Characterising the Aboriginal and Torres Strait Islander patient journey after a serious road traffic injury and barriers to access to compensation: a protocol

INTRODUCTION

Road safety has been a long-enduring policy concern in Australia, with significant financial burden of road trauma and evident socioeconomic disparities. Transport injuries disproportionately impact individuals in remote areas, those in lower socioeconomic situations, and Aboriginal and Torres Strait Islander populations. There is a lack of insight into transport injuries in Aboriginal and Torres Strait Islander communities, absence of Indigenous perspective in published research and limited utilisation of linked data assets to address the inequity. Aim 1 is to determine the breadth, cost and causal factors of serious injury from road traffic crashes in South Australia (SA) and New South Wales (NSW) with a focus on injury prevention. Aim 2 is to identify enablers and barriers to compensation schemes for Aboriginal and Torres Strait Islander patients in SA and NSW.

METHODS AND ANALYSIS

This study will be guided by an Aboriginal and Torres Strait Islander Governance Group, applying Knowledge Interface Methodology and Indigenous research principles to ensure Indigenous Data Sovereignty and incorporation of informed perspectives. A mixed-method approach will be undertaken to explore study aims including using big data assets and mapping patient journey.

CONCLUSION

The results of this study will provide valuable insights for the development of focused injury prevention strategies and policies tailored to Aboriginal and Torres Strait Islander communities. By addressing the specific needs and challenges faced by these communities, the study aims to enhance road safety outcomes and promote equitable access to healthcare and compensation for affected individuals and their families.

Trends in assault-related hospitalizations during the SARS-CoV-2 pandemic

INTRODUCTION

Violence remains a priority issue in the United States (US) requiring public health input to discern the magnitude and impact of violence on the health system. Concerns over violence and the injuries resulting from violence have increased following the SARS-CoV-2 pandemic which exacerbated an array of individual and economic stressors related to violence including increased unemployment, alcohol intake, social isolation, anxiety and panic and decreased access to health services. The aim of this study was to analyze the trends in violence-related injuries in the state of Illinois during the SARS-CoV-2 lockdown periods and post-lockdown in order to inform future public health policy.

MATERIAL AND METHODS

Outpatient and inpatient assault related injuries treated in Illinois hospitals from 2016 through March 2022 were analyzed. Segmented regression models evaluating change in time trends were adjusted for seasonality, serial correlation, overall trend and economic variables.

RESULTS

The annual rate of assault related hospitalizations per one million Illinois residents decreased from 3857.8 pre-pandemic to 3458.7 pandemic period. However, during the pandemic there was an increase in deaths and in the proportion of injuries involving open wounds, internal injuries, and fractures, while there was a reduction in less serious injuries. Segmented regression time series models demonstrated significant increase in firearm violence in all four pandemic periods examined. Firearm violence increased particularly in subgroups including African-American victims, 15-34-year-olds, and Chicago residents.

CONCLUSION

During SARS-CoV-2, we saw an overall reduction in assault related hospitalization, however, findings demonstrated an increase in serious injuries which may be associated with social and economic stressors of the pandemic, increased gun-violence while decrease in less serious injuries may be linked to hospital avoidance for non-lethal injuries during the peak waves of the pandemic. Our findings have implications for ongoing surveillance, service planning and management of the increased gunshot and penetrating assault cases and further demonstrate the need for public health input into the violence epidemic in the US.

Poor adherence to dust, noise and safety regulations predict injury rates in underground coal mines

BACKGROUND

While safety in US coal mining has improved over the past two decades, general occupational health research shows that risk of injury varies across individual worksites and is influenced by worksite safety cultures and practices.

METHODS

In this longitudinal study, we evaluated whether mine-level characteristics reflecting poor adherence to health and safety regulations in underground coal mines are associated with higher acute injury rates. We aggregated Mine Safety and Health Administration (MSHA) data by year for each underground coal mine for the period 2000-2019. Data included part-50 injuries, mine characteristics, employment and production, dust sampling, noise sampling, and violations. Multivariable hierarchical generalised estimating equations (GEE) models were developed.

RESULTS

Based on the final GEE model, despite an average annual decline in injury rates by 5.5%, the following indicators of inadequate adherence to health and safety regulations were associated with increased average annual injury rates: +2.9% for each 10% increase in dust samples exceeding the permissible exposure limit; +0.6% for each 10% increase of permitted 90 dBA 8-hour noise exposure dose; +2.0% for every 10 substantial-significant MSHA violations in a year; +1.8% for each rescue/recovery procedure violation; +2.6% for each safeguard violation. If a fatality occurred in a mine, injury rates increased by 11.9% in the same year, but declined by 10.4% in the following year. The presence of safety committees was associated with a 14.5% decline in injury rates.

DISCUSSION

In US underground coal mines, injury rates are associated with poor adherence to dust, noise and safety regulations.

Systematic scoping review of occupational health injuries and illnesses among Indigenous workers

Indigenous populations in the USA, Australia, New Zealand (NZ) and Canada total more than 13 million, but continue to be marginalised in their respective regions. The goal of this comprehensive review of all studies evaluating adverse occupational health outcomes among Indigenous populations in these countries was to identify gaps in the literature and future research directions. A systematic scoping review of research published between 1970 and 2020 was undertaken using the methodological framework initially proposed by Arksey and O'Malley. Country, Indigenous participants, study type, exposure, adverse health outcome, occupation and industry were identified for each paper. Of the 1272 research papers identified, only 51 articles met the inclusion criteria of this scoping review. Almost half of the studies (n=24, 47.1%) were published after 2010. Only 13 (25.5%) studies specifically focused on Indigenous persons at the time of the study design, and less than half of the studies (47.1%) included more than 100 Indigenous participants. Most studies used the following general terms without mention of specific indigenous groups: Indigenous (Australia), Māori (NZ), Aboriginal (Canada) and American Indian or Alaskan Native (USA). Only one study acknowledged asking respondents their preferred terminology. Over the past 50 years, there has been a paucity of research directly or indirectly evaluating occupational health outcomes of Indigenous populations in these four countries. There is a need for better sampling strategies and inclusion of demographic questions that capture Indigenous status in surveys, workers' compensation data and other commonly used data sources to develop adequate baseline data for targeted future interventions.

