Electrophysiological signatures of visual statistical learning in 3-month-old infants at familial and low risk for autism spectrum disorder

Visual statistical learning (VSL) refers to the ability to extract associations and conditional probabilities within the visual environment. It may serve as a precursor to cognitive and social communication development. Quantifying VSL in infants at familial risk (FR) for Autism Spectrum Disorder (ASD) provides opportunities to understand how genetic predisposition can influence early learning processes which may, in turn, lay a foundation for cognitive and social communication delays. We examined electroencephalography (EEG) signatures of VSL in 3-month-old infants, examining whether EEG correlates of VSL differentiated FR from low-risk (LR) infants. In an exploratory analysis, we then examined whether EEG correlates of VSL at 3 months relate to cognitive function and ASD symptoms at 18 months. Infants were exposed to a continuous stream of looming shape pairs with varying probability that the shapes would occur in sequence (high probability-deterministic condition; low probability-probabilistic condition). EEG was time-locked to shapes based on their transitional probabilities. EEG analysis examined group-level characteristics underlying specific components, including the late frontal positivity (LFP) and N700 responses. FR infants demonstrated increased LFP and N700 response to the probabilistic condition, whereas LR infants demonstrated increased LFP and N700 response to the deterministic condition. LFP at 3 months predicted 18-month visual reception skills and not ASD symptoms. Our findings thus provide evidence for distinct VSL processes in FR and LR infants as early as 3 months. Atypical pattern learning in FR infants may lay a foundation for later delays in higher level, nonverbal cognitive skills, and predict ASD symptoms well before an ASD diagnosis is made.

Mobile applications for breast cancer survivorship and self-management: A systematic review

The use of mobile technology and mobile apps has become pervasive in our daily lives for completing a variety of daily tasks. Mobile health (mHealth) apps can provide an accessible platform for self-management among breast cancer (BC) survivors, as they recover from not just the intensive cancer treatments, but also their associated side-effects. They also offer a means to learn about survivorship topics and connect with peer survivors online, irrespective of their geographical location. This study is an attempt to assess the availability and characterize the self-management features of free mobile apps for breast cancer survivors on the Google Play (Android) and Apple App Store (iOS). Out of 249 such apps for the Android, only eight satisfied initial criteria, while only one of 174 iOS apps that met inclusion criteria was included for further analysis. A content analysis of the nine apps that met inclusion criteria was conducted to assess the inclusion of the following mHealth self-management features derived from the Chronic Care Model: symptom tracking; survivorship education; information-sharing with family and/or caregivers; scheduling follow-up visits; personal alerts and reminders; and social networking. Survivorship education was found to be the most common self-management feature among the apps reviewed, followed by social networking. The results of this study highlight the dearth of available mHealth resources for BC survivors. Future efforts in app development should involve survivors and healthcare providers to ensure comprehensive resources that address their unmet needs are made more accessible.

The effects of oxytocin administration on individuals with ASD: Neuroimaging and behavioral evidence

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by difficulties in social communication and the presence of restricted interests and repetitive behaviors. Although behavioral interventions are numerous, there are no Federal Drug Administration approved pharmacological treatments for the core symptoms of ASD. The neuropeptide oxytocin has been studied in animals for decades, and is involved in pair bonding and social affiliation. Given oxytocin's involvement in social communication in animals, researchers have begun exploring whether oxytocin administration in humans affects social behaviors and attachment. Particular attention has been paid to whether oxytocin has therapeutic benefits for improving social behaviors in individuals with ASD. Research on oxytocin administration in ASD has utilized both behavioral and brain-based outcomes. This chapter reviews the effects of oxytocin administration in ASD, with a focus on functional outcomes from neuroimaging investigations. Evidence of potential therapeutic benefits are reviewed, as well as limitations of extant research. A proposed model for future research into the therapeutic benefits of oxytocin includes combining pharmacological (e.g. oxytocin) and behavioral (e.g. evidence-based behavioral interventions) techniques to improve social communication skills in ASD.

Gender discrimination and depressive symptoms among child-bearing women: ELSPAC-CZ cohort study

BACKGROUND

Depression is approximately two-fold more prevalent among women than men. Social theories suggest that discrimination is a pathway through which gender inequalities affect women's lives, but data are lacking. This cohort study evaluates whether perceived gender discrimination is linked to depressive symptoms among child-bearing women.

