A call to develop opioid risk assessment programs for implementation in the pharmacy setting

The United States persists in combatting the opioid epidemic. Collectively, researchers should be in search of evidence-based solutions. One such could be an appropriate screening tool to determine a patient's risk of opioid misuse. The screening tool should be transparent, provide high specificity, be validated across a variety of healthcare settings, and be a guided clinical decision-making tool to avoid weaponizing an opioid risk score. We should shift our focus from the number of opioid prescriptions dispensed to appropriateness of each prescription. We should be aware of utilizing non-opioid therapy options. In addition, healthcare providers should be knowledgeable of opioid misuse resources in their area to avoid practicing defensively, while instead concentrating their efforts on patients' best interests. The patients' dignity should be upheld through empathetic care from healthcare providers. We need to reduce the stigma surrounding opioid use, and ensure patient safety with one, cohesive, validated, opioid risk assessment tool.

Managing the Risk of COVID-19 Using Model Based Predictors: The Case of North Dakota

OBJECTIVE

North Dakota (ND) had the highest coronavirus disease 2019 (COVID-19) case and mortality rate in the United States for nearly 2 mo. This study aims to compare 3 metrics ND used to guide public health action across its 53 counties.

METHODS

Daily COVID-19 case and death totals in North Dakota were evaluated using data from the COVID-tracker website provided by the North Department of Health (NDDoH). It was reported as: active cases per 10,000, tests administered per 10,000, and test positivity rate (the North Dakota health metric). The COVID-19 Response press conferences provided data for the Governor's metric. The Harvard model used daily new cases per 100,000. A chi-squared test was used to compare differences in these 3 metrics on July 1, August 26, September 23, and November 13, 2020.

RESULTS

On July 1, no significant difference between the metrics was found. By September 23, Harvard's health metric indicated critical risk while ND's health metric was moderate risk, and the Governor's metric was still low risk.

CONCLUSIONS

ND's and the Governor's metric underrepresented the risk of the COVID-19 outbreak in North Dakota. The Harvard metric reflected North Dakota's increasing risk; it should be considered as a national standard in future pandemics.

PUBLIC HEALTH IMPLICATIONS

Model-based predictors could guide policy-makers to effectively control spread of infectious disease; proactive models could reduce risk of disease as it progresses in vulnerable communities.

Nurse delivered medication safety screening program for home care visits

Home care clients have safety barriers related to medication storage, disposal, and safe use of opioids. Limited research is available regarding medication safety initiatives in the home care setting. This study evaluates a medication safety initiative, linked with opioid misuse and overdose prevention screening, for home care clients with different levels of service. Training and screening tools designed for community pharmacies by the Opioid & Naloxone Education (ONE) Program were modified for use by home health nurses. All new admits to the home health services were screened for medication storage, medication disposal, and use of pain medications. Patients taking opioids were screened for opioid-specific risks. Interventions based on screening results included education, provision of medication lock boxes, drug disposal packets, and/or naloxone. Most home care clients (85%) are properly storing their medication and 38% were not properly disposing unused medications. Higher levels of care had greater pain medication needs, including the provision of naloxone. This study demonstrates the opportunity to incorporate medication safety screening into nursing home health visits.

Improving Community Pharmacist-Delivered Care for Patients With Psychiatric Disorders Filling an Opioid Prescription

Pharmacists tend to provide care to patients with psychiatric disorders less frequently than to other types of patients, yet patients with psychiatric disorders experience more drug-related problems and use more opioids than those without psychiatric disorders. The Opioid and Naloxone Education (ONE) program equipped pharmacists to screen for opioid misuse and overdose risk and to implement a set of interventions for any patient filling an opioid prescription. Patients with a psychiatric disorder (N=1,980; 24.1% of those screened) were significantly more likely to receive more than one intervention from a ONE program pharmacist than were those without a psychiatric disorder. The use of an objective screening tool and training in stigma reduction and nonjudgmental communication approaches, which are part of the ONE program process, deserve further exploration as ways to increase the frequency of pharmacist-provided education and other critical interventions for patients with psychiatric disorders.

Evaluating the Association of Face Covering Mandates on COVID-19 Severity by State

Objective:

During the COVID-19 pandemic in the United States, mitigation measures were implemented on a state-by-state basis. Governors were responsible for establishing interventions appropriate for their states and the timing of implementation. This paper evaluated the association between the presence and timing of a mask mandate and the severity of the COVID-19 epidemic by state.

Methods:

The states were divided into 3 categories based on when the governors of each state implemented a mask mandate: Early (mask mandate implemented between March 2020 and June 2020), Late (July 2020-December 2020), and Never (no mask mandate implemented). The rates of hospitalizations and mortality (per 100 000) were assessed at the different time points during the pandemic across these categories from March to December 2020.

Results:

The mortality rates across all 3 groups were observed to be highest in the beginning and toward the end of the pandemic in 2020 with the peak observed in the Early group between April and May 2020. Also, the rates of hospitalization increased steadily across all groups. The Early mask group was comprised of 86.7% and 13.3% states with Democratic and Republican governors respectively, and no states in the Never category had Democratic governors.

Conclusion:

These results support the benefit of implementing a mask mandate to minimize the impact of the COVID-19 pandemic and the role of political affiliation of governors on that impact.