Rapid review of five years of Aboriginal and Torres Strait Islander health research in Australia - persisting under-representation of urban populations

OBJECTIVE

To review how published Aboriginal and Torres Strait Islander health research reflects the geographical distribution of the Indigenous population of Australia.

METHODS

Rapid review using Lowitja Institute Lit.search tool for PubMed indexed Indigenous health research papers (January 2013 to January 2018). Geographic location, participant age, study type and recruitment site were identified for each paper.

RESULTS

A total of 1,258 research papers were identified: 190 (15%) focused exclusively on Indigenous people living in urban areas; 563 (45%) in rural/remote areas; and 505 (40%) spanned urban and rural/remote areas. Despite similar burdens of disease, three times as many papers were published per 1,000 DALYs for rural/remote areas than urban areas.

CONCLUSIONS

Indigenous health research publications have more than doubled since 2010. However, research focusing on the health needs of urban Indigenous people remains low relative to disease burden and population. Implications for public health: More research to address the health needs of Indigenous people living in urban areas is required although this should not be at the expense of research for rural and remote areas. Increased funding quarantined for Indigenous health research, coupled with self-determination of the research agenda and reporting on the geographic representativeness of research, may help address geographical inequities in research outputs.

Impact of Standard Bacterial Vaginosis Treatment on the Genital Microbiota, Immune Milieu, and Ex Vivo Human Immunodeficiency Virus Susceptibility

BACKGROUND

Genital immunology is a key determinant of human immunodeficiency virus (HIV) susceptibility. Both factors are modulated by bacterial vaginosis (BV) and, to some extent, by Lactobacillus iners, the genital Lactobacillus spp. that predominates in African, Caribbean, and other Black (ACB) women. We conducted a clinical trial to assess the impact of oral metronidazole treatment on the genital immune parameters of HIV acquisition risks in Kenyan women with BV.

METHODS

The primary endpoint was ex vivo cervical CD4+ T-cell HIV susceptibility after 1 month; secondary endpoints included genital cytokine/chemokine levels, cervical immune cell populations, and the composition of the cervico-vaginal microbiota by 16S ribosomal RNA gene amplicon sequencing.

RESULTS

BV resolved (Nugent score ≤ 3) at 1 month in 20/45 participants, and cervical CD4+ T-cell HIV entry was moderately reduced in all participants, regardless of treatment outcome. Resolution of BV and reduced abundances of BV-associated gram-negative taxa correlated with reduced genital interleukin (IL)-1α/β. However, BV resolution and the concomitant colonization by Lactobacillus iners substantially increased several genital chemokines associated with HIV acquisition, including interferon-γ inducible protein (IP)-10, macrophage inflammatory protein (MIP)-3α, and monokine induced by gamma interferon (MIG). In an independent cohort of ACB women, most of whom were BV-free, vaginal chemokines were again closely linked with L. iners abundance, though not other Lactobacillus spp.

CONCLUSIONS

BV treatment reduced genital CD4+ T-cell HIV susceptibility and IL-1 levels, but dramatically increased the genital chemokines that may enhance HIV susceptibility; the latter effect was related to the restoration of an Lactobacillus iners-dominated microbiota. Further studies are needed before treatment of asymptomatic BV can be recommended for HIV prevention in ACB communities.

Association of HPV infection and clearance with cervicovaginal immunology and the vaginal microbiota

Cervical human papillomavirus (HPV) infection may increase HIV risk. Since other genital infections enhance HIV susceptibility by inducing inflammation, we assessed the impact of HPV infection and clearance on genital immunology and the cervico-vaginal microbiome. Genital samples were collected from 65 women for HPV testing, immune studies and microbiota assessment; repeat HPV testing was performed after 6 months. All participants were HIV-uninfected and free of bacterial STIs. Cytobrush-derived T cell and dendritic cell subsets were assessed by multiparameter flow cytometry. Undiluted cervico-vaginal secretions were used to determine cytokine levels by multiplex ELISA, and to assess bacterial community composition and structure by 16S rRNA gene sequence analysis. Neither HPV infection nor clearance were associated with broad differences in cervical T cell subsets or cytokines, although HPV clearance was associated with increased Langerhans cells and HPV infection with elevated IP-10 and MIG. Individuals with HPV more frequently had a high diversity cervico-vaginal microbiome (community state type IV) and were less likely to have an L. gasseri predominant microbiome. In summary, HPV infection and/or subsequent clearance was not associated with inflammation or altered cervical T cell subsets, but associations with increased Langerhans cells and the composition of the vaginal microbiome warrant further exploration.

Distinct Effects of the Cervicovaginal Microbiota and Herpes Simplex Type 2 Infection on Female Genital Tract Immunology

Background

Genital inflammation is a key determinant of human immunodeficiency virus (HIV) transmission, and may increase HIV-susceptible target cells and alter epithelial integrity. Several genital conditions that increase HIV risk are more prevalent in African, Caribbean, and other black (ACB) women, including bacterial vaginosis and herpes simplex virus type-2 (HSV-2) infection. Therefore, we assessed the impact of the genital microbiota on mucosal immunology in ACB women and microbiome-HSV-2 interactions.

Methods

Cervicovaginal secretions and endocervical cells were collected by cytobrush and Instead Softcup, respectively. T cells and dendritic cells were assessed by flow cytometry, cytokines by multiplex enzyme-linked immunosorbent assay (ELISA), and the microbiota by 16S ribosomal ribonucleic acid gene sequencing.

