COVID-19 upswing expected as Albertans wait for latest case counts, booster rollout plan - Yahoo News Canada

Alberta hasn't updated its COVID-19 data since July 26. The provincial government says it's changing how it reports COVID-19 information. Moving ahead the dashboard will include information on other respiratory illnesses including RSV and influenza. (Evan Mitsui/CBC - image credit)

Experts say Albertans can expect another uptick in COVID-19 cases this fall and calls are emerging for swift action.

Other jurisdictions are already seeing increases and officials announced this week that Canada's first case of the new variant, BA.2.86, has been identified in British Columbia.

"We need to be vigilant. We need to keep surveillance up," said Craig Jenne, professor in the department of microbiology, immunology and infectious diseases at the University of Calgary.

"Both in the U.S. and other places in the world this new variant is leading to increased hospitalizations. And the big question is, is it causing more severe disease or are more people getting infected and then a small percentage are requiring hospitalization."

While Jenne was already expecting Alberta's COVID numbers would rise as people move indoors and children return to school this fall, he said the detection of the highly mutated variant in B.C. could lead to more rapid spread.

"This variant does lead to an increased strain on the health-care system. So we need to be doing what we can to avoid that spike in cases."

While Jenne isn't predicting COVID will surge to crisis levels seen earlier in the pandemic, he said the new variant will likely be in Alberta soon, if it isn't already, and could spread province-wide by late fall.

No new data

The emergence of this latest variant in Canada comes at a time when Albertans are largely in the dark about the current COVID situation.

The provincial website indicated COVID-19 data would be updated on Wednesday, for the first time in more than a month. But that didn't happen.

In a statement, the press secretary for health Minister Adriana LaGrange said the government is changing how it presents the data to "more accurately depict the current situation."

"We are working to expand the data and dashboard to include other respiratory diseases such as RSV and influenza," Charlotte Taillon said.

It is unclear when the data will be available.

"An update will be posted as soon as this work is completed," Taillon said.

Craig Jenne is an associate professor in the department of microbiology, immunology and infectious diseases at the University of Calgary.

Craig Jenne is a professor in the department of microbiology, immunology and infectious diseases at the University of Calgary. (Colin Hall/CBC)

Action needed, Opposition says

In a letter to the health minister on Wednesday the Alberta NDP called on the Alberta government to issue a "broad and comprehensive" COVID-19 vaccination plan as quickly as possible.

"We should be seeing a proactive approach from the government. So far we have seen a fair bit of silence," health critic for primary and rural care, David Shepherd, said in an interview with CBC News.

"We'd like to know when the government of Alberta intends to begin to roll out those vaccinations and how they intend to make them available."

The letter, signed by both Shepherd and education critic, Rakhi Pancholi, also asks the government to improve access for children, to both COVID-19 boosters and flu shots, by offering them in schools.

Last fall, a trio of respiratory illnesses — influenza, RSV and COVID-19 — overwhelmed Alberta's pediatric hospitals.

And Shepherd wants to see updated COVID data released as quickly as possible.

"We are encouraging [the minister] to provide that transparency to Albertans, provide a clear public health plan for this fall."

There are no new details from the provincial government on its COVID booster rollout plan.

In response to inquiries from CBC News, Taillon said the government is aware of the National Advisory Committee on Immunization's recommendations for a fall COVID booster program. The updated guidance was issued in July.

"We will work with the Alberta Advisory Committee on Immunization and the Office of the Chief Medical Officer of Health to determine the best approach for implementing the recommendations for Albertans," Taillon said.

Meanwhile Jenne said new variant-specific vaccine formulations, expected through the fall rollout, will be key to keeping the latest variant in check.

"So we will be able to get boosters that are more closely aligned with the variants in the community. It may not be an exact match but it will be a close enough match still to afford really good protection," he said.

"The big variables I think are not necessarily the virus ... but when when will the vaccine be available, how will it be distributed and, ultimately, the biggest question of all is what would uptake look like?"

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COVID-19 upswing expected as Albertans wait for latest case counts, booster rollout plan - Yahoo News Canada
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Covid Isn’t Seasonal. So Why Are Covid Booster Shots? - BNN Bloomberg

(Bloomberg) -- In a few weeks, the new Covid booster shot will roll out to Americans, designed to fight recent variants just as cases begin to tick up with colder weather. There is just one hitch with this plan: Covid does not actually appear to be a seasonal virus, as many expected.

When it comes to Covid, “everybody’s using the paradigm they know, which is influenza,” said Gregory Poland, director of the Vaccine Research Group at the Mayo Clinic. “It isn’t working. We just have to be really careful with fooling ourselves into thinking we understand this by saying this is seasonal.”Since the start of the global pandemic in 2020, the only certain thing about the virus has been that it’s full of surprises. Earlier this year, the Food and Drug Administration announced it was considering a shift away from frequent boosters, replacing them with a seasonal shot for most people, much like the flu.  The new shot this fall will target XBB.1.5, the variant that was driving infections in June, when the FDA released guidelines for vaccine developers. 

But Covid has not behaved like a seasonal virus. There has been no particular time of year without Covid cases. Mini waves of the virus occur every few months. Recently, hospitalizations in the US started rising after a dip in spring, with 15,000 new Covid hospitalizations the week of August 13, a 19% increase from the week before. By contrast, the flu all but disappears in the warmer months and surges in the cold. All this raises the question: Why are we treating Covid like a seasonal virus?Bloomberg surveyed 11 immunologists, public health officials and infectious disease experts about the best approach to Covid vaccination. While there was no clear consensus, they all agreed that Covid has continued to outsmart us,  making it hard to know whether our current vaccination strategy is the best fit for a virus that appears one step ahead. 

Covid remains unpredictable. Scientists still don’t know exactly why infections occur year-round, while other respiratory diseases like the flu and RSV are usually just a winter concern. The virus also mutates rapidly, leaving epidemiologists playing catch-up to understand the behavior of new variants and the severity of infection they can cause.That means that as Covid changes, our approach to fighting it — including vaccine schedules — may have to shift, too. 

“Everybody’s doing this with both their fingers and their toes crossed,” said William Schaffner, an infectious disease specialist at Vanderbilt University. “If [the virus] doesn’t misbehave, this strategy will work.” 

The fall booster plan was determined with a few factors in mind. People generally spend more time indoors during the winter, including gathering with large groups over the holidays that often spread the virus. Six of the experts surveyed said that a fall booster campaign has an important role to play in protecting a large part of the population against serious infection during an anticipated surge this winter. That’s especially true for elderly people and those who are immunocompromised.And one of the biggest hurdles for vaccination is getting people to actually show up — after all, as of May just 17% of eligible Americans had gotten the Covid booster that became available last fall. A regular fall vaccination schedule might encourage higher numbers, by both being easier to remember and allowing people to combine their Covid shot with their flu shot.This year, though, summer travel and heat waves drove more people indoors, which experts have linked to the recent rise in cases. Accordingly, some experts surveyed said they would like to see an earlier roll-out to beat the summer surge and immunize students before returning to school.

Three experts even suggested going back to a more frequent vaccination schedule, though part of the reasons health officials switched to an annual vaccination plan was low vaccine uptake. It’s also more realistic for vaccinemakers to update the vaccine annually — it’s a process that requires extensive time and money even with the flexibility of messenger RNA technology. (Those most at risk of severe illness have still been encouraged to get extra booster doses.)

Health experts will review the latest shots from Moderna, Pfizer and Novavax at a meeting on September 12, after which the Centers for Disease Control and Prevention is expected to recommend them for most Americans. The companies have said this season’s vaccine provides some protection against currently-circulating variants like EG.5, which is related to the strain the new jab was designed to fight. Novavax, for one, said that it anticipates Covid shots will continue to be an annual seasonal shot for most of the population. Poland, at the Mayo Clinic, said the only way to get ahead of the virus is to stay nimble — changing vaccination plans as the virus evolves.

“It just has to be flexible,” he said. “It has to be nuanced. It has to be informed, so that people can take appropriate precautions.”

--With assistance from Madison Muller.

©2023 Bloomberg L.P.

