Association of mobile health (mHealth) use with health status and COVID-19-related concerns by people with mobility impairments

PURPOSE

Mobile health (mHealth) technology has increased dramatically in the wake of the pandemic. Less research has focused on people with mobility impairing (PMI) disabilities. This study determined the prevalence of mHealth use among PMI adults during the COVID-19 escalation and examines demographic, health and COVID-19 concerns correlates.

METHODS

PMI adults (N = 304) completed an online survey investigating mHealth use and COVID-19 concerns related to food access in June of 2020. Smartphone and mHealth use were measured with an adapted version of the survey used in the Pew Internet & American Life project. Descriptive and multivariable analyses were conducted to determine associations of demographics, health status, and COVID-19 concerns with mHealth use. About two-thirds (N = 201) of the sample were mHealth users (owned a smartphone and engaged in health-promoting behaviors with the smartphone; e.g., sought online information, tracked health behaviors, used patient portals).

RESULTS

Having hypertension was associated with higher mHealth use, and having higher COVID-19 concerns about food access was associated with higher mHealth use. Those who used mHealth were also more engaged with smartphone apps for communication, services, and entertainment. Only the association between educational attainment and mHealth use remained significant after adjusting for other covariates in multivariable logistic regression models.

DISCUSSION

PMIs continue to need support in the use of mHealth technology to help maximize access to potentially important tools for rehabilitation and health management. There is a need to continue to investigate mHealth and its applications for people with disabilities.Implications for RehabilitationMany people with mobility impairing disabilities may be missing opportunities for mHealth rehabilitation and healthcare.COVID-19 has widened existing gaps in access and use of mHealth technology among people with mobility impairing disabilities.Focused education is needed to help people with disabilities exploit the full range of services of their smartphones to increase access to care, social connectivity, and other important goods and services to enhance rehabilitation and health management.

Psychometric properties of the Food Environment Assessment Survey Tool (FEAST) in people with mobility impairment

OBJECTIVE

Approximately one in ten adults under the age of 65 in the USA has a mobility impairing disability. People with mobility impairment generally have poorer dietary habits contributing to obesity and related negative health outcomes. This article presents the psychometric properties of the Food Environment Assessment Survey Tool (FEAST) instrument that measures barriers to accessing healthy food from the perspective of people with mobility impairment (PMI).

DESIGN

The current study presents cross-sectional data from two sequential independent surveys.

SETTING

Surveys were administered online to a national sample of PMI.

PARTICIPANTS

Participants represented PMI living throughout the USA. The pilot FEAST survey involved 681 participants and was used to shape the final instrument; 25 % completed a retest survey. After following empirically and theoretically guided item reduction strategies, the final FEAST instrument was administered to a separate sample of 304 PMI.

RESULTS

The final twenty-seven-item FEAST instrument includes items measuring Neighbourhood Environment, Home Environment, Personal Control and Access to Support (Having Help, Food Delivery Services, Parking/Transportation). The final four scales had acceptable intra-class correlations, indicating that the scales could be used as reliable measures of the hypothesised constructs in future studies.

CONCLUSIONS

The FEAST instrument is the first of its kind developed to assess the food environment from the perspective of PMI themselves. Future studies would benefit from using this measure in research and practice to help guide the development of policy aimed at improving access to healthy food and promoting healthy eating in community-dwelling PMI.

A scorecard for osteoporosis in Canada and seven Canadian provinces

The scorecard evaluates the burden and management of osteoporosis in Canada and how care pathways differ across Canadian provinces. The results showed there are inequities in patients' access to diagnosis, treatment, and post-fracture care programs in Canada. Interventions are needed to close the osteoporosis treatment gap and minimize these inequities.

INTRODUCTION

The purpose of this study was to develop a visual scorecard that assesses the burden of osteoporosis and its management within Canada and seven Canadian provinces.

METHODS

We adapted the Scorecard for Osteoporosis in Europe (SCOPE) to score osteoporosis indicators for Canada and seven provinces (British Columbia, Alberta, Saskatchewan, Ontario, Quebec, New Brunswick, and Newfoundland). We obtained data from a comprehensive literature review and interviews with osteoporosis experts. We scored 20 elements across four domains: burden of disease, policy framework, service provision, and service uptake. Each element was scored as red, yellow, or green, indicating high, intermediate, or low risk, respectively. Elements with insufficient data were scored black.

RESULTS

Canada performed well on several elements of osteoporosis care, including high uptake of risk assessment algorithms and minimal wait times for hip fracture surgery. However, there were no established fracture registries, and reporting on individuals with high fracture risk who remain untreated was limited. Furthermore, osteoporosis was not an official health priority in most provinces. Government-backed action plans and other osteoporosis initiatives were primarily confined to Ontario and Alberta. Several provinces (Saskatchewan, New Brunswick, Newfoundland) did not have any registered fracture liaison service (FLS) programs. Access to diagnosis and treatment was also inconsistent and reimbursement policies did not align with clinical guidelines.

