Descending thoracic endovascular aneurysm repair: antegrade approach via ascending aortic conduit

Challenging access situations continue to arise in endovascular aneurysm repair, despite evolving arterial access techniques. We report a modified access approach, where an ascending aortic conduit was successfully used for antegrade delivery of a thoracic endograft to repair a descending thoracic aortic aneurysm, in a patient with previous surgical ligation of the infra-renal aorta.

Sociodemographic variation of caries risk factors in toddlers and caregivers

Objectives. Dental caries is the most common chronic childhood disease, with numerous identified risk factors. Risk factor differences could indicate the need to target caregiver/patient education/preventive care intervention strategies based on population and/or individual characteristics. The purpose of this study was to evaluate caries risk factors differences by race/ethnicity, income, and education. Methods. We enrolled 396 caregiver-toddler pairs and administered a 105-item questionnaire addressing demographics, access to care, oral bacteria transmission, caregiver's/toddler's dental and medical health practices, caregiver's dental beliefs, and caregiver's/toddler's snacking/drinking habits. Logistic regressions and ANOVAs were used to evaluate the associations of questionnaire responses with caregiver's race/ethnicity, income, and education. Results. Caregivers self-identified as Non-Hispanic African-American (44%), Non-Hispanic White (36%), Hispanic (19%), and "other" (1%). Differences related to race/ethnicity, income, and education were found in all risk factor categories. Conclusions. Planning of caregiver/patient education/preventive care intervention strategies should be undertaken with these caries risk factor differences kept in mind.

The role of alcohol in unintentional falls among young and middle-aged adults: a systematic review of epidemiological studies

OBJECTIVE

To appraise the published epidemiological evidence quantifying the risk of falls associated with acute and usual alcohol consumption among young and middle-aged adults.

DESIGN

Systematic review.

METHODS

DATA SOURCES

searches of electronic databases (eg, Medline, EMBASE, CINAHL, PsycINFO, Scopus), websites of relevant organisations, major injury journals, reference lists of relevant articles, and contact with experts in the field.

INCLUSION CRITERIA

epidemiological studies with an English language abstract investigating alcohol use as a risk factor (exposure) for unintentional falls or related injuries among individuals aged 25-60 years. Studies were critically appraised using the GATE LITE tool. Meta-analysis was not attempted because of the heterogeneity of the eligible studies.

RESULTS

Four case-control, three cohort and one case-crossover study fulfilled the inclusion criteria. The studies showed an increased risk of unintentional falls among young and middle-aged adults with increasing exposure to alcohol use. However, the magnitude of this risk varied considerably across studies with most estimates being relatively imprecise. Modest evidence of a dose-response relationship with acute alcohol use was observed. The association between usual alcohol use and fall risk was inconclusive, and evidence of a gender difference was inconsistent.

CONCLUSIONS

Alcohol use appears to be an important risk factor for falls among young and middle-aged adults. Controlled studies with sufficient power that adjust effect estimates for potential confounders (eg, fatigue, recreational drug use) are required to determine the population-based burden of fall-related injuries attributable to alcohol. This can help inform and prioritize falls prevention strategies for this age group.

The classic: the cervical syndrome. 1949

This Classic article is a reprint of the original work by Ruth Jackson, MD, FACS, The Cervical Syndrome. An accompanying biographical sketch on Ruth Jackson, MD, FACS, is available at DOI 10.1007/s11999-010-1277-9. The Classic Article is ©1949 by The Dallas County Medical Society and is reprinted with permission from Jackson R. The cervical syndrome. Dallas Med J. 1949;35:139–146. A second Classic Article, The Cervical Syndrome, is attached to this article as Electronic Supplementary Material (supplemental materials are available with the online version of CORR). This article is ©1955 by Lippincott Williams and Wilkins and is reprinted with permission from Jackson R. The cervical syndrome. Clin Orthop Relat Res. 1955;5:138–148.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s11999-010-1278-8) contains supplementary material, which is available to authorized users. Richard A. Brand MD (✉) Clinical Orthopaedics and Related Research, 1600 Spruce Street, Philadelphia, PA 19103, USA e-mail: dick.brand@clinorthop.org

Hip structural geometry and incidence of hip fracture in postmenopausal women: what does it add to conventional bone mineral density?

