Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Improving awareness of the HCR-20 and risk assessment process

BACKGROUND

In 2011 Mrs A assaulted two people, one who died. In the hours prior to the attack she made multiple attempts to gain help including attending accident and emergency, contact with an inpatient service and the police. Subsequent investigation highlighted that her risk was not well documented or understood.

OBJECTIVE

This quality improvement project aimed to improve knowledge and awareness of HCR-20 risk assessments amongst mental health professionals.

METHOD

The Quality Improvement approach was taken and various initiatives were introduced to improve knowledge of the location and purpose of the HCR-20 and to ensure that these risk assessments were regularly updated.

RESULTS

The results indicated that knowledge relating to the HCR-20 significantly improved amongst staff and breaches of deadlines for updating these risk assessments dramatically declined after the induction of the interventions.

CONCLUSION

Including the 'risk formulation' and 'scenarios' from the HCR-20 in clients' crisis plans, introducing training relating to the HCR-20, and including discussions relating to the HCR-20 at the beginning of CPA meetings resulted in improved MDT awareness and knowledge of the HCR-20. A broader understanding and awareness of risk factors enabled the service to move towards a culture of risk being everyone's business.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

Assessment of TB underreporting by level of reporting system in Lagos, Nigeria

BACKGROUND: Nigeria has an estimated TB prevalence of 219 per 100,000 population. In 2019, Nigeria diagnosed and notified 27% of the WHO-estimated cases of all forms of TB and contributed 11% of the missing TB cases globally.OBJECTIVE: To assess TB underreporting by type and level of health facility (HF), and associated factors in Lagos State, Nigeria.METHODOLOGY: Quantitative secondary data analysis of TB cases was conducted in 2015. χ2 test was used to assess the association between treatment initiation, TB underreporting, local government area (LGA) and HF characteristics.RESULTS: Overall, 2,064 persons with bacteriologically confirmed TB (15.5%) were not matched to patients in sampled TB registers. Treatment status was unknown for 86 cases (IQR 55–97) per LGA. LGAs with higher case-loads had higher proportions of cases with unknown TB status. Discrepant reporting of treated TB was also common (60% HFs). Primary-level TB treatment facilities and unengaged private facilities were less likely to notify.CONCLUSION: There was TB under-reporting across all types and levels of HFs and LGAs. There is a need to revise or strengthen the process of supervision and data quality assurance system at all levels

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Aortic Stiffness, Pulse Pressure, and Cerebral Pulsatility Progress Despite Best Medical Management: The OXVASC Cohort

BACKGROUND

Increased cerebral arterial pulsatility is associated with cerebral small vessel disease, recurrent stroke, and dementia despite the best medical treatment. However, no study has identified the rates and determinants of progression of arterial stiffness and pulsatility.

METHODS

In consecutive patients within 6 weeks of transient ischemic attack or nondisabling stroke (OXVASC [Oxford Vascular Study]), arterial stiffness (pulse wave velocity [PWV]) and aortic systolic, aortic diastolic, and aortic pulse pressures (aoPP) were measured by applanation tonometry (Sphygmocor), while middle cerebral artery (MCA) peak (MCA-PSV) and trough (MCA-EDV) flow velocity and Gosling pulsatility index (PI; MCA-PI) were measured by transcranial ultrasound (transcranial Doppler, DWL Doppler Box). Repeat assessments were performed at the 5-year follow-up visit after intensive medical treatment and agreement determined by intraclass correlation coefficients. Rates of progression and their determinants, stratified by age and sex, were determined by mixed-effects linear models, adjusted for age, sex, and cardiovascular risk factors.

RESULTS

In 188 surviving, eligible patients with repeat assessments after a median of 5.8 years. PWV, aoPP, and MCA-PI were highly reproducible (intraclass correlation coefficients, 0.71, 0.59, and 0.65, respectively), with progression of PWV (2.4%; P<0.0001) and aoPP (3.5%; P<0.0001) but not significantly for MCA-PI overall (0.93; P=0.22). However, PWV increased at a faster rate with increasing age (0.009 m/s per y/y; P<0.0001), while aoPP and MCA-PI increased significantly above the age of 55 years (aoPP, P<0.0001; MCA-PI, P=0.009). Higher aortic systolic blood pressure and diastolic blood pressure predicted a greater rate of progression of PWV and aoPP, but not MCA-PI, although current MCA-PI was particularly strongly associated with concurrent aoPP (P<0.001).

CONCLUSIONS

Arterial pulsatility and aortic stiffness progressed significantly after 55 years of age despite the best medical treatment. Progression of stiffness and aoPP was determined by high blood pressure, but MCA-PI predominantly reflected current aoPP. Treatments targetting cerebral pulsatility may need to principally target aortic stiffness and pulse pressure to have the potential to prevent cerebral small vessel disease.