CONCLUSION

Government-backed action plans are needed to address provincial inequities in patients' access to diagnosis, treatment, and FLS programs in Canada. Further characterization of the treatment gap and the establishment of fracture registries are critical next steps in providing high-quality osteoporosis care.

Physical activity, dietary protein and insulin-like growth factor 1: Cross-sectional analysis utilising UK Biobank

BACKGROUND

Insulin-like growth factor-I (IGF-1) is an anabolic hormone that stimulates cell growth and division. The effects of IGF-1 may be beneficial (muscle growth/repair) or detrimental (increased risk of several types of cancer and mortality) for health. Dietary protein and physical activity are thought to be factors that modulate IGF-1.

OBJECTIVE

This study analysed the relationships dietary protein vs IGF-1 and physical activity vs IGF-1 independently with a large sample size, and determined if/how physical activity affected the association between dietary protein and IGF-1 in healthy adults.

METHODS

Regression models were used to assess the association between dietary protein and/or physical activity on serum IGF-1 in a cross-sectional sample of 60,677 healthy adults that were enrolled in the UK Biobank project.

RESULTS

Dietary protein was positively associated with IGF-1 (0.030 nmol/L;95%CI 0.027-0.033;p < 0.001). Individuals undertaking 10-50 excess MET h/week of physical activity had 0.129 nmol/L greater IGF-1 than participants completing less than 10 excess MET h/week (95%CI 0.028-0.230). The "high" category of physical activity (>50 excess MET h/week) was not correlated with IGF-1 (-0.055 nmol/L;95%CI -0.185-0.076). When dietary protein and physical activity were included in the same model, physical activity did not change the relationship between dietary protein and IGF-1, nor visa-versa.

CONCLUSIONS

The positive association between dietary protein and IGF-1 was not influenced by physical activity. The former association was stronger than the latter. Thus, when seeking to adjust IGF-1 for possible health concerns, regulating dietary protein may be more pertinent than physical activity as a primary intervention.

Developing Content for the Food Environment Assessment Survey Tool (FEAST): A Systematic Mixed Methods Study with People with Disabilities

Almost 1 in every 8 adults in the U.S. have a physical disability that impairs mobility. This participatory project aimed to identify and describe environmental and personal barriers to healthy eating among people with mobility impairments using a rigorous, structured mixed methodology. Community-dwelling adults with a self-reported mobility impairment (N = 20, M = 40.4 years old, 60% female) participated in nominal group technique focus groups. The Ecologic Model of Obesity grounded stimulus questions asked about barriers to obtaining and preparing healthy food. Participants emphasized common barriers across everyday settings—focusing, for example, on the ability to reach shelved food inside the home, navigating to and inside stores and restaurants, and using delivery services. Home environments often did not afford suitable spaces for food preparation and storage. Participants reported inadequate transportation and numerous additional barriers in many settings to be able to eat healthfully. Participants reported lack of accessible transportation and architectural barriers inside stores, restaurants, and their own homes, highlighting the need for efforts aimed at improving accessibility and usability. Findings support the use of the Ecologic Model of Obesity to guide research and suggest the need for improvement in assessment practices and policies that enhance access to healthy food.

Diagram comprehension ability of college students in an introductory biology course

College biology courses commonly use diagrams to convey information. These visual representations are embedded in course materials with the expectation that students can comprehend and learn from them. Educational research, however, suggests that many students have difficulty understanding diagrams and the conventions (e.g., labels, arrows) they contain. The present study evaluates biology students' ability to comprehend scientific diagrams and the diagram characteristics that affect this comprehension. Participants were students in a physiology course who completed a multiple-choice test of diagram comprehension ability (DCA) (Cromley JG, Perez TC, Fitzhugh SL, Newcombe NS, Wills TW, Tanaka JC. J Exp Educ 81: 511-537, 2013). We coded the conventions used in each test diagram and used these codes to capture the diagram characteristics of conventions and complexity. Descriptive analyses examine students' ability to understand scientific diagrams and which diagram characteristics cause the most difficulty. We also compared groups with low and high DCA scores to evaluate how students at different levels of comprehension ability are affected by diagram characteristics. Results show relatively poor DCA; the average total test score was only 69.5%. The conventions used in a diagram also affected diagram comprehension, and results show students had the most difficulty comprehending diagrams using a letter or numbering system, where arbitrary letters/numbers were used to signify objects and diagrams using cut-outs that showed cross sections and magnified interior views. Additionally, students' comprehension was higher on diagrams with higher complexity (i.e., more types of conventions used), potentially indicating students are able to take advantage of the supports that different conventions provide. Implications for instruction are identified.

Adjusted treatment COMPArisons between guSelkumab and uStekinumab for treatment of moderate-to-severe plaque psoriasis: the COMPASS analysis

Background

Guselkumab is an interleukin‐23 inhibitor indicated for the treatment of moderate‐to‐severe plaque psoriasis in adults. Guselkumab has demonstrated additional benefit in patients with early inadequate response to ustekinumab. Long‐term efficacy comparisons of guselkumab and ustekinumab are currently lacking among ustekinumab‐naive patients.

