Contraceptive Behavior Dynamics and Unintended Pregnancy: A Latent Transition Analysis

The average U.S. woman wants to have two children; to do so, she will spend about three years pregnant, postpartum, or trying to become pregnant, and three decades trying to avoid pregnancy. However, few studies have examined individual patterns of contraceptive use over time. These trajectories are important to understand given the high rate of unintended pregnancy and how little we know about the complex relationship between contraceptive use, pregnancy intention, and patterns of reproductive behavior. We use data from the 2015-2017 National Survey of Family Growth to examine reproductive behavior and pregnancies across three years of calendar data. We identify seven behavior typologies, their prevalence, how women transition between them, and how pregnancies affect transitions. At any given time, half of women are reliably using contraception. A small proportion belong to a high pregnancy risk profile of transient contraceptive users, but some transition to using condoms or other methods consistently. An unintended pregnancy may initiate a transition into stable contraceptive use for some women, although that is primarily condom use. These findings have important implications for the ways contraception fits into women's lives and how that behavior interacts with relationships, sex, and life stage trajectories.

Left ventricular morphology in patients with aortic coarctation and bicuspid aortic valve: novel insights from a statistical shape modelling framework

Background

The functional implications of left ventricular (LV) morphological characterization in congenital heart disease (CHD) are not widely explored.

Purpose

This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV).

Methods

A statistical shape modelling (SSM) framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) imaging data in n=110 cases including: isolated CoA (n=25), CoA+BAV (n=30), isolated BAV (n=30), and age-matched healthy controls (n=25). Average 3D templates (Picture 1) and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters (i.e. sphericity, conicity) as well as CMR-derived global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture (i.e. gothicity, tortuosity) was also explored by means of regression analysis.

Results

The LV template was shorter and more spherical in CoA patient (Picture 1), as also confirmed by statistical analysis of the SSM-derived shape modes. LV sphericity, which was higher in CoA, was associated (p≤0.04) with lower global longitudinal, radial and circumferential strain, irrespective of the presence of aortic stenosis and/or regurgitation. Conversely, neither LV morphology nor LV strain was not associated with arch architecture.

Conclusions

Differences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and NIHR BRC

In Vivo Measurements of the Bulk Ultrasonic Attenuation Coefficient of Breast Tissue Using a Novel Phase-Insensitive Receiver

This study describes the first in vivo acoustic attenuation measurements of breast tissue undertaken using a novel phase-insensitive detection technique employing a differential pyroelectric sensor. The operation of the sensor is thermal in nature, with its output signal being dictated by the acoustic power integrated over its surface. The particularly novel feature of the sensor lies in its differential principle of operation, which significantly enhances its immunity to background acoustic and vibration noise. A large area variant of the sensor was used to detect ultrasonic energy generated by an array of 14 discrete 3.2-MHz plane piston transducers, transmitted through pendent breasts in water. The transduction and reception capability represent key parts of a prototype Quantitative Ultrasound Computed Tomography Test Facility developed at the National Physical Laboratory to study the efficacy of phase-insensitive ultrasound computed tomography of breast phantoms containing a range of appropriate inclusions, in particular, the measurement uncertainties associated with quantitative reconstructions of the acoustic attenuation coefficient. For this study, attenuation coefficient measurements were made using 1-D projections on 12 nominally healthy study volunteers, whose age ranged from 19 to 65 years. Averaged or bulk attenuation coefficient values were generated in the range 1.7-4.6 dBcm ^-1 at 3.2 MHz and have been compared with existing literature, derived from in vivo and ex vivo studies. Results are encouraging and indicate that the relatively simple technique could be applied as a robust method for assessing the properties of breast tissue, particularly the balance of fatty (adipose) and fibroglandular components.

A comparison of approaches to measuring maternal mortality in Bangladesh, Mozambique, and Bolivia

Background

Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality.

Objective

The objective is to inform on potential options for measuring maternal mortality.