SUMMARY

Hip geometry measurements of outer diameter and buckling ratio at the intertrochanter and shaft of the hip dual energy X-ray absorptiometry (DXA) scan predicted incident hip fracture in postmenopausal women. These associations, independent of age, body size, clinical risk factors, and conventional areal bone mineral density, suggest hip geometry plays a role in fracture etiology and may aid in improving identification of older women at high fracture risk.

INTRODUCTION

This study examined whether hip geometry parameters predicted hip fracture independent of body size, clinical risk factors, and conventional femoral neck bone mineral density (aBMD) and whether summary factors could be identified to predict hip fracture.

METHODS

We studied 10,290 postmenopausal women from the Women's Health Initiative. Eight thousand eight hundred forty-three remained fracture free during follow-up to 11 years of follow-up, while 147 fractured their hip, and 1,300 had other clinical fractures. Hip structural analysis software measured bone cross-sectional area, outer diameter, section modulus, average cortical thickness, and buckling ratio on archived DXA scans in three hip regions: narrow neck, intertrochanter, and shaft. Hazard ratios were estimated using Cox proportional hazards models for individual parameters and for composite factors extracted from principal components analysis from all 15 parameters.

RESULTS

After adjustment for age, body size, clinical risk factors, and aBMD, intertrochanter and shaft outer diameter measurements remained independent predictors of hip fracture with hazard ratios for a one standard deviation increase of 1.61 (95% confidence interval (CI), 1.25-2.08) for the intertrochanter and 1.36 (95% CI, 1.06-1.76) for the shaft. Average buckling ratios also independently predicted incident hip fracture with hazard ratios of 1.43 (95% CI, 1.10-1.87) at the intertrochanter and 1.24 (95% CI, 1.00-1.55) at the shaft. Although two composite factors were extracted from principal components analysis, neither was superior to these individual measurements at predicting incident hip fracture.

CONCLUSIONS

Two hip geometry parameters, intertrochanter outer diameter and buckling ratio, predict incident hip fracture after accounting for clinical risk factors and aBMD.

Baseline serum estradiol and fracture reduction during treatment with hormone therapy: the Women's Health Initiative randomized trial

INTRODUCTION

The purpose of the study was to test the hypothesis that the reduction in fractures with hormone therapy (HT) is greater in women with lower estradiol levels.

METHODS

We conducted a nested case-control study within the Women's Health Initiative HT Trials. The sample included 231 hip fracture case-control pairs and a random sample of 519 all fracture case-control pairs. Cases and controls were matched for age, ethnicity, randomization date, fracture history, and hysterectomy status. Hormones were measured prior to randomization. Incident cases of fracture were identified over an average follow-up of 6.53 years.

RESULTS

There was no evidence that the effect of HT on fracture differed by baseline estradiol (E2) or sex hormone binding globulin (SHBG). Across all quartiles of E2 and SHBG, women randomized to HT had about a 50% lower risk of fracture, including hip fracture, compared to placebo.

CONCLUSION

The effect of HT on fracture reduction is independent of estradiol and SHBG levels.

Baseline Endogenous Estradiol and the Association of Hormone Therapy with Breast Cancer Risk, the Women's Health Initiative Clinical Trials

