Development of the national consensus statement on ear health and hearing check recommendations for Aboriginal and Torres Strait Islander children aged under 6 years attending primary care: systematic scoping review and e-Delphi

BACKGROUND

Early detection of long-term, often asymptomatic, middle ear infection in young Aboriginal and Torres Strait Islander children is more likely to be achieved when ear health and hearing checks are routinely undertaken in primary healthcare. Evidence consistently demonstrates the adverse impacts of this condition on the development and wellbeing of children and their families. We aimed to develop feasible, evidence- and consensus-based primary healthcare recommendations addressing the components and timing of ear health and hearing checks for Aboriginal and Torres Strait Islander children aged under 6 years, not already known to have, nor being actively managed for, ear and hearing problems.

METHODS

A 22-person working group comprising Aboriginal and Torres Strait Islander and non-Indigenous members from the primary healthcare, ear, hearing, and research sectors provided guidance of the project. A systematic scoping review addressed research questions relating to primary health ear health and hearing checks for Aboriginal and Torres Strait Islander and other populations at increased risk of persistent ear health problems. Twelve primary studies and eleven guidelines published between 1998 and 2020 were identified and reviewed. Quality and certainty of evidence and risk of bias ratings were completed for studies and guidelines. In the absence of certain and direct evidence, findings and draft recommendations were presented for consensus input to a 79-member expert panel using a modified e-Delphi process. Recommendations were finalised in consultation with working group members and presented to expert panel members for input on considerations relating to implementation.

RESULTS

Overall, the quality, certainty, and directness of evidence in the studies and guidelines reviewed was low. However, the findings provided a basis and structure for the draft recommendations presented during the consensus-building process. After two e-Delphi rounds, seven goals and eight recommendations on the components and timing of Ear Health and Hearing Checks in primary healthcare for young Aboriginal and Torres Strait Islander children were developed.

CONCLUSIONS

The systematic scoping review and consensus-building process provided a pragmatic approach for producing strong recommendations within a reasonably short timeframe, despite the low quality and certainty of evidence, and paucity of studies pertaining to primary healthcare settings.

Examining relationships between parent-reported factors and recurring ear symptoms among Aboriginal and Torres Strait Islander children

ISSUE ADDRESSED

Aboriginal and Torres Strait Islander child ear health is complex and multiple. We examined relationships between parent-reported sociodemographic, child health, health service access factors and ear symptoms among Aboriginal and Torres Strait Islander children aged 3 to 7 years.

METHODS

The Longitudinal Study of Indigenous Children is a large child cohort study with annual parent-reported data collection. Generalised linear mixed model analyses examined Wave 1 (1309 children 0-5 years; 2008) predictors of being free of parent-reported ear symptoms in both Waves 2 and 3.

RESULTS

A total of 1030 (78.7%) had no reported ear symptoms in either Wave 2 or 3. In the fully adjusted model, children who had been hospitalised in the past year (aOR = 2.16; 95% CI 1.19-3.93) and those with no ear symptoms (aOR = 2.94; 95% CI, 1.59-5.46) at Wave 1 had higher odds of no ear symptoms in both the subsequent waves. There were also relationships between parent main source of income-government pension or allowance as well as parents who reported no history of their own ear symptoms and higher odds of no ear symptoms in Waves 2 and 3 after partial adjustment for sociodemographic factors.

CONCLUSION

These findings suggest relationships between different sociodemographic and health factors and parent-reported ear symptoms among Aboriginal and Torres Strait Islander children that warrant further investigation. So what? Children with parent-reported ear symptoms during the early years need holistic support to prevent future ear symptoms that impact health, social and educational life trajectories.

Definitions, perspectives, and reasons for conscientious objection among healthcare workers, facility managers, and staff in South Africa: a qualitative study

Conscientious objection (CO) on the part of healthcare providers is a growing threat to safe abortion access. In South Africa, evidence suggests that this legal clause may be manipulated as a justification for public-sector healthcare providers to exempt themselves from their duties to provide essential reproductive health services as required by national laws and protocols. This qualitative study improves our understanding of the definitions, perspectives, and use of CO among providers, staff, and facility managers in South Africa, and CO's effect on public-sector abortion availability. Using 18 focus group discussions and 23 in-depth interviews, we examined CO attitudes and behaviours of staff from health facilities that provide abortion care in Gauteng, Limpopo, KwaZulu-Natal, and Eastern Cape Provinces. We find that CO is invoked for a variety of reasons, some unrelated to the legal basis for objection. There have been progressive shifts in attitudes towards abortion over time, but stigma against women and girls who seek abortion remains substantial among staff at facilities providing abortion. Providers who offer abortion services also report high levels of discrimination and isolation from colleagues. Such factors, combined with operational barriers to offering quality abortion care (such as lack of training support or financial incentives) and lack of clarity on CO definitions and procedures, may incentivise some providers to invoke CO inappropriately. Dissemination of national guidelines on CO should be prioritised to reduce ambiguity, and interventions addressing abortion stigma should be considered for all facility staff to safeguard abortion availability in South Africa.