Results

The cervicovaginal microbiota of 51 participants were composed of community state types (CSTs) showing diversity (20/51; 39%) or predominated by Lactobacillus iners (22/51; 42%), L. crispatus (7/51; 14%), or L. gasseri (2/51; 4%). High-diversity CSTs and specific bacterial phyla (Gardnerella vaginalis and Prevotella bivia) were strongly associated with cervicovaginal inflammatory cytokines, but not with altered endocervical immune cells. However, cervical CD4+ T-cell number was associated with HSV-2 infection and a distinct cytokine profile.

Conclusions

This suggests that the genital microbiota and HSV-2 infection may influence HIV susceptibility through independent biological mechanisms.

Chemokine Levels in the Penile Coronal Sulcus Correlate with HIV-1 Acquisition and Are Reduced by Male Circumcision in Rakai, Uganda

Individual susceptibility to HIV is heterogeneous, but the biological mechanisms explaining differences are incompletely understood. We hypothesized that penile inflammation may increase HIV susceptibility in men by recruiting permissive CD4 T cells, and that male circumcision may decrease HIV susceptibility in part by reducing genital inflammation. We used multi-array technology to measure levels of seven cytokines in coronal sulcus (penile) swabs collected longitudinally from initially uncircumcised men enrolled in a randomized trial of circumcision in Rakai, Uganda. Coronal sulcus cytokine levels were compared between men who acquired HIV and controls who remained seronegative. Cytokines were also compared within men before and after circumcision, and correlated with CD4 T cells subsets in foreskin tissue. HIV acquisition was associated with detectable coronal sulcus Interleukin-8 (IL-8 aOR 2.26, 95%CI 1.04–6.40) and Monokine Induced by γ-interferon (MIG aOR 2.72, 95%CI 1.15–8.06) at the visit prior to seroconversion, and the odds of seroconversion increased with detection of multiple cytokines. Coronal sulcus chemokine levels were not correlated with those in the vagina of a man’s female sex partner. The detection of IL-8 in swabs was significantly reduced 6 months after circumcision (PRR 0.59, 95%CI 0.44–0.87), and continued to decline for at least two years (PRR 0.29, 95%CI 0.16–0.54). Finally, prepuce IL-8 correlated with increased HIV target cell density in foreskin tissues, including highly susceptible CD4 T cells subsets, as well as with tissue neutrophil density. Together, these data suggest that penile inflammation increases HIV susceptibility and is reduced by circumcision.

The per-contact risk of infection with HIV through sexual exposure is low and highly variable. Understanding the biological basis for this variability could help in the development of new methods to prevent infection. There is some evidence that penile inflammation, even in the absence of any clinical symptoms, may increase HIV-susceptibility by recruiting CD4 T cells, the immune cell type that is the principal target of HIV. We analyzed soluble inflammatory mediators in prepuce swabs collected longitudinally from initially HIV-negative men enrolled in a randomized controlled trial of adult circumcision. We found that these inflammatory mediators were elevated in men who went on to acquire HIV. We also found that higher levels of these mediators were associated with an increased density of HIV-susceptible target cells in the underlying foreskin tissue and that circumcision reduced their levels, which may help to explain why circumcision reduces HIV risk by 60% or more. Together, these data suggest that penile inflammation, in the absence of genital infections, increases HIV susceptibility and is reduced by adult male circumcision.

Inflammation and HIV Transmission in Sub-Saharan Africa

While the per-contact risk of sexual HIV transmission is relatively low, it is fourfold higher in sub-Saharan Africa, and this may partly explain the major global disparities that exist in HIV prevalence. Genital immune parameters are key determinants of HIV transmission risk, including epithelial integrity and the presence of highly HIV-susceptible intraepithelial or submucosal CD4+ T cell target cells. Biological parameters that may enhance mucosal HIV susceptibility in highly HIV-affected regions of sub-Saharan Africa include increased levels of mucosal inflammation, which can affect both epithelial integrity and target cell availability, as well as the increased mucosal surface area that is afforded by an intact foreskin, contraceptive choices, and intravaginal practices. There are multifactorial causes for increased mucosal inflammation, with the prevalence and nature of common co-infections being particularly relevant.

Effect of Intercurrent Infections and Vaccinations on Immune and Inflammatory Biomarkers Among Human Immunodeficiency Virus-Infected Adults on Suppressive Antiretroviral Therapy

We used generalized estimating equations to quantify the impact of recent vaccination or intercurrent infections on immune and inflammatory biomarkers among 144 human immunodeficiency virus (HIV)-infected adults with HIV RNA < 50 copies/mL on antiretroviral therapy. These events were associated with a 2.244 µg/mL increase in high sensitivity C-reactive protein and should be routinely assessed in future studies.

Herpes simplex virus type 2 serostatus is not associated with inflammatory or metabolic markers in antiretroviral therapy-treated HIV

Systemic inflammation and immune activation may persist in HIV-infected persons on suppressive combination antiretroviral therapy (cART) and contribute to adverse health outcomes. We compared markers of immune activation, inflammation, and abnormal glucose and lipid metabolism in HIV-infected adults according to herpes simplex virus type 2 (HSV-2) serostatus in a 6-month observational cohort study in Toronto, Canada. HIV-infected adults on suppressive (viral load <50 copies/ml) cART were categorized as HSV-2 seropositive or seronegative using the HerpeSelect ELISA, and underwent study visits at baseline, 3 months, and 6 months. The primary outcome was the median percentage of activated (CD38(+)HLADR(+)) CD8 T cells. Secondary outcome measures included additional immune (activated CD4, regulatory T cells) and inflammatory (hsCRP, D-dimer, IL-1b, IL-6, MCP-1, TNF, sICAM-1, sVCAM-1, Ang1/Ang2 ratio) markers. Metabolic outcomes included the proportion with impaired fasting glucose/impaired glucose tolerance/diabetes, insulin sensitivity (calculated using the Matsuda index), insulin resistance (homeostasis model assessment of insulin resistance), and fasting lipids. The impact of HSV-2 on each outcome was estimated using generalized estimating equation regression models. Of 84 participants, 38 (45%) were HSV-2 seropositive. HSV signs and symptoms were uncommon. Aside from D-dimer, which was more often detectable in HSV-2 seropositives (adjusted odds ratio=3.58, 95% CI=1.27, 10.07), HSV-2 serostatus was not associated with differences in any other immune, inflammatory cytokine, acute phase reactant, endothelial activation, or metabolic markers examined in univariable or multivariable models. During the study, CD8 and CD4 T cell activation declined by 0.16% and 0.08% per month, respectively, while regulatory T cells increased by 0.05% per month. HSV-2 serostatus was not consistently associated with immune activation, inflammatory, or lipid and glucose metabolic markers in this cohort of HIV-infected adults on suppressive cART.