METHODS

Data were obtained from 4,688 participants enrolled in pregnancy in 1991-92 in the European Longitudinal Cohort Study of Pregnancy and Childhood, Czech Republic. Perceived gender discrimination was assessed in mid-pregnancy, year seven, and year eleven. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale at eight time-points between mid-pregnancy and year eleven post-delivery. Linear mixed error-component models of depressive symptoms were estimated.

FINDINGS

Perceived gender discrimination, reported by 10.7% of women, was related to higher depressive symptoms, both in the unadjusted analysis (b = 0.15 [95% confidence interval (CI): 0.12, 0.19], p < 0.001) and in the fully adjusted model (b = 0.12 [95% CI: 0.09, 0.16], p < 0.001). Covariates linked to higher depressive symptoms included financial hardship (b = 0.12 [95% CI: 0.10, 0.14], p < 0.001), childhood emotional/physical neglect (b = 0.18 [95% CI: 0.14, 0.22], p < 0.001), and childhood sexual abuse (b = 0.04 [95% CI: 0.03, 0.06], p < 0.001); an inverse relationship was evident for social support (-0.05 [95% CI: -0.07, -0.04], p < 0.001) and having a partner who performs female-stereotypical household tasks (b=-0.03 [95% CI: -0.05, -0.01], p = 0.001).

INTERPRETATION

The findings provide the first evidence that perceived gender discrimination is associated with depressive symptoms among child-bearing women. Social intervention programs aimed at reducing gender discrimination can potentially contribute to better mental health of women.

FUNDING

Bill and Melinda Gates Foundation.

Biology-inspired microphysiological systems to advance patient benefit and animal welfare in drug development

The first microfluidic microphysiological systems (MPS) entered the academic scene more than 15 years ago and were considered an enabling technology to human (patho)biology in vitro and, therefore, provide alternative approaches to laboratory animals in pharmaceutical drug development and academic research. Nowadays, the field generates more than a thousand scientific publications per year. Despite the MPS hype in academia and by platform providers, which says this technology is about to reshape the entire in vitro culture landscape in basic and applied research, MPS approaches have neither been widely adopted by the pharmaceutical industry yet nor reached regulated drug authorization processes at all. Here, 46 leading experts from all stakeholders - academia, MPS supplier industry, pharmaceutical and consumer products industries, and leading regulatory agencies - worldwide have analyzed existing challenges and hurdles along the MPS-based assay life cycle in a second workshop of this kind in June 2019. They identified that the level of qualification of MPS-based assays for a given context of use and a communication gap between stakeholders are the major challenges for industrial adoption by end-users. Finally, a regulatory acceptance dilemma exists against that background. This t4 report elaborates on these findings in detail and summarizes solutions how to overcome the roadblocks. It provides recommendations and a roadmap towards regulatory accepted MPS-based models and assays for patients' benefit and further laboratory animal reduction in drug development. Finally, experts highlighted the potential of MPS-based human disease models to feedback into laboratory animal replacement in basic life science research.

Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction

BACKGROUND

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.

METHODS

The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.

RESULTS

A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P < 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.

CONCLUSION

TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.

Race-ethnic and gender differences in representation within the English National Health Service: a quantitative analysis

OBJECTIVES

To evaluate race-ethnic and gender disparities in National Health Service (NHS) England employment in position, prestige and pay.

DESIGN

National study using data from NHS Digital.

SETTING

Trusts and clinical commissioning groups in England.

PARTICIPANTS

1 105 390 NHS Hospital and Community Health Service staff.

RESULTS

Chinese people (42.9%, 95% CI 41.7% to 44.1%) are the most likely to be employed as doctors, followed by Asians (28.6%, 95% CI 28.3% to 28.8%) and people of mixed race/ethnicity (17.9%, 95% CI 17.3% to 18.4%); while white people (6.8%, 95% CI 6.7% to 6.8%) are less likely to be employed as doctors. However, white doctors are the most likely to be in the highest paid positions: 46.0% (95% CI 45.6% to 46.4%) of white doctors are consultants, whereas only 33.4% (95% CI 31.6% to 35.2%) of Chinese doctors are consultants. Black people are under-represented both among doctors and as consultants: 6.5% (95% CI 6.4% to 6.7%) of black employees are doctors and 30.6% (95% CI 29.2% to 32.0%) of black doctors are consultants. We found similar results for nurses and health visitors, where white people are over-represented in the higher pay bands. However, among support staff for doctors, nurses and midwives, we found that Chinese people were over-represented in the higher pay bands. These race-ethnic differences were similar for women and men. Additionally, we found that men were more likely to be employed in higher pay bands than women, and this gender disparity was apparent across race-ethnic groups.

