Health literacy, governance and systems leadership contribute to the implementation of the One Health approach: a virtuous circle

One Health is an important approach to addressing health threats and promoting health through interdisciplinary health, policy, legislation and leadership research to achieve better human and animal health and better outcomes for the planet. The Covid-19 pandemic has triggered an urgent awareness of the need to develop innovative integrative solutions to address root causes of such threats to health, which requires collaboration across disciplines and amongst different sectors and communities. We explore how achieving the Quadripartite Organizations' One Health Joint Plan of Action can be supported by the concepts of 'One Health literacy' and 'One Health governance' and promote both academic and policy dialogue. We show how One Health literacy and One Health governance influence and reinforce each other, while an interdisciplinary systems leadership approach acts as a catalyst and mechanism for understanding and enacting change. Based on our understanding of how these elements influence the implementation of the One Health approach, we describe a model for considering how external triggering events such as the Covid-19 pandemic may prompt a virtuous circle whereby exposure to and exploration of One Health issues may lead to improved One Health literacy and to better governance. We close with recommendations to international organisations, national governments and to leaders in policy, research and practice to enhance their influence on society, the planetary environment, health and well-being.

'Ageing well': Discursive constructions of ageing and health in the public reach of a national longitudinal study on ageing

Established in 2006, the Irish Longitudinal Study on Ageing (TILDA) investigates the health, economic and social circumstances of a nationally-representative sample of people aged fifty years and older in a series of biennial data collection waves. Irish newspapers have been reporting the results of TILDA for over a decade and a half, and their texts represent reports of scientific research distilled through the pen of journalists. In their totality, their texts constitute a public discourse on ageing and health. Using critical discourse analysis, we examined the discourse within the texts of a purposive sample of two national daily newspapers. As sites of public discourse, newspapers reflect social life and are influential in forming and legitimating public attitudes. Like other sites of discourse, their language-in-use is contextually located, is rarely neutral and may employ strategies to discursively construct, sustain and privilege particular social identities, including ageing identities. Discursively constructed as 'ageing well', our analysis of newspaper texts revealed a discernible meta-discourse on ageing and health in which ageing was framed as a life course stage that may be cultivated, diligently self-nurtured and exploited for its positive aspects. When considered in light of literature on health and social inequalities, the consequences of this broadly positive ageing discourse can, somewhat perversely, frame older adults in unintended negative ways, including homogenising them and attributing to them capacities for ageing well that they may not possess. Discursively constructing older adults as a social and economic resource can also impose unrealistic expectations on them and may legitimise exploitation and demonstrate how normative ideologies of ageism and ableism are conveyed through legitimising language. Despite these potentially unintended consequences, the available media resources associated with TILDA may represent one of the most important contributions of the study, in terms of informing positive public attitudes towards ageing.

Reformulation of Processed Yogurt and Breakfast Cereals over Time: A Scoping Review

Poor diet is responsible for a quarter of European non-communicable disease (NCD)-related deaths. The reformulation of sugar, salt, and saturated fat in processed packaged foods offers an opportunity to reduce consumption of nutrients of concern and also support a reduction in energy intake. To date, there have been no publications measuring progress in food reformulation by compiling published evidence for a food category. The aim of this scoping review was to identify, characterize and summarise the findings of studies analysing the reformulation of processed yogurt and breakfast cereals. The review answered the research question: "What is the impact of food reformulation on the nutrient quality of yogurt and breakfast cereals available in the retail environment?" The research protocol was defined based on PRISMA-ScR guidelines. Five databases were searched in May 2022. Thirteen studies, published between 2010 and 2021 and completed across seven countries were eligible for inclusion. There were sufficient eligible studies to identify trends in sodium, salt, and sugar reduction in breakfast cereals. However, there was minimal or no reduction in energy, which may bring into question the use of food reformulation as part of an overall health strategy for obesity reduction.

Toward Systems Models for Obesity Prevention: A Big Role for Big Data

The relation among the various causal factors of obesity is not well understood, and there remains a lack of viable data to advance integrated, systems models of its etiology. The collection of big data has begun to allow the exploration of causal associations between behavior, built environment, and obesity-relevant health outcomes. Here, the traditional epidemiologic and emerging big data approaches used in obesity research are compared, describing the research questions, needs, and outcomes of 3 broad research domains: eating behavior, social food environments, and the built environment. Taking tangible steps at the intersection of these domains, the recent European Union project "BigO: Big data against childhood obesity" used a mobile health tool to link objective measurements of health, physical activity, and the built environment. BigO provided learning on the limitations of big data, such as privacy concerns, study sampling, and the balancing of epidemiologic domain expertise with the required technical expertise. Adopting big data approaches will facilitate the exploitation of data concerning obesity-relevant behaviors of a greater variety, which are also processed at speed, facilitated by mobile-based data collection and monitoring systems, citizen science, and artificial intelligence. These approaches will allow the field to expand from causal inference to more complex, systems-level predictive models, stimulating ambitious and effective policy interventions.

“Data is the new oil”: citizen science and informed consent in an era of researchers handling of an economically valuable resource

As with other areas of the social world, academic research in the contemporary healthcare setting has undergone adaptation and change. For example, research methods are increasingly incorporating citizen participation in the research process, and there has been an increase in collaborative research that brings academic and industry partners together. There have been numerous positive outcomes associated with both of these growing methodological and collaborative processes; nonetheless, both bring with them ethical considerations that require careful thought and attention. This paper addresses the ethical considerations that research teams must consider when using participatory methods and/or when working with industry and outlines a novel informed consent matrix designed to maintain the high ethical standard to which academic research in the healthcare arena has traditionally adhered.

Exploring Associations Between Children's Obesogenic Behaviors and the Local Environment Using Big Data: Development and Evaluation of the Obesity Prevention Dashboard

BACKGROUND

Obesity is a major public health problem globally and in Europe. The prevalence of childhood obesity is also soaring. Several parameters of the living environment are contributing to this increase, such as the density of fast food retailers, and thus, preventive health policies against childhood obesity must focus on the environment to which children are exposed. Currently, there are no systems in place to objectively measure the effect of living environment parameters on obesogenic behaviors and obesity. The H2020 project "BigO: Big Data Against Childhood Obesity" aims to tackle childhood obesity by creating new sources of evidence based on big data.

OBJECTIVE

This paper introduces the Obesity Prevention dashboard (OPdashboard), implemented in the context of BigO, which offers an interactive data platform for the exploration of objective obesity-related behaviors and local environments based on the data recorded using the BigO mHealth (mobile health) app.