Impact of asymptomatic herpes simplex virus type 2 infection on mucosal homing and immune cell subsets in the blood and female genital tract

HSV-2 infection is common and generally asymptomatic, but it is associated with increased HIV susceptibility and disease progression. This may relate to herpes-mediated changes in genital and systemic immunology. Cervical cytobrushes and blood were collected from HIV-uninfected African/Caribbean women in Toronto, and immune cell subsets were enumerated blindly by flow cytometry. Immune differences between groups were assessed by univariate analysis and confirmed using a multivariate model. Study participants consisted of 46 women, of whom 54% were infected with HSV-2. T cell activation and expression of the mucosal homing integrin α4β7 (19.60 versus 8.76%; p < 0.001) were increased in the blood of HSV-2-infected women. Furthermore, expression of α4β7 on blood T cells correlated with increased numbers of activated (coexpressing CD38/HLA-DR; p = 0.004) and CCR5(+) (p = 0.005) cervical CD4(+) T cells. HSV-2-infected women exhibited an increase in the number of cervical CD4(+) T cells (715 versus 262 cells/cytobrush; p = 0.016), as well as an increase in the number and proportion of cervical CD4(+) T cells that expressed CCR5(+) (406 versus 131 cells, p = 0.001; and 50.70 versus 34.90%, p = 0.004) and were activated (112 versus 13 cells, p < 0.001; and 9.84 versus 4.86%, p = 0.009). Mannose receptor expression also was increased on cervical dendritic cell subsets. In conclusion, asymptomatic HSV-2 infection was associated with significant systemic and genital immune changes, including increased immune activation and systemic α4β7 expression; correlation of the latter with highly HIV-susceptible CD4(+) T cell subsets in the cervix may provide a mechanism for the increased HIV susceptibility observed in asymptomatic HSV-2-infected women.

A randomized controlled pilot trial of valacyclovir for attenuating inflammation and immune activation in HIV/herpes simplex virus 2-coinfected adults on suppressive antiretroviral therapy

BACKGROUND

Human immunodeficiency virus (HIV) is associated with increased systemic inflammation and immune activation that persist despite suppressive antiretroviral therapy (ART). Herpes simplex virus type 2 (HSV-2) is a common coinfection that may contribute to this inflammation.

METHODS

Sixty HIV type 1 (HIV-1)/HSV-2-coinfected adults on suppressive ART were randomized 1:1:1 to 12 weeks of placebo, low-dose valacyclovir (500 mg twice daily), or high-dose valacyclovir (1 g twice daily) in this 18-week trial. Co-primary outcome measures were the percentage of activated (CD38(+)HLA-DR(+)) CD8 T cells in blood, and highly sensitive C-reactive protein, interleukin 6, and soluble intercellular adhesion molecule 1 in plasma. Secondary outcomes included additional immune, inflammatory cytokine, and endothelial activation markers. The impact of valacyclovir (both groups combined) on each outcome was estimated using treatment × time interaction terms in generalized estimating equation regression models.

RESULTS

Participants were mostly white (75%) men who have sex with men (80%). Median age was 51 (interquartile range [IQR], 47-56) years, median duration of HIV infection was 15 (IQR, 8-21) years, median CD4 count at enrollment was 520 (IQR, 392-719) cells/µL, and median nadir CD4 count was 142 (IQR, 42-240) cells/µL. Valacyclovir was not associated with significant changes in any primary or secondary immunological outcomes in bivariate or multivariable models. Medication adherence was 97% by self-report, 96% by pill count, and 84% by urine monitoring. Eight patients had adverse events deemed possibly related to the study drug (5 placebo, 1 low-dose, 2 high-dose), and 6 patients reported at least 1 HSV outbreak (3 placebo, 3 low-dose, 0 high-dose).

CONCLUSIONS

Valacyclovir did not decrease systemic immune activation or inflammatory biomarkers in HIV-1/HSV-2-coinfected adults on suppressive ART.

CLINICAL TRIALS REGISTRATION

NCT01176409.

Genital immunology and HIV susceptibility in young women

Women account for a substantial majority of HIV infections in endemic regions, where women are also infected at a much younger age than men. Part of this epidemiological skewing is due to socio-cultural factors, but it is clear that biological factors enhance the susceptibility of women--particularly young women--to HIV acquisition after sexual exposure. These factors, including important differences in mucosal immunology at the site of genital HIV exposure, are the focus of this concise review. Compared to heterosexual men, women have an increased surface area of mucosal HIV exposure, increased mucosal expression of the HIV co-receptor CCR5 and a greater probability of virus exposure on the rectal mucosa. Differences that are specific to young women include a pro-inflammatory immune environment and a proportionate increase in single-cell, columnar genital epithelium. These important biological reasons for enhanced HIV susceptibility in young women highlight the need for targeted HIV prevention within this vulnerable population.