CONCLUSIONS

Race-ethnic and gender disparities exist in the NHS in position, prestige and pay. To begin to overcome such disparities, the NHS must collect data using consistent race-ethnic categories in order to examine differences over time.

Focus group testing of a mobile app for pharmacogenetic-guided dosing

BACKGROUND

A common barrier to implementation of precision medicine is the lack of use of published clinical practice guidelines. Consequently, a user-friendly mechanism to easily adopt these guidelines is imperative.

PURPOSE

The purpose of this study was to evaluate the perceptions of a prototype of a clinical decision support tool through a mobile application for pharmacogenetics.

METHODOLOGICAL ORIENTATION

A case study on a patient requiring pharmacogenetic testing was provided to the participants. The participants were given up to 30 minutes to identify the correct dosing in the clinical decision support tool based on clinical evidence-based guidelines. Immediately after the utilization of the mobile app, focus group interviews were conducted to identify the perceptions of the tool, obstacles associated with the tool, and suggestions for improvement of the tool.

SAMPLE

Focus group interviews with 23 nurse practitioners and nurse practitioner students were conducted. Field notes and audio recordings were taken.

CONCLUSIONS

Specific feedback for improvement in the font and size of text, color contrast, use of drug calculator, automatic input, and desire for further development of education portal were found within the data. The findings revealed useful feedback to adjust the prototype to improve the ease of use among nurse practitioners.

IMPLICATIONS FOR PRACTICE

The revision of this mobile app will improve user friendliness to increase applicability within health care. The mobile app can be used for future research to identify improvements in patient outcomes after implementing this tool.

Zika virus knowledge, contraception use, and lessons learned from a Dominican Republic pilot study

OBJECTIVE

To assess knowledge of the Zika virus (ZIKV), use of contraceptives, and sources of health information in rural communities in the Dominican Republic.

METHODS

Over 4 days in March 2017, a research team traveled to four rural communities in the Dominican Republic to provide healthcare services. Overall, 90 men and women consented to a voluntary verbal 12-question survey.

RESULTS

Of the participants, 55% were not certain whether ZIKV is transmitted sexually; 75% of participants were either not sure or thought ZIKV was not present in their community. Charlas (informal discussions led by community health workers) were cited as the most common source for public health information. Prevalence of contraceptive use was 26.6% hormonal and 1.1% long-acting reversible contraception (LARC); 30.0% cited no use of contraception.

CONCLUSION

Significant deficits in ZIKV knowledge, underutilization of LARCs, and socioeconomic factors exist that constrain the application of WHO recommendations for preventing ZIKV infection. Additional and more robust surveys are needed to assess public health education and interventions, critical for disease prevention in communities facing current and future epidemics.

Mammaglobin-A, VEGFR3, and Ki67 in Human Breast Cancer Pathology and Five Year Survival

Background/Methods:

This study determines the co-expression of mammaglobin-A, vascular endothelial growth factor receptor-3 (VEGFR3) and Ki67 by immunohistochemistry (IHC) in tissue samples from 80 patients undergoing breast surgery (cancer or benign disease). The tissue expression was compared with the tumour histopathology and Kaplan Meier 5-year survival analysis was performed.

Results:

Positive breast tissue expression was observed in 53% samples for mammaglobin, 41% Ki67 and 65% VEGFR3 with a significant positive correlation between Ki67 and VEGFR3 co-expression. Ki67 and VEGFR3 expression correlated with the breast tumour grade and Ki67 expression also correlated with oestrogen receptor (ER) status. At 5 years post-operatively, 6/80 patients had died and 3 patients were alive but had cancer recurrence. High Ki67 expression significantly correlated with poor survival (disease-free and overall).

Conclusions:

In this study, VEGFR3 and Ki67 expression but not mammaglobin-A correlated with breast tumour pathology. Positive Ki67 expression was also associated with a poor 5-year survival outcome.