Screening at a Federally Qualified Health Center in the Midwest for Hepatitis C Among People Who Inject Drugs, 2019-2020

Introduction

Hepatitis C virus (HCV) infection is a public health epidemic. People who inject drugs (PWID) are at high risk for transmitting and contracting HCV. The objective of this study was to assess the effectiveness of a multifaceted intervention at a federally qualified health center in the US Midwest to improve HCV screening rates among PWID.

Methods

A prospective quality improvement initiative was conducted to increase the proportion of PWID screened for HCV. Inclusion criteria consisted of being seen by a primary care provider from April 16, 2019, through February 28, 2020, being aged 18 years or older, and confirmation of intravenous drug use. PWID status was confirmed by reviewing electronic health records. The multifaceted intervention consisted of educational sessions for the health care team and workflow changes. We analyzed the proportion of patients screened preintervention and postintervention by using χ² tests.

Results

Of 742 patients who met the inclusion criteria, the proportion of PWID screened preintervention was 59.6% (n = 329) and the proportion of PWID screened postintervention was 65.1% (n = 283), increasing the screening rate by 5.5 percentage points. A χ² test of homogeneity indicated a significant relationship between the preintervention and postintervention periods, and screening outcomes (P < .001).

Conclusion

This multifaceted intervention to increase HCV screening resulted in a modest increase in the proportion of PWID screened. Consistent and health care system–wide screening approaches are needed to optimize the potential of HCV treatment and cure options now available.

Pharmacists' stigma toward patients engaged in opioid misuse: When "social distance" does not mean disease prevention

Background: Health professionals may stigmatize and prefer social distance from patients with opioid misuse, leading to poorer quality of care provided. The degree to which pharmacists prefer social distance from patients with opioid misuse and opioid use disorder (OUD) is not known. Methods: Pharmacists (n = 187) completed a survey comprised of demographics, attitudinal, and Social Distance Scale (SDS) questions based on a vignette patient who displayed opioid misuse. SDS question responses and total scores (maximum of 30; higher scores representing great preference for social distance) were tallied and associations with attitudes and demographics were examined. Results: Mean SDS total score was 16.32 (range 9-23). More than 59% of respondents had an SDS score >15, indicating overall lack of willingness to interact with the vignette patient. Females had a higher mean SDS score vs male pharmacists (16.58 vs. 15.36, respectively; p = 0.023). Pharmacists were more likely to prefer social distance from the vignette patient in personal situations (i.e. renting a room) than work-related interactions (i.e. providing patient education). Pharmacists with >10 years of experience, those without personal experience with a substance use disorder, those who strongly agreed that patients with OUD require excessive time and effort, and those who agreed that some people lack self-discipline to use prescription pain medication without becoming addicted had significantly higher SDS scores than pharmacists without these characteristics. Conclusions: Pharmacists expressed significant preference for social distance indicating stigmatization of patients with opioid misuse. Pharmacists were comfortable performing pharmacy tasks with patients with opioid misuse, but were less comfortable forming therapeutic relationships, an important tenet of patient-centered care. Efforts are needed to examine contributions to social distance preferences and implement measures to reduce them. Targeting of pharmacists with >10 years' experience and without personal experience with OUD may also be most beneficial.

Community Pharmacists' Contributions to Disease Management During the COVID-19 Pandemic

Community pharmacists assist patients to manage disease and prevent complications. Despite the enormous challenge the coronavirus disease 2019 (COVID-19) pandemic has dealt to the health care system, community pharmacists have maintained the delivery of critical health services to communities, including those most at risk for COVID-19. Community pharmacists are in a key position to deliver priority pandemic responses including point-of-care testing for chronic disease management, vaccinations, and COVID-19 testing.

Process evaluation of a community-based diabetes prevention program in China: the Pathway to Health (PATH)

High prevalence of diabetes and prediabetes has emerged as a concern in China. The Pathway to Health Program was designed to prevent type 2 diabetes onset in prediabetic women in a north China urban community. This process evaluation of a randomized controlled trial analysed participant surveys at the 6- and 12-month assessment times, participant weekly logs, class attendance records and post-study participant focus group results. The reported levels of participant engagement in physical activity (PA)-related behaviors were higher than diet-related behaviors at the 6-month assessment. The engagement in both PA- and diet-related behaviors declined during the 6-month follow-up period. Step counts from the participants' pedometers indicated an increase in PA in the first 6 months of the intervention. Study participants expressed high levels of satisfaction with the intervention and increased their scores on diabetes-related knowledge. Conflicts with work and family responsibilities were the main barriers for missing health lessons, likely contributing to minimal weight loss. There was good fidelity in program implementation. Intensive lifestyle modification programs are difficult to sustain once the program is complete. A more structured 6-month follow-up phase may have provided needed support to enable participants to maintain their lifestyle changes.

Road dust and its effect on human health: a literature review

The purpose of this study was to determine the effects of road dust on human health. A PubMed search was used to extract references that included the words "road dust" and "health" or "fugitive dust" and "health" in the title or abstract. A total of 46 references were extracted and selected for review after the primary screening of 949 articles. The respiratory system was found to be the most affected system in the human body. Lead, platinum-group elements (platinum, rhodium, and bohrium), aluminum, zinc, vanadium, and polycyclic aromatic hydrocarbons were the components of road dust that were most frequently referenced in the articles reviewed. Road dust was found to have harmful effects on the human body, especially on the respiratory system. To determine the complex mechanism of action of various components of road dust on the human body and the results thereof, the authors recommend a further meta-analysis and extensive risk-assessment research into the health impacts of dust exposure.

