Risk-based lung cancer screening performance in a universal healthcare setting

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Evaluating an Integrated Local System Response to the COVID-19 Pandemic: Case Study of East Toronto Health Partners

Introduction

East Toronto Health Partners (ETHP) is a network of organizations that serve residents of East Toronto, Ontario, Canada. ETHP is a newly formed integrated model of care in which hospital, primary care, community providers and patients/families work together to improve population health. We describe and evaluate the evolution of this emerging integrated care system as it responded to a global health crisis.

Description

This paper begins by describing ETHP's pandemic response mapping out over two years of data. To evaluate the response, semi-structured interviews were conducted with 30 decision makers, clinicians, staff, and volunteers who were part of the response. The interviews were thematically analyzed, and emergent themes mapped onto the nine pillars of integrated care.

Discussion

The ETHP pandemic response evolved rapidly. Early siloed responses gave way to collaborative efforts and equity emerged as a central priority. New alliances formed, resources were shared, leaders emerged, and community members stepped forward to contribute. Interviewees identified positives as well as many opportunities for improvement post-pandemic.

Conclusion

The pandemic was a catalyst for change in East Toronto that accelerated existing initiatives to achieve integrated care. The East Toronto experience may serve as a useful guide for other emerging integrated care systems.

Organising healthcare services for persons with an intellectual disability

BACKGROUND

When compared to the general population, persons with an intellectual disability have lower life expectancy, higher morbidity, and more difficulty finding and obtaining healthcare. Organisational interventions are used to reconfigure the structure or delivery of healthcare services. This is the first update of the original review.

OBJECTIVES

To assess the effects of organisational interventions of healthcare services for the mental and physical health problems of persons with an intellectual disability.

SEARCH METHODS

For this update we searched CENTRAL, MEDLINE, EMBASE, CINAHL and other databases, from April 2006 to 4 September 2015. We checked reference lists of included studies and consulted experts in the field.

SELECTION CRITERIA

Randomised controlled trials of organisational interventions of healthcare services aimed at improving care of mental and physical health problems of adult persons with an intellectual disability.

DATA COLLECTION AND ANALYSIS

We employed standard methodological procedures as outlined in the Cochrane Handbook of Systematic Reviews of Interventions, in addition to specific guidance from the Cochrane Effective Practice and Organisation of Care (EPOC) Group.

MAIN RESULTS

We identified one new trial from the updated searches.Seven trials (347 participants) met the selection criteria. The interventions varied but had common components: interventions that increased the intensity and frequency of service delivery (4 trials, 200 participants), community-based specialist behaviour therapy (1 trial, 63 participants), and outreach treatment (1 trial, 50 participants). Another trial compared two active arms (traditional counselling and integrated intervention for bereavement, 34 participants).The included studies investigated interventions dealing with the mental health problems of persons with an intellectual disability; none focused on physical health problems. Four studies assessed the effect of organisational interventions on behavioural problems for persons with an intellectual disability, three assessed care giver burden, and three assessed the costs associated with the interventions. None of the included studies reported data on the effect of organisational interventions on adverse events. Most studies were assessed as having low risk of bias.It is uncertain whether interventions that increase the frequency and intensity of delivery or outreach treatment decrease behavioural problems for persons with an intellectual disability (two and one trials respectively, very low certainty evidence). Behavioural problems were slightly decreased by community-based specialist behavioural therapy (one trial, low certainty evidence). Increasing the frequency and intensity of service delivery probably makes little or no difference to care giver burden (MD 0.03, 95% CI -3.48 to 3.54, two trials, moderate certainty evidence). It is uncertain whether outreach treatment makes any difference for care giver burden (one trial, very low certainty evidence). There was very limited evidence regarding costs, with low to very low certainty evidence for the different interventions.

AUTHORS' CONCLUSIONS

There is very limited evidence on the organisation of healthcare services for persons with an intellectual disability. There are currently no well-designed studies focusing on organising the health services of persons with an intellectual disability and concurrent physical problems. There are very few studies of organisational interventions targeting mental health needs and the results of those that were found need corroboration. There is an urgent need for high-quality health services research to identify optimal health services for persons with an intellectual disability and concurrent physical problem.