Routine ear health and hearing checks for Aboriginal and Torres Strait Islander children aged under 6 years attending primary care: a national consensus statement

This consensus statement provides new recommendations for primary care assessment of ear health and hearing status of young Aboriginal and Torres Strait Islander children who are not known to have, or are not being actively managed for, ear health and hearing problems. Any child identified with otitis media should be actively managed. This national consensus statement extends existing treatment and management guidelines. MAIN RECOMMENDATIONS: Undertake checks at least 6-monthly, commencing at 6 months until 4 years of age, then at 5 years. Undertake checks more frequently in high risk settings for children under 2 years, when acceptable to families, or in response to parent/carer concerns. Ask parents/carers about concerns, signs, and symptoms; check children's listening and communication skills; and assess middle ear appearance and mobility. Otoacoustic emissions testing is suggested when equipment is available, primary health practitioners have capability and confidence to use the equipment, and there is local preference for its use. Video otoscopy is suggested for health promotion purposes, and/or for sharing images with other health practitioners. Audiometry should be done as per existing guidelines: when there are parent/carer concerns, signs of persistent/recurrent otitis media, or when listening and communication development is not yet on track. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Key practice changes include routine use of tympanometry, and listening and communication skills checklists. Implementation will require access to equipment and training; clear information on immediate, practical actions for families; timely pathways to referral services; and a change management process that shifts perception and tolerance of otitis media and its impacts and raises expectations that Aboriginal and Torres Strait Islander children can have healthy ears and hearing.

Ear and hearing care programs for First Nations children: a scoping review

BACKGROUND

Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs.

METHOD

A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services.

RESULTS

Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases.

CONCLUSION

The result of this study highlighted that programs primarily operate at two points along the care pathway-detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

Standardised data on initiatives-STARDIT: Beta version

BACKGROUND AND OBJECTIVE

There is currently no standardised way to share information across disciplines about initiatives, including fields such as health, environment, basic science, manufacturing, media and international development. All problems, including complex global problems such as air pollution and pandemics require reliable data sharing between disciplines in order to respond effectively. Current reporting methods also lack information about the ways in which different people and organisations are involved in initiatives, making it difficult to collate and appraise data about the most effective ways to involve different people. The objective of STARDIT (Standardised Data on Initiatives) is to address current limitations and inconsistencies in sharing data about initiatives. The STARDIT system features standardised data reporting about initiatives, including who has been involved, what tasks they did, and any impacts observed. STARDIT was created to help everyone in the world find and understand information about collective human actions, which are referred to as 'initiatives'. STARDIT enables multiple categories of data to be reported in a standardised way across disciplines, facilitating appraisal of initiatives and aiding synthesis of evidence for the most effective ways for people to be involved in initiatives. This article outlines progress to date on STARDIT; current usage; information about submitting reports; planned next steps and how anyone can become involved.

METHOD

STARDIT development is guided by participatory action research paradigms, and has been co-created with people from multiple disciplines and countries. Co-authors include cancer patients, people affected by rare diseases, health researchers, environmental researchers, economists, librarians and academic publishers. The co-authors also worked with Indigenous peoples from multiple countries and in partnership with an organisation working with Indigenous Australians.

RESULTS AND DISCUSSION

Over 100 people from multiple disciplines and countries have been involved in co-designing STARDIT since 2019. STARDIT is the first open access web-based data-sharing system which standardises the way that information about initiatives is reported across diverse fields and disciplines, including information about which tasks were done by which stakeholders. STARDIT is designed to work with existing data standards. STARDIT data will be released into the public domain (CC0) and integrated into Wikidata; it works across multiple languages and is both human and machine readable. Reports can be updated throughout the lifetime of an initiative, from planning to evaluation, allowing anyone to be involved in reporting impacts and outcomes. STARDIT is the first system that enables sharing of standardised data about initiatives across disciplines. A working Beta version was publicly released in February 2021 (ScienceforAll.World/STARDIT). Subsequently, STARDIT reports have been created for peer-reviewed research in multiple journals and multiple research projects, demonstrating the usability. In addition, organisations including Cochrane and Australian Genomics have created prospective reports outlining planned initiatives.

CONCLUSIONS

STARDIT can help create high-quality standardised information on initiatives trying to solve complex multidisciplinary global problems.

Inequalities in the utilisation of the Child Dental Benefits Schedule between Aboriginal and non-Aboriginal children