Methods

This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS).

Results

For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003.

Conclusions

Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches.

Contribution

Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-022-00281-8.

Perspectives of community-dwelling older adults with dementia and their carers regarding their oral health practices and care: rapid review

AIM

To review evidence on oral health practices, beliefs/views and experiences of community-dwelling older adults living with dementia, including their carers.

MATERIALS AND METHODS

A search of key terms across six databases including Pubmed, Web of Science and OVID (Embase, MEDLINE [R] and PsycINFO) and Google Scholar was conducted, supplemented by reference screening. The Mixed Methods Appraisal Tool (MMAT) 2018 was used to assess the methodological quality.

RESULTS

Eighteen studies reported across 19 papers were included in the review. Papers largely focused on normative needs (n = 13), whilst also reporting oral health-related experiences (n = 2), practices (n = 7), and beliefs/views (n = 9), of community dwellers with dementia. Generally, people living with dementia presented with poor oral and dental health, the exception being one study where dental care was integrated with memory clinic services. Maintenance of oral health focused only on toothbrushing. Overall, people living with dementia have reduced capacity for self-performed oral hygiene and high reliance on caregivers. There was a paucity of evidence on their perceptions of oral health and quality of life, the findings of which were equivocal, with weak evidence suggesting possible difficulty in identifying and communicating their needs. Experiences of accessing dental care, when explored, appear to be system dependent.

CONCLUSION

There was limited research evidence on oral health-related practices, beliefs/views and experiences of people with dementia. Recommendations for future research are presented.

Entanglement of Cape fur seals (Arctocephalus pusillus pusillus) at colonies in central Namibia

Marine pollution is increasing, and pinnipeds are commonly affected by entanglement in waste. We investigated entanglement rates, common materials, and the demographic profile of Cape fur seals (Arctocephalus pusillus pusillus) affected at two Namibian colonies. Overall, we identified 366 cases of entanglement, and present a global rate of entanglement of 0.17%. Entanglement rates were 0.17% and 0.15% for the Pelican Point and Cape Cross colonies, respectively. We identified 17% more entanglements through photographs than binocular scans. Of the 347 entanglements analysed in detail, juveniles were most commonly affected and fishing materials were the primary cause of entanglements (53%), with 8% of entangled seals exhibiting 'very severe' injuries. Overall, 191 individuals were successfully disentangled, and citizen scientists contributed 51% of total entanglement data. We highlight the negative impact of plastic marine waste among seals and the importance of disentanglement for individual animal welfare.

Transition for patients with congenital heart disease in the UK: need for a universal model with adequate training and support

Background

Adolescence is a vulnerable period for patients with congenital heart disease (CHD). Transition is a process that guides these patients through adolescence and ensures a smooth transfer to adult services, in order improve adherence to medical care and reduce loss to follow-up. While the importance of a formal Transition process is widely recognised and a requirement for specialist services in the UK, the optimal structure and delivery of Transition remains a matter of debate.

Aims

To examine the different models of Transition currently in place in specialist CHD centres around the UK.

Methods

A survey of Adult CHD centres in the UK was performed. A focus was placed on the structure of the Transition service, relevant training and areas of perceived improvement.

Results

There were 10 responses to our survey covering 10 specialist CHD centres. All respondents were consultant adult CHD specialists, looking after patients from the age of 16 [14–17] years. All centres have a specialised Transition service, which runs from the age 13 [11–15] to 18 [16–25] years (duration of transition 5 [2–13] years). The majority of centres (80%) report providing transition care “well before” transfer to adult care, whereas 20% provide transition care at or immediately before transfer (i.e. first adult CHD appointment). Transition is delivered by physicians and clinical specialist nurses in approximately equal numbers in 9 (90%) centres and exclusively by clinical nurse specialists in 1 (10%) centre. A median of 2 [1–5] visits are planned for each patient, with 7 (70%) centres seeing patients at least twice during transition. The majority, but not all centres (70%) provide a health passport during transition. A significant number of centres felt they werer not receiving sufficient support in the following domains: financial (50%), training (30%), clinical space (30%), referrals from paediatrics (50%). All respondents felt that their Transition service had room for improvement. Other areas of improvement highlighted included reduction in loss to follow-up, difficulties in providing a Transition service to patients followed in peripheral hospitals, the need for more support from paediatric services in referring all appropriate patients, and dedicated administrative support. The vast majority of respondents (9, 90%) felt equipped with the appropriate skills to care for transition patients. However, few (2, 20%) had completed formal training in more than one area related to adolescent health and transition.

