Predictors of seasonal influenza and COVID-19 vaccination coverage among adults in Tennessee during the COVID-19 pandemic

Background

The COVID-19 pandemic has convoluted hesitancy toward vaccines, including the seasonal influenza (flu) vaccine. Because of COVID-19, the flu season has become more complicated; therefore, it is important to understand all the factors influencing the uptake of these vaccines to inform intervention targets. This article assesses factors related to the uptake of influenza and COVID-19 vaccines among adults in Tennessee.

Methods

A cross-sectional, secondary data analysis of 1,400 adults was conducted in Tennessee. The adult sample came from two data sources: Data source 1 completed a baseline survey from January to March 2022, and data source 2 was completed from May to August 2022. Data on vaccine attitudes, facilitators and barriers, and communication needs were collected via random digit dial by Scientific Telephone Samples (STS). Two multivariable logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to predict sociodemographic and overall vaccine-related factors associated with receipt or non-receipt (referent) of COVID-19 and influenza vaccines.

Results

Approximately 78% of the adult sample had received the COVID-19 vaccination. A significant positive association for COVID-19 vaccine uptake was seen among those who were older (aged 50-65) (aOR = 1.9; 95% CI: 1.2-3.2), Black (aOR = 2.0; 95% CI:1.3-2.8), and had a college education and higher (aOR = 2.3; 95% CI: 1.5-3.6). However, there was a significant negative association for persons reporting they were extremely religious (aOR = 0.5; 95% CI:0.3-0.9). Over 56% of the adult sample had received the influenza vaccination this season. Those who had a higher annual household income ($80,000+) (aOR = 1.9; 95% CI: 1.3-2.6) and had health insurance (aOR = 2.6; 95% CI: 1.4-4.8) had a significant positive association with influenza vaccine receipt. However, those who were employed part-time or were unemployed had a significant negative association for influenza vaccine receipt (aOR = 0.7; 95% CI: 0.5-0.9). Both COVID-19 and influenza vaccine receipt had strongly significant positive trends with increasing belief in effectiveness and trust (p < 0.0001) and strongly significant negative trends with higher levels of overall vaccine hesitancy (p < 0.0001).

Conclusion

Strategies to increase COVID-19 and influenza vaccination should be age-specific, focus on increasing geographical and financial access, and offer tailored messages to address concerns about these vaccines.

Mortality and histopathology in sheepshead minnow (Cyprinodon variegatus) larvae exposed to pectenotoxin-2 and Dinophysis acuminata

Toxic species of the dinoflagellate genus Dinophysis can produce diarrheic toxins including okadaic acid (OA) and dinophysistoxins (DTXs), and the non-diarrheic pectenotoxins (PTXs). Okadaic acid and DTXs cause diarrheic shellfish poisoning (DSP) in human consumers, and also cause cytotoxic, immunotoxic and genotoxic effects in a variety of mollusks and fishes at different life stages in vitro. The possible effects of co-produced PTXs or live cells of Dinophysis to aquatic organisms, however, are less understood. Effects on an early life stage of sheepshead minnow (Cyprinodon variegatus), a common finfish in eastern USA estuaries, were evaluated using a 96-h toxicity bioassay. Three-week old larvae were exposed to PTX2 concentrations from 50 to 4000 nM, live Dinophysis acuminata culture (strain DAVA01), live cells resuspended in clean medium or culture filtrate. This D. acuminata strain produced mainly intracellular PTX2 (≈ 21 pg cell^-1), with much lower levels of OA and dinophysistoxin-1. No mortality or gill damages were observed in larvae exposed to D. acuminata (from 5 to 5500 cells mL^-1), resuspended cells and culture filtrate. However, exposure to purified PTX2 at intermediate to high concentrations (from 250 to 4000 nM) resulted in 8 to 100% mortality after 96 h (24-h LC₅₀ of 1231 nM). Histopathology and transmission electron microscopy of fish exposed to intermediate to high PTX2 concentrations revealed important gill damage, including intercellular edema, necrosis and sloughing of gill respiratory epithelia, and damage to the osmoregulatory epithelium, including hypertrophy, proliferation, redistribution and necrosis of chloride cells. Tissue damage in gills is likely caused by the interaction of PTX2 with the actin cytoskeleton of the affected gill epithelia. Overall, the severe gill pathology observed following the PTX2 exposure suggested death was due to loss of respiratory and osmoregulatory functions in C. variegatus larvae.

Developing architecture of system management in the English NHS: evidence from a qualitative study of three Integrated Care Systems

OBJECTIVE

Integrated Care Systems (ICSs) mark a change in the English National Health Service to more collaborative interorganisational working. We explored how effective the ICS form of collaboration is in achieving its goals by investigating how ICSs were developing, how system partners were balancing organisational and system responsibilities, how partners could be held to account and how local priorities were being reconciled with ICS priorities.

DESIGN

We carried out detailed case studies in three ICSs, each consisting of a system and its partners, using interviews, documentary analysis and meeting observations.

SETTING/PARTICIPANTS

We conducted 64 in-depth, semistructured interviews with director-level representatives of ICS partners and observed eight meetings (three in case study 1, three in case study 2 and two in case study 3).