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Only a small fraction of "Covid deaths" directly attributed to the actual virus - Earth.com

Recent data from the Centers for Disease Control and Prevention (CDC) reveals a surprising statistic: nearly 99% of reported “Covid deaths” each week are not primarily caused by the virus. 

This finding, based on the CDC’s Covid dashboard, indicates that only 1.7% of the 324 Covid deaths registered in the week ending August 19 had the coronavirus as the primary cause of death.

Secondary causes 

This means that only a handful of American lives are being lost directly to the virus each week, a stark contrast to the pandemic’s peak in 2021 when the virus accounted for one in three “Covid deaths.”

The primary or underlying cause of death is the disease, situation, or event that initiated the chain of events directly resulting in death. 

Complications arising from the primary cause are usually considered secondary causes when doctors register a death certificate. 

For instance, Covid could be listed as a secondary cause of death when the virus puts too much stress on a person with a pre-existing heart condition. In this case, the primary cause of death would be heart disease, with Covid listed as a contributing cause.

Drastic decline in Covid deaths

Despite a slight increase from the previous week and a five-week upward trend, the percentage of Covid deaths for the week ending August 19 represents a drastic decline from the peak of the pandemic when 30% of deaths listed Covid as the primary cause. 

Although the CDC has not reported the primary cause of death in cases where Covid was a secondary factor, separate data from the agency shows that, thus far in August, the largest cause of death in the US has been cancer, followed by heart diseases.

Death rates per state

Furthermore, the data reveals that some states, including Washington, Florida, Tennessee, North Carolina, Maryland, and New York, have higher rates of deaths due to Covid, with Maryland and Florida having the highest at 3.4%. 

Other states, like Washington, Tennessee, North Carolina, and New York, hover around 2%, while more than two dozen states experienced just one to nine deaths due to Covid in the week ending on August 19. The death rate is slightly higher among women than men, and highest in people 75 years and older.

New variants on the rise

This new Covid data comes as a relief at a time when panic is rising across the US due to the circulation of highly transmissible new Covid variants, leading to more infections and hospitalizations and causing the reimplementation of some Covid mandates. 

Recently detected variants EG.5, or Eris, and BA.8.26, or Pirola, have been found in several countries and the US. These variants, highly mutated, are thought to be better at avoiding vaccine and natural immunity, causing more infections. 

Infections have reportedly doubled 

Infections have reportedly doubled across the US amid the emergence of these variants, and hospital admissions among people with the virus have risen for the fifth week in a row. 

However, they still remain at near-historic lows, and crucially, Covid deaths are not rising quickly.

Mask mandates 

This uptick in Covid cases led Hollywood movie studio Lionsgate to reinforce mask mandates at its Santa Monica, California offices last week. However, just several days later, the studio reversed its decision. 

Similarly, Rutgers University in New Jersey and Morris Brown College in Georgia announced that face masks would be required for staff and students. Kaiser Permanente hospital in Santa Rosa, California, and Upstate Community Hospital in Syracuse, New York, also reinstated mask mandates for doctors, nurses, patients, and visitors.

In Kentucky, the Lee County School District canceled classes less than two weeks after opening because nearly one-fifth of its students were out sick with a “tripledemic” illness, including Covid, strep throat, and the flu.

Covid vaccines

As the situation evolves, President Biden indicated that his administration would “likely” recommend Americans receive another Covid booster vaccine in the coming weeks. 

Biden signed a proposal on Friday asking Congress for more funding to update Covid vaccines to better protect against the new variants. 

However, there seems to be little interest among Americans to receive boosters, with only 18% of eligible Americans having received any version of a booster.

While the rise of new variants and the reimplementation of some Covid mandates have caused a surge in panic, the CDC data shows a drastic decline in the percentage of deaths primarily caused by Covid since the peak of the pandemic. 

As the situation continues to unfold, it is crucial to stay informed, follow the guidelines provided by health officials, and consider the broader context when interpreting new data.

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Sex-based disparities in cardiovascular care may be linked to higher stroke risk among females - News-Medical.Net

Aug 30 2023

Higher stroke risk among females with atrial fibrillation may be related to sex-based disparities in cardiovascular care, according to a new study from Women's College Hospital, the Peter Munk Cardiac Centre (PMCC) at University Health Network (UHN) and ICES.

Atrial fibrillation (AF) is a common type of irregular heart rhythm that is associated with a higher risk of stroke-;after the age of 40, one in four strokes are caused by AF. Previous studies have found that female sex (assigned at birth) is a risk factor for AF-associated stroke. Recent research suggested that females are only at higher risk than males with AF if they have another factor predisposing them to stroke (such as older age, hypertension, or diabetes).

The reasons for this higher stroke risk in females has not been well-examined. The authors hypothesized this was because these risk factors were less well-treated in older females, rather than female sex intrinsically predisposing to this higher risk.

The population-based cohort study, published in the European Heart Journal, analyzed health records for people aged 65 and older recently diagnosed with AF in Ontario, Canada. The cohort included 354,254 people (49% female), with an average age of 78 years. The study was made possible through the Early Career Women's Heart and Brain Health Chair and a National New Investigator Award from the Heart and Stroke Foundation of Canada.

After taking into account the age of the individual and differences in cardiovascular care, the data show that stroke risk was similar between males and females under the age of eighty, but that female sex was an independent risk factor over the age of eighty. Females tend to be diagnosed with atrial fibrillation at older ages, and they may not be receiving adequate monitoring or treatment to reduce their stroke risk."

Hifza Buhari, lead author, family medicine resident at the University of Toronto and former Temerty medical student at Women's College Hospital

The data also show that, compared to males:

• Females were diagnosed more often in emergency departments (30% versus 25% for males)
• Females received fewer cardiologist appointments, both in the year before (12% versus 17%) and after (31% versus 37%) AF diagnosis.
• Females were also less likely to get LDL-C testing and be treated with statins, despite having higher LDL-C levels and higher BP than their male counterparts.

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"Equalizing cardiovascular care for males and females is an important step towards healthier hearts and lives for everyone," says senior author Husam Abdel-Qadir, cardiologist at Women's College Hospital and Peter Munk Cardiac Centre, University Health Network, and scientist with Women's College Research Institute, Ted Rogers Centre for Heart Research, and ICES. "By addressing sex inequities, we can increase the likelihood that every individual receives the best chance at a heart-healthy future."

One limitation of the data is that the researchers could not account for variables such as race, AF type or severity, and other clinical factors, which may had led to an underestimation of inequities in cardiovascular care that disproportionately affect older females.

"This study is another reminder that heart disease and stroke are not male diseases. Despite there being widespread appreciation that females with AF are at higher stroke risk than males, they are getting less cardiovascular care with real consequences. These data emphasize that females, particularly those at older ages, require appropriate care to reduce their risk of these serious diseases," says Dr. Abdel-Qadir.

Institute for Clinical Evaluative Sciences

Journal reference:

Buhari, H., et al. (2023) Stroke risk in women with atrial fibrillation. European Heart Journal. doi.org/10.1093/eurheartj/ehad508.

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Dr. Erik Pioro appointed to Professorship in ALS Research at UBC - UBC Faculty of Medicine

The ALS Society of BC and UBC Faculty of Medicine are pleased to announce Dr. Erik Pioro has been appointed to the ALS Society of BC Professorship in ALS Research.

“I am delighted that Dr. Pioro is joining the UBC Faculty of Medicine to provide leadership and catalyze research collaborations that will accelerate the development of lifechanging treatments for people with ALS,” says Dr. Dermot Kelleher, Dean of the Faculty of Medicine and Vice-President, Health at UBC.

Dr. Dermot Kelleher

“Dr. Pioro brings decades of experience caring for thousands of people with ALS and conducting leading-edge research spanning the mechanisms of neurodegeneration in ALS to clinical trials of novel therapies to slow the progression of a disease that harms far too many lives in BC communities and globally. This truly is a hopeful step forward on our path to curing ALS.”

With many promising ALS therapies currently in late-stage clinical trials, and the UBC Faculty of Medicine poised to accelerate translational research, it is a critical time to invest in building research capacity in ALS in BC. As part of PROJECT HOPE, the ALS Society of BC, in partnership with the Province of BC, contributed $5.3M to establish the ALS Society of BC Professorship in ALS Research. The ALS Society of BC has also committed a further $1.5M over 10 years to support the professorship and pledged to raise an additional $20M to create a world-class ALS Centre at UBC.