A polymorphism in the methylenetetrahydrofolate reductase gene predisposes to colorectal cancers with microsatellite instability

BACKGROUND

The enzyme methylenetetrahydrofolate reductase (MTHFR) catalyses the formation of folate intermediates that are vital to methylation reactions. A polymorphic variant (TT) has been linked to reduced levels of plasma folate, aberrant DNA methylation in leucocytes, and increased risk of colorectal cancer (CRC) under conditions of low folate intake. The cystathionine beta-synthase (CBS) enzyme reduces homocysteine levels and thus may protect against CRC. The CBS gene has a variant, 844ins68, that has been linked with increased activity. These variants may be involved in the development of the subgroup of CRC displaying aberrant DNA methylation and frequently associated with microsatellite instability (MSI).

AIM

To investigate the frequencies of the TT and 844ins68 genotypes in CRC patients with MSI+ tumours compared with those with MSI- tumours and a control population.

SUBJECTS

Patients with CRC (n=501) and healthy control subjects (n=1207) were studied. CRC cases were classified as MSI+ (n=75) or MSI- (n=426) based on deletions within the BAT-26 mononucleotide repeat.

METHODS

Subjects were genotyped for MTHFR using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) and PCR-restriction fragment length polymorphism (PCR-RFLP) techniques, and for CBS using PCR.

RESULTS

The MTHFR TT genotype was more frequent in older CRC patients (>or=70 y) compared with equivalent aged controls (p=0.03), was associated with a significantly later age of diagnosis in patients with proximal colon tumours (p=0.02), and was almost twice as frequent in MSI+ than in MSI- tumours (p=0.05). Compared with normal controls, the 844ins68 variant of CBS was less frequent in patients with proximal tumours (p=0.02).

CONCLUSIONS

The TT genotype of MTHFR is associated with an increased risk of CRC in older populations, possibly due to age related disturbances in folate metabolism. The TT genotype appears to predispose to CRC that is MSI+. This may reflect the involvement of aberrant DNA methylation frequently associated with MSI+. The 844ins68 CBS polymorphism may protect against proximal tumours.

Diet quality of young children who received nutrition education promoting lower dietary fat

OBJECTIVE

: To evaluate the impact of nutrition education promoting lower dietary fat on the overall diet quality in children using a multidimensional index that measures nutrient and food intakes in relation to US dietary recommendations.

DESIGN

: Prospective cohort study with two intervention and two control groups. Children with elevated low density lipoprotein (LDL) cholesterol were randomized to one of two intervention groups or an at-risk control group. The intervention children received either the parent-child autotutorial (PCAT) programme, a 10-week home-based self-instruction nutrition education programme, or nutrition counselling from a registered dietitian. Children with non-elevated plasma cholesterol formed the not-at-risk control group. Dietary and blood data were collected at baseline and at 3 months.

SETTING

: Paediatric practices in suburbs north of Philadelphia, PA.

SUBJECTS

: Two hundred and twenty-seven 4-10-year-old children with elevated LDL cholesterol between the 80th and 98th percentiles, and 76 age- and gender-matched children with non-elevated plasma cholesterol, were studied.

RESULTS

: Children who received PCAT or counselling significantly improved their overall diet quality (-0.6 and -0.4 change in diet quality index (DQI) scores) compared with at-risk control children. Children who received either form of nutrition education were more likely to meet the recommendations for three components of the DQI (total fat, saturated fat, sodium) (OR >1.7), but did not improve their intakes of three components of the DQI (vegetables and fruits, complex carbohydrates, calcium) at 3 months.

CONCLUSIONS

: Nutrition education promoting lower dietary fat improved children's overall diet quality. However, several dietary behaviours important for long-term health remained unchanged.

Responses of older adults to theory-based nutrition newsletters

OBJECTIVE

To evaluate the effect of a theory-based newsletter on knowledge, attitude, and behavior change in older adults.

DESIGN

Pretest-posttest, random assignment, and treatment-control design with 2 treatment groups: 1 that received newsletters only and 1 that received newsletters with follow-up telephone interviews. Control group completed pretest-posttest surveys only.

SUBJECTS/SETTING

Four hundred eighty men and women, aged 60 to 74 years, were recruited to participate in a home-based educational intervention using a patient list generated from a rural tertiary care hospital database, Geisinger Medical Center in Danville, Pa.

INTERVENTION

Five nutrition newsletters designed using the nutrition communication model and adult learning theory principles were mailed biweekly. Telephone interviews followed each of the 5 newsletters 10 to 14 days after distribution.

OUTCOME MEASURES

Nutrition knowledge and interest, food behavior related to dietary fat, and stages of change for dietary fat and fiber.

STATISTICAL ANALYSES PERFORMED

Analysis of covariance was used to determine group differences in posttest outcome measures using pretest as covariate.

RESULTS

In addition to achieving higher scores than the control group, the treatment groups were significantly different from each other in correct and perceived nutrition knowledge at posttest. Those in the treatment group receiving telephone calls scored higher (mean change = 19.0% for correct and 20.3% for perceived) than those who received the newsletters only (mean change = 12.5% for correct and 14.3% for perceived; P < .05). Treatment groups also rated their interest in nutrition higher than the control group did; there was no between-treatment difference. Treatment groups performed significantly better than the control group for dietary fiber stage of change (P < .05). Those receiving only newsletters scored significantly better than the control for the "avoid fat" food behavior (P < .05).

APPLICATIONS/CONCLUSIONS

This study provides an example of the incorporation of a theoretical model in development and evaluation of newsletters. Home-delivered nutrition newsletters based on this model can communicate health and nutrition information to older adults. Consumers today have more opportunities than ever before to access nutrition information quickly and inexpensively. Newsletters can help dietetics professionals filter and limit what consumers must process, saving clients time and improving the accuracy of information obtained. Dietetics professionals in both clinical and community practice are uniquely positioned to provide highly focused and understandable information to consumers via a newsletter format.