Road dust and its effect on human health: a literature review

The purpose of this study was to determine the effects of road dust on human health. A PubMed search was used to extract references that included the words “road dust” and “health” or “fugitive dust” and “health” in the title or abstract. A total of 46 references were extracted and selected for review after the primary screening of 949 articles. The respiratory system was found to be the most affected system in the human body. Lead, platinum-group elements (platinum, rhodium, and bohrium), aluminum, zinc, vanadium, and polycyclic aromatic hydrocarbons were the components of road dust that were most frequently referenced in the articles reviewed. Road dust was found to have harmful effects on the human body, especially on the respiratory system. To determine the complex mechanism of action of various components of road dust on the human body and the results thereof, the authors recommend a further meta-analysis and extensive risk-assessment research into the health impacts of dust exposure.

Burden of severe neonatal jaundice: a systematic review and meta-analysis

CONTEXT

To assess the global burden of late and/or poor management of severe neonatal jaundice (SNJ), a common problem worldwide, which may result in death or irreversible brain damage with disabilities in survivors. Population-based data establishing the global burden of SNJ has not been previously reported.

OBJECTIVE

Determine the burden of SNJ in all WHO regions, as defined by clinical jaundice associated with clinical outcomes including acute bilirubin encephalopathy/kernicterus and/or exchange transfusion (ET) and/or jaundice-related death.

DATA SOURCES

PubMed, Scopus and other health databases were searched, without language restrictions, from 1990 to 2017 for studies reporting the incidence of SNJ.

STUDY SELECTION/DATA EXTRACTION

Stratification was performed for WHO regions and results were pooled using random effects model and meta-regression.

RESULTS

Of 416 articles including at least one marker of SNJ, only 21 reported estimates from population-based studies, with 76% (16/21) of them conducted in high-income countries. The African region has the highest incidence of SNJ per 10 000 live births at 667.8 (95% CI 603.4 to 738.5), followed by Southeast Asian, Eastern Mediterranean, Western Pacific, Americas and European regions at 251.3 (132.0 to 473.2), 165.7 (114.6 to 238.9), 9.4 (0.1 to 755.9), 4.4 (1.8 to 10.5) and 3.7 (1.7 to 8.0), respectively. The incidence of ET per 10 000 live births was significantly higher for Africa and Southeast Asian regions at 186.5 (153.2 to 226.8) and 107.1 (102.0 to 112.5) and lower in Eastern Mediterranean (17.8 (5.7 to 54.9)), Americas (0.38 (0.21 to 0.67)), European (0.35 (0.20 to 0.60)) and Western Pacific regions (0.19 (0.12 to 0.31). Only 2 studies provided estimates of clear jaundice-related deaths in infants with significant jaundice [UK (2.8%) and India (30.8%).

CONCLUSIONS

Limited but compelling evidence demonstrates that SNJ is associated with a significant health burden especially in low-income and middle-income countries.

Linking pharmacists to the delivery of public health services

OBJECTIVE

To describe components fundamental to the process of linking pharmacy to the delivery of public health services in a sustainable way.

SUMMARY

Pharmacists deliver public health services with varying frequency. A literature review was conducted to create a set of fundamental links necessary for pharmacists to deliver public health services in a sustainable way. The service needed to be in alignment with public health priorities, be incorporated in the pharmacy curriculum, have postgraduate training opportunities, have a policy or legal platform supporting the service, and have a business model for financial sustainability. Immunization delivery was identified as an exemplary public health service delivered by pharmacists. Additional services evaluated were tobacco cessation counseling, transitions of care, hypertension screening, and substance abuse counseling.

CONCLUSION

Pharmacists are well positioned to provide public health services. Although pharmacists can offer these services, their delivery is variable because of unclearly defined links in the process necessary for their implementation. This article identifies actionable steps to establish sustainable methods for community pharmacists to deliver public health services.

Nutritional rickets around the world: an update

Worldwide, nutritional rickets continues to be an evolving problem with several causes. This paper provides an updated literature review characterising the prevalence, aetiology, pathophysiology and treatment of nutritional rickets worldwide. A systematic review of articles on nutritional rickets from various geographical regions was undertaken. For each region, key information was extracted, including prevalence, cause of rickets specific to the region, methods of confirming the diagnosis and current treatment and preventive measures. Calcium deficiency continues to be a major cause of rickets in Africa and Asia. Vitamin D deficiency rickets is perhaps increasing in the Americas, Europe and parts of the Middle East. There continues to be a distinct presentation of calcium-predominant versus vitamin D predominant rickets, although there are overlapping features. More careful diagnosis of rickets and reporting of 25-OHD concentrations has improved accurate knowledge of rickets prevalence and better delineated the cause. Nutritional rickets continues to be an evolving and multi-factorial problem worldwide. It is on a spectrum, ranging from isolated vitamin D deficiency to isolated calcium deficiency. Specific areas which require emphasis include a consistent community approach to screening and diagnosis, vitamin D supplementation of infants and at-risk children, prevention of maternal vitamin D deficiency and the provision of calcium in areas with low calcium diets.

