Trends in lung cancer diagnosis and care among visible minorities and non-visible minorities in Canada

BACKGROUND

Identifying factors that influence the diagnosis and treatment of lung cancer is an important public health initiative. Various sociodemographic factors, including race and ethnicity, may influence an individual's risk of developing lung cancer, as well as access to relevant diagnostic and therapeutic procedures.

METHODS

Data from the 2006 Canadian long-form census were cross-linked with the Canadian Cancer Registry and hospital data to determine rates of lung cancer diagnosis among visible minorities and non-visible minorities in Canada, and to assess for differences in rates of hospital-based procedures pertaining to a lung cancer diagnosis based on visible-minority status. Individuals were allocated into six visible-minority categories, and separate results were generated nationally and across seven regions. Multivariate logistic regression controlled for relevant confounders.

RESULTS

Rates of lung cancer were significantly lower among visible minorities versus non-visible minorities (329 versus 1108 cases per 100 000). This result is consistent across all visible-minority subgroups. Among those with a diagnosis of lung cancer, procedure rates were higher for all visible minorities nationally (53.4% [95% CI 53.2-53.6]). Multivariable analysis demonstrated higher procedure rates in general for visible minorities with a lung cancer diagnosis compared to non-visible minorities (OR 1.158 95% CI 1.053-1.273).

INTERPRETATION

In Canada, visible minorities experience lower rates of lung cancer diagnosis than non-visible minorities. Among those with a lung cancer diagnosis, we did not identify any negative disparities in rates of relevant diagnostic or therapeutic procedures, based on visible-minority status.

Social determinants of health and disease in companion dogs: a cohort study from the Dog Aging Project

Exposure to social environmental adversity is associated with health and survival across many social species, including humans. However, little is known about how these health and mortality effects vary across the lifespan and may be differentially impacted by various components of the environment. Here, we leveraged a relatively new and powerful model for human aging, the companion dog, to investigate which components of the social environment are associated with dog health and how these associations vary across the lifespan. We drew on comprehensive survey data collected on 21,410 dogs from the Dog Aging Project and identified five factors that together explained 33.7% of the variation in a dog's social environment. Factors capturing financial and household adversity were associated with poorer health and lower physical mobility in companion dogs, while factors that captured social support, such as living with other dogs, were associated with better health when controlling for dog age and weight. Notably, the effects of each environmental component were not equal: the effect of social support was 5× stronger than financial factors. The strength of these associations depended on the age of the dog, including a stronger relationship between the owner's age and the dog's health in younger as compared to older dogs. Taken together, these findings suggest the importance of income, stability and owner's age on owner-reported health outcomes in companion dogs and point to potential behavioral and/or environmental modifiers that can be used to promote healthy aging across species.

Big data from small animals: integrating multi-level environmental data into the Dog Aging Project

Environmental exposures can have large impacts on health outcomes. While many resources have been dedicated to understanding how humans are influenced by the environment, few efforts have been made to study the role of built and natural environmental features on animal health. The Dog Aging Project (DAP) is a longitudinal community science study of aging in companion dogs. Using a combination of owner-reported surveys and secondary sources linked through geocoded coordinates, DAP has captured home, yard and neighbourhood variables for over 40,000 dogs. The DAP environmental data set spans four domains: the physical and built environment; chemical environment and exposures; diet and exercise; and social environment and interactions. By combining biometric data, measures of cognitive function and behaviour, and medical records, DAP is attempting to use a big-data approach to transform the understanding of how the surrounding world affects the health of companion dogs. In this paper, the authors describe the data infrastructure developed to integrate and analyse multi-level environmental data that can be used to improve the understanding of canine co-morbidity and aging.

Perinatal Stroke in Fetuses, Preterm and Term Infants

Perinatal stroke is a well-defined heterogenous group of disorders involving a focal disruption of cerebral blood flow between 20 weeks gestation and 28 days of postnatal life. The most focused lifetime risk for stroke occurs during the first week after birth. The morbidity of perinatal stroke is high, as it is the most common cause of hemiparetic cerebral palsy which results in lifelong disability that becomes more apparent throughout childhood. Perinatal strokes can be classified by the timing of diagnosis (acute or retrospective), vessel involved (arterial or venous), and underlying cause (hemorrhagic or ischemic). Perinatal stroke has primarily been reported as a disorder of term infants; however, the preterm brain possesses different vulnerabilities that predispose an infant to stroke injury both in utero and after birth. Accurate diagnosis of perinatal stroke syndromes has important implications for investigations, management, and prognosis. The classification of perinatal stroke by age at presentation (fetal, preterm neonatal, term neonatal, and infancy/childhood) is summarized in this review, and includes detailed descriptions of risk factors, diagnosis, treatment, outcomes, controversies, and resources for family support.

Long-term efficacy and safety of addition of carboplatin with or without veliparib to standard neoadjuvant chemotherapy in triple-negative breast cancer: 4-year follow-up data from BrighTNess, a randomized phase 3 trial

BACKGROUND

Primary analyses of the phase 3 BrighTNess trial showed addition of carboplatin with/without veliparib to neoadjuvant chemotherapy significantly improved pathological complete response (pCR) rates with manageable acute toxicity in patients with triple-negative breast cancer (TNBC). Here, we report 4.5-year follow-up data from the trial.

DESIGN

Women with untreated stage II-III TNBC were randomized (2:1:1) to paclitaxel (weekly for 12 doses) plus either: (a) carboplatin (every 3 weeks for four cycles) plus veliparib (twice daily); (b) carboplatin plus veliparib placebo; or (c) carboplatin placebo plus veliparib placebo. All patients then received doxorubicin and cyclophosphamide (AC) every 2‒3 weeks for four cycles. The primary endpoint was pCR. Secondary endpoints included event-free survival (EFS), overall survival (OS), and safety. Since the co-primary endpoint of increased pCR with carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel was not met, secondary analyses are descriptive.

