Search for the standard model Higgs boson in associated WH production in 9.7 fb(-1) of pp collisions with the D0 detector

We present a search for the standard model Higgs boson in final states with a charged lepton (electron or muon), missing transverse energy, and two or three jets, at least one of which is identified as a b-quark jet. The search is primarily sensitive to WH→ℓνbb production and uses data corresponding to 9.7 fb(-1) of integrated luminosity collected with the D0 detector at the Fermilab Tevatron pp Collider at √s = 1.96 TeV. We observe agreement between the data and the expected background. For a Higgs boson mass of 125 GeV, we set a 95% C.L. upper limit on the production of a standard model Higgs boson of 5.2 × σ(SM), where σ(SM) is the standard model Higgs boson production cross section, while the expected limit is 4.7 × σ(SM).

Combined search for the standard model Higgs boson decaying to bb using the D0 run II data set

We present the results of the combination of searches for the standard model Higgs boson produced in association with a W or Z boson and decaying into bb using the data sample collected with the D0 detector in pp collisions at √s = 1.96 TeV at the Fermilab Tevatron Collider. We derive 95% C.L. upper limits on the Higgs boson cross section relative to the standard model prediction in the mass range 100 GeV ≤ M(H) ≤ 150 GeV, and we exclude Higgs bosons with masses smaller than 102 GeV at the 95% C.L. In the mass range 120 GeV ≤ M(H) ≤145 GeV, the data exhibit an excess above the background prediction with a global significance of 1.5 standard deviations, consistent with the expectation in the presence of a standard model Higgs boson.

Search for the standard model Higgs boson in ZH→ℓ(+)ℓ(-)bb production with the D0 detector in 9.7 fb(-1) of pp collisions at √s = 1.96 TeV

We present a search for the standard model (SM) Higgs boson produced in association with a Z boson in 9.7 fb(-1) of pp collisions collected with the D0 detector at the Fermilab Tevatron Collider at √s = 1.96 TeV. Selected events contain one reconstructed Z→e(+)e(-) or Z→μ(+)μ(-) candidate and at least two jets, including at least one jet identified as likely to contain a b quark. To validate the search procedure, we also measure the cross section for ZZ production in the same final state. It is found to be consistent with its SM prediction. We set upper limits on the ZH production cross section times branching ratio for H→bb at the 95% C.L. for Higgs boson masses 90 ≤ M(H) ≤ 150 GeV. The observed (expected) limit for M(H) = 125 GeV is 7.1 (5.1) times the SM cross section.

Evidence for a particle produced in association with weak bosons and decaying to a bottom-antibottom quark pair in higgs boson searches at the tevatron

We combine searches by the CDF and D0 Collaborations for the associated production of a Higgs boson with a W or Z boson and subsequent decay of the Higgs boson to a bottom-antibottom quark pair. The data, originating from Fermilab Tevatron pp collisions at √s = 1.96 TeV, correspond to integrated luminosities of up to 9.7 fb(-1). The searches are conducted for a Higgs boson with mass in the range 100-150 GeV/c(2). We observe an excess of events in the data compared with the background predictions, which is most significant in the mass range between 120 and 135 GeV/c(2). The largest local significance is 3.3 standard deviations, corresponding to a global significance of 3.1 standard deviations. We interpret this as evidence for the presence of a new particle consistent with the standard model Higgs boson, which is produced in association with a weak vector boson and decays to a bottom-antibottom quark pair.

On the prevention and analysis of missing data in randomized clinical trials: the state of the art

We summarize and elaborate on the recently published National Research Council report entitled "The Prevention and Treatment of Missing Data in Clinical Trials." We tailor our discussion to orthopaedic trials. In particular, we discuss the intent-to-treat principle, review study design and prevention ideas to minimize missing data, and present state-of-the-art sensitivity analysis methods for analyzing and reporting the results of studies with missing data.

Treatment for Schistosoma japonicum, reduction of intestinal parasite load, and cognitive test score improvements in school-aged children

Background

To determine whether treatment of intestinal parasitic infections improves cognitive function in school-aged children, we examined changes in cognitive testscores over 18 months in relation to: (i) treatment-related Schistosoma japonicum intensity decline, (ii) spontaneous reduction of single soil-transmitted helminth (STH) species, and (iii) ≥2 STH infections among 253 S. japonicum-infected children.