Pharmacist contributions to the ten essential services of public health in three National Association of Boards of Pharmacy regions

BACKGROUND

Pharmacists have contributed to improved population health through the delivery of public health services, but their contributions often go unrecognized within the larger health care system.

OBJECTIVES

To determine pharmacist perceptions of their contributions to the 10 essential services of public health and to compare those contributions among pharmacists in Iowa, North Dakota, and Manitoba.

METHODS

Licensed pharmacists in Iowa, North Dakota, and Manitoba were sent an online survey of their perceived level of achievement of the 10 essential services of public health.

RESULTS

A total of 649 pharmacists completed the survey. The 3 essential services that scored the highest overall were enforce laws and regulations that protect health and ensure safety, inform and educate people about health issues, and participate in ongoing training beyond continuing education requirements. Contributions of pharmacists to the 10 essential services of public health were previously evaluated by frequency of citation in the published literature. There was relative agreement between what was reported in the literature and what was determined by survey. One exception was "enforce laws and regulations that protect health and ensure safety," which was rarely reported in the literature but was reported in the survey to be the most frequently delivered service.

CONCLUSION

Pharmacist contributions to improved population health should be reported with the use of the 10 essential services of public health. This will increase recognition of pharmacist contributions and better align the disciplines of pharmacy and public health. In particular, pharmacists should consider ways to increase their level of involvement in the community and in partnership with other health care professionals.

A community-based cross-sectional survey of medication utilization among chronic disease patients in China

OBJECTIVES

To determine medication use patterns and associated health outcomes in Chinese individuals with diabetes, hypertension or hyperlipidaemia.

METHODS

This community-based cross-sectional study was done in a north China city of 300 000 people. Participants were recruited by poster and phone call through Community Health Centres. Data were collected on 638 Chinese individuals. Interviews were done to screen for disease and health behaviours. Fasting blood was collected and analyzed.

KEY FINDINGS

Participants' average age was 52 years. Self-reported prevalence of type 2 diabetes, hypertension and hyperlipidaemia was 9.6, 29.9 and 20.5% respectively. Medication adherence was found among 88, 60 and 81.5% of individuals with diabetes, hypertension and hyperlipidaemia respectively. Treatment success, as defined by medication adherence and treatment to goal was achieved by 21, 23 and 10% of diabetic, hypertensive and hyperlipidaemic patients.

CONCLUSIONS

A large proportion of individuals with chronic disease in this China-based study were not being successfully treated, putting them at high risk for poor health outcomes. In this urban China setting, healthcare services need to be strengthened in order to achieve better treatment outcomes among chronic disease patients. It is recommended that community pharmacists contribute to improving these outcomes through participation in patient education, medication reconciliation and disease state management.

Depression Screening in Diabetes Care to Improve Outcomes

Purpose

Evidence-based guidelines recommend regular depression screening among individuals with type 2 diabetes mellitus (T2DM). The purpose of this study is to examine depression screening patterns among a primary care population with T2DM, through use of the Patient Health Questionnaire-9 (PHQ-9).

Methods

In total, 1817 patients with T2DM were analyzed through a retrospective observational study at 2 sites, a regional health center and a federally qualified health center (FQHC). The T2DM sample was divided into those with and without a major depressive disorder (MDD) diagnosis. Depression screening rates and depression severity were assessed through the PHQ-9.

Results

Both sites had higher rates of PHQ-9 screening among individuals with a history of MDD (64.82%) vs those without MDD (11.39%). Individuals from the FQHC without a history of depression had a higher mean PHQ-9 score (10.11) than those with a previous MDD diagnosis at both RHS and FQHC (7.16 and 9.85, respectively).

Conclusions

Depression screening rates among individuals with diabetes and no history of MDD were remarkably low. Patients with diabetes but no MDD diagnosis who sought health care at a FQHC clinic had more depressive symptoms than those with a history of MDD at both sites. Individuals with diabetes and who have a MDD diagnosis are much more likely to receive regular depression screening than those without MDD, which leaves a substantial proportion of patients with undetected depression. Depression screening must be enhanced for all individuals with diabetes, particularly for low-income individuals and those without a previous diagnosis of MDD.

Preventing Rickets in Locally Appropriate Ways: A Case Report from North China

A rickets prevention program was carried out in Shanxi Province, China using locally appropriate methods. At the end of two and one-half years, the prevalence of rickets was 18% lower in program townships (56%) than in a control township that had no rickets prevention program (74%). Maternal awareness of how to prevent rickets was higher in program townships (43%) than in the control township (28%). However, the actual effect of maternal awareness on the prevention of rickets was negligible. In conclusion, this rickets prevention program was effective at reducing the prevalence of rickets. It appears the program was effective because of the presence of concerned program workers regularly visiting mothers and their infants, and using locally appropriate methods, but neither the vitamin supplements used nor the kind of rickets prevention education provided the mothers was shown to be positively correlated.

Disease Control Among Patients With Diabetes and Severe Depressive Symptoms

OBJECTIVE

Major depressive disorder and type 2 diabetes commonly co-occur and disease control tends to be poorer when both conditions are present. However, little research has examined the disease characteristics of patients with diabetes and more severe depressive symptoms.