Background: The effect of exogenous hormones on breast cancer risk may depend on baseline endogenous levels of estradiol (E2). We investigated whether women with lower E2 levels will have the greatest increase in breast cancer risk during treatment with estrogen plus progestin ((E+P); combined conjugated equine estrogens (CEE) plus medroxyprogesterone acetate) or estrogen-alone ((E-alone); CEE) therapy. Additionally, we examined whether the risk of breast cancer varies by untreated levels of endogenous E2.Methods: We performed an ancillary study within the Women's Health Initiative E+P and E-alone clinical trials. We used a case-only design to test for interactions between untreated levels of E2 and hormone therapy (E+P or E-alone) on breast cancer risk. We measured baseline levels of bioavailable E2 in 346 cases of invasive breast cancer from the E+P trial and 231 cases from the E-alone trial. To estimate the risk of breast cancer by endogenous E2 levels (expressed as quartiles), we used a case-cohort design which included the cases described above in addition to a randomly selected comparison group (N=387; 203 from the E+P and 184 from the E-alone trial). Incident breast cancer cases were identified over an average follow-up of 4.1 years in the E+P trial and 5.4 years in the E-alone trial. All analyses were performed separately for the E+P and the E-alone trials.Results: In the case-only study, the effect of E+P therapy on breast cancer risk did not seem to vary by endogenous E2 quartiles (p-heterogeneity= 0.16). Breast cancer risk associated with E-alone treatment tended to be greater among women with the lowest E2 levels; however this association was not significant (hazard ratio (HR)= 1.44, 95% confidence interval (CI)= 0.79-2.59).Table 1. Effects of E+P and E-alone treatments on breast cancer risk (HR (95% CI)) by quartiles of baseline estradiol: case-only results E+PE-aloneEstradiol  Quartile 11.20 (0.80-1.80)1.44 (0.79-2.59)Quartile 20.88 (0.58-1.34)0.98 (0.58-1.67)Quartile 31.27 (0.81-2.00)0.79 (0.47-1.33)Quartile 40.67 (0.43-1.06)0.92 (0.57-1.49)P-heterogeneity0.160.51P-trend0.160.20 In the case-cohort analysis, higher endogenous E2 levels were associated with increased breast cancer risk (p-trend= 0.01), independent of hormone therapy.Table 2. Effects of baseline estradiol and hormone therapy (E+P vs. E-alone) on breast cancer risk (HR (95% CI)): case-cohort results E+PE-aloneHormone therapy treatment (Reference= placebo group)1.01 (0.96-1.07)0.84 (0.56-1.26)   Estradiol  Quartile 1 (Reference)1.001.00Quartile 21.22 (0.75-2.00)1.30 (0.77-2.17)Quartile 31.41 (0.87-2.32)1.32 (0.77-2.27)Quartile 41.85 (1.12-3.03)2.38 (1.32-4.35)P-trend0.010.01 Conclusion: The risk of breast cancer increases with higher levels of untreated endogenous E2. However, untreated E2 level does not modify the effect of E+P or E-alone therapy on breast cancer risk. Estradiol measurement is unlikely to identify women where hormone therapy may substantially increase the risk of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 906.

Alcohol, cardiovascular diseases and all causes of death: a review of the epidemiological evidence

This paper reviews the epidemiological evidence on the association of alcohol consumption with the major cardiovascular diseases (hypertension, stroke and coronary heart disease), and all causes of death. The focus is on light and moderate consumption and several important methodological issues are apparent with the epidemiological evidence on alcohol and mortality. The epidemiological data justify the following recommendations on alcohol consumption. The evidence does not support the unqualified claim that light and moderate drinking confers overall health benefits. However, in persons over 35 years of age, there is no consistent evidence that daily consumption of up to 2-3 drinks in men or up to 1-2 drinks in women increases the risk of dying. Non-drinkers should not be encouraged to change their drinking status. The consumption of more than 2-3 drinks per day in men and more than 1-2 drinks per day in women should be actively discouraged. Further research on the effects of light and moderate alcohol consumption on cardiovascular disease and all causes of death are required, particularly in young people, women and the elderly.

Amantadine, oseltamivir and zanamivir for the prophylaxis of influenza (including a review of existing guidance no. 67): a systematic review and economic evaluation

OBJECTIVES

To evaluate the clinical effectiveness and incremental cost-effectiveness of amantadine, oseltamivir and zanamivir for seasonal and post-exposure prophylaxis of influenza.

DATA SOURCES

A MEDLINE search strategy was used and searches were carried out in July 2007.

REVIEW METHODS

An independent health economic model was developed based on a review of existing cost-effectiveness models and clinical advice.The model draws together a broad spectrum of evidence relating to the costs and consequences associated with influenza and its prevention. Where direct evidence concerning the effectiveness of prophylaxis within specific model subgroups was lacking, the model uses estimates from mixed subgroups or extrapolates from other mutually exclusive subgroups.