RESULTS

Of 634 patients, 316 were randomized to carboplatin plus veliparib with paclitaxel, 160 to carboplatin with paclitaxel, and 158 to paclitaxel. With median follow-up of 4.5 years, the hazard ratio [HR] for EFS for carboplatin plus veliparib with paclitaxel versus paclitaxel was 0.63 (95% confidence interval [CI] 0.43‒0.92, P=0.02), but 1.12 (95% CI 0.72‒1.72, P=0.62) for carboplatin plus veliparib with paclitaxel versus carboplatin with paclitaxel. In post hoc analysis, HR for EFS was 0.57 (95% CI 0.36‒0.91, P=0.02) for carboplatin with paclitaxel versus paclitaxel. OS did not differ significantly between treatment arms, nor did rates of myelodysplastic syndromes, acute myeloid leukemia, or other secondary malignancies.

CONCLUSION

Improvement in pCR with addition of carboplatin was associated with long-term EFS benefit with a manageable safety profile, and without increasing the risk of second malignancies, while adding veliparib did not impact EFS. These findings support the addition of carboplatin to weekly paclitaxel followed by AC neoadjuvant chemotherapy for early stage TNBC.

Characteristics associated with HIV and hepatitis C seroprevalence among sexual and injecting partners of HIV positive persons who inject drugs in Nairobi and coastal Kenya

Background

Persons who inject drugs (PWID) have higher HIV and hepatitis C virus (HCV) seroprevalence than the general population in many parts of sub-Saharan Africa (SSA). The seroprevalences of HIV and HCV are also higher in coastal Kenya than in Nairobi. Understanding drivers of regional HIV and HCV variation among PWID in Kenya may inform population-specific prevention interventions.

Methods

Using a cross-sectional study, we defined HIV and HCV seroprevalence among persons identified as sexual or injecting partners of HIV positive PWID in two regions of Kenya and used logistic regression to identify demographic and behavioral characteristics associated with higher seroprevalence.

Results

Among 2386 partners, 469 (19.7%) tested HIV positive and 297(12.4%) tested HCV antibody positive. Partners on the Coast were more likely to live with HIV (seroprevalences: Coast = 23.8%, Nairobi = 17.1%; p < 0.001) and be HCV antibody positive (seroprevalences: Coast = 17.0%, Nairobi = 8.6%; p < 0.001). After adjusting for sex, age, and years injecting and accounting for clustering by site, the higher prevalence of both diseases in the Coast remained significant for HIV (OR 1.68, 95% CI 1.13–2.51) but not for HCV (OR 1.72, 95% CI 0.84–3.74). Compared to those recruited in Nairobi, partners on the Coast were older (Coast = 35 years, Nairobi = 31 years; p < 0.001), more likely to be male (Coast = 77.6%, Nairobi = 61.7%; p < 0.001), to have paid (Coast = 59.2%, Nairobi = 32.8%; p < 0.001) or received (Coast = 44.2%, Nairobi 35.4%; p < 0.001) money for sex, or to have had sex with someone they knew to be HIV positive (Coast 22.0%, Nairobi 10.8%; p < 0.001). Partners who had injected for five or more years had 1.48 times greater odds (95% CI 1.20–1.82) of living with HIV compared to partners who injected less than 5 years and more than twice the odds of HCV (95% CI 1.84–4.11).

Conclusion

HIV and HCV seroprevalence among sexual and injecting partners of PWID was, respectively, 5 times and > 12 times greater than is reported among the general population in Kenya (4% and < 1%, respectively). Providing resources and education will be crucial to reduce exposure and to maintain the lower needle and equipment sharing that we observed compared to other studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07036-8.

The Link Between Environment, Age, and Health in a Large Cohort of Companion Dogs from the Dog Aging Project

Exposure to social environmental adversity strongly predicts health and survival in many species such as non-human primates, wild mammals, and humans. However, little is known about how the health and mortality effects of these social determinants vary across the lifespan. Using the companion dog, which serves as a powerful comparative model for human health and aging due to our shared biology and environment, we examined which components of the social environment impact health, and how the effects vary with age, in dogs. We first drew on detailed survey data from owners of 27,547 dogs from the Dog Aging Project and identified six factors that together explained 35% of the variation in dog’s social environment. These factors all predicted measures of health, disease, and mobility, when controlling for dog age and weight. Factors capturing measures of financial and household adversity were linked to poorer companion dog health, while factors associated with the social companions, like dogs and adults, were linked to better health. Interestingly, some of these effects differed across a dog’s lifespan: for instance, the effect of neighborhood disadvantage on disease instances was strongest in older dogs. Together, our findings point to similar links between adversity and health in companion dogs, and set up future work on the molecular and biological changes associated with environmental variation in order to identify ways to mitigate or even reverse the negative environmental effects.

Sociodemographic predictors of attendance at a Scottish pain management programme

We examined relationships between various sociodemographic factors and attendance at the Glasgow Pain Management Programme (n = 2899 from 2011 to 2019). We tested for associations between gender, age and socioeconomic deprivation of patients who were invited to attend, and uptake to a programme when invited, attendance at screening assessment, eligibility, adherence and attendance at 3- and 6-month reviews. Uptake was significantly higher for patients from more affluent areas (95% confidence interval (CI) = 0.93–0.99, p = 0.002) and for older patients (95% CI = 0.98–0.99, p = 0.006), although effect sizes were very small. Patients were significantly more likely to be assessed as suitable if they were younger (95% CI = 0.98–0.99, p = 0.013) or female (95% CI = 0.55–0.84, p < 0.001). Attendance at sessions and at 3- and 6-month reviews was higher for patients from more affluent areas (95% CI = 1–1.09, p = 0.001, and 95% CI = 1–1.1, p = 0.044 respectively). We argue that there are multiple potential explanations for these findings and that future work should attempt to determine whether these patterns replicate in other populations and to determine any modifiable causes.