METHODS

We report a retrospective observational study of 517 patients with diabetes from 2 primary care centers. Patients with diabetes and moderately-severe/severe depression symptoms (Patient Health Questionnaire [PHQ-9] score >15) were compared with patients with diabetes without moderate or severe depression symptoms (PHQ-9 score <15; the comparison group) with regard to control of diabetes, blood pressure, and lipid parameters. Frequency of HbA1c and PHQ-9 testing were also examined.

RESULTS

Patients with diabetes and moderately severe/severe depressive symptoms had higher HbA1c (7.56% vs. 7.09%), diastolic blood pressure (78.43 vs. 75.67 mm Hg), and low-density lipoprotein cholesterol (109.12 vs. 94.22 mg/dL) versus the comparison group. Patients with diabetes and moderately-severe/severe depression underwent HbA1c and PHQ-9 testing with similar frequency to the comparison group.

CONCLUSIONS

The presence of moderately severe/severe depressive symptoms was associated with poorer glucose, lipid, and blood pressure control among patients with diabetes. Further research should prospectively examine whether a targeted depression treatment goal (PHQ-9 score <15) in patients with diabetes results in improved control of these important disease parameters.

Use of the 9-Item Patient Health Questionnaire for Depression Assessment in Primary Care Patients With Type 2 Diabetes

The purpose of the current study was to assess the frequency and distribution of the 9-Item Patient Health Questionnaire (PHQ-9) among individuals with type 2 diabetes with and without depression. The current case-control study used electronic medical record data from two primary care institutions. The sample was divided into cases with coexisting depression and type 2 diabetes and controls without depression. Data included demographics, biomarkers, number of services delivered, and clinic visits in 2013. Similar PHQ-9 use was seen between unique primary care practices. However, less than one third of patients at either site received depression screening with the PHQ-9 in 2013. Male and older adult patients were less likely to receive assessment. Guideline ambiguity and lack of accountability in primary care practice has made the use of depression metrics arbitrary in diabetic populations at risk for depression. To assure adequate care provision, it is imperative that proven tools for assessing depressive symptoms are used.

The achievement of public health services in pharmacy practice: A literature review

BACKGROUND

It is known that pharmacists are currently contributing to public health; however, the extent of this contribution as reported in the literature has not been examined. Investigating the ways that pharmacists are currently participating in public health is critical for the profession of pharmacy, pharmacy educators, and the public health community.

OBJECTIVES

The purpose of this study was to determine the reported contributions of pharmacy to each of the ten essential services of public health, and which of the five core competencies of public health were most frequently utilized in those contributions.

METHODS

A PubMed search was used to extract references that included both the words pharmacy and services in the title or abstract, and the words public health in any part of the document. A total of 247 references were extracted and categorized into the essential services and core competencies.

RESULTS

The essential services Inform, Educate, and Empower, and Link to/Provide Care were more frequently represented in the literature, and the core competency of Health Policy and Administration was most frequently utilized.

CONCLUSION

To further contribute to and integrate their contributions within population health, pharmacists must consider ways to strategically contribute to the essential services of public health and seek to increase competency in public health.

Pharmacy and public health: a pathway forward

OBJECTIVE To identify a pathway forward for practicing pharmacists in supporting public health initiatives by applying the five core competencies of public health. SUMMARY The pharmacist is well positioned to improve population health. Until now, increased impact of pharmacists has been based on the expansion of patient services rather than guided by a population approach to health. To increase their effectiveness and breadth of impact, pharmacists would benefit from applying the five core competencies of public health (social and behavioral science, health policy and administration, epidemiology, biostatistics, and environmental health sciences) to the practice of pharmacy. This article aims to explain how each of the core competencies applies to pharmacy practice and how pharmacists might apply public health skills in a more specific manner. CONCLUSION With increased clarity of the role of public health, and mastery of the five core competencies of public health, pharmacists can make unique and valuable contributions to the health of the public.

A Descriptive Study of the Progression of the Metabolic Syndrome in Middle-Aged Chinese Population

This longitudinal study investigated the prevalence of the Metabolic Syndrome (MetS) in middle-aged (44–56 years) men and women in China. The presence of the components of the MetS was determined in a cohort of 643 persons born in 1956, 1960–1961, and 1964 in Shanxi Province China in 2008 and 2012. The rate of MetS in 2008 was 51.63% (95% CI [44.73, 58.48]) and 37.15% (95% CI [32.56, 41.92]) and in 2012 was 50.23% (95% CI [43.35, 57.10]) and 46.26% (95% CI [41.46, 51.11]) for men and women, respectively. Increased blood glucose and triglycerides and decreased high-density lipoprotein for women, and blood glucose and triglycerides for men were the components responsible for the development of MetS from 2008 to 2012. MetS develops differently between men and women. From age 44 to 56, the rate is unchanged among men and increasing among women.

An appraisal of China's progress toward the Millennium Development Goals as they relate to children

Since their inception in 2000, the Millennium Development Goals (MDGs) have improved understanding of the global development process. Although the goals will not be significantly achieved on a global scale, each country has had accomplishments deserving of attention and analysis. With regard to the MDGs as they relate to children, China has made significant achievements, the deeper understanding of which might help in the process of refreshing the MDGs beyond 2015. China's accomplishments in economic development and human welfare, and the benefits this has brought to its children potentially teach lessons that can be modelled by other countries moving from low- to middle-income status.

