Adding Triage Ultrasound to a Breast-Cancer Detection Model in Peru

Background: The rising breast-cancer burden in middle-income countries is straining the capacity of health systems to provide early detection and diagnostic services. To bring these services to women in a northern region of Peru, community education and clinical breast exam (CBE) by midwives was introduced as a method for screening asymptomatic women and evaluating women with symptoms; if positive, women were evaluated further by fine needle aspiration (FNA) by a trained physician at a local hospital. Aim: During the pilot phase, this early detection program resulted in increased demand for cytopathology services, invasive procedures for patients, delays in results, and high rates of benign findings. We added basic triage ultrasound (US), performed and interpreted by general physicians at a local hospital, to further evaluate women with a positive CBE and reduce the number of unnecessary FNAs. We aim to evaluate the changes in the FNA rate. Methods: PATH worked with an expert radiologist to develop a breast-US training program that included: teaching physicians to perform and interpret breast US using a triage algorithm based on the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) and a standardized checklist to document clinical and US findings. The triage algorithm was reviewed and validated by oncologists at Peru's national cancer institute, and later introduced in ten networks in northern Peru. Results: After adding triage ultrasound in 2015, a total of 133 CBE+ women received US at the local hospital; 73 women had a finding on US indicating a need for FNA biopsy, and all received it. Eleven of these women were subsequently diagnosed with breast cancer. Without triage US, all 133 CBE+ women would have received FNA. This represents a 55% decrease (60/133) in FNA biopsies. Conclusion: Triage ultrasound, as part of a resource-adapted model of breast screening, combined with FNA sampling increases the ability of general physicians to manage CBE+ women locally, thereby reducing health system burdens and assuring that patients at highest risk receive timely referrals to a specialized hospital. Triage ultrasound reduces the biopsy rate following a positive CBE. As ultrasound technology becomes more accessible and less expensive, we anticipate there will be an even more significant role for it in early detection models.

Venous flaps for coverage of traumatic soft tissue defects of the hand: a systematic review

A PRISMA-guided systematic review was performed of all published cases that detail the use of venous flaps for soft tissue reconstruction of the hand following trauma. Outcome measures examined included flap survival rates, venous congestion, and return to theatre. Database searches were performed on Medline, Embase, AHMED, CINAHL. A total of 381 articles were identified. Data were extracted from 45 articles that met inclusion criteria. A total of 756 flaps were described and their data analysed. A total of 75% of flaps were arterialized and 25% were pure venous flaps. There was no difference in survival rate for arterialized or pure venous flaps. Unplanned return to theatre occurred in 5.3% due to flap compromise or necrosis. Early venous congestion was present in 60% of cases. Total early failure requiring re-operation occurred in 19 flaps (2.5%) of cases. Venous flaps offer a versatile and well-tolerated reconstructive option. Early venous congestion is common, but can be managed non-operatively.

LEVEL OF EVIDENCE

II.

Consumption of sugar-sweetened beverages and type 2 diabetes incidence in Thai adults: results from an 8-year prospective study

Background:

The global prevalence of type 2 diabetes mellitus (T2DM) is high and is increasing in countries undergoing rapid socio-economic development, including Thailand. Sugar-sweetened beverage (SSB) intake may contribute to the risk of developing T2DM. However, few studies have assessed this association in Asian populations, and the results have been inconsistent. We aimed to assess that association in a prospective study of Thai adults.

Methods:

Data were from Thai Cohort Study participants surveyed in 2005, 2009 and 2013. The nation-wide sample included adult cohort members who were free of diabetes in 2005 and who were followed-up in 2013 (n=39 175). We used multivariable logistic regression to assess associations between SSB intake and eight-year T2DM incidence. We used a counterfactual mediation analysis to explore potential mediation of the SSB intake and T2DM-risk relationship.

Results:

In women (but not men) consuming SSBs once or more per day (versus rarely) was associated with increased T2DM incidence at the 8-year follow-up (odds ratio (OR)=2.4, 95% confidence interval (CI) 1.5–3.9). Obesity in 2009 was found to mediate ~23% of the total association between SSB intake in 2005 and T2DM risk in 2013 (natural indirect effect 1.15, 95% CI (1.02, 1.31).

Conclusions:

Frequent SSB consumption associated with higher T2DM incidence in women but not men. We found that a moderate proportion of the SSB-T2DM relationship was mediated through body mass index (BMI). Our findings suggest that targeting SSB consumption can help prevent a national rise in the incidence of T2DM.

