Healthcare — Open Access Journal

Lyme disease, caused by the spirochetal bacterium, Borrelia burgdorferi sensu lato (Bbsl), is typically transmitted by hard-bodied ticks (Acari: Ixodidae). Whenever this tick-borne zoonosis is mentioned in medical clinics and emergency rooms, it sparks a firestorm of controversy. Denial often sets in, and healthcare practitioners dismiss the fact that this pathogenic spirochetosis is present in their area. For distribution of Bbsl across Canada, we conducted a 4-year, tick–host study (2013–2016), and collected ticks from avian and mammalian hosts from Atlantic Canada to the West Coast. Overall, 1265 ticks representing 27 tick species belonging to four genera were collected. Of the 18 tick species tested, 15 species (83%) were positive for Bbsl and, of these infected ticks, 6 species bite humans. Overall, 13 of 18 tick species tested are human-biting ticks. Our data suggest that a 6-tick, enzootic maintenance cycle of Bbsl is present in southwestern B.C., and five of these tick species bite humans. Biogeographically, the groundhog tick, Ixodes cookei, has extended its home range from central and eastern Canada to southwestern British Columbia (B.C.). We posit that the Fox Sparrow, Passerella iliaca, is a reservoir-competent host for Bbsl. The Bay-breasted Warbler, Setophaga castanea, and the Tennessee Warbler, Vermivora peregrina, are new host records for the blacklegged tick, Ixodes scapularis. We provide the first report of a Bbsl-positive Amblyomma longirostre larva parasitizing a bird; this bird parasitism suggests that a Willow Flycatcher is a competent reservoir of Bbsl. Our findings show that Bbsl is present in all provinces, and that multiple tick species are implicated in the enzootic maintenance cycle of this pathogen. Ultimately, Bbsl poses a serious public health contagion Canada-wide. Full article

Background: Studies evaluating the end-of-life care for longer periods of illness trajectories and in several care places are currently lacking. This study explored bereaved family members’ satisfaction with care during the last three months of life for people with advanced illness, and associations between satisfaction with care and characteristics of the deceased individuals and their family members. Methods: A cross-sectional survey design was used. The sample was 485 family members of individuals who died at four different hospitals in Sweden. Results: Of the participants, 78.7% rated the overall care as high. For hospice care, 87.1% reported being satisfied, 87% with the hospital care, 72.3% with district/county nurses, 65.4% with nursing homes, 62.1% with specialized home care, and 59.6% with general practitioners (GPs). Family members of deceased persons with cancer were more likely to have a higher satisfaction with the care. A lower satisfaction was more likely if the deceased person had a higher educational attainment and a length of illness before death of one year or longer. Conclusion: The type of care, diagnoses, length of illness, educational attainment, and the relationship between the deceased person and the family member influences the satisfaction with care. Full article

We present a precision medical perspective to assist in the definition, diagnosis, and management of Post Treatment Lyme Disease Syndrome (PTLDS)/chronic Lyme disease. PTLDS represents a small subset of patients treated for an erythema migrans (EM) rash with persistent or recurrent symptoms and functional decline. The larger population with chronic Lyme disease is less understood and well defined. Multiple Systemic Infectious Disease Syndrome (MSIDS) is a multifactorial model for treating chronic disease(s), which identifies up to 16 overlapping sources of inflammation and their downstream effects. A patient symptom survey and a retrospective chart review of 200 patients was therefore performed on those patients with chronic Lyme disease/PTLDS to identify those variables on the MSIDS model with the greatest potential effect on regaining health. Results indicate that dapsone combination therapy decreased the severity of eight major Lyme symptoms, and multiple sources of inflammation (other infections, immune dysfunction, autoimmunity, food allergies/sensitivities, leaky gut, mineral deficiencies, environmental toxins with detoxification problems, and sleep disorders) along with downstream effects of inflammation may all affect chronic symptomatology. In part two of our observational study and review paper, we postulate that the use of this model can represent an important and needed paradigm shift in the diagnosis and treatment of chronic disease. Full article