Methodology

Helminth infections were assessed at baseline and quarterly by the Kato-Katz method. S. japonicum infection was treated at baseline using praziquantel. An intensity-based indicator of lower vs. no change/higher infection was defined separately for each helminth species and joint intensity declines of ≥2 STH species. In addition, S. japonicum infection-free duration was defined in four categories based on time of schistosome re-infection: >18 (i.e. cured), >12 to ≤18, 6 to ≤12 and ≤6 (persistently infected) months. There was no baseline treatment for STHs but their intensity varied possibly due to spontaneous infection clearance/acquisition. Four cognitive tests were administered at baseline, 6, 12, and 18 months following S. japonicum treatment: learning and memory domains of Wide Range Assessment of Memory and Learning (WRAML), verbal fluency (VF), and Philippine nonverbal intelligence test (PNIT). Linear regression models were used to relate changes in respective infections to test performance with adjustment for sociodemographic confounders and coincident helminth infections.

Principal Findings

Children cured (β = 5.8; P = 0.02) and those schistosome-free for >12 months (β = 1.5; P = 0.03) scored higher in WRAML memory and VF tests compared to persistently infected children independent of STH infections. A decline vs. no change/increase of any individual STH species (β:11.5–14.5; all P<0.01) and the joint decline of ≥2 STH (β = 13.1; P = 0.01) species were associated with higher scores in WRAML learning test independent of schistosome infection. Hookworm and Trichuris trichiura declines were independently associated with improvements in WRAML memory scores as was the joint decline in ≥2 STH species. Baseline coinfection by ≥2 STH species was associated with low PNIT scores (β = −1.9; P = 0.04).

Conclusion/Significance

Children cured/S. japonicum-free for >12 months post-treatment and those who experienced declines of ≥2 STH species scored higher in three of four cognitive tests. Our result suggests that sustained deworming and simultaneous control for schistosome and STH infections could improve children's ability to take advantage of educational opportunities in helminth-endemic regions.

Parasitic worm infections are associated with cognitive impairment and lower academic achievement for infected relative to uninfected children. However, it is unclear whether curing or reducing worm infection intensity improves child cognitive function. We examined the independent associations between: (i) Schistosoma japonicum infection-free duration, (ii) declines in single helminth species, and (iii) joint declines of ≥2 soil-transmitted helminth (STH) infections and improvements in four cognitive tests during18 months of follow-up. Enrolled were schistosome-infected school-aged children among whom coinfection with STH was common. All children were treated for schistosome infection only at enrolment with praziquantel. Children cured or schistosome-free for >12 months scored higher in memory and verbal fluency tests compared to persistently infected children. Likewise, declines of single and polyparasitic STH infections predicted higher scores in three of four tests. We conclude that reducing the intensity of certain helminth species and the frequency of multi-species STH infections may have long-term benefits for affected children's cognitive performance. The rapidity of schistosome re-infection and the ubiquity of concurrent multi-species infection highlight the importance of sustained deworming for both schistosome and STH infections to enhance the learning and educational attainment of children in helminth-endemic settings.

Longitudinal study of aortic isthmus Doppler in appropriately grown and small-for-gestational-age fetuses with normal and abnormal umbilical artery Doppler

OBJECTIVE

To establish reference ranges using longitudinal data for aortic isthmus (AoI) Doppler indices in appropriate-for-gestational-age (AGA) fetuses and to document the longitudinal trends in a cohort of small-for-gestational-age (SGA) fetuses with normal umbilical artery Doppler and in fetuses with intrauterine growth restriction (IUGR) and abnormal umbilical artery Doppler.

METHODS

AoI Doppler reference ranges were established from longitudinal data on 72 AGA singleton fetuses. Reliability of AoI Doppler flow measurements at two different sites and reproducibility between two operators was reviewed. A prospective longitudinal study of AoI Doppler indices in 48 SGA fetuses with normal umbilical artery Doppler and 10 IUGR fetuses was performed.

RESULTS

The AoI pulsatility index (PI) and peak systolic velocity (PSV) in AGA fetuses showed a significant increase with gestational age. Analysis of intra- and interoperator variability revealed no significant mean difference in measurements of AoI-PI or AoI-PSV. Observations of AoI-PI and AoI-PSV from SGA fetuses did not differ significantly from those of AGA or IUGR fetuses. Retrograde flow in the AoI did not predate changes in the ductus venosus in IUGR fetuses.