Patient and community attitudes toward perioperative biobanking and genomic research

We surveyed hospital patients and clinicians to ascertain their attitudes to the establishment of a perioperative biobank for future genomics research, and whether the requirements for an opt-out approach to consent can be met. We enrolled hospital patients (n=187), patient spouse/family members (n=64), ethics committee members (n=14), and clinical staff (doctors and nurses [n=67]), and unspecified community members (n=10). They were asked to rate and describe their views on medical research and biobanking, the need for individual consent, and the importance of confidentiality. Of 406 survey forms distributed, 342 (84%) were returned. Nearly all participants (98%) indicated that a perioperative biobank is important, 93% were comfortable with de-identified genetic research, and 90% indicated that the hospital should be able to use leftover blood for medical research, provided the research has been approved by an ethics committee and personally identifying information has been removed. Participants were more likely to support biobanking if it used de-identified samples, and if, for this reason, their consent was not sought. Participants with chronic medical and surgical conditions were significantly more supportive and comfortable with genetic research, as were most in the hospital community. Most hospital patients, community members and clinicians are supportive of the development of a perioperative biobank used for genomic research. This supports the adoption of an opt-out approach to consent model.

General practitioners' views on perceived and actual gains, benefits and barriers associated with the implementation of an Australian health assessment for people with intellectual disability

BACKGROUND

Health assessments for people with intellectual disability have been implemented in the UK, New Zealand and Australia, and have led to improved health outcomes. The Comprehensive Health Assessment Program (CHAP) has been shown to improve the health of people with intellectual disability. Similar to other health assessments, it is designed to address healthcare needs, many of which are often overlooked in this population, through better communication between the general practitioner (GP), support worker and the person with intellectual disability. This study investigates GP views of the perceived and actual benefits, gains and barriers associated with its uptake and use in practice.

METHOD

As part of a larger randomised controlled trial of the CHAP, 46 GPs in Queensland, Australia, completed two telephone interviews that included open-ended questions about their perceptions of the health assessment. The GPs were enrolled in the intervention arm of the trial. Interviews took place at commencement and conclusion of the trial to gain the views of GPs as they experienced using the CHAP. Thematic analysis was used to identify key themes and patterns from the GP responses.

RESULTS

Four themes were identified: better healthcare and uncertain benefits captured GP perceptions of the potential gains associated with use of the CHAP, while two further themes, organisational barriers in the general practice setting and engagement across the healthcare triad highlighted strengths and barriers related to implementation. Anticipated concerns about time raised by GPs at commencement of the trial were borne out in practice, but concerns about communication and cooperation of people with disabilities were not. Matters associated with support worker engagement emerged as an area of concern.

CONCLUSIONS

GPs perceive the CHAP as a structured and comprehensive approach to the detection of medical problems as well as an aid in overcoming communication barriers between the doctor and the person with disability. Our findings suggest that some GPs may find it difficult to predict the benefits of using health assessments such as the CHAP. Achieving optimal uptake is likely to require attention at policy and systems levels to address: GP time constraints in providing healthcare to this population; enhancement of support worker training and organisational structures to encourage comprehensive health assessment and follow-up activities; and GP awareness of the improved health outcomes shown to derive from the use of comprehensive health assessments.

Effects of individual and combined dietary weight loss and exercise interventions in postmenopausal women on adiponectin and leptin levels

BACKGROUND

Excess body weight and a sedentary lifestyle are associated with the development of several diseases, including cardiovascular disease, diabetes and cancer in women. One proposed mechanism linking obesity to chronic diseases is an alteration in adipose-derived adiponectin and leptin levels. We investigated the effects of 12-month reduced calorie, weight loss and exercise interventions on adiponectin and leptin concentrations.

METHODS

Overweight/obese postmenopausal women (n = 439) were randomized as follows: (i) a reduced calorie, weight-loss diet (diet; N = 118), (ii) moderate-to-vigorous intensity aerobic exercise (exercise; N = 117), (iii) a combination of a reduced calorie, weight-loss diet and moderate-to-vigorous intensity aerobic exercise (diet + exercise; N = 117), and (iv) control (N = 87). The reduced calorie diet had a 10% weight-loss goal. The exercise intervention consisted of 45 min of moderate-to-vigorous aerobic activity 5 days per week. Adiponectin and leptin levels were measured at baseline and after 12 months of intervention using a radioimmunoassay.

RESULTS

Adiponectin increased by 9.5% in the diet group and 6.6% in the diet + exercise group (both P ≤ 0.0001 vs. control). Compared with controls, leptin decreased with all interventions (diet + exercise, -40.1%, P < 0.0001; diet, -27.1%, P < 0.0001; exercise, -12.7%, P = 0.005). The results were not influenced by the baseline body mass index (BMI). The degree of weight loss was inversely associated with concentrations of adiponectin (diet, P-trend = 0.0002; diet + exercise, P-trend = 0.0005) and directly associated with leptin (diet, P-trend < 0.0001; diet + exercise, P-trend < 0.0001).

CONCLUSION

Weight loss through diet or diet + exercise increased adiponectin concentrations. Leptin concentrations decreased in all of the intervention groups, but the greatest reduction occurred with diet + exercise. Weight loss and exercise exerted some beneficial effects on chronic diseases via effects on adiponectin and leptin.