“I am honoured to take the lead for PROJECT HOPE. We will work diligently to create opportunities for persons living with ALS to have access to clinical trials here at the University of British Columbia. Our goal for ALS research at UBC is to become a leader not only nationally but also internationally,” says Dr. Pioro. “We look forward to collaborating with our clinicians and researchers working on other neurodegenerative diseases, including Alzheimer’s, frontotemporal dementia, and Parkinson’s since we will now all be located at the Djavad Mowafaghian Centre for Brain Health at UBC.”

Dr. Lynn Raymond

Dr. Pioro comes to UBC from Northwestern University’s Feinberg School of Medicine, where he is Medical Director of the Neuromuscular Division and Vice-Chair of Translational Neurology. He was also previously Director of the Section of ALS & Related Disorders at the Cleveland Clinic for over 20 years. He will officially start his role at UBC in March 2024.

“Dr. Pioro’s extensive expertise in motor neuron diseases and strong background in neuroimaging will complement our team of talented clinician-scientists who are working on research and treatment for ALS and other neurodegenerative disorders,” says Dr. Lynn Raymond, Director of the Djavad Mowafaghian Centre for Brain Health. “His leadership will not only strengthen translational research but also improve patient care and enable expanded access to clinical trials in British Columbia. We look forward to welcoming Dr. Pioro to the Djavad Mowafaghian Centre for Brain Health as we continue to advance brain health across the lifespan.”

A version of this story originally appeared on the Djavad Mowafaghian Centre for Brain Health website.

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Infant antibiotics tied to eczema, asthma, food allergies - Prince Rupert Northern View - The Northern View

Bacteria in the gut are linked to childhood eczema, asthma, hay fever and allergies to certain foods, suggests a Canadian study, and researchers note infants who are prescribed antibiotics are at greater risk of developing one or more of the conditions.

Dr. Stuart Turvey, one of the senior researchers of the study published Tuesday in the journal Nature Communications, said disruptions to a maturing microbiome have the immune system waging a battle against innocuous foods or pollens including grass, in that case triggering reactions such as a stuffy nose, sneezing, coughing and swollen skin under the eyes.

The risk of developing at least one of the major allergies more than doubled by age five for kids who had been prescribed antibiotics before their first birthday because the medication wipes out protective bacteria and introduces harmful ones that cause burdensome lifelong impacts, Turvey noted.

“We linked that back to the structure of the microbiome because what we know and understand, through this work and other work, is that the early-life bacterial colonization is key for training the immune system and helping it to know what it should react to and what it shouldn’t,” said Turvey, a pediatrician and investigator at the BC Children’s Hospital Research Institute.

“The immune system becomes confused and that lies at the heart of these allergic diseases,” said Turvey, also a professor at the University of British Columbia who led the study that involved multiple universities across the country.

The study considered eczema, asthma, hay fever and food allergies together, though their unique symptoms mean they have typically been researched separately. It included 1,115 children who were tracked from birth to age five, with 523 of them having no evidence of allergies. The remaining 592 kids had been diagnosed with one or more allergies by age five. Of the latter group, 367 of the children had eczema, or atopic dermatitis, 165 had asthma and some suffered from three or all of the conditions.

Researchers evaluated each child’s microbiome from stool samples collected at clinical visits when they were three months and a year old. The samples showed a “bacterial signature” associated with the children developing any of the four allergies by age five. The signature is considered a hallmark of dysbiosis, or an imbalance between good and bad bacteria in the gut, making people prone to allergies.

The data that researchers used was from the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study, the largest population-based study in the country since its launch in 2008.

Turvey said a powerful message of the study is that antibiotics should not be used unless the medication is absolutely necessary for a bacterial infection. That can include an ear or a bloodstream infection or something as severe as meningitis. Antibiotics do not work for viral infections.

“But we know that many antibiotic prescriptions in that first year of life are not for bacterial infections and could be avoided,” said Turvey, adding parents should also be educated about the drugs’ role in disrupting the microbiome.

“Some parents will come to the clinic, essentially demanding antibiotics,” he said.

The study also bolstered previous research that found breastfeeding babies up to six months is a protective measure because the milk has bacteria that promote a healthy microbiome.

Turvey and his colleagues hope their work will lead to treatments or ways to predict whether a child will develop allergies, which affect one in three kids in Canada and millions around the world.

“They’re the No. 1 reason children come to the emergency room, the No. 1 reason children miss school, the No. 1 reason for billing our health-care system in Canada.”

Jennifer Gerdts, executive director of the non-profit Food Allergy Canada, said milk and eggs are the most common culprits but some people interpret an allergy to milk as lactose intolerance although each condition has very different consequences.

Food allergies can create a lot of anxiety for parents who worry about their children being exposed to unsafe food in different settings, especially when they rely on others to understand the condition, she said.

“It comes with a serious psychological impact because there’s that fear of not being able to control the environment that you’re in, that fear of the next reaction.”

About 40 to 50 per cent of children with food allergy also have asthma, Gerdts said.

“They are all tied together. I think that’s what’s interesting about this (study), that there may be possibilities for the research community taking a look at this and saying ‘How can we explore the treatment possibilities for those that have the highest burden of allergic disease across all of these?’”

Her twin sons, now 21, were both diagnosed at age three as being allergic to peanuts, eggs, sesame, seafood and fish. They also had eczema.

They were diagnosed after they had an anaphylactic reaction to seafood and ended up in an emergency room, Gerdts said. She happened to have an EpiPen in a first aid kit the family took on camping trips.

The device is used to quickly deliver a measured dose of epinephrine, which reverses the symptoms of anaphylaxis and potentially saves someone’s life.

Gerdts said education is crucial for the public health concern but childhood allergies remain under-recognized because most of the kids look healthy — until they have a severe reaction.

In the new school year, Food Allergy Canada will be offering a national food safety program that has already been launched online. It was piloted at 55 schools in Ontario, New Brunswick and Alberta in May with “outstanding results” showing 97 per of them would teach it again, she said.

“All About Food Allergy” for Grade 4-6 students is meant for children with allergies as well as those who could be a “food allergy ally,” she said.

“If you can cement the understanding in kids that this is a serious medical condition with the science behind it, that this is what’s happening in a child’s body, then it becomes just a part of life.”

READ ALSO: Kids prescribed antibiotics but not fed breast milk at triple risk of asthma: study

READ ALSO: Lower childhood asthma rates from less prescribing of antibiotics: B.C. study

BabiesHealthScience

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B.C. COVID-19 hospitalization data differs by who's reporting it - CTV News Vancouver

Did COVID-19 hospitalizations in B.C. increase or decrease last year? The answer, it turns out, depends on who you ask and how they're counting.

The Canadian Institute for Health Information says there were more COVID-19 hospitalizations in the 12 months from April 2022 through March 2023 than there were in the 12 months preceding that period, both in B.C. and Canada-wide.

The B.C. Centre for Disease Control says the opposite. Its data shows fewer hospitalizations in 2022-23 than in 2021-22.

They can't both be right, so what's going on here?

WHAT THE DATA SAYS

CIHI released data last week showing more than 120,000 hospital stays for COVID-19 from April 2022 through March 2023. That total is for all of Canada except Quebec, and it's almost a 20-per-cent increase in hospitalizations compared to the roughly 101,000 recorded from April 2021 through March 2022. 

In British Columbia, CIHI reports a total of 18,199 hospitalizations for the most recent April through March period, up roughly 7 per cent from the 16,939 it reported for April 2021 through March 2022. 

The BCCDC, on the other hand, says hospitalizations in the province decreased from one year to the other.

The BCCDC's online data portal shows 15,018 hospital admissions for the 2021-22 period, decreasing to 14,437 for 2022-23. 

All of this is separate from how many people are currently in B.C. hospitals with COVID-19, which CTV News has been tracking since the start of the pandemic. That number comes from the BCCDC, and is now released monthly, though it used to be shared more frequently.

The BCCDC released its most recent count on Aug. 3, showing just 76 people in hospital with COVID-19 on that date. That was the lowest total in roughly two years, and the metric has shown a consistent downward trend for most of 2023, so far.