Objectives

To assess the relative efficacy of guselkumab and ustekinumab for maintenance therapy of moderate‐to‐severe plaque psoriasis, using individual patient data (IPD) from randomized controlled trials.

Methods

IPD for guselkumab from the VOYAGE 1 and 2 trials were pooled and compared with IPD for ustekinumab from the NAVIGATE trial. Multivariable logistic regression analyses compared guselkumab 100 mg and ustekinumab 45 mg or 90 mg for the achievement and maintenance of Psoriasis Area and Severity Index (PASI) 90, 75 and 100 responses up to 40 weeks. The regression models accounted for a range of clinically relevant covariates (e.g. age, sex, psoriasis duration). Relative efficacy was expressed using odds ratios (ORs) and predicted probability of treatment response associated with each intervention.

Results

Patients receiving guselkumab had significantly higher probabilities of achieving a PASI 90 response than patients receiving ustekinumab, at both week 16 [70·4% vs. 46·0%, OR 2·79, 95% confidence interval (CI) 2·22–3·45] and week 40 (74·2% vs. 54·5%, OR 2·40, 95% CI 1·89–3·13]. Guselkumab was also associated with a significantly increased likelihood of achieving both PASI 75 and PASI 100 responses at weeks 16 and 40, compared with ustekinumab.

Conclusions

Adjusted analyses leveraging IPD demonstrate that guselkumab has a significantly higher probability of achieving and maintaining PASI treatment responses through week 40 than ustekinumab does.

Linked Comment: Yiu. Br J Dermatol 2020; 183:202–203.

What's already known about this topic?

The NAVIGATE trial demonstrated improved treatment responses in patients with moderate‐to‐severe plaque psoriasis who switched to guselkumab after inadequate responses to ustekinumab induction therapy.

What does this study add?

To date, no head‐to‐head randomized controlled trials have compared ustekinumab and guselkumab in a combination of biologic‐naive and biologic‐experienced patients.

The present study leveraged individual patient data from randomized controlled trials to compare guselkumab and ustekinumab maintenance therapy indirectly in a combination of biologic‐naive and biologic‐experienced patients.

Linked Comment: Yiu. Br J Dermatol 2020; 183:202–203.

Plain language summary available online

Socio-economic inequalities in timing of childhood immunizations in Scotland

In Scotland, like many other European countries, childhood immunization coverage is generally high, often exceeding levels typically required to achieve herd immunity (95%): uptake of the primary vaccines (excluding rotavirus) is ∼96% (at 12month(m)), with the 1st dose of measles, mumps and rubella (MMR) at 97% (by 5 years). However, the recommended age to receive these vaccines is 2-4m and 12-13m respectively. Delays beyond these ages may indicate vaccine hesitancy or barriers to access and can increase the likelihood of disease outbreaks, especially if clustered among certain geographical or social groups. We used quantile regression to examine the age by which 95% coverage was met in different groups.

We analyzed data from the Scottish Immunisation and Recall System, for all children born in Scotland 2010-12 (n∼200,000), estimating proportions immunized ‘on time’ with the primary (by age 5m) and MMR (by 14m) vaccines. Next we used quantile regression (with 95% cut-points) to calculate the age by which 95% coverage was reached among this cohort of children, overall and according to neighbourhood deprivation (Scottish Index of Multiple Deprivation[SIMD] deciles).

As in national reports, uptake of the primaries (at 12m) and MMR (at 5y) was &gt;95%, with 91% and 89% immunized ‘on time’ (as defined above). Nationally, primary vaccines uptake reached 95% by age 7m. This varied by SIMD, from 6m in the least disadvantaged decile, to 9m in the most disadvantaged decile (difference 3m, CI: 2.7-3.3). Uptake of MMR reached 95% a year later than recommended (26m), with no discernible pattern by SIMD.

In Scotland, the age by which immunization levels meet those typically required to achieve herd immunity may be suboptimal, particularly for MMR and (for primary vaccines) disadvantaged neighborhoods. This same approach might be used in other nations with high coverage to identify population groups that may be experiencing barriers to access and inform local intervention content

Abstract P6-18-33: GI toxicities in metastatic breast cancer: A comprehensive literature review

Background

Treatments for advanced or metastatic breast cancer (aBC/mBC) are associated with gastrointestinal (GI) toxicities. The objective of this study was to assess the association between GI toxicities in mBC/aBC and health-related quality of life (HRQoL) and economic burden.

Methods

We conducted a comprehensive literature search of the Cochrane Central Register of Controlled Trials (2017), NHS Economic Evaluation Database (2016), Embase (1988 – 2017 week 34), and Ovid MEDLINE (1946 to August 2017). Eligible studies evaluated an intervention/comparator treatment in adult patients (age ≥18 years) with aBC/mBC and reported a direct connection between GI toxicities (ie, diarrhea, constipation, nausea, vomiting) and HRQoL and economic evidence. All studies published from January 2000 to August 2017 were assessed for eligibility. Editorials, case reports, conference abstracts, and studies of early, locally advanced, or inflammatory BC were excluded