Exploring the contribution of general self-efficacy to the use of self-care symptom management strategies by people living with HIV infection

General self-efficacy (GSE), the expectation that one is able to perform a behavior successfully, may differentiate those who are able to successfully utilize self-care symptom management strategies (SCSMS). This subanalysis (n=569) of an international 12 site longitudinal randomized controlled trial (RCT) (n=775), investigated GSE as an important factor determining symptom burden, SCSMS, engagement with the provider, and medication adherence over time, and identified differences in those with high and low GSE ratings concerning these variables. Parametric and nonparametric repeated-measures tests were employed to assess GSE and the perceived effectiveness of SCSMS for anxiety, depression, diarrhea, fatigue, nausea, and neuropathy. Symptom burden, engagement with the provider, and antiretroviral adherence were analyzed with regard to GSE. Our data indicated that there were differences in the perceived symptom burden over time of HIV infected individuals by GSE. Those individuals with higher GSE had fewer symptoms and these symptoms were perceived to be less intense than those experienced by the low GSE group. There were few meaningful differences in the SCSMS used by those with high versus low GSE other than the use of illicit substances in the low GSE group. The low GSE group was also significantly (p= < 0.001) less engaged with their healthcare providers. Given the difference in substance use by perceived GSE, and the importance of engagement with the healthcare provider, more attention to the resolution of the concerns of those with low GSE by healthcare providers is warranted.

Validity of self-reported abdominal obesity in Thai adults: a comparison of waist circumference, waist-to-hip ratio and waist-to-stature ratio

BACKGROUND AND AIMS

Waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-stature ratio (WSR), being common proxy measures of abdominal obesity, are useful tools in epidemiologic studies, but little is known about their validity when the indices are derived from self-reported measurements. We determine and compare the validity of self-reported WC, WHR and WSR in order to identify the optimal index for use in epidemiologic surveys.

METHODS AND RESULTS

Technician- and self-reported measurements of height, waist and hip circumference were obtained from 613 Thai adults (mean age 35 years). Regarding technician-reported measurements as reference, diagnostic test properties were derived and performances of the indices compared using receiver-operator-characteristic curves and the area-under-the-curve (AUC) analyses. There was good agreement between technician- and self-reported measurements for WC and WSR (concordance correlation coefficients ranged from 0.84 to 0.90) but not for WHR (0.50 in men, 0.45 in women). The sensitivity and specificity of self-reported WC and self-reported WSR as measures of abdominal obesity were superior to those of self-reported WHR in both sexes. AUCs for WC and WSR were comparable (0.93 and 0.92, respectively, in men; 0.88 and 0.87 in women) and significantly higher than for WHR (0.80 in men; 0.76 in women; p<0.0001).

CONCLUSION

WC and WSR derived from self-reported waist and height measurements are valid methods for determining abdominal obesity. Self-reported measurements should not be used to derive the WHR. In Asian populations, WSR may be the optimal index of abdominal obesity when measurements are derived from self-reports in epidemiologic surveys.

Risk factors for injury in a national cohort of 87,134 Thai adults

BACKGROUND

Information is needed regarding risk factors associated with injury. In middle- and lower-income countries, injury studies have focused on road traffic injuries and less attention has been given to other types of injuries.

METHODS

This study is part of overarching health-risk transition research in Thailand with a large national cohort study that began in 2005 (n = 87,134). Associations between potential determinants and overall injury were measured, as well as injury by location (transport, home, work and sport), using data gathered from the baseline questionnaire.

RESULTS

In total, 21.5% of the cohort reported at least one incidence of injury over the last 12 months. Risk factors associated with injury were being male [odds ratio (OR) 1.20], having lower income (OR 1.70), having problems with vision (OR 1.46), having epilepsy (OR 3.02), having depression/anxiety (OR 1.62), poor self-assessed health (OR 1.68), being obese (OR 1.24) and death of father due to injury (OR 1.59). Analysis of injury by location provided more specific information on risk factors. For example, females were more likely to report injuries at home, while males, urban residents and regular alcohol drinkers were more likely to report transport injuries.

CONCLUSIONS

The risk of injury in Thailand varies considerably by location, sociodemographic group and several categories of co-existing morbidities. Such epidemiological information identifying risk factors for injury is useful for designing targeted injury prevention programmes in Thailand and other middle-income countries.

Systematic review and economic modelling of the effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of non-surgical treatments for women with stress urinary incontinence (SUI) through systematic review and economic modelling.

DATA SOURCES

The Cochrane Incontinence Group Specialised Register, electronic databases and the websites of relevant professional organisations and manufacturers, and the following databases: CINAHL, EMBASE, BIOSIS, Science Citation Index and Social Science Citation Index, Current Controlled Trials, ClinicalTrials.gov and the UKCRN Portfolio Database.