RESULTS

Collaborative working was welcomed by system members. The agreement of local governance arrangements was ongoing and challenging. System members found it difficult to balance system and individual responsibilities, with concerns that system priorities could run counter to organisational interests. Conflicts of interest were seen as inherent, but the benefits of collaborative decision-making were perceived to outweigh risks. There were multiple examples of work being carried out across systems and 'places' to share resources, change resource allocation and improve partnership working. Some interviewees reported reticence addressing difficult issues collaboratively, and that organisations' statutory accountabilities were allowing a 'retreat' from the confrontation of difficult issues facing systems, such as agreeing action to achieve financial sustainability.

CONCLUSIONS

There remain significant challenges regarding agreeing governance, accountability and decision-making arrangements which are particularly important due to the recent Health and Care Act 2022 which gave ICSs allocative functions for the majority of health resources for local populations. An arbiter who is independent of the ICS may be required to resolve disputes, along with increased support for shaping governance arrangements.

When technology precedes regulation: the challenges and opportunities of e-pharmacy in low-income and middle-income countries

The recent growth of medicine sales online represents a major disruption to pharmacy markets, with COVID-19 encouraging this trend further. While e-pharmacy businesses were initially the preserve of high-income countries, in the past decade they have been growing rapidly in low-income and middle-income countries (LMICs). Public health concerns associated with e-pharmacy include the sale of prescription-only medicines without a prescription and the sale of substandard and falsified medicines. There are also non-health-related risks such as consumer fraud and lack of data privacy. However, e-pharmacy may also have the potential to improve access to medicines. Drawing on existing literature and a set of key informant interviews in Kenya, Nigeria and India, we examine the e-pharmacy regulatory systems in LMICs. None of the study countries had yet enacted a regulatory framework specific to e-pharmacy. Key regulatory challenges included the lack of consensus on regulatory models, lack of regulatory capacity, regulating sales across borders and risks of over-regulation. However, e-pharmacy also presents opportunities to enhance medicine regulation—through consolidation in the sector, and the traceability and transparency that online records offer. The regulatory process needs to be adapted to keep pace with this dynamic landscape and exploit these possibilities. This will require exploration of a range of innovative regulatory options, collaboration with larger, more compliant businesses, and engagement with global regulatory bodies. A key first step must be ensuring that national regulators are equipped with the necessary awareness and technical expertise to actively oversee this e-pharmacy activity.

Challenges of maintaining accountability in networks of health and care organisations: A study of developing Sustainability and Transformation Partnerships in the English National Health Service

The English National Health Service (NHS) constitutes a unique institutional context, which combines elements of hierarchy, markets and networks. This has always raised issues about competing forms of accountability. Recent policy has emphasised a move from quasi market competition towards collaboration in the form of new regional organisational arrangements known as Sustainability and Transformation Partnerships (STPs). We explore accountability relationships in STPs, focusing on the challenges of increasing horizontal accountability given existing vertical accountabilities, most notably to national regulators. We utilize a case study approach concentrated on three Clinical Commissioning Groups (CCGs) in urban and rural settings in England. We conducted in-person interviews with 22 managers from NHS organisations and local authorities and examined local documents to obtain information on governance and accountability structures. The fieldwork was undertaken between November 2017 and July 2018. We analysed results by considering which actors were accountable to what forums and the nature of the obligation (vertical or horizontal). We found that individual organisations still retained vertical accountabilities and were reluctant to be held accountable for the whole STP, given they were responsible for only part of the joint effort. Moreover, organisations did not feel accountable to STPs and instead highlighted vertical accountabilities upwards to their own boards and to national regulators; and downwards to the public. But while local commissioning organisations, CCGs engaged with their members and the public, STPs failed to engage adequately with the public. Nevertheless, there were indications that horizontal accountability was starting to develop. This could become complementary to vertical accountability by facilitating mutual learning and peer review to anticipate and defer regulatory intervention. While vertical accountability is necessary to provide oversight and apply sanctions, it is not sufficient and should be accompanied by horizontal accountability.

The regulation of competition and procurement in the National Health Service 2015-2018: enduring hierarchical control and the limits of juridification

Since 1990, market mechanisms have occurred in the predominantly hierarchical National Health Service (NHS). The Health and Social Care Act 2012 led to concerns that market principles had been irrevocably embedded in the NHS and that the regulators would acquire unwarranted power compared with politicians (known as 'juridification'). To assess this concern, we analysed regulatory activity in the period from 2015 to 2018. We explored how economic regulation of the NHS had changed in light of the policy turn back to hierarchy in 2014 and the changes in the legislative framework under Public Contracts Regulations 2015. We found the continuing dominance of hierarchical modes of control was reflected in the relative dominance and behaviour of the sector economic regulator. But there had also been a limited degree of juridification involving the courts. Generally, the regulatory decisions were consistent with the 2014 policy shift away from market principles and with the enduring role of hierarchy in the NHS, but the existing legislative regime did allow the incursion of pro market regulatory decision making, and instances of such decisions were identified.