Design of a randomised, double-blind, crossover, placebo-controlled trial of effects of sildenafil on cerebrovascular function in small vessel disease: Oxford haemodynamic adaptation to reduce pulsatility trial (OxHARP)

Background

Cerebral small vessel disease (SVD) is associated with increased cerebrovascular pulsatility, endothelial dysfunction, and impaired vascular reactivity. Vasodilating phosphodiesterase inhibitors may improve cardiovascular pulsatility and reactivity, and potentially reduce progression of SVD.

Hypothesis: Sildenafil, a PDE5 inhibitor, will reduce cerebrovascular pulsatility and increase cerebrovascular reactivity compared to placebo, and is non-inferior to cilostazol, a PDE3 inhibitor.

Methods

OxHARP is a randomised, double-blind, crossover trial of sildenafil 50 mg thrice daily, cilostazol 100 mg twice daily and placebo in 75 patients with mild to moderate small vessel disease and a previous lacunar or cryptogenic stroke or TIA. Participants undergo a physiological assessment at baseline and on each treatment, including transcranial Doppler ultrasound (TCD, DWL DopplerBox) to assess cerebrovascular pulsatility and reactivity to 4–6% carbon dioxide. In up to 60 patients, cerebrovascular pulsatility, perfusion and reactivity will also be assessed by MRI.

Outcome measures

The primary outcome is difference in middle cerebral artery pulsatility (Gosling’s Pulsatility Index, PI) after 3 weeks of sildenafil versus placebo. Secondary outcomes including non-inferiority of sildenafil vs cilostazol in effects on PI, percentage increase in MCA blood flow velocity and BOLD-fMRI response during inhalation of 4–6% carbon dioxide.

Discussion

Reduction in cerebral pulsatility and increased cerebrovascular reactivity during treatment with sildenafil would indicate potential benefit to prevent progression of SVD, suggesting a need for trials with clinical outcomes.

Trial Registration OxHARP is registered with ClinicalTrials.org, NCT03855332

589 Role of Liver Support Systems in The Management of Post Hepatectomy Liver Failure: A Meta-Analysis and Systematic Review of Literature

Aim

Post hepatectomy liver failure (PHLF) is a rare but serious complication following liver resection. PHLF is associated with high mortality of up to 50% in severe cases. With limited treatment options available, there is a need to evaluate the role of systems that support the function of the liver as treatment modalities following PHLF development.

Method

The aim of this study was to review the literature and summarise the role of liver support systems (LSS) in the management of PHLF. Publications of interest were identified using systematically designed searches. Following screening, data from the relevant publications were extracted, pooled where possible, and analysed.

Results

Systematic review identified ten studies, which used either Plasma Exchange (PE) or Molecular Adsorbent Recirculating System (MARS) as LSS after PHLF development. The sample sizes of included studies were small, ranging from N = 2 to N = 13. Across all studies, the pooled 90-day mortality rate was 40% (95% CI: 15% - 68%). However, there was substantial heterogeneity (I2=64%), likely since the studies used a variety of definitions for PHLF and had different selection criteria for patient eligibility for LSS treatment.

Conclusions

Despite potential benefits, the current evidence is insufficient to recommend LSS for the routine management of severe PHLF, with the current literature consisting of only a limited number of studies. There is a definite need for larger, multicentre, prospective studies evaluating the conventional and newer modalities of support systems with a view to improve the outcomes in this group of patients.

Physiological determinants of residual cerebral arterial pulsatility on best medical treatment after TIA or minor stroke

Cerebral arterial pulsatility is strongly associated with cerebral small vessel disease and lacunar stroke yet its dependence on central versus local haemodynamic processes is unclear. In a population-based study of patients on best medical managment, 4-6 weeks after a TIA or non-disabling stroke, arterial stiffness and aortic systolic, diastolic and pulse pressures were measured (Sphygmocor). Middle cerebral artery peak and trough flow velocities and Gosling's pulsatility index were measured by transcranial ultrasound. In 981 participants, aortic and cerebral pulsatility rose strongly with age in both sexes, but aortic diastolic pressure fell more with age in men whilst cerebral trough velocity fell more in women. There was no significant association between aortic systolic or diastolic blood pressure with cerebral peak or trough flow velocity but aortic pulse pressure explained 37% of the variance in cerebral arterial pulsatility, before adjustment, whilst 49% of the variance was explained by aortic pulse pressure, arterial stiffness, age, gender and cardiovascular risk factors. Furthermore, arterial stiffness partially mediated the relationship between aortic and cerebral pulsatility. Overall, absolute aortic pressures and cerebral blood flow velocity were poorly correlated but aortic and cerebral pulsatility were strongly related, suggesting a key role for transmission of aortic pulsatility to the brain.

Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven.

METHODS

This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms.

DISCUSSION

The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04153864 . Registered on November 6, 2019.

