4.07, 3.93) or 16 weeks post-intervention (1.22; 95% CI −3.00, 5.44). No significant between-group differences in HEI-2015 scores by sex or age group were identified. HEI-2015 subscores did not significantly differ at post-intervention; however, at 16-weeks post-intervention, the FMNCP group had significantly lower subscores for fatty acids and significantly higher subscores for dairy compared to the control group.

Conclusions

Participation in the FMNCP did not result in significant changes in overall diet quality among low-income adults.

Funding Sources

Canadian Institutes of Health Research and the Maple Leaf Centre for Action on Food Security.

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies

INTRODUCTION

The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures.

METHODS AND ANALYSIS

594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04725630.

PROTOCOL VERSION

Version 1.1; February 2022.

A Subsidized Healthy Food Prescription Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Randomized Controlled Trial

Objectives

It is vital for individuals with type 2 diabetes (T2DM) to adhere to a healthy dietary pattern to maintain optimal blood glucose levels and overall health. Increasing costs of healthy foods, however, are a barrier to maintaining healthful dietary patterns, particularly for individuals with T2DM who are experiencing food insecurity. Poor diet quality may result in difficulties maintaining optimal blood glucose levels, leading to higher rates of diabetes complications, and increased acute care usage and costs. Although the adverse impacts of food insecurity on maintaining optimal blood glucose levels are well documented, effective strategies to this among individuals with T2DM are lacking. One approach is providing subsidies to purchase healthy foods through subsidized healthy food prescription programs. These programs may help reduce food insecurity and improve diet quality, thereby improving blood glucose levels and reducing diabetes complications over time.

Methods

A parallel group randomized controlled trial will examine the effectiveness of a subsidized healthy food prescription program compared to a healthy food prescription alone in improving average blood glucose levels (primary outcome), and other secondary outcomes among 404 adults who are experiencing food insecurity and persistent hyperglycemia. The subsidized healthy food prescription program consists of two core elements: 1) A one-time healthy food prescription pamphlet that outlines an evidence-based healthy dietary pattern; 2) A healthy food subsidy of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. At baseline and 6-month follow-up, participants will provide responses to sociodemographic and health-related items, and a variety of patient-reported outcomes. Biochemical and physical measurements will also be obtained.

Results

The study's theory of change posits that reducing food insecurity and improving diet quality will be key mediators in improving blood glucose levels, which may reduce diabetes complications, and healthcare usage and costs over time.

Conclusions

The results of this study will demonstrate if a subsidized healthy food prescription program results in meaningful changes in average blood glucose levels and other clinically relevant outcomes.

Funding Sources

Alberta Innovates, Alberta Health Services.

Perspectives of hematology oncology clinicians about integrating palliative care in oncology

Patients with hematologic malignancies receive palliative care (pc) less frequently and later than patients with solid tumours. We compared survey responses of hematology oncology clinicians with other oncology clinicians to better understand their challenges with providing primary pc or using secondary pc. Patients' negative perceptions of pc and limited time or competing priorities were challenges for all clinicians. Compared with other oncology clinicians, more hematology oncology clinicians perceived pc referral criteria as too restrictive (40% vs. 22%, p = 0.021) and anticipated that integrating pc supports into their practice would require substantial change (53% vs. 28%, p = 0.014). This study highlights barriers that may need targeted interventions to better integrate pc into the care of patients with hematologic malignancies.

Impact of a farmers' market nutrition coupon programme on diet quality and psychosocial well-being among low-income adults: protocol for a randomised controlled trial and a longitudinal qualitative investigation

INTRODUCTION

Low-income populations have poorer diet quality and lower psychosocial well-being than their higher-income counterparts. These inequities increase the burden of chronic disease in low-income populations. Farmers' market subsidies may improve diet quality and psychosocial well-being among low-income populations. In Canada, the British Columbia (BC) Farmers' Market Nutrition Coupon Programme (FMNCP) aims to improve dietary patterns and health among low-income participants by providing coupons to purchase healthy foods from farmers' markets. This study will assess the impact of the BC FMNCP on the diet quality and psychosocial well-being of low-income adults and explore mechanisms of programme impacts.