Conclusions

While all CHD centres have a Transition service, Transition models and delivery differs significantly. There is urgent need for research in this area to develop a unified model, greater financial support and relevant training to optimise care.

Figure 1. Participating UK centres

Funding Acknowledgement

Type of funding source: None

A study of the clinical, treatment planning and dosimetric feasibility of dose painting in external beam radiotherapy of prostate cancer

BACKGROUND AND PURPOSE

Radiotherapy dose painting is a promising technique which enables dose escalation to areas of higher tumour cell density within the prostate which are associated with radioresistance, known as dominant intraprostatic lesions (DILs). The aim of this study was to determine factors affecting the feasibility of radiotherapy dose painting in patients with high and intermediate risk prostate cancer.

MATERIALS & METHODS

Twenty patients were recruited into the study for imaging using a 3 T magnetic resonance imaging (MRI) scanner. Identified DILs were outlined and the scan registered with the planning computed tomography (CT) dataset. Intensity-modulated plans were produced and evaluated to determine the effect of the organ-at-risk constraints on the dose that could be delivered to the DILs. Measurements were made to verify that the distribution could be safely delivered.

RESULTS

MRI scans were obtained for nineteen patients. Fourteen patients had one to two DILs with ten overlapping the urethra and/or rectum. The target boost of 86 Gy was achieved in seven plans but was limited to 80 Gy for five patients whose boost volume overlapped or abutted the urethra. Dosimetric measurements gave a satisfactory gamma pass rate at 3%/3 mm.

CONCLUSIONS

It was feasible to produce dose-painted plans for a boost of 86 Gy for approximately half the patients with DILs. The main limiting factor was the proximity of the urethra to the boost volumes. For a small proportion of patients, rigid registration between CT and MRI images was not adequate for planning purposes.

Are community health workers effective in retaining women in the maternity care continuum? Evidence from India

Objectives

Despite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the maternity care continuum has been limited. We use the example of the Accredited Social Health Activist (ASHA) programme in India, to understand the role of community health workers in retaining women in the maternity care continuum.

Methods

Using the Indian Human Development Survey data from 2011 to 2012, we assess the association between individual and cluster-level exposure to ASHA and four key components along the continuum of care—at least one antenatal care (ANC) visit, four or more ANC visits, presence of a skilled birth attendance (SBA) at the time of birth and postnatal care for the mother or child within 48 hours of birth, for 13 705 women with a live birth since 2005. To understand which of these services experience maximum dropout along the continuum, we use a linear probability model to calculate the weighted percentages of using each service. We assess the association between exposure to ASHA and number of services utilised using a multinomial logistic regression model adjusted for a range of confounding variables and survey weights.

Results

Our study indicates that exposure to the ASHA is associated with an increased probability of women receiving at least one ANC and SBA. In terms of numbers of services, exposure to ASHA accounts for a 12% (95% CI: 9.1 to 15.1) increase in women receiving at least some of the services, and an 8.8% (95% CI: −10.2 to −7.4) decrease in women receiving no services. However, exposure to ASHA does not increase the likelihood of women utilising all the services along the continuum.

Conclusions

While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affect the completion of all services along the continuum.

Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome

OBJECTIVE

Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited.

DESIGN

A retrospective cohort study.