Body Mass Index and Arterial Stiffness Are Associated With Greater Beat-to-Beat Blood Pressure Variability After Transient Ischemic Attack or Minor Stroke

[Figure: see text].

Progression of Beat-to-Beat Blood Pressure Variability Despite Best Medical Management

Supplemental Digital Content is available in the text.

Beat-to-beat variability in blood pressure (BP) is associated with recurrent stroke despite good control of hypertension. However, no study has identified rates of progression of beat-to-beat BP variability (BPV), its determinants, or which patient groups are particularly affected, limiting understanding of its potential as a treatment target. In consecutive patients one month after a transient ischaemic attack or nondisabling stroke (Oxford Vascular Study), continuous noninvasive BP was measured beat-to-beat over 5 minutes (Finometer). Arterial stiffness was measured by carotid-femoral pulse wave velocity (Sphygmocor). Repeat assessments were performed at the 5-year follow-up visit and agreement determined by intraclass correlation coefficient. Rates of progression of systolic BPV (SBPV) and diastolic BPV (DBPV) and their determinants were estimated by mixed-effect linear models, adjusted for age, sex, and cardiovascular risk factors. One hundred eighty-eight of 310 surviving, eligible patients had repeat assessments after a median of 5.8 years. Pulse wave velocity was highly reproducible but SBPV and DBPV were not (intraclass correlation coefficient: 0.71, 0.10, and 0.16, respectively), however, all 3 progressed significantly (pulse wave velocity, 2.39%, P<0.0001; SBPV, 8.36%, P<0.0001; DBPV, 9.7, P<0.0001). Rate of progression of pulse wave velocity, SBPV, and DBPV all increased significantly with age (P<0.0001), with an increasingly positive skew and were particularly associated with female sex (pulse wave velocity P=0.00035; SBPV P<0.0001; DBPV P<0.0001) and aortic mean SBP (SBPV P=0.037, DBPV P<0.0001). Beat-to-beat BP variability progresses significantly in high-risk patients, particularly in older individuals with elevated aortic systolic pressure. Beat-to-beat BPV and its progression represent potential new therapeutic targets to reduce cardiovascular risk.

Age and sex distribution of beat-to-beat blood pressure variability after transient ischemic attack and minor stroke: A population-based study

Background

Beat-to-beat blood pressure variability is associated with increased stroke risk but its importance at different ages is unclear.

Aims

To determine the age-sex distribution of blood pressure variability in patients with transient ischemic stroke or minor stroke.

Methods

In consecutive patients within six weeks of transient ischemic stroke or non-disabling stroke (Oxford Vascular Study), non-invasive blood pressure was measured beat-to-beat over five minutes (Finometer). The age-sex distribution of blood pressure variability (residual coefficient of variation) was determined for systolic blood pressure and diastolic blood pressure. The risk of top-decile blood pressure variability was estimated (logistic regression), unadjusted, and adjusted for age, sex, and cardiovascular risk factors.

Results

In 908 of 1013 patients, excluding 54 in atrial fibrillation and 51 with low quality recordings, residual coefficient of variation was positively skewed with a median systolic residual coefficient of variation of 4.2% (IQR 3.2–5.5) and diastolic residual coefficient of variation of 3.9% (3.0–5.5), with 90th centile thresholds of 7.2 and 7.3%. Median systolic residual coefficient of variation was higher in patients under 50 years (4.5 and 3.0–5.3) compared to 60–70 years (4.1 and 3.2–5.2), but rose to 4.5% (3.5–6.9) above 80 years, with an increasingly positive skew. The proportion of patients with markedly elevated blood pressure variability in the top-decile increased significantly per decade (OR 1.72, p < 0.001), after adjustment for sex and risk factors.

Conclusions

Median beat-to-beat blood pressure variability fell in midlife, reflecting loss of physiological, organized blood pressure variability. However, rates of markedly elevated blood pressure variability significantly increased with greater age, suggesting that blood pressure variability may be particularly important in older patients.

Integration of animal health and public health surveillance sources to exhaustively inform the risk of zoonosis: An application to visceral leishmaniasis data in Brazil

Visceral leishmaniasis (VL) is a parasitic disease that is endemic in more than 80 countries, and leads to high fatality rates when left untreated. We investigate the relationship of VL cases in dogs and human cases, specifically for evidence of VL in dogs leading to excess cases in humans. We use surveillance data for dogs and humans for the years 2007-2011 to conduct both spatial and spatio-temporal analyses. Several models are evaluated incorporating varying levels of dependency between dog and human data. Models including dog data show marginal improvement over models without; however, for a subset of spatial units with ample data, models provide concordant risk classification for dogs and humans at high rates (∼70%). Limited reported dog case surveillance data may contribute to the results suggesting little explanatory value in the dog data, as excess human risk was only explained by dog risk in 5% of regions in the spatial analysis.