Hypermethylation of the MYF-3 gene in colorectal cancers: associations with pathological features and with microsatellite instability

Myf-3 is the human homologue of the murine Myo-D1 gene involved in muscle-cell differentiation. Using Southern blot analysis, we examined methylation of Myf-3 in histologically normal colonic mucosae, adenomas and carcinomas from a large series of patients with primary colorectal cancer. Hypermethylation of this gene in comparison with normal mucosa was observed in 88% of adenomas and in 99% of carcinomas. The pattern of Myf-3 methylation was similar in different areas of the same tumour, suggesting that methylation imbalances occur before the bulk of clonal-cell expansion. Significantly increased levels of Myf-3 methylation were observed in tumours which were more invasive, located in the proximal colon or from older patients. Patients whose tumours had extensive methylation showed a trend for shortened survival, though this was probably related to their being more invasive. Extensive methylation was significantly more frequent in tumours with microsatellite instability. Further work is required to determine whether the hypermethylation of Myf-3 observed in colorectal cancers is a specific alteration with functional significance or whether it reflects non-specific methylation imbalances occurring early during tumorigenesis.

Superantigen-based immunotherapy: a phase I trial of PNU-214565, a monoclonal antibody-staphylococcal enterotoxin A recombinant fusion protein, in advanced pancreatic and colorectal cancer

PURPOSE

To establish the maximum-tolerated dose (MTD) and define the toxicities of a single-dose infusion of PNU-214565, a recombinant Escherichia coli-derived fusion protein of Staphylococcal enterotoxin A (SEA) and the Fab-fragment of the C242 monoclonal antibody in patients with advanced colorectal and pancreatic carcinomas. To investigate the capability of PNU-214565 to induce a superantigen (SAg) response resulting in cytokine production and tumor regression.

PATIENTS AND METHODS

Twenty-one patients (age range, 39 to 76 years; median, 64; 12 men, nine women; 18 colorectal, three pancreatic cancers) were treated with a single 3-hour infusion of PNU-214565, with doses ranging from 0.01 to 1.5 ng/kg. All patients had prior chemotherapy and a good performance status Eastern Cooperative Oncology Group [ECOG] performance status [PS] = 0 [n = 10]; PS = 1 [n = 11]), 10 had prior radiation, and 18 had prior surgery.

RESULTS

Fever and hypotension were the most common toxicities. Fever of any grade occurred in 16 of 21 patients (76%): four of 21 (19%) with grade 2 and two of 21 (9.5%) with grade 3. Hypotension of any grade occurred in 13 of 21 (62%): four of 21 with grade 2 and one of 21 (5%) with grade 3. Interleukin-2 (IL-2) and tumor necrosis factor alpha (TNF alpha) induction correlated with toxicity. In the two patients with grade 3 fever, peak IL-2 and TNF alpha levels were 2.9 IU/mL and 165 pg/mL, and 8.3 IU/mL and 245 pg/mL, respectively. Transient, > or = 50% decreases in circulating monocytes were observed in 17 of 21 patients as early as 0.5 hours (median time, 2 hours) from the start of infusion. Decreases (mean 33%) in circulating lymphocytes were observed in seven of 21 patients. All three patients with grade 3 toxicity were treated at the 0.5-ng/kg dose. The significance of baseline anti-SEA, human antimouse antibody (HAMA), CA242-soluble antigen levels, and T-cell receptor variable beta region (TCR V beta) subsets and histocompatibility leukocyte antigen-DR (HLA-DR) genotypes was assessed as possible predictors of toxicity. All toxicities were transient and easily managed. No grade 3 toxicity occurred at the higher dose levels.

CONCLUSION

PNU-214565, a SAg-based tumor targeted therapy, is safe when given as a single 3-hour infusion at doses up to 1.5 ng/kg. The MTD for a single dose was not determined. The safety of a repeated dose schedule is currently under investigation, beginning with doses determined to be safe in this trial.

Change in nutrient intakes, number of servings, and contributions of total fat from food groups in 4- to 10-year-old children enrolled in a nutrition education study

OBJECTIVE

To determine change in nutrient intakes, number of servings, and contributions of total fat from food groups in children who lowered their dietary fat intake.

DESIGN

A research and demonstration study designed to lower plasma low-density lipoprotein cholesterol level. There were four study groups: two intervention and two control groups. All children had hypercholesterolemia except for those in one control group. There 24-hour dietary recalls were collected on randomly assigned days over a 2-week period at baseline and 3 months after the intervention.

SUBJECTS

Three hundred three 4-to 10-year old children from suburbs north of Philadelphia, Pa.

INTERVENTIONS

One intervention involved a home-based, parent-child autotutorial program (PCAT group) with audiotaped stories and print materials for the children and their families; the other intervention involved one face-to-face counseling session with a registered dietitian (counseling group).

OUTCOME MEASURES

Change in mean nutrient intakes compared with the Recommended Dietary Allowance (RDA); change in number of servings and mean grams of total fat contributed from 10 different food groups.

STATISTICAL ANALYSES PERFORMED

Analyses of variance and chi 3 analyses.

RESULTS

Children in every study group had mean intakes of all nutrients (except vitamin D) greater than 67% of the RDA 3 months after the baseline measurement. Several food groups (ie, meats, dairy products, fats/oils, and desserts) provided less total fat to the diets of children who reduced their dietary lipid intake after 3 months (i.e., PCAT and counseling groups). These children also reduced the mean number of servings selected from these food groups. Within these same food groups, some children consumed fewer servings of higher fat foods and more servings of lower fat foods.

APPLICATIONS/CONCLUSIONS

Children who lowered their dietary fat intake after intervention reported both quantitative and qualitative changes in food choices from several food groups. These choices did not significantly reduce their nutrient intakes.