Peer-mediated HIV assisted partner services to identify and link to care HIV-positive and HCV-positive people who inject drugs: a cohort study protocol

INTRODUCTION

Targeted, tailored interventions to test high-risk individuals for HIV and hepatitis C virus (HCV) are vital to achieving HIV control and HCV microelimination in Africa. Compared with the general population, people who inject drugs (PWID) are at increased risk of HIV and HCV and are less likely to be tested or successfully treated. Assisted partner services (APS) increases HIV testing among partners of people living with HIV and improves case finding and linkage to care. We describe a study in Kenya examining whether APS can be adapted to find, test and link to HIV care the partners of HIV-positive PWID using a network of community-embedded peer educators (PEs). Our study also identifies HCV-positive partners and uses phylogenetic analysis to determine risk factors for onward transmission of both viruses.

METHODS

This prospective cohort study leverages a network of PEs to identify 1000 HIV-positive PWID for enrolment as index participants. Each index completes a questionnaire and provides names and contact information of all sexual and injecting partners during the previous 3 years. PEs then use a stepwise locator protocol to engage partners in the community and bring them to study sites for enrolment, questionnaire completion and rapid HIV and HCV testing. Outcomes include number and type of partners per index who are mentioned, enrolled, tested, diagnosed with HIV and HCV and linked to care.

ETHICS AND DISSEMINATION

Potential index participants are screened for intimate partner violence (IPV) and those at high risk are not eligible to enrol. Those at medium risk are monitored for IPV following enrolment. A community advisory board engages in feedback and discussion between the community and the research team. A safety monitoring board discusses study progress and reviews data, including IPV monitoring data. Dissemination plans include presentations at quarterly Ministry of Health meetings, local and international conferences and publications.

TRIAL REGISTRATION NUMBER

NCT03447210, Pre-results stage.

Supply of care by dental therapists and emergency dental consultations in Alaska native communities in the Yukon-Kuskokwim delta: a mixed methods evaluation

OBJECTIVES

Examine the relationship between supply of care provided by dental therapists and emergency dental consultations in Alaska Native communities.

METHODS

Explanatory sequential mixed-methods study using Alaska Medicaid and electronic health record (EHR) data from the Yukon-Kuskokwim Health Corporation (YKHC), and interview data from six Alaska Native communities. From the Medicaid data, we estimated community-level dental therapy treatment days and from the EHR data we identified emergency dental consultations. We calculated Spearman partial correlation coefficients and ran confounder-adjusted models for children and adults. Interview data collected from YKHC providers (N=16) and community members (N=125) were content analysed. The quantitative and qualitative data were integrated through connecting. Results were visualized with a joint display.

RESULTS

There were significant negative correlations between dental therapy treatment days and emergency dental consultations for children (partial rank correlation = -0.48; p⟨0.001) and for adults (partial rank correlation = -0.18; p=0.03). Six pediatric themes emerged: child-focused health priorities; school-based dental programs; oral health education and preventive behaviors; dental care availability; healthier teeth; and satisfaction with care. There were four adult themes: satisfaction with care; adults as a lower priority; difficulties getting appointments; and limited scope of practice of dental therapy.

CONCLUSIONS

Alaska Native children, and to a lesser extent adults, in communities served more intensively by dental therapists have benefitted. There are high levels of unmet dental need as evidenced by high emergency dental consultation rates. Future research should identify ways to address unmet dental needs, especially for adults.

Cardiffians' perceptions of English in the UK

This Perceptual Dialectology (PD) study asked residents of Cardiff, Wales, about their perceptions of English in the United Kingdom (UK). In addition, because face to face exposure to dialect variation has rarely been included as a variable in PD studies, participants were asked about their travel experience to ascertain whether this might influence their responses to a PD map task. Participants' responses to the map task were analyzed using ArcGIS to create composite maps. Results show that these Cardiffians perceive "dialect or regional" speech boundaries to be located around major cities in England and Wales but also southwest Wales. Composite maps and polygon counts suggest that the more traveled respondents have a more nuanced perception of dialect regions than those who claim to travel less, suggesting that travel experience may influence PD participants' responses to map tasks.

Improving Information and Communications Technology (ICT) Knowledge and Skills to Develop Health Research Capacity in Kenya

Objectives Information and communication technology (ICT) tools are increasingly important for clinical care and international research. Many technologies would be particularly useful for healthcare workers in resource-limited settings; however, these individuals are the least likely to utilize ICT tools due tolack of knowledge and skills necessary to use them. Our program aimed to train researchers in low-resource settings on using ICT tools and to understand how different didactic modalities build knowledge and skills in this area. Methods We conducted a tiered, blended learning program for researchers in Kenya on three areas of ICT: geographic information systems, data management, and communication tools. Each course included three tiers: online courses, skills workshops, and mentored projects. Concurrently, a training of trainers course was taught to ensure sustainable ongoing training. A mixed qualitative and quantitative survey was conducted at the end of each training to assess knowledge and skill acquisition. Results Course elements that incorporated local examples and hands-on skill building activities were most valuable. Discussion boards were sometimes distracting, depending on multiple factors. Mentored projects were most useful when there were clear expectations, pre-existing projects, and clear timelines. Discussion Training in the use of ICT tools is highly valued among researchers in low-income settings, particularly when it includes hands-on skill-building and local examples. Our students demonstrated acquisition of new skills and felt these skills to be valuable in their workplaces. Conclusions Further training in ICT skills should be considered in other low-resource settings using our program as a foundational model.

Venetoclax, bendamustine, and rituximab in patients with relapsed or refractory NHL: a phase Ib dose-finding study

Background

Venetoclax is a selective, potent inhibitor of the anti-apoptotic B-cell leukemia/lymphoma-2 protein approved for treatment of chronic lymphocytic leukemia. We conducted a dose-finding study of venetoclax in combination with bendamustine-rituximab (BR) in patients with relapsed/refractory non-Hodgkin's lymphoma (NHL).

Patients and methods

BR was given for six cycles at standard doses. Intermittent and continuous oral venetoclax administration was explored at 50-1200 mg daily doses. Co-primary objectives included safety, pharmacokinetics (PKs), maximum-tolerated dose (MTD), and recommended phase II dose (RP2D); secondary objective was preliminary efficacy.