Objectives The Child Dental Benefits Schedule (CDBS) is an Australian Government initiative providing basic dental care to children from low-income households. We sought to investigate levels of utilisation of the CDBS among Aboriginal and non-Aboriginal children to determine whether there is equal access to dental services provided through the schedule. Methods CDBS data were obtained for four financial (July-June) years (from 2013-14 to 2016-17). The data captured all claims made during this period. The data included estimates of usage by Aboriginal status, age group and Dental Benefits groups (administrative categories of related dental procedures). Results The utilisation of CDBS services was lower for Aboriginal children. However, in 2013-14, although the odds of using the schedule were higher for non-Aboriginal children (odds ratio (OR) 0.89; P<0.0001) this was reversed in 2015-16 and 2016-17 (OR 1.11 and 1.21 respectively; P<0.0001 in both years). The odds of Aboriginal children using preventive services was below that of non-Aboriginal children in 2013-14 (OR 0.82), 2014-15 (OR 0.76), 2015-16 (OR 0.83) and 2016-17 (OR 0.90; P<0.0001) in all years. Conclusions The data are encouraging with regard to equity because they show that for services overall, Australian Aboriginal and non-Aboriginal children have similar levels of utilisation. However, lower levels of the use of preventive services may indicate future inequalities in oral health among Aboriginal children. What is known about the topic? The CDBS is an Australian Government initiative aimed at improving access to dental care for children from low-income households, including for Aboriginal people. By facilitating greater access to dental care, the schedule has the potential to help address inequalities in oral health for both Aboriginal and non-Aboriginal children. What does this paper add? There are no analyses available comparing the utilisation of the CDBS by Aboriginal and non-Aboriginal children. This study compared levels of utilisation of the schedule overall and specifically for preventive services. What are the implications for practitioners? Greater efforts should be made to address inequalities in the utilisation of the CDBS between Aboriginal and non-Aboriginal children. Although there are some hopeful signs, inequalities remain that may affect the oral health of Aboriginal children. There is also potential to encourage utilisation of the CDBS for greater provision of preventive services, including targeted population oral health initiatives.

Assessment of structural chromosomal instability phenotypes as biomarkers of carboplatin response in triple negative breast cancer: the TNT trial

BACKGROUND

In the TNT trial of triple negative breast cancer (NCT00532727), germline BRCA1/2 mutations were present in 28% of carboplatin responders. We assessed quantitative measures of structural chromosomal instability (CIN) to identify a wider patient subgroup within TNT with preferential benefit from carboplatin over docetaxel.

PATIENTS AND METHODS

Copy number aberrations (CNAs) were established from 135 formalin-fixed paraffin-embedded primary carcinomas using Illumina OmniExpress SNP-arrays. Seven published [allelic imbalanced CNA (AiCNA); allelic balanced CNA (AbCNA); copy number neutral loss of heterozygosity (CnLOH); number of telomeric allelic imbalances (NtAI); BRCA1-like status; percentage of genome altered (PGA); homologous recombination deficiency (HRD) scores] and two novel [Shannon diversity index (SI); high-level amplifications (HLAMP)] CIN-measurements were derived. HLAMP was defined based on the presence of at least one of the top 5% amplified cytobands located on 1q, 8q and 10p. Continuous CIN-measurements were divided into tertiles. All nine CIN-measurements were used to analyse objective response rate (ORR) and progression-free survival (PFS).

RESULTS

Patients with tumours without HLAMP had a numerically higher ORR and significantly longer PFS in the carboplatin (C) than in the docetaxel (D) arm [56% (C) versus 29% (D), PHLAMP,quiet = 0.085; PFS 6.1 months (C) versus 4.1 months (D), Pinteraction/HLAMP = 0.047]. In the carboplatin arm, patients with tumours showing intermediate telomeric NtAI and AiCNA had higher ORR [54% (C) versus 20% (D), PNtAI,intermediate = 0.03; 62% (C) versus 33% (D), PAiCNA,intermediate = 0.076]. Patients with high AiCNA and PGA had shorter PFS in the carboplatin arm [3.4 months (high) versus 5.7 months (low/intermediate); and 3.8 months (high) versus 5.6 months (low/intermediate), respectively; Pinteraction/AiCNA = 0.027, Padj.interaction/AiCNA = 0.125 and Pinteraction/PGA = 0.053, Padj.interaction/PGA = 0.176], whilst no difference was observed in the docetaxel arm.

CONCLUSIONS

Patients with tumours lacking HLAMP and demonstrating intermediate CIN-measurements formed a subgroup benefitting from carboplatin relative to docetaxel treatment within the TNT trial. This suggests a complex and paradoxical relationship between the extent of genomic instability in primary tumours and treatment response in the metastatic setting.

Runs of homozygosity and testicular cancer risk

BACKGROUND

Testicular germ cell tumour (TGCT) is highly heritable but > 50% of the genetic risk remains unexplained. Epidemiological observation of greater relative risk to brothers of men with TGCT compared to sons has long alluded to recessively acting TGCT genetic susceptibility factors, but to date none have been reported. Runs of homozygosity (RoH) are a signature indicating underlying recessively acting alleles and have been associated with increased risk of other cancer types.

OBJECTIVE

To examine whether RoH are associated with TGCT risk.

METHODS

We performed a genome-wide RoH analysis using GWAS data from 3206 TGCT cases and 7422 controls uniformly genotyped using the OncoArray platform.

RESULTS

Global measures of homozygosity were not significantly different between cases and controls, and the frequency of individual consensus RoH was not significantly different between cases and controls, after correction for multiple testing. RoH at three regions, 11p13-11p14.3, 5q14.1-5q22.3 and 13q14.11-13q.14.13, were, however, nominally statistically significant at p < 0.01. Intriguingly, RoH200 at 11p13-11p14.3 encompasses Wilms tumour 1 (WT1), a recognized cancer susceptibility gene with roles in sex determination and developmental transcriptional regulation, processes repeatedly implicated in TGCT aetiology.