METHODS AND ANALYSIS

In a parallel group randomised controlled trial, low-income adults will be randomised to an FMNCP intervention (n=132) or a no-intervention control group (n=132). The FMNCP group will receive 16 coupon sheets valued at CAD$21/sheet over 10-15 weeks to purchase fruits, vegetables, dairy, meat/poultry/fish, eggs, nuts and herbs at farmers' markets and will be invited to participate in nutrition skill-building activities. Overall diet quality (primary outcome), diet quality subscores, mental well-being, sense of community, food insecurity and malnutrition risk (secondary outcomes) will be assessed at baseline, immediately post-intervention and 16 weeks post-intervention. Dietary intake will be assessed using the Automated Self-Administered 24-hour Dietary Recall. Diet quality will be calculated using the Healthy Eating Index-2015. Repeated measures mixed-effect regression will assess differences in outcomes between groups from baseline to 16 weeks post-intervention. Furthermore, 25-30 participants will partake in semi-structured interviews during and 5 weeks after programme completion to explore participants' experiences with and perceived outcomes from the programme.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary Conjoint Health Research Ethics Board, Rutgers University Ethics and Compliance, and University of Waterloo Office of Research Ethics. Findings will be disseminated through policy briefs, conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03952338.

Pediatric sacral nerve stimulator explanation due to complications or cure: a survival analysis

INTRODUCTION

Historically, there have been few treatment options for children with severe refractory bladder and bowel dysfunction (BBD). Sacral neuromodulation (SNM) continues to show promising results in this challenging pediatric population with recalcitrant lower urinary tract symptoms. At the authors institution, they have begun offering explantation to those with persistent improvement after >6 months of having device turned off. The authors hypothesized that (1) SNM explantation for cure increases with extended follow-up and (2) those explanted for cure would have improved symptoms and quality of life when compared to those explanted for complication.

MATERIALS & METHODS

The authors retrospectively reviewed all consecutive patients aged <18 years who underwent SNM placements at their institution (2012-2017). They excluded those without the second stage procedure. Reasons for device explantation were categorized as cure (resolution of symptoms with the device turned off for at least 6 months) or a complication (e.g. infection, need for magnetic resonance imaging, or pain). Non-parametric tests and survival analysis were used for analysis to account for differential follow-up time. Of those explanted, surveys were electronically sent to assess BBD severity and overall quality of life.

RESULTS

Of 67 children who underwent a first stage procedure, 62 (92.5%) underwent a second stage procedure. 61 met inclusion criteria (68.9% female, 29.5% with previous filum section, median age at implantation 10.3 years). During follow-up (median 2.3 years), 12 patients (19.7%) had the SNM exchanged/revised because of lead fracture/breakage and return of urinary symptoms. To date, 50 patients remain with their SNM implanted, and 11 have been explanted. Adjusting for follow-up time, the risk of explantation was 6.5% at 2 years (2.2% for cure, 4.3% for complications) (Figure 1). Explantation increased to 24.5% at 3 years (16.5% for cure, 8.0% for complications) and 40.4% at 4 years (32.4% for cure, 8.0% for complications). Questionnaires were collected on patients after explant (median 2.2 years), with improvement in those explanted for cure compared to complication (Figure 2).

DISCUSSION

Sacral neuromodulation explantation for cure is a novel concept previously not described in the literature. Limitations of this study include the relatively small numbers and lack of objective data in the cohort that remains with SNM device implanted.

CONCLUSION

Sacral neuromodulation is a safe, viable option for the pediatric patient with refractory bladder dysfunction. Furthermore, SNM explantation for cure is an option with increasing likelihood after 2 years.