RESULTS

Twenty-six published references relating to 22 randomised controlled trials (RCTs) were included in the clinical effectiveness review, along with one unpublished report. Eight, six and nine RCTs were included for amantadine, oseltamivir and zanamivir respectively. The study quality was variable and gaps in the evidence base limited the assessment of the clinical effectiveness of the interventions. For seasonal prophylaxis, there was limited evidence for the efficacy of amantadine in preventing symptomatic, laboratory-confirmed influenza (SLCI) in healthy adults [relative risk (RR) 0.40, 95% confidence interval (CI) 0.08-2.03]. Oseltamivir was effective in preventing SLCI, particularly when used in at-risk elderly subjects (RR 0.08, 95% CI 0.01-0.63). The preventative efficacy of zanamivir was most notable in at-risk adults and adolescents (RR 0.17, 95% CI 0.07-0.44), and healthy and at-risk elderly subjects (RR 0.20, 95% CI 0.02-1.72). For post-exposure prophylaxis, data on the use of amantadine were again limited: in adolescents an RR of 0.10 (95% CI 0.03-0.34) was reported for the prevention of SLCI. Oseltamivir was effective in households of mixed composition (RR 0.19, 95% CI 0.08-0.45). The efficacy of zanamivir in post-exposure prophylaxis within households was also reported (RR 0.21, 95% CI 0.13-0.33). Interventions appeared to be well tolerated. Limited evidence was available for the effectiveness of the interventions in preventing complications and hospitalisation and in minimising length of illness and time to return to normal activities. No clinical effectiveness data were identified for health-related quality of life or mortality outcomes. With the exception of at-risk children, the incremental cost-utility of seasonal influenza prophylaxis is expected to be in the range 38,000-428,000 pounds per QALY gained (depending on subgroup). The cost-effectiveness ratios for oseltamivir and zanamivir as post-exposure prophylaxis are expected to be below 30,000 pounds per QALY gained in healthy children, at-risk children, healthy elderly and at-risk elderly individuals. Despite favourable clinical efficacy estimates, the incorporation of recent evidence of viral resistance to amantadine led to it being dominated in every economic comparison.

CONCLUSIONS

All three interventions showed some efficacy for seasonal and post-exposure prophylaxis. However, weaknesses and gaps in the clinical evidence base are directly relevant to the interpretation of the health economic model and rendered the use of advanced statistical analyses inappropriate. These data limitations should be borne in mind in interpreting the findings of the review.

Comparison of event rates among three MONICA centres

Data from three MONICA centres in Auckland (New Zealand) and Newcastle and Perth (Australia) are used to explore some of the issues involved in comparing event rates and case fatality among MONICA centres. Auckland and Newcastle follow the "hot pursuit" method of identifying and interviewing patients while they are still in hospital. Perth follows the "cold pursuit" method, in which patients are identified by search of computerized hospital records after discharge and all data are abstracted retrospectively from case notes. Fatal cases are identified by the same method in the three centres. The distribution of events by MONICA diagnostic classification varied among centres, with Perth having the highest proportion of definite myocardial infarction events and the lowest proportion of possible myocardial infarction events. These differences appear to be due to the different methods of event ascertainment and data collection, and to variations in post mortem rates between centres. For comparisons among these three centres, the categories of non-fatal definite myocardial infarction and of all coronary heart disease deaths (that is those in the MONICA categories fatal definite myocardial infarction, fatal possible myocardial infarction, and fatal cases with insufficient data) appear to be the most useful.

Acephate resistance in populations of the tarnished plant bug (Heteroptera: Miridae) from the Mississippi River Delta

A monitoring program that used a glass-vial bioassay to detect acephate resistance in populations of the tarnished plant bug, Lygus lineolaris (Palisot de Beauvois) (Heteroptera: Miridae), was carried out with weed-collected populations from 20 sites in the delta of Arkansas, Louisiana, and Mississippi. Additional results from field tests using recommended rates of formulated acephate in cotton showed that plant bug populations with resistance ratio (RR50) values > 3.0 for acephate (from the glass-vial bioassay) would be difficult to control in the field. Over a 4-yr-period from 2001 through 2004, only one population tested with the glass-vial bioassay was found with an RR50 value > 3.0 for acephate, but six populations having RR50 values > 3.0 were found in the delta in 2005. In fall 2005, an additional 10 populations from the hill region (the cotton growing areas outside the delta) were tested and four of these populations had RR50 values > 3.0. The number of populations with RR50 values > 3.0 increased to five of 10 and 18 of 20 in the hills and delta, respectively, in fall 2006. Laboratory tests using resistant populations found that resistance to acephate was not sex-linked and the alleles controlling the resistance were semidominant in nature. Because of the large increase in resistant populations and the nature of the resistance found in this study, along with control problems experienced by growers in 2006, entomologists in the mid-South strongly recommended that alternation of insecticide classes in field treatments for plant bug control be used by growers in 2007. This control strategy probably helped control plant bugs in the hills of MS where plant bug pressure was low in 2007, and only one population was found in the fall with an RR50 value > 3.0. Plant bug pressure was very high in many parts of the delta in 2007, and 15 of the 20 populations tested in the fall had RR50 values > 3.0. In one field test in cotton, a population with multiple resistance was tested and not effectively controlled in treatments using recommended rates of carbamate, organophosphate, and pyrethroid insecticides. Alternation of insecticide classes may not work very well when populations are present that are resistant to three of the four main classes of cotton insecticides. New insecticides in different classes are badly needed for control of tarnished plant bugs in cotton in the mid-South.