METHODS

The OPdashboard, which can be accessed on the web, allows for (1) the real-time monitoring of children's obesogenic behaviors in a city area, (2) the extraction of associations between these behaviors and the local environment, and (3) the evaluation of interventions over time. More than 3700 children from 33 schools and 2 clinics in 5 European cities have been monitored using a custom-made mobile app created to extract behavioral patterns by capturing accelerometer and geolocation data. Online databases were assessed in order to obtain a description of the environment. The dashboard's functionality was evaluated during a focus group discussion with public health experts.

RESULTS

The preliminary association outcomes in 2 European cities, namely Thessaloniki, Greece, and Stockholm, Sweden, indicated a correlation between children's eating and physical activity behaviors and the availability of food-related places or sports facilities close to schools. In addition, the OPdashboard was used to assess changes to children's physical activity levels as a result of the health policies implemented to decelerate the COVID-19 outbreak. The preliminary outcomes of the analysis revealed that in urban areas the decrease in physical activity was statistically significant, while a slight increase was observed in the suburbs. These findings indicate the importance of the availability of open spaces for behavioral change in children. Discussions with public health experts outlined the dashboard's potential to aid in a better understanding of the interplay between children's obesogenic behaviors and the environment, and improvements were suggested.

CONCLUSIONS

Our analyses serve as an initial investigation using the OPdashboard. Additional factors must be incorporated in order to optimize its use and obtain a clearer understanding of the results. The unique big data that are available through the OPdashboard can lead to the implementation of models that are able to predict population behavior. The OPdashboard can be considered as a tool that will increase our understanding of the underlying factors in childhood obesity and inform the design of regional interventions both for prevention and treatment.

Establishing consensus on key public health indicators for the monitoring and evaluating childhood obesity interventions: a Delphi panel study

BACKGROUND

Childhood obesity is influenced by myriad individual, societal and environmental factors that are not typically reflected in current interventions. Socio-ecological conditions evolve and require ongoing monitoring in terms of assessing their influence on child health. The aim of this study was to identify and prioritise indicators deemed relevant by public health authorities for monitoring and evaluating childhood obesity interventions.

METHOD

A three-round Delphi Panel composed of experts from regions across Europe, with a remit in childhood obesity intervention, were asked to identify indicators that were a priority in their efforts to address childhood obesity in their respective jurisdictions. In Round 1, 16 panellists answered a series of open-ended questions to identify the most relevant indicators concerning the evaluation and subsequent monitoring of interventions addressing childhood obesity, focusing on three main domains: built environments, dietary environments, and health inequalities. In Rounds 2 and 3, panellists rated the importance of each of the identified indicators within these domains, and the responses were then analysed quantitatively.

RESULTS

Twenty-seven expert panellists were invited to participate in the study. Of these, 16/27 completed round 1 (5 9% response rate), 14/16 completed round 2 (87.5% response rate), and 8/14 completed the third and final round (57% response rate). Consensus (defined as > 70% agreement) was reached on a total of 45 of the 87 indicators (49%) across three primary domains (built and dietary environments and health inequalities), with 100% consensus reached for 5 of these indicators (6%).

CONCLUSION

Forty-five potential indicators were identified, pertaining primarily to the dietary environment, built environment and health inequalities. These results have important implications more widely for evaluating interventions aimed at childhood obesity reduction and prevention.

BigO: A public health decision support system for measuring obesogenic behaviors of children in relation to their local environment

Obesity is a complex disease and its prevalence depends on multiple factors related to the local socioeconomic, cultural and urban context of individuals. Many obesity prevention strategies and policies, however, are horizontal measures that do not depend on context-specific evidence. In this paper we present an overview of BigO (http://bigoprogram.eu), a system designed to collect objective behavioral data from children and adolescent populations as well as their environment in order to support public health authorities in formulating effective, context-specific policies and interventions addressing childhood obesity. We present an overview of the data acquisition, indicator extraction, data exploration and analysis components of the BigO system, as well as an account of its preliminary pilot application in 33 schools and 2 clinics in four European countries, involving over 4,200 participants.

Increasing Health Literacy May Reduce Health Inequalities: Evidence from a National Population Survey in Ireland

Background. Health literacy has been separately associated with socio-economic status and worse health status and outcomes. However, the magnitude of the associations between health literacy and health status and outcomes may not be evenly distributed across society. This study aims to estimate and compare the associations between health status, health behaviours, and healthcare utilisation within different levels of social status in the Irish population. Materials and methods. Data from Ireland collected as part of the 2011 European Health Literacy Survey were analysed. General health literacy was measured on a 0-50 scale, low to high. There were four binary outcomes: long-standing health conditions, smoking, hospital visits in the last 12 months, and self-rated health status. Logistic regression analysis was conducted to estimate the likelihood of each health outcome. Health literacy was treated as the main independent variable. Marginal effects were calculated using the delta method to demonstrate the change in likelihood of each outcome associated with a 5-point increase in health literacy score. The sample was grouped into tertiles based on self-reported social status, and models were replicated and compared for each tertile. Models were adjusted for known correlates of health literacy and health: age, gender, and education. Analysis was conducted using Stata V14. Results. Higher health literacy scores were associated with a lower probability of having a limiting illness within the low social status group only. Higher health literacy scores were associated with a lower probability of three or more hospital visits in the past 12 months in the low and middle social status groups. For people in the low and middle social status groups, higher health literacy levels were associated with a lower probability of being a current smoker. The associations between health literacy and self-rated health status were similar in each social status group. Conclusions: Improvement in population health literacy may reduce the prevalence of long-term chronic health conditions, reduce smoking levels, and result in fewer hospital visits. Whilst improved health literacy should improve behaviours and outcomes in all groups, it should have a more marked impact in lower social status groups, and hence contribute to reducing the observed social disparities in these health outcomes.

Mobile Health Apps in Pediatric Obesity Treatment: Process Outcomes From a Feasibility Study of a Multicomponent Intervention

BACKGROUND

Multicomponent family interventions underline current best practice in childhood obesity treatment. Mobile health (mHealth) adjuncts that address eating and physical activity behaviors have shown promise in clinical studies.

OBJECTIVE

This study aimed to describe process methods for applying an mHealth intervention to reduce the rate of eating and monitor physical activity among children with obesity.