SETTING

Eight specialist UK centres.

SAMPLE

Pregnant women with LDS.

METHODS

Data was collated on cardiac, obstetric, and neonatal outcomes.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes in pregnancies complicated by LDS.

RESULTS

Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery.

CONCLUSION

Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit.

TWEETABLE ABSTRACT

Pregnancy outcomes in women with Loeys-Dietz syndrome.

Best-practice care pathway for improving management of mastitis and breast abscess

BACKGROUND

Surgical subspecialization has resulted in mastitis and breast abscesses being managed with unnecessary admission to hospital, prolonged inpatient stay, variable antibiotic prescribing, incision and drainage rather than percutaneous aspiration, and loss to specialist follow-up. The objective was to evaluate a best-practice algorithm with the aim of improving management of mastitis and breast abscesses across a multisite NHS Trust. The focus was on uniformity of antibiotic prescribing, ultrasound assessment, admission rates, length of hospital stay, intervention by aspiration or incision and drainage, and specialist follow-up.

METHODS

Management was initially evaluated in a retrospective cohort (phase I) and subsequently compared with that in two prospective cohorts after introduction of a breast abscess and mastitis pathway. One prospective cohort was analysed immediately after introduction of the pathway (phase II), and the second was used to assess the sustainability of the quality improvements (phase III). The overall impact of the pathway was assessed by comparing data from phase I with combined data from phases II and III; results from phases II and III were compared to judge sustainability.

RESULTS

Fifty-three patients were included in phase I, 61 in phase II and 80 in phase III. The management pathway and referral pro forma improved compliance with antibiotic guidelines from 34 per cent to 58·2 per cent overall (phases II and III) after implementation (P = 0·003). The improvement was maintained between phases II and III (54 and 61 per cent respectively; P = 0·684). Ultrasound assessment increased from 38 to 77·3 per cent overall (P < 0·001), in a sustained manner (75 and 79 per cent in phases II and III respectively; P = 0·894). Reductions in rates of incision and drainage (from 8 to 0·7 per cent overall; P = 0·007) were maintained (0 per cent in phase II versus 1 per cent in phase III; P = 0·381). Specialist follow-up improved consistently from 43 to 95·7 per cent overall (P < 0·001), 92 per cent in phase II and 99 per cent in phase III (P = 0·120). Rates of hospital admission and median length of stay were not significantly reduced after implementation of the pathway.

CONCLUSION

A standardized approach to mastitis and breast abscess reduced undesirable practice variation, with sustained improvements in process and patient outcomes.

MRSA infections among patients in the emergency department: a European multicentre study

BACKGROUND

MRSA is a therapeutic concern worldwide, and a major agent of community-acquired skin and soft tissue infections (CA-SSTIs). While the US epidemiology of MRSA in CA-SSTIs is well described and reports the high prevalence of the USA300 clone, data on the European situation are lacking.

OBJECTIVES

To determine the prevalence and clonal characteristics of MRSA in CA-SSTIs in seven European emergency departments.

PATIENTS AND METHODS

From April to June 2015, patients presenting to the tertiary hospital emergency department with a Staphylococcus aureus CA-SSTI were prospectively enrolled. S. aureus isolates were characterized by antimicrobial susceptibility testing, detection of Panton-Valentine leucocidin encoding genes and spa-typing, MLST and/or DNA microarray.

RESULTS

Two-hundred and five cases of S. aureus-associated CA-SSTIs were included, comprising folliculitis, furuncles, abscesses, paronychia, impetigo, carbuncles and cellulitis. Of the 205 cases, we report an MRSA prevalence rate of 15.1%, with a north (0%) to south (29%) increasing gradient. Fifty-one isolates were Panton-Valentine leucocidin-positive (24.9%), whether MSSA or MRSA, with a heterogeneous distribution between countries. Clonal distribution of MSSA and MRSA showed high diversity, with no predominant circulating clone and no archetypical USA300 CA-MRSA clone.