STUDY SELECTION

The study comprised three distinct elements. (1) A survey of 188 women with SUI to identify outcomes of importance to them (activities of daily living; sex, hygiene and lifestyle issues; emotional health; and the availability of services). (2) A systematic review and meta-analysis of non-surgical treatments for SUI to find out which are most effective by comparing results of trials (direct pairwise comparisons) and by modelling results (mixed-treatment comparisons - MTCs). A total of 88 randomised controlled trials (RCTs) and quasi-RCTs reporting data from 9721 women were identified, considering five generic interventions [pelvic floor muscle training (PFMT), electrical stimulation (ES), vaginal cones (VCs), bladder training (BT) and serotonin-noradrenaline reuptake inhibitor (SNRI) medications], in many variations and combinations. Data were available for 37 interventions and 68 treatment comparisons by direct pairwise assessment. Mixed-treatment comparison models compared 14 interventions, using data from 55 trials (6608 women). (3) Economic modelling, using a Markov model, to find out which combinations of treatments (treatment pathways) are most cost-effective for SUI.

DATA EXTRACTION

Titles and abstracts identified were assessed by one reviewer and full-text copies of all potentially relevant reports independently assessed by two reviewers. Any disagreements were resolved by consensus or arbitration by a third person.

RESULTS

Direct pairwise comparison and MTC analysis showed that the treatments were more effective than no treatment. Delivering PFMT in a more intense fashion, either through extra sessions or with biofeedback (BF), appeared to be the most effective treatment [PFMT extra sessions vs no treatment (NT) odds ratio (OR) 10.7, 95% credible interval (CrI) 5.03 to 26.2; PFMT + BF vs NT OR 12.3, 95% CrI 5.35 to 32.7]. Only when success was measured in terms of improvement was there evidence that basic PFMT was better than no treatment (PFMT basic vs NT OR 4.47, 95% CrI 2.03 to 11.9). Analysis of cost-effectiveness showed that for cure rates, the strategy using lifestyle changes and PFMT with extra sessions followed by tension-free vaginal tape (TVT) (lifestyle advice-PFMT extra sessions-TVT) had a probability of greater than 70% of being considered cost-effective for all threshold values for willingness to pay for a QALY up to 50,000 pounds. For improvement rates, lifestyle advice-PFMT extra sessions-TVT had a probability of greater than 50% of being considered cost-effective when society's willingness to pay for an additional QALY was more than 10,000 pounds. The results were most sensitive to changes in the long-term performance of PFMT and also in the relative effectiveness of basic PFMT and PFMT with extra sessions.

LIMITATIONS

Although a large number of studies were identified, few data were available for most comparisons and long-term data were sparse. Challenges for evidence synthesis were the lack of consensus on the most appropriate method for assessing incontinence and intervention protocols that were complex and varied considerably across studies.

CONCLUSIONS

More intensive forms of PFMT appear worthwhile, but further research is required to define an optimal form of more intensive therapy that is feasible and efficient for the NHS to provide, along with further definitive evidence from large, well-designed studies.

Childhood dairy and calcium intake and cardiovascular mortality in adulthood: 65-year follow-up of the Boyd Orr cohort

BACKGROUND

Dairy consumption in childhood may have long-term effects on cardiovascular mortality through influencing the development of risk factors or programming effects.

OBJECTIVE

To investigate whether dairy and calcium consumption in childhood is associated with adult mortality due to coronary heart disease (CHD), stroke and all causes.

METHODS

In 1937-9, 4999 children in England and Scotland participated in a study of family food consumption, assessed from 7-day household food inventories. Cause of death was ascertained between 1948 and 2005 in 4374 traced cohort members with complete data. Per capita household intake estimates for dairy products and calcium were used as proxies for individual intake.

RESULTS

No strong evidence that a family diet in childhood high in dairy products was associated with CHD or stroke mortality was found. However, childhood calcium intake was inversely associated with stroke mortality (multivariable adjusted hazard ratio (HR) for highest versus lowest calcium group: 0.41; 95% confidence interval (CI) 0.16 to 1.05; p for trend = 0.04), but not CHD mortality. All-cause mortality was lowest in those with the highest family dairy (HR = 0.77; 95% CI 0.61 to 0.98; p for trend = 0.04) and calcium intake (HR = 0.77, 95% CI 0.60 to 0.98; p for trend = 0.05).

CONCLUSIONS

Children whose family diet in the 1930s was high in calcium were at reduced risk of death from stroke. Furthermore, childhood diets rich in dairy or calcium were associated with lower all-cause mortality in adulthood. Replication in other study populations is needed to determine whether residual confounding explains part of these findings.

A randomised comparison of microwave endometrial ablation with transcervical resection of the endometrium: follow up at a minimum of 10 years

OBJECTIVE

To compare outcomes and further operations at a minimum of 10 years following microwave endometrial ablation (MEA) or transcervical resection of the endometrium (TCRE).

DESIGN

Follow up of a randomised controlled trial using postal questionnaires and operative databank review.