The Diabetes, Depression, and Alcohol Triad

Type 2 diabetes, depression and alcohol abuse exist in many populations as co-morbidities. These conditions contribute to worsened health status and lost productivity. Such diseases also contribute to high medical expenses and other societal costs. Diabetes, depression and alcohol abuse are individually associated with compromised financial status. Treating these combined conditions as a syndrome rather than as isolated disease states may result in improved quality of care, better health outcomes, and reduced costs to society. A conceptual model that could be used to address this triad is the Social Ecological Model in which intrapersonal, interpersonal, institutional and community factors as well as public policy are considered for their impact on outcomes. The triad of diabetes, depression and alcohol abuse may have common etiological factors such as social isolation and poverty, and such a holistic approach to the common determinants underlying all three conditions holds out the most hope to reduce both the prevalence of this unique disease triad and the associated costs to society.

Risk factors for metabolic syndrome in a cohort study in a north China urban middle-aged population

As China undergoes urbanization, lifestyles and disease profiles are changing. In this study, metabolic syndrome (MetS) was discovered in 53.5% and 42.7% of men and women, respectively. In 3 age cohorts (44, 48, and 52 years), prevalence of MetS among women was 33.3%, 41.4%, and 50.8%, respectively (χ(2) = 10.27, P = .006), whereas among men it was 51.5%, 56.3%, and 52.3%, respectively (χ(2) = 0.46, P = .796). The component contributing to the presence of MetS was increased waist circumference, especially among women. MetS among men results from higher rates of elevated triglycerides, blood pressure, and blood glucose when compared with women. Risk factors for MetS included less than 60 minutes of exercise a week (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.3-2.4) and rarely consuming milk (OR = 1.7, 95% CI = 1.2-2.3). Abstaining from or occasionally consuming alcohol (OR = 0.7, 95% CI = 0.4-1.1) and having parents with no chronic disease (OR = 0.4, 95% CI = 0.2-0.6) suggest increased protection against MetS.

Social Determinants of Delayed Diagnosis of Tuberculosis in a North China Urban Setting

A quantitative/qualitative mixed methodology was used to investigate treatment delay and determine social determinants of TB among 70 pulmonary TB patients in China. Median total diagnostic delay (TDD) time was 4 weeks for men and 5 weeks for women; 25% of patients experienced a TDD of 20 or more weeks. Seventy-six percent of patients who had a delay of more than 2 weeks attributed the delay to their own personal lack of awareness. Fifty-seven percent of the population reported experiencing more than one of the four common TB symptoms, and 30% reported experiencing three or more symptoms. Patients' qualitative descriptions of the process from onset of symptoms to diagnosis of TB described a circuitous and imprecise one. Delay in seeking treatment among TB patients in China is prolonged because of both personal and systemic reasons. It is essential that diagnostic delay be understood and reduced to decrease the burden of disease globally.

Doing the month: rickets and post-partum convalescence in rural China

OBJECTIVE

to analyse the health beliefs underlying the Chinese custom of 'doing the month', in particular mothers' perceptions of rickets.

DESIGN

a qualitative approach was used. Four focus group discussions were tape recorded. Translated transcripts were analysed and coded.

SETTING

Yuci District, rural Shanxi Province, China.

PARTICIPANTS

eighteen young mothers with children aged between 12 and 24 months, five grandmothers aged between 48 and 55 years, five township clinic maternal and child health workers, and seven traditional medicine doctors.

FINDINGS

Zuo yuezi (doing the month) is accepted by Chinese mothers as a time of respite and physical recovery. It is also burdensome to mothers, as cloistering indoors compromises both mother and baby's exposure to the sun, resulting in vitamin D deficiency and rickets.

KEY CONCLUSIONS

in order to reduce the rates of rickets in children, it is important to promote a more balanced and health-enhancing form of zuo yuezi that maintains necessary vitamin D status of both the mother and her baby. By understanding this custom, medical professionals caring for pregnant and post-partum Chinese women in Western countries will be able to better serve their health needs.

Severe Vitamin D-deficiency and the Health of North China Children

OBJECTIVES

To determine the health and nutritional status of rural Chinese children ages 12-24 months.

METHODS

This study used a cross-sectional design with a longitudinal component. Anthropometry and blood chemistry were measured on each child twice (n = 250). Caretaker knowledge and behaviors that relate to the child's health and diet were evaluated by interview.

RESULTS

Children were taken outdoors at an average age of 131.8 days. 65.3% of surveyed children had serum 25-OH-D levels less than 12 ng/ml in the spring. This declined to 2.8% in the fall. Mean blood lead levels were 15.7 +/- 11.0 microg/dl in the spring declining to 12.4 +/- 12.5 microg/dl in the fall (t = 6.47, P = 0.000). This still left 63.5 and 54.9% of the children with toxic blood lead levels in spring and fall. Rates of respiratory disease declined significantly from spring to fall. A summer outdoors remarkably improved vitamin D-deficiency and lead toxicity. However, nutritional status worsened as during the summer diet was unable to keep up with growth and increased nutritional demand. From spring to fall serum zinc declined from 0.77 +/- 0.19 to 0.66 +/- 0.21 microg/ml (t = 3.33, P = 0.001) and blood hemoglobin declined from 12.5 +/- 1.2 to 12.0 +/- 1.2 gm/dl (t = 4.07, P = 0.000).