CONCLUSIONS

This original prospective multicentre study highlights stark differences in European MRSA epidemiology compared with the USA, and that the USA300 CA-MRSA clone is not predominant among community-infected patients in Europe.

Trends in equity in use of maternal health services in urban and rural Bangladesh

BACKGROUND

Maternal healthcare utilization is a major determinant of maternal mortality. Bangladesh is experiencing a rapid pace of urbanization with all future growth in population expected to be in urban areas. Health care infrastructure is different in urban and rural areas thus warranting an examination of equity in use rates of maternal healthcare. This paper addresses whether the urban-rural and rich-poor gaps in use of selected maternal healthcare indicators have narrowed or widened over the last decade. The paper also explores changes in the service provider environment in urban and rural domains.

METHODS

The 2001 and 2010 Bangladesh Maternal Mortality and Health Care Survey data were used to examine trends in use of antenatal care from medically trained providers and in deliveries taking place at health facilities. Separate wealth quintiles were constructed for urban and rural areas. The concentration index was calculated for urban and rural areas to measure equity in distribution of antenatal care (ANC) and facility deliveries across wealth quintiles in urban and rural domains.

RESULTS

The gap in use of ANC provided by medically trained personnel narrowed in urban and rural areas between 2001 and 2010 while that in facility deliveries widened. The difference in use of ANC by the rich and the poor was not as pronounced as that in utilization of facilities for deliveries. Over the last decade, equity in utilization of health facilities for deliveries has improved at a faster rate in urban areas. Private sector has surpassed the public sector and appears to be the dominant provider of maternal healthcare in both domains with the share of NGOs increasing in urban areas.

CONCLUSIONS

The faster pace of improvement in equity in maternal healthcare utilization in urban areas is reflective of the changing service environment in urban and rural areas, among other factors.

A randomized, double-blind, placebo-controlled, sixteen-week study of subcutaneous golimumab in patients with active nonradiographic axial spondyloarthritis

OBJECTIVE

Axial spondyloarthritis (SpA) is a chronic inflammatory disease characterized by back pain and stiffness. The objective of this study was to determine whether golimumab is superior to placebo in patients with nonradiographic axial SpA.

METHODS

This phase III, double-blind, randomized, placebo-controlled trial was performed to evaluate subcutaneous golimumab (50 mg) versus placebo in patients ages ≥18 years to ≤45 years who had active nonradiographic axial SpA according to the Assessment of SpondyloArthritis international Society (ASAS) criteria for ≤5 years since diagnosis, high disease activity, and an inadequate response to or intolerance of nonsteroidal antiinflammatory drugs. Patients were randomized 1:1 to receive golimumab or placebo subcutaneously every 4 weeks. The primary end point was 20% improvement according to the ASAS criteria (ASAS20) at week 16. Key secondary end points were an ASAS40 response, ASAS partial remission, 50% improvement in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and change in the Spondyloarthritis Research Consortium of Canada (SPARCC) magnetic resonance imaging (MRI) index for sacroiliac (SI) joint inflammation (SPARCC score).

RESULTS

Of the 198 patients randomized, 197 were treated (97 received golimumab, and 100 received placebo). The mean age of the patients was 31 years, and 57.1% were male. At baseline, the mean ± SD BASDAI was 6.5 ± 1.5, the mean ± SD ASDAS was 3.5 ± 0.9, and the mean ± SD SPARCC score was 11.3 ± 14.0. The primary end point, an ASAS20 response, was achieved by significantly more patients in the golimumab group compared with the placebo group (71.1% versus 40.0%; P < 0.0001). An ASAS40 response was also achieved by significantly more patients in the golimumab group compared with the placebo group (56.7% versus 23.0%; P < 0.0001). The incidence of adverse events did not differ meaningfully between groups.