Holding personal information in a disease-specific register: the perspectives of people with multiple sclerosis and professionals on consent and access

OBJECTIVE

To determine the views of people with multiple sclerosis (MS) and professionals in relation to confidentiality, consent and access to data within a proposed MS register in the UK.

DESIGN

Qualitative study using focus groups (10) and interviews (13).

SETTING

England and Northern Ireland.

PARTICIPANTS

68 people with MS, neurologists, MS nurses, health services management professionals, researchers, representatives from pharmaceutical companies and social care professionals.

RESULTS

People with MS expressed open and altruistic views towards the use of their personal information to facilitate service provision and research, placing trust in responsible guardianship and legitimate use of their information. Participant's proposed that people with MS should be able to select their individual level of involvement in a register using levels of consent. It was agreed that access to the register should be governed by a guardianship committee composed of a range of stakeholders. People with MS did not wish their details to be used by marketing agencies and did not consider this a legitimate use of their data. Whilst participants were positive of the role a register could play in promoting research, participants felt that access to data by pharmaceutical industries should be administered by the guardianship committee. People with MS are concerned should their employers be able to access their personal information. Professionals were more cautious than people with MS in their approach to the use of patient personal data within a register.

CONCLUSIONS

Whilst all stakeholders were positive of the benefits of an MS register, development of such a resource must incorporate robust data security and guardianship measures in order to ensure that, whilst opportunities are maximised, risks to the privacy of individuals and legal challenges to professionals are avoided.

Predictors of adherence in the Women's Health Initiative Calcium and Vitamin D Trial

The authors analyzed data from the Women's Health Initiative (WHI) Calcium and Vitamin D Supplementation Trial (CaD) to learn more about factors affecting adherence to clinical trial study pills (both active and placebo). Most participants (36,282 postmenopausal women aged 50-79 years) enrolled in CaD 1 year after joining either a hormone trial or the dietary modification trial of WHI. The WHI researchers measured adherence to study pills by weighing the amount of remaining pills at an annual study visit; adherence was primarily defined as taking > or = 80% of the pills. The authors in this study examined a number of behavioral, demographic, procedural, and treatment variables for association with study pill adherence. They found that relatively simple procedures (ie, phone contact early in the study [4 weeks post randomization] and direct social contact) later in the trial may improve adherence. Also, at baseline, past pill-use experiences, personal supplement use, and relevant symptoms may be predictive of adherence in a supplement trial.

Prevalence of pathogenic Leptospira spp. in sheep in a sheep-only abattoir in New Zealand

AIM

To determine the prevalence of the two most commonly diagnosed pathogenic Leptospira spp. serovars, Hardjobovis and Pomona, in sheep in a sheep-only abattoir in New Zealand, and to determine the prevalence of kidneys which were leptospire culture-positive collected from sheep seropositive or seronegative to the microscopic agglutination test (MAT).

METHODS

A repeated cross-sectional observational study was conducted of serological and kidney culture prevalences of Leptospira borgpetersenii serovar Hardjobovis and Leptospira interrogans serovar Pomona. Lines of sheep and individual sheep were systematically randomly selected at a sheep-only abattoir during 18 May 2004 to November 2004 and 06 December 2004 to 14 June 2005. Additionally, a cross-sectional study examined prevalences in a purposively selected line of sheep from a flock with clinical evidence of an outbreak of leptospirosis.