METHODS

The study protocol was designed to incorporate 2 mHealth apps as an adjunct to usual care treatment for obesity. Children and adolescents (aged 9-16 years) with obesity (BMI ≥98th centile) were recruited in person from a weight management service at a tertiary health care center in the Republic of Ireland. Eligible participants and their parents received information leaflets, and informed consent and assent were signed. Participants completed 2 weeks of baseline testing, including behavioral and quality of life questionnaires, anthropometry, rate of eating by Mandolean, and physical activity level using a smart watch and the myBigO smartphone app. Thereafter, participants were randomized to the (1) intervention (usual clinical care+Mandolean training to reduce the rate of eating) or (2) control (usual clinical care) groups. Gender and age group (9.0-12.9 years and 13.0-16.9 years) stratifications were applied. At the end of a 4-week treatment period, participants repeated the 2-week testing period. Process evaluation measures included recruitment, study retention, fidelity parameters, acceptability, and user satisfaction.

RESULTS

A total of 20 participants were enrolled in the study. A web-based randomization system assigned 8 participants to the intervention group and 12 participants to the control group. Attrition rates were higher among the participants in the intervention group (5/8, 63%) than those in the control group (3/12, 25%). Intervention participants undertook a median of 1.0 training meal using Mandolean (25th centile 0, 75th centile 9.3), which represented 19.2% of planned intervention exposure. Only 50% (9/18) of participants with smart watches logged physical activity data. Significant differences in psychosocial profile were observed at baseline between the groups. The Child Behavior Checklist (CBCL) mean total score was 71.7 (SD 3.1) in the intervention group vs 57.6 (SD 6.6) in the control group, t-test P<.001, and also different among those who completed the planned protocol compared with those who withdrew early (CBCL mean total score 59.0, SD 9.3, vs 67.9, SD 5.6, respectively; t-test P=.04).

CONCLUSIONS

A high early attrition rate was a key barrier to full study implementation. Perceived task burden in combination with behavioral issues may have contributed to attrition. Low exposure to the experimental intervention was explained by poor acceptability of Mandolean as a home-based tool for treatment. Self-monitoring using myBigO and the smartwatch was acceptable among this cohort. Further technical and usability studies are needed to improve adherence in our patient group in the tertiary setting.

Associations between health literacy and patient outcomes in adolescents and young adults with cystic fibrosis

BACKGROUND

Interactive health literacy (HL) skills enable individuals to participate more fully in healthcare activities and play a role in improving their outcomes. We examine the associations between HL and cystic fibrosis (CF) outcomes and compare HL in a sample from both the Irish CF and general populations.

METHODS

A total of251 CF Registry participants aged 13-30 years completed the HLS-EU-Q16 survey and a disease-specific instrument for measuring quality of life (QoL) in CF. Health outcome and healthcare resource utilization (HCRU) data were sourced from the registry. CF patient outcomes were examined using generalized linear models (GLMs) with interactive HL categorization included as a factor. General population interactive HL data are from the 2011 European HL Survey (HLS-EU). Interactive HL in 180 age-sex matched CF and general population individuals was examined using a GLM with study population, sex and educational level included as factors and age as a covariate.

RESULTS

Sufficient interactive HL (total sum score ≥13) was self-reported by 81.7% of individuals with CF. Sufficient HL was associated with fewer outpatient visits [7.02(SD = 6.7: 7.4) vs. 8.74(SD = 7.9: 9.6), P < 0.001], days hospitalized [10.25(SD = 9.8: 10.7) vs. 12.8(SD = 11.8: 13.9), P < 0.001], days on intravenous antibiotics [15.3(SD = 14.7: 15.8) vs. 19.7(18.5: 21.1), P < 0.001], days on oral antibiotics [27.4(SD = 26.7: 28.1) vs. 48.48(38.7: 42.4), P < 0.001] and better QoL [77.1(SD = 75.4-78.9) vs. 64.6(60.8-68.3), P < 0.001]. Mean HL scores in CF and general populations were sufficient, although higher among individuals with CF (14.3 vs. 13.1, P < 0.01).

CONCLUSION

CF adolescents and young adults with sufficient levels of HL to obtain, understand, appraise and apply health information have better health-related outcomes.

One year update following removal of high sugar sweetened beverages from a university campus

Key messages

Removal of high sugar sweetened drinks from a university campus is possible; advice must be provided to those who may feel negatively impacted by the change. Sales can grow despite health-related changes of the food environment.

Clinical handover practices among healthcare practitioners in acute care services: A qualitative study

AIMS AND OBJECTIVES

To examine clinical handover practices in acute care services in Ireland. Objectives were to examine clinical handover practices between and within teams and between shifts, to identify resources and supports to enhance handover effectiveness and to identify barriers and facilitators of effective handover.

BACKGROUND

Clinical handover is a high-risk activity, and ineffective handover practice constitutes a risk to patient safety. Evidence suggests that handover effectiveness is achieved through staff training and standardised handover protocols.

DESIGN

The study design was qualitative-descriptive using inductive analysis.

METHODS

The study involved a series of focus group discussions and interviews among a sample of healthcare practitioners recruited from 12 urban and regional acute hospitals in Ireland. A total of 116 healthcare professionals took part in 28 interviews and 13 focus group discussions. We analysed the data using the directed content analysis method.

RESULTS

Data collection generated rich qualitative data, yielding five categories from which two broad themes emerged: "policy and practice" and "handover effectiveness." The themes and their associated categories indicate that there is limited organisational-level policy and limited explicit training in clinical handover, that medical and nursing handovers are separate activities with somewhat different purposes and different modes of execution, and that several factors in the acute care setting, including location, timing and documentation, act as either barriers or enablers to handover effectiveness.

CONCLUSION

The evidence in the current study suggests that clinical handover merits increased level of prominence in hospital policies or operating procedures. Medical and nursing handover practices represent distinct activities in their content and execution that may be related to cultural and organisational factors.

RELEVANCE TO CLINICAL PRACTICE

Achieving multidisciplinary team handover requires a change in embedded traditional practices. Several aspects of the clinical handover activities of nursing and medical staff appear to diverge from best-practice evidence.

Implementing a National Electronic Referral Program: Qualitative Study

BACKGROUND

Electronic referrals or e-referrals can be defined as the electronic transmission of patient data and clinical requests between health service providers. National electronic referral systems have proved challenging to implement due to problems of fit between the technical systems proposed and the existing sociotechnical systems. In seeming contradiction to a sociotechnical approach, the Irish Health Service Executive initiated an incremental implementation of a National Electronic Referral Programme (NERP), with step 1 including only the technical capability for general practitioners to submit electronic referral requests to hospital outpatient departments. The technology component of the program was specified, but any changes required to embed that technology in the existing sociotechnical system were not specified.

OBJECTIVE

This study aimed to theoretically frame the lessons learned from the NERP step 1 on the design and implementation of a national health information technology program.