Barriers to providing palliative care to patients with advanced cancer: A province-wide survey of oncology clinicians’ perceptions

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Background: Despite known benefits, cancer care systems struggle to provide early, integrated palliative care (PC). Previously, we identified barriers to providing early PC as perceived by gastrointestinal oncology clinicians in Alberta, Canada (top barrier: time/competing priorities). Here, we expand on the previous study to better understand barriers to early PC for clinicians working with all tumor groups across Alberta. Methods: A 33-item survey was emailed to oncology clinicians in Alberta between November 2017 - January 2018. Questions were informed by Michie’s Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW) and queried (a) providing PC in oncology clinics, (b) referral to specialist PC consultation, and (c) working with PC consultants and homecare. Results: Respondents (n = 268) were nurses (42%), physicians (25%), and allied health professionals (20%). Barriers most frequently identified were "patients’ negative perceptions of PC” (68%), “my limited time/competing priorities” (66%), and "capability to manage patients’", social (65%) and spiritual (63%) concerns. These factors map to all three BCW domains: motivation, opportunity, and capability. In contrast, least frequently identified barriers were in clinician’s own motivation, e.g. perceived benefits of PC. There were few significant differences in response by tumor group or profession (χ2 test, responses coded: disagree [1-3], neutral [4], agree [5-7]). Most notably, tumor groups differed in their perception that “the criteria for PC services are too restrictive” (p = 0.003), while nurses and allied staff reported that patients’ negative perception of PC is a barrier more frequently than physicians (p = 0.003). Conclusions: Surveying across clinicians and tumor groups using Michie’s TDF/BCW revealed that the challenges to an early integrated PC approach include all three sources of behavior, though not equally for all clinicians. Determining this has allowed us to tailor multifaceted interventions, e.g. tip sheets to enhance capability, re-framing PC with patients, and earlier secondary PC nursing access, to enhance clinicians use and patients benefit from an early PC approach.

Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid

Background

Major haemorrhage is a leading cause of mortality following major trauma. Increasingly, Helicopter Emergency Medical Services (HEMS) in the United Kingdom provide pre-hospital transfusion with blood products, although the evidence to support this is equivocal. This study compares mortality for patients with suspected traumatic haemorrhage transfused with pre-hospital packed red blood cells (PRBC) compared to crystalloid.

Methods

A single centre retrospective observational cohort study between 1 January 2010 and 1 February 2015. Patients triggering a pre-hospital Code Red activation were eligible. The primary outcome measure was all-cause mortality at 6 hours (h) and 28 days (d), including a sub-analysis of patients receiving a major and massive transfusion. Multivariable regression models predicted mortality. Multiple Imputation was employed, and logistic regression models were constructed for all imputed datasets.

Results

The crystalloid (n = 103) and PRBC (n = 92) group were comparable for demographics, Injury Severity Score (p = 0.67) and mechanism of injury (p = 0.73). Observed 6 h mortality was smaller in the PRBC group (n = 10, 10%) compared to crystalloid group (n = 19, 18%). Adjusted OR was not statistically significant (OR 0.48, CI 0.19–1.19, p = 0.11). Observed mortality at 28 days was smaller in the PRBC group (n = 21, 26%) compared to crystalloid group (n = 31, 40%), p = 0.09. Adjusted OR was not statistically significant (OR 0.66, CI 0.32–1.35, p = 0.26). A statistically significant greater proportion of the crystalloid group required a major transfusion (n = 62, 60%) compared to the PRBC group (n = 41, 40%), p = 0.02. For patients requiring a massive transfusion observed mortality was smaller in the PRBC group at 28 days (p = 0.07).

Conclusion

In a single centre UK HEMS study, in patients with suspected traumatic haemorrhage who received a PRBC transfusion there was an observed, but non-significant, reduction in mortality at 6 h and 28 days, also reflected in a massive transfusion subgroup. Patients receiving pre-hospital PRBC were significantly less likely to require an in-hospital major transfusion. Further adequately powered multi-centre prospective research is required to establish the optimum strategy for pre-hospital volume replacement in patients with traumatic haemorrhage.