DISCUSSION AND CONCLUSION

Overall, our data do not support a major role in the risk of TGCT for recessively acting alleles acting through homozygosity, as measured by RoH in outbred populations of cases and controls.

Is a Drain Necessary after Colonic Anastomosis?

To date, there have been no clinical investigations of the usefulness of drains following colonic anastomosis in elective operations. We report a prospective study in which 49 patients were randomized to have a corrugated silastic drain (Portex) placed next to the colonic anastomosis. These patients were compared with a control group of 57 patients who had no drain. The two groups were similar in age, sex, diagnosis and site of anastomosis. There was no difference in outcome between the two groups. Anastomotic leakage occurred in six patients in each group. Wound infections were noted in 10 patients in each group. Two patients with a drain and one patient without a drain died from leakage at the anastomosis. This study provides no evidence to support the use of a corrugated drain after anastomosis of the colon.

The emergence of psychological themes in the South African Medical Journal, 1927–1975

The articles published in the South African Medical Journal between 1927 and 1975 were examined for the presence of psychological and psychiatric themes. Two hundred and seventy-seven articles and editorials were identified and analysed. The relative space allocated to issues psychological remained quite stable at low levels in the period under investigation. The following themes are discussed: psychopathology and treatment, psychoneuroses, psychology and physical disease, psychological testing, and psychology as an auxiliary to the medical profession.

FGF receptor genes and breast cancer susceptibility: results from the Breast Cancer Association Consortium

BACKGROUND

Breast cancer is one of the most common malignancies in women. Genome-wide association studies have identified FGFR2 as a breast cancer susceptibility gene. Common variation in other fibroblast growth factor (FGF) receptors might also modify risk. We tested this hypothesis by studying genotyped single-nucleotide polymorphisms (SNPs) and imputed SNPs in FGFR1, FGFR3, FGFR4 and FGFRL1 in the Breast Cancer Association Consortium.

METHODS

Data were combined from 49 studies, including 53 835 cases and 50 156 controls, of which 89 050 (46 450 cases and 42 600 controls) were of European ancestry, 12 893 (6269 cases and 6624 controls) of Asian and 2048 (1116 cases and 932 controls) of African ancestry. Associations with risk of breast cancer, overall and by disease sub-type, were assessed using unconditional logistic regression.

RESULTS

Little evidence of association with breast cancer risk was observed for SNPs in the FGF receptor genes. The strongest evidence in European women was for rs743682 in FGFR3; the estimated per-allele odds ratio was 1.05 (95% confidence interval=1.02-1.09, P=0.0020), which is substantially lower than that observed for SNPs in FGFR2.

CONCLUSION

Our results suggest that common variants in the other FGF receptors are not associated with risk of breast cancer to the degree observed for FGFR2.

Harnessing the power of advertising to prevent childhood obesity

Background

Social marketing integrates communication campaigns with behavioural and environmental change strategies. Childhood obesity programs could benefit significantly from social marketing but communication campaigns on this issue tend to be stand-alone.

Methods

A large-scale multi-setting child obesity prevention program was implemented in the Hunter New England (HNE) region of New South Wales (NSW), Australia from 2005–2010. The program included a series of communication campaigns promoting the program and its key messages: drinking water; getting physically active and; eating more vegetables and fruit. Pre-post telephone surveys (n = 9) were undertaken to evaluate awareness of the campaigns among parents of children aged 2–15 years using repeat cross-sections of randomly selected cohorts. A total of 1,367 parents (HNE = 748, NSW = 619) participated.

Results

At each survey post baseline, HNE parents were significantly more likely to have seen, read or heard about the program and its messages in the media than parents in the remainder of the state (p < 0.001). Further, there was a significant increase in awareness of the program and each of its messages over time in HNE compared to no change over time in NSW (p < 0.001). Awareness was significantly higher (p < 0.05) in HNE compared to NSW after each specific campaign (except the vegetable one) and significantly higher awareness levels were sustained for each campaign until the end of the program. At the end of the program participants without a tertiary education were significantly more likely (p = 0.04) to be aware of the brand campaign (31%) than those with (20%) but there were no other statistically significant socio-demographic differences in awareness.

Conclusions

The Good for Kids communication campaigns increased and maintained awareness of childhood obesity prevention messages. Moreover, messages were delivered equitably to diverse socio-demographic groups within the region.

The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial)

BACKGROUND

The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge.

METHODS

The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an 'early intervention' and two to a 'late intervention' group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30-80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques.

RESULTS

804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months.

CONCLUSION

The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses.

TRIAL REGISTRATION

ACTRN12609001081202.

The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial

BACKGROUND

Lifestyle risk factors like smoking, nutrition, alcohol consumption, and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care is an appropriate setting to address these risk factors in individuals. Generalist community health nurses (GCHNs) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time. The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practices of GCHNs.

METHODS

The trial used a quasi-experimental design involving four generalist community nursing services in NSW, Australia. The services were randomly allocated to either an intervention group or control group. Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessments and interventions. The control group provided usual care. A sample of 129 GCHNs completed surveys at baseline, 6 and 12 months to examine changes in their practices and levels of confidence related to the management of SNAP risk factors. Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice.