METHODS

A case study design was employed, using qualitative interviews with key stakeholders of the NERP step 1 (N=41). A theory-driven thematic analysis of the interview data was conducted, using Barker et al's Framework for Going to Full Scale.

RESULTS

The NERP step 1 was broadly welcomed by key stakeholders as the first step in the implementation of electronic referrals-delivering improvements in the speed, completeness of demographic information, and legibility and traceability of referral requests. National leadership and digitalized health records in general practice were critical enabling factors. Inhibiting factors included policy uncertainty about the future organizational structures within which electronic referrals would be implemented; the need to establish a central referral office consistent with these organizational structures; outstanding interoperability issues between the electronic referral solution and hospital patient administration systems; and an anticipated need to develop specialist referral templates for some specialties. A lack of specification of the sociotechnical elements of the NERP step 1 inhibited the necessary testing and refinement of the change package used to implement the program.

CONCLUSIONS

The key strengths of the NERP step 1 are patient safety benefits. The NERP was progressed beyond the pilot stage despite limited resources and outstanding interoperability issues. In addition, a new electronic health unit in Ireland (eHealth Ireland) gained credibility in delivering national health information technology programs. Limitations of the program are its poor integration in the wider policy and quality improvement agenda of the Health Service Executive. The lack of specification of the sociotechnical elements of the program created challenges in communicating the program scope to key stakeholders and restricted the ability of program managers and implementers to test and refine the change package. This study concludes that while the sociotechnical elements of a national health information technology program do not need to be specified in tandem with technical elements, they do need to be specified early in the implementation process so that the change package used to implement the program can be tested and refined.

State of Diabetes Self-Management Education in the European Union Member States and Non-EU Countries: The Diabetes Literacy Project

BACKGROUND

Diabetes self-management education (DSME) is considered essential for improving the prevention and care of diabetes through empowering patients to increase agency in their own health and care processes. However, existing evidence regarding DSME in the EU Member States (EU MS) is insufficient to develop an EU-wide strategy.

OBJECTIVES

This study presents the state of DSME in the 28 EU MS and contrasts it with 3 non-EU countries with comparable Human Development Index score: Israel, Taiwan, and the USA (ITU). Because type 2 diabetes mellitus (T2DM) disproportionately affects minority and low-income groups, we paid particular attention to health literacy aspects of DSME for vulnerable populations.

METHODS

Data from multiple stakeholders involved in diabetes care were collected from Feb 2014 to Jan 2015 using an online Diabetes Literacy Survey (DLS). Of the 379 respondents (249 from EU MS and 130 from ITU), most were people with diabetes (33% in the EU MS, 15% in ITU) and care providers (47% and 72%). These data were supplemented by an expert survey (ES) administered to 30 key informants.

RESULTS

Access to DSME varies greatly in the EU MS: an average of 29% (range 21% to 50%) of respondents report DSME programs are tailored for people with limited literacy, educational attainment, and language skills versus 63% in ITU. More than half of adult T2DM patients and children/adolescents participate in DSME in EU MS; in ITU, participation of T1DM patients and older people is lower. Prioritization of DSME (6.1 ± 2.8 out of 10) and the level of satisfaction with the current state of DSME (5.0 ± 2.4 out of 10) in the EU MS were comparable with ITU.

CONCLUSION

Variation in availability and organization of DSME in the EU MS presents a clear rationale for developing an EU-wide diabetes strategy to improve treatment and care for people with diabetes.

Estimating Direct Cost of Cystic Fibrosis Care Using Irish Registry Healthcare Resource Utilisation Data, 2008-2012

BACKGROUND

Understanding the determinants of cost of cystic fibrosis (CF) care and health outcomes may be useful for financial planning for the delivery of CF services. Registries contain information otherwise unavailable to healthcare activity/cost monitoring systems. We estimated the direct medical cost of CF care using registry data and examined how cost was affected by patient characteristics and CF gene (CF Transmembrane Conductance Regulator [CFTR]) mutation.

METHODS

Healthcare resource utilisation data (2008-2012) were obtained for CF patients enrolled with the Irish CF Registry by 2013 from linked registry and national hospitalisation database records. Mean annual hospitalisation and medication per-patient costs were estimated by demographic profile, CFTR mutation, clinical status, and CF co-morbidity, and were presented in 2014 euro values. A mixed-effects regression model was used to examine the effect of demographic, CFTR mutation, and clinical outcomes on the log₁₀ cost of direct medical CF care.

RESULTS

Using 4261 observations from 1100 patients, we found that the median annual total cost per patient increased over the period 2008-2012 from €12,659 to €16,852, inpatient bed-day cost increased from €14,026 to €17,332, and medication cost increased from €5863 to €12,467. Homozygous F508-CFTR mutation (class II) cost was highest and milder mutation (class IV/V) cost was 49% lower. Baseline estimated cost in 2008 for a hypothetical underweight, homozygous F508del-CFTR 6-year-old female without chronic Pseudomonas aeruginosa/Staphylococcus aureus, CF-related diabetes (CFRD) or methicillin-resistant S. aureus (MRSA), and with a poor percent predicted forced expiratory volume in 1 s (ppFEV₁) was €10,113, and was €21,082 in a 25-year-old with the same hypothetical profile. Chronic P. aeruginosa infection increased baseline cost by 39%, CF co-morbidity diabetes by 18%, and frequency of pulmonary exacerbation by 15%. Underweight, declining ppFEV₁, chronic S. aureus colonisation, and time also influenced cost.

CONCLUSIONS

CFTR mutation is an important factor influencing the cost of CF care. Costs differ among cohorts of CF patients eligible to access new and emerging CFTR repair therapies. These findings support the evaluation of outcome-associated cost in CFTR mutation-specific CF patient groups.

Health Literacy, Health Care Utilization, and Direct Cost of Care Among Linguistically Diverse Patients with Type 2 Diabetes Mellitus

Background

Low functional health literacy (HL) has been associated with poor self-management of chronic conditions, including type 2 diabetes mellitus (T2DM), an inefficient use of health services, and higher health care costs. Low functional HL and limited English language proficiency both independently predict poor glycemic control among Latino and Chinese immigrants in the United States, and is more common among patients with diabetes with limited HL.

Objective

This study investigated the relationship between low functional HL, health care utilization, and costs of health care among a cohort of low-income patients with T2DM whose primary language was English, Spanish, or Cantonese (N = 277).