Massage therapy improves the development of HIV-exposed infants living in a low socio-economic, peri-urban community of South Africa

The aim of this study was to assess the effect of massage therapy on the growth and development of infants of HIV-infected mothers in a low socio-economic community in Cape Town. It was a prospective, randomised, controlled intervention trial that included massage therapy and control groups of HIV-infected mothers and their normal birth weight infants who were enrolled in the prevention of mother-to-child transmission (PMTCT) programme. Participants were recruited at the 6-week clinic visit and followed up every 2 weeks until their infants were 9 months of age. Mother-infant pairs in the massage therapy and control groups included 73 and 88 at 6 weeks and 55 and 58 at 9 months, respectively. Mothers in the intervention group were trained to massage their infants for 15 min daily. The socioeconomic status, immunity, relationship with the partner and mental pain of mothers; the infants' dietary intake, anthropometry and development (Griffiths Mental Development Scales); and haematological and iron status of mothers and infants were assessed at baseline and follow-up. Nine infants (5.3%) were HIV-infected on the HIV DNA PCR test at 6 weeks. Despite significantly higher levels of maternal mental pain, infants in the massage therapy compared to control group scored higher in all five of the Griffiths Scales of Mental Development and significantly higher in the mean quotient (p=0.002) and mean percentile (p=0.004) for the hearing and speech scale at 9 months. Based on the mean difference in scores, the massage therapy group showed greater improvement for all five scales compared to the control group. The mean difference in scores was significantly greater for the hearing and speech quotient (21.9 vs. 11.2) (p<0.03) and the general quotient percentile (19.3 vs. 7.7) (p=0.03) in the massage therapy compared to the control group. These scales remained significant when adjusting for the relationship with the partner and maternal mental pain. Both groups had lower scores in the performance scale at 9 months although this was significantly worse in the control compared to the massage therapy group when adjusting for maternal CD4 count, anaemia, relationship with the partner and mental pain. There were no significant differences in the anthropometric measurements between the two groups. In conclusion, based on the Griffiths Scales, massage therapy improved the overall development and had a significant effect on the hearing and speech and general quotient of HIV-exposed infants in this study.

Organising health care services for persons with an intellectual disability

BACKGROUND

When compared to the general population, persons with an intellectual disability have lower life expectancy, higher morbidity, higher rates of unmet health needs, and more difficulty finding and getting health care. Organisational interventions are used to reconfigure the structure or delivery of health care services and may prove useful to decrease the noted disparities.

OBJECTIVES

To assess the effects of organisational interventions for the mental and physical health problems of persons with an intellectual disability.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (no year restriction), MEDLINE, EMBASE, CINAHL, other databases from January 1990 to April 2006 reference lists of included studies, and we consulted experts in the field.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of organisational interventions aimed at improving care of mental and physical health problems of adult persons with an intellectual disability.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality. Missing data were requested from authors of included studies.

MAIN RESULTS

Eight studies met the selection criteria: six were randomised controlled trials, one was a controlled before and after study, and one was an interrupted time series. In general the studies were of acceptable methodological quality. The included studies investigated interventions dealing with the mental health problems of persons with an intellectual disability, none focused on physical health problems. Three of the studies identified effective organisational interventions and five showed no evidence of effect. Only two studies were similar enough to analyse using a meta-analysis. In the pooled analyses 25 participants received assertive community treatment and 25 received standard community treatment. Results from measures of function, caregiver burden and quality of life were non-significant.

AUTHORS' CONCLUSIONS

There are currently no well designed studies focusing on organising the health services of persons with an intellectual disability and concurrent physical problems. There are very few studies of organisational interventions targeting mental health needs and the results of those that were found need corroboration. There is an urgent need for high quality health services research to identify optimal health services for persons with an intellectual disability and concurrent physical problem.

An assessment of preliminary food-based dietary guidelines for infants 6–12 months of age in the Little Karoo area of the Western Cape Province of South Africa

Objective

This study aimed to assess mother's/caregiver's understanding, practical application and cultural acceptability of a preliminary set of South African food-based dietary guidelines (FBDGs) for children aged 6–12 months living in the Little Karoo area of the Western Cape Province.

Design

An observational, descriptive and cross-sectional study design was followed. Focus group interviews, recorded on videotape, were analysed for qualitative data. Quantitative questionnaires measured knowledge and comprehension of guidelines, perceived constraints to compliance with and importance of guidelines as well as socio demographic data prior to the focus group interviews.

Setting

Afrikaans-, English- and Xhosa-speaking communities of the Little Karoo area of the Western Cape Province of South Africa, including the urban areas of Oudtshoorn, Bongulethu, Bridgton, Toekomsrus and the adjacent rural areas of Dysselsdorp, Calitzdorp, Uniondale, Ladismith and Zoar.

Subjects

Sixty-four mothers or caregivers to infants 6–12 months of age were included in the sample.