RESULTS

Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers. Nurses in the intervention group reported assessing physical activity, weight and nutrition more frequently, as well as providing more brief interventions for physical activity, weight management and smoking cessation. There was little change in referral rates except for an improvement in weight management related referrals. Nurses' perception of the importance of 'client and system-related' barriers to risk factor management diminished over time.

CONCLUSIONS

This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practices of GCHNs. Barriers to referral remained. The service model needs to be adapted to sustain these changes and enhance referral.

TRIAL REGISTRATION

ACTRN12609001081202.

Abstract P3-08-04: Impact of CYP3A variation on estrone levels and breast cancer risk

Background: Epidemiological studies provide strong evidence for a role of endogenous sex steroids in the etiology of breast cancer. Our aim was to identify common variants in genes involved in sex steroid synthesis or metabolism that were associated with premenopausal hormone levels and breast cancer risk.

Methods: We measured urinary estrone glucuronide (E1G) and pregnanediol glucuronide (PG) using a protocol specifically developed to account for cyclic variation in hormone levels during the menstrual cycle, plasma sex hormone-binding globulin (SHBG) and androgenic precursors in up to 763 healthy premenopausal women. We genotyped 642 single nucleotide polymorphisms (SNPs) in these women; a single SNP was further tested for association with breast cancer risk in data from 10,551 breast cancer case patients and 17,535 control subjects. All statistical tests were two-sided.

Results: rs10273424 mapping approximately 50kb centromeric to the cytochrome P450 3A (CYP3A) cluster (7q22.1) was associated with a 21.8% reduction in E1G levels (P = 2.7 × 10−9) and a modest reduction in breast cancer risk in cases diagnosed at or before age 50 (OR = 0.91; P = 0.03) but not older cases (odds ratio (OR) = 1.01; P = 0.82). A rare non-synonymous SHBG SNP was associated with reduced plasma SHBG levels.

Conclusions: Genetic variation in non-coding sequences flanking the CYP3A locus contributes to variance in premenopausal E1G levels and breast cancer risk in younger cases. Since CYP3A4, the most predominantly expressed CYP3A gene, is responsible for metabolism of endogenous and exogenous hormones and hormonal agents such as tamoxifen, used in the treatment of breast cancer this association may have wider implications.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-08-04.

Evaluation of the 2008 NSW water campaign

ISSUE ADDRESSED

The consumption of soft and other sweetened drinks is an emerging nutrition issue in Australia. In 2005-6, 63% of NSW children aged between 2 and 15 years consumed sweetened drinks (soft drinks, cordials or sports drinks) weekly, 33% of which consumed at least 6 cups per week. In 2008 NSW Health implemented the 'Water Campaign' to increase the proportion of NSW children up to 15 years of age who consume water in place of sweetened drinks.

METHODS

A pre-post survey study design was used to evaluate the Campaign. Two telephone surveys of stratified random samples of 500 respondents each from the primary target audience (parents and carers of children up to 15 years of age) were conducted across NSW.

RESULTS

Fifty-three per cent of respondents in the post-survey said that they recalled the mass media Campaign when it was described to them compared to 19% in the pre-survey. There was an increase in parents' knowledge of the high sugar content of sweetened drinks and a decline in the reported consumption of sweetened drinks by boys.

CONCLUSIONS

Though modest in size and duration, the campaign was successful in achieving a number of campaign objectives, particularly changes in parent's and carer's knowledge and awareness of water related nutrition and reduced reported consumption of sweetened drinks among boys.

Stage 2 Genome-Wide Association Study of Candidate Low Penetrance Genes Implicated in Breast Cancer Risk

The risk of breast cancer in the first-degree female relatives of breast cancer cases is approximately double the risk in the general population. BRCA1 and BRCA2 account for less than 20% of this excess risk; the majority is probably due to the multiplicative effects of large numbers of low penetrance risk alleles. Genome-wide association studies (GWAS) have successfully identified 13 low-penetrance breast cancer risk alleles (Easton et al 2007, Hunter et al 2007, Stacey et al 2007, Zheng et al 2009, Ahmed et al 2009, Thomas et al 2009) but power calculations suggest that many more are still to be discovered.We have recently conducted a genome wide association study of 1,500 bilateral breast cancer cases, 200 cases with at least two affected first degree relatives and 1,450 controls from the 1958 birth cohort (WTCCC, 2007) using the Illumina HumanHap 370 chip. Based on these data and publicly available data from the Cancer Genetic Markers of Susceptibility (CGEMS) study we have selected 1,200 of the most significant SNPs to genotype in a stage 2 study comprising 5,500 breast cancer cases and 4,500 controls. All 13 of the known loci were replicated in this 2-stage analysis.Additional candidates at novel genomic loci are being genotyped in a replication study of 6,000 cases and 6,000 controls.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6136.