RESULTS

In the study population of 15,855 sheep of which 2,758 were sampled, 5.7 (95% CI=4.9-6.7)% were seropositive to one or both serovars; 44.2 (95% CI=34.6-54.2)% of 95 lines of sheep and 44.9 (95% CI=35.0-55.3)% of 89 farms showed serological evidence of infection. The serological prevalence of serovar Hardjobovis was significantly higher than that of serovar Pomona both at line (33% and 4%, respectively) and individual (5% and 1%, respectively) levels. A low but persistent seroprevalence of Hardjobovis throughout both years suggested low-level endemicity to this serovar, whereas Pomona infections appeared to be sporadic. Leptospires were isolated from kidneys of 8/37 (22%) Hardjobovis- and 1/6 (17%) Pomona-seropositive, and 5/499 (1%) seronegative animals. Of the animals purposively sampled from a farm with a clinical outbreak of leptospirosis, all kidneys from the 13 seropositive animals were culture-positive, indicating a high risk of exposure of meat workers in outbreak situations. Kidneys of MAT-seropositive sheep were 21.7 (95% CI=7.6-61.9) times more likely to test culture-positive than kidneys from animals with negative MAT titres. In general, the results indicated that 13/1,000 sheep slaughtered were potentially shedding leptospires.

CONCLUSIONS

The study demonstrated the presence of a definite risk of occupational exposure of meat workers in a sheep-only slaughterhouse to the two most commonly diagnosed pathogenic Leptospira spp. serovars in New Zealand.

Yield response of dual-toxin Bt cotton to Helicoverpa zea infestations

Field cage experiments were conducted to determine the impact of bollworms, Helicoverpa zea (Boddie), on yields of Bollgard II and Widestrike cotton, Gossypium hirsutum L. One-day-old bollworm larvae were infested in white flowers of Bollgard II and in white flowers and terminals of Widestrike cotton. The infestation levels included 0, 50, and 100% of white flowers for each type of cotton. Terminal infestations included one or two larvae per terminal on Widestrike cotton. Larvae were placed in flowers of Bollgard II cotton each day for 1 to 4 wk during the first 4 wk of flowering during 2003, 2004, and 2005 seasons and in the flowers or terminals of Widestrike cotton each day for 1 to 3 wk. Averaged across years and durations of infestation, yields of Bollgard II cotton were significantly reduced compared with noninfested Bollgard II cotton when 100% of white flowers were infested. For Widestrike cotton, there was a reduction in yield when 100% of white flowers were infested in 2005, but not in 2006. There was a significant relationship for cumulative numbers of white flowers infested on seedcotton yield of Bollgard II during one of the 3 yr of the experiment. The regression equation during that year had a slope of -0.77. No significant relationships were observed for cumulative numbers of white flowers infested on yields of Widestrike cotton. Results of the current experiment suggest bollworms will rarely cause yield losses of Bollgard II and Widestrike cotton. Future research will need to focus on developing specific thresholds for bollworms on Bollgard II and Widestrike cotton.

Animal-side serologic assay for rapid detection of Mycobacterium bovis infection in multiple species of free-ranging wildlife

Numerous species of mammals are susceptible to Mycobacterium bovis, the causative agent of bovine tuberculosis (TB). Several wildlife hosts have emerged as reservoirs of M. bovis infection for domestic livestock in different countries. In the present study, blood samples were collected from Eurasian badgers (n=1532), white-tailed deer (n=463), brushtail possums (n=129), and wild boar (n=177) for evaluation of antibody responses to M. bovis infection by a lateral-flow rapid test (RT) and multiantigen print immunoassay (MAPIA). Magnitude of the antibody responses and antigen recognition patterns varied among the animals as determined by MAPIA; however, MPB83 was the most commonly recognized antigen for each host studied. Other seroreactive antigens included ESAT-6, CFP10, and MPB70. The agreement of the RT with culture results varied from 74% for possums to 81% for badgers to 90% for wild boar to 97% for white-tailed deer. Small numbers of wild boar and deer exposed to M. avium infection or paratuberculosis, respectively, did not cross-react in the RT, supporting the high specificity of the assay. In deer, whole blood samples reacted similarly to corresponding serum specimens (97% concordance), demonstrating the potential for field application. As previously demonstrated for badgers and deer, antibody responses to M. bovis infection in wild boar were positively associated with advanced disease. Together, these findings suggest that a rapid TB assay such as the RT may provide a useful screening tool for certain wildlife species that may be implicated in the maintenance and transmission of M. bovis infection to domestic livestock.

Explaining trends in coronary heart disease hospitalisations in New Zealand: trend for admissions and incidence can be in opposite directions

BACKGROUND

A recent increase in the absolute number of hospitalisations for acute myocardial infarction (AMI) in New Zealand may signal a new epidemic of coronary heart disease (CHD).

OBJECTIVE

To quantify the impact of factors other than incidence of disease on these national hospitalisation trends.