CONCLUSIONS

Reference ranges for fetal AoI Doppler parameters in AGA fetuses constructed using longitudinal data are consistent with those obtained from cross-sectional data. The AoI Doppler parameters in SGA fetuses did not differ from those in AGA fetuses. Preterm IUGR fetuses did not manifest alterations in AoI-PI or AoI-PSV prior to changes in biophysical profile or ductus venosus Doppler. Further large-scale prospective studies are needed to determine whether AoI Doppler parameters are of any value in timing delivery or reducing adverse neurodevelopmental outcome.

A clinician-nurse model to reduce early mortality and increase clinic retention among high-risk HIV-infected patients initiating combination antiretroviral treatment

BACKGROUND

In resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting.

METHODS

The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm3 were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods.

RESULTS

Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm3. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45-0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55-0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57-0.67).

CONCLUSIONS

Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.

Maternal obesity and inpatient medication usage

What is already known about this subject •  Maternal obesity is associated with an increased use of healthcare resources including medication costs in an outpatient setting. What this study adds •  This study shows an increase in inpatient medication usage associated with maternal obesity. This is the case in the antenatal period but not in the peripartum period.

SUMMARY

Maternal obesity is associated with increased medical and obstetric complications. We compared the inpatient antenatal and peripartum medication usage in obese women to that in women in the normal body mass index (BMI) category. White European women with a singleton pregnancy were enrolled after a glucose tolerance test excluded diabetes mellitus at 28 weeks gestation. Weight and height were measured in the first trimester and BMI calculated. Records of medications administered were collated from patient drug charts. Of the 284 women studied, there were 97, 85 and 102 women in the normal, overweight and obese categories, respectively. Delivery details across the weight categories did not vary significantly and Caesarean section rates were 22.7, 22.4 and 26.5%, respectively. The length of hospital stay postpartum for each category was similar. The administration of antenatal medication showed a trend towards increasing usage with increasing BMI category with increases in analgesic and antibiotic use. There was no difference in peripartum medication usage. The study showed that maternal obesity was associated with an increased inpatient usage of medication in the antenatal period. This has implications for healthcare costs particularly if the prevalence of maternal obesity continues to increase.

Maternity services for obese women in Ireland

Nearly one in five women booking for antenatal care in Ireland is obese. The purpose of this survey was to audit the services and facilities for obese pregnant women in the country's maternity units. In June 2010, a detailed questionnaire was sent to all 20 units which included questions on services, equipment and facilities for obese women. All 20 units responded: 17 (85%) were calculating and recording Body Mass Index in pregnancy. Only 15 (75%) were screening obese women for gestational diabetes mellitus and 2 (10%) were omitting thromboprophylaxis for caesarean section in obese women. Only 3 (15%) had clinical guidelines for obesity and pregnancy. The facilities and equipment, particularly for severely obese women, were inadequate in the majority of units. This survey showed variations nationally in obstetric practices and facilities. It highlights the need to develop, disseminate and implement standardised guidelines on maternal obesity.

Strengthening biostatistics resources in sub-Saharan Africa: research collaborations through U.S. partnerships

On September 30, 2009, the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH) conducted a workshop on strengthening biostatistics resources in sub-Saharan Africa (SSA). An increase in global spending on health research over the last decade has boosted funds available to conduct biomedical research in low- to mid-income countries. The HIV/AIDS pandemic, the re-emergence of malaria and tuberculosis, and other emerging infectious agents are major driving forces behind the increase in biomedical research and clinical care programs (clinical trials, observational studies and, other public health programs) in SSA (Exp. Biol. Med. 2008; 233:277-285). In addition, the increased engagement of the United States (U.S.) government through the Global Health Initiative, which expands the traditional focus beyond infectious diseases to other causes of poor health and to the recognition of need the to strengthen health systems for a sustainable response, only increases the need for in-depth in-country expertise in all aspects of biomedical research (White House Press Release, 2009). In this workshop, researchers both from the U.S. and SSA were invited to discuss their collaborative work, to discuss ways in which biostatistical activities are carried out within their research projects, and to identify both general and specific needs for capacity building in biostatistics. Capacity building discussions highlighted the critical need to increase the number of well-trained in-country biostatisticians, both to participate in ongoing studies and to contribute to an infrastructure that can produce the next generation of biostatistical researchers.

Misclassification of first-line antiretroviral treatment failure based on immunological monitoring of HIV infection in resource-limited settings

BACKGROUND

The monitoring of patients with human immunodeficiency virus (HIV) infection who are treated with antiretroviral medications in resource-limited settings is typically performed by use of clinical and immunological criteria. The early identification of first-line antiretroviral treatment failure is critical to prevent morbidity, mortality, and drug resistance. Misclassification of failure may result in premature switching to second-line therapy.