Substance Use Stigma and Antiretroviral Therapy Adherence Among a Drug-Using Population Living with HIV

Among people living with HIV (PLWH), HIV-related stigma predicts nonadherence to antiretroviral therapy (ART); however, the role of stigma associated with drug use is largely unknown. We examined the association between substance use (SU) stigma and optimal ART adherence in a sample of 172 self-reported HIV-infected drug users. Participants completed surveys on SU, stigma, and ART adherence. The three substance classes with the greatest number of participants exhibiting moderate/high-risk scores were for cocaine/crack cocaine (66.28%), cannabis (64.53%), and hazardous alcohol consumption (65.70%). Multivariable logistic regression was conducted to investigate associations between levels of SU stigma and optimal ART adherence, adjusting for sociodemographic characteristics, severity of illicit drug use (alcohol, smoking and substance involvement screening test) and alcohol use severity (Alcohol Use Disorders Identification Test-C), HIV-related stigma, and social support. The odds of optimal adherence among participants experiencing moderate [Adjusted Odds Ratio (AOR) = 0.36, p = 0.039] and very high (AOR = 0.25, p = 0.010) levels of anticipated SU stigma were significantly lower than participants experiencing low levels of anticipated SU stigma. No other stigma subscales were significant predictors of ART adherence. Interventions aiming to improve ART adherence among drug-using PLWH need to address anticipated SU stigma.

Phase 0, including microdosing approaches: Applying the Three Rs and increasing the efficiency of human drug development

Phase 0 approaches, including microdosing, involve the use of sub-therapeutic exposures to the tested drugs, thus enabling safer, more-relevant, quicker and cheaper first-in-human (FIH) testing. These approaches also have considerable potential to limit the use of animals in human drug development. Recent years have witnessed progress in applications, methodology, operations, and drug development culture. Advances in applications saw an expansion in therapeutic areas, developmental scenarios and scientific objectives, in, for example, protein drug development and paediatric drug development. In the operational area, the increased sensitivity of Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS), expansion of the utility of Positron Emission Tomography (PET) imaging, and the introduction of Cavity Ring-Down Spectroscopy (CRDS), have led to the increased accessibility and utility of Phase 0 approaches, while reducing costs and exposure to radioactivity. PET has extended the application of microdosing, from its use as a predominant tool to record pharmacokinetics, to a method for recording target expression and target engagement, as well as cellular and tissue responses. Advances in methodology include adaptive Phase 0/Phase 1 designs, cassette and cocktail microdosing, and Intra-Target Microdosing (ITM), as well as novel modelling opportunities and simulations. Importantly, these methodologies increase the predictive power of extrapolation from microdose to therapeutic level exposures. However, possibly the most challenging domain in which progress has been made, is the culture of drug development. One of the main potential values of Phase 0 approaches is the opportunity to terminate development early, thus not only applying the principle of 'kill-early-kill-cheap' to enhance the efficiency of drug development, but also obviating the need for the full package of animal testing required for therapeutic level Phase 1 studies. Finally, we list developmental scenarios that utilised Phase 0 approaches in novel drug development.

The Push and Pull of Self-Managing Mild COPD: An Evaluation of Participant Experiences of a Nurse-Led Telephone Health Coaching Intervention

Health coaching is a novel population intervention to support self-management but it is untested in people with mild disease. People with chronic obstructive pulmonary disease with mild dyspnea are a population excluded from supported self-management and whose illness might progress without intervention. We explored participants' experiences about how health coaching motivated behavior change. Interviews were conducted with 21 intervention and 10 control participants at 6 months, and 20 intervention participants at 12 months. Participants were identified from a randomized controlled trial of telephone health coaching. Data were analyzed using the framework method. Participants positively enacted behavior change to become more physically active. Participants took advantage of environmental affordances to pull themselves toward activity targets, or relied on being pushed to be more active by the health coach or significant others. Behavior change was maintained where efforts to be more active were built into the everyday lifeworld of participants.