Towards integrated surveillance of zoonoses: spatiotemporal joint modeling of rodent population data and human tularemia cases in Finland

Background

There are an increasing number of geo-coded information streams available which could improve public health surveillance accuracy and efficiency when properly integrated. Specifically, for zoonotic diseases, knowledge of spatial and temporal patterns of animal host distribution can be used to raise awareness of human risk and enhance early prediction accuracy of human incidence.

Methods

To this end, we develop a spatiotemporal joint modeling framework to integrate human case data and animal host data to offer a modeling alternative for combining multiple surveillance data streams in a novel way. A case study is provided of spatiotemporal modeling of human tularemia incidence and rodent population data from Finnish health care districts during years 1995–2012.

Results

Spatial and temporal information of rodent abundance was shown to be useful in predicting human cases and in improving tularemia risk estimates in 40 and 75% of health care districts, respectively. The human relative risk estimates’ standard deviation with rodent’s information incorporated are smaller than those from the model that has only human incidence.

Conclusions

These results support the integration of rodent population variables to reduce the uncertainty of tularemia risk estimates. However, more information on several covariates such as environmental, behavioral, and socio-economic factors can be investigated further to deeper understand the zoonotic relationship.

Spatially explicit survival modeling for small area cancer data

In this paper we propose a novel Bayesian statistical methodology for spatial survival data. Our methodology broadens the definition of the survival, density and hazard functions by explicitly modeling the spatial dependency using direct derivations of these functions and their marginals and conditionals. We also derive spatially dependent likelihood functions. Finally we examine the applications of these derivations with geographically augmented survival distributions in the context of the Louisiana Surveillance, Epidemiology, and End Results (SEER) registry prostate cancer data.

Spatial small area smoothing models for handling survey data with nonresponse

Spatial smoothing models play an important role in the field of small area estimation. In the context of complex survey designs, the use of design weights is indispensable in the estimation process. Recently, efforts have been made in these spatial smoothing models, in order to obtain reliable estimates of the spatial trend. However, the concept of missing data remains a prevalent problem in the context of spatial trend estimation as estimates are potentially subject to bias. In this paper, we focus on spatial health surveys where the available information consists of a binary response and its associated design weight. Furthermore, we investigate the impact of nonresponse as missing data on a range of spatial models for different missingness mechanisms and different degrees of missingness by means of an extensive simulation study. The computations were performed in R, using INLA and other existing packages. The results show that weight adjustment to correct for missingness has a beneficial effect on the bias in the missing at random setting for all models. Furthermore, we estimate the geographical distribution of perceived health at the district level based on the Belgian Health Interview Survey (2001). Copyright © 2017 John Wiley & Sons, Ltd.

Spinal clearance practices at a regional Australian hospital: A window to major trauma management performance outside metropolitan trauma centres

Background: Prevention of secondary spinal injury via spinal protection measures is a standard component of trauma management, and a high-quality spinal clearance process is imperative in achieving this aim. To evaluate the current practice with a view to achieving best practice, we sought to examine the spinal clearance process and outcomes at a regional Australian referral hospital, which services a large geographical catchment area. Methods: A retrospective review of medical records of all patients with major trauma who presented to an Australian regional hospital during 2014 was conducted. The primary outcome measure was missed or delayed diagnosis of spinal injury. Secondary outcome measures included compliance with internationally accepted spinal clearance process measures, timing and choice of appropriate imaging modalities, rates of spinal injury and documentation of spinal clearance. Results: Of the 112 patients with major trauma who met the study eligibility criteria and were discharged from hospital during the study period from 1 January to 31 December 2014, 11 spinal injuries were missed or delayed in diagnosis. The injuries occurred in 3.6% of patients and all were thoracolumbar spine (TLS) injuries. The predominant reasons for missed or delayed diagnosis were reduced sensitivity of plain X-ray compared with computed tomography for spinal injury screening and incomplete full spinal imaging to detect non-contiguous fractures. Conclusion: Evidence-based clinical decision rules are imperative in ascertaining the need for imaging in the TLS and would be enhanced by an internationally recognised definition of clinical significance based on injury morphology rather than clinician management decision alone. In addition, regional hospitals may have limited capacity to achieve spinal clearance, and other trauma quality assurance standards commensurate with national and international benchmarks without the valuable performance feedback provided by state trauma registries, as is currently the case in Queensland.

Osimertinib benefit in EGFR-mutant NSCLC patients with T790M-mutation detected by circulating tumour DNA

Background

Approximately 50% of epidermal growth factor receptor (EGFR) mutant non-small cell lung cancer (NSCLC) patients treated with EGFR tyrosine kinase inhibitors (TKIs) will acquire resistance by the T790M mutation. Osimertinib is the standard of care in this situation. The present study assesses the efficacy of osimertinib when T790M status is determined in circulating cell-free tumour DNA (ctDNA) from blood samples in progressing advanced EGFR-mutant NSCLC patients.