Results

Information obtained through the questionnaires supported what was said during discussions. Although perceived as important by the majority of respondents, some of the guidelines were not well understood without prior explanation. Such guidelines were those pertaining to meal frequency and cup feeding, while application of the guideline to prolonged breast-feeding seemed the most problematic.

Conclusions

The FBDGs for this age group will have to be supported by extensive and appropriate educational material to be effective when introduced to the public. The fact that the applicability of the guideline to prolonged breast-feeding seemed to be the most problematic is a cause for concern.

Are opportunities for vitamin A supplementation being utilised at primary health-care clinics in the Western Cape Province of South Africa?

OBJECTIVES

To determine missed opportunities and problems relating to implementation of the Vitamin A Supplementation Programme in urban and rural regions of the Western Cape Province of South Africa.MethodA cross-sectional survey was conducted at primary health-care (PHC) clinics in Cape Metropole, an urban region, and West Coast Winelands, a rural region, of the Western Cape. A purposive sample of clinics where more than 30 children were seen per day was drawn from 10 of the 11 districts in the Cape Metropole region and the two districts of the West Coast Winelands region. The number of children selected from each district was weighted in terms of population size for the two regions. At each clinic visited, the first five to 10 children seen on a day, and meeting the inclusion criteria for vitamin A supplementation (VAS) based on the vitamin A provincial policy guidelines, were selected. These included children with low birth weight (LBW), growth faltering, underweight and severe undernutrition, recurrent diarrhoea and lower respiratory tract infection (LRTI), tuberculosis, measles, HIV/AIDS and eye signs of vitamin A deficiency. Clinic records were reviewed following consultation with the PHC nurse to identify if the child required vitamin A, exit interviews were conducted with mothers/caregivers, and Road to Health Charts (RTHCs) were reviewed. At the end of the study, PHC managers were interviewed to determine if problems could be identified with the Programme.

RESULTS

Forty-three of 123 (35%) and 13 of 40 (33%) of the fixed PHC clinics in the Cape Metropole and West Coast Winelands regions were visited, and a total of 300 children (234 from Cape Metropole, 66 from West Coast Winelands) with a mean (standard deviation) age of 24.3 (16.3) months and who met the inclusion criteria for VAS were selected. Of the total sample of children, 198 (66%) had multiple (i.e. more than one) indication and 102 (34%) had a single indication for VAS. There were a total of 617 indications for VAS in the two regions; 238 (39%) for growth faltering, 119 (19%) for underweight, 98 (16%) for LBW, 70 (11%) for LRTI, 51 (8%) for diarrhoea, 21 (3%) for HIV/AIDS and 20 (3%) for tuberculosis. A total of 102 (34%) of the children in the two regions received vitamin A supplements (Cape Metropole 29%; West Coast Winelands 52%). A record was made on the RTHC of 79 (77%) of the children who received VAS (Cape Metropole 76%; West Coast Winelands 79%). Twenty-four per cent of the mothers knew why their child had been given vitamin A (Cape Metropole 29%; West Coast Winelands 12%). Eleven per cent of the mothers had previously heard about the Vitamin A Supplementation Programme (Cape Metropole 12%; West Coast Winelands 6%). More than 81% of PHC managers indicated that health staff had been trained to implement the Vitamin A Supplementation Programme. The main problems identified by health staff in the two regions were lack of vitamin A capsules, inadequate training and difficulties in implementing the Programme.

CONCLUSIONS

Opportunities to administer vitamin A were underutilised in both regions. Recommendations such as improving mothers' awareness of the benefits of vitamin A and training of PHC nurses were made to the provincial Department of Health and are being implemented to improve the effectiveness of the Programme.

Ferulic acid excretion as a marker of consumption of a French maritime pine (Pinus maritima) bark extract

French maritime pine (Pinus maritima) bark extract (PBE) is a polyphenol-rich food supplement patented under the name of Pycnogenol and known to have strong antioxidant activity and different beneficial effects on human health. Although its biological properties have begun to be extensively studied both in vitro, in laboratory animals and more recently in humans, little is known about its bioavailability. The present study investigated the urinary excretion of free and conjugated ferulic acid, present in quantitatively detectable amounts in PBE, after oral PBE administration to human subjects. Eleven healthy adult subjects (4 women and 7men) consumed either a single dose (200 mg PBE) or two doses of PBE (100 and 200 mg, respectively) within a 48-h interval. Two days before the oral administration of PBE and during the urine sample collection period volunteers adhered to a diet low in polyphenols. Aliquots of all urine production were collected over 24 h. Free and conjugated ferulic acid was assessed in urine by HPLC using diode array detection. A close association between the dietary intake of PBE and the urinary excretion of ferulic acid was detected. Moreover, the results indicate that a considerable proportion of ferulic acid is excreted as glucuronide or sulfate after PBE consumption, varying over the range 2 to 20% between individuals. The kinetics of excretion associated with the administration of 100 mg PBE was quite similar to that obtained after 200 mg PBE. A a biphasic trend was evident in a number of subjects. All subjects studied here displayed a significant, although variable level of excretion of ferulic acid after supplementation with PBE, Thus, the data provide evidence that at least a part of the phenolic components of PBE are absorbed, metabolized, and eliminated by humans.