SETTING

Gynaecology department of a large UK teaching hospital.

MAIN OUTCOME MEASURES

Women's satisfaction with treatment, menstrual symptoms, changes in health-related quality of life, and additional treatments received.

RESULTS

One-hundred and eighty-nine of the original 263 women returned questionnaires (72%) after a minimum of 10 years post-treatment. Those totally or generally satisfied with treatment numbered 77/129 (60%) in the microwave arm and 70/134 (52%) in the resection arm, the difference is not statistically significant. Bleeding and pain scores were highly significantly reduced and similar following both MEA and TCRE, achieving amenorrhoea rates of 83 and 88% respectively. The hysterectomy rate after 10 years was significantly different with 22 (17%) in the MEA and 38 (28%) in the TCRE arm (95% CI: -0.21, -0.13).

CONCLUSIONS

Both techniques achieve significant and comparable improvements in menstrual symptoms, health-related quality of life and high rates of satisfaction. With the known operative advantages, lower costs and fewer hysterectomies, it is clear that MEA is a more effective and efficient treatment for heavy menstrual loss than TCRE.

Body mass index and health-related behaviours in a national cohort of 87,134 Thai open university students

BACKGROUND

Thailand is undergoing a health-risk transition with overweight and obesity emerging as an important population health problem. This paper reports on a study of the transition, focusing on "lifestyle" factors such as diet (fried foods, soft drinks, Western-style fast foods) and physical activity (mild, moderate, strenuous exercise, housework/gardening and screen time).

METHODS

A baseline survey was administered to 87 134 adult students from all regions of Thailand attending an open university.

RESULTS

54% of the cohort was female. Participants' median age was 29 years. By self-reported Asian standards, 16% of the sample was obese (body mass index (BMI)>or=25) and 15% overweight at risk (BMI>or=23-24.9). Men were twice as likely as women to be overweight (21% vs 9%) or obese (23% vs 10%). Obesity was associated with urban residence and doing little housework or gardening and with spending more than 4 hours a day watching television or using computers. The latter occurred among 30% of the cohort, with a population attributable fraction (PAF) suggesting that it accounts for 11% of the current problem. Daily consumption of fried food was associated with obesity, and eating fried foods every second day or daily had a PAF of nearly 20%.

CONCLUSIONS

These health-related behaviours underpinning the Thai health transition are associated with increasing obesity. They are modifiable through policies addressing structural issues and with targeted health promotion activities to prevent future obesity gains. Insights into future trends in the Thai health transition can be gained as this student cohort ages.

Injury risk from popular childhood physical activities: results from an Australian primary school cohort

BACKGROUND

Children engage in various physical activities that pose different injury risks. However, the lack of adequate data on exposure has meant that these risks have not been quantified or compared in young children aged 5-12 years.

OBJECTIVES

To measure exposure to popular activities among Australian primary school children and to quantify the associated injury risks.

METHOD

The Childhood Injury Prevention Study prospectively followed up a cohort of randomly selected Australian primary and preschool children aged 5-12 years. Time (min) engaged in various physical activities was measured using a parent-completed 7-day diary. All injuries over 12 months were reported to the study. All data on exposure and injuries were coded using the International classification of external causes of injury. Injury rates per 1000 h of exposure were calculated for the most popular activities.

RESULTS

Complete diaries and data on injuries were available for 744 children. Over 12 months, 314 injuries relating to physical activity outside of school were reported. The highest injury risks per exposure time occurred for tackle-style football (2.18/1000 h), wheeled activities (1.72/1000 h) and tennis (1.19/1000 h). Overall, boys were injured more often than girls; however, the differences were non-significant or reversed for some activities including soccer, trampolining and team ball sports.

CONCLUSION

Although the overall injury rate was low in this prospective cohort, the safety of some popular childhood activities can be improved so that the benefits may be enjoyed with fewer negative consequences.

Comparison of the long-term effects of simple total abdominal hysterectomy with transcervical endometrial resection on urinary incontinence

OBJECTIVE

To test the hypothesis that the hospital referral rate for urinary incontinence (UI) symptoms, within 10 years of a simple total abdominal hysterectomy (TAH) for dysfunctional uterine bleeding (DUB), would differ to that after a transcervical resection of the endometrium (TCRE).

DESIGN

Retrospective case note review.

SETTING

Teaching hospital in north east Scotland.

POPULATION

All women who had a TAH (316) or a TCRE (229) for DUB, during the period from 1 January 1990 to 31 December 1994, who had never been referred for symptoms of UI prior to their operation.

METHODS

Independent t tests, Mann-Whitney U tests and Chi-squared tests were used to compare the two study groups in terms of demographic details and outcome measures. Newcombe's method for the comparison of two unpaired proportions was used to calculate 95% CIs for the differences in outcome measures between the two operations. Logistic regression was conducted to investigate associations with hospital referral for UI.