Lay health educators within primary care practices to improve cancer screening uptake for South Asian patients: challenges in quality improvement

BACKGROUND

Cancer screening uptake is known to be low among South Asian residents of Ontario. The objective of this pilot study was to determine if lay health educators embedded within the practices of primary care providers could improve willingness to screen and cancer screening uptake for South Asian patients taking a quality improvement approach.

MATERIALS AND METHODS

Participating physicians selected quality improvement initiatives to use within their offices that they felt could increase willingness to screen and cancer screening uptake. They implemented initiatives, adapting as necessary, for six months.

RESULTS

Four primary care physicians participated in the study. All approximated that at least 60% of their patients were of South Asian ethnicity. All physicians chose to work with a preexisting lay health educator program geared toward South Asians. Health ambassadors spoke to patients in the office and telephoned patients. For all physicians, ~60% of South Asian patients who were overdue for cancer screening and who spoke directly to health ambassadors stated they were willing to be screened. One physician was able to track actual screening among contacted patients and found that screening uptake was relatively high: from 29.2% (colorectal cancer) to 44.6% (breast cancer) of patients came in for screening within six months of the first phone calls. Although physicians viewed the health ambassadors positively, they found the study to be time intensive and resource intensive, especially as this work was additional to usual clinical duties.

DISCUSSION

Using South Asian lay health educators embedded within primary care practices to telephone patients in their own languages showed promise in this study to increase awareness about willingness to screen and cancer screening uptake, but it was also time intensive and resource intensive with numerous challenges. Future quality improvement efforts should further develop the phone call invitation process, as well as explore how to provide infrastructure for lay health educator training and time.

Perovskite BiFeO3 thin film photocathode performance with visible light activity

Perovskite materials are now an important class of materials in the application areas of photovoltaics and photocatalysis. Inorganic perovskites such as BiFeO3 (BFO) are promising photocatalyst materials with visible light activity and inherent stability. Here we report the large area sol-gel synthesis of BFO films for solar stimulated water photo oxidation. By modifying the sol-gel synthesis process we have produced a perovskite material that has p-type behaviour and a flat band potential of ∼1.15 V (versus NHE). The photocathode produces a density of -0.004 mA cm(-2) at 0 V versus NHE under AM1.5 G illumination. We further show that 0.6 μmol h(-1) of O2 was produced at an external bias of -0.5 V versus Ag/AgCl. The addition of a non-percolating conducting network of Ag increases the photocurrent to -0.07 mA cm(-2) at 0 V versus NHE (at 2% Ag loading) with an increase to 2.7 μmol h(-1) for O2 production. We attribute the enhancement in photoelectrochemical performance to increased light absorption due light scattering by the incorporated Ag particles, improved charge transfer kinetics at the Ag/BFO interface and reduced over potential losses. We support these claims by an observed shift in flat band and onset potentials after Ag modification through UV-vis spectroscopy, Mott-Schottky plots and j-v curve analysis.

Shared decision making for infants born at the threshold of viability: a prognosis-based guideline

OBJECTIVE

Making prenatal decisions regarding resuscitation of extremely premature infants, based on gestational age alone is inadequate. We developed a prognosis-based guideline.

STUDY DESIGN

We followed a five step approach and used the AGREE II framework: (1) systematic review and critical appraisal of published guidelines; (2) identification of key medical factors for decision making; (3) systematic reviews; (4) creation of a multi-disciplinary working group and (5) external consultation and appraisal.

RESULT

No published guideline met high-quality appraisal criteria. Survival, neurodevelopmental disability, quality of life of child and parents, and maternal mortality and risk of long-term morbidity were identified as key for quality decision-making. Eighteen stakeholders (including parents) advocated for the incorporation of parents' values and preferences in the process.

CONCLUSION

A novel framework, based on prognosis, was generated to guide when early intensive and palliative care may both be offered to expectant parents. Pre-implementation assessment is underway to identify barriers and facilitators to putting in practice.