Agreeing the allocation of scarce resources in the English NHS: Ostrom, common pool resources and the role of the state

A challenge facing health systems such as the English National Health Service (NHS), which operate in a context of diversity of provision and scarcity of financial resources, is how organisations engaged in the provision of services can be encouraged to adopt collective resource utilisation strategies to ensure limited resources are utilised in the interests of service users and, in the case of tax funded services, the general public. In this paper the authors apply Elinor Ostrom's work concerning communities' self-governance of common pool resources to the development of collective approaches to the utilisation of resources for the provision of health services. Focusing on the establishment of Sustainability and Transformation Partnerships (STPs) in the English NHS, and drawing on interviews with senior managers in English NHS purchaser and provider organisations, we use Ostrom's work as a frame to analyse STPs, as vehicles to agree and enact shared rules governing the allocation of financial resources, and the role of the state in relation to the development of this collective governance. While there was an unwillingness to use STPs to agree collective rules for resource allocation, we found that local actors were discussing and agreeing collective approaches regarding how resources should be utilised to deliver health services in order to make best use of scarce resources. State influence on the development of collective approaches to resource allocation through the STP was viewed by some as coercive, but also provided a necessary function to ensure accountability. Our analysis suggests Ostrom's notion of resource 'appropriation' should be extended to capture the nuances of resource utilisation in complex production chains, such as those involved in the delivery of health services where the extraction of funds is not an end in itself, but where the value of resources depends on how they are utilised.

Divergence of NHS choice policy in the UK: what difference has patient choice policy in England made?

OBJECTIVES

To examine the types of choices available to patients in the English NHS when being referred for acute hospital care in the light of the divergence of patient choice policy in the four countries of the UK.

METHODS

Case studies of eight local health economies in England, Scotland, Northern Ireland and Wales (two in each country); 125 semi-structured interviews with staff in acute services providers, purchasers and general practitioners (GPs).

RESULTS

GPs and providers in England both had a clear understanding of the choice of provider policy and the right of patients to choose a provider. Other referral choices potentially available to patients in all four countries were date and time of appointment, site and specialist. In practice, the availability of these choices differed between and within countries and was shaped by factors beyond choice policy, such as the number of providers in an area. There were similarities between the four countries in the way choices were offered to patients, namely lack of clarity about the options available, limited discussion of choices between referrers and patients, and tension between offering choice and managing waiting lists.

CONCLUSIONS

There are challenges in implementing pro-choice policy in health care systems where it has not traditionally existed. Differences between England and the other countries of the UK were limited in the way choice was offered to patients. A cultural shift is needed to ensure that patients are fully informed by GPs of the choices available to them.

Acute assessment of an aspalathin-enriched green rooibos (Aspalathus linearis) extract with hypoglycemic potential

Rooibos, an endemic South African plant, known for its use as herbal tea, has potential as an antidiabetic herbal product, following recent demonstration of the glucose lowering effect of its major flavonoid, the dihydrochalcone C-glucoside aspalathin. The purpose of this study was to confirm antidiabetic activity for rooibos extract high in aspalathin content. An extract (SB1) was selected after screening for high aspalathin content and α-glucosidase inhibition activity. On-line HPLC-biochemical detection confirmed α-glucosidase inhibitory activity for aspalathin. In vitro the extract induced a dose response increase in glucose uptake (5 × 10⁻⁵ to 5 μg/ml) on C2C12 myotubules. Aspalathin was effective at 1, 10 and 100 μM, while rutin was effective at 100 μM. In the Chang cells only the extract was effective. In vivo the extract sustained a glucose lowering effect comparable to metformin over a 6h period after administration (25mg/kg body weight (BW)) to STZ-induced diabetic rats. In an oral glucose tolerance test the extract (30 mg/kg BW) was more effective than vildagliptin (10mg/kg BW), a dipeptidyl peptidase-4 inhibitor. An aspalathin-rutin mixture (1:1; m/m) dosed at 1.4 mg/kg BW, but not the single compounds separately, reduced blood glucose concentrations of STZ-induced diabetic rats over a 6h monitoring period. The improved hypoglycemic activity of the aspalathin-rutin mixture and the extract illustrated synergistic interactions of polyphenols in complex mixtures.

Investigating effects of between- and within-host variability on Escherichia coli O157 shedding pattern and transmission

Healthy cattle and their environment are the reservoir for the human pathogen Escherichia coli O157. In E. coli O157 epidemiology, supershedders have been loosely defined as cattle that shed high concentrations of E. coli O157 (≥ 10(4)colony-forming cells (CFU)/g of feces) at a single (or multiple) cross-section in time. Due to the variability in the pathogen shedding level among animals (between-host variability), as well as fluctuations in the level shed by a single animal (within-host variability), it is difficult to interpret fecal bacteria distributions, as well as to parse the relative contribution of between- and within-host variability to the observed shedding patterns at the pen level. We developed an agent-based model that integrates individual animal data on temporal fecal shedding dynamics with pen-level E. coli O157 transmission to study how the temporal (and aggregation) patterns of E. coli O157 shedding loads and prevalence arise at the pen level. We demonstrated that even without between-host variability, the prevalence of animals with concentration of E. coli O157 in feces that exceeds 10(4)CFU/g is similar to that observed in cross-sectional field data. Both within-host and between-host variability can generate supershedders.

