Strategic planning in academic paediatric hospitals: The need for child health input

Over the past two decades, a number of Canadian paediatric academic programs, previously operated as separate hospitals, have been integrated into larger teaching hospitals or regional health authorities. The present article describes the recent experience of the Children’s Hospital of Western Ontario within the London Health Sciences Centre (London, Ontario) to illustrate the potential deleterious effects of planning, system and program changes in a large academic hospital without child health input at the executive decision-making level. The vision of the London Health Sciences Centre Executive Leadership Team and Board of Directors was divergent from that of the paediatric health care providers, which resulted in the resignation of a number of paediatric subspecialists and compromised the ability of the Department of Paediatrics to deliver paediatric care and educate future professionals. The present article highlights the need for the involvement of paediatric stakeholders in strategic planning in the hope that other academic centres can learn from this experience.     

Virion-bound ICAM-1 and activated LFA-1: a combination of factors conferring resistance to neutralization by sera from human immunodeficiency virus type 1-infected individuals independently of the disease status and phase

The role of the supplementary interaction between virion-bound host ICAM-1 and LFA-1 on target cells in sensitivity to neutralization of human immunodeficiency virus type 1 (HIV-1) is poorly studied. Serum samples from four long-term nonprogressors (LTNPs) and sequential sera from one progressor were used to assess neutralization sensitivity of isogenic ICAM-1-negative and ICAM-1-bearing HIV-1(NL4-3), a prototype of T-cell-line-adapted viruses. We found that virus neutralization sensitivity to the studied sera is not modified by the additional interaction between virally embedded ICAM-1 and LFA-1 under an inactive state. However, expression on the target cell surface of an activated LFA-1 form renders ICAM-1-bearing virus particles, but not viruses devoid of ICAM-1, more refractory to neutralization by sera from three out of four LTNPs and all sequential sera from the person who has experienced a progression of the HIV-1-associated disease. Although no conclusive correlation could be drawn between virus susceptibility to neutralization and the disease status or stages of HIV-1 infection, these findings demonstrate that other nonspecific virus-cell interactions mediated by virion-anchored host proteins and their normal cognate ligands on target cells represent factors that can affect the mechanism of HIV-1 neutralization.     

Vulvovaginal candidiasis among symptomatic women of childbearing age attended at a Medical Analysis Laboratory in Franceville,Gabon

BackgroundVulvovaginal candidiasis (VVC) is one of the most common lower genital tract infections in women; this unpleasant and extremely embarrassing pathology is one of the main reasons for gynaecological consultation. In Gabon, the prevalence of VVC remains poorly described even though VVC is known to be the leading gynaecological condition in several countries. This retrospective cross-sectional study sought to assess the prevalence of VVC among symptomatic women in southeastern Gabon.MethodsClinical samples were collected from patients suspected to have VVC during a 2-year period (from January 2016 to December 2017). Gram staining of vaginal smears provided indications of vaginal flora and confirmed the presence of yeast. Sabouraud-chloramphenicol and chromID Candida media were used to isolate yeast, and species identification was performed using morphological tests and the Vitek 2 Compact automated system.ResultsFor the 873 patients included in this study, the prevalence of VVC was 28.52%. Eleven Candida species were identified, with greater representation of Candida albicans (82.73%) than of Non C. albicans candida (NCAC) (17.27%), which were distributed as follows: Candida famata (4.02%), Candida spp. (3.61%), Candida rugosa (3.21%), Candida lipolytica (1.61%), Candida parapsilosis (1.61%), Candida glabrata (1.21%), Candida tropicalis (0.80%), Candida krusei (0.40%), Candida dubliniensis (0.40%), and Candida sphaerica (0.40%).ConclusionThis study offers the first estimation of VVC among Gabonese women in childbearing age with the symptoms. It showed that VVC is very common in Gabon. C. albicans as the most commonly represented species.     