Results

Sixty patients were enrolled: 32 with follicular lymphoma, 22 with diffuse large B-cell lymphoma, and 6 with marginal zone lymphoma. Nausea (70%), neutropenia (68%), diarrhea (55%), and thrombocytopenia (52%) were the most frequent adverse events (AEs). Most common grade 3/4 AEs were neutropenia (60%) and lymphopenia (38%). Serious AEs were reported in 24 patients; the most frequent were febrile neutropenia and disease progression (8% each). Five patients died from either disease progression (n = 4) or respiratory failure (n = 1). MTD was not reached; RP2D for venetoclax-BR combination was established as 800 mg daily continuously. Venetoclax PK exposure with and without BR was comparable. For all patients, overall response rate was 65%. Median duration of overall response, overall survival, and progression-free survival was 38.3 months [95% confidence interval (CI) 10.4-NR], not yet reached, and 10.7 months (95% CI 4.3-21.0), respectively.

Conclusions

This study established the safety profile of venetoclax in combination with BR, and results demonstrated tolerability and preliminary efficacy of the combination. Additional follow-up is needed to better determine the future role of BR plus venetoclax in the treatment of relapsed/refractory B-cell NHL.

Trial registered

Clinicaltrials.gov, NCT01594229.

Reducing Implant Infection in Orthopaedics (RIIiO): Results of a pilot study comparing the influence of forced air and resistive fabric warming technologies on postoperative infections following orthopaedic implant surgery

BACKGROUND

Active warming during surgery prevents perioperative hypothermia but the effectiveness and postoperative infection rates may differ between warming technologies.

AIM

To establish the recruitment and data management strategies needed for a full trial comparing postoperative infection rates associated with forced air warming (FAW) versus resistive fabric warming (RFW) in patients aged >65 years undergoing hemiarthroplasty following fractured neck of femur.

METHODS

Participants were randomized 1:1 in permuted blocks to FAW or RFW. Hypothermia was defined as a temperature of <36°C at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections.

FINDINGS

A total of 515 participants were randomized at six sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7% in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were four deep surgical site infections in the FAW group and three in the RFW group. All participants who developed a postoperative infection had antibiotic prophylaxis, a cemented prosthesis, and were operated under laminar airflow; none was hypothermic. There were no serious adverse events related to warming.

CONCLUSION

Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate.

Time to surgery after hip fracture across Canada by timing of admission

The extent of Canadian provincial variation in hip fracture surgical timing is unclear. Provinces performed a similar proportion of surgeries within three inpatient days after adjustment. Time to surgery varied by timing of admission across provinces. This may reflect different approaches to providing access to hip fracture surgery.

INTRODUCTION

The aim of this study was to compare whether time to surgery after hip fracture varies across Canadian provinces for surgically fit patients and their subgroups defined by timing of admission.

METHODS

We retrieved hospitalization records for 140,235 patients 65 years and older, treated surgically for hip fracture between 2004 and 2012 in Canada (excluding Quebec). We studied the proportion of surgeries on admission day and within 3 inpatient days, and times required for 33%, 66%, and 90% of surgeries across provinces and by subgroups defined by timing of admission. Differences were adjusted for patient, injury, and care characteristics.

RESULTS

Overall, provinces performed similar proportions of surgeries within the recommended three inpatient days, with all provinces requiring one additional day to perform the recommended 90% of surgeries. Prince Edward Island performed 7.0% more surgeries on admission day than Ontario irrespective of timing of admission (difference = 7.0; 95% CI 4.0, 9.9). The proportion of surgeries on admission day was 6.3% lower in Manitoba (difference = - 6.3; 95% CI - 12.1, - 0.6), and 7.7% lower in Saskatchewan (difference = - 7.7; 95% CI - 12.7, - 2.8) compared to Ontario. These differences persisted for late weekday and weekend admissions. The time required for 33%, 66%, and 90% of surgeries ranged from 1 to 2, 2-3, and 3-4 days, respectively, across provinces by timing of admission.

CONCLUSIONS

Provinces performed similarly with respect to recommended time for hip fracture surgery. The proportion of surgeries on admission day, and time required to complete 33% and 66% of surgeries, varied across provinces and by timing of admission. This may reflect different provincial approaches to providing access to hip fracture surgery.

Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta

OBJECTIVES

Dental Health Aide Therapists (DHATs) have been part of the dental workforce in Alaska's Yukon-Kuskokwim (YK) Delta since 2006. They are trained to provide preventive and restorative care such as filling and extractions. In this study, we evaluated community-level dental outcomes associated with DHATs.

METHODS

This was a secondary data analysis of Alaska Medicaid and electronic health record data for individuals in Alaska's YK Delta (2006-2015). The independent variable was the number of DHAT treatment days in each community. Child outcomes were preventive care, extractions, and general anesthesia. Adult outcomes were preventive care and extractions. We estimated Spearman partial correlation coefficients to test our hypotheses that increased DHAT treatment days would be associated with larger proportions utilizing preventive care and smaller proportions receiving extractions at the community-level.

RESULTS

DHAT treatment days were positively associated with preventive care utilization and negatively associated with extractions for children and adults (P < 0.0001). DHAT treatment days were not associated with increased dental treatment under general anesthesia for children.

CONCLUSIONS

Dental therapists are associated with more preventive care and fewer extractions. State-level policies should consider dental therapists as part of a comprehensive solution to meet the dental care needs of individuals in underserved communities and help achieve health equity and social justice.

Follicle cell processes: a shark thing?

Follicle cell processes (FCP) are identified in two species of carcharhinid shark (Selachii) but are absent in the little skate Leucoraja erinacea (Batoidea). This suggests that FCPs are either a unique structure that evolved in selachians or were lost by the batoids after their divergence, some 280 mya. The presence of FCPs in the selachians would be consistent with the evolution of large oocytes in this group of animals.

Assisted partner notification services to augment HIV testing and linkage to care in Kenya: study protocol for a cluster randomized trial

Background

HIV case-finding and linkage to care are critical for control of HIV transmission. In Kenya, >50% of seropositive individuals are unaware of their status. Assisted partner notification is a public health strategy that provides HIV testing to individuals with sexual exposure to HIV and are at risk of infection and disease. This parallel, cluster-randomized controlled trial will evaluate the effectiveness, cost-effectiveness, and feasibility of implementing HIV assisted partner notification services at HIV testing sites (clusters) in Kenya.