Nurse leaders in middle management positions in Norway and other Western countries perform additional new tasks due to high demands for quality and efficacy in healthcare services. These nurses are increasingly becoming responsible for service development and innovation in addition to their traditional leadership and management roles. This article analyses two Norwegian nurse leaders efforts in developing an emergency service in rural municipal healthcare. The analysis applies an ethnographic approach to the data collection by combining interviews with the nurse leaders with observations and interviews with six nurses in the emergency service. The primary theoretical concepts used to support the analysis include “organizing work” and “articulation work”. The results show that in the development of an existing emergency room service, the nurse leaders drew upon their experience as clinical nurses and leaders in various middle management positions in rural community healthcare. Due to their local knowledge and experience, the nurses were able to mobilize and facilitate cooperation among relevant actors in the community and negotiate for resources required for emergency medical equipment, professional development, and staffing to perform emergency care within the rural healthcare context. Due to their distinctive professional and organizational competency and experience, the nurse leaders were well equipped to play a key role in developing services. While mobilizing actors and negotiating for resources, the nurses creatively balanced these two aspects of nursing work to develop the service in accordance to their expectation of providing the highest quality of nursing care to their patients. The nurse leaders balanced their professional ambitions for the service with legal directives, economic incentives, and budgets. Throughout the development process, the nurses carefully combined value-based and goal-based management concerns. In contrast, other studies investigating nursing management and leadership have described that these orientations are in opposition to each other. This study shows that nurses leading the processes of change in rural communities manage the change process by combining the professional and organizational domains of the services. Full article

Background: Craniosynostoses are congenital defects in the construction of the skull involving premature fusion of one or more cranial sutures. Premature fusion of sutures causes characteristic skull deformation(s). This affect the structure and thus the appearance of the entire head and face. The aim of this study was to analyze parents’ subjective assessments of head and facial appearance in children with craniosynostoses before and after surgery. Parents also assessed the interpersonal relationship of their children with peers and adults (after surgery). Methods: This study was conducted among parents of 230 children treated in Poland, in two multidisciplinary centers. Detailed statistical analysis was conducted among children who had undergone surgery. Independent variables were age (at survey) of the child (three years and less, four years, and five years and more) and type of craniosynostosis (isolated and syndromic). A chi-square independence test was used. Data was collected using surveys. Results: In the opinion of most parents, the appearance of their child’s head and face after surgery did not differ or differed only slightly from that of their peers. The results of subjective assessment of appearance of children’s face and head after reconstructive treatment remains comparable in three subgroups of patients according to the age. It seems that specific head shape according to the type of craniosynostosis does not have an impact on relations with peers and adults. Conclusion: Surgical treatment of children with craniosynostoses improves the appearance of their head and face. This improvement seems not to depend on the type of isolated craniosynostosis, and is constant over time. Full article

This article proposes taking another look at behavioral symptoms of dementia (BSDs) both from a theoretical perspective that informs research and practice and from a measurement perspective. We discuss why this rethinking of behaviors impacts current models of care and our ability to better detect outcomes from interventions. We propose that BSDs be viewed from a pattern perspective and provide some suggestions for how to identify and measure these patterns that can influence the timing and type of intervention. Evidence suggests that BSDs are complex, sequential, patterned clusters of behavior recurring repeatedly in the same individual and escalate significantly without timely intervention. However, BSDs are frequently viewed as separate behaviors rather than patterns or clusters of behaviors, a view that affects current research questions as well as the choice, timing, and outcomes of interventions. These symptoms cause immense distress to persons with the disease and their caregivers, trigger hospitalizations and nursing home placement, and are associated with increased care costs. Despite their universality and that symptoms manifest across disease etiologies and stages, behaviors tend to be underrecognized, undertreated, and overmanaged by pharmacological treatments that may pose more harm than benefit. Full article

Lyme disease arises from infection with pathogenic Borrelia species. In Canada, current case definition for confirmed Lyme disease requires serological confirmation by both a positive first tier ELISA and confirmatory second tier immunoblot (western blot). For surveillance and research initiatives, this requirement is intentionally conservative to exclude false positive results. Consequently, this approach is prone to false negative results that lead to underestimation of the number of people with Lyme disease. The province of New Brunswick (NB), Canada, can be used to quantify under-detection of the disease as three independent data sets are available to generate an estimate of the true human disease prevalence and incidence. First, detailed human disease incidence is available for the US states and counties bordering Canada, which can be compared with Canadian disease incidence. Second, published national serology results and well-described sensitivity and specificity values for these tests are available and deductive reasoning can be used to query for discrepancies. Third, high-density tick and canine surveillance data are available for the province, which can be used to predict expected human Lyme prevalence. Comparison of cross-border disease incidence suggests a minimum of 10.2 to 28-fold under-detection of Lyme disease (3.6% to 9.8% cases detected). Analysis of serological testing predicts the surveillance criteria generate 10.4-fold under-diagnosis (9.6% cases detected) in New Brunswick for 2014 due to serology alone. Calculation of expected human Lyme disease cases based on tick and canine infections in New Brunswick indicates a minimum of 12.1 to 58.2-fold underestimation (1.7% to 8.3% cases detected). All of these considerations apply generally across the country and strongly suggest that public health information is significantly under-detecting and under-reporting human Lyme cases across Canada. Causes of the discrepancies between reported cases and predicted actual cases may include undetected genetic diversity of Borrelia in Canada leading to failed serological detection of infection, failure to consider and initiate serological testing of patients, and failure to report clinically diagnosed acute cases. As these surveillance criteria are used to inform clinical and public health decisions, this under-detection will impact diagnosis and treatment of Canadian Lyme disease patients. Full article