The effects of human ankle muscle vibration on posture and balance during adaptive locomotion

This study investigated the contribution of ankle muscle proprioception to the control of dynamic stability and lower limb kinematics during adaptive locomotion, by using mechanical vibration to alter the muscle spindle output of individuals' stance limbs. It was hypothesised that muscle length information from the ankle of the stance limb provides information describing location as well as acceleration of the centre of mass (COM) with respect to the support foot during the swing phase of locomotion. Our prediction, based on this hypothesis was that ankle muscle vibration would cause changes to the position and acceleration of the COM and/or compensatory postural responses. Vibrators were attached to both the stance limb ankle plantarflexors (at the Achilles tendon) and the opposing dorsiflexor muscle group (over tibialis anterior). Participants were required to walk along a 9-m travel path and step over any obstacles placed in their way. There were three task conditions: (1) an obstacle (15 cm in height) was positioned at the midpoint of the walkway prior to the start of the trial, (2) the same obstacle was triggered to appear unexpectedly one step in front of the participant at the walkway midpoint and (3) the subjects' walking path remained clear. The participants' starting position was manipulated so that the first step over the obstacle (when present) was always performed with their right leg. For each obstacle condition participants experienced the following vibration conditions: no vibration, vibration of the left leg calf muscles or vibration of the anterior compartment muscles of the lower left leg. Vibration began one step before the obstacle at left leg heel contact and continued for 1 s. Vibrating the ankle muscles of the stance limb during the step over an obstacle resulted in significant changes to COM behaviour [measured as displacement, acceleration and position with respect to the centre of pressure (COP)] in both the medial/lateral (M/L) and anterior/posterior planes. There were also significant task-specific changes in stepping behaviour associated with COM control (measured as peak M/L acceleration, M/L foot displacement and COP position under the stance foot during the step over the obstacle). The results provide strong evidence that the primary endings of ankle muscle spindles play a significant role in the control of posture and balance during the swing phase of locomotion by providing information describing the movement of the body's COM with respect to the support foot. Our results also provide supporting evidence for the proposal that there are context-dependent changes in muscle spindle sensitivity during human locomotion.     

Effects of restriction of forefoot rocker functions by immobilisation of metatarsophalangeal joints on kinematics and kinetics during walking

ObjectiveThis study was conducted to investigate the effects of restriction of forefoot rocker (FFR) functions by immobilisation of unilateral metatarsophalangeal joints (MPJs) on kinematic and kinetic factors during walking.MethodsEighteen healthy young adults participated in this study. To immobilise the MPJs of the right leg, an aluminium sole plate (AS) was fixed on the sole of the foot. Kinematic and kinetic data were collected while each subject walked at a comfortable speed with the AS and without.ResultsIn the AS condition, the walking speed and contralateral step length were significantly decreased, and an asymmetrical centre of mass (COM) movement was observed. The range of plantarflexion motion and positive work by the ankle joint were decreased markedly during the late stance of the AS limb. In contrast, maximum hip and knee flexion angles in the swing phase of the AS limb and positive work by the bilateral hip joints over the gait cycle were increased.ConclusionsThe results suggested that MPJ immobilisation may result in marked motion limitation of ankle plantarflexion and inhibition of push-off by the ankle joint despite no restrictions on the ankle joint. These changes may interfere with gait speed and a smooth and symmetrical COM shift during walking.     

Relationship between corneal thickness and measured intraocular pressure in a general ophthalmology clinic

OBJECTIVE: To assess whether central corneal thickness (CCT) is a confounding factor in the classification of patients attending for glaucoma assessment in a district general hospital. DESIGN: Cross-sectional study by a single observer. PARTICIPANTS: Patients attending a general ophthalmic clinic: 235 clinically normal eyes, 52 eyes with normal-tension glaucoma (NTG), 335 eyes with primary open-angle glaucoma (POAG), 12 eyes with pseudoexfoliative glaucoma (PXE), 42 eyes with chronic angle closure glaucoma (CACG), and 232 glaucoma suspect (GS) eyes. INTERVENTION: Central corneal thickness was measured using ultrasonic pachymetry. MAIN OUTCOME MEASURE: Correlation of CCT and diagnosis. RESULTS: Mean CCT was 553.9 microm (95% confidence intervals [CI] for the mean, 549.0-558.8 microm) in the clinically normal eyes, 550.1 microm (95% CI, 546.6-553.7 microm) in the POAG eyes, 514.0 microm (95% CI, 504.8-523.3 microm) in the NTG eyes, 530.7 microm (95% CI, 511.2-550.1 microm) in the PXE eyes, 559.9 microm (95% CI, 546.8-573.0 microm) in the CACG eyes, and 579.5 microm (95% CI, 574.8-584.1 microm) in the GS eyes. The differences of mean CCT between the groups were highly significant (P< 0.001 analysis of variance). Eighty-five percent of eyes with NTG and only 36% of eyes with POAG had a mean CCT of 540 microm or less. Thirteen percent of eyes with POAG and 42% of GS eyes had a mean CCT greater than 585 microm. CONCLUSIONS: The CCT measurement is desirable in patients attending for glaucoma assessment in a district general hospital to avoid misclassification resulting from the relationship between CCT and tonometric pressure. Central corneal thickness alone is not an accurate predictor for the clinical diagnosis in this group of eyes. However, many eyes diagnosed as having NTG have thin corneas, which would tend to lower the tonometrically recorded intraocular pressure (IOP), so the finding of a less-than-normal thickness cornea introduces some doubt as to the diagnosis of NTG. For the GS eyes, most eyes had thick corneas, which would tend to increase the tonometrically recorded IOP. Thus, GS eyes with modest elevation of IOP and a thick cornea may be at low risk of progressing to POAG. Thus, many patients with "high IOPs" and a thick CCT do not necessarily have high IOPs and may not need to be followed as GS eyes.     