Satisfaction with a digitally-enabled telephone health coaching intervention for people with non-diabetic hyperglycaemia

International evidence shows that lifestyle interventions can effectively reduce the risk of developing diabetes in people with non-diabetic hyperglycaemia (NDH). A candidate intervention that has potential to be rolled out at population level is health coaching. Digital interventions offer the means to potentially enhance user satisfaction with health coaching and improve efficiencies. We used a randomised controlled trial to test whether a digitally-enabled health coaching intervention that included an online dashboard and telephone health coaching improved user satisfaction and cost-efficiencies compared with a telephone only health coaching intervention. The primary outcome was satisfaction measured by Client Satisfaction Questionnaire (CSQ-8). 103 participants with NDH were allocated to the telephone coaching only intervention and 106 participants with NDH were allocated to the digital and telephone coaching intervention. In an intention-to-treat analysis satisfaction was higher in participants allocated to the digital and telephone coaching intervention than those allocated to the telephone only intervention, but the difference was not significant. There were no significant differences between the groups on secondary outcomes (HbA1c, BMI, activation, depression, self-management, health status). From a service commissioning perspective the mean incremental cost of the digitally-enabled intervention was £236 ($332; €270). Call times, including administration, were longer for participants allocated to the digitally-enabled intervention. The results show that user satisfaction with digitally-enabled intervention is broadly equivalent with that of telephone delivered interventions in the context of routinely delivered diabetes prevention programmes. There is scope for future work that assesses how economies of scale can be achieved at larger user bases.

EEG Data Collection in Children with ASD: The Role of State in Data Quality and Spectral Power

BACKGROUND

Electroencephalography can elucidate neurobiological mechanisms underlying heterogeneity in ASD. Studying the full range of children with ASD introduces methodological challenges stemming from participants' difficulties tolerating the data collection process, leading to diminished EEGdataretentionandincreasedvariabilityin participant 'state' during the recording. Quantifying state will improve data collection methods and aide in interpreting results.

OBJECTIVES

Observationally quantify participant state during the EEG recording; examine its relationship to child characteristics, data retention and spectral power.

METHODS

Participants included 5-11 year-old children with D (N=39) and age-matched TD children (N=16). Participants were acclimated to the EEG environment using behavioral strategies. EEG was recorded while participants watched a video of bubbles. Participant 'state' was rated using a Likert scale (Perceived State Rating: PSR).

RESULTS

Participants with ASD had more elevated PSR than TD participants. Less EEG data were retained in participants with higher PSR scores, but this was not related to age or IQ. TD participants had higher alpha power compared with the ASD group. Within the ASD group, participants with high PSR had decreased frontal alpha power.

CONCLUSIONS

Given supportive strategies, EEG data was collected from children with ASD across cognitive levels. Participant state influenced both EEG data retention and alpha spectral power. Alpha suppression is linked to attention and vigilance, suggesting that these participants were less 'at rest'. This highlights the importance of considering state when conducting EEG studies with challenging participants, both to increase data retention rates and to quantify the influence of state on EEG variables.

Patient perceived impact of nurse-led self-management interventions for COPD: A systematic review of qualitative research

BACKGROUND

Self-management interventions are increasingly implemented to manage the health impact and economic burden of the growing prevalence of chronic obstructive pulmonary disease. Nurses are the primary providers of self-management education, yet there have been few attempts to assess their contribution in delivering these programmes. Qualitative evidence that explores patients' perceptions of the benefits of self-management is limited.

OBJECTIVE

To synthesize qualitative evidence on patient perceived benefits of nursing interventions to support self-management.

DESIGN

Systematic review and qualitative synthesis.

METHODS

Data were collected from six electronic databases: British Nursing Index (BNI, Proquest), MEDLINE (Ovid), CINAHL (EBSCO), AMED (Ovid), Embase (Ovid), and PsycINFO (Ovid). Pre-defined keywords were used to identify qualitative or mixed methods English-language studies published in any year. The included studies were selected by screening titles, abstracts and full-texts against inclusion and exclusion criteria that were established a priori. The Critical Appraisal Skills Programme tool was used to undertake a quality review. Data were analysed with a framework approach using categories of self-management outcomes reported in a previous review as a coding structure.

RESULTS

Fourteen articles were included in the review. Four key themes were identified from the original research: Empowerment through new knowledge, Psychological wellbeing, Expanding social worlds and Increased physical activity.

CONCLUSIONS

When provided with adequate knowledge and support, patients gained self-confidence and their coping behaviour increased. Social and psychological support were identified as key aspects of self-management interventions that patients found improved their sense of wellbeing. Group exercise components of self-management programmes were also favourably evaluated due to a perceived sense of increased well-being and enhanced social interaction.