Methods/design

Eighteen sites were selected among health facilities in Kenya with well-established, high-volume HIV testing programs, to reflect diverse communities and health-care settings. Restricted randomization was used to balance site characteristics between study arms (n = 9 per arm). Sixty individuals testing HIV positive (‘index partners’) will be enrolled per site (inclusion criteria: ≥18 years, positive HIV test at a study site, willing to disclose sexual partners, and never enrolled for HIV care; exclusion criteria: pregnancy or high risk of intimate partner violence). Index partners provide names and contact information for all sexual partners in the past 3 years. At intervention sites, study staff immediately contact sexual partners to notify them of exposure, offer HIV testing, and link to care if HIV seropositive. At control sites, passive partner referral is performed according to national guidelines, and assisted partner notification is delayed by 6 weeks. Primary outcomes, assessed 6 weeks after index partner enrollment and analyzed at the cluster level, are the number of partners accepting HIV testing and number of HIV infections diagnosed and linked to care per index partner. Secondary outcomes are the incremental cost-effectiveness of partner notification and the costs of identifying >1 partner per index case. Participants are closely monitored for adverse outcomes, particularly intimate partner violence. The study is unblinded due to practical limitations.

Discussion

This rigorously designed trial will inform policy decisions regarding implementation of HIV partner notification services in Kenya, with possible application to other parts of sub-Saharan Africa. Examination of effectiveness and cost-effectiveness in diverse settings will enable targeted application and define best practices.

Trial registration

ClinicalTrials.gov NCT01616420.

The importance of perceived helplessness and emotional health in understanding the relationship among pain, function, and satisfaction following revision knee replacement surgery

OBJECTIVE

Little is known about the relationships among pain, function, psychological variables like perceived helplessness and emotional health, and patient satisfaction in people with revision knee replacement surgery. We hypothesized that pain and function would have a direct association with satisfaction as well as an indirect association through patient perceptions of helplessness and emotional health.

DESIGN

This longitudinal study included 145 participants undergoing revision knee replacement surgery. Demographic data and expectation of benefit from surgery were recorded prior to surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Arthritis Helplessness Scale (AHS) and the Mental Component Scale (MCS) of the SF-36 (emotional health) were collected prior to and 2 years post-surgery. Satisfaction was recorded 2 years post-surgery. Regression analyses were conducted to test for mediation effects of helplessness and MCS.

RESULTS

Participants were on average 69 years old and 54% were women. Participants were satisfied with the results of the surgery (mean ± standard deviation (SD) = 70.42 ± 31.46). Less pain and functional disability were associated with increased patient satisfaction and, the effect of pain or function was also mediated through helplessness whereby more pain and disability were associated with perceptions of helplessness and helplessness was associated with lower satisfaction. MCS did not mediate the relationship of pain and function with satisfaction.

CONCLUSION

Helplessness plays an important role in understanding patient satisfaction. Interventions aimed at improving patient outcome should target not only pain and function but also should address strategies to support people in managing following knee revision surgery to maximize satisfaction with outcome.

A Geography-Specific Approach to Estimating the Distributional Impact of Highway Tolls: An Application to the Puget Sound Region of Washington State

This study contributes to the debate about tolls' equity impacts by examining the potential economic costs of tolling for low-income and non-low-income households. Using data from the Puget Sound metropolitan region in Washington State and GIS methods to map driving routes from home to work, we examine car ownership and transportation patterns among low-income and non-low-income households. We follow standard practice of estimating tolls' potential impact only on households with workers who would drive on tolled and non-tolled facilities. We then redo the analysis including broader groups of households. We find that the degree of regressivity is quite sensitive to the set of households included in the analysis. The results suggest that distributional analyses of tolls should estimate impacts on all households in the relevant region in addition to impacts on just users of roads that are currently tolled or likely to be tolled.

Maternal versus paternal orphans and HIV/STI risk among adolescent girls in Zimbabwe

The AIDS epidemic has contributed to a drastic increase in the number of orphans in Zimbabwe. Orphans (whether orphaned by AIDS or other causes) have been shown to have economic and educational disadvantages as well as poor reproductive health outcomes. We recruited a convenience sample of 200 girls in a peri-urban area of Zimbabwe to examine the impact of orphan status (compared to non-orphans) on household composition, education, risk behaviour, pregnancy and prevalent HIV and HSV-2 infection. In our population, maternal orphans were more likely to be in households headed by themselves or a sibling, to be sexually active, to have had an STI, to have been pregnant and to be infected with HIV. Paternal orphans were more likely to have ever been homeless and to be out of school. Our findings suggest that maternal care and support is important for HIV prevention. This finding corroborates previous research in Zimbabwe and has implications for intervention strategies among orphan girls.

Foot progression angle and the knee adduction moment: a cross-sectional investigation in knee osteoarthritis

OBJECTIVE

To test the hypothesis that an association exists between the characteristics of the knee adduction moment and foot progression angle (FPA) in asymptomatic individuals and those with mild to moderate and severe knee osteoarthritis (OA).

DESIGN

Fifty asymptomatic individuals, 46 patients with mild to moderate and 44 patients with severe knee OA were recruited. Maximum knee adduction moment during late stance and principal component analysis (PCA) were used to describe the knee adduction moment captured during gait. Multiple regression models were used for each of the three group assignments to analyze the association between the independent variables and the knee adduction moment.

RESULTS

FPA explained a significant amount of the variability associated with the shape of the knee adduction moment waveform for the asymptomatic and mild to moderate groups (P<0.05), but not for the severe group (P>0.05). Walking velocity alone explained significant variance associated with the shape of the knee adduction moment in the severe OA group (P<0.05).

CONCLUSION

A toe out FPA was associated with altered knee adduction moment waveform characteristics, extracted using PCA, in asymptomatic individuals and those with mild to moderate knee OA only. These findings are directly implicated in medial knee compartment loading. This relationship was not evident in those with severe knee OA.

Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations

A systematic search of the literature published between January 1985 and February 2006 identified 62 studies which reported the results of arthroscopic procedures for chronic anterior shoulder instability or comparisons between arthroscopic and open surgery. These studies were classified by surgical technique and research methodology, and when appropriate, were included in a meta-analysis. The failure rate of arthroscopic shoulder stabilisation using staples or transglenoid suture techniques appeared to be significantly higher than that of either open surgery or arthroscopic stabilisation using suture anchors or bio-absorbable tacks. Arthroscopic anterior stabilisation using the most effective techniques has a similar rate of failure to open stabilisation after two years.

Clear not simple: An approach to community consultation for a maternal pneumococcal vaccine trial among Indigenous women in the Northern Territory of Australia

PneuMum is a randomised controlled maternal vaccination trial, using 23-valent Pneumococcal Polysaccharide Vaccine (23vPPV) during the third trimester or at delivery compared to vaccination at 7 months post delivery. The primary outcomes are infant middle ear disease and nasopharyngeal pneumococcal carriage at 7 months of age. PneuMum is the first vaccine trial to be conducted among Indigenous people in the Northern Territory. We describe the study design and the approach taken to develop the PneuMum message in collaboration with key Indigenous stakeholders and then to communicate the PneuMum message with Indigenous communities and potential participants. We hope that these methods will provide a model for future research involving Indigenous communities to ensure Indigenous involvement in research and ultimate improvements in Indigenous health.

Parathyroid hormone-related protein maintains mammary epithelial fate and triggers nipple skin differentiation during embryonic breast development

Prior reports have demonstrated that both parathyroid hormone-related protein (PTHrP) and the type I PTH/PTHrP receptor are necessary for the proper development of the embryonic mammary gland in mice. Using a combination of loss-of-function and gain-of-function models, we now report that PTHrP regulates a series of cell fate decisions that are central to the survival and morphogenesis of the mammary epithelium and the formation of the nipple. PTHrP is made in the epithelial cells of the mammary bud and, during embryonic mammary development, it interacts with the surrounding mesenchymal cells to induce the formation of the dense mammary mesenchyme. In response, these mammary-specific mesenchymal cells support the maintenance of mammary epithelial cell fate, trigger epithelial morphogenesis and induce the overlying epidermis to form the nipple. In the absence of PTHrP signaling, the mammary epithelial cells revert to an epidermal fate, no mammary ducts are formed and the nipple does not form. In the presence of diffuse epidermal PTHrP signaling, the ventral dermis is transformed into mammary mesenchyme and the entire ventral epidermis becomes nipple skin. These alterations in cell fate require that PTHrP be expressed during development and they require the presence of the PTH/PTHrP receptor. Finally, PTHrP signaling regulates the epidermal and mesenchymal expression of LEF1 and (β)-catenin, suggesting that these changes in cell fate involve an interaction between the PTHrP and Wnt signaling pathways.

Distinct roles for PI3K in proliferation and survival of oligodendrocyte progenitor cells

Phosphoinositol 3-kinase (PI3K) is a downstream effector for multiple ligand-activated receptors and modulates cell responses through activation of its target protein kinase B (Akt). We examined the roles of PI3K-Akt signaling in a primary glial (oligodendrocyte) progenitor cell culture system that is ligand-dependent for cell proliferation, survival, and prevention of differentiation. We demonstrate that PI3K and Akt (Ser-473 phosphorylation) are activated in response to platelet-derived growth factor but not basic fibroblast growth factor-2 (FGF2) and that distinct forms of PI3K are activated in early progenitors and later-maturation pro-oligodendroblasts as identified by their sensitivity to wortmannin. By establishing conditions to examine effects on cell proliferation and survival independently, we demonstrate that PI3K is necessary for a full mitogenic response and that PI3K is also necessary for early progenitor survival. Our results therefore demonstrate that PI3K-Akt signaling independently regulates proliferation and survival, that the form of PI3K is distinct in early progenitors and pro-oligodendroblasts, and that FGF2 does not activate this pathway in either primary glial cell population.

Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden

During a validation process of the Swedish Knee Arthroplasty Register (SKAR), living registered patients were sent a questionnaire to ask if they had been reoperated on. This gave an opportunity to pose a simple four-point question with respect to patient satisfaction which 95% of patients answered. We analyzed the answers of patients operated on between 1981 and 1995 and found that only 8% of the patients were dissatisfied regarding their knee arthroplasty 2-17 years postoperatively. The satisfaction rate was constant, regardless of when the operation had been performed during the 15-year period. The proportion of satisfied patients was affected by the preoperative diagnosis, patients operated on for a long-standing disease more often being satisfied than those with a short disease-duration. There was no difference in proportions of satisfied patients, whether they had primarily been operated on with a total knee arthroplasty (TKA) or a medial unicompartmental arthroplasty (UKA). For TKAs performed with primary patellar resurfacing, there was a higher ratio of satisfied patients than for TKAs not resurfaced, but this increased ratio diminished with time passed since the primary operation. Unrevised knees had a higher proportion of satisfied patients than knees that had been subject to revision, and among patients revised for medial UKA, the proportion of satisfied patients was higher than among patients revised for TKA. We conclude that satisfaction after knee arthroplasty is stable and long-lasting in unrevised cases and that even after revision most patients are satisfied.

A confirmatory factor analysis of the Hospital Anxiety and Depression scale: comparing empirically and theoretically derived structures

OBJECTIVES

To compare the fit of various factor solutions for the Hospital Anxiety and Depression scale (HAD; Zigmond & Snaith, 1983).

DESIGN

A cross-sectional postal survey was used to collect the data from community-based participants in the West of Scotland Twenty-07 study.

METHODS

The HAD scale, a 14-item self-administered measure of anxiety and depression, was completed by 2547 participants from three age cohorts (aged approximately 18, 39 and 58 years). Using confirmatory factor analyses four models suggested by prior exploratory factor analyses were compared to a model derived from Clark and Watson's (1991) tripartite theory of anxiety and depression.