Alcohol and Drug Misuse, Risk of Re-admission to a General Hospital and Psychiatric Contact

Patients with physical problems related to the use of alcohol or drugs often present to general hospitals in an unplanned, emergency fashion. In 2005, the Kerr report concluded that fundamental changes were needed in our approach, shifting the emphasis from a reactive to a more proactive, prevention-based model in the treatment of acute medical conditions. We studied patients who had at least one alcoholor drug-related emergency admission, whose most recent admission was to Aberdeen Royal Infirmary and who, using the Scottish Patients at Risk of Re-admission and Admission (SPARRA) All Ages Tool, were thought to be at high risk of further emergency admission. We examined data sets derived from the National Health Service National Services Scotland Information Services Division, a Liaison Psychiatry database, data from the local psychiatric Patient Information Management System and data collected by the hospital alcohol liaison nurse to examine this group of patients further and consider the scope for any future intervention. Patients who have an alcoholor drug-related emergency admission to the general hospital are at increased risk of re-admission. A substantial proportion of these patients has come into contact with the psychiatric services, often attracting a substance misuse and/or personality disorder diagnosis. A significant proportion also presents in the context of self-harm. In conclusion, this group of frequent hospital attenders may be difficult to engage but may benefit from more proactive intervention, a more joined-up management approach and the development of an enhanced general hospital alcohol liaison service.

HEPARINEMIA (?) : AN ANTICOAGULANT IN THE BLOOD OF DOGS WITH HEMORRHAGIC TENDENCY AFTER TOTAL BODY EXPOSURE TO ROENTGEN RAYS

When the entire body of dogs was exposed to 450 units of Roentgen irradiation a hemorrhagic syndrome developed which was characterized by thrombo-cytopenia, prolonged clotting and bleeding times, and neutropenia. The prothrombin time remained normal until about 24 hours before death. The calcium, phosphorus, and magnesium levels were not altered. Fibrinogen was present but syneresis was poor. Toluidine blue and protamine sulfate, substances which can inhibit the biologic action of heparin, restored the clotting time to normal. The hemorrhagic state was not materially altered by transfusions, vitamin K, or vitamin C. Toluidine blue and protamine sulfate were ineffective in the control of hemorrhage produced by dicumarol. The defect responsible for bleeding after irradiation appeared to be the presence in the circulation of an anticoagulant whose properties, so far as tested, were indistinguishable from those of heparin.

Detection of fetal growth restriction in patients with chronic hypertension: is it feasible?

OBJECTIVE

To determine the utility of sonographic estimated fetal weight (EFW) in diagnosing intrauterine growth restriction (IUGR, birth weight < 10% for gestational age) in patients with chronic hypertension.

METHODS

All pregnant patients with hypertension delivered during a 5-year period at three centers were identified retrospectively. Patients with gestational hypertension, pre-eclampsia, diabetes mellitus, fetal anomalies and absence of a sonographic examination within 3 weeks of delivery were excluded. Likelihood ratio (LR) and guidelines established by the Evidence-Based Medicine Working Group were used to determine whether sonographic EFW is a reliable diagnostic test to detect IUGR.

RESULTS

At the three centers, there were 264 patients with chronic hypertension (122, 77 and 65 at centers I, II and III, respectively). The incidence of IUGR ranged from 13% to 27% but was similar at the three locations (p = 0.064). The LR (with 95% confidence interval (CI)) of detecting IUGR was 4.4 (95% CI 2.5, 7.7), 2.3 (95% CI 1.4, 3.7) and 6.1 (95% CI 2.7, 13.7) at centers I, II and III, respectively. Based on the proportions of abnormal growth, we required 253 and 71 newborns with fetal growth restriction at centers I and II, respectively, to have narrow confidence intervals around the clinically important LR of 10. The extremely low incidence of IUGR at center III (13%) precluded the estimation of required sample size.

CONCLUSION

Use of Evidence-Based Medicine Working Group guidelines indicates that sonographic EFW is slightly to moderately useful in detecting fetal growth restriction in patients with chronic hypertension.

Health risk behaviors and work injury among hispanic adolescents and farmworkers

Adolescents may engage in health risk behaviors that increase their likelihood of injury. Employment places adolescents at risk of work-related injuries. This study responds to the paucity of data on the relationship between adolescent health risk behaviors and work-related injury. This cross-sectional study included the administration of anonymous surveys to ninth graders (n=4914) who attended high schools in south Texas. An aggregate risk score (ARS) was developed based on health risk behaviors. The ARS was analyzed as an outcome using linear regression. Associations between health risk behaviors and work-related injury were assessed with logistic regression. Of the respondents, 19% reported they had a job, and 14% reported that they had been employed in farmwork. Farmwork-related injury was reported by 9% of adolescents, and 12% reported other work-related injury. Mean ARS scores were significantly higher (p < 0.05) for both male and female adolescents who reported a work-related injury compared to nonworking adolescents, and for males who had done migrant farmwork compared to all other adolescent males. The ARS increased as hours worked per week increased. After controlling for confounding factors, a statistically significant association was found between ARS and non-farmwork, work-related injury, but not between ARS and farmwork-related injury. Farmworkers with high ARS were more likely to report non-farmwork, work-related injuries. The predictors of work-related injury in the adolescent groups, particularly for farmworkers and migrants who are under additional stress, remain an important occupational health area to be addressed.