Perinatal Maternal Stress and Susceptibility to Infectious Diseases in Later Childhood: An Early Life Programming Perspective

There is evidence of transmission of stress-related dysregulation from parents to offspring during early developmental stages, leading to adverse health outcomes. This study investigates whether perinatal stress is linked to the risk of infectious diseases in children aged 7-11 years. We hypothesize that stress exposure during pregnancy and the first 6 months after birth independently predict common infectious diseases. Data are obtained from ELSPAC-CZ, a prospective birth cohort. Maternal stress, operationalized as the number of life events, is examined for pregnancy and the first 6 months postpartum. Children's diseases include eye infection, ear infection, bronchitis/lung infection, laryngitis, strep throat, cold sores, and flu/flu-like infection. More prenatal and postnatal life events are both independently linked to a higher number of infectious diseases between the ages of 7-11 years. The effect is larger for postnatal vs. prenatal events, and the effect of prenatal events is attenuated after maternal health in pregnancy is controlled. The results suggest that perinatal stress is linked to susceptibility to infectious diseases in school-age children. Interventions to address stress in pregnant and postpartum women may benefit long-term children's health.

Current practice and short-term outcomes of therapeutic mammaplasty in the international TeaM multicentre prospective cohort study

BACKGROUND

Therapeutic mammaplasty, which combines breast reduction and mastopexy techniques with tumour excision, may extend the boundaries of breast-conserving surgery and improve outcomes for patients, but current practice is unknown and high-quality outcome data are lacking. This prospective multicentre cohort study aimed to explore the practice and short-term outcomes of the technique.

METHODS

Consecutive patients undergoing therapeutic mammaplasty at participating centres between 1 September 2016 and 30 June 2017 were recruited to the study. Demographic, preoperative, operative, oncological and complication data were collected. The primary outcome was unplanned reoperation for complications within 30 days of surgery. Secondary outcomes included re-excision rates and time to adjuvant therapy.

RESULTS

Overall, 880 patients underwent 899 therapeutic mammaplasty procedures at 50 centres. The most common indications were avoidance of poor cosmetic outcomes associated with standard breast-conserving surgery (702 procedures, 78·1 per cent) or avoidance of mastectomy (379, 42·2 per cent). Wise-pattern skin incisions were the most common (429 of 899, 47·7 per cent), but a range of incisions and nipple-areola pedicles were used. Immediate contralateral symmetrization was performed in one-third of cases (284 of 880, 32·3 per cent). In total, 205 patients (23·3 per cent) developed a complication, but only 25 (2·8 per cent) required reoperation. Median postoperative lesion size was 24·5 (i.q.r. 16-38) mm. Incomplete excision was seen in 132 procedures (14·7 per cent), but completion mastectomy was required for only 51 lesions (5·7 per cent). Median time to adjuvant therapy was 54 (i.q.r. 42-66) days.

CONCLUSION

Therapeutic mammaplasty is a safe and effective alternative to mastectomy or standard breast-conserving surgery. Further work is required to explore the impact of the technique on quality of life, and to establish cost-effectiveness.

Perspectives on cervical cancer screening and prevention: challenges faced by providers and patients along the Texas–Mexico border

Background:

The Rio Grande Valley (RGV) and Laredo regions located along the Texas–Mexico border consist of seven counties with a population of approximately 1.5 million people and a high uninsured rate (33.5%). Cervical cancer mortality in these border counties is approximately 30% higher than the rest of Texas. The RGV and Laredo areas were studied to better understand the state of access to cervical cancer prevention services along the Texas–Mexico border.

Methods:

Data on the population served and the services provided were analyzed to determine the gap between cervical cancer screenings recommended versus those received. Through interviews, we gathered the perspectives of 16 local stakeholders regarding cervical cancer screening for underserved individuals in the region.

Findings:

It is estimated that 69,139 uninsured women aged 21–64 years in the RGV/Laredo per year are recommended to undergo cervical cancer screening with Papanicolaou (Pap) and/or human papillomavirus (HPV) testing, but only 8941 (12.9%) Pap tests are being performed by the Federally Qualified Health Center (FQHC) serving uninsured women in these regions. Systemic barriers identified include insufficient provider clinical capacity, the high cost of healthcare, and uncertainty about government funding sources. Patient barriers identified include inadequate knowledge on navigating the local healthcare system, low health literacy, lack of money and childcare, an inability to miss work, limited transportation, and fear of deportation.