CONCLUSIONS

Northern climate and cloistering of children creates a host of health risks for north China children. Vitamin D-deficiency, lead poisoning and respiratory disease are significantly worse during the winter months. These children need vitamin D supplementation during the winter and improved overall nutritional status during the summer to maintain ideal growth and development.

Diagnosis of rickets and reassessment of prevalence among rural children in northern China

BACKGROUND

Rates of rickets from 15.9 to 26.7% have been reported in China.

METHODS

Combining the methods of epidemiology and the behavioral sciences, this study investigated the prevalence of rickets in children in rural Shanxi Province, China. A total of 250 children age 12-24 months were examined physically for the presence of rickets, blood was drawn for laboratory analysis, and X-rays were taken of each child's wrists.

RESULTS

Vitamin D deficiency in the spring was found among 65.3% of children. Rickets diagnosis relying on clinical signs alone determined a rickets prevalence of 41.6%, declining to 17.0% in the fall after a summer of sun exposure (chi(2) = 8.356, P = 0.004). But an integrated diagnostic method exploiting clinical signs, X-ray and alkaline phosphatase levels found the prevalence of active rickets to be 3.7%. Furthermore, it was demonstrated that only five clinical signs reflect active rickets--wide wrists, frontal bossing, rachitic rosary, Harrison's sulcus, and bowed legs.

CONCLUSIONS

The prevalence of active rickets in young children in northern China is lower than previously reported. Even in poor countries, simple tests such as X-rays and alkaline phosphatase can be added to physical examination to more accurately diagnose active rickets.

Nutritional rickets around the world: causes and future directions

INTRODUCTION

Nutritional rickets has been described from at least 59 countries in the last 20 years. Its spectrum of causes differs in different regions of the world.

METHODS

We conducted a systematic review of articles on nutritional rickets from various geographical regions published in the last 20 years. We extracted information about the prevalence and causes of rickets.

RESULTS

Calcium deficiency is the major cause of rickets in Africa and some parts of tropical Asia, but is being recognised increasingly in other parts of the world. A resurgence of vitamin D deficiency has been observed in North America and Europe. Vitamin D-deficiency rickets usually presents in the 1st 18 months of life, whereas calcium deficiency typically presents after weaning and often after the 2nd year. Few studies of rickets in developing countries report values of 25(OH)D to permit distinguishing vitamin D from calcium deficiency.

CONCLUSIONS

Rickets exists along a spectrum ranging from isolated vitamin D deficiency to isolated calcium deficiency. Along the spectrum, it is likely that relative deficiencies of calcium and vitamin D interact with genetic and/or environmental factors to stimulate the development of rickets. Vitamin D supplementation alone might not prevent or treat rickets in populations with limited calcium intake.

Phosphorylation of the porcine skeletal and cardiac muscle sarcoplasmic reticulum ryanodine receptor

Porcine skeletal and cardiac muscle sarcoplasmic reticulum (SR) vesicle fractions enriched in the ryanodine receptor were phosphorylated in the presence of [gamma-32P]MgATP and either exogenous cAMP-dependent protein kinase (cAMP-PK), or Ca2+ plus calmodulin. Phosphorylation of the cardiac muscle ryanodine receptor in the presence of either cAMP-PK or calmodulin (6.4 and 10.6 pmol Pi/mg SR respectively) was approximately equal to or twice the [3H]ryanodine binding activity of this preparation (5.2 pmol/mg). Furthermore, cardiac muscle ryanodine receptor Pi incorporation catalyzed by cAMP-PK and calmodulin was approximately additive. In skeletal muscle SR, however, the level of cAMP-PK or calmodulin catalyzed phosphorylation of the intact ryanodine receptor (0.2 or 2.9 pmol Pi/mg SR, respectively) was much less than the [3H]ryanodine binding activity of this fraction (11.6 pmol/mg). Furthermore, Pi incorporation into the intact skeletal muscle ryanodine receptor was 3-8-fold less than that incorporated into a component of slightly lower M(r). Although this latter component comigrated with an immunoreactive fragment of the ryanodine receptor on polyacrylamide gels, it did not appear to be derived from the ryanodine receptor. We conclude that the significant phosphorylation of the cardiac muscle SR ryanodine receptor indicates a likely physiological role for protein kinase-mediated regulation of this Ca(2+)-channel. In contrast, the minimal phosphorylation of the skeletal muscle SR ryanodine receptor indicates that such a role of protein kinases is unlikely in this tissue.

Ryanodine receptor in different malignant hyperthermia-susceptible porcine muscles

The sarcoplasmic reticulum (SR) ryanodine receptor was studied in SR vesicles isolated from the vastus intermedius skeletal muscle and cardiac muscle of malignant hyperthermia-susceptible (MHS) and normal pigs. MHS and normal heavy SR preparations isolated from the vastus intermedius muscle had similar yields, polyacrylamide gel electrophoretic patterns, Ca2(+)-ATPase activities, mitochondrial enzyme activities, calsequestrin contents, and maximal [3H]ryanodine-binding activities. However, while half-maximal calcium concentrations (Ca0.5) for stimulation of MHS and normal vastus intermedius SR [3H]ryanodine binding were not significantly different, the Ca0.5 for inhibition of [3H]ryanodine binding to MHS vastus intermedius SR (76 +/- 17 microM) was significantly greater than to normal SR (16 +/- 9 microM). MHS vastus intermedius SR also exhibited a significantly lower Kd value (62 +/- 15 nM) for [3H]ryanodine binding compared with normal SR (Kd = 284 +/- 102 nM). These values for MHS and normal vastus intermedius SR are similar to those reported using SR isolated from a muscle composed of predominantly fast-twitch fibers, indicating the similarity of the ryanodine receptor in fast- and slow-twitch skeletal muscles. In contrast, there were no differences in the properties of the ryanodine receptor of porcine cardiac SR isolated from MHS and normal pigs. We therefore conclude that there is a defect in the SR ryanodine receptor of both slow- and fast-twitch skeletal muscle fiber types but not in cardiac muscle of MHS individuals.