The global atmospheric environment for the next generation

Air quality, ecosystem exposure to nitrogen deposition, and climate change are intimately coupled problems: we assess changes in the global atmospheric environment between 2000 and 2030 using 26 state-of-the-art global atmospheric chemistry models and three different emissions scenarios. The first (CLE) scenario reflects implementation of current air quality legislation around the world, while the second (MFR) represents a more optimistic case in which all currently feasible technologies are applied to achieve maximum emission reductions. We contrast these scenarios with the more pessimistic IPCC SRES A2 scenario. Ensemble simulations for the year 2000 are consistent among models and show a reasonable agreement with surface ozone, wet deposition, and NO2 satellite observations. Large parts of the world are currently exposed to high ozone concentrations and high deposition of nitrogen to ecosystems. By 2030, global surface ozone is calculated to increase globally by 1.5 +/- 1.2 ppb (CLE) and 4.3 +/- 2.2 ppb (A2), using the ensemble mean model results and associated +/-1 sigma standard deviations. Only the progressive MFR scenario will reduce ozone, by -2.3 +/- 1.1 ppb. Climate change is expected to modify surface ozone by -0.8 +/- 0.6 ppb, with larger decreases over sea than over land. Radiative forcing by ozone increases by 63 +/- 15 and 155 +/- 37 mW m(-2) for CLE and A2, respectively, and decreases by -45 +/- 15 mW m(-2) for MFR. We compute that at present 10.1% of the global natural terrestrial ecosystems are exposed to nitrogen deposition above a critical load of 1 g N m(-2) yr(-1). These percentages increase by 2030 to 15.8% (CLE), 10.5% (MFR), and 25% (A2). This study shows the importance of enforcing current worldwide air quality legislation and the major benefits of going further. Nonattainment of these air quality policy objectives, such as expressed by the SRES-A2 scenario, would further degrade the global atmospheric environment.

Development of multidimensional scales to measure key leaders' perceptions of community capacity and organizational capacity for teen pregnancy prevention

This study discusses the development of scales to measure key leaders' self-reported involvement in community capacity building, perceptions of organizational capacity for teen pregnancy prevention, and the relationship between capacity and teen pregnancy rates. Data were collected from 1,516 key leaders across a rural southern state. Findings indicate that key leaders' perceptions of organizational capacity are related to their involvement in community capacity building efforts and community capacity is associated with teen pregnancy rates. This research represents progress toward measuring community and organizational capacity and may be used to inform future work focusing on developing quantitative measures of community capacity.

Diabetes mellitus and prostate cancer risk among older men: population-based case-control study

We investigate the relation between diabetes mellitus and risk of prostate cancer among older (age 65–79 years) men in a population-based case–control study of 407 incident histologically confirmed cases registered in the South Carolina Central Cancer Registry between 1999 and 2001 (70.6% response rate); controls were 393 men identified through the Health Care Financing Administration Medicare beneficiary file for South Carolina in 1999 (63.8% response rate). After adjusting for age, race, and prostate cancer screening in the past 5 years, a history of diabetes mellitus was associated with a reduced risk of prostate cancer (adjusted odds ratio (aOR)=0.64; 95% confidence interval (CI)=0.45, 0.91). The protective effect was stronger for those with complications associated with diabetes (aOR=0.61; 95% CI=0.42, 0.90) and for African-American men (aOR=0.36; 95% CI=0.21, 0.62). Additional research is needed to understand the biologic mechanisms by which diabetes may influence prostate cancer risk; genetic factors may play an important role in understanding this association.

Weight at birth and adolescence and premenopausal breast cancer risk in a low-risk population

We assessed breast cancer risk in relation to weight at birth and adolescence. In-person interviews were completed with the biological mothers of women aged 45 years and younger who participated in the Shanghai Breast Cancer Study in 1996-98 (288 cases, 350 controls). After adjustment for confounding, women who were 4000 g or more at birth were not at increased risk of breast cancer (odds ratio=0.7; 95% confidence interval 0.4-1.4) relative to women whose birth weight was 2500-2999 g. Compared with women of average perceived weight at age 15 years, no relation was apparent for heavier than average weight based on maternal report (odds ratio=0.7; 95% confidence interval 0.5-1.2) or self-report (odds ratio=1.0; 95% confidence interval 0.7-1.6). Perceived adolescent weight and height did not modify the association of birth weight with breast cancer risk. These results suggest that weight early in life is not related to premenopausal breast cancer risk in this low-risk population.

Abortion history and breast cancer risk: results from the Shanghai Breast Cancer Study

Studies of the association between induced abortion and breast cancer risk have been inconsistent, perhaps due to underreporting of abortions. Induced abortion is a well-accepted family planning procedure in China, and women who have several induced abortions do not feel stigmatized. The authors used data from a population-based case-control study of breast cancer among women age 25-64 conducted between 1996 and 1998 in urban Shanghai to assess whether a history of and the number of induced abortions were related to breast cancer risk. In-person interviews were completed with 1,459 incident breast cancer cases ascertained through a population-based cancer registry, and 1,556 controls randomly selected from the general population in Shanghai (with respective response rates of 91% and 90%). After adjusting for confounding, there was no relation between ever having had an induced abortion and breast cancer (odds ratio [OR] = 0.9, 95% confidence interval [CI] 0.7-1.2). Women who had 3 or more induced abortions were not at increased risk of premenopausal breast cancer (OR = 0.9, 95% CI 0.6-1.4) or postmenopausal breast cancer (OR = 1.3, 95% CI 0.8-2.3). These results suggest that a history of several induced abortions has little influence on breast cancer risk in Chinese women.