Material and methods

ctDNA T790M mutational status was assessed by Inivata InVision™ (eTAm-Seq™) assay in 48 EGFR-mutant advanced NSCLC patients with acquired resistance to EGFR TKIs without a tissue biopsy between April 2015 and April 2016. Progressing T790M-positive NSCLC patients received osimertinib (80 mg daily). The objectives were to assess the response rate to osimertinib according to Response Evaluation Criteria in Solid Tumours (RECIST) 1.1, the progression-free survival (PFS) on osimertinib, and the percentage of T790M positive in ctDNA.

Results

The ctDNA T790M mutation was detected in 50% of NSCLC patients. Among assessable patients, osimertinib gave a partial response rate of 62.5% and a stable disease rate of 37.5%. All responses were confirmed responses. After median follow up of 8 months, median PFS by RECIST criteria was not achieved (95% CI: 4-NA), with 6- and 12-months PFS of 66.7% and 52%, respectively.

Conclusion(s)

ctDNA from liquid biopsy can be used as a surrogate marker for T790M in tumour tissue.

Model-based inference for small area estimation with sampling weights

Obtaining reliable estimates about health outcomes for areas or domains where only few to no samples are available is the goal of small area estimation (SAE). Often, we rely on health surveys to obtain information about health outcomes. Such surveys are often characterised by a complex design, stratification, and unequal sampling weights as common features. Hierarchical Bayesian models are well recognised in SAE as a spatial smoothing method, but often ignore the sampling weights that reflect the complex sampling design. In this paper, we focus on data obtained from a health survey where the sampling weights of the sampled individuals are the only information available about the design. We develop a predictive model-based approach to estimate the prevalence of a binary outcome for both the sampled and non-sampled individuals, using hierarchical Bayesian models that take into account the sampling weights. A simulation study is carried out to compare the performance of our proposed method with other established methods. The results indicate that our proposed method achieves great reductions in mean squared error when compared with standard approaches. It performs equally well or better when compared with more elaborate methods when there is a relationship between the responses and the sampling weights. The proposed method is applied to estimate asthma prevalence across districts.

Foodborne Illness Among School Children in Ga East, Accra

BACKGROUND

A food borne illness was reported in Ga-East district of Greater Accra Region among school children in May, 2007 after eating food provided at school. The objective of the investigation was to determine the source, mode of contamination and the causative agent.

METHODS

A case-control study was conducted, cases were schoolchildren with abdominal symptoms and controls were children of the same sex and class without any symptom during the same period. The school children were selected by systematic sampling. Food handlers and the children were interviewed by a structured questionnaire. Food handlers were physically examined and their stools and blood examined. The kitchen for food preparation was inspected. Risks of food borne infection from the foods eaten were determined using attack rates.

RESULTS

The minimum, peak and maximum incubation periods were 2, 11 and 61 hours respectively. The source was rice and groundnut soup (with the highest attack rate difference). Stool and blood samples of food handlers were not infective. Storage facility for food items was poor. No food samples were available for organism isolation. A protocol to prevent such outbreaks was nonexistent.

CONCLUSION

The short incubation period and symptoms presented suggest an infective origin. The storage of the meat may potentially have been the point of contamination. The study showed that the schoolchildren ate contaminated food although the investigation could not determine the causative agent. Protocols to prevent such outbreaks need to be developed for the schools.

Filtration to reduce paediatric dose for a linear slot-scanning digital X-ray machine

This paper describes modelling, application and validation of a filtration technique for a linear slot-scanning digital X-ray system to reduce radiation dose to paediatric patients while preserving diagnostic image quality. A dose prediction model was implemented, which calculates patient entrance doses using variable input parameters. Effective dose is calculated using a Monte Carlo simulation. An added filter of 1.8-mm aluminium was predicted to lower the radiation dose significantly. An objective image quality study was conducted using detective quantum efficiency (DQE). The PTW Normi 4FLU test phantom was used for quantitative assessment, showing that image contrast and spatial resolution were maintained with the proposed filter. A paediatric cadaver full-body imaging trial assessed the diagnostic quality of the images and measured the dose reduction using a 1.8-mm aluminium filter. Assessment by radiologists indicated that diagnostic quality was maintained with the added filtration, despite a reduction in DQE. A new filtration technique for full-body paediatric scanning on the Lodox Statscan has been validated, reducing entrance dose for paediatric patients by 36 % on average and effective dose by 27 % on average, while maintaining image quality.