Conclusion:

Decreasing the disparity between cervical cancer screening services provided and those recommended requires addressing the barriers, identified by local experts, which prevent uninsured women from accessing care. These challenges are being addressed through ongoing programs and collaborations.

WIDENING THE SCOPE OF SOCIAL SUPPORT: THE FLORIDA MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM

The Florida Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is designed to support pregnant women and families in developing skills and utilizing resources necessary to promote their children's physical, social, and emotional development. Little evaluation attention has focused on large-scale, public policy driven home-visiting programs. Social support provision is a critical component of a successful home-visiting program; therefore, there is a need to better understand participants' perceptions of social support provided to them in this context. Forty-five home-visiting participants from five Florida MIECHV programs completed semistructured telephone interviews. Participants discussed their experiences with the MIECHV program, including descriptions of their interactions with home visitors. Content analysis revealed that participants experienced multilayered social support from home-visiting staff. Families needed and received substantial emotional, instrumental, informational, and appraisal support at the individual level. This support was embedded within and strengthened by the strategies and activities of the home-visiting model of service provision. Results highlight the powerful opportunity home visiting offers as a method of service delivery within the larger system of care to increase social support in families experiencing high risk for negative maternal and child health outcomes. Implications for policy and practice are discussed.

Ethical Use and Impact of Participatory Approaches to Research in Post-Disaster Environments: An Australian Bushfire Case Study

This paper presents a case study of Beyond Bushfires, a large, multisite, mixed method study of the psychosocial impacts of major bushfires in Victoria, Australia. A participatory approach was employed throughout the study which was led by a team of academic investigators in partnership with service providers and government representatives and used on-site visits and multiple methods of communication with communities across the state to inform decision-making throughout the study. The ethics and impacts of conducting and adapting the approach within a post-disaster context will be discussed in reference to theories and models of participatory health research. The challenges of balancing local interests with state-wide implications will also be explored in the description of the methods of engagement and the study processes and outcomes. Beyond Bushfires demonstrates the feasibility of incorporating participatory methods in large, post-disaster research studies and achieving rigorous findings and multilevel impacts, while recognising the potential for some of the empowering aspects of the participatory experience to be reduced by the scaled-up approach.

A Framework Facilitates Development of a Mobile App

Due to the advance of mobile technology, use of mobile devices such as smartphones has been growing rapidly in the U.S. and worldwide. Many health related mobile apps have been developed for care professionals and patients as well. However, studies indicate that there is a gap between science and commercially developed mobile apps. In addition to this, there is no framework to guide devlopment of a mobile app to overcome many challenges and obstacles. Through the development of a pain management mobile app for cancer patients, a framework was developed. A proposed framework was based on the technology acceptance model, ensuring usefulness and ease of use for end users. The first two steps in the framework enforce accurate knowledge translation and communication to build a science based mobile app. Iterative decisions points between steps enhance accomplishment of each step.

How do clinical competency committees use different sources of data to assess residents' performance on the internal medicine milestones?A mixed methods pilot study

PURPOSE

This study examines how Clinical Competency Committees (CCCs) synthesize assessment data to make judgments about residents' clinical performances.

METHODS

Between 2014 and 2015, after four six-month reporting periods to the Accreditation Council for Graduate Medical Education (ACGME), 7 of 16 CCC faculty at Rush University Medical Center completed questionnaires focused on their perspectives about rating residents on their achievement of the milestones and participated in a focus group. Qualitative data were analyzed using grounded theory. Milestones ratings for two six-month ACGME reporting cycles (n = 100 categorical residents) were also analyzed.

RESULTS

CCC members weighted resident rotation ratings highest (weight = 37%), followed by faculty rotation comments (weight = 27%) and personal experience with residents (weight = 14%) for making judgments about learner's milestone levels. Three assessment issues were identified from qualitative analyses: (1) "design issues" (e.g. problems with available data or lack thereof); (2) "synthesis issues" (e.g. factors influencing ratings and decision-making processes) and (3) "impact issues" (e.g. how CCC generated milestones ratings are used).

CONCLUSIONS

Identifying factors that affect assessment at all stages of the CCC process can contribute to improving assessment systems, including support for faculty development for CCCs. Recognizing challenges in synthesizing first and second-hand assessment data is an important step in understanding the CCC decision-making process.