Putting medical practice guidelines into practice: the cholesterol model

As more and more medical practice guidelines are developed in the United States, commensurate evaluation efforts should assess their impact on professional practice and patient outcomes. We describe an ongoing research program designed to develop and test practice models for applying the 1988 Adult Treatment Panel Guidelines for the clinical management of high blood cholesterol. Four studies are evaluating different models to assist nonacademic community practices in the detection, evaluation, and treatment of high blood cholesterol. We have designed randomized controlled trials set in solo and small-group primary care practices of family or general practitioners and internists situated in rural, suburban, and urban settings. Patients include adult men and women who represent diverse socioeconomic and ethnic backgrounds. We are measuring rates of cholesterol screening; dietary and drug treatment and follow-up; changes in dietary intake and compliance with drug therapy; changes in quality of life and cost of intervention; and reduction in cholesterol level. Scheduled for completion in 1994, this program will provide insights into practical and effective methods of lipid management. It serves as a model for studying the application of health guidelines in the context of nonacademic primary care practices serving diverse patient populations.

Inaccuracies in self-reported weights and heights of a sample of sixth-grade children

We collected self-reported weights and heights of 806 sixth-graders in Pennsylvania and compared these values with measures of the children obtained by trained personnel who used standard clinical scales and rigid stadiometers. Approximately 10% of the children either were unable to specify a value for weight, height, or both or reported values of a magnitude indicating that they could not quantitatively conceptualize these measurements. Of the remaining 90%, both boys and girls tended to underreport their weight. Underreporting weight was more pronounced among girls than among boys; for both sexes, the degree of underreporting was much greater among taller, heavier children than among shorter, lighter children. Deviation between self-reported and measured height was substantial for many individuals, but there was no consistent trend toward underreporting or overreporting. These findings indicate that children's self-reported weight data may have a systematic bias, particularly if a large proportion of the sample is over-weight; height data may have considerable random error. We, therefore, conclude that self-reported weights and heights of children may be subject to errors that could confound results if used in clinical or research efforts.

A dietary education program for hypercholesterolemic children and their parents

A parent-child autotutorial dietary education program for 4- to 10-year-old, hypercholesterolemic children and their families was developed and pilot tested. The 10-lesson program, designed for weekly use at home, uses a "talking-book" approach (audiotapes with accompanying picture booklet) for the child. Parents are provided with information on ways to make recommended dietary changes, along with hands-on activities to do with the children. To help match the instructional approach to the wide developmental range within the children's age span, materials are divided into three program levels that use different story characters and concept presentations. During program development, evaluation by two children (and their parents) for each of the program levels guided the design and refinement of the lessons. A pilot test among 22 hypercholesterolemic children (whose treatment was limited to diet modification) revealed that children within the 4- to 10-year age range liked the "talking-book" approach and identified positively with the story characters. Parents indicated that their materials were clear and helpful. Between the baseline and 3-month follow-up visits, the children exhibited a significant increase in knowledge of heart healthy foods, a decrease in total fat consumption that approached significance, and a significant decrease in plasma low-density-lipoprotein cholesterol values.

Examination of specific nutrition/health behaviors using a social cognitive model

Nutrition intervention programs are not always successful. In some cases, an insufficient understanding of the interrelationships among factors influencing health behaviors may be responsible for the failures. This study used social cognitive theory, a framework for studying behaviors, to structure the relationships between measurable factors important to the frequency of health-oriented food consumption. We developed a model that incorporated factors for social environment, reinforcement, commitment, behavior modeling, knowledge, and attitude relative to the frequency of consumption of four beverages (whole milk, low-fat/skin milk, regular soda, and diet soda). Four-hundred fifty-seven middle-aged adults (mean age, 47 years; 58% female) and 709 college students (mean age, 21 years; 50% female) responded to a written questionnaire designed as a self-report on frequency of consumption and measures for 10 social cognitive variables. For all four beverages, the model explained 35% or more of the variance in frequency of consumption, thus confirming its predictive power. We used the statistical approach known as path analysis to examine the relationships within the model. The analysis demonstrated that factors influencing the consumption varied between the two age groups (e.g., nutrition knowledge was related to attitude in adult soda-drinking models but not in student soda-drinking models) and between forms of the beverages (e.g., for student models, nutrition knowledge was related to taste enjoyment for low-fat/skim milk but not for whole milk).(ABSTRACT TRUNCATED AT 250 WORDS)

Psychosocial determinants of compliance in adolescents with iron deficiency

The relationship between selected psychosocial variables and compliance was studied in 71 adolescents prescribed medication for iron deficiency. The mean compliance rate in the study group was 67%. Home pill counts were highly correlated with the other methods of measuring compliance, ie, change in serum ferritin level and urinary assay for tracer riboflavin. Statistically significant predictors of compliance included adverse side effects, initial estimate by the adolescent as to his probable level of compliance, and frequency of family reminders to take the medication. There was no significant correlation between self-esteem, locus of control, or most variables of the Health Belief Model and the level of patient compliance. Our findings suggest that home pill counts are an accurate method of assessing compliance and that instituting family reminders may be helpful in those adolescents who are potentially non-compliant.

A nutrition curriculum for health education: its effect on students' knowledge, attitude, and behavior

The objective of the study was to determine the effect of nutrition instruction, using the curriculum guides, Nutrition In A Changing World, A Curriculum for Junior High Health, and A Curriculum for Senior High Health, on improving the nutrition knowledge, selected food/nutrition attitudes, and dietary behavior of students enrolled in secondary level health courses. Three groups of students were utilized including one experimental and two control groups at each level (junior high and senior high). The experimental group was pretested, taught the nutrition curriculum, and posttested. One control group was posttested only to measure the effect of the pretest on posttest performance. A second control group was pretested and posttested. Neither control group received nutrition instruction until after the study was completed. The three instruments used to collect data were a nutrition knowledge test, a food/nutrition attitude instrument, and a food frequency form. The results indicate that, at all grade levels, the experimental group had significantly improved knowledge scores. Little change in attitude scale scores was noted in grades seven and eight, while ninth grade experimental students scored significantly higher on the posttest for all attitude scales. Little improvement was seen in the posttest food frequency scores.

