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1.  Prevalence and incidence of antimicrobial-resistant organisms among hospitalized inflammatory bowel disease patients 
BACKGROUND:
Patients with inflammatory bowel disease (IBD) experience frequent hospitalizations and use of immunosuppressive medications, which may predispose them to colonization with antimicrobial-resistant organisms (ARO).
OBJECTIVE:
To determine the prevalence of ARO colonization on admission to hospital and the incidence of infection during hospitalization among hospitalized IBD patients.
METHODS:
A chart review comparing the prevalence of colonization and incidence of infection with methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL) in hospitalized IBD patients with those of non-IBD controls was performed.
RESULTS:
On admission, there were no significant differences between IBD inpatients and controls in the prevalence of colonization of methicillin-resistant S aureus (1.0% versus 1.2%; P=0.74), vancomycin-resistant enterococci (0.2% versus 0%; P=1.0) or ESBL (4.1% versus 5.5%; P=0.33). Pooling data from historical clinic-based cohorts, IBD patients were more likely than controls to have ESBL colonization (19% versus 6.6%; P<0.05). Antibiotic use on admission was associated with ESBL colonization among IBD inpatients (OR 4.2 [95% CI 1.4 to 12.6]). The incidence of ARO infections during hospitalization was not significantly different between IBD patients and controls. Among IBD patients who acquired ARO infections during hospitalizations, the mean time interval from admission to infection was shorter for those who were already colonized with ARO on admission.
CONCLUSIONS:
This particular population of hospitalized IBD patients was not shown to have a higher prevalence or incidence of ARO colonization or infection compared with non-IBD inpatients.
PMCID: PMC3905012  PMID: 24489571
Crohn disease; Extended spectrum beta-lactamase; Inflammatory bowel disease; Methicillin-resistant Staphylococcus aureus; Ulcerative colitis; Vancomycin-resistant enterococci
2.  Methicillin-resistant Staphylococcus aureus colonization among health care workers in a downtown emergency department in Toronto, Ontario 
BACKGROUND:
Methicillin-resistant Staphylococcus aureus (MRSA) acquired in the community, otherwise known as community-acquired MRSA, has emerged rapidly in recent years. Colonization with MRSA has been associated with an increased risk of symptomatic and serious infections and, in some settings, health care workers (HCWs) exhibit a higher prevalence of MRSA colonization.
OBJECTIVE:
To determine MRSA colonization in emergency department (ED) HCWs in the setting of a moderate prevalence of MRSA in skin and soft tissue infections.
METHODS:
The present study was conducted at a downtown ED in Toronto, Ontario. ED HCWs completed a brief questionnaire and swabs were taken from one anterior nare, one axilla and any open wounds (if present). Swabs were processed using standard laboratory techniques.
RESULTS:
None of the 89 staff (registered nurses [n=55], physicians [n=15], other [n=19]) were MRSA positive and 25 (28.1%) were colonized with methicillin-susceptible S aureus.
CONCLUSIONS:
Contrary to common belief among HCWs and previous studies documenting MRSA colonization of HCWs, MRSA colonization of this particular Canadian ED HCW cohort was very low and similar to that of the local population.
PMCID: PMC3852458  PMID: 24421831
Emergency department; Health care workers; MRSA colonization
3.  Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study 
Background:
To assist physicians with difficult decisions about hospital admission for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) presenting in the emergency department, we sought to identify clinical characteristics associated with serious adverse events.
Methods:
We conducted this prospective cohort study in 6 large Canadian academic emergency departments. Patients were assessed for standardized clinical variables and then followed for serious adverse events, defined as death, intubation, admission to a monitored unit or new visit to the emergency department requiring admission.
Results:
We enrolled 945 patients, of whom 354 (37.5%) were admitted to hospital. Of 74 (7.8%) patients with a subsequent serious adverse event, 36 (49%) had not been admitted after the initial emergency visit. Multivariable modelling identified 5 variables that were independently associated with adverse events: prior intubation, initial heart rate ≥ 110/minute, being too ill to do a walk test, hemoglobin < 100 g/L and urea ≥ 12 mmol/L. A preliminary risk scale incorporating these and 5 other clinical variables produced risk categories ranging from 2.2% for a score of 0 to 91.4% for a score of 10. Using a risk score of 2 or higher as a threshold for admission would capture all patients with a predicted risk of adverse events of 7.2% or higher, while only slightly increasing admission rates, from 37.5% to 43.2%.
Interpretation:
In Canada, many patients with COPD suffer a serious adverse event or death after being discharged home from the emergency department. We identified high-risk characteristics and developed a preliminary risk scale that, once validated, could be used to stratify the likelihood of poor outcomes and to enable rational and safe admission decisions.
doi:10.1503/cmaj.130968
PMCID: PMC3971051  PMID: 24549125
4.  Practice patterns of graduates of a CCFP(EM) residency program 
Canadian Family Physician  2012;58(7):e385-e389.