MAIN OUTCOME MEASURES

Hospital referral for UI at 10 years follow up.

RESULTS

There were significantly more hospital referrals for UI in the TAH group compared with the TCRE group (46 [15%] versus 16 [7%]; OR 2.27, 95% CI 1.25-4.12). More women were referred for urological investigations after a TAH than after a TCRE (39 [12%] versus 13 [6%], 95% CI for the difference in proportions 2-11%). A higher, but statistically nonsignificant, proportion of women had objectively demonstrated UI after a TAH than after a TCRE (25 [8%] versus 10 [4%], 95% CI for the difference in proportions -1 to 8%). There were a greater number of hospital referrals for treatment of UI in the TAH group (36, 11%) than in the TCRE group (12, 5%), 95% CI for the difference in proportions (1-11%). After adjusting for age, weight, smoking status and mode of delivery, the increased rate of hospital referral for UI after TAH remained, with an odds ratio of 2.31, 95% CI 1.24-4.30.

CONCLUSIONS

TAH is associated with a significantly increased incidence of hospital referral for UI, urological investigations and treatment for UI at 10 years of follow up compared with TCRE.

Aspirin and lung cancer risk in a cohort study of women: dosage, duration and latency

Aspirin may reduce the risk of cancer at some sites but its effect at the lung is unclear. We prospectively examined associations between aspirin use and risk of lung cancer in 109,348 women in the Nurses' Health study from 1980 to 2004. During this time, 1,360 lung cancers were documented in participants 36-82 years of age. Aspirin use and smoking were assessed every 2 years. Risk of lung cancer was a non-significant 16% lower for regular aspirin users of one or two tablets per week and a significant 55% higher for users of 15 or more tablets per week compared with women who never regularly used aspirin. Results were similar when limited to never smokers. For both the low and high quantity aspirin users, risk of lung cancer did not decline or increase with longer durations of use, and associations attenuated as the latency period between aspirin assessment and lung cancer diagnosis was lengthened. Our findings, together with those from previous clinical trials and prospective studies, do not provide consistent evidence that aspirin influences the development of lung cancer and further investigation is required with adjustment for smoking.

Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety

BACKGROUND

Several event studies, including the Australian Safety and Quality in Healthcare Study, emphasize gaps in safety for hospitalized patients. It is now recognized that system-based factors contribute significantly to risk of adverse events and this has led to a shift in focus of patient safety from the autonomous responsibility of medical clinicians to a systems-based approach. The aim of this study was to determine medical practitioner awareness of, level of engagement in and barriers to engagement in a systems approach to patient safety and quality.

METHODS

Information from acute and subacute care medical practitioners at a metropolitan public hospital was collected within an anonymous structured electronic survey, a discussion group and key informant interviews.

RESULTS

There were 73 survey respondents (response rate 7.6%). Fifty-one (69.9%) were unaware of the Institute of Medicine report 'To Err is human'. Thirty-six (49.3%) were unaware of the Australian Quality in Healthcare Study and 12 (16.4%) had read the article. There was a positive relation identified between awareness and seniority. There was a low level of participation in systems-focused quality and safety activities and limited understanding of the role of systems in medical error causation. There was uncertainty about the changing role of medical practitioners in patient safety and perceived lack of skills to effectively engage with hospital management about safety and quality issues.

CONCLUSION

Several factors are limiting engagement of medical practitioners in a systems approach to patient safety. Increased educational support is needed and may be best focused within clinical effectiveness activities pertinent to practitioner interest and expertise.

The properties of the International Classification of the External Cause of Injury when used as an instrument for injury prevention research

OBJECTIVE

To demonstrate properties of the International Classification of the External Cause of Injury (ICECI) as a tool for use in injury prevention research.

METHODS

The Childhood Injury Prevention Study (CHIPS) is a prospective longitudinal follow up study of a cohort of 871 children 5-12 years of age, with a nested case crossover component. The ICECI is the latest tool in the International Classification of Diseases (ICD) family and has been designed to improve the precision of coding injury events. The details of all injury events recorded in the study, as well as all measured injury related exposures, were coded using the ICECI. This paper reports a substudy on the utility and practicability of using the ICECI in the CHIPS to record exposures. Interrater reliability was quantified for a sample of injured participants using the Kappa statistic to measure concordance between codes independently coded by two research staff.

RESULTS

There were 767 diaries collected at baseline and event details from 563 injuries and exposure details from injury crossover periods. There were no event, location, or activity details which could not be coded using the ICECI. Kappa statistics for concordance between raters within each of the dimensions ranged from 0.31 to 0.93 for the injury events and 0.94 and 0.97 for activity and location in the control periods.

DISCUSSION

This study represents the first detailed account of the properties of the ICECI revealed by its use in a primary analytic epidemiological study of injury prevention. The results of this study provide considerable support for the ICECI and its further use.