Lyme disease is caused by the bacteria borrelia burgdorferi and is spread primarily through the bite of a tick. There is considerable uncertainty in the medical community regarding the best approach to treating patients with Lyme disease who do not respond fully to short-term antibiotic therapy. These patients have persistent Lyme disease symptoms resulting from lack of treatment, under-treatment, or lack of response to their antibiotic treatment protocol. In the past, treatment trials have used small restrictive samples and relied on average treatment effects as their measure of success and produced conflicting results. To provide individualized care, clinicians need information that reflects their patient population. Today, we have the ability to analyze large data bases, including patient registries, that reflect the broader range of patients more typically seen in clinical practice. This allows us to examine treatment variation within the sample and identify groups of patients that are most responsive to treatment. Using patient-reported outcome data from the MyLymeData online patient registry, we show that sub-group analysis techniques can unmask valuable information that is hidden if averages alone are used. In our analysis, this approach revealed treatment effectiveness for up to a third of patients with Lyme disease. This study is important because it can help open the door to more individualized patient care using patient-centered outcomes and real-world evidence. Full article

The ingestion of fluoride-contaminated water causes serious health issues in people all over the world. In the current study, the adsorption of fluoride onto chicken bone char (CBC) was investigated as a defluoridation technique. Finer-sized CBC with a diameter of 106–212 µm was used to investigate the fluoride adsorption capacity onto CBC. Results revealed that finer-sized CBC yielded an unusually high fluoride adsorption capacity of 11.2 mg/g at the equilibrium fluoride concentration of 10 mg/L. The study shows that CBC can be utilized in the defluoridation of drinking water and that finer-sized CBC enhances ion exchange to perform a higher adsorption capacity. Full article

This study investigated healthcare workers’ perceptions of hand hygiene practices by comparing personal reports, as assessed by questionnaires, to direct observations of the workers’ hand hygiene practices. The study employed a cross-sectional research design. Observations were made using a 16-item checklist, based on three sources: Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and Boyce and Pittet’s guidelines of hand hygiene. The checklist was used for both direct-observation and self-reported data collection purposes. Pearson correlation and Multivariate Analysis of Covariance (MANCOVA) were utilized to statistically determine the relationship between healthcare workers’ reports of hand hygiene practices and observed hand hygiene behaviors. The study was conducted in the outpatient examination rooms and emergency departments of three types of hospitals in the Eastern region of Saudi Arabia where Middle East respiratory syndrome coronavirus (MERS-CoV) is endemic and is observed in routine cases and outbreaks. The total sample size included 87 physicians and nurses recruited while on duty during the scheduled observation periods, with each healthcare worker being observed during individual medical examinations with at least three patients. No statistically significant correlations between the healthcare workers’ perceptions of hand hygiene practices and healthcare workers’ actual behaviors were evident. Based on the self-report questionnaires, significant differences were found between physicians’ and nurses’ hand hygiene practices reports. Healthcare workers clearly understand the importance of careful hand hygiene practices, but based on researchers’ observations, the medical personnel failed to properly implement protocol-driven hand hygiene applications. However, the significant differences between physicians’ and nurses’ self-reports suggest further inquiry is needed to fully explore these discrepancies. Full article

Androgen deficiency in males has traditionally been predominantly limited to older men aged 50+ years. However, little is known of the correlation between hormonal disruption, stress, and sleep in college-aged males. This cross-sectional study investigates lifestyle behavior patterns in young men and a screening for potential androgen deficiency. A survey of 409 male students, as part of a larger USDA-funded GetFruved study, was analyzed for this subproject. Survey instruments used include the Androgen Deficiency in the Aging Male Questionnaire (ADAM) to assess for inadequate ADAM scores, the Perceived Stress Scale to measure stress levels and the Pittsburgh Sleep Quality Index to evaluate sleep quality. In total, 144 male participants (35%) met criteria for potential androgen deficiency defined by the ADAM questionnaire. Correlation was found between having a positive ADAM score and both increased stress levels (p < 0.001) and poor sleep quality (p < 0.001), with stress displaying the strongest effect (p < 0.001 vs p = 0.124). An increased prevalence of having a positive ADAM score versus established norms for this age group was also noted. These findings highlight the need for investigation of endocrine disruptions in young men. Full article