METHODS

A total of 324,663 electronic records of New Zealand public CHD hospitalisations from 1993 to 2005 were examined. Repeat admissions were identified by record linkage using a unique national health identifier for each patient.

RESULTS

Hospitalisations for AMI increased by about 8% a year throughout the 13-year study period. Interhospital transfers increased by 117% over the study period, while readmissions increased by 42%. By 2005 over 60% of all admissions for CHD were readmissions. After accounting for readmissions, hospital transfers and population changes, the age-standardised first AMI hospitalisation rate peaked in 1995 and has since declined by 15%. Reciprocal trends in AMI and angina hospitalisations were seen, indicating changing diagnostic criteria. Overall hospitalisation rates for first CHD events remained relatively steady at about 216.4 events per 100,000 between 1993 and 2000 and subsequently declined by 25% to 162.2 events per 100,000 in 2005.

CONCLUSION

Recent trends in hospitalisation rates for AMI are significantly influenced by factors other than underlying changes in CHD incidence. Increasing absolute numbers of admissions coded as AMI in New Zealand between 1993 and 2005 can be accounted for by increases in readmissions, increases in interhospital transfers, changes in diagnostic criteria for AMI and in demography.

A systematic review of epidemiological studies investigating risk factors for work-related road traffic crashes and injuries

OBJECTIVE

To critically appraise the published evidence for risk factors for injuries and deaths relating to work-related road traffic crashes.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases searched included Medline, EMBASE, PsycINFO, Transport database, and the Australian Transport and Road Index (ATRI) database. Additional searches included websites of relevant organizations, reference lists of included studies, and issues of major injury journals published within the past 5 years.

INCLUSION CRITERIA

Studies were included if they investigated work-related traffic crashes or related injuries or deaths as the outcome, measured any potential risk factor for work-related road traffic crash as an exposure, included a relevant comparison group, and were written in English.

METHODS

Included studies were critically appraised using the GATE-lite critical appraisal form (www.epiq.co.nz). Meta-analysis was not attempted because of the heterogeneity of the included studies.

FINDINGS

Of 25 studies identified, three of four robust (case-control and case-crossover) studies found an increased injury risk (i) among workers after extended shifts, (ii) for tractor-trailers with brake and steering defects, and (iii) for "double configuration" trucks. The fourth study showed that alcohol and drug use were not risk factors in an industry with a random testing policy. The best cross-sectional studies showed associations between injury and sleepiness, time spent driving, occupational stress, non-insulin-dependent uncomplicated diabetes, and use of narcotics and antihistamines.

CONCLUSIONS

Modifiable behavioral and vehicle-related risk factors are likely to contribute to work-related traffic injury. Fatigue and sleepiness-the most commonly researched topics-were consistently associated with increased risk.

Application of modelling to determine the absence of foot-and-mouth disease in the face of a suspected incursion

AIM

To use disease modelling to inform a response team about the number of animals per herd/flock to be examined, and the start date and duration of clinical surveillance required to be confident that foot-and-mouth disease (FMD) was not present on an island in New Zealand with a population of approximately 1,600 cattle, 10,000 sheep and a small number of pigs, goats and alpacas.

METHODS

Because the probability of detecting clinical disease in (the) primary case(s) in larger herds and flocks was extremely low, deterministic and stochastic mathematical SLIR (susceptible, latent, infectious, recovered) models for the transmission of infection were constructed to estimate the date when clinical lesions in herds and flocks would be detected with 95% confidence. Surveillance targeted the first wave of infections following a suspect index case.

RESULTS

If 70 cattle in herds of about 400 cattle were examined it was estimated it would take approximately 13 (90% stochastic range 9-19) days from first exposure before it would be possible to achieve 95% confidence for detecting clinical signs for a low-virulence virus, and 9 (7-14) days for a high-virulence virus. The duration of sufficiently accurate clinical detection was 17 (15-19) days and 13 (12-14) days for low- and high-virulence viruses, respectively. A sample of 70 sheep from flocks of >1,000 would be required to achieve clinical detection at about the same time but with a shorter period of detection than for cattle. The duration of effective detection could be increased by examining a larger sample in most sheep flocks, however the small size of many cattle herds in the study population limited the confidence of detecting group-level disease in cattle, therefore necessitating repeated herd inspections. The model suggested that group-level detection was not feasible if it was based on elevated body temperature alone because of short durations of fever in infected animals.