Primary and memory T cell responses induced by hepatitis C virus multiepitope long peptides

To develop a vaccine against hepatitis C virus, we synthesized four long peptides from nonstructural proteins NS3, NS4 and NS5B containing HLA-class I and class II epitopes mainly inducing responses in natural infection. In HLA-A2.1 transgenic mice, the four peptides primed higher CTL responses to 6:7 minimal HLA-A2 epitopes than those induced by the minimal epitopes. HLA-A2.1/HLA-DR1 transgenic mice immunized with one peptide, containing a class II epitope implicated in viral resolution, developed IFNgamma-producing CD4+-T and CD8+-T cells. These peptides recalled HCV-specific IFNgamma-producing cells from HCV-infected patients' PBMC. This support the selection of these domains for inclusion in a vaccine formulation.

Beating the barriers: recruitment of people with intellectual disability to participate in research

BACKGROUND

The health status of people with intellectual disability (ID) is poor, yet very little research has been done on their health needs. There are several barriers to performing this research. The aim of our research was to examine the significant barriers encountered in recruiting adults with ID to participate in research.

METHODS

Our project was a randomized controlled trial aiming to improve health advocacy of people with ID. We approached many organizations to recruit participants and kept records of our results. Recruitment was very low for the first 4 months. Then we adopted two new recruitment strategies--in-service telephone recruitment and meetings with prospective participants. We then monitored the subsequent recruitment rates. We also questioned participants about the difficulties they encountered when considering recruitment.

RESULTS

Initial recruitment of participants yielded less than one-third of the expected number. Additional strategies implemented were partially successful. Significant barriers to recruitment included several sectoral issues and the challenges arising from the research process.

CONCLUSIONS

While this population is a difficult one to reach for research, attempts to do so should not be abandoned, because the potential health benefits for this underserved group far outweigh the recruitment barriers experienced.

Genetic immunization and comprehensive screening approaches in HLA-A2 transgenic mice lead to the identification of three novel epitopes in hepatitis C virus NS3 antigen

Interferon-gamma (IFN gamma)-producing CD8+ T cells have been shown to play a key role in the control or eradication of hepatitis C virus (HCV) infections. In particular, T cells specific of the non-structural protein 3 (NS3) are often associated with control of viremia. The aim of the study was to identify novel HLA-A2 restricted CD8+ T cell epitopes specific of NS3 using a combination of comprehensive approaches. HLA-A2.1 transgenic mice were immunized with a DNA vaccine optimized for NS3 specific epitope presentation and induced CD8+ T cell reactivity was screened using 42 algorithm-predicted peptides as well as a library of 78 overlapping 15-mer peptides spanning the whole protein. Three epitopes mapping within the NS3 protease (GLL: aa 1038-1047) or helicase (ATL: aa 1260-1268 and TLH: aa 1617-1625) were identified. These epitopes, which display similar and high in vitro binding capacities to soluble HLA-A2 molecules, are able to induce either cytotoxic T lymphocytes (CTL) and/or IFN gamma-producing T cells. Comparative in vitro target cell sensitization studies revealed a higher immunogenicity of the GLL peptide as compared with both ATL and TLH peptides. This peptide was capable to recall in vitro HCV-specific IFN gamma and IL-10-producing T cells from peripheral blood mononuclear cells (PBMC) of chronically infected patients. These data increase the pool of NS3-specific CD8+ T cell epitopes available to analyze HCV associated immunity and could contribute to the design and evaluation of candidate vaccines.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Cigarette smoking and risk of epithelial ovarian cancer (Australia)

OBJECTIVES

We studied the association between cigarette smoking and ovarian cancer in a population-based case control study.

METHODS

A total of 794 women with histologically confirmed epithelial ovarian cancer who were aged 18-79 years and resident in one of three Australian states were interviewed, together with 855 controls aged 18-79 years selected at random from the electoral roll from the same states. Information was obtained about cigarette smoking and other factors including age, parity, oral contraceptive use, and reproductive factors. We estimated the relative risk of ovarian cancer associated with cigarette smoking, accounting for histologic type, using multivariable logistic regression to adjust for confounding factors.

RESULTS

Women who had ever smoked cigarettes were more likely to develop ovarian cancer than women who had never smoked (adjusted odds ratio (OR) = 1.5; 95% confidence interval (CI) = 1.2-1.9). Risk was greater for ovarian cancers of borderline malignancy (OR = 2.4; 95% CI = 1.4-4.1) than for invasive tumors (OR = 1.7; 95% CI = 1.2-2.4) and the histologic subtype most strongly associated overall was the mucinous subtype among both current smokers (OR = 3.2; 95% CI = 1.8-5.7) and past smokers (OR = 2.3; 95% CI = 1.3-3.9).

CONCLUSIONS

These data extend recent findings and suggest that cigarette smoking is a risk factor for ovarian cancer, especially mucinous and borderline mucinous types. From a public health viewpoint, this is one of the few reports of a potentially avoidable risk factor for ovarian cancer.