Understanding the "Why" for High-Risk Behavior: Adolescent Girls' Motivations for Sex

Identifying why girls participate in safe and risky sexual behaviors is key to developing successful intervention strategies. This study identified motivations for sex in 738 girls enrolled in the Health Improvement Project for Teens (HIPTeens) randomized controlled trial and analyzed differences in sex motives among at-risk subgroups. Sexually active girls, ages 15-19 years, were recruited from urban community-based settings. Baseline data were collected via audio computer-assisted self-interview surveys including a modified Sex Motives Scale based on six domains (intimacy, enhancement, self-affirmation, coping, peer pressure, and partner approval), assessing drivers of both protective and risk-promoting motivations. Statistically significant motive differences across domains were identified among subgroups with different risk profiles, including mental health issues (depression, drug and alcohol use) as well as demographic group characteristics (race, age, and parental status). Understanding why girls have sex provides an opportunity to address motivation-focused strategies that may augment intervention efficacy.

Trajectories of dementia-related cognitive decline in a large mental health records derived patient cohort

BACKGROUND

Modeling trajectories of decline can help describe the variability in progression of cognitive impairment in dementia. Better characterisation of these trajectories has significant implications for understanding disease progression, trial design and care planning.

METHODS

Patients with at least three Mini-mental State Examination (MMSE) scores recorded in the South London and Maudsley NHS Foundation Trust Electronic Health Records, UK were selected (N = 3441) to form a retrospective cohort. Trajectories of cognitive decline were identified through latent class growth analysis of longitudinal MMSE scores. Demographics, Health of Nation Outcome Scales and medications were compared across trajectories identified.

RESULTS

Four of the six trajectories showed increased rate of decline with lower baseline MMSE. Two trajectories had similar initial MMSE scores but different rates of decline. In the faster declining trajectory of the two, a higher incidence of both behavioral problems and sertraline prescription were present.

CONCLUSIONS

We find suggestive evidence for association of behavioral problems and sertraline prescription with rate of decline. Further work is needed to determine whether trajectories replicate in other datasets.

Identification of Biological Pathways to Alzheimer's Disease Using Polygenic Scores

Introduction

Single nucleotide polymorphisms (SNPs) contribute small increases in risk for late-onset Alzheimer's disease (LOAD). LOAD SNPs cluster around genes with similar biological functions (pathways). Polygenic risk scores (PRS) aggregate the effect of SNPs genome-wide. However, this approach has not been widely used for SNPs within specific pathways.

Objectives

We investigated whether pathway-specific PRS were significant predictors of LOAD case/control status.

Methods

We mapped SNPs to genes within 8 pathways implicated in LOAD. For our polygenic analysis, the discovery sample comprised 13,831 LOAD cases and 29,877 controls. LOAD risk alleles for SNPs in our 8 pathways were identified at a P-value threshold of 0.5. Pathway-specific PRS were calculated in a target sample of 3332 cases and 9832 controls. The genetic data were pruned with R2 > 0.2 while retaining the SNPs most significantly associated with AD. We tested whether pathway-specific PRS were associated with LOAD using logistic regression, adjusting for age, sex, country, and principal components. We report the proportion of variance in liability explained by each pathway.

Results

The most strongly associated pathways were the immune response (NSNPs = 9304, = 5.63 × 10−19, R2 = 0.04) and hemostasis (NSNPs = 7832, P = 5.47 × 10−7, R2 = 0.015). Regulation of endocytosis, hematopoietic cell lineage, cholesterol transport, clathrin and protein folding were also significantly associated but accounted for less than 1% of the variance. With APOE excluded, all pathways remained significant except proteasome-ubiquitin activity and protein folding.

Conclusions

Genetic risk for LOAD can be split into contributions from different biological pathways. These offer a means to explore disease mechanisms and to stratify patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A "Triple Threat" to Research Protocols and Logistics: Adolescents, Sexual Health, and Poverty

The purpose of this article is to discuss lessons learned from conducting research with urban communities. A brief overview of the Health Improvement Project for Teens (HIPTeens) will be provided. It will be followed by several suggestions concerning recruitment and retention of participants, challenges related to working in impoverished environments, hiring and training of research teams, interacting with administration and community, and strategies for doing research in diverse settings.