RESULTS

The model derived from the tripartite theory of anxiety and depression (with factors labelled negative affectivity, anhedonic depression and autonomic anxiety) produced the closest fit to the data. This model produced a good fit in all three cohorts although group comparisons suggested that there were variations in the strength of some factor loadings across the three age groups. A model that had a hierarchical arrangement of the three factors in the tripartite model was also produced. This model fit the data equally as well as did the 'flat' tripartite model.

CONCLUSIONS

Three factors appear to underlie the HAD scale. Research is needed that examines whether or not using sub-scales based on these factors increases the ability of the HAD scale to detect cases of anxiety and depression.

Validation of the Swedish Knee Arthroplasty Register: a postal survey regarding 30,376 knees operated on between 1975 and 1995

The Swedish Knee Arthroplasty Register is dependent on the participating clinics regarding accuracy of information. As the register is prospective, and since revision is used as the endpoint in survival analyses, it is important that all revisions of registered primary arthroplasties are reported. To validate the register, we sent a questionnaire to all living patients with 30,796 knees registered as having been operated on from 1975-1995. Of living patients, 99% could be located and 93% answered. We found that one fifth of the revisions had not been reported and that relatively fewer revisions were lost to follow-up during the first decade of the register than in the following years. To investigate whether the Patient Administrative System (PAS), a database based on ICD coding and run by the Swedish health authorities, could be used to locate missing revisions found by the postal survey, we compared this database with the Swedish Knee Arthroplasty Register. 84% of the missing revisions revealed by the postal survey were found by using this method. Hence after the survey and the use of the PAS to find unreported revisions in deceased and non-responding patients, we estimate that 94% of all revisions are accounted for. Apart from a generally higher cumulative revision rate, conclusions reported from the Register in recent years regarding survivorship seem to be unaffected by the underreporting.

Marital food interaction and dietary behavior

The objective of this investigation is to consider the role of family food interaction in healthful dietary activity. A theoretical model is proposed in which three sets of determinate variables are specified as leading to interaction in the family on food issues which, in turn, is predicted to have a positive effect on four indicators of dietary quality. 155 married couples from a midwestern US state were randomly selected and interviewed. The findings provide clear evidence of the importance of family food interaction for the quality of marital partners' diet. Also differences found between husbands and wives indicate that wives contribute more to husbands' dietary quality than the reverse, suggesting again the dominant status of wives in family food selection and preparation.

Judicial case management and the custody and access assessment: melding the approaches

BACKGROUND

The presence of the Unified Family Court, with procedures emphasizing judicial case management and settlement in custody disputes, provided an opportunity to combine these practices with those of a university hospital-based family court clinic experienced in the provision of custody assessments. Specifically, a process integrating the clinical custody assessment with the work of counsel and court procedures was developed. This format, incorporating the preparation of a clinical settlement conference brief, was then evaluated with emphasis on time management, outcome in relation to settlement or trial, and the effect of clinical assessment at critical points in the combined endeavour.

METHOD

Seventy-two judicial referrals conducted using this format were reviewed. To assess efficiency, we determined time intervals to various points in the process and compared them to previous local practice. Settlement rates, recorded incrementally to mark each component's contribution, were compared with rates noted in the literature. Assessment functions were identified according to the point of resolution of the dispute and in a manner to facilitate comparison with previously published work.

RESULTS

The format resulted in 50% of cases settling without trial in under 5 months, a minimum settlement rate of 50%, and confirmed the ability of clinical assessment to contribute flexibly to dispute resolution in several conciliation venues and at trial.

CONCLUSIONS

Combining legal and mental health efforts can results in more efficient use of resources and a substantial diversion of cases from continuing litigation. While altering the process of clinical assessments enhances such findings, further work is required to assure appropriate selection criteria for various intervention formats.

The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine

A survey of patients attending 2 Glasgow genitourinary medicine (GUM) clinics was conducted in 2 3-month periods in 1993 and 1994. Three hundred and twenty-five attendees who had travelled abroad in the preceding 3 months completed anonymous self-administered questionnaires about their sexual behaviour during these recent journeys abroad. There were 112 women and 213 men (185 heterosexuals and 28 homosexuals). Twenty-two (19.6%) women, 56 (31%) heterosexual men and 13 (42%) homosexual men had a sexual contact with a new partner while abroad. Of those who had had a new sexual contact abroad, 11 women (50% of those who had sex with a new partner) and 33 heterosexual men (59% of those who had sex with a new partner) were inconsistent users of condoms. Analysis of data found that homosexual and heterosexual men, and business travellers, are at increased risk of exposure to sexually transmitted diseases, including HIV infection, and should be targeted with safer sex health promotion prior to travel.

The effects of caring on health: a community-based longitudinal study

This paper begins with a critical review of studies which have examined the effects of caring on health. Most are shown to suffer from defects in sampling and design, so that the evidence for detrimental effects is suggestive rather than conclusive. The substantive part of the paper then utilizes data on a cohort of 55-year-olds to compare the health of carers with the health of non-carers and to examine changes in caring and health over a 3-year period. The comparison yields no systematic evidence of the deleterious effects of caring on health; indeed, if there is a tendency in the accumulated data, it is in the opposite direction i.e. that carers report better health and functioning than non-carers. It is suggested that part of the explanation relates to selection and self-selection and the longitudinal data reveals high volatility in caring status, even over a short time period. The paper goes on to examine sub-groups of carers considered to be at greater risk. There is no evidence that their health is compromised but the authors acknowledge weaknesses in the data and argue for a specially designed study. The paper concludes with a discussion of the findings and their implications for research, policy and practice.