Using visual plate waste measurement to assess school lunch food behavior

Data reflecting consumption of foods offered in an elementary school cafeteria were collected over a four-day period prior to and after implementation of a nutrition education program. Two methods were employed to measure plate waste, one involving the physical weighing of the returned foods and the other visual examination of the wastes on each child's tray. The two measurement techniques provided similar data on all food items except for stewed tomatoes. For them the visual method consistently exhibited a higher percent plate waste. The sex of the child influenced the amount of food wasted, with the plate waste of 18 food items being higher for girls than for boys. Plate waste of six food items were influenced by grade level; however, except for one item, there was no consistent trend from lower to higher grades.

Nutrition knowledge and attitudes of elementary school students after receiving nutrition education

The effect of a nine-week nutrition education program on nutrition knowledge and selected nutrition/food attitudes of kindergarten through sixth grade pupils was examined. Children in the experimental group participated in the program for a nine-week instructional period; those in the control group participated later. Knowledge and attitude assessment instruments were administered to both groups immediately before and after the instructional period. In the lower grades (kindergarten through grade 3), responses on two of the three attitude scales were positively influenced by the nutrition education program. On the third attitude scale there was a trend toward a positive effect in all but one of the lower grades, but the trend was significant only in first grade. In the upper grade levels (4 through 6), the effect of nutrition education on the nutrition and food attitude scale responses was mixed; it tended to be most positive in grade 4 and least positive in grade 6. The nutrition education program also had a significant positive effect on the nutrition knowledge score of pupils in all grades except sixth. In this grade, the trend was positive but was not significant.

Food behavior of elementary school students after receiving nutrition education

A nine-week nutrition education program for kindergarten through sixth grade was implemented and its influence on children's food behavior assessed using a pretest/post-test design involving children who were and were not exposed to the program. The food behavior response was mixed. Consumption of some food items, at post-test time, was higher among pupils exposed to the program, but that of other items was lower, and consumption of some items was unaffected. Responses to questionnaires by parents indicated that they perceived a favorable effect of the nutrition education program on their children's food behavior.

Evaluation of two nutrition education modules for hospital staff members

Two nutrition education modules for inservice training of hospital food service personnel were evaluated in 16 hospitals. The modules, dealing with cardiovascular disease and diet, contained a leader's guide, a teaching package, audiovisual material, and suggested learning activities. Pretests and post-tests were used to assess knowledge gains resulting from learning sessions. Participants were divided so that one group took the post-tests before the sessions and one group after the sessions. When differences between groups were controlled, the sessions were shown to have a significant positive effect on post-test scores. Three-fourths of the participants rated the sessions as "very good" to "excellent."

Influence of estrogen treatment on hepatic cystathionine synthase and cystathionase of female rats fed varying levels of vitamin B-6

Diets containing 8, 4, 2, or 0 mg vitamin B-6/kg were fed to intact, female rats designated high-, medium-, low-, and deficient-diet groups, respectively. After receiving the diets for 2 weeks, each group was subdivided so as to receive scheduled subcutaneous injections of corn oil with or without estradiol benzoate (Es and NoEs rats, respectively). In experiment 1, rats were fed ad libitum and injections given daily for 2 weeks. In experiment 2, rats were pair-fed and injections given every other day for 3 weeks. Es injections contained 10 microgram and 20 microgram of estradiol benzoate in experiments 1 and 2, respectively. Hepatic cysthionine synthase (CStase) and cystathionase (CNase) activities were determined both with and without exogenous pyridoxal-5-phosphate (stimulated and basal activities, respectively). Regardless of estradiol treatment, the deficient-diet decreased food intake, weight gain, and the basal and stimulated activities of both enzymes with the exception of stimulated CNase activity in Es rats. Estradiol reduced stimulated CNase activity in the medium- and high-diet groups in experiment 1. In experiment 2, estradiol reduced basal CNase activity of all diet groups and reduced stimulated CNase of low- and high-diet groups. It had little effect on CStase activity.

Impact of fast food meals on nutrient intake of two groups

Two groups in different population centers were studied to determine how often consumers frequented fast food restaurants, and consequently, how heavily they relied on this type of food for nutrients. A questionnaire was answered by 280 customers of two fast food restaurants of the same chain. They were asked how often they patronized fast food restaurants, their specific food choices, and other pertinent questions. Food choices were evaluated for energy and seven nutrients on the basis of published analyses of the menu items of the particular fast food chain. Fifty-two per cent of the subjects in the two groups considered their purchases to be meals. Seventy-seven per cent of these consumed one-third or more of the recommended dietary allowance for protein, but no more than 30 per cent received that amount of the other nutrients examined, including food energy. Calcium and particularly vitamin A were least often consumed in amounts equal to one-third of the recommended allowances. Consumer choices were responsible for low consumption of calcium, but no good sources of vitamin A were included on the menus. Fast food items were purchased so infrequently by the majority of our respondents that nutrient composition of the fast food meals or snacks would be of concern in only a small number of cases. This study indicates that any attempts to improve nutritive value of fast food snacks or meals must include efforts to lead consumers to make wiser food choices, as well as encourage the fast food industry to provide rich sources of all the nutrients in their menus.

The influence of childbirth on psychiatric morbidity

The Camberwell Psychiatric Register was searched for contacts by the 2257 women resident in the register catchment area who were known to have had a child in 1970. Of these, 99 women (and 39 of their husbands) were found to have had a 'new episode' of psychiatric illness in the two years before or the two years after the birth of their child. The distribution of these 'new episodes' relative to the time of childbirth was then studied. In the women, both functional psychoses and depressive illnesses showed a sharp rise in the new episode rate in the three months immediately after delivery. There was also a suggestion of a secondary rise, less dramatic but more sustained, from the 10th to the 24th month after delivery. There was no comparable rise in the husbands. Women whose children were illegitimate had high new episode rates throughout the four-year study period, but not particularly so in the puerperium itself.