The use of a closed-circuit hospital television channel to promote health: the reach and appeal of RPAtv to patients and visitors

Closed-circuit television has the potential to promote health in hospitals, as a significant number of patients watch large amounts of television (TV) during their stays. This project sought to investigate the potential of a dedicated hospital TV channel to communicate health messages in an entertaining way by assessing the reach and appeal of a closed-circuit hospital TV channel - RPAtv. A cross-sectional survey of 162 inpatients and visitors at the Royal Prince Alfred Hospital was conducted. Sixty-four percent of participants were aware of RPAtv, with patients (72%) significantly more likely (P < 0.001) to be aware of RPAtv than visitors (41%). Almost 60% of those who were aware of the channel had viewed it. Of those who had viewed RPAtv, 73.3% rated the programming as "good" or "very good". When asked about programming preferences, 34% suggested that the channel should include health and hospital information. However, 66% said that they would rather watch programming that was entertaining, light-hearted and escapist. The high approval rating of programming by viewers suggests that the channel is improving the experience of patients and visitors during their time in hospital. However, its effectiveness as a vehicle for health promotion could be somewhat limited. Any health education-focused objectives of similar channels need to be realistic about the extent of likely increases in health knowledge.

The role of ethnicity in determining access to and acceptability of home visiting for early childhood health and wellbeing

This paper explores access to and acceptability of home visiting for early childhood health and wellbeing among the New South Wales population. The study examined demographic and social characteristics of children and their families to identify the factors that predicted home visiting by a community health nurse or volunteer, as well as the level of acceptability of home visiting as a strategy for improving child health. The data were extracted from the 2001 NSW Child Health Survey and a total of 3570 respondents who reported having a child aged 4 years or under were included in the study. The results show that culturally and linguistically diverse populations were less likely to be visited by a nurse or volunteer (adjusted odds ratio (OR), 0.78; 95% CI, 0.64-0.97), and when they were visited were more likely to find the visit "uncomfortable" or "very uncomfortable" (adjusted OR, 1.54; 95% CI, 1.19-1.99). Other factors associated with acceptability included the age of both children and mothers, education levels of parents and home smoking status. For home visiting to be effective in promoting child health, these factors must be considered.

"It's not an issue at the moment": a qualitative study of mothers about childhood obesity

PURPOSE

To explore childhood obesity through mothers' perceptions, attitudes, beliefs, and behaviors.

STUDY DESIGN AND METHODS

Descriptive qualitative study using in-depth interviews. Sixteen in-depth interviews were conducted with primiparous mothers of children aged 0-2 years. The questions focused on nutrition, the context of eating in the family, physical activity, television viewing, and the responsibility of parents as role models. Thematic analysis was used to identify regular patterns of meaning regarding the major issues pertaining to childhood obesity, nutrition, and physical activity.

RESULTS

Five themes were identified: (1) developing eating habits, (2) developing active and sedentary habits, (3) differences between age groups, (4) sources of information, and (5) response to information. Although awareness about the need to provide a nutritious diet and opportunities for children to be active was high among the mothers, this was not always reflected in their behaviors. For many mothers, obesity became a concern only if excessive weight gain occurred. Prevention through establishing good habits early, although considered, was not always actively pursued.

CLINICAL IMPLICATIONS

Interventions to prevent overweight and obesity need to focus on equipping parents with the skills to translate their knowledge into behavior and lay the foundations early for their children to develop healthy habits.

The flow-cytometry-based evaluation of cellular immunity in cases of cutaneous leishmaniasis and healthy controls from the endemic area in southern Israel

Only limited data are available on the early immunological events associated with human cutaneous leishmaniasis (CL). In this study, peripheral-blood mononuclear cells were obtained from 66 individuals (34 patients with cutaneous lesions and 32 apparently healthy controls) who had each spent no more than 3 months in the endemic region of Qetzioth, in southern Israel. These cells' responses to Leishmania major antigen were then explored, by the flow-cytometry-based evaluation of blast transformation (BT). The lymphocytes from 17 (50%) of the patients but only one (3%) of the controls displayed BT. When, in an ELISA, most (52) of the subjects were checked for anti-L. major antibodies, none of the 22 controls investigated but 19 (63%) of the 30 patients were found seropositive. Although 14 (47%) of the 30 patients who were checked for antibodies were BT-positive, the seropositive patients were not significantly more or less likely to be BT-positive than the seronegative patients (P<0.919). These data indicate that, in CL, the hosts' cellular and humoral responses develop independently within the first 3 months post-infection, but further investigation is required to confirm this hypothesis.

Driving to work and overweight and obesity: findings from the 2003 New South Wales Health Survey, Australia

OBJECTIVES

To examine possible associations between driving to work, physical activity and overweight and obesity.

DESIGN

Secondary analysis of cross-sectional data from a representative sample of the 2003 New South Wales Adult Health Survey, Australia.

SUBJECTS

A total of 6810 respondents aged 16 years or over.

MEASUREMENTS

Self-reported height and weight, modes of transport to work, level of physical activity, fruit and vegetable intake and social-economic status.