Adaptative effects of loss of vision on upright undisturbed stance

In order to evaluate the long term effect of blindness on an undisturbed postural task, seven blind individuals (BLI) were compared to twelve healthy individuals (REF) who were required to close their eyes. To this aim, centre of pressure (CP) trajectories were recorded through a force platform on which the subjects remained upright. Through a low-pass filter, the vertical projection of the centre of gravity (CG(v)) and consequently the difference CP-CG(v) were estimated. The former represents the controlled variable whilst the latter is assumed to express the resultant joint stiffness. A first analysis consisted in studying the frequency distribution of these motions. Increased mean amplitudes in both elementary motions and no difference between frequency distributions were observed for the BLI when compared to the REF group. These trajectories were then modelled as a fractional Brownian motion process in order to gain insight about the nature of the control mechanisms called into play and their spatio-temporal organisation. Moreover, the main characteristic observed in the BLI group is a decreased in CP-CG(v) motions, which, according to Winter's model, may be related to joint stiffness. In addition, reduced spatial transition point co-ordinates and more deterministic control mechanisms aimed at returning the estimated CG to an equilibrium point during the longest Deltat were observed. This phenomenon is more pronounced in the antero-posterior direction and also allows the blind subject to significantly diminish their CG sways. Finally, these features are discussed in relation to other similarly analysed investigations.     

Improving Physician Knowledge: A Necessary but Not Sufficient Requirement of Improving Intrauterine Contraception Access in Canada

ObjectiveThis study sought to identify knowledge gaps and attitudinal barriers to prescribing intrauterine contraception (IUC).MethodsA national, Web-based survey of Canadian gynaecology (GYN) and family medicine (FM) physicians was conducted. The survey was distributed through several channels, including physicians’ databases, invitations through a commercial email aggregating service, and contacting residency programs. For knowledge-based questions, correct answers were those consistent with Canadian practice guidelines. Ethics approval was granted through Queen's Health Sciences Research Ethics Board. Project funding was through a research grant from Bayer, Inc. (Canadian Task Force Classification III).ResultsA total of 600 responses were received. GYN physicians’ knowledge about IUC (number correct / 40) was better than that of the FM and FM with additional women's health training (FMWH) groups (median [interquartile range] 39 [37–40], 36 [32–38], and 37 [35–39]; P < 0.0001). Factors associated with lower scores included rural practice location, lack of affiliation with medical trainees, extremes of practice duration, and self-perceived lack of knowledge about IUC. Most respondents prescribed IUC (93.7%). Among prescribers, 97.0% inserted IUC. The most common reasons for not prescribing or inserting IUC included lack of training, lack of comfort, and referral to other physicians to provide this service. Respondents indicated that they would be more likely to prescribe and/or insert IUC if cost barriers were removed, patient interest was increased, or if there was improved access to patient-centred educational materials and hands-on training modules.ConclusionThis study suggests that although many GYN and FM physicians are offering IUC, misconceptions regarding contraindications still exist, and several barriers are related to deficiencies in providers’ knowledge. Therefore, educational efforts should be prioritized to increase the usage of IUC.