The cost of treatment failure: resource use and costs incurred by hepatitis C virus genotype 1-infected patients who do or do not achieve sustained virological response to therapy

Chronic hepatitis C virus (HCV) infection places a considerable economic burden on health services. Cost-effectiveness analyses of antiviral treatment for patients with chronic HCV infection are dependent on assumptions about cost reductions following sustained virological response (SVR) to therapy. This study quantified the medium-term difference in health resource usage and costs depending on treatment outcome. Retrospective chart review of patients with HCV genotype 1 infection who had received at least 2 months pegylated interferon and ribavirin therapy, with known treatment outcome was conducted. Disease status was categorized as chronic hepatitis, cirrhosis or decompensated liver disease. Health resource use was documented for each patient in each disease state. Unit costs were from the NHS 'Payment by Results' database and the British National Formulary. One hundred and ninety three patients (108 SVR, 85 non-SVR) with mean follow-up of 3.5 (SVR) and 4.9 (non-SVR) years were enrolled. No SVR patient progressed to a more severe liver disease state. Annual transition rates for non-SVR patients were 7.4% (chronic hepatitis to cirrhosis) and 4.9% (cirrhosis to decompensated liver disease). By extrapolation of modelled data over a 5-year post-treatment period, failure of patients with chronic hepatitis to achieve SVR was associated with a 13-fold increase (roughly £2300) in costs, whilst for patients who were retreated, the increase was 56-fold, equating to more than £10 000. Achievement of an SVR has significant effects on health service usage and costs. This work provides real-life data for future cost-effectiveness analyses related to the treatment for chronic HCV infection.

Effect of aluminium filtration on dose and image quality in paediatric slot-scanning radiography

This paper examines the effect that a 1.8 mm aluminium filter has on paediatric patient dose and image quality for linear slot scanning radiography (LSSR). A dynamic dose prediction model for LSSR accurately predicted the dose reduction effects of added aluminium filtration. A cadaver imaging study was carried out to assess the effects of filtration on image quality. With 1.8 mm added aluminium filtration, no visible degradation to image contrast or clarity was found, and in some cases the aluminium filtration improved the image quality as judged by radiologists.

Service provision for liver disease in the UK: a national questionnaire-based survey

The National Plan for Liver Services in 2009 called for a review of current liver services across the UK to identify areas of good and poor provision. We present the results of a national questionnaire survey of liver services, which focussed on staffing and training, access to key facilities and clinical management of liver disease. Areas of good practice include the increased proportion of consultants who trained at a liver centre, the introduction of specific liver clinics and the widespread use of terlipressin and antibiotics for variceal bleeding. Areas of poor practice include limited access to alcohol psychiatry services and transjugular intrahepatic portosystemic shunts (TIPS) and limited recording of outcome measures or patient databases. Wide variation in the clinical management of serious liver diseases supports the need for managed clinical networks. These results will help to guide the development of standards of care for liver services across the UK.

Approximate Bayesian computation reveals the factors that influence genetic diversity and population structure of foxsnakes

Contemporary geographical range and patterns of genetic diversity within species reflect complex interactions between multiple factors acting across spatial and temporal scales, and it is notoriously difficult to disentangle causation. Here, we quantify patterns of genetic diversity and genetic population structure using mitochondrial DNA sequences (101 individuals, cytochrome b) and microsatellites (816 individuals, 12 loci) and use Approximate Bayesian computation methods to test competing models of the demographic history of eastern and western foxsnakes. Our analyses indicate that post-glacial colonization and past population declines, probably caused by the infilling of deciduous forest and cooler temperatures since the mid-Holocene, largely underpin large-scale genetic patterns for foxsnakes. At finer geographical scales, our results point to more recent anthropogenic habitat loss as having accentuated genetic population structure by causing further declines and fragmentation.

Electronic learning and open educational resources in the health sciences in ghana

OBJECTIVES

To determine whether a group of Ghanaian students are able to easily use electronic learning material and whether they perceive this method of learning as acceptable.

SETTING

The University of Ghana Medical School (UGMS) and the School of Medical Sciences (SMS), Kwame Nkrumah University of Science and Technology (KNUST) PARTICIPANTS: One hundred and fifty third year medical students at SMS and nineteen fifth year medical students at UGMS METHODS: Two e-learning materials were developed, one on the polymerase chain reaction and the other on total abdominal hysterectomy and these were distributed to selected medical students. Two weeks after the distribution of the programmes, a one-page, self-administered questionnaire was distributed to the target groups of students at the two institutions.

RESULTS

Ninety three percent (139) of respondents at KNUST and 95% (18) at UG report having access to a computer for learning purposes. All of the UG students viewed the TAH programme; 82% (130) of the KNUST students viewed the PCR animations. All students who viewed the programmes at both institutions indicated that the e-learning pro-grammes were "more effective" in comparison to other methods of learning.

CONCLUSION

Computer ownership or availability at both medical schools is sufficient to permit the distribution and viewing of e-learning materials by students and the medical students considered both programmes to be very helpful.