RESULTS

Almost half of the respondents (49%) were overweight. The main mode of transport to work was driving a car (69%), 15% used public transport, 7% walked, 2% cycled and 6% worked at home. People who drove to work were less likely to achieve recommended levels of physical activity compared to non-car users (56.3 vs 44.3%, chi2 = 82.5, P<0.0001). Driving to work was associated with being overweight or obese (adjusted odds ratio = 1.13 (95% CI 1.01-1.27), P = 0.047). Inadequate level of physical activity was independently associated with overweight or obesity. Socially and economically disadvantaged people were also more likely to be overweight and obese. In addition, being female or never married or having higher level of education was associated with a significantly reduced odds ratio of being overweight or obese, as was speaking a language other than English at home. No association was found between weight status and recommended vegetable or fruit intake.

CONCLUSIONS

Driving to work is the dominant mode of commuting in a modern society and its impact on health requires scrutiny. The association found in this study between driving to work and overweight and obesity warrants further investigation to establish whether this relationship is causal. If proved as such, then promoting active transport modes such as walking, cycling and public transport should form a key component of global obesity prevention efforts.

Molecular analysis of noroviruses involved in acute gastroenteritis outbreaks in military units in Israel, 1999–2004

The study presented here was conducted to determine the genetic properties of noroviruses (NoVs) identified between 1999 and 2004 in army recruits with acute gastroenteritis. Partial sequence analysis of the RNA-dependent RNA polymerase gene revealed the presence of two major sub-genogroups, all of which were related to genogroup II of NoV. Serological analysis using recombinant antigens confirmed this observation. Local strains associated with a 1999 outbreak were closely related to GII-6 strains, while those identified later were very closely related to GII-4 strains. GII-4 strains were also associated with an outbreak in civilian nursing homes in Israel in 2002 and samples from this outbreak were included in this study for comparison. This is the first report describing the molecular properties of NoV strains associated with diarrhea-related morbidity in Israel.

A large-scale gastroenteritis outbreak associated with Norovirus in nursing homes

An increase in gastroenteritis outbreaks due to Norovirus has been reported worldwide. We investigated a large-scale outbreak affecting 246 residents and 33 staff members in six nursing homes in the Tel-Aviv district, Israel, during 3 weeks in 2002. Person-to-person spread was noticed in all nursing homes. The spread of disease could not be attributed to social interactions. Among the elderly residents, the hospitalization rate was 10.2% and the case-fatality rate was 2.0%. Bacteriological cultures were negative. Overall, 7 out of 15 stool specimens were positive for Norovirus by RT-PCR. All were sequenced and found to be 90% identical. The characteristics of this outbreak and the RT-PCR results suggest that illness was caused by Norovirus. Due to the high case-fatality rate of Norovirus gastroenteritis, there should be a high index of suspicion when encountering a gastroenteritis outbreak among the elderly. This will enable prompt action to stop the spread of illness.

Correlation of IgA, IgM and IgG antibody-detecting assays based on filamentous haemagglutinin, pertussis toxin and Bordetella pertussis sonicate in a strictly adult population

Pertussis diagnosis among adults is primarily based on serology. In this study, receiver operation characteristics (ROC) analysis was utilized to evaluate three IgA, IgM and IgG ELISAs based on B. pertussis whole-cell sonicate (WC), pertussis toxin (PT), or combined PT-filamentous haemagglutinin (FHA) antigens in a healthy adult population and in adults suffering from symptoms consistent with pertussis. The assays were compared to a PT and FHA reference ELISA. The reference assay showed high correlation with PT- and PT-FHA-based ELISAs but low correlation was found with the WC-based ELISA. However, ROC analysis indicated that all the assays enabled fine differentiation between healthy subjects and subjects suffering from symptoms suggestive of pertussis. The WC IgA ELISA showed the best diagnostic performance [highest specificity (98.8%) with highest sensitivity (53.8%)]. We conclude that despite a low correlation between the various assays they all carry good diagnostic capability for an adult population.

Promoting active transport in a workplace setting: evaluation of a pilot study in Australia

Promoting active transport is an increasingly important focus of recent health promotion initiatives addressing the major public health concerns of car dependence, decreased levels of physical activity and environmental health. Using active transport that relies less on the use of private cars and more on alternatives such as walking, cycling and public transport has the potential to increase population levels of physical activity and to improve the environment. Over 12 months, a combined social and individualized marketing campaign was delivered to a cohort of randomly selected health service employees (n = 68) working at a health care facility in inner-city Sydney, Australia. Pre- and post-intervention surveys measured changes in mode of transport, awareness of active transport and attitudes towards mode of transport. Following the intervention, we found there was a reduction in the proportion of participants who drove to work 5 days per week and a decrease in trips travelled by car on weekends. In addition, there was high awareness of the intervention amongst participants and their understanding of the concept of active transport improved from 17.6% at baseline to 94.1% at the follow-up survey (p < 0.01). There was also a significant shift in attitudes, which suggested increased positive regard for active transport. Our findings suggest that a combined social and individualized marketing campaign in the workplace setting can increase the use of active transport for the journey to work and trips on weekends. However, before these findings are widely applied, the intervention needs to be tested in a controlled study with a larger sample size.