The comprehensive assessment of delayed childbearing needs a valid and reliable instrument. Therefore, the aim of the present study was to develop an instrument to evaluate factors influencing delayed childbearing among women and to assess its psychometric properties. The current methodological study was performed in two phases of (i) qualitative instrument development, and (ii) quantitative psychometric assessment of the developed instrument. Face and content validity of the instrument was assessed by eligible women and a panel of experts. Construct validity was assessed using the exploratory factor analysis (EFA). For reliability, internal consistency reliability and intra-rater reliability analysis were used. The initial instrument developed from the qualitative phase consisted of 60 items, which were reduced to 55 items after the face and content validity processes. EFA (n = 300) using the Kaiser criteria (Eigenvalues > 1) and the scree plot led to a six-factor solution accounting for 61.24% of the observed variance. The Cronbach’s alpha coefficient, Spearman’s correlation, test–retest and intra-class correlation coefficients for the whole instrument were reported as 0.83, 0.86 and 0.81, respectively. The final instrument entitled the delayed childbearing questionnaire (DCBQ-55) included 50 items with six domains of ‘readiness for childbearing’, ‘stability in the partner relationship’, ‘awareness about the adverse outcomes of pregnancy in advanced maternal age’, ‘attitude toward delayed childbearing’, ‘family support’, and ‘social support’ on a five-point Likert scale. The DCBQ-55 as a simple, valid and reliable instrument can assess factors influencing delayed childbearing. It can be used by reproductive healthcare providers and policy makers to understand factors influencing delayed childbearing and devise appropriate strategies. Full article

Lyme carditis (LC) is a manifestation of the early disseminated stage of Lyme disease and often presents as high-degree atrioventricular (AV) block. High-degree AV block in LC can be treated with antibiotics, usually resolving with a highly favorable prognosis, thus preventing the unnecessary implantation of permanent pacemakers. We present a systematic approach to the diagnosis and management of LC that implements the Suspicious Index in Lyme Carditis (SILC) risk stratification score. Full article

Medicine has always been characterized by a tension between the particular and the general. A clinician is obligated to treat the individual in front of her, yet she accomplishes this task by applying generalized knowledge that describes an abstract average but not necessarily a specific person. Efforts to systematize this process of moving between the particular and the general have led to the development of randomized controlled trials and large observational studies. Inclusion of tens of thousands of people in such studies, it is argued, will enhance the applicability of the data to more individual circumstances. Yet, as genetic sequencing data have become more widely obtained and used, there has been an increased focus on what has been broadly termed “precision medicine”, a highly individualized approach to therapeutics. Moreover, advances in statistical methods have enabled researchers to use N-of-1 study data—traditionally considered too individualized to be broadly applicable—in new ways. This paper contextualizes these apparently modern debates with reference to historical arguments about methods of disease diagnosis and treatment, and earlier physicians’ concerns about the tension between the particular and the general that is intrinsic to medical practice. Full article

Background: The number of acute medical paediatric emergency admissions is rising. We undertook qualitative interviews with parents and clinicians to better understand what factors, other than the health status of the child, may influence decision making leading to emergency admission. Methods: Semi-structured interviews were conducted with parents; clinicians working in general practice, out-of-hours or the emergency department (referring clinicians); and doctors working in acute medical paediatrics (receiving clinicians). Results: Ten parents, 7 referring clinicians and 10 receiving clinicians were interviewed. Parents described “erring on the side of caution” when seeking medical opinion and one mentioned anxiety. Among themes seen among referring clinicians, “erring on the side of caution” was also identified as was managing “parental anxiety” and acting on “gut instinct”. Among receiving clinicians, themes included managing parental anxiety and increasing parental expectations of the health service. Conclusions: The study of parent and referring clinician decision-making prior to a hospital admission can identify “teachable moments” where interventions might be delivered to slow or even arrest the rise in short-stay acute medical admissions in Britain and other countries. Interventions could assure parents or referring clinicians that hospital referral is not required and help clinicians understand what they perceive as “parental anxiety”. Full article