CONCLUSION

Patients with active nonradiographic axial SpA treated with golimumab had significantly greater improvement in symptoms compared with patients treated with placebo. Golimumab was well tolerated and had a favorable risk/benefit profile.

Assessing gaps and poverty-related inequalities in the public and private sector family planning supply environment of urban Nigeria

Nigeria is the most populous country in Africa, and its population is expected to double in <25 years (Central Intelligence Agency 2012; Fotso et al. 2011). Over half of the population already lives in an urban area, and by 2050, that proportion will increase to three quarters (United Nations, Department of Economic and Social Affairs, Population Division 2012; Measurement Learning & Evaluation Project, Nigerian Urban Reproductive Health Initiative, National Population Commission 2012). Reducing unwanted and unplanned pregnancies through reliable access to high-quality modern contraceptives, especially among the urban poor, could make a major contribution to moderating population growth and improving the livelihood of urban residents. This study uses facility census data to create and assign aggregate-level family planning (FP) supply index scores to 19 local government areas (LGAs) across six selected cities of Nigeria. It then explores the relationships between public and private sector FP services and determines whether contraceptive access and availability in either sector is correlated with community-level wealth. Data show pronounced variability in contraceptive access and availability across LGAs in both sectors, with a positive correlation between public sector and private sector supply environments and only localized associations between the FP supply environments and poverty. These results will be useful for program planners and policy makers to improve equal access to contraception through the expansion or redistribution of services in focused urban areas.

The emergence of meticillin-resistant Staphylococcus aureus among injecting drug users

OBJECTIVE

To quantify an observed increase in meticillin-resistant Staphylococcus aureus (MRSA) infections in injecting drug users (IDUs) and, using genetic analysis and clinical presentation, contrast findings with those from previous studies in Brighton to further understanding of the clinical epidemiology and underlying molecular biology associated with the increase.

METHODS

From 2006 to 2008, isolates of S. aureus were collected, together with clinical details from infected IDUs. Isolates were characterised using antibiotic susceptibilities, multilocus-sequence typing (MLST) and spa typing. The molecular epidemiology and patterns of clinical presentation were compared with results from 1999-2000 to 2000-2003.

RESULTS

From 2006 to 2008, 18/37 (49%) of clinical isolates from IDUs were MRSA compared with 4/59 (7%) in 2000-2003 and 0/48 (0%) in 1999-2000. Despite this increase, hospital attendances by IDUs for treatment of infection dropped from 3.2 to 1.1 patients per month. MLST showed a shift in population structure towards a single MRSA clone, ST1, rather than epidemic hospital-associated strains.

CONCLUSION

In IDUs between 2000-2003 and 2006-2008, an increase occurred in the percentage of community-associated S. aureus isolates showing meticillin-resistance, but hospital attendances decreased. IDUs may act as a focus for the emergence of resistant S. aureus strains.

Mental health needs, service use and costs among Somali refugees in the UK

OBJECTIVE

To assess the mental health needs and service use of Somali refugees living in London.

METHOD

Subjects (n = 143) were sampled from conventional and non-conventional sites. Needs and service use were measured using the Camberwell Assessment of Need and the Client Service Receipt Inventory, respectively. Comparisons between sites were made and cost predictors identified.

RESULTS

Basic needs occurred frequently but were often not fully addressed. The mean number of needs was around four out of a possible 22. The most used services were GPs, other clinicians and refugee services. Higher non-inpatient costs were associated with length of stay in the UK and lower costs with being at risk of suicide and having panic disorder or agoraphobia.

CONCLUSION

Somali refugees living in London have a relatively high level of need but a low level of service use. Refugee characteristics could only account for a limited amount of cost variation.

Use of gastroprotective agents and discontinuations due to dyspepsia with the selective cyclooxygenase-2 inhibitor etoricoxib compared with non-selective NSAIDs

BACKGROUND

Most nonsteroidal anti-inflammatory drugs (NSAIDs) are non-selective cyclooxygenase-1 (COX-1) and COX-2 inhibitors and are associated with upper gastrointestinal (GI) dyspeptic symptoms often resulting in GI co-medication usage or treatment discontinuation.