The number of people in hospital with COVID-19 in 2023, as reported by the BCCDC, is shown. (CTV)

Recent wastewater surveillance data, it should be noted, suggests increasing coronavirus transmission in the province, making a continued decline in the hospital census unlikely when the BCCDC releases its September update next week. 

WHY ARE THE TWO DATA SOURCES SO DIFFERENT?

To a certain extent, CIHI and the BCCDC are measuring two different things. Though both agencies are counting hospitalizations, they're recording their findings at different points in the process.

The BCCDC's data is described as "hospital admissions," and the criteria for what is included has changed over the years.

Between April 1, 2022, and April 22 of this year, the definition was limited to "a first positive lab test," meaning reinfections were not included in the count. Anyone who tested positive on a lab-based PCR test for the first time and was hospitalized within 14 days was counted, as was anyone identified by a hospital as a COVID-19 patient based on a positive lab test, regardless of how long it had been since the test.

CIHI's data was collected through the Discharge Abstract Database, which "contains administrative, clinical and demographic information on hospital discharges" for all provinces except Quebec, according to CIHI data tables.

Nicole Loreti, program lead with CIHI's clinical administrative databases team, told CTV News her agency's data aims to include "anybody who was discharged during (the time in question) that had a documented case of COVID-19, whether that's confirmed or suspected."

Loreti noted a couple of key differences between CIHI's approach and the BCCDC's, which could help explain the discrepancy between the agencies' numbers.

First, she said CIHI's definition of a COVID case includes both lab-based and rapid antigen tests, the latter of which are not counted in B.C.'s data.

"Another difference is the admissions versus discharges," Loreti said. "If you're admitted in March but discharged in April, that hospital data doesn't flow to CIHI until April."

Those factors, as well as B.C.'s exclusion of reinfections, likely contribute to the disparity between the two agencies' numbers, but it's unclear whether they account for the entirety of the gulf.

Asked to weigh in on the differences between the two systems, the BCCDC provided a written statement that mentioned some of the same factors, while also emphasizing that each data set serves a different purpose.

"CIHI and BCCDC use different data sources for COVID-19 hospitalization numbers and count hospitalizations differently, so the two numbers are not directly comparable," the BCCDC said.

"The aim of BCCDC’s system is surveillance. It is to have information available rapidly to assess trends and inform provincial decision-making and action. Specifically, we are interested in capturing broad trends and changes in the population."

The purpose of the CIHI data, meanwhile, is to "assess health-care system impact," according to the BCCDC.

"Additional data from rapid antigen tests, hospital transfers, and readmissions are incorporated in their counts and reports," the centre said. "BCCDC does not use these data sources as they’re less reliable when needing them for timelier, more frequent reporting."

SO WHOSE DATA IS CORRECT?

Neither CIHI nor the BCCDC claimed that the other agency's data was wrong, and each one told CTV News the other's data served a valuable purpose.

However, the BCCDC's statement did seem to acknowledge that CIHI's numbers are more complete than its own.

"The BCCDC approach incorporates fewer data elements than CIHI, and the CIHI data are therefore more applicable to assessing the impact of COVID-19 on the health-care system," the provincial agency said.

But while CIHI's data adds thoroughness, it lacks timeliness. The agency publishes reports on COVID-19 data every six months, and its initial reports are typically missing data from Quebec, which is added later.

The BCCDC, by contrast, says it monitors hospital admissions in "nearly real time" to achieve the aforementioned goals of picking up on trends and informing provincial decision-making.

"The aims of these systems differ as they are attempting to answer different questions, which is why they’re not directly comparable," the BCCDC said. "However, together they strengthen our understanding of the burden of disease on population health." 

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Following reports of new variant, Hochul announces new steps for protection against COVID-19, as summer hospitalizations rise - Niagara Frontier Publications

Tue, Aug 29th 2023 04:20 pm

World-renowned Wadsworth Lab monitoring samples for new BA.2.86 Variant, not yet detected in New York

√ Department of Health contacted nursing home providers to remind them of ‘responsibility to keep residents protected’; state continues to make high-quality N-95 masks and test kits available to state and county officials by request

√ Hochul: All New Yorkers – especially those in high-risk groups – are encouraged to talk to their primary care doctor about updated COVID-19 vaccines coming this fall

Gov. Kathy Hochul has announced new steps the state of New York is taking to protect individuals from COVID-19 following reports of a new variant, BA.2.86. These steps come after COVID-19 hospitalizations in New York increased as the summer progressed. As a reminder, an updated COVID-19 vaccine tailored to guard against certain variants is expected to arrive in pharmacies and doctor’s offices this fall.

“While New Yorkers might want to be done with COVID-19, COVID-19 isn’t done with us,” Hochul said. “With the increase in hospitalizations and reported cases this summer, I strongly urge everyone to take appropriate precautions to protect themselves and their communities. To keep New Yorkers safe, my administration will continue to monitor this situation, share information on the new boosters as soon as it’s available, and continue to make N-95 masks available statewide.”

Earlier this year, the Food and Drug Administration advised vaccine manufactures to develop a new COVID-19 vaccine to target Omicron variants. The new shot is expected to be released by the three major COVID-19 vaccine producers in September. Hochul encourages New Yorkers to monitor the CDC and the New York State Department of Health (DOH) websites frequently for information on updated COVID-19 vaccine administration recommendations.

To protect all New Yorkers, DOH and the Wadsworth Center continue monitoring for and analyzing samples of SARS-CoV-2, the virus that causes COVID-19, as reports emerge of new strains.

Hochul’s team said, “The ongoing dual surveillance strategies of wastewater surveillance and laboratory clinical analysis, conducted with partners at Syracuse University and across the state, have proven vital to New York state's ability to understand variant spread and the potential impact on public health.

“In response to identifying the new BA.2.86 variant, the Wadsworth Center immediately enhanced early detection efforts in New York state. In conjunction with the collaborators at Syracuse University, analysts searched wastewater data from the last six months to confirm the new strain was not detected in New York. This process will continue to be used to help monitor for the variant in new wastewater samples. Additionally, Wadsworth Center is coordinating with numerous health care professionals across the state and collaborating laboratories to expand the pool of clinical COVID samples submitted for analysis to increase the opportunity for detecting BA.2.86, should it enter the state.”

State Health Commissioner Dr. James McDonald said, "The Department of Health remains vigilant for changes to the virus that could further threaten our public health. We continue to monitor as new strains have emerged, with a particular focus on BA.2.86, the most genetically different strain we have seen since the original Omicron variant. These significant changes are important to note as mutations may allow the virus to evade prior immunity. Remember, COVID is now a treatable disease, and tests are both easy and highly accurate. Antivirals such as Paxlovid are most effective when started within five days of the onset of symptoms."

As students begin to return to school for the next academic year, Hochul and DOH recommend that schools review current CDC school guidance for COVID-19 prevention, and work with their local health department to implement effective and feasible public health measures.

To prevent the spread of COVID-19, the CDC recommends schools:

√ Promote vaccination and testing;

√ Encourage students, teachers and faculty to stay home if they are sick and exhibiting symptoms;

√ Optimize ventilation and maintain improvements to indoor air quality to reduce the risk of germs and contaminants spreading through the air; and

√ Teach and reinforce proper handwashing and hygiene practices.

Hochul’s team said, “Schools that experience outbreaks should work with their local health department for timely outbreak response support. More guidance for schools is available here.

“All individuals who have symptoms of COVID-19 should immediately get tested. If a test is positive, consult a health care provider about treatment, as it's important to begin treatment soon after the onset of symptoms to ensure the utmost effectiveness. Individuals who do not have a regular health care provider can find locations for treatment here. Those with COVID-19 should follow CDC guidance to avoid transmitting it to others, including isolating for five days after the onset of symptoms, as well as masking and avoiding contact with those who may be at higher risk of negative outcomes.

“At-home tests are available at many local pharmacies statewide, and New York continues to make high-quality N-95 masks and test kits available to state and county officials by request. New Yorkers should contact their respective county health department or local emergency management office for more information.

“The New York State Department of Health recently contacted nursing home providers statewide to alert them of the increase in COVID-19 infections reported over the past several weeks, and to remind facilities of measures that can be taken to help reduce transmission among vulnerable populations.”