A comparison of the natural history and outcome of treatment for Asian and non-Asian hepatitis C-infected patients

Ethnicity is an important host variable, but its impact on disease progression and response to therapy in Hepatitis C infection is unclear. Here we compare the natural history and outcome of therapy in white and Asian (Indian subcontinent) Hepatitis C infected patients. A total of 2123 White and 120 Asian HCV infected patients were identified within the Trent HCV study. Response to therapy was assessed in 224 white and 46 Asian patients with genotype 3 infection who received pegylated interferon and ribavirin. Asian patients were more likely to be older, female, infected with genotype 3 and to consume no alcohol. At time of first biopsy, fibrosis stage was significantly higher in Asian patients than in Whites (3.0 ± 2.3 vs 1.8 ± 2.0, P < 0.001), as were necro-inflammation and steatosis scores. However, in those patients where duration of infection could be estimated, fibrosis progression was similar for both groups (0.25 ± 0.31 vs. 0.16 ± 0.54 Ishak points/year, P = 0.068). 78.3% of Asian and 67.9% of White genotype 3 patients had a sustained virological response following Pegylated Interferon and Ribavirin. Cirrhosis and increased levels of GGT, but not ethnicity were associated with a reduction in the likelihood of a sustained virological response on multivariate analysis. Asian patients with Hepatitis C are more likely to be female, less likely to give a history of risk factors, present to medical services at an older age, and have more severe liver disease at diagnosis, but disease progression and response to treatment are similar to white patients.

Antibody fragments as tools in crystallography

While antibody-based therapeutics have become firmly established as front-line drugs, the use of antibodies as research tools in small molecule drug discovery is still in its infancy. In this review we focus on the use of antibody fragments as crystallization chaperones to aid the structural determination of otherwise 'uncrystallizable' or 'undruggable' target proteins. We also highlight a potential application for this technology, in which antibody-mediated structures may be used to inform the design of new chemical entities.

Staffs' knowledge and perceptions of working with women with intellectual disabilities and mental health problems

AIM

There is a growing evidence of the physical and mental health inequalities in people with intellectual disability (ID) although less has been written concerning the mental health of women with ID (International Association for the Scientific Study of Intellectual Disabilities). This is compared with the substantive literature published within mainstream psychiatry on gender. The aim of this study was to explore a range of health and social care staffs' knowledge and perceptions of caring for women with ID who have mental health problems focusing upon risk and resilient/protective factors.

METHOD

A qualitative methodology was used. Eight focus groups were conducted with hospital, community and residential staff across one region of the UK. The focus groups were audiotaped and the transcriptions were subjected to a thematic content analysis using Newell & Burnard's framework.

FINDINGS

Six inter-related risk factors were identified by the participants as potential causes for the women with ID to develop a mental illness and these were: having an ID and being female, unmet expectations, dysfunctional family upbringing, unstable relationships/loss of children, domestic violence and negative life experiences. Few of the participants acknowledged hormonal issues as a risk factor. Resilient/protective factors included being proactive, greater community participation, early recognition and mental health maintenance.

CONCLUSION

These results are discussed in light of current developments and policy within mainstream psychiatric gender approaches. Greater recognition of a proactive health approach for both staff and women with an ID is recommended.

Hepatitis C virus-infected patients with a persistently normal alanine aminotransferase: do they exist and is this really a group with mild disease?

Opinion varies on whether or not hepatitis C virus (HCV) infected patients with persistently normal aminotransferase (PNALT) levels represent a group with mild disease. To evaluate the risk of ALT flare and fibrosis progression in patients with PNALT followed up as part of the Trent HCV cohort. Treatment-naïve patients with an elevated ALT (n = 1140) or PNALT, the latter defined as either an ALT < or = 30 IU/L (n = 43) or an ALT < or = 40 IU/L (n = 87) on > or =2 occasions in the 6 months following diagnosis, and no ALT > 40 U/L were included. The likelihood of maintaining a PNALT < or = 30 IU/L was 42.2% and PNALT < or = 40 IU/L 41.7% at 3 years. The Ishak fibrosis score was > or =3 in 3.7%, 8.3% and 29.6% of patients with PNALT < or = 30 IU/L, PNALT < or = 40 IU/L and elevated ALT, respectively. Fibrosis progression between paired biopsies was similar for patients with PNALT < or = 30 IU/L (0.33 +/- 0.94 Ishak fibrosis points/year), PNALT < or = 40 IU/L (0.35 +/- 0.82) and elevated ALT (0.19 +/- 0.48). The majority of those defined as PNALT subsequently have an abnormal ALT. They have a similar risk of disease progression to other HCV infected patients and, therefore, warrant the same consideration with regard to treatment.