METHODS

Adult patients in western Kenya had their viral loads (VLs) determined if they had adhered to first-line therapy for >6 months and were suspected of experiencing immunological failure (ie, their CD4 cell count decreased by 25% in 6 months). Misclassification of treatment failure was defined as a 25% decrease in CD4 cell count with a VL of <400 copies/mL. Logistic and tree regressions examined relationships between VL and 4 variables: CD4 T cell count (hereafter CD4 cell count), percentage of T cells expressing CD4 (hereafter CD4 cell percentage), percentage decrease in the CD4 T cell count (hereafter CD4 cell count percent decrease), and percentage decrease in the percentage of T cells expressing CD4 (hereafter CD4% percent decrease).

RESULTS

There were 149 patients who were treated for 23 months; they were identified as having a 25% decrease in CD4 cell count (from 375 to 216 cells/microL) and a CD4% percent decrease (from 19% to 15%); of these 149 patients, 86 (58%) were misclassified as having experienced treatment failure. Of 42 patients who had a 50% decrease in CD4 cell count, 18 (43%) were misclassified. In multivariate logistic regression, misclassification odds were associated with a higher CD4 cell count, a shorter duration of therapy, and a smaller CD4% percent decrease. By combining these variables, we may be able to improve our ability to predict treatment failure.

CONCLUSIONS

Immunological monitoring as a sole indicator of virological failure would lead to a premature switch to valuable second-line regimens for 58% of patients who experience a 25% decrease in CD4 cell count and for 43% patients who experience a 50% decrease in CD4 cell count, and therefore this type of monitoring should be reevaluated. Selective virological monitoring and the addition of indicators like trends CD4% percent decrease and duration of therapy may systematically improve the identification of treatment failure. VL testing is now mandatory for patients suspected of experiencing first-line treatment failure within the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya, and should be considered in all resource-limited settings.

Antiretroviral drug concentrations and HIV RNA in the genital tract of HIV-infected women receiving long-term highly active antiretroviral therapy

OBJECTIVE

Our objective was to determine antiretroviral drug concentrations and human immunodeficiency virus (HIV) RNA rebound in cervicovaginal fluid (CVF) in relation to blood plasma (BP) in women receiving suppressive highly active antiretroviral therapy (HAART).

METHODS

Thirty-four HIV-infected women who had plasma HIV RNA levels < or =80 copies/mL for at least 6 months were enrolled. Sixty-eight paired CVF and BP drug concentrations and HIV RNA levels were determined before and 3-4 h after drug administration. For each woman and antiretroviral drug, the CVF:BP drug concentration ratios before and after drug administration were calculated. The nonparametric Wilcoxon rank sum test was used to determine if these ratios were different from 1.0.

RESULTS

Lamivudine (administered to 20 patients) and tenofovir (administered to 16) had significantly higher concentrations in CVF than in BP before drug administration, with mean CVF:BP concentration ratios of 3.19 (95% confidence interval, 1.2-8.5) and 5.2 (95% confidence interval, 1.2-22.6), respectively. Efavirenz (administered to 13 patients) and lopinavir (administered to 6) had significantly lower concentrations in CVF, with mean CVF:BP concentration ratios of 0.01 (95% confidence interval, 0.00-0.03) and 0.03 (0.01-0.11), respectively. During the study visit (median time after enrollment, 6 months), BP and CVF detectable HIV RNA levels were observed 7 patients (20.6%) and 1 patient (2.9%), respectively.

CONCLUSION

Despite lower CVF concentrations of key HAART components, such as efavirenz and lopinavir, virologic rebound was rare. The high concentrations of tenofovir and lamivudine in CVF may have implications for the prevention of sexual transmission during HAART and for pre-exposure or postexposure prophylaxis.

Association between paired plasma and cervicovaginal lavage fluid HIV-1 RNA levels during 36 months

OBJECTIVE

To determine the patterns and predictors of genital tract HIV-1 RNA levels during a 36-month period.

METHODS

HIV-1 RNA levels were measured blood in plasma and the genital tract (by cervicovaginal lavage [CVL]) at baseline before highly, active antiretroviral therapy, at 2 and 4 weeks and every 6 months. Viral loads were measured using nucleic acid sequence-based amplification assay with a lower limit of detection of 2.6 log10 copies/mL.