The Comprehensive Cancer Network (NCCN) recommends genetic cancer risk assessment (GCRA) referral to women at high risk of hereditary breast and ovarian cancer. Latinas affected by breast cancer have the second highest prevalence of BRCA1/2 mutations after Ashkenazi Jews. Compared to non-Hispanic Whites, Latinas have lower GCRA uptake. While some studies have identified barriers for GCRA use in this population, few studies have focused on health care providers’ perspectives. The purpose of the study was to examine providers’ perceptions of barriers and facilitators for at-risk Latina women to participate in GCRA and their experiences providing services to this population. We conducted semi-structured interviews with 20 healthcare providers (e.g., genetic counselors, patient navigators) recruited nationally through snowballing. Interviews were transcribed. Two coders independently coded each interview and then met to reconcile the codes using Consensual Qualitative Research guidelines. Providers identified several facilitators for GCRA uptake (e.g., family, treatment/prevention decisions) and barriers (e.g., cost, referrals, awareness, stigma). Genetic counselors described important aspects to consider when working with at-risk Latina including language barriers, obtaining accurate family histories, family communication, and testing relatives who live outside the US. Findings from this study can inform future interventions to enhance uptake and quality of GCRA in at-risk Latina women to reduce disparities. Full article

A focused reflection on rational medicines use in neonates is valuable and relevant, because indicators to assess rational medicines use are difficult to apply to neonates. Polypharmacy and exposure to antibiotics are common, while dosing regimens or clinical guidelines are only rarely supported by robust evidence in neonates. This is at least in part due to the extensive variability in pharmacokinetics and subsequent effects of medicines in neonates. Medicines utilization research informs us on trends, on between unit variability and on the impact of guideline implementation. We illustrate these aspects using data on drugs for gastroesophageal reflux, analgesics or anti-epileptic drugs. Areas for additional research are drug-related exposure during breastfeeding (exposure prediction) and how to assess safety (tools to assess seriousness, causality, and severity tailored to neonates) since both efficacy and safety determine rational drug use. To further improve rational medicines use, we need more data and tools to assess efficacy and safety in neonates. Moreover, we should facilitate access to such data, and explore strategies for effective implementation. This is because prescription practices are not only rational decisions, but also have psychosocial aspects that may guide clinicians to irrational practices, in part influenced by the psychosocial characteristics of this population. Full article

Despite decades of training health workers in communication, complaints from clients and communities about poor health worker attitudes abound. This was found to be so in Zambia where the More Mobilizing Access to Maternal Health Services in Zambia (MORE MAMaZ) program was trying to ensure the inclusion of under-supported women in a community-based maternal and newborn health program in five intervention districts. Under-supported women suffer a disproportionate burden of child mortality and are poor users of health services. An exploratory small-scale qualitative survey involving nurses from training schools and health facilities found that nurses knew how to communicate well, but were selective with whom and in what circumstances they did this. In general, those who received the worst communication were under-supported and had low confidence—the very people who needed the best communication. An experiential training program was started to help health workers reflect on the reasons for their poor communication. The training was evaluated after 14 months using semi-structured interviews and focus group discussions with staff at participating health facilities. The results showed improved inclusion of under-supported women but also increased attendance generally for ante-natal clinics, deliveries and under-five clinics. Another outcome was improved communication between, and a sense of job satisfaction among, the health workers themselves. The program demonstrated an effective way to improve the inclusion and involvement of the least-supported women and girls. There are important lessons for other health programs that aim to operationalize the goals of the Global Strategy for Women’s, Children’s and Adolescent’s Health, which include an emphasis on reaching every woman. Full article

Background: Pediatric severe sepsis is a public health problem with significant morbidities in those who survive. In this article, we aim to present an overview of the important studies highlighting the limited data available pertaining to long-term outcomes of survivors of pediatric severe sepsis. Materials and Methods: A review of literature available was conducted using PUBMED/Medline on pediatric severe sepsis outcomes. Long-term outcomes and health-related quality of life (HRQL) following severe sepsis was defined as any outcome occurring after discharge from the hospital following an episode of severe sepsis which affected either the survivor or the survivor’s family members. Results: Many children are discharged with worse clinical and functional outcomes, depending on their diagnosis, treatments received, psychological effects, and the impact of their illness on their parents. Additionally, they utilize healthcare services more than their peers and are often readmitted soon after discharge. However, pediatric HRQL studies with worthwhile outcome measures are limited and the current data on pediatric sepsis is mainly retrospective. Conclusions: There is significant and longstanding morbidity seen in children and their families following a severe sepsis illness. Further prospective data are required to study the long-term outcomes of sepsis in the pediatric population. Full article