Absorption of ferulic acid from low-alcohol beer

Flavonoids and monophenolic compounds have been well-described over recent years for their properties as antioxidants and scavengers of reactive oxygen and nitrogen species. A number of epidemiological studies implicate a role for flavonoids in reducing the risk of coronary heart disease. In particular, the focus has been on flavonol-rich fruit and vegetables and flavonoid-rich beverages, especially tea and red wine. Mechanisms of protection are unclear since the absorption, distribution, metabolism and elimination of dietary phenolics have not yet been extensively investigated. Here we report the bioavailability of ferulic acid, 4-hydroxy-3-methoxy-cinnamic acid, the major hydroxycinnamate in beer. Studies of the pharmacokinetics of urinary excretion of ferulic acid from low alcohol beer consumption in humans have been undertaken. The results show that ferulic acid is absorbed with a peak time for maximal excretion of ca. 8 h and the mean cumulative amount excreted is 5.8 +/- 3.2 mg. These findings are consistent with the uptake of ferulic acid from dietary sources, such as tomatoes, and suggest that ferulic acid is more bioavailable than individual dietary flavonoids and phenolics so far studied.

Anthropometric profile of a black population of the Cape Peninsula in South Africa

This study describes the anthropometry of an urban black population living in the Cape Peninsula, South Africa. A random sample of 986 selected adults aged 15-64 years and 163 children aged three to six years, included data on heights, weights, and mid-upper arm circumferences and calculation of the body mass index (BMI). The mean height of men was 168.3 cm and that of women 158.3 cm. Mean weight, BMI and mid-upper arm circumference for men were 66.2 kg, 23.4 and 28.1 cm and for women 69.8 kg, 27.8 and 30.6 cm respectively. The prevalence of underweight in men (BMI < 20) was 19% and in women (BMI < 19) 3.7%; 22% of the men were overweight (BMI > or = 25) and 7.9% obese (BMI > or = 30), while 36.4% of women were overweight (BMI > or = 24) and 34.4% obese (BMI > or = 30). More than half of the women above the age of 35 years were obese. Anthropometry of the three to six year old children was calculated for stunting, wasting and underweight, expressed in terms of the National Centre for Health Statistics standards, and revealed co-existing evidence of growth retardation and wasting with emergent obesity. These findings suggest that a part of this community, who may have been nutritionally deprived during childhood, has moved from undernutrition to extreme overnutrition without having achieved optimal nutritional status. Complexities that need to be considered when planning strategies to address malnutrition in the black South African population are identified.

Hypertension in the black community of the Cape Peninsula, South Africa

Hypertension prevalence, treatment status and factors relating to high blood pressure were determined in an urban black community of the Cape Peninsula, South Africa. A study population of 986 subjects aged 15-64 years was randomly selected. Blood pressure, height, weight and serum cholesterol levels were measured, while demographic information, personal and family history relating to hypertension and attendance of health services were determined by questionnaire. Overall 9.2% of males and 12.9% of females were hypertensive according to WHO criteria. Blood pressures between 160/95 and 140/90 mmHg were found in 10% of males and 10.5% of females. The treatment status of hypertensives showed that 24.3% had a blood pressure below 160/95 mmHg, and 16% below 140/90 mmHg. Hypertensives used more alcohol and were more overweight than normotensives. Multiple logistic regression revealed that hypertension was independently related to age, being overweight and more urbanised. The degree of urbanisation also predicted to what extent hypertension prevalence increases with age. This black population had low hypertension rates compared with other similar groups in South Africa. These data suggest that as rural blacks increasingly undergo urbanisation, hypertension prevalence increases. Necessary diagnostic and treatment regimens and hypertension services are not yet in place in the South African health services, and need to be established.

The lipid and lipoprotein profile of the urban black South Africa population of the Cape Peninsula - the BRISK study

OBJECTIVE

To determine the lipid and lipoprotein profile of the urban black South African population of the Cape Peninsula.

DESIGN

Cross-sectional design.

SETTING

The seven black residential areas of the Cape Peninsula.