OBJECTIVE

To compare the rates of new use of gastroprotective agents and discontinuations due to dyspepsia with the COX-2 selective inhibitor etoricoxib compared with non-selective NSAIDs.

RESEARCH DESIGN AND METHODS

This pre-specified combined analysis used data from nine randomized, double-blind, controlled, clinical trials with etoricoxib in patients with osteoarthritis, rheumatoid arthritis, chronic low back pain, or ankylosing spondylitis. The cumulative incidences of (1) new use (new prescription or increased dose) of gastroprotective agents (GPA) and (2) discontinuation due to dyspeptic symptoms were compared among patients treated with etoricoxib (60 mg, 90 mg, or 120 mg daily) vs. non-selective NSAIDs (diclofenac 50 mg. t.i.d. or naproxen 500 mg. b.i.d.).

RESULTS

The overall rates/100 patient-years for new use of GPAs were 9.1 and 13.0 for etoricoxib and NSAIDs, respectively (RR = 0.75; 95% confidence interval [CI] 0.64, 0.89; p < 0.001). A benefit with etoricoxib was seen in the first 6 months when most new GPA usage occurred; after 6 months new use of GPAs was similar between etoricoxib and NSAIDs. The rates/100 patient-years of treatment discontinuation due to dyspeptic symptoms with etoricoxib and NSAIDs were 1.5 and 2.7, respectively (RR = 0.60; 95% CI 0.41, 0.87; p = 0.007). Analyses of placebo-controlled treatment periods showed significantly more new GPA use and more discontinuations due to dyspeptic symptoms with NSAIDs vs. placebo, but not with etoricoxib vs. placebo.

CONCLUSION

In this combined analysis of clinical trials of patients with OA, RA, chronic low back pain, or AS, new use of gastroprotective agents was significantly lower with etoricoxib than with the comparator non-selective NSAIDs during the initial 6 months of treatment and similar thereafter. There were significantly fewer discontinuations for dyspeptic symptoms with etoricoxib than with NSAIDs over the entire follow-up period.

Enhancing the evidence base for health impact assessment

Health impact assessment differs from other purposes for which evidence is collated in a number of ways, including:the focus on complex interventions or policy and their diverse effects on determinants of health;the need for evidence on the reversibility of adverse factors damaging to health;the diversity of the evidence in terms of relevant disciplines, study designs, quality criteria and sources of information;the broad range of stakeholders involved;the short timescale and limited resources generally available;the pragmatic need to inform decision makers regardless of the quality of the evidence. These have implications for commissioning and conducting reviews. Methods must be developed to: facilitate comprehensive searching across a broad range of disciplines and information sources; collate appropriate quality criteria to assess a range of study designs; synthesise different kinds of evidence; and facilitate timely stakeholder involvement. Good practice standards for reviews are needed to reduce the risk of poor quality recommendations. Advice to decision makers must make explicit limitations resulting from absent, conflicting, or poor quality evidence.

Neuromodulation paired with learning dependent practice to enhance post stroke recovery?

Over the past two decades, experimental studies following brain injury have shown that the central nervous system is dynamic and malleable to internal and external inputs. Neuromodulation and/or direct manipulation of motor and sensory experience can modify brain plasticity and functional outcome after experimental lesions. Specifically, pharmacologic modulation has been found to facilitate recovery of various behavioral deficits following occlusive injury. Additionally, the behavioral experience that induces long-term plasticity in motor and sensory maps after injury appears to be limited to those that entail the development of new skills. These data have strong application to human rehabilitation. This review will: (1) overview critical experimental studies that show that pharmacologic manipulation and/or specific behavioral experience may modify the functional organization of the injured brain and (2) review beginning studies which are exploring the application of this knowledge clinically.