Contrast sensitivity in dyslexia

Contrast sensitivity was determined for dyslexic and normal readers. When testing with temporally ramped (i.e. stimuli with gradual temporal onsets and offsets) gratings of 0.6, 4.0, and 12.0 cycles/deg, we found no difference in contrast sensitivity between dyslexic readers and controls. Using 12.0 cycles/deg gratings with transient (i.e. abrupt) onsets and offsets, we found that dyslexic individuals had, compared to controls, markedly inferior contrast sensitivity at the shortest stimulus durations (i.e. 17, 34, and 102 ms). This deficit may reflect more sluggish temporal summation. There was no difference in sensitivity to 0.6 cycles/deg gratings with transient onsets and offsets. Under these conditions, the two groups showed a consistent and equal increase in sensitivity relative to the ramped baseline condition at 0.6 cycles/deg at the longer stimulus durations. This demonstrates that dyslexic readers have no deficit in their ability to detect stimulus transients, a finding which appears to be inconsistent with a transient system deficit. That detection of the low-frequency stimuli was mediated by the transient system is further indicated by the fact that these stimuli were more susceptible to forward masking than were the high-frequency stimuli. The effects of masking of both high and low spatial-frequency stimuli were about equal for dyslexic readers and controls. This is not in agreement with the transient system deficit theory, according to which one would expect there to be less masking of high spatial-frequency stimuli in the case of dyslexic readers.

Hip dysplasia with bilateral ischiatic nerve entrapment in a dog

Dysfunction of both ischiatic nerves was detected in a 5-year-old spayed Labrador Retriever with radiographic evidence of severe bilateral hip dysplasia. Marked hyperflexion of the hip and stifle was evident when the dog walked. Results of electromyography confirmed the ischiatic nerve involvement. At staged operations, both ischiatic nerves were found to be compressed between the sacrotuberous ligament and proliferative tissue around the hip. One year after surgery, electromyographic and physical findings were essentially normal.

Development of an objective comedogenicity assay

The rabbit ear comedogenicity assay is useful as a screening procedure for evaluating agents that come in contact with human skin. Controversy exists regarding the reliability of this assay because of differences in results from various laboratories. The subjective nature of the standard method of grading may also contribute to this variation. We use a more objective comedogenicity assay that utilizes increasing follicular orifice size on the rabbit ear as a measure of comedogenic activity. A generally linear increase in the degree of follicular orifice area was noted with several agents evaluated over a four-week application period. Further, a noninvasive Silastic elastomer mold was used to allow measurement of the same follicular orifice areas over time.

Angiotensin II receptors in the kidney

Angiotensin II (AngII) receptors have been localized in rat kidney by using the high-affinity agonist analog 125I-labeled [Sar1]AngII as a probe for in vitro autoradiography. Receptors were associated with four morphologically distinct patterns of distribution. First, a high density of receptors occurs in glomeruli. These are diffusely distributed, consistent with a mesangial localization. AngII receptor density shows a cortical gradient, which is highest in superficial and midcortical glomeruli and lowest in juxtamedullary glomeruli. Receptors associated with both superficial and deep glomeruli show down-regulation during low-sodium intake. Second, low levels of tubular AngII binding were seen in the outer cortex. Third, a very high density of AngII receptors occurs in longitudinal bands in the inner zone of the outer medulla in association with vasa recta bundles. Receptors in this site also show down-regulation during low dietary sodium intake. Fourth, a moderate density of receptors occurs diffusely throughout the inner zone of the outer medulla in the interbundle areas. These results suggest that AngII exerts a number of different intrarenal regulatory actions. In addition to the known vascular, glomerular, and proximal tubular effects of AngII, these findings focus attention on possible actions of AngII in the renal medulla where it could regulate medullary blood flow and thereby modify the function of the countercurrent concentrating system.

In vitro autoradiographic localization of angiotensin-converting enzyme in rat brain using 125I-labelled MK351A

A method has been developed to localize angiotensin-converting enzyme in tissues by in vitro autoradiography. The potent angiotensin-converting enzyme inhibitor, MK351A, was labelled with 125I and shown to exhibit saturable, high affinity, reversible binding to membrane fractions of rat lung and caudate-putamen. The radio-ligand bound with a T 1/2 2-3 min at 20 degrees C and dissociated with a T 1/2 of approximately 5 min on addition of excess unlabelled inhibitor. The potency of a series of converting enzyme inhibitors in displacing the radio-ligand closely paralleled their anticatalytic potency, strongly suggesting that the ligand labels the active site of converting enzyme. In vitro autoradiographic analysis using this system revealed a very high density of converting enzyme in rat lung, small bowel muocosa, adrenal zona glomerulosa, adrenal medulla and brain. In the brain, a discrete and characteristic distribution of the enzyme was observed. A very high density of converting enzyme was found in the choroid plexus, subfornical organ, caudate-putamen, globus pallidus and substantia nigra. The enzyme was also localized in discrete regions of the hypothalamus, thalamus, amygdala, brain stem and cerebellum.

Behavior of ewes and lambs subjected to restraint fostering

The objective of this study was to investigate the development of maternal-filial social attachments between ewes and alien lambs using the technique of "restraint fostering." Forty-eight to 72 h after parturition, 22 Targhee -type ewes were separated from their natural lambs, placed in restraining devices ( stanchions ) and each exposed to a single alien lamb. After a period of 1 or 4 d of restraint, the ewes were subjected to five 10-min lamb acceptance tests over a 48-h period. The observer recorded butts and butt attempts by the ewe and successful and unsuccessful suckle attempts by the lamb. The ewe-lamb pairs were then housed in pens with other groups of ewes and lambs and observed intermittently for acceptance behaviors. Six of the 14 ewes restrained for 4 d and none of the eight ewes restrained for 24 h met the criterion for successful adoption within 48 h. After being housed in group pens, adoptions were achieved by three ewes in the 1-d group and an additional four ewes in the group restrained for 4 d. Ewes restrained for 24 h were significantly more aggressive toward fostered young than ewes restrained for 4 d. In addition, the proportion of successful suckling attempts was significantly lower for lambs fostered on ewes in the 1-d group. Both groups showed a decline in butts and butt attempts over successive acceptance tests, but while the proportion of successful suckling attempts declined for lambs housed with 1-d ewes, they increased over time for lambs fostered on ewes restrained for 4 d.(ABSTRACT TRUNCATED AT 250 WORDS)