Primary care physicians' perceptions about and confidence in deciding which patients to refer for total joint arthroplasty of the hip and knee

OBJECTIVE

The purpose of this study is to examine the perceptions of primary care physicians (PCPs) regarding indications, contraindications, risks and benefits of total joint arthroplasty (TJA) and their confidence in selecting patients for referral for TJA.

DESIGN

PCPs recruited from among those providing care to participants in an established community cohort with hip or knee osteoarthritis (OA). Self-completed questionnaires were used to collect demographic and practice characteristics and perceptions about TJA. Confidence in referring appropriate patients for TJA was measured on a scale from 1 to 10; respondents scoring in the lowest tertile were considered to have 'low confidence'. Descriptive analyses were conducted and multiple logistic regression was used to determine key predictors of low confidence.

RESULTS

212 PCPs participated (58% response rate) (65% aged 50+ years, 45% female, 77% >15 years of practice). Perceptions about TJA were highly variable but on average, PCPs perceived that a typical surgical candidate would have moderate pain and disability, identified few absolute contraindications to TJA, and overestimated both the effectiveness and risks of TJA. On average, PCPs indicated moderate confidence in deciding who to refer. Independent predictors of low confidence were female physicians (OR = 2.18, 95% confidence interval (CI): 1.06-4.46) and reporting a 'lack of clarity about surgical indications' (OR = 3.54, 95% CI: 1.87-6.66).

CONCLUSIONS

Variability in perceptions and lack of clarity about surgical indications underscore the need for decision support tools to inform PCP - patient decision making regarding referral for TJA.

Plasmon enhanced visible light photocatalysis for TiO2 supported Pd nanoparticles

A photocatalyst consisting of nanostructured Pd photochemically deposited on 20 nm TiO2 displays a reaction half-life for rhodamine b decolourisation of 0.5 minute compared to the 9.4 minutes for unmodified P25 under identical reaction conditions. We associate this increased decolourisation rate to the increase in solar light harvesting which we have measured at 8% due to a significant red shift in the absorption profile of the catalyst. We relate the increased absorption of light with a visible active plasmon effect that is associated with the Pd nanostructures on the TiO2. This overall red-shift in the light harvesting for the catalyst leads to photocatalytic activity for excitations up to 600 nm.

Reduction of noise in the neonatal intensive care unit using sound-activated noise meters

OBJECTIVES

To determine if sound-activated noise meters providing direct audit and visual feedback can reduce sound levels in a level 3 neonatal intensive care unit (NICU).

DESIGN/METHODS

Sound levels (in dB) were compared between a 2-month period with noise meters present but without visual signal fluctuation and a subsequent 2 months with the noise meters providing direct audit and visual feedback.

RESULTS

There was a significant increase in the percentage of time the sound level in the NICU was below 50 dB across all patient care areas (9.9%, 8.9% and 7.3%). This improvement was not observed in the desk area where there are no admitted patients. There was no change in the percentage of time the NICU was below 45 or 55 dB.

CONCLUSIONS

Sound-activated noise meters seem effective in reducing sound levels in patient care areas. Conversations may have moved to non-patient care areas preventing a similar change there.

Examining the effects of a targeted noise reduction program in a neonatal intensive care unit

OBJECTIVES

To determine whether implementation of a noise reduction policy followed by the addition of direct audit and feedback reduces noise levels in a tertiary-level neonatal intensive care unit (NICU).

STUDY DESIGN

Noise level data was collected in three phases: (1) baseline (preintervention), (2) immediately postimplementation of our noise reduction policy, (3) postunveiling of direct audit and feedback mechanism.

SETTING

A level 3 NICU in Ontario, Canada.

INTERVENTIONS

Noise reduction policy and a direct audit and feedback mechanism.

MAIN OUTCOME MEASURES

Average noise level.

RESULTS

The baseline level of noise in our unit consistently exceeds guidelines with an average baseline noise of 49 dB (±1.4). Our intervention resulted in a significant reduction in noise levels for one of the four areas in our NICU [-1.06 dB (-1.52, -0.6)], with a trend towards reduction in a second area (-0.21 dB (-0.6, 0.18)). Unexpectedly, two other areas experienced a significant increase in noise (2.05 dB (1.18, 2.94); 0.85 dB (0.11, 1.59)).