Methods

Patient data were collected from Medicaid administrative health care records as part of a low-income managed care program administered by the San Francisco Health Plan between April 2009 and March 2011. HL was measured with the Brief Questions Screening Tool for Health Literacy, administered via telephone survey. We used negative binomial regression with robust standard errors to estimate the effect of low functional HL on health care utilization, adjusting for demographic, socioeconomic, and health covariates. Results were reported as rate-ratios (RRs). We used two-part regression models to estimate the marginal difference in cost per patient associated with low functional HL. Utilization and cost models were also estimated, stratified by patient language.

Key Results

We observed a nonsignificant association between low functional HL and lower health care utilization, and lower total health care costs (-$1,493.53, 95% confidence interval [CI]: $3,602 to $615). While we observed a nonsignificant trend for low functional HL and lower utilization and total cost among people who speak English and Cantonese, low functional HL was significantly associated with more outpatient visits among patients who spoke Spanish (RR 1.31, 95% CI 1 to 1.72).

Conclusions

The relationship between low functional HL and health care utilization among this linguistically diverse cohort of patients with T2DM varied by patient language. Further research is needed to determine if lower utilization and costs in certain linguistic subgroups is indicative of barriers to access. [Health Literacy Research and Practice. 2017;1(3):e116-e126.].

Plain Language Summary

This study attempts to understand the relationship between health literacy, health care utilization, and costs of health care among an ethnically and linguistically diverse cohort of low-income patients with type 2 diabetes mellitus. We observed differences that could be due to actual differential effects of low HL by language status, or could be explained by unmeasured differences in health-seeking behaviors, access to care, degree of acculturation, or comorbidities.

Patient level cost of diabetes self-management education programmes: an international evaluation

OBJECTIVES

The objective of this study was to examine the value of time-driven activity-based costing (TDABC) in understanding the process and costs of delivering diabetes self-management education (DSME) programmes in a multicountry comparative study.

SETTING

Outpatient settings in five European countries (Austria, Denmark, Germany, Ireland, UK) and two countries outside Europe, Taiwan and Israel.

PARTICIPANTS

Providers of DSME programmes across participating countries (N=16) including healthcare professionals, administrators and patients taking part in DSME programmes.

PRIMARY AND SECONDARY MEASURES

Primary measure: time spent by providers in the delivery of DSME and resources consumed in order to compute programme costs. Secondary measures: self-report measures of behavioural self-management and diabetes disease/health-related outcomes.

RESULTS

We found significant variation in costs and the processes of how DSME programmes are provided across and within countries. Variations in costs were driven by a combination of price variances, mix of personnel skill and efficiency variances. Higher cost programmes were not found to have achieved better relative outcomes. The findings highlight the value of TDABC in calculating a patient level cost and potential of the methodology to identify process improvements in guiding the optimal allocation of scarce resources in diabetes care, in particular for DSME that is often underfunded.

CONCLUSIONS

This study is the first to measure programme costs using estimates of the actual resources used to educate patients about managing their medical condition and is the first study to map such costs to self-reported behavioural and disease outcomes. The results of this study will inform clinicians, managers and policy makers seeking to enhance the delivery of DSME programmes. The findings highlight the benefits of adopting a TDABC approach to understanding the drivers of the cost of DSME programmes in a multicountry study to reveal opportunities to bend the cost curve for DSME.

Effects on Engagement and Health Literacy Outcomes of Web-Based Materials Promoting Physical Activity in People With Diabetes: An International Randomized Trial

Background

Developing accessible Web-based materials to support diabetes self-management in people with lower levels of health literacy is a continuing challenge.

Objective

The objective of this international study was to develop a Web-based intervention promoting physical activity among people with type 2 diabetes to determine whether audiovisual presentation and interactivity (quizzes, planners, tailoring) could help to overcome the digital divide by making digital interventions accessible and effective for people with all levels of health literacy. This study also aimed to determine whether these materials can improve health literacy outcomes for people with lower levels of health literacy and also be effective for people with higher levels of health literacy.

Methods

To assess the impact of interactivity and audiovisual features on usage, engagement, and health literacy outcomes, we designed two versions of a Web-based intervention (one interactive and one plain-text version of the same content) to promote physical activity in people with type 2 diabetes. We randomly assigned participants from the United Kingdom, Austria, Germany, Ireland, and Taiwan to either an interactive or plain-text version of the intervention in English, German, or Mandarin. Intervention usage was objectively recorded by the intervention software. Self-report measures were taken at baseline and follow-up (immediately after participants viewed the intervention) and included measures of health literacy, engagement (website satisfaction and willingness to recommend the intervention to others), and health literacy outcomes (diabetes knowledge, enablement, attitude, perceived behavioral control, and intention to undertake physical activity).

Results

In total, 1041 people took part in this study. Of the 1005 who completed health literacy information, 268 (26.67%) had intermediate or low levels of health literacy. The interactive intervention overall did not produce better outcomes than did the plain-text version. Participants in the plain-text intervention group looked at significantly more sections of the intervention (mean difference –0.47, 95% CI –0.64 to –0.30, P<.001), but this did not lead to better outcomes. Health literacy outcomes, including attitudes and intentions to engage in physical activity, significantly improved following the intervention for participants in both intervention groups. These improvements were similar across higher and lower health literacy levels and in all countries. Participants in the interactive intervention group had acquired more diabetes knowledge (mean difference 0.80, 95% CI 0.65-0.94, P<.001). Participants from both groups reported high levels of website satisfaction and would recommend the website to others.

Conclusions

Following established practice for simple, clear design and presentation and using a person-based approach to intervention development, with in-depth iterative feedback from users, may be more important than interactivity and audiovisual presentations when developing accessible digital health interventions to improve health literacy outcomes.

ClinicalTrial

International Standard Randomized Controlled Trial Number (ISRCTN): 43587048; http://www.isrctn.com/ISRCTN43587048. (Archived by WebCite at http://www.webcitation.org/6nGhaP9bv)

Recent trends in breast, cervical, and colorectal cancer screening test utilization in Canada, using self-reported data from 2008 and 2012

In Canada, self-reported data from the Canadian Community Health Survey 2008 and 2012 provide an opportunity to examine overall utilization of breast, cervical, and colorectal cancer screening tests for both programmatic and opportunistic screening. Among women 50-74 years of age, utilization of screening mammography was stable (62.0% in 2008 and 63.0% in 2012). Pap test utilization for women 25-69 years of age remained high and stable across Canada in 2008 and 2012 (78.9% in 2012). The percentage of individuals 50-74 years of age who reporting having at least 1 fecal test within the preceding 2 years increased in 2012 (to 23.0% from 16.9% in 2008), but remains low. Stable rates of screening mammography utilization (about 30%) were reported in 2008 and 2012 among women 40-49 years of age, a group for which population-based screening is not recommended. Although declining over time, cervical cancer screening rates were high for women less than 25 years of age (for whom screening is not recommended). Interestingly, an increased percentage of women 70-74 years of age reported having a Pap test. In 2012, a smaller percentage of women 50-69 years of age reported having no screening test (5.9% vs. 8.5% in 2008), and more women reported having the three types of cancer screening tests (19.0% vs. 13.2%). Efforts to encourage use of screening within the recommended average-risk age groups are needed, and education for stakeholders about the possible harms of screening outside those age groups has to continue.

Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU)

Background: Health literacy concerns the capacities of people to meet the complex demands of health in modern society. In spite of the growing attention for the concept among European health policymakers, researchers and practitioners, information about the status of health literacy in Europe remains scarce. This article presents selected findings from the first European comparative survey on health literacy in populations. Methods: The European health literacy survey (HLS-EU) was conducted in eight countries: Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland and Spain (n = 1000 per country, n = 8000 total sample). Data collection was based on Eurobarometer standards and the implementation of the HLS-EU-Q (questionnaire) in computer-assisted or paper-assisted personal interviews. Results: The HLS-EU-Q constructed four levels of health literacy: insufficient, problematic, sufficient and excellent. At least 1 in 10 (12%) respondents showed insufficient health literacy and almost 1 in 2 (47%) had limited (insufficient or problematic) health literacy. However, the distribution of levels differed substantially across countries (29–62%). Subgroups within the population, defined by financial deprivation, low social status, low education or old age, had higher proportions of people with limited health literacy, suggesting the presence of a social gradient which was also confirmed by raw bivariate correlations and a multivariate linear regression model. Discussion: Limited health literacy represents an important challenge for health policies and practices across Europe, but to a different degree for different countries. The social gradient in health literacy must be taken into account when developing public health strategies to improve health equity in Europe.

Small and medium agility dogs alter their kinematics when the distance between hurdles differs

There is currently a lack of research examining the health and welfare implications for competitive agility dogs. The aim of this study was to examine if jump kinematics and apparent joint angles in medium (351-430 mm to the withers) and small (<350 mm to the withers) agility dogs altered when distances between consecutive upright hurdles differ. Dogs ran a course of nine hurdles; three set at 3.6 m apart; three at 4 m apart and three at 5 m apart. Both medium (P=0.044) and small (P=0.006) dogs landed closer to the hurdle when consecutive hurdles were set 3.6 m apart, with small dogs jumping slower at this distance (P=0.006). Results indicate that jump kinematics, but not apparent joint angles, alter when the spacing between hurdles differs. These findings may have implications for the health and welfare of agility dogs and should be used to inform future changes to rules and regulations.

Enhancing the effectiveness of diabetes self-management education: the diabetes literacy project

Patient empowerment through self-management education is central to improving the quality of diabetes care and preventing Type 2 Diabetes. Although national programs exist, there is no EU-wide strategy for diabetes self-management education, and patients with limited literacy face barriers to effective self-management. The Diabetes Literacy project, initiated with the support of the European Commission, aims to fill this gap. The project investigates the effectiveness of diabetes self-management education, targeting people with or at risk of Type 2 Diabetes in the 28 EU Member States, as part of a comprehensive EU-wide diabetes strategy. National diabetes strategies in the EU, US, Taiwan, and Israel are compared, and diabetes self-management programs inventorized. The costs of the diabetes care pathway are assessed on a per person basis at national level. A comparison is made of the (cost)-effectiveness of different methods for diabetes self-management support, and the moderating role of health literacy, organization of the health services, and implementation fidelity of education programs are considered. Web-based materials are developed and evaluated by randomized trials to evaluate if interactive internet delivery can enhance self-management support for people with lower levels of health literacy. The 3-year project started in December 2012. Several literature reviews have been produced and protocol development and research design are in the final stages. Primary and secondary data collection and analysis take place in 2014. The results will inform policy decisions on improving the prevention, treatment, and care for persons with diabetes across literacy levels.

Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q)

BACKGROUND

Several measurement tools have been developed to measure health literacy. The tools vary in their approach and design, but few have focused on comprehensive health literacy in populations. This paper describes the design and development of the European Health Literacy Survey Questionnaire (HLS-EU-Q), an innovative, comprehensive tool to measure health literacy in populations.

METHODS

Based on a conceptual model and definition, the process involved item development, pre-testing, field-testing, external consultation, plain language check, and translation from English to Bulgarian, Dutch, German, Greek, Polish, and Spanish.

RESULTS

The development process resulted in the HLS-EU-Q, which entailed two sections, a core health literacy section and a section on determinants and outcomes associated to health literacy. The health literacy section included 47 items addressing self-reported difficulties in accessing, understanding, appraising and applying information in tasks concerning decisions making in healthcare, disease prevention, and health promotion. The second section included items related to, health behaviour, health status, health service use, community participation, socio-demographic and socio-economic factors.

CONCLUSIONS

By illuminating the detailed steps in the design and development process of the HLS-EU-Q, it is the aim to provide a deeper understanding of its purpose, its capability and its limitations for others using the tool. By stimulating a wide application it is the vision that HLS-EU-Q will be validated in more countries to enhance the understanding of health literacy in different populations.

Shaping medicinal product information: a before and after study exploring physicians' perspectives on the summary of product characteristics

OBJECTIVE

To establish, in the context of the revised European Pharmacovigilance Directive and based on physicians' perspectives, how Summaries of Product Characteristics (SmPCs) could be more user friendly and better support physicians' interactions with patients, thereby improving patients' own understanding of their medicines.

DESIGN

Qualitative focus group discussions (step 1), development of an alternative SmPC (step 2) and an online quantitative survey (step 3) comparing the alternative SmPC to the currently approved version.

SETTING

Office-based physicians (n=218) from all federal states of Germany.

PARTICIPANTS

218 German physicians participated, with an equal representation of office-based general practitioners and specialists. For step 1 (n=18), physicians were recruited who frequently consulted SmPCs.

OUTCOME MEASURES

Planned and performed: Mayring's qualitative content analysis of focus group discussions (step 1), rating on a five-point Likert scale of preference of current versus alternative SmPCs (step 3).

RESULTS

Physicians confirmed the importance of SmPCs as a comprehensive source of medicinal product information, but were moderately satisfied with the current SmPCs, utilised it infrequently and were more likely to engage additional sources of information. The alternative SmPC was consistently preferred. It differed in the way information for particular patient groups was presented, included additional sections (synopsis, checklist for patient information) and used a tabular format. Physicians indicated that SmPCs should be available with search and hyperlink functions, as well as be automatically updated and integrated in available practice software or similar solutions.