PARTICIPANTS

A stratified proportional sample was drawn from the study area. The sample consisted of 422 men and 544 women aged between 15 and 64 years.

OUTCOME MEASURES

Lipid and lipoprotein levels. Risk levels for coronary heart disease (CHD).

RESULTS

The total cholesterol (TC level) was low compared with other South African groups studied. Men had a mean TC of 3.98 mmol/l and women 4.15 mmol/l. Low-density lipoprotein cholesterol (LDLC) values for men (2.03 mmol/l) were lower than those for women (2.30 mmol/l). Men (1.35 mmol/l) and women (1.37 mmol/l) had similar high-density lipoprotein cholesterol (HDLC) levels. Both sexes had a prevalence of protective HDL/TC ratios above 30% for all age groups. High HDL3C levels and low HDL2C levels were found in both men and women. Apolipoprotein A and B followed the trends of HDLC and LDLC and showed no difference between the sexes. The plasma triglyceride (TG) levels increased with age in both sexes. Men displayed higher TG levels than women in all age groups. Seventeen per cent of men and 26% of women had a moderate-to-high risk for CHD, given their TC levels. Other lipid-related risk factors indicated low risk for CHD.

The haematological profile of urban black Africans aged 15-64 years in the Cape Peninsula

A stratified probability sample (n = 986) with quotas was drawn from black residential areas in the Cape Peninsula, South Africa. Subjects (n = 819) aged 15-64 years, participated in a coronary heart disease (CHD) risk factor survey, the BRISK Study. Nutritional status and prevalence of CHD was determined in this population undergoing rapid urbanization. Full blood and differential white blood cell counts provided data to calculate population reference values based on the 95% reference limits of the haematological parameter. Mean haemoglobin concentrations (Hb) in men (14.0 g/dl) and women (12.4 g/dl) were +/- 1.5 g/dl lower than previous South African reports. Mean BRISK Hb values were very similar to the World Health Organization's Hb cutoff criteria (< 13 g/dl men; < 12 g/dl women), indicating a possible high prevalence of anaemia. Significantly higher (P < 0.05) mean values for red cell indices were confirmed in men, which also reflected equally higher red blood cell counts (RBC), haematocrit (HCT) and mean corpuscular haemoglobin (MCH) values. Mean Hb values were significantly lower in the younger (15-24 years) and older (55-64 years) men compared with 25-54 year-olds (P < 0.05). Hypochromic microcytic anaemia was more prevalent in women, possibly due to iron deficiency (ID), while macrocytic anaemia was more prevalent in men. No significant differences were noted in mean total and differential white blood cell counts (WBC) between men and women.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of lipid hydroperoxides in the myoglobin-dependent oxidation of LDL

It has previously been reported that mb in both the iron-oxo ferryl and the ferric oxidation states can promote lipid peroxidation and lead to oxidative modification of low-density lipoprotein. The mechanism of these oxidation reactions is unclear and could involve either lipid hydroperoxide-dependent or independent reactions. In order to ascertain which of the afore-mentioned mechanisms predominates, the effects of exogenous lipid hydroperoxides on the ability of Mb, in its various oxidation states, to oxidize low-density lipoprotein has been investigated. The results suggest that oxidation proceeds through a one-electron redox cycle between met and ferryl myoglobin and that the reactions of both redox forms are at least partially dependent on lipid hydroperoxides within the LDL particle.

Risk factors for coronary heart disease in the black population of the Cape Peninsula. The BRISK study

A cross-sectional study of risk factors for ischaemic heart disease (IHD) in a random sample of 986 black people aged 15-64 years living in the Cape Peninsula revealed a population at lower risk for IHD than other South Africans. Blood pressures of 140/95 mmHg or above were found in 14.4% of males and 13.7% of females. Fifty-two per cent of males and 8.4% of females smoked, while 16.5% of males and 25.8% of females had a total cholesterol (TC) level imparting risk for developing IHD. In this population the TC level is not a good surrogate measure for low-density lipoprotein cholesterol because of the high level of high-density lipoprotein cholesterol (HDLC) found in this population. A protective HDLC/TC ratio of 20% was found in 96% of males and 96.1% of females. When considering the three major reversible IHD risk factors at a high level of risk, 30.8% of males and 12.5% of females had at least one such a risk factor. The population was frequently exposed to the media, with 80% listening to the radio every day and 55% watching television at least once a week. This suggests that a healthy lifestyle could be promoted successfully by means of these media. In addition, schools should promote a healthy lifestyle and the prevention of chronic degenerative diseases should be incorporated into the evolving primary health care services in South Africa.