CONCLUSIONS

The baseline noise in the NICU consistently exceeds guidelines, but reductions in noise levels are achievable. Nonetheless, more work is needed to find the optimal NICU design and noise reduction strategy.

Effluent Storage and Biomat Occurrence among Septic System Absorption Field Architectures in a Typic Fragiudult

On-site wastewater treatment systems (OWTSs) are commonly used by households in areas of low population density to treat household wastewater and recycle it back to the environment. However, new absorption field products of differing architecture types have recently become available. A 3-yr field study was conducted in Bethel Heights, northwest Arkansas to assess several newer architecture types (i.e., chambers, polystyrene-aggregate, and gravel-less pipe) relative to the traditional pipe-and-gravel design under wet- and dry-soil conditions. Thirteen products of four different architecture types were installed in 46-cm-deep trenches in a Captina silt loam (fine-silty, siliceous, active, mesic Typic Fragiudult). Products were evaluated based on in-trench solution storage measured with an electronic water-level sensor approximately weekly from January 2009 through January 2012. Between May 2010 and January 2012, the thickness of any biomat formation was measured approximately weekly by insertion of a wooden dowel through in-trench monitoring ports. Architecture type alone did not affect ( > 0.05) in-trench solution storage. However, solution storage among individual products differed under wet- and dry-soil conditions ( < 0.05). When present, biomat thickness differed significantly ( < 0.05) among all four architecture types, ranging from 1.4 to 6.2 cm thick on average in the pipe-and-aggregate and polystyrene-aggregate types, respectively. Regression analyses showed that biomat thickness increased in three products, did not change in nine products, and decreased in one product over time. Results showed that several currently approved alternative products had similar in-trench solution storage but that several alternative products also had greater solution storage than that of the traditional pipe-and-gravel system. With no observed effluent surfacing, the soil morphology approach appears to be adequate and appropriately environmentally conservative for assigning typical single-family loading rates to alternative OWTS products and to the traditional pipe-and-gravel system.

Non-ST-elevation myocardial infarction following foam ultrasound-guided sclerotherapy

The objective of the study was to describe a very rare complication of foam ultrasound-guided sclerotherapy (FUGS). An unusual case of persisting chest discomfort following FUGS in a 61-year-old woman led to a diagnosis of non-ST-elevation myocardial infarction. The patient was found to have a patent foramen ovale (PFO). The differential diagnoses of paradoxical embolism, gas embolism or vasospasm are discussed, with reference to relevant literature. A hypothesis of post sclerotherapy release of endothelin-1 (in a patient with a known PFO) leading to sustained coronary artery spasm causing sufficient myocardial damage to be reflected in elevated troponin levels is suggested.

Any episode of chest tightness or pain following FUGS should be considered as possibly cardiac in origin. Sustained symptoms warrant admission to hospital for troponin monitoring and ECG assessment.

2008 Niday Perinatal Database quality audit: report of a quality assurance project

INTRODUCTION

This quality assurance project was designed to determine the reliability, completeness and comprehensiveness of the data entered into Niday Perinatal Database.

METHODS

Quality of the data was measured by comparing data re-abstracted from the patient record to the original data entered into the Niday Perinatal Database. A representative sample of hospitals in Ontario was selected and a random sample of 100 linked mother and newborn charts were audited for each site. A subset of 33 variables (representing 96 data fields) from the Niday dataset was chosen for re-abstraction.

RESULTS

Of the data fields for which Cohen's kappa statistic or intraclass correlation coefficient (ICC) was calculated, 44% showed substantial or almost perfect agreement (beyond chance). However, about 17% showed less than 95% agreement and a kappa or ICC value of less than 60% indicating only slight, fair or moderate agreement (beyond chance).

DISCUSSION

Recommendations to improve the quality of these data fields are presented.