CONCLUSIONS

This research contributes to the development of an official, reliable medicinal product information system meeting the needs of a modern information society while providing the reliability of an officially authorised source. In the context of health literacy, SmPCs should be established as the primary information source for healthcare professionals to ensure compliant and safe utilisation of medicinal products.

Health literacy and public health: a systematic review and integration of definitions and models

Background

Health literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy.

Methods

A systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model.

Results

The review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively.

Conclusions

Based upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.

Health literacy and public health: a systematic review and integration of definitions and models

BACKGROUND

Health literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy.

METHODS

A systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model.

RESULTS

The review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively.

CONCLUSIONS

Based upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.

Circulating melanoma cells and survival in metastatic melanoma

A validated assay for the enumeration of circulating melanoma cells (CMCs) may facilitate the development of more effective therapies for metastatic melanoma patients. In this study CD146+ cells were immunomagnetically enriched from 7.5 ml of blood. Isolated cells were fluorescently stained with DAPI, anti-molecular weight melanoma-associated antigen (HMW-MAA), anti-CD45 and CD34 and Ki67. CMCs were identified as CD146+, HMW-MAA+, CD45-, CD34-, Ki67-/+ cells. Eighty-eight percent of spiked SK-MEL28 cells in 7.5 ml blood were recovered. In all 55 healthy donors ≤1 CMCs were detected in 7.5 ml of blood. A retrospective analysis was conducted comparing CMC counts and overall survival in 79 blood samples from 44 melanoma patients. CMCs ranged from 0 to 8,042 per 7.5 ml. Two or more CMCs were detected in 18 (23%) of the patients and 30-100% (mean 84%) of the CMCs expressed the proliferation marker Ki67. Patients with ≥2 CMCs per 7.5 ml of whole blood, as compared with the group with <2 CMCs, had a shorter overall survival (2.0 months vs. 12.1 months, P=0.001).

Abstract P3-02-06: Correlation of BCL-2 and Apoptosis on Circulating Tumor Cells and Breast Cancer Tissue

Background: Circulating Tumor Cell (CTC) levels are prognostic markers in metastatic breast cancer (MBC). Further phenotypic characterization of CTC may provide an opportunity for non-invasive evaluation of predictive and prognostic markers. Apoptosis is a common form of chemotherapy-induced cell death. Monoclonal antibody (MAb) M30 recognizes a neo-epitope on fragmented cytokeratin and is a marker of apoptosis. BCL-2 is an anti-apoptotic marker and may predict for resistance to anti-neoplastic therapy. We have previously reported the results of a pilot clinical trial to estimate M30 and BCL-2 expression in CTC from patients with MBC. The current study was performed to correlate the expression of both BCL-2 and M30 in CTC with breast cancer tissue samples. Methods: Of the 85 patients in the original pilot study, 52 (61%) had evaluable tissue available (39 primary and 12 metastatic lesions; one unknown) and were included in this analysis. CTC were collected at baseline and were isolated, enumerated, and phenotypically characterized for M30 and BCL-2 using the CellSearch® System. CTC phenotype is reported as percentage of cells with positive staining. Tissue Microarrays (TMA) were constructed and immunohistochemically stained for M30 (anti-Cytodeath™ M30, Roche) and Bcl-2 (M-0887, DAKO) and scored using the Allred method.

Results: Tissue staining for M30 and Bcl-2 were inversely correlated. Of the 52 patients with TMA available for investigation, 22 (42%) had &gt; 5 CTC/7.5 ml whole blood. A positive, but non-significant, correlation was observed between increasing numbers of CTC levels and tissue BCL-2 Allred Score (Spearman r=0.36; p=0.1310). M30 staining was detected in ≥10% of CTC in 20 of the 22 (91%) patients with elevated CTC, while BCL-2 staining was detected in ≥10% of CTC in 19 of the 22 (86%) patients. Little if any correlation was observed between CTC M30 and tissue M30 expression, however CTC BCL-2 was positively correlated with tissue Bcl-2 expression (Spearman r=0.47; p=0.0440). Conclusions: BCL-2 and M30 can be characterized in both CTC and breast cancer tissue. The likelihood of having elevated CTC may be associated with higher BCL-2 expression, and CTC BCL-2 was associated with tissue BCL-2 expression. Although the clinical implications of these findings are unknown, they offer the opportunity for future trials to investigate whether CTC BCL-2 and M30 might be useful to identify patients with cancers that are resistant to standard therapies. Furthermore, CTC BCL-2 and M30 might be monitored in clinical trials of novel, apoptosis-inducing therapeutic agents.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-02-06.

Multi-center study evaluating circulating tumor cells (CTCs) as a surrogate for survival in men treated for castration refractory prostate cancer (CRPC)

5016

Background: Monitoring CTCs in patients undergoing therapy for metastatic breast cancer is an effective means to predict outcome and monitor treatment. The primary endpoint of this prospective multi-center study was to demonstrate a significant relation between the presence of CTCs and survival in men treated for CRPC. Methods: 276 patients with diagnosed CRPC, PSA progression, and an ECOG score of 0–2 about to begin initial or salvage chemo and/or combination therapy were enrolled. CTCs were enumerated with the CellSearch System in blood drawn pre-treatment and monthly thereafter for up to 18 months. Patient data were collected and maintained by an independent CRO. Median overall survival (OS) was determined for patients with =5 CTC /7.5mL at baseline and specified intervals. Results: Of 240 evaluable patients, 142 (59%) are alive - mean follow-up 11.4 ± 4.4 months. Median OS (in months) and significance between the two groups (logrank p-value) at different time points after the initiation of therapy are indicated in the table . Median OS for 40 (19%) patients with a reduction of CTCs below 5 CTCs 2–5 weeks after initiation of therapy was significantly longer as compared to those 78 (38%) patients that remained above 5 CTCs (>20 vs. 9.3mth, p=0.0000) and was not significantly different from the 83 (40%) patients with 20 vs. >20mth, p=0.2725). In multivariate analyses, which included stage at diagnosis, age, ECOG, Gleason score, LDH, Alkaline Phosphotase, and PSA, CTCs remained the most significant independent predictor of outcome. Conclusions: CTC levels in CRPC patients are a strong predictor of OS. The persistence of CTCs after initiation of therapy suggests that the patients are deriving less than optimal benefit from their current therapy. CTC levels may be a valid surrogate end-point in monitoring response to chemotherapy.