RESULTS

Ninety-seven women had a median of 30.4 months' follow-up, with 530 paired PVL and CVL specimens. The strongest predictor of CVL fluid HIV-1 RNA detection was PVL of more than 2.6 log10 copies/mL, with an odds ratio of 13.7 (P < 0.0001). Each log10 unit increase in PVL increased the odds of detecting HIV-1 RNA in CVL fluid by 2.6 folds (P = 0.0002). Cervicovaginal lavage fluid HIV-1 RNA exceeded PVL on 5% of visits. When patients achieved undetectable levels of HIV-1 RNA in both plasma and CVL fluid, rebound of HIV-1 RNA occurred in plasma first or concurrently with CVL fluid HIV-1 RNA.

CONCLUSIONS

Plasma viral load is the strongest predictor of CVL fluid HIV-1 RNA detection. Cervicovaginal lavage fluid HIV-1 RNA levels are generally lower than PVL. Plasma viral load is more likely to rebound first or at the same time as CVL fluid viral load.

Bringing together technology and market roadmaps

Effective technology development is a difficult challenge. This article reports on one company's system, which has helped it achieve consistent, predictable success.

Look to the future and embrace the changes

The positive aspects of change can be found using scenario-planning techniques. This article explores how these techniques can be a useful tool for establishing and testing a company's product development pipeline.

The efficacy of moderate‐intensity exercise as an aid for smoking cessation in women: A randomized controlled trial

Evidence suggests that vigorous-intensity exercise interventions may be effective for smoking cessation among women; however, few studies have examined the efficacy of a moderate-intensity exercise program. The present study examined the efficacy of moderate-intensity exercise for smoking cessation among female smokers. Healthy, sedentary female smokers (N = 217) were randomly assigned to an 8-week cognitive-behavioral smoking cessation program plus moderate-intensity exercise (CBT+EX) or to the same cessation program plus equal contact (CBT). A subsample received nicotine replacement therapy. Results indicated that the CBT+EX and CBT groups were equally likely to attain smoking cessation at the end of treatment, as measured by cotinine-verified 7-day point-prevalence abstinence (20.2% for CBT+EX vs. 18.5% for CBT). The CBT+EX group was more likely to report smoking cessation, as measured by 7-day point prevalence at the 3-month follow-up (11.9% vs. 4.6%, p<.05), compared with the CBT group. No group differences were found at 12 months by either 7-day point prevalence (7.3% for CBT+EX vs. 8.3% for CBT) or continuous abstinence (0.9% for CBT+EX vs. 0.9% for CBT). Additionally, among participants in the CBT+EX group, those with higher adherence to the exercise prescription were significantly more likely to achieve smoking cessation at the end of treatment than were participants reporting lower adherence to exercise. Our findings indicate that the empirical support for moderate-intensity exercise as an adjunctive treatment to CBT for smoking cessation may be limited. Perhaps future studies could compare moderate- vs. vigorous-intensity physical activity to test their relative efficacy.

Create products by going virtual

A virtual organisation is a business that outsources the majority of its operations. This enables it to be highly responsive to the market and to fast track the creation of specialist products. Tips for the successful implementation of this approach are offered here, with an example of one profitable business.

Insights on ideation and innovation

Even when companies are struggling or seeking to cut costs, it is still important for them to generate new ideas. This article discusses the concept of ideation and provides strategies for successful innovation.

Being sucessfully disruptive

Small companies can more easily create "disruptive" innovation than large companies. This article discusses why and how they can introduce some basic processes to make sure they do not become victims of their own success.

The benefits of design partnership

Collaboration with outside agencies on product design is still often regarded as a risky venture. Its advantages, and the advice on getting the most out of a design partner described here, suggest it is a good option, particularly for small companies.

Open innovation or open house: how to protect your most valuable assets

Many businesses have difficulty in effectively managing their intellectual property. This article offers advice, particularly for smaller companies, on how to protect their ideas and thereby be able to benefit from an open system of product innovation.

Marriage guidance for collaborators

Collaboration with external partners is a way to accelerate product innovation. Tips on building successful partnerships are offered here.

Rationale, design, and baseline data for Commit to Quit II: an evaluation of the efficacy of moderate-intensity physical activity as an aid to smoking cessation in women

BACKGROUND

Commit to Quit II is a 4-year randomized controlled trial comparing the efficacy of a cognitive-behavioral smoking cessation treatment plus moderate-intensity physical activity with the same cessation treatment plus contact control.

METHODS

Sedentary women smokers (n = 217) were randomized to receive 8 weeks of treatment followed by 12 months of follow-up. This article outlines the study design, presents baseline data about the sample, and compares the sample to national samples and to our previous study examining vigorous-intensity exercise as an aid to smoking cessation.