CONCLUSION AND CLINICAL RELEVANCE

Simulation modelling is a useful and powerful tool for informing ongoing surveillance activities in the face of an exotic disease incursion. Results of modelling suggested to start clinical inspection activities at 4 days and to continue regular inspection twice a week for about 35 days after the date of first exposure, to satisfy the required 95% confidence threshold of clinical detection of FMD in cattle herds and sheep flocks.

Pathways to diagnosis of cervical cancer: screening history, delay in follow up, and smear reading

BACKGROUND

The aim of this study was to determine the most important ways to reduce incidence of and mortality from cervical cancer by a nationally co-ordinated screening programme.

DESIGN

Descriptive study.

SETTING

The New Zealand National Cervical Screening Programme: a nationally organised and co-ordinated programme.

SAMPLE

Women aged younger than 80 years with histologically proven primary invasive cervical cancer, including microinvasive disease, diagnosed between 1 January 2000 and 30 September 2002. Consent for access to medical records was gained for 371 of 445 eligible women (83%). A total of 359 (81%) of eligible women or their next of kin consented to interview.

METHODS

Data on events prior to diagnosis were obtained from routine sources, interview, medical record review and slide reread.

MAIN OUTCOME MEASURES

Frequency of screening in the 7 years prior to diagnosis, time from abnormal smear or symptoms to appropriate diagnostic confirmation, proportion of negative smears upgraded to high grade on reread.

RESULTS

Half of the 371 participants (83% of 445 eligible women) had not had a screening smear in the 3 years prior to diagnosis, and 80% were defined as inadequately screened. A maximum of 17% of women overall or within any defined subgroup experienced delays in follow up of abnormal smears or bleeding. Only 11% of women overall had had a high-grade smear, which was originally read as negative.

CONCLUSIONS

The most important factor in women's pathways to a diagnosis of cervical cancer was inadequate screening. While delays in diagnosis could be reduced and laboratory performance improved, priority must be given to improving uptake and frequency of screening.

Assessment of the transtheoretical model as used by dietitians in promoting physical activity in people with type 2 diabetes

BACKGROUND

The transtheoretical model of change (TTM) is an approach to behaviour change, which has been successful in increasing physical activity levels. This study examined the application of a TTM approach to increase physical activity in people with type 2 diabetes by a specialist dietitian.

METHODS

Forty participants were recruited to either an exercise consultation interview (ECI) or a control group. All participants received a physical activity leaflet and those in the ECI group also received a one-to-one interview with a dietitian a week after their routine appointment. Both self-reported physical activity levels and stage of change were measured at baseline and after 6 weeks.

RESULTS

Thirty-four participants (17 in each group) completed the study. Both groups showed an increase in physical activity levels. However, there was a significant difference in change of physical activity levels in the ECI group alone [F(1,32)=15.99;P<or=0.01]. In the ECI group, eight participants increased their stage of change compared with just one in the control group. There was a highly significant difference between the ECI and control group for success rates of stage progression (P=0.007).

CONCLUSIONS

A specialist dietitian with motivational interviewing and behavioural change training can successfully deliver a TTM intervention to people with diabetes that results in an increase in physical activity and stage of change. Dietitians with behavioural change skills may wish to include this approach within their practice.

MAMMOT--a set of tools for the design, management and visualization of genomic tiling arrays

The MAMMOT software suite is a collection of Perl and PHP scripts for designing, annotating and visualizing genome tiling arrays to, for example, facilitate studies into the epigenetics of gene regulation. The web design allows rapid experimental data entry from multiple users, and results can easily be shared between groups and individuals.

AVAILABILITY

http://www.mammot.org.uk/

CONTACT

e.ryder@gen.cam.ac.uk.

Tuberculosis in a free-living brown hare (Lepus europaeus occidentalis)

A free-living brown hare (Lepus europaeus occidentalis) trapped during a survey of tuberculous possums in the Ahaura Valley, Westland, was found to have both microbiological and histopathological evidence of infection with Mycobacterium bovis. The mesenteric lymph nodes were enlarged and showed extensive caseation, tuberculous nodules were present in the liver and kidney, and there was a proliferative pleurisy. Histologically, characteristic tuberculous granulomatous foci were seen in the mesenteric lymph nodes, liver, kidney, pleura and lungs, often in association with small numbers of acid-fast organisms. This is the first report of naturally occurring tuberculosis due to M. bovis in the brown hare.