[Table: see text]

No significant financial relationships to disclose.

Preliminary study of immunomagnetic quantification of circulating tumor cells in patients with advanced disease

OBJECTIVES

To enumerate the amount of circulating tumor cells (CTCs) in patients with advanced prostate cancer and to investigate the relationship between these numbers, prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSM) expression, and clinical parameters.

METHODS

Whole blood was collected in proprietary CellSave tubes. Mononuclear cell fractions were isolated using epithelial cell antibody-coated magnetic nanoparticles. On one half of each immunomagnetically enriched cell fraction, automated fluorescent microscopy was used to identify the epithelial tumor cells. From the remainder of each sample, RNA extraction, cDNA synthesis, and polymerase chain reaction amplification of PSA and PSM were performed.

RESULTS

Eighty-four patients with advanced prostate cancer submitted 130 samples for analysis. Intact CTCs were identified in 62% of samples; 83.3% of CTC-positive and 0% of CTC-negative samples were reverse transcriptase-polymerase chain reaction positive for PSA and PSM (P = 0.001). A significant positive correlation was found between the CTC number and PSA (r = 0.49), alkaline phosphatase (r = 0.47), and lactate dehydrogenase (r = 0.55) levels, and a significant negative correlation with hemoglobin (r = -0.35). The initial Gleason grade, prior therapy, current therapy, and type of metastasis (bone, soft tissue) did not correlate significantly with the CTC number.

CONCLUSIONS

The presence of intact CTCs and the expression of PSA and PSM demonstrated robust agreement. The tumor cell numbers reflected current disease status and correlated significantly with the clinical disease indicators of PSA, hemoglobin, and liver function tests. These findings warrant further investigation of the diagnostic and prognostic value of enumerating intact CTCs.

Carpal tunnel syndrome - is high-frequency ultrasound a useful diagnostic tool?

This study assessed the clinical use of three ultrasound measurements; median nerve cross-sectional area, median nerve flattening ratio and palmar displacement of the flexor retinaculum, for the diagnosis of carpal tunnel syndrome. The measurements were made in 20 carpal tunnel sufferers and 20 controls. The sensitivity, specificity and predictive values of each were calculated in various clinical settings. Values for each of the three variables were significantly different in the patient and control populations. The differences we recorded were smaller than those found in previous studies. The tests had a sensitivity of 72% and a specificity of 90%. Alterations in the morphology of the carpal tunnel in patients with carpal tunnel syndrome can be measured in the district general hospital setting. The measurements described maybe a useful non-invasive confirmatory test in patients in whom there is a strong clinical suspicion of carpal tunnel syndrome. However, they would be of no benefit in epidemiological surveys of populations with a low incidence of carpal tunnel syndrome.

Onset of analgesia for liquigel ibuprofen 400 mg, acetaminophen 1000 mg, ketoprofen 25 mg, and placebo in the treatment of postoperative dental pain

Ibuprofen is a peripherally acting nonsteroidal anti-inflammatory drug indicated fo ranalgesia, antipyresis, and various arthritic conditions. A solubilized 200 mg liquigel formulation of ibuprofen has been shown to have a more rapid rate of absorption compared with ibuprofen 200 mg tablets. Ibuprofen liquigels have a kinetic profile similar to ibuprofen suspension, with both a higher Cmax and an earlier tmax than any solid tablet. The objective of this single-dose, double-blind, triple-dummy, parallel-group study was to assess the time to onset of relief and overall analgesic efficacy of liquigel ibuprofen 400 mg, ketoprofen 25 mg compared with acetaminophen 1000 mg, and placebo in 239 patients with moderate or severe pain following third molar extractions. Treatments were compared over 6 hours using standard scales for pain intensity and relief and stopwatch onset of meaningful relief. All active treatments provided meaningful relief significantly faster compared with placebo. Ibuprofen provided significantly faster relief compared with acetaminophen and ketoprofen. By the end of the study (6 h), onset of meaningful relief was achieved by 36%, 99%, 96%, and 88% of the patients in the placebo, ketoprofen, ibuprofen, and acetaminophen groups, respectively. The median times to onset of relief were > 6 hours for placebo, 25.5 minutes for ketoprofen, 24.2 minutes for ibuprofen, and 29.9 minutes for acetaminophen. In addition, both ibuprofen and ketoprofen showed statistical superiority over acetaminophen at earlier time points on the time-effect curves for pain relief and pain intensity difference. Consistent results were seen with respect to the 6-hour summary efficacy variables: the three active treatments were significantly better than placebo, and ibuprofen was significantly better than both acetaminophen and ketoprofen. Liquigel ibuprofen 400 mg was shown to provide faster relief and superior overall efficacy compared with ketoprofen 25 mg, acetaminophen 1000 mg, and placebo. No serious adverse effects were reported in this single-dose study.

Changes in circulating carcinoma cells in patients with metastatic prostate cancer correlate with disease status

OBJECTIVES

To investigate the diurnal variations in circulating tumor cells (CTCs) in metastatic carcinoma of the prostate (CAP) and to determine whether the change in CTCs correlated with disease progression.

METHODS

Samples were prepared by immunomagnetic selection of cells from 7 mL of blood targeting the epithelial cell adhesion molecule and differential fluorescent labeling of the collected cells using a nucleic acid dye, antibodies directed against the common leukocyte (CD45), and cytokeratin antigens. Events that stained with the nucleic acid dye and expressed cytokeratin but lacked CD45 were defined as CTCs by multiparameter flow cytometry.

RESULTS

Male controls (n = 22) exhibited 0.8 +/- 1.2 events per 7 mL blood compared with 5.9 +/- 4.7 in 10 samples from patients with localized CAP and 46.6 +/- 65.6 events in 10 samples from patients with metastatic CAP. Diurnal testing of 8 cases demonstrated stable levels of CTCs. Ten patients were serially analyzed during a 6-month period for serum prostate-specific antigen and CTCs. The correlation between the prostate-specific antigen level and CTC number was fair. Slow disease progression was found in 4 patients with low CTC numbers (3.0 +/- 3) but it was significantly higher than the control group (P <0.002). Rapid disease progression occurred in 6 patients who demonstrated high CTC numbers (68.5 +/- 71.9). Two patients received chemotherapy that caused substantial fluctuations in the CTCs with less pronounced changes in the prostate-specific antigen level.

CONCLUSIONS

We conclude that the level of CTCs can be quantified in the circulation of patients with metastatic CAP and that the change in CTCs correlates with disease progression with no diurnal variations.