RESULTS

Married and white participants reported significantly higher levels of nicotine dependence than unmarried and minority participants. Higher levels of nicotine dependence were also significantly related to lower smoking cessation self-efficacy and higher levels of self-reported depression, anxiety, and perceived stress. Additionally, participants smoked significantly more cigarettes (mean 20.6) than a national sample of female smokers (mean 16.1). On average, participants were significantly older, weighed significantly more, and scored significantly higher on a measure of anxiety than participants in our previous trial.

CONCLUSIONS

Our sample consisted of women who were heavier smokers than national samples seeking treatment. It remains to be determined how this will impact their ability to attain cessation in the present study.

Continuity of medical care and risk of incarceration in HIV-positive and high-risk HIV-negative women

OBJECTIVES

Incarceration rates in the United States have tripled over the past two decades and have increased even more rapidly among women than men. To identify risk factors that predict incarceration in HIV-positive (HIV+) and high-risk HIV-negative (HIV-) women and to evaluate the association between continuity of medical care and risk of incarceration, this analysis was conducted.

METHODS

This was a prospective cohort study of HIV+ and high-risk HIV- women enrolled between April 1993 and January 1995 at four urban centers: Providence, Rhode Island; New York, New York; Baltimore, Maryland; and Detroit, Michigan. The HIV Epidemiology Research (HER) Study enrolled 871 HIV+ and 439 high-risk HIV- innercity women between the ages of 16 and 55 years. All participants had a history of injection drug use or high-risk sexual behavior. Interviews, including questions on continuity of medical care and incarceration, were administered at baseline and 6 and 12 months after enrollment. Any incarceration in the 1-year period following enrollment was the main outcome measure. Continuity of care was measured as having seen one healthcare provider for at least 2 years, having received medical care from one usual physician or clinic, and having obtained medical care in a primary care setting as opposed to an emergency room or drug treatment center.

RESULTS

Twelve percent of women were incarcerated within 1 year postenrollment. Factors associated with incarceration included recent drug use, prior incarceration, lack of college education, engaging in sex for drugs or money, and having multiple unmet basic needs at the time of enrollment in the study. Continuity of care with a single healthcare provider for more than 2 years prior to enrollment in the study was associated with decreased rates of incarceration even after adjusting for possible confounding factors (OR = 0.67, 95% CI = 0.48 - 0.92). HIV serostatus did not correlate with incarceration.

CONCLUSIONS

History of prior incarceration and recent drug use were associated with increased risk of incarceration. Continuity of medical care by a single healthcare provider was associated with decreased likelihood of incarceration, suggesting that the provider may play an important role in designing interventions to prevent incarceration in this high-risk population.

A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial

BACKGROUND

Previous research indicates that younger women (i.e., <or= 50) with breast carcinoma experience greater emotional distress than older women (i.e., > 50) and that coping style is significantly related to the psychosocial adjustment of women with this disease. The purpose of this study was to evaluate through a randomized controlled trial the effectiveness of a problem-solving training intervention designed to empower women with breast carcinoma to cope with a range of difficulties when diagnosed in mid-life.

METHODS

The study population consisted of women aged 50 years or younger who had no prior history of breast carcinoma, were diagnosed with Stage I-IIIA tumors, and for whom a first course of chemotherapy had been initiated recently. The intervention consisted of two in-person and four telephone sessions with an oncology nurse who provided problem-solving skills training and informational materials to the women over a 12-week period. All subjects were assessed for physical and psychosocial adjustment through telephone and mailed surveys at baseline, at 4 -months, and at 8 months.

RESULTS

Of 183 eligible women, 164 participated (a 90% participation rate), 149 of whom completed the study (a 91% completion rate). The subjects had significantly lower unmet needs and better mental health at the 4-month assessment. The intervention significantly decreased the number and severity of difficulties experienced by women with average or good problem-solving skills at 8 months, but was not effective in alleviating or resolving the problems encountered by women with poor problem-solving skills, relative to the control group.

CONCLUSIONS

We conclude that this problem-solving therapy-based home care training intervention is an effective method of helping the majority of women with breast carcinoma to reduce the stresses associated with the diagnosis and treatment of cancer in mid-life.

Are Maori under-served for cardiac interventions?

AIMS

To examine hospitalisation rates for selected heart-disease-related diagnoses by age, gender, ethnicity and deprivation.