An Outbreak of Norovirus Gastroenteritis on an Israeli Military Base

BACKGROUND

Noroviruses (NVs) are a predominant cause of viral gastroenteritis outbreaks, but they are difficult to identify because they cannot be cultivated in cell culture. Therefore, reverse-transcriptase polymerase chain reaction (RT-PCR) assays are widely used in the testing of clinical stool specimens for NV. However, testing of perianal swabs in the context of an outbreak is considered to be an insensitive method for identification of NV using the RT-PCR technique. An outbreak of acute gastroenteritis involving 159 soldiers on a training base of the Israel Defense Force in December 1999 allowed us to evaluate this identification method.

PATIENTS AND METHODS

An epidemiologic investigation, a sanitation survey and a case-control study of exposure to different food items served up to 48 h preceding the outbreak were conducted. Stool samples in the form of post-defecation perianal swabs were collected from 24 ill personnel and three non-ill food handlers. Swabs were tested for the presence of NV by RT-PCR assay.

RESULTS

Epidemiologic data were consistent with a pointsource food-borne outbreak which was associated with consumption of fresh vegetable salad in the base mess hall (OR = 4.38, 95% CI 1.51-13.35). Both epidemiologic and clinical features were suggestive of gastroenteritis caused by NV, and upon laboratory analysis perianal swabs from four of 24 cases were positive for NV.

CONCLUSION

The combination of practical specimen collection with perianal post-defecation swabs, and the utilization of a molecular epidemiology approach, can simplify the rapid identification of outbreaks caused by NVs.

The occurrence and significance of triploidy in the liver fluke, Fasciola hepatica

Karyotyping of Fasciola hepatica samples from Britain and Ireland has identified a triploid isolate which is effectively aspermic, rendering it necessarily asexually reproducing. Considering the extensive presence of asexually reproducing diploid and triploid Fasciola in Asia it is suggested that facultative gynogenesis is widespread in this parasite. This has important implications for the population genetics and evolution of Fasciola, especially in relation to the development and spread of drug resistance, and must be considered in the mathematical modelling of this process.

An outbreak of pertussis among young Israeli soldiers

In winter 2001, an outbreak of pertussis involving an estimated 75 people occurred among soldiers serving in an infantry regiment of the Israeli Defense Forces (IDF). Nasopharyngeal swabs were obtained from patients and contacts for culture and PCR. Serum samples were obtained and assayed by ELISA for the presence of IgA, IgM and IgG antibodies to a lysate antigen of Bordetella pertussis. The calculated attack rate was 21% based on clinical signs alone (cough lasting 30 days or longer) and 9.5% based on clinical signs with laboratory confirmation (by PCR, IgA or IgM). A high carriage rate was observed; 20% of the asymptomatic and previously symptomatic subjects were PCR-positive for B. pertussis. These findings emphasize the importance of B. pertussis as a causative agent of epidemic respiratory infections in young adults and reveal the occurrence of a significant proportion of pertussis transient carriers during an outbreak of the disease.

Retrospective analysis of the first clonal outbreak of nalidixic acid-resistant Shigella sonnei shigellosis in Israel

Reported here is a retrospective molecular analysis of the isolates recovered from the first outbreak of nalidixic acid (NA)-resistant Shigella sonnei shigellosis to occur in Israel. The outbreak affected 94 children. In the retrospective analysis, a total of 13 NA-resistant isolates and five NA-susceptible isolates recovered during the outbreak period were examined. Restriction fragment length polymorphism profiles obtained by digestion with BamHI, PvuI, HinfI or SmaI yielded identical profiles for all 18 isolates. All NA-resistant strains had an identical plasmid profile, but this profile differed from that displayed by the susceptible strains. In all of the NA-resistant strains a 304 bp fragment in the gyrA gene coding for a region associated with NA resistance was sequenced and showed a single point mutation, Ser83-->Phe. In this outbreak, the isolates of NA-resistant Shigella sonnei belonged to a single clone and NA resistance was associated with a point mutation in the gyrA gene.

Promoting physical activity in women: evaluation of a 2-year community-based intervention in Sydney, Australia

Women are less likely than men to reach recommended levels of physical activity and have unequal access to active leisure time. Studies in Australia have consistently found that women are only half as likely as men to be adequately active. A community-based multi-strategic health promotion intervention, 'Concord, A Great Place to be Active', was implemented from 1997 to 1999. It aimed to increase the physical activity levels of women aged 20-50 years living in the Concord Local Government Area (LGA), an inner-western region of Sydney, Australia. A key feature of this intervention was a partnership between Concord Council (the local government) and the Central Sydney Health Promotion Unit (CSHPU). The project was evaluated using qualitative and quantitative methods. Key informant interviews and focus groups were conducted to inform the development of the intervention and to assess the impact of the project on Concord Council. Pre- and post-intervention telephone surveys of the target group were also conducted. Following the intervention, there was a statistically significant (6.4%) reduction in the proportion of sedentary women. Further, there were a number of positive enhancements in the Council's capacity to promote physical activity in the community. These findings demonstrate that a community-based intervention targeting a specific population can achieve positive changes in physical activity and that a local government has the capacity to be involved in and sustain physical activity interventions.