Individuals who have not yet been vaccinated or are behind on booster doses can find the current COVID-19 vaccine sites here.

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Following reports of new variant, Hochul announces new steps for protection against COVID-19, as summer hospitalizations rise - Niagara Frontier Publications
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B.C. on pace for deadliest year in drug crisis as July brings another 198 deaths - Coast Reporter

VANCOUVER — British Columbia is on pace for the deadliest year in its unregulated toxic-drug crisis, with the BC Coroners Service saying another 198 deaths were reported in July.

It says there have been at least 1,455 deaths in the first seven months of 2023, the most ever recorded.

Fifty-six per cent of deaths this year have occurred in the Vancouver Coastal Health and Fraser Health authorities, but the coroners service says Northern Health continues to have the highest per-capita toxic-drug death rate at 59.8 per 100,000 residents.

Chief Coroner Lisa Lapointe says in a statement that the unregistered illicit drug market is "highly unpredictable," and the lack of access to stable, lower-risk alternatives continues to put lives at risk.

Provincial Mental Health and Addictions Minister Jennifer Whiteside says in a statement the new numbers are "a stark reminder" of the ongoing drug crisis, and the province is continuing to expand access to treatment options and counselling.

Opposition BC United MLA Elenore Sturko says in a post on the social media platform X, formerly known as Twitter, that "condolences alone aren't enough" and she is calling for a "recovery-oriented" care system.

She says a third of the province's fatal overdoses in July happened inside social housing, shelters and hotels.

This report by The Canadian Press was first published Aug. 29, 2023.

The Canadian Press

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Peel COVID cases remain low but recent uptick raises concern as school returns - The Pointer

By Hafsa Ahmed - Local Journalism Initiative Reporter
Aug 28, 2023 - Brampton, Mississauga

During the COVID-19 pandemic, the Region of Peel was overrepresented in cases across the province. In September 2020, The Pointer reported Brampton and Mississauga accounted for 25 percent of Ontario’s reported cases and 40 percent of the 116 schools reporting COVID-19 infections at the time, while only ten percent of the province’s population lived in the region. 

Three years later, many COVID-19 restrictions and regulations in public spaces, such as mask mandates and physical distancing requirements, have long been rolled back. However, cases in hospitals and data from wastewater systems indicate the virus is still circulating, and health professionals continue to track the mutations of the disease, with a new variant of concern coming to light in recent weeks. 

A recent uptick in cases — while overall numbers are still low compared to much of the pandemic — has raised concerns of a possible early fall wave of COVID-19 coinciding with the return to school for many students and educators. On August 9, the World Health Organization published an Initial Risk Evaluation of the most recent COVID-19 variant of concern, EG.5, an Omicron subvariant. 

It highlighted in its evaluation that the reported cases globally indicate an uptick, and despite determining the subvariant as “low” risk in the evaluation, said there is a risk of global transmission that could contribute to a surge in cases. “Several countries with rising EG.5 prevalence have seen increases in cases and hospitalizations, although at present there is no evidence of an increase in disease severity directly associated with EG.5,” the evaluation reads.

While the WHO says there currently is no evidence of more severity in this particular subvariant, there is risk around its transmissibility, especially regarding its immune escape properties. “EG.5 may cause a rise in case incidence and become dominant in some countries or even globally,” according to the organization. 

The Johns Hopkins Bloomberg School of Public Health reports cases of the EG.5 subvariant have increased recently in the U.S., making it the “most prevalent variant in the U.S.—accounting for more than 17 percent of cases,” although it still represents a low number of total recorded cases. In Canada, the EG.5 has been “steadily increasing in national samples since early July, following sporadic detections in the months prior,” according to data from the Government of Canada. 

Data from the federal wastewater surveillance dashboard shows 10 out of the 27 regions under wastewater surveillance have seen an increase in COVID-19 levels. 

In an email, the PDSB told The Pointer that, “for the 2023-2024 school year, the Peel District School Board will continue to follow the guidance and directions of Ontario’s Chief Medical Officer of Health and Peel Public Health regarding COVID-19, other respiratory viruses circulating in the community, and cold and flu season.” 

With the emergence of a new variant of concern, the return to school in early September could create the conditions for an early fall wave of COVID cases. 

(PDSB)

“The Peel District School Board is committed to providing safe learning and working environments for our students and staff this coming school year. The safety of our students and staff is our highest priority,” the board spokesperson said. 

In a letter to families of students attending PDSB schools in September of 2022, Peel Public Health listed recommendations to support their role in helping schools provide “safe learning environments for students and staff.” It encourages families to get up to date with all student immunizations, including COVID-19 vaccines for children aged 6 months to 5 years, and boosters for youth aged 5 to 18 years. 

The letter directs families to the provincial School and Child Care Screening Tool, which tells them to stay home if they are sick and says to review the new provincial guidance on returning to school after developing COVID-19 symptoms or testing positive. The letter also tells families to have students wear a mask but only if they are at higher risk of severe illness; ended isolation after COVID-19/symptoms or for 10 days after symptoms started; for 10 days after their last exposure to someone with COVID-19 or COVID-19 symptoms; and “when it is right for you.” 

The Pointer spoke with Peel Public Health in an email about the uptick in cases and the recent variant of concern, and asked what current plans are in place to address any potential risks of COVID-19 transmission in fall. Dr. Rebecca Shalansky, Peel Region’s Associate Medical Officer of Health, told The Pointer that Peel Public Health is, “aware of new variants of concern and… continues to make use of the tools we have available for monitoring and responding to all respiratory illness activity, including COVID-19, regardless of the variant.”

Shalansky highlighted that while COVID-19 activity in Peel remains low at this time, fall surges of COVID-19, influenza and RSV “are expected.” 

“Peel residents are encouraged to follow provincial guidance applicable to all respiratory illnesses, including staying up to date with vaccinations, staying home when ill, and washing hands,” she wrote. “NACI’s recently updated guidance directs individuals aged 5+ to consider delaying a COVID-19 booster until the fall for optimum protection.”

Dr. Shalansky wrote that routine school immunizations will continue to be promoted to eligible individuals over the summer months. “We have a great deal of confidence that our school board partners are well equipped to handle the upcoming respiratory illness season, and our close working relationship with Peel school boards allows us and the boards to adjust quickly as required.”

A Public Health Ontario report revised in April this year, titled Heating, Ventilation and Air Conditioning (HVAC) Systems in Buildings and COVID-19, found that indoor settings “pose an elevated risk of COVID-19 infection,” and that “improper or insufficient ventilation” has frequently been reported as a risk factor in outbreak investigations. 

“As part of a multi-layered strategy following public health guidelines, enhancing outdoor air ventilation and/or enhancing filtration where possible, and a well-functioning HVAC system can complement other public health measures by removing and diluting virus from indoor air, thereby lowering exposure to COVID-19,” it says. 

The report further highlights that filtration and ventilation are “important components in an indoor air quality improvement strategy to exhaust or capture gases, vapours and airborne particles including virus-containing dust and aerosols,” and says the removal of these matter can reduce exposure to occupants of the indoor spaces. It also shares that there are "case reports of unfiltered, recirculated air in a space linked to COVID-19 transmission in indoor settings with low or inadequate ventilation.”

The Pointer spoke with Mary Jo Nabuurs, Officer of Media Relations and Outreach at Ontario School Safety (OSS), a volunteer-led organization which has been advocating for clean indoor air conditions in Ontario schools for the past year. Nabuurs told The Pointer that members of their organization, especially those who have children returning to school across Ontario, are “really, really anxious” about air quality conditions in Ontario schools. 

“The impact of wildfire smoke on children is even worse and this has to do with the size of their airways,” said Nabuurs, highlighting that these additional impacts on the outdoor environment are impacting indoor environments and causing greater concern for their community members. She shared how exposure to wildfire smoke can increase people’s susceptibility to respiratory infections or viruses like COVID-19, which enters through the respiratory system. 

The CDC shares that wildfire smoke can “irritate your lungs, cause inflammation, affect your immune system, and make you more prone to lung infections, including SARS-CoV-2, the virus that causes COVID-19,” as written on the organization's website. 