[Dendritic cells and hepatitis C virus]

Hepatitis C virus (HCV) induces chronic persistent infection that can lead to the development of hepatocellular carcinoma. We have searched for the presence of HCV genomic RNA in cells from hematopoietic origin and have, among others, documented such sequences in B cells as well as dendritic cells (DC) derived from monocytes. The allostimulatory capacity of these latter cells was found altered in chronic patients while it appeared restored in long term responders to therapy.

Impaired allostimulatory function of dendritic cells in chronic hepatitis C infection

BACKGROUND & AIMS

Dendritic cells (DC), which play an essential role in the triggering of primary antiviral immune reactions, may also contribute, in some viral models, to the propagation of viral infection and the pathogenesis of viral disease. During natural infection with hepatitis C virus (HCV), the interactions between the virus and DC may contribute to viral persistence, a general feature of HCV infection.

METHODS

We compared the phenotypical and biological functions of monocyte-derived DC from patients with chronic hepatitis C (HCV-DC; n = 6), seronegative individuals (naive-DC; n = 8), long-term responders to antiviral therapy (LTR-DC; n = 8), and a group of patients with non-HCV-hepatic disorders (n = 11). The presence and the nature of HCV sequences during the DC cultures was assessed by reverse transcription-polymerase chain reaction and the analysis of the viral quasispecies distribution.

RESULTS

Although HCV-DC displayed a normal morphology, phenotype, and capacity to capture antigen, their ability to stimulate the proliferation of allogeneic T cells was dramatically impaired in comparison with naive-DC (P = 0.0013). Mixing experiments revealed that HCV-DC did not affect the proliferation of T cells induced by naive-DC. Remarkably, the allostimulatory function of LTR-DC or DC from patients with non-HCV-hepatic disorders did not show any impairment. The presence of HCV genomic sequences could be documented for 5 of 6 HCV carriers either in the cells and/or the supernatants of the DC cultures. The presence of HCV sequences was found in the DC cultures from one patient showing a dramatic allostimulation defect. For that patient, extensive analysis of the viral quasispecies distribution revealed the presence, in the DC cultures, of genomic sequences of a unique nature, distinct from those identified in the patient's mononuclear cells, serum, or liver.

CONCLUSIONS

Overall, these results indicate that chronic infection by HCV is associated with an allostimulatory defect of monocyte-derived DC, possibly because these cells constitute an extrahepatic reservoir for the virus. Although the exact mechanism responsible for such an alteration remains to be unraveled, our observations argue against an active immunosuppression-based mechanism.

Electronic telephone directory listings: preferred sampling frame for a population-based study of childhood cancer in Australia

PURPOSE

We report our telephone-based system for selecting community control series appropriate for a complete Australia-wide series of Ewing's sarcoma cases.

METHODS

We used electronic directory random sampling to select age-matched controls. The sampling has all listed telephone numbers on an up-dated CD-Rom.

RESULTS

95% of 2245 telephone numbers selected were successfully contacted. The mean number of attempts needed was 1.94, 58% answering at the first attempt. On average, we needed 4.5 contacts per control selected. Calls were more likely to be successful (reach a respondent) when made in the evening (except Saturdays). The overall response rate among contacted telephone numbers was 92.8%. Participation rates among female and male respondents were practically the same. The exclusion of unlisted numbers (13.5% of connected households) and unconnected households (3.7%) led to potential selection bias. However, restricting the case series to listed cases only, plus having external information on the direction of potential bias allow meaningful interpretation of our data.

CONCLUSION

Sampling from an electronic directory is convenient, economical and simple, and gives a very good yield of eligible subjects compared to other methods.

Beyond ovulation: oral contraceptives and epithelial ovarian cancer

In a case-control study in three Australian states that included 794 women with epithelial ovarian cancer and 853 community controls for whom we had adequate contraceptive and reproductive histories, we examined the effects of oral contraceptive use after controlling for estimated number of ovulatory cycles. Other covariates included in the multiple logistic regression analysis were parity, smoking, and history of pelvic surgery. The protective effect of duration of oral contraceptive use appeared to be multiplicative, with a 7% decrease in relative risk per year [95% confidence interval (CI) = 4-9%], persisting beyond 15 years of exposure. Use for up to 1 year may have a greater effect than predicted (odds ratio = 0.57; 95% CI = 0.40-0.82), whereas use before the first pregnancy may be additionally beneficial (odds ratio = 0.95; 95% CI = 0.87-1.03, adjusted for overall duration of use). Better control for ovulatory life might attenuate these estimates somewhat. There was little evidence of waning protection with time since last exposure or of extra benefit with early commencement of oral contraceptive use. We found no convincing evidence of effect modification in any factor examined or differences in effect among the three main histologic cancer types or between borderline and malignant tumors. Oral contraceptives may act by both suppressing ovulation and altering the tumor-promoting milieu.