Abstract
Objective
To determine the practice settings of graduates of a residency program that leads to a Certificate of Special Competence in Emergency Medicine (CCFP[EM]).
Design
Web-based survey using standard Dillman methodology.
Setting
Canada.
Participants
All graduates of the CCFP(EM) residency training program at the University of Toronto (U of T) in Ontario between 1982 and 2009.
Main outcome measures
Practice type and location, job satisfaction, and nonclinical EM activities of graduates of a CCFP(EM) residency program.
Results
Of 146 graduates surveyed, 88 responded (response rate of 60.3%). All of the respondents indicated that they had practised EM at some point after completing the CCFP(EM) program at U of T. At survey completion, 76.7% were practising EM. Of the EM-practising cohort, 93.9% worked in urban or suburban hospitals as opposed to rural settings. Those practising EM expressed high levels of job satisfaction, with 83.3% reporting a score of 8 or higher on a 10-point satisfaction scale. Most (57.0%) of the graduates of the CCFP(EM) residency program at U of T had participated in leadership activities in EM on local, provincial, or national levels.
Conclusion
Most graduates of the CCFP(EM) residency program continue to practise EM, and most of them practise in urban and suburban environments. The low attrition rate of CCFP(EM) graduates should be regarded as a success of the CCFP(EM) program, and the geographic distribution of all physicians, including EM providers, warrants further study to help plan future physician resources in Canada.
PMCID: PMC3395545  PMID: 22798475
5.  Self-Collected Mid-Turbinate Swabs for the Detection of Respiratory Viruses in Adults with Acute Respiratory Illnesses 
PLoS ONE  2011;6(6):e21335.
Background
The gold standard for respiratory virus testing is a nasopharyngeal (NP) swab, which is collected by a healthcare worker. Midturbinate (MT) swabs are an alternative due to their ease of collection and possible self-collection by patients. The objective of this study was to compare the respiratory virus isolation of flocked MT swabs compared to flocked NP swabs.
Methods
Beginning in October 2008, healthy adults aged 18 to 69 years were recruited into a cohort and followed up for symptoms of influenza. They were asked to have NP and MT swabs taken as soon as possible after the onset of a fever or two or more respiratory symptoms with an acute onset. The swabs were tested for viral respiratory infections using Seeplex® RV12 multiplex PCR detection kit. Seventy six pairs of simultaneous NP and MT swabs were collected from 38 symptomatic subjects. Twenty nine (38%) of these pairs were positive by either NP or MT swabs or both. Sixty nine (91%) of the pair results were concordant. Two samples (3%) for hCV OC43/HKU1 and 1 sample (1%) for rhinovirus A/B were positive by NP but negative by MT. One sample each for hCV 229E/NL63, hCV OC43/HKU1, respiratory syncytial virus A, and influenza B were positive by MT but negative by NP.
Conclusions
Flocked MT swabs are sensitive for the diagnosis of multiple respiratory viruses. Given the ease of MT collection and similar results between the two swabs, it is likely that MT swabs should be the preferred method of respiratory cell collection for outpatient studies. In light of this data, larger studies should be performed to ensure that this still holds true and data should also be collected on the patient preference of collection methods.
doi:10.1371/journal.pone.0021335
PMCID: PMC3121745  PMID: 21731708
6.  Non-ST segment elevation acute coronary syndromes: A simplified risk-oriented algorithm 
Non-ST segment elevation acute coronary syndromes (NSTE ACS) include a clinical spectrum that ranges from unstable angina to NSTE myocardial infarction. Management goals aim to prevent recurrent ACS and improve long-term outcomes by choosing a treatment strategy according to an estimate of the risk of an adverse outcome. Recent registry data suggest that patients with NSTE ACS frequently do not receive recommended treatment, and that risk stratification is not used to determine either the choice of treatment or the speed of access to coronary angiography.
The present article evaluates the evidence for recommended treatment using information from recent trials and guidelines published by the major cardiac organizations in Europe and North America. Using this information, a multidisciplinary group developed a simplified algorithm that uses risk stratification to select an optimal early management strategy. Long-term outcomes are improved by a multi-faceted vascular protection strategy that is initiated at the time of hospitalization for NSTE ACS.
PMCID: PMC2560559  PMID: 16801997
Anticoagulants; Coronary disease; Myocardial infarction; Platelet aggregation inhibitors; Thrombosis
7.  Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak 
Emerging Infectious Diseases  2006;12(12):1924-1932.
TOC Summary Line: Healthcare workers in hospitals affected by SARS experience increased psychological stress 1–2 years after the outbreak.
Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.
doi:10.3201/eid1212.060584
PMCID: PMC3291360  PMID: 17326946
Severe Acute Respiratory Syndrome; Stress, Psychological; Health Personnel; Stress, Traumatic; Burnout, Professional, research

Results 1-8 (8)