“We have legitimate concerns that this fall/winter may be worse than what we experienced last fall/winter,” said Nabuurs. 

“If we expect clean drinking water, we should be able to expect clean air, especially with the knowledge we have that it matters,” said Nabuurs. OSS is focused on air quality in schools for many reasons, Nabuurs shared, highlighting the adverse effects of the wildfire smoke that had caused Ontario to receive Air Quality Alerts and the importance of addressing this, along with disease transmission, through the kind of air quality improvements in schools the organization is advocating for. 

On its website, the PDSB outlines ventilation efforts made by the Board in June 2020 to improve indoor air quality as a means to combat COVID-19 transmission. “The Board initiated and is continuing to undertake steps to improve the air quality, filtration and operation of HVAC and heating and ventilation systems in PDSB schools and other facilities,” it reads. “Working closely with the Ministry of Education, and utilizing all available Provincial and Federal funding provided, Facilities and Maintenance staff have been implementing several effective strategies to help reduce the spread of COVID-19.”

The website provides a list of these strategies, including efforts to “adjust HVAC system settings to increase the amount of fresh air into the building,” as well as providing standalone HEPA filter units “for schools or parts of schools with full mechanical ventilation.” However, not all classrooms in Peel, or even Ontario, have air conditioning  systems. 

The Pointer asked the PDSB if it is currently maintaining or building upon its efforts to implement its ventilation strategies to help reduce the spread of COVID-19 during the upcoming academic year. They responded saying they will, “continue to implement COVID-19 prevention and mitigation strategies that follow direction and guidance from the Ministry of Health and Peel Public Health to ensure that students and staff are safe.” 

Regarding ventilation, the PDSB responded that, when possible, its schools will continue to implement its existing strategies such as keeping windows open to encourage natural ventilation and adjust HVAC systems to increase fresh air flow. They also said they would continue with using HEPA filters, when possible, among other strategies. 

A Public Health Ontario report revised in July of 2022 notes that, “the use of a portable air cleaner is one component of a multi-layered strategy to mitigate SARS-CoV-2 transmission and is not a substitute for other public health measures, e.g., physical distancing, masking.”

“As we move forward during the school year, we will continue to do so and ensure our educators and education workers are implementing the appropriate safety measures,” the PDSB wrote. “For the upcoming school year, our schools and worksites remain mask-friendly environments for students, staff and visitors where needed.” They shared that “enhanced cleaning protocols” would continue to be in place, with hand sanitizer and disinfectant still available in schools. 

 

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Email: [email protected]

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At a time when vital public information is needed by everyone, The Pointer has taken down our paywall on all stories to ensure every resident of Brampton and Mississauga has access to the facts. For those who are able, we encourage you to consider a subscription. This will help us report on important public interest issues the community needs to know about now more than ever. You can register for a 30-day free trial HERE. Thereafter, The Pointer will charge $10 a month and you can cancel any time right on the website. Thank you

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Peel COVID cases remain low but recent uptick raises concern as school returns - The Pointer
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Canadian mortality rose in 2021: StatCan - CTV News

More people died in Canada in 2021 than the previous year, with cancer, heart disease, overdoses and COVID-19 cited as the leading causes of death.

Data from Statistics Canada shows an increase in mortality among men as driving the rise in deaths to 311,640 -- an increase of one per cent from the previous year.

The life expectancy also fell once again from 81.7 years to 81.6 years. It had decreased in 2020 by 0.6 years.

StatCan says that while cancer and heart disease remain the top two leading causes of death, accidental deaths rose by 14.5 per cent 2021, mostly due to fatal overdoses and falls.

COVID-19 also continued to affect Canadians' health as the fourth leading cause of death that year, with notable increase among younger people.

The data shows COVID-19 deaths among people under age 65 more than doubled in the second year of the pandemic. The agency says just over 2,600 younger Canadians died of the disease in 2021 and that nearly 66 per cent of them were men.

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Dexmedetomidine and Esketamine and Breast Cancer | DDDT - Dove Medical Press

Department of Anesthesiology, Bengbu Medical College, Anqing Municipal Hospital, Anqing, People’s Republic of China

Purpose: This study evaluated the effect of a combined infusion of dexmedetomidine and esketamine on the quality of recovery in patients undergoing modified radical mastectomy.
Methods: A total of 135 patients were randomly divided into three groups: dexmedetomidine group (group D) received dexmedetomidine (0.5 μg/kg loading, 0.4 μg/kg/h infusion), dexmedetomidine plus low-dose esketamine group (group DE₁) received dexmedetomidine (0.5 μg/kg loading, 0.4 μg/kg/h infusion) and esketamine (0.5 mg/kg loading, 2 μg/kg/min infusion), dexmedetomidine plus high-dose esketamine group (group DE₂) received dexmedetomidine (0.5 μg/kg loading, 0.4 μg/kg/h infusion) and esketamine (0.5 mg/kg loading, 4 μg/kg/min infusion). The primary outcome was the overall quality of recovery-15 (QoR-15) scores at 1 day after surgery. The secondary endpoints were total QoR-15 scores at 3 days after surgery, propofol and remifentanil requirement, awaking and extubation time, postoperative visual analogue scale (VAS) pain scores, rescue analgesic, nausea and vomiting, bradycardia, excessive sedation, nightmares, and agitation.
Results: The overall QoR-15 scores were much higher in groups DE₁ and DE₂ than in groups D 1 and D 3 days after surgery (P 0.05). VAS pain scores at 6, 12, 24 h postoperatively, propofol and remifentanil requirements were significantly lower in groups DE₁ and DE₂ than in group D (P 0.05). Compared with group D, awaking time, extubation time, and post-anesthesia care unit (PACU) stay were significantly prolonged in groups DE₁ and DE₂ (P 0.05) and were much longer in group DE₂ than in group DE₁ (P 0.05). The proportion of postoperative rescue analgesics and bradycardia was higher and the incidence of excessive sedation was lower in group D than in groups DE₁ and DE₂ (P 0.05).
Conclusion: Dexmedetomidine plus esketamine partly improved postoperative recovery quality and decreased the incidence of bradycardia but prolonged awaking time, extubation time, and PACU stay, especially dexmedetomidine plus 4 μg/kg/min esketamine.

Keywords: dexmedetomidine, esketamine, quality of recovery, modified radical mastectomy

Introduction

Breast cancer is a common malignancy in women. Modified radical mastectomy (MRM) is an effective intervention for patients with breast cancer. Most patients who undergo MRM experience acute postoperative pain. Moreover, if acute postoperative pain is not sufficiently controlled, it may be develop chronic pain.¹ Currently, and opioids are currently the mainstay of drugs for moderate or severe postoperative pain. However, opioid-related adverse events may also affect the quality of the postoperative recovery. Multimodal analgesia is usually used in postoperative pain management to control pain and reduce opioid requirements.

Dexmedetomidine (DEX), a selective α₂ adrenal receptor agonist, has sedative and analgesic effects.² Two meta-analysis revealed that DEX administration alleviated postoperative pain and reduced postoperative nausea and vomiting (PONV).^3,4 Current evidence indicates that the use of DEX enhances postoperative recovery quality.^5,6 Esketamine, the dextral isomer of ketamine, is an antagonist of the N-methyl-D-aspartate (NMDA) receptor. It has higher potency, faster recovery time, and fewer adverse effects than ketamine.^7,8 Some clinical studies have demonstrated that S (+)-ketamine administration can reduce the intensity of postoperative pain,⁹ decrease the requirement for postoperative analgesics,¹⁰ and prolong the analgesic time.¹¹ Bornemann-Cimenti H et al found that S (+)-ketamine reduced opioid consumption and hyperalgesia after surgery.¹² In addition, a clinical study showed that esketamine administration enhanced the quality of recovery by alleviating postoperative pain.^13,14 However, the effect of esketamine combined with dexmedetomidine on the postoperative quality of recovery in patients undergoing MRM has not been reported. This study aimed to investigate whether the combination of esketamine and DEX administration further improves the quality of recovery after surgery in patients with MRM.