A clinically applicable method to preserve urine and bladder washing cells for flow cytometric monitoring of bladder cancer patients

We describe a method to fix exfoliated bladder cells that is suitable for followup of bladder cancer patients by deoxyribonucleic acid flow cytometry. After fixation with room temperature methanol plus acetic acid (20:1, volume:volume) urine and bladder washing samples from these patients can be stored at room temperature for 3 to 7 days and then assessed reliably for the presence of aneuploidy and the percentage of hyperdiploid cells. For those with active transitional cell carcinoma diagnostic accuracy comparing fresh to fixed specimens was improved from 58 to 92% with urine and from 50 to 100% with washing samples. For patients with a history of transitional cell carcinoma who currently are free of disease the false positive rate remains unchanged after fixation. The procedure described is suitable for use in the outpatient clinic and should permit shipping of samples without refrigeration to a central flow cytometry facility for analysis.

Deoxyribonucleic acid flow cytometry of benign prostatic disease

Deoxyribonucleic acid flow cytometry was performed on aspirated prostatic cells from 198 patients who had benign cytological or histological findings. Unsatisfactory acellular histograms were obtained from 10.6 per cent of the cases. Three-fourths of the satisfactory samples (more than 5,000 cells after subtracting debris) showed the expected single peak deoxyribonucleic acid diploid to near diploid histograms. Unexpectedly, the remaining samples were deoxyribonucleic acid aneuploid, most having 2 peridiploid peaks (deoxyribonucleic acid index 0.82 to 1.31). Usually, proliferation was low with less than 20 per cent hyperdiploid cells and with 2.5 +/- 1.5 per cent G2 cells. In 10 per cent of the single peak histograms there was evidence of inflammation, identified as an increase in hyperdiploid cells without an increased percentage of G2 cells but with a tail of high channel values. The aforementioned histogram features were considered to be benign findings. Seven per cent of the samples had deoxyribonucleic acid histograms suggestive of prostate cancer. Of these samples 7 had diploid or peridiploid aneuploid histograms with high proliferation (more than 20 per cent hyperdiploid cells with 8.5 +/- 3.8 per cent G2 cells), while 5 had histograms with deoxyribonucleic acid aneuploidy other than peridiploidy.

Characterization of urinary keratin number 18 using a new assay

The levels of the low-molecular weight keratin 18 appearing in the voided urine of 130 healthy volunteers was studied using a new immunoradiometric assay for keratin 18 (IRMAK-18). Keratin 18 was detected in 79 urines with an average level of 2.5 +/- 4.7 ng./ml. The assay does not detect complex epidermal keratins or non-keratin intermediate filaments. Only 50% of the purified keratin added to urine could be recovered. The recovered keratin had the same molecular weight as the input molecules, implying that substances in the urine physically inhibited the assay rather than destroyed the keratin. The independent variables of cell count, dead cells, and protein concentration were not found to be important in evaluating the results. However, the urine concentration, as measured by creatinine, might be an important consideration for assessing the levels of keratin detected.

Urine: a suitable sample for deoxyribonucleic acid flow cytometry studies in patients with bladder cancer

Deoxyribonucleic acid flow cytometry of bladder washings has proved to be a valuable procedure for the diagnosis and followup of patients with transitional cell carcinoma. However, for this procedure to gain maximal acceptance, it should be possible to use voided urine specimens instead of bladder washings. To evaluate this possibility we compared histogram findings for 114 bladder washings and 122 concomitantly obtained urine samples (voided and catheterized) from 89 consecutive patients who had active or a history of transitional cell carcinoma. Unsatisfactory histograms were obtained in 4 per cent of the urine samples and in 2.6 per cent of the bladder washing samples. The satisfactory rate for voided or catheterized urine samples was the same. We conclude that in this patient population satisfactory deoxyribonucleic acid histograms can be obtained from samples of voided urine.

Softening of thermoplastic polyurethanes: a structure/property study

Softening of thermoplastic polyurethanes (TPU) in a simulated body environment (37 degrees C n-saline) was studied as a function of composition, structure and resultant morphology of these (AB)n type block copolymers. The structural variations were attempted by changing chemical composition and molecular weight of both hard A and soft B segments and their weight ratio in the polymer. In addition, the influence of bulk and/or surface modifiers, such as "reacted-in" polysiloxanes and fluorinated polyalkylether glycols, was also investigated. The degree of softening, expressed as a percentage decrease of the elastic modulus (5% tensile modulus) upon two hours exposure to the testing environment, is significant, reversible and depends on the ratio of hard to soft segment and the extent of microphase separation. Since these parameters can be selected during the polymer synthesis and processing into desirable shapes, the degree of softening can thus be controlled. This softening at body temperature represents one of the most notable performance advantages of these biomaterials.