METHODS

Four years' data on publicly-funded hospital discharges for: (i) heart failure and (ii) cardiac interventions were cross-classified by age group, gender, ethnicity (Maori/non-Maori) and deprivation (NZDep96). Population hospitalisation rates were calculated and displayed in multi-dimensional trellis graphs.

RESULTS

The graphs show patterns of hospitalisation for chosen variables simultaneously. The expected increase in heart failure with age is found, as is an increase for the cardiac group up to ages 65-74 years. Clear gender differences were found. A further increase of heart failure with higher deprivation is evident throughout. For cardiac interventions, the relationship with deprivation is complex. Differences by ethnicity are disturbing. Hospitalisation rates for heart failure for Maori are typically more than double the non-Maori rates. In contrast, for the cardiac group Maori intervention rates are much lower.

CONCLUSIONS

Graphical analysis that displays age, gender, ethnicity and deprivation simultaneously provides great insight into hospitalisation rates. Ethnic differences are particularly concerning and raise important questions about how well Maori needs are being met and how equitable is access to cardiac interventions for Maori.

HIV infection in families of HIV-positive and 'at-risk' HIV-negative women

Research of HIV infection within the family has focused upon sexual partners and vertical transmission. The scope of the problem of multiple infections and clustering of HIV among family members has, thus far, been less extensively explored. The objectives of this study are to investigate HIV infection in family members of HIV-seropositive and HIV-seronegative high-risk women and to consider the impact of multiple HIV infections within the family. Baseline data were evaluated from a prospective observational cohort of 871 HIV-seropositive and 439 seronegative at-risk women who are participants in a longitudinal study of HIV in women at four sites in the USA (Montefiore, Bronx, NY; Johns Hopkins University, Baltimore, MD; Brown University, Providence, RI; Wayne State University, Detroit, MI). Women were asked if anyone close to them had HIV/AIDS or had died from HIV/AIDS. Responses which included HIV-positive family members were analyzed. In the seropositive cohort, 35% (307/871) of the women had a family member with HIV infection. Of these 307 women, 38% reported having a sibling, 24% a husband and 27% had more than one family member with HIV/AIDS. Forty-nine per cent of Latina women, 34% of black women, and 21% of white women reported having a family member with HIV/AIDS. Using logistic regression analysis, we found that Latina and black women were significantly more likely than white women to have a sibling, extended family member or more than one family member with HIV/AIDS. Compared to seropositive women, seronegative high-risk women enrolled in this study appear equally likely to have an HIV-infected family member. In this study of HIV-positive women and high-risk seronegative women, a third reported having multiple family members with HIV infection, most often in a sibling. The high prevalence of HIV within families, particularly in the families of Latina and black women, mandates attention in planning both prevention and care.

Characterization of the Hox cluster from the mosquito Anopheles gambiae (Diptera: Culicidae)

The Hox genes have been found to encode transcription factors, which specify the morphological identity of structures along the anteroposterior axis of animals ranging from worms to mice. The canonical set of nine genes is organized in a cluster in the genome of several protostomes and deuterostomes. However, within insects, whereas the Hox genes are organized in a single cluster in the beetle Tribolium castaneum, they are split into two separate groups in the flies Drosophila melanogaster and Drosophila virilis. The significance of a split Hox cluster is unknown and has been observed in only one organism outside the Drosophila lineage: the nematode Caenorhabditis elegans. We have cloned a majority of the Hox genes from the mosquito Anopheles gambiae (Diptera: Culicidae) and compared their genomic organization with that of Tribolium and Drosophila to determine if a split Hox cluster is found in dipterans aside from the Drosophilidae. We find that the Hox genes in Anopheles, as in Tribolium, are organized in a single cluster that spans a genomic region of at least 700 kb. This finding suggests that, within the insect genome, the partition of the Hox cluster may have evolved exclusively within the Drosophila lineage. The genomic structures of the resident genes, however, appear to be largely conserved between A. gambiae and D. melanogaster.

Glucocorticoid-associated maternal hyperglycemia: a randomized trial of insulin prophylaxis

OBJECTIVES

To study the degree and timing of maternal hyperglycemia following betamethasone therapy in nondiabetic patients and establish a prophylactic dose of insulin.

METHODS

Forty-five patients receiving betamethasone 12 mg i.m. at 7 AM on two consecutive days were randomized to no insulin (n = 20), low-dose insulin (n = 18), and high-dose insulin (n = 7) protocols. Each treatment group received s.c. insulin at 7 AM on the 2 days of betamethasone therapy (20 units NPH/10 units regular, and 40 units NPH/20 units regular, respectively). Capillary plasma glucose measurements were obtained at fasting and 2 h after meals for 3 days. A multivariate normal regression model was used to estimate and compare mean glucose levels.