Assessment of clinical partner violence screening tools

OBJECTIVE

To compare the Women's Experience with Battering Scale (WEB) with the Index of Spouse Abuse-Physical Scale (ISA-P) as screening tools to identify intimate partner violence (IPV).

METHODS

We conducted a large cross-sectional survey of women age 18 to 65 attending one of two family practice clinics from 1997 to 1998. All women completed both the WEB and the ISA-P and a telephone interview. We figured agreement estimates between the two tools, used stratified analyses to evaluate attributes of those more likely to screen as battered or physically assaulted, and compared associations between the WEB and ISA-P and a range of mental and physical health indicators known to be associated with IPV.

RESULTS

18% of 1152 eligible women surveyed had experienced IPV in a current or most recent intimate relationship with a male partner; 17% had been battered (WEB+), and 10% had been physically assaulted (ISA-P+). Had we used the ISA-P alone to assess IPV, we would have missed almost 45% of IPV. As anticipated, the ISA-P was more strongly associated with IPV-associated injuries and number of physician visits in the last year. The WEB was more strongly associated with self-perceived mental health, anxiety, depression, drug abuse, and low social support.

CONCLUSION

Clinicians need validated screening tools to rapidly and reliably screen patients for IPV. Most screening tools assess physical violence and injury without considering the more chronic experience of battering and the psychological terror associated with this violence. The WEB may identify more abused women than tools measuring physical assaults.

Screening for fetal alcohol syndrome in primary schools: a feasibility study

BACKGROUND

This project was undertaken as a feasibility study to determine the possibility of screening for fetal alcohol syndrome (FAS) in early school-age children for epidemiological and interventional purposes.

METHODS

All elementary schools in two counties in Washington State were asked to screen first graders for possible FAS. A child was screen positive if found to be growth deficient, to have certain specific facial abnormalities, or have a known history of substantial alcohol exposure in gestation. All screen-positive children were invited to "special diagnostic clinics" for final diagnosis and treatment planning.

RESULTS

In County A, virtually all students were screened. In County B only about 25% of children were screened. This difference was related to the number of schools that agreed to participate in the project and the methods employed by each county to obtain parental permission. In each county, only about one-half of the screen-positive children were seen in the special clinics for diagnostic considerations. Only one of the seven children found to have FAS had been diagnosed previously. The minimal prevalence of FAS in County A was 3.1 in 1,000 students. The minimal prevalence of FAS in County B could not be calculated. The most efficient component in the screening process leading to a diagnosis of FAS was finding the specific facial features of the disorder. The diagnosis of FAS was generally helpful in improving educational planning.

CONCLUSIONS

This study demonstrated that population-based FAS screening within a school system may be possible, but participation is dependent on local trust and understanding of the project before its inception within the schools and the community at large.

Association between level of delivery hospital and neonatal outcomes among South Carolina Medicaid recipients

OBJECTIVE

The purpose of this study was to examine relationships between level of delivery hospital and neonatal mortality rate, length of stay, and Medicaid reimbursement.

STUDY DESIGN

This was a retrospective cohort study of 2560 infants with birth weights between 500 and 1499 g who were born between 1991 and 1995 to South Carolina mothers and whose care was covered by Medicaid.

RESULTS

The relative risk of neonatal death for infants born in level I and II hospitals (relative risk, 1.9; 95% confidence interval, 1.6-2.2) but not level II hospitals with 24-hour neonatology coverage (relative risk, 1.2; 95% confidence interval, 0.7-1.9) was higher than that for infants born in level III hospitals. Compared with infants born in level III hospitals mean length of stay was longer and Medicaid reimbursement was similar for infants born in level I and II hospitals. Among infants born in level II hospitals with 24-hour neonatology coverage length of stay was shorter and Medicaid reimbursement was lower.

CONCLUSION

Infants born in level I and II hospitals had higher neonatal mortality rates and longer stays than did infants born in level III hospitals, despite similar Medicaid reimbursement.

Severe dating violence and quality of life among south carolina high school students

BACKGROUND

Little research has addressed the impact of dating violence and forced-sex victimization and perpetration on adolescent well-being. In this cross-sectional study, we provide (1) estimates of severe dating violence (SDV) by victimization and perpetration status, (2) estimates of lifetime forced-sex victimization and perpetration, (3) demographic and health behaviors correlated with SDV, and (4) associations between SDV and forced sex and well-being as assessed by (1) health-related quality of life (H-R QOL) and (2) life satisfaction measures.

METHODS

We used a stratified cluster sample of 5414 public high school students, grades 9 through 12, who responded to the 1997 self-administered South Carolina Youth Risk Behavior Survey.

RESULTS

Nearly 12% of adolescents self-reported SDV as a victim (7.6%) or a perpetrator (7.7%), and SDV rates (victimization/perpetration combined) are higher in girls (14.4%) than boys (9.1%). Race, aggressive behaviors, substance use, and sexual risk-taking are correlates of SDV. Among young women, SDV victimization, not perpetration, was associated with recent poor H-R QOL and suicide ideation or attempts, but not lower life-satisfaction scores. Among young men, SDV perpetration, not victimization, was strongly associated with poor H-R QOL and suicide attempts, and lower scores for all domains of life satisfaction.

CONCLUSIONS

This research provides evidence that SDV and forced sex are associated with poor H-R QOL, low life-satisfaction scores, and adverse health behaviors in adolescent female victims and male perpetrators. Screening for dating violence is needed to identify and intervene early to reduce the impact of dating violence.