Methods and Materials

Study Participants

The present study was approved by The Ethics Committee of Anqing Municipal Hospital (2022028). The study was registered at www.clinicaltrials.gov (March 17, 2022; NO: NCT05283408) and implemented from April 2022 to March 2023. This study was conducted in compliance with the principles of the Declaration of Helsinki. Informed consent was obtained from each patient who agreed to participate in the study one day before surgery. 135 female patients undergoing MRM with ASA I-II, aged 30–65 years were participated in our trial. The exclusion criteria included a history of preoperative psychiatric, renal, or hepatic insufficiency; severe respiratory or circulatory disease; preoperative atrioventricular block; pregnant or lactating women; and preoperative bradycardia.

Randomisation and Blinding

Participants were randomly divided into the dexmedetomidine group (group D), dexmedetomidine combined with low-dose esketamine group (group DE₁), and dexmedetomidine combined with high-dose esketamine group (group DE₂) at a 1:1:1 ratio using a computer-generated list of random numbers. The random numbers were sealed with opaque envelopes to conceal arm allocation. Patients were given 0.5 µg/kg dexmedetomidine (a total of 20 mL with normal saline) and normal saline (20 mL) over 10 minutes before anesthesia induction, and 0.4 µg/kg/h dexmedetomidine (a total of 20 mL with normal saline) and normal saline (20 mL) were continuously infused at 20 mL/h until 20 minutes before the end of surgery in group D, respectively. Patients were given 0.5 µg/kg dexmedetomidine (a total of 20 mL with normal saline) and 0.5 mg/kg esketamine (a total of 20 mL with normal saline) over 10 minutes before anesthesia induction, and 0.4 µg/kg/h dexmedetomidine (a total of 20 mL with normal saline) and 2 µg/kg/min esketamine (a total of 20 mL with normal saline) were continuously infused at 20 mL/h until 20 minutes before the end of surgery in group DE₁, respectively. Patients were given 0.5 µg/kg dexmedetomidine (a total of 20 mL with normal saline) and 0.5 mg/kg esketamine (a total of 20 mL with normal saline) over 10 minutes before anesthesia induction, and 0.4 µg/kg/h dexmedetomidine (a total of 20 mL with normal saline) and 4 µg/kg/min esketamine (a total of 20 mL with normal saline) were continuously infused at 20 mL/h until 20 minutes before the end of surgery in group DE₂, respectively. Patients, anesthesia providers, surgeons, operating room nurses, and outcome assessors were blinded to the group allocation.

Anesthesia Protocol

Each participant entered the operating room, and routine monitoring including mean blood pressure (MBP), peripheral oxygen saturation (SPO₂), electrocardiogram (ECG), and heart rate (HR) was established. The anesthesiologist recorded the baseline values during routine monitoring. An operating room nurse established an intravenous line to infuse the crystalloid solution. Dexamethasone 10 mg and penehyclidine 0.5 mg were given for each patient. All participants received preoxygenation with 100% oxygen for 3–5 minutes using a face mask. Midazolam 0.05 mg/kg, remifentanil 0.5 µg/kg (over 60 seconds), etomidate 0.3 mg/kg, and rocuronium 1.0 mg/kg were intravenously injected for induction of anesthesia. Tracheal intubation was performed when the patient lost consciousness and the jaw was relaxed. After tracheal intubation, a Fabius Draeger machine was attached to perform mechanical ventilation. The end-tidal CO₂ pressure (PetCO₂) was maintained between 35 and 45 mmHg by adjusting tidal volume (6–8 mL/kg) and respiratory rate (12–14 beat/min). The fraction of inspired oxygen was set at 50–60%. Flurbiprofen axetil 50 mg was intravenously administered before skin incision. Remifentanil 0.06–0.2 µg/kg/min and propofol 4–6 mg/kg/h were infused to maintain anesthesia during the perioperative period. cis-atracurium 1–2 mg was administered according to the surgical requirements. Hemodynamic variables were maintained within 20% of the baseline measurements. If the HR was < 50 beats/min during the intraoperative period, atropine 0.5 mg was administered intravenously. The infusion of dexmedetomidine and esketamine were stopped 20 minutes before the end of surgery, meanwhile, sufentanil 0.2 µg/kg and dezocine 0.1 mg/kg were injected for controlling postoperative pain. Propofol and remifentanil were discontinued at the end of skin suture. Ondansetron 4 mg was administered intravenously to prevent postoperative nausea and vomiting. After endotracheal tube removal, patients were transferred to the PACU and continuously observed until they left the PACU.

Primary and Secondary Outcomes

The primary outcome was the total QoR-15 score according to the QoR-15 scale at 1 day after surgery. The total QoR-15 scores were evaluated based on physical comfort (five items), emotional state (four items), psychological support (two items), physical independence (two items), and pain (two items) for QoR-15 questionnaire. The total QoR-15 score ranges from 0 to 150 points, with higher scores representing better recovery quality after operation.¹⁵

Postoperative pain intensity was assessed using the VAS pain scale at 2, 6, 12, 24, and 48 hours after surgery (0, painless; 10, worst imaginable pain). Patients were administered flurbiprofen axetil 50 mg when the postoperative VAS pain scores were ≥4. In addition, opioids are not routinely used for postoperative analgesia in patients undergoing modified radical mastectomy at our hospital. The awakening time was defined as the time when remifentanil and propofol were stopped to open the eye, and the extubation time was defined as the time when remifentanil and propofol were stopped to remove the endotracheal tube. An HR < 60 beats/min was considered indicative of bradycardia. The Ramsay Sedation Scale (RSS) was used to evaluate the level of sedation after surgery in the PACU (1 represents patient anxiety, agitation, or restlessness; 2 represents patient cooperation and orientation; 3 represents patient response to commands only; 4 represents asleep but strong response to stimulation; 5 represents asleep and slow response to stimulation; 6 represents asleep, no response). An RSS score of ≥4 was considered excessive sedation. The secondary outcomes included preoperative total QoR-15 scores; total QoR-15 scores at 3 days after surgery; perioperative remifentanil and propofol requirement; awaking time; extubation time; VAS pain scores at postoperative 2, 6, 12, 24, and 48 h; postoperative rescue analgesic; postoperative nausea and vomiting; bradycardia; excessive sedation; nightmares; and agitation within 30 min after surgery.

Sample Size Calculation

The sample size was calculated using PASS 11.0 according to the primary endpoint of the present study. The results of our pilot study showed that the mean values and standard deviations (SD) of the total QoR-15 scores in all three groups were 125.3, 128.9, 130.0, 5.8, 3.8, and 4.2, respectively. Therefore, 37 patients in each group were required with an α of 0.05, and β=0.1. Allowing for a 20% dropout rate, we selected 135 patients for the present study.

Statistical Analysis

SPSS v.20 (IBM Corp., Armonk, NY, USA) was used for data analysis. Categorical data including ASA classification, rescue analgesic use, and the incidence of bradycardia, PONV, excessive sedation, nightmares, and agitation within 30 min after surgery were analyzed using χ² or Fisher’s exact test, as appropriate, and are shown as number (proportion, %). The Kolmogorov–Smirnov test and Levene’s test were used to evaluate the normality and homogeneity of continuous data, respectively. Normally distributed data were expressed as mean (SD) and analyzed using one-way analysis of variance (ANOVA). The total QoR-15 scores, VAS pain scores during the first 48 h after surgery, propofol dose, remifentanil dose, awaking time, extubation time, and PACU stay were reported as median (interquartile range [IQR]) and analyzed using the Kruskal–Wallis test. The level of significance was set at P < 0.05.

Results

A total of 160 participants were recruited for the study. Eighteen participants did not meet the inclusion criteria, seven refused to participate in the study, and 135 completed the study (Figure 1).

Figure 1 CONSORT flow diagram for the study.

The Comparison of the Baseline Data in Three Groups

There were no differences in age, operation time, anesthesia time, ASA grade, body mass index (BMI), fluid infusion volume, or blood loss (Table 1).

Table 1 Clinical Data of Patients

The Comparison of the Overall QoR-15 Scores Before and After Surgery

The preoperative overall QoR-15 scores did not differ among the three groups (P > 0.05). The overall QoR-15 scores were significantly higher in groups DE₁ and DE₂ than in group D 1 and 3 days after surgery (P = 0.000, P = 0.000, P = 0.003, P = 0.000, respectively). No significant difference was found in the overall QoR-15 scores between groups DE₁ and DE₂ at 1 and 3 days after surgery (P>0.05 and P > 0.05, respectively) (Table 2).