RESULTS

Eighty-five percent of patients who did not receive insulin exhibited hyperglycemia at levels previously associated with fetal acidosis. Significant differences in mean postprandial plasma glucose levels were found between the no-treatment and insulin groups on days 1 and 2. No significant differences were noted between groups on day 3.

CONCLUSIONS

Transient maternal hyperglycemia occurs in a consistent pattern in nondiabetic patients receiving betamethasone, which can be limited by the concurrent use of insulin. Further studies to assess fetal acidosis in this setting are warranted.

Pregnancy and pregnancy outcome in hepatitis C type 1b

A large cohort of rhesus-negative women in Ireland were inadvertently infected with hepatitis C virus following exposure to contaminated anti-D immunoglobulin in 1977-8. This major iatrogenic episode was discovered in 1994. We studied 36 women who had been infected after their first pregnancy, and compared them to an age- and parity-matched control group of rhesus-positive women. The presence of hepatitis C antibody was confirmed in all 36 by enzyme-linked immunosorbent assay and by recombinant immunoblot assay, while 26 (72%) of the cohort were HCV-RNA-positive (type 1b) on PCR testing. In the 20 years post-infection, all members of the study group had at least one pregnancy, and mean parity was 3.5. They had a total of 100 pregnancies and 85 of these went to term. There were four premature births, one being a twin pregnancy, and 11 spontaneous miscarriages. One miscarriage occurred in the pregnancy following HCV infection. There were two neonatal deaths due to severe congenital abnormalities in the PCR-positive women. Of the children born to HCV-RNA positive mothers, only one (2.3%) tested positive for the virus. Significant portal fibrosis on liver biopsy was confined to HCV-RNA-positive mothers apart from one single exception in the antibody-positive HCV-RNA-negative group. Comparison with the control group showed no increase in spontaneous miscarriage rate, and no significant difference in obstetric complications; birth weights were similar for the two groups.

Outcome of very low birth weight infants with histopathologic chorioamnionitis

OBJECTIVE

To determine neonatal outcome at 7 months of corrected age in very low birth weight (VLBW) infants with placental chorioamnionitis.

METHODS

We conducted a cohort study of 287 VLBW infants delivered as a result of preterm premature rupture of membranes (PROM) or preterm labor. Control subjects (n = 123) had placentas with absent umbilical cord inflammation and absent or low-grade membrane inflammation. Case subjects (n = 164) had moderate membrane inflammation or any umbilical cord inflammation. Neonatal and 7-month outcomes were compared. A power analysis showed that 98 total subjects were needed to reject the two-sided null hypothesis with a difference in mean Bayley index scores of at least 8.

RESULTS

Infants in the study group had significantly more preterm PROM, antenatal antibiotics, lower birth weight, lower gestational age, longer duration of ruptured membranes, and clinical chorioamnionitis. Intraventricular hemorrhage occurred more commonly in infants with placentas demonstrating chorioamnionitis (relative risk = 1.6, 95% confidence interval 1.1, 2.4, P =.013). One hundred sixty-seven (69%) of the 243 surviving infants had 7-month follow-up. There was no difference between cases and controls in mean Bayley mental developmental index (93 compared with 90, P =.25), psychomotor developmental index (89 compared with 90, P =.68), or in the number of infants that were developmentally delayed.

CONCLUSION

Despite a higher frequency of intraventricular hemorrhage, no difference in developmental scores was detected at 7 months of corrected age in VLBW infants with histologic chorioamnionitis.

Staff ratios in intensive care: are they adequate?

The Department of Health (DoH) (2000) review of adult critical care services recommends a move away from the rigid 1:1 nurse/patient staffing ratio that operates within intensive care units (ICUs) to a more flexible system based on the assessment of nursing workload.

The utilization of the healthcare assistant role in intensive care

The increasing role of healthcare assistants (HCAs) in intensive care in relation to patient monitoring has raised concerns among some clinical managers, particularly where such roles are not underpinned by a sound knowledge base and critical reasoning ability. This article describes a study which was undertaken in an attempt to identify how HCAs are currently utilized within the general intensive care environment. The results show a wide variation between units in relation to the activities undertaken by HCAs, their training and the levels of remuneration. This article seeks to open up the debate as to whether or not nurses should be challenging the nursing care that is now delivered by non-nurses and makes recommendations for the way forward in this area.