Intimate partner violence and cervical neoplasia

Intimate partner violence (IPV) is associated with a range of adverse physical health outcomes, including chronic and infectious diseases. An emerging literature suggests that partner violence and specifically sexual violence may be associated with an increased risk of cervical neoplasia. To assess the risk of preinvasive and invasive cervical cancer in a cross-sectional study of women screened for IPV by type, frequency and duration, 1152 women ages 18-65 were recruited from family practice clinics in 1997-1998. They were screened for IPV during a brief in-clinic interview, and health history and current status were assessed in a follow-up interview. Of 1152 women surveyed, 14 (1.2%) reported cervical cancer, and 20. 3% (n = 234) reported treatment for cervical neoplasia. Ever experiencing IPV was associated with an increased risk of invasive cervical cancer (adjusted relative risk [aRR] = 4.28; 95% CI 1.94, 18.39) and with preinvasive cervical neoplasia (aRR = 1.47; 95% CI 1. 16, 1.82). This association was stronger for women experiencing physical or sexual IPV than for women experiencing psychological IPV. Women with cervical cancer reported being in violent relationships longer and experiencing more frequent physical and sexual assaults and more IPV-associated injuries than did controls. This exploratory study suggests that IPV may increase a woman's risk of cervical neoplasia. The mechanism by which IPV effects cervical neoplasia may be indirect through psychosocial stress or negative coping behaviors or direct through sexual assaults and transmission of human papillomavirus (HPV).

Oral contraceptives and epithelial ovarian cancer. Does dose matter?

OBJECTIVE

To determine the risk of ovarian cancer among women who use low-estrogen-dose oral contraceptives.

STUDY DESIGN

The study used data on white women under 70 years of age who had been enrolled in a population-based case-control study conducted between 1986 and 1988 in three western Washington counties. Women with ovarian cancer (n = 276) were ascertained through a population-based cancer registry, and controls (n = 391) were selected by random digit dialing. Unconditional logistic regression was used to estimate the risk of ovarian cancer associated with oral contraceptive use.

RESULTS

After adjustment for age and parity, women who took oral contraceptives for at least three months were at decreased risk of ovarian cancer (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.5-1.1) relative to women who never used this form of contraception. The reduced risk of ovarian cancer was present among women whose only preparation contained a low (< 50 micrograms ethinyl estradiol or < 80 micrograms mestranol) (OR 0.6, 95% CI 0.3-1.1) and high (OR 0.8, 95% CI 0.5-1.2) estrogen dose.

CONCLUSION

While our results are limited in their statistical precision and by the inability of many subjects to recall the brands of oral contraceptives that they took, they suggest that the newer, low-estrogen-dose oral contraceptives confer a benefit regarding ovarian cancer risk similar to that conferred by earlier, high-estrogen-dose formulations.

A DNA-porphyrin minor-groove complex at atomic resolution: the structural consequences of porphyrin ruffling

The crystal structure of a B-type DNA hexanucleotide duplex complexed with the porphyrin molecule nickel-[tetra-N-methyl-pyridyl] porphyrin has been solved by multiwavelength anomalous diffraction phasing and refined to an R factor of 11.5% at a resolution of 0.9 A. The structure has been solved and refined as two crystallographically independent duplexes, stacked end to end. Contrary to expectation, the porphyrin molecule is not intercalated into the duplex but is stacked onto the ends of the two-duplex stack. The porphyrin molecule is highly buckled as a consequence of the nickel coordination, which produces large changes in local DNA structure. A second mode of porphyrin binding is apparent as a consequence of crystal packing, which places the ligand in the minor groove of an adjacent duplex. This structure thus provides, to our knowledge, the first atomic visualization of minor-groove binding for a porphyrin molecule. The geometry of groove binding provides a ready explanation for porphyrin-induced DNA strand cleavage at deoxyribose residues.

The amniotic fluid index, single deepest pocket, and two-diameter pocket in normal human pregnancy

OBJECTIVE

This study was undertaken to determine normative values for amniotic fluid index, single deepest pocket, and 2-diameter pocket across gestation.

STUDY DESIGN

Fifty patients with normal pregnancies at each gestational age between 14 and 41 weeks' gestation were recruited prospectively and scanned once. Data were transformed into logarithmic (base 10) values for analysis. Polynomial regression equations were used to predict the normal values for amniotic fluid index, single deepest pocket, and 2-diameter pocket across gestational age and to predict the weekly percentage changes.

RESULTS

The mean amniotic fluid index, single deepest pocket, and 2-diameter pocket values were significantly lower among patients at <37 weeks' gestation (n = 1150) than among those at > or =37 weeks' gestation (n = 250; P <.001 for all comparisons). The calculated prevalences of oligohydramnios (amniotic fluid index < or =5 cm, single deepest pocket <2 cm, or 2-diameter pocket <15 cm(2)) were significantly different (P <.0001) for the three techniques (8%, 1%, and 30%, respectively). Hydramnios (amniotic fluid index >24 cm, single deepest pocket >8 cm, or 2-diameter pocket >50 cm(2)) was also diagnosed with significantly different (P <.0001) frequencies (0%, 0.7%, and 3%, respectively).