Table 2 Comparison of QoR-15 Scores at Different Time Points

The Comparison of VAS Pain Scores Within 48 h After Operation

The VAS pain scores at 6, 12, and 24 h postoperatively were significantly lower in the DE₁ and DE₂ groups than in the D group (all P < 0.05). The VAS pain scores at 2 and 48 h postoperatively were not significantly different among the three groups (all P > 0.05). The VAS pain scores during the first 48 postoperative hours did not differ significantly between the DE₁ and DE₂ groups (all P > 0.05) (Table 3).

Table 3 Comparison of VAS Pain Scores at Different Time Points

The Comparison of Intraoperative Remifentanil and Propofol Requirement, Awaking Time, Extubation Time, and PACU Stay

The intraoperative remifentanil and propofol requirements were significantly lower in groups DE₁ and DE₂ than in group D (all P = 0.000). There was no difference in intraoperative remifentanil requirement between the DE₁ and DE₂ groups (P > 0.05). Compared with group D, awakening time, extubation time, and PACU stay were significantly prolonged in the DE₁ and DE₂ groups (all P < 0.05). The awakening time, extubation time, and PACU stay were much longer in the group DE₂ than in the group DE₁ (all P = 0.000) (Table 4).

Table 4 Comparison of Propofol Dose, Remifentanil Dose, Awaking Time, Extubation Time, and PACU Stay

The Comparison of Postoperative Rescue Analgesic, Nausea and Vomiting, Bradycardia, Excessive Sedation, Nightmare, and Agitation Within 30 Min After Surgery

The proportion of postoperative rescue analgesics and bradycardia was higher in group D than in groups DE₁ and DE₂ (all P < 0.05). No significant difference was found with respect to bradycardia and postoperative rescue analgesic use between the DE₁ and DE₂ groups (P>0.05 and P > 0.05, respectively). Compared with group D, the incidence of excessive sedation was higher in groups DE₁ and DE₂ (P < 0.05, and P < 0.05, respectively). The incidence of PONV, nightmares, and agitation within 30 min after surgery was not significantly different among the three groups (all P > 0.05) (Table 5).

Table 5 Comparison of Postoperative Rescue Analgesic, Nausea and Vomiting, Bradycardia, Excessive Sedation, Nightmares, and Agitation Within 30 Min After Surgery

Discussion

The results of our study indicate that dexmedetomidine combined with esketamine partly improves postoperative recovery quality, alleviates postoperative pain intensity, and decreases the incidence of bradycardia and rescue analgesia compared with dexmedetomidine alone in patients undergoing modified radical mastectomy for breast cancer. However, the combination of dexmedetomidine and esketamine prolonged awakening time, extubation time, and PACU stay, especially dexmedetomidine combined with high-dose esketamine (4 µg/kg/min).

The quality of postoperative recovery was evaluated based on the total QoR-15 score, which is an effective tool in clinical practice. It was reported that ketamine with sub-anesthetic dose improved the quality of recovery after surgery in colorectal cancer patients by antidepressant and analgesic effect.¹⁶ Yu et al revealed that pectoral nerve block type II combined with esketamine enhanced postoperative recovery quality for breast cancer.¹⁷ Zhu et al demonstrated that low- or high-dose esketamine improved the quality of postoperative recovery on postoperative days 1 and 3.¹⁸ Some clinical studies proved that dexmedetomidine administration alleviated the intensity of postoperative pain, experienced lower postoperative nausea and vomiting, and improved postoperative quality of recovery.^19–21 In the present study, we found that there were higher QoR-15 scores in groups DE₁ and DE₂ than in group D on postoperative days 1 and 3, suggesting that dexmedetomidine combined with esketamine infusion provided better quality of postoperative recovery, which may be related to lower VAS pain scores and improved QoR-15 questionnaire.

Perioperative management of analgesia minimizes the use of opioids, based on the concept of enhanced recovery after surgery. Some evidence showed that dexmedetomidine had an opioid-sparing effect and alleviated postoperative pain intensity.^22,23 Zhang et al found that intravenous dexmedetomidine reduced postoperative VAS pain scores within the first 24 h of undergoing modified radical mastectomy for breast cancer.²⁴ In addition, López et al revealed that ketamine had a lower ratio of acute postoperative pain, alleviated intensity of pain, and reduced rescue analgesia requirement in breast cancer.²⁵ Meta analysis by Bi et al showed that ketamine effectively reduced wound pain, decreased incidence of postmastectomy pain syndrome, and improved depression after surgery.²⁶ Dexmedetomidine combined with esketamine infusion improved postoperative analgesia.²⁷ The results of our study found that dexmedetomidine combined with esketamine was significantly decreased postoperative VAS pain scores at 6, 12, 24 h, and the rate of postoperative rescue analgesic compared to dexmedetomidine administration. This indicates that the combination of dexmedetomidine and esketamine controlled postoperative pain better than dexmedetomidine alone, which may be related to esketamine analgesia²⁸ or the additive analgesic effect of dexmedetomidine combined with esketamine administration.²⁹

Dexmedetomidine and esketamine have opioid-sparing effects. Some studies have suggested that intravenous dexmedetomidine reduces intraoperative opioid requirement.^22,30 Zhu et al argued that intravenous ketamine had an opioid-reducing effect.³¹ Our results showed that dexmedetomidine combined with esketamine further reduced intraoperative remifentanil requirement compared with dexmedetomidine alone, which implies that dexmedetomidine combined with esketamine had a better opioid-sparing effect. In addition, our results also showed that the propofol requirement was lower in groups DE₁ and DE₂ than in group D.

Intravenous dexmedetomidine had a longer time to awaken and extubation.^32,33 Esketamine infusion may prolong recovery time.³⁴ Chen et al reported that dexmedetomidine combined with esketamine administration lengthened awakening time in patients undergoing gynecological laparoscopic surgery.³⁵ In the present study, we found that awake time, extubation time, and PACU stay were longer in groups DE₁ and DE₂ than in group D, in addition, they were longer in group DE₂ than in group DE₁. The results showed that dexmedetomidine plus esketamine resulted in better sedation in a dose-dependent manner.

The use of dexmedetomidine results in a higher rate of bradycardia during the perioperative period. It was reported that dexmedetomidine infusion significantly increased the incidence of bradycardia.³⁶ Single low-dose esketamine administration experienced transient tachycardia.³⁷ We observed that the combination of dexmedetomidine and esketamine had lower rate of bradycardia than dexmedetomidine during the perioperative period, which may be associated with tachycardia-induced esketamine and continuous infusion of esketamine.

The limitations of this study are as follows. First, we observed only a few adverse effects of esketamine, such as nightmares. However, esketamine may cause hallucinations, visual disturbances, confusion, and disorientation. However, further studies are required to confirm these adverse effects. Second, we only evaluated pain scores during the first 48 hours after surgery, which does not reflect long-term outcomes; postoperative chronic pain affects patient satisfaction and quality of life. Therefore, we need to further evaluate the effect of dexmedetomidine plus esketamine infusion on postoperative chronic pain. Third, dexmedetomidine and esketamine may affect hemodynamic changes. Therefore, the effect of their combination on hemodynamic changes should be further evaluated. Finally, the sample size was small and this was a single-center trial, and the results of this study require a multi-center and large sample for further confirmation.

Conclusion

Dexmedetomidine combined with esketamine partly improved postoperative recovery quality, alleviated postoperative pain intensity, and decreased the incidence of bradycardia and rescue analgesia compared with dexmedetomidine alone in patients undergoing modified radical mastectomy. However, the combination of dexmedetomidine and esketamine prolonged awakening time, extubation time, and PACU stay, especially dexmedetomidine combined with high-dose esketamine (4 µg/kg/min). The lower dose of esketamine infusion was better than the higher dose in combination with dexmedetomidine infusion.

Data Sharing Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Funding

This study was supported by the Clinical Research Foundation of Hubei and Chen Xiaoping Science and Technology Development Foundation (CXPJJH12000005-07-43).

Disclosure

The authors report no conflicts of interest in this work.

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