Listening to women with intellectual disabilities and mental health problems: a focus on risk and resilient factors

Women without intellectual disabilities are more likely to develop mental health problems as a result of physiological functioning and psychosocial risk factors. However, little is known about the mental health of women with intellectual disabilities. The aim of this study was to explore a small group of women's perceptions of the risk and protective factors pertaining to their mental health conditions. Twelve semi-structured interviews were conducted in 2007 in Northern Ireland. Thematic content analysis identified three risk factors and four protective/resilient factors. None of the women identified physiological functioning as a risk factor. Results suggest that women with intellectual disabilities experience psychosocial risk factors similar to those reported by women without intellectual disability. Additional risk factors place them at higher risk of developing mental health problems. However, more research is required.

Listening to women with intellectual disabilities and mental health problems: a focus on risk and resilient factors

Women without intellectual disabilities are more likely to develop mental health problems as a result of physiological functioning and psychosocial risk factors. However, little is known about the mental health of women with intellectual disabilities. The aim of this study was to explore a small group of women's perceptions of the risk and protective factors pertaining to their mental health conditions. Twelve semi-structured interviews were conducted in 2007 in Northern Ireland. Thematic content analysis identified three risk factors and four protective/resilient factors. None of the women identified physiological functioning as a risk factor. Results suggest that women with intellectual disabilities experience psychosocial risk factors similar to those reported by women without intellectual disability. Additional risk factors place them at higher risk of developing mental health problems. However, more research is required.

Effect of improved home ventilation on asthma control and house dust mite allergen levels

BACKGROUND

The warm, humid environment in modern homes favours the dust mite population, but the effect of improved home ventilation on asthma control has not been established. We tested the hypothesis that a domestic mechanical heat recovery ventilation system (MHRV), in addition to allergen avoidance measures, can improve asthma control by attenuating re-colonization rates.

METHODS

We conducted a randomized double-blind placebo-controlled parallel group trial of the installation of MHRV activated in half the homes of 120 adults with asthma, allergic to Dermatophagoides pteronyssinus. All homes had carpets steam cleaned and new bedding and mattress covers at baseline. The primary outcome was morning peak expiratory flow (PEF) at 12 months.

RESULTS

At 12 months, the primary end-point; change in mean morning PEF as compared with baseline, did not differ between the MHRV group and the control group (mean difference 13.5 l/min, 95% CI: -2.6 to 29.8, P = 0.10). However, a secondary end-point; evening mean PEF, was significantly improved in the MHRV group (mean difference 24.5 l/min, 95% CI: 8.9-40.1, P = 0.002). Indoor relative humidity was reduced in MHRV homes, but there was no difference between the groups in Der p 1 levels, compared with baseline.

CONCLUSIONS

The addition of MHRV to house dust mite eradication strategies did not achieve a reduction in mite allergen levels, but did improve evening PEF.

Autoantibodies in chronic hepatitis C virus infection and their association with disease profile

Autoantibodies are commonly detected in chronic hepatitis C (HCV) but their significance remains uncertain. We assessed the prevalence of anti-nuclear (ANA) and anti-smooth muscle (ASM) antibodies within a cohort of 963 treatment-naïve HCV patients. We also assessed for differences between autoantibody-positive and autoantibody-negative patients in demographics, markers of disease activity and response to anti-viral treatment. One hundred and seventy-two patients (17.9%) had at least one autoantibody, of which were 104 (10.8%) ASM, 54 (5.6%) ANA and 14 (1.5%) positive for both. Autoantibody-positive patients were older (43 vs 39 years, P = 0.001) caused by an age-related increase in ANA (but not ASM). There were no differences in gender, alcohol intake, ethnicity or viral genotype. The presence of autoantibodies, and specifically ASM, was associated with an increase in interface hepatitis score amongst men (1.1 vs 0.8, P = 0.005) but no difference in other necroinflammatory measures, liver function tests or immunoglobulins (Ig). There was no difference in initial fibrosis stage or rate of fibrosis progression. Autoantibodies did not affect response to anti-viral treatment. We conclude that autoantibodies are frequent in HCV infection. Anti-nuclear antibodies increase with age, whereas ASM antibodies are associated with interface hepatitis in men. Neither autoantibody carries increased risk of fibrosis progression or failure of therapy.

The many faces of hydatid disease

No abstact

Women with and without intellectual disability and psychiatric disorders: an examination of the literature

This article examines the literature on women with and without intellectual disability and psychiatric disorders, using a gender social model of health. Relevant empirical studies, international literature reviews and policies between 1980 and 2007 were identified from electronic databases, journals and secondary sources. Three areas were examined: psychiatric disorders, their contextual background, and their clinical presentation. There are minimal levels of research into women with intellectual disability and psychiatric disorders. However, this article hypothesizes that women with intellectual disability have higher rates of psychiatric disorders than women without. This may result from greater vulnerability related both to internal factors (;intra': cognitive deficits, poorer communication skills, limited social skills) and to the external world (;inter': lack of opportunities, stigma, poor social support networks). The article argues that such women require gender-sensitive mental health services. However, more empirical evidence is required to support this claim and to inform development and delivery of services.