CONCLUSIONS

This is the largest prospective study to date to provide normative data for each of three ultrasonographic techniques used to assess amniotic fluid volume. The single deepest pocket appears to be the preferable method, because its use is least likely to lead to the false-positive diagnosis of either oligohydramnios or hydramnios.

Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis

OBJECTIVE

Our purpose was to perform a meta-analysis of studies on the risks of cesarean delivery for fetal distress, 5-minute Apgar score <7, and umbilical arterial pH <7.00 in patients with antepartum or intrapartum amniotic fluid index >5.0 or <5.0 cm.

STUDY DESIGN

Using a MEDLINE search, we reviewed all studies published between 1987 and 1997 that correlated antepartum or intrapartum amniotic fluid index with adverse peripartum outcomes. The inclusion criteria were studies in English that associated at least one of the selected adverse outcomes with an amniotic fluid index of </=5.0 cm versus >5.0 cm. Contingency tables were constructed for each study, and relative risks and standard errors of their logs were calculated. Fixed-effects pooled relative risks were calculated for groups of studies that were homogeneous, whereas random-effects pooled relative risks were calculated for significantly heterogeneous groups of studies.

RESULTS

Eighteen reports describing 10,551 patients met our inclusion criteria. An antepartum amniotic fluid index of </=5.0 cm, in comparison with >5.0 cm, is associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 2.2; 95% confidence interval, 1.5-3.4) and an Apgar score of <7 at 5 minutes (pooled relative risk, 5.2; 95% confidence interval, 2.4-11.3). An intrapartum amniotic fluid index of </=5.0 cm is also associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 1.7; 95% confidence interval, 1.1-2.6) and an Apgar score <7 at 5 minutes (pooled relative risk, 1.8; 95% confidence interval, 1.2-2.7). A poor correlation between the amniotic fluid index and neonatal acidosis was noted in the only study that examined this end point. More than 23,000 patients are necessary to demonstrate that the incidence of umbilical arterial pH <7.00 is 1.5 times higher among those with oligohydramnios in labor than among those with adequate amniotic fluid index (alpha = 0.05; beta = 0.2)

CONCLUSIONS

An antepartum or intrapartum amniotic fluid index of </=5.0 cm is associated with a significantly increased risk of cesarean delivery for fetal distress and a low Apgar score at 5 minutes. There are few reports linking amniotic fluid index and neonatal acidosis, the only objective assessment of fetal well-being. A multicenter study with sufficient power should be undertaken to demonstrate that a low amniotic fluid index is associated with an umbilical arterial pH <7.00.

Physical violence during pregnancy: maternal complications and birth outcomes

OBJECTIVE

To assess the association between physical violence during the 12 months before delivery and maternal complications and birth outcomes.

METHODS

We used population-based data from 6143 women who delivered live-born infants between 1993 and 1995 in South Carolina. Data on women's physical violence during pregnancy were based on self-reports of "partner-inflicted physical hurt and being involved in a physical fight." Outcome data included maternal antenatal hospitalizations, labor and delivery complications, low birth weights, and preterm births. Odds ratios and 95% confidence intervals were calculated to measure the associations between physical violence, maternal morbidity, and birth outcomes.

RESULTS

The prevalence of physical violence was 11.1%. Among women who experienced physical violence, 54% reported having been involved in physical fights only and 46% had been hurt by husbands or partners. In the latter group, 70% also reported having been involved in fighting. Compared with those not reporting physical violence, women who did were more likely to deliver by cesarean and be hospitalized before delivery for maternal complications such as kidney infection, premature labor, and trauma due to falls or blows to the abdomen.

CONCLUSION

Physical violence during the 12 months before delivery is common and is associated with adverse maternal conditions. The findings support the need for research on how to screen for physical violence early in pregnancy and to prevent its consequences.

The value of strength training for older adults

Health in older adults can best be measured in terms of functional status. Skeletal muscle strength has been reported to be a determinant of functional status in older individuals. Two major contributors to the decline in muscle function as a person ages are disuse and physical inactivity. Declining muscle function through a loss of muscular strength may decrease functional independence and mobility and increase the risk for falls and injuries, physical frailty, and disability. Older individuals lacking an appropriate amount of muscular strength may not be able to perform various activities of daily living, which are important indicators of independence.

Maternal factors and breast cancer risk among young women

The results from previous studies have provided evidence to support the hypothesised association between intrauterine oestrogen exposure and subsequent risk of breast cancer. Information has not been available to study this relationship for several perinatal factors thought to be related to pregnancy oestrogen levels. Data collected from the mothers of women in two population-based case-control studies of breast cancer in women under the age of 45 years (510 case mothers, 436 control mothers) who were diagnosed between 1983 and 1992 in three western Washington counties were used to investigate further the relationship between intrauterine oestrogen exposure and risk of breast cancer. A pregnancy weight gain of 25-34 pounds was associated with breast cancer risk (odds ratio [OR] = 1.5; 95% confidence interval [CI] 1.1, 2.0); however, women whose mothers gained 35 pounds or more were not at increased risk. Use of antiemetic medication in women with any nausea and vomiting (OR = 2.9; 95% CI 1.1, 8.1) and use of diethylstilboestrol (DES) (OR = 2.3; 95% CI 0.8, 6.4) appeared to be positively associated with breast cancer risk. The results from this study provide limited support for the hypothesis that in utero oestrogen exposure may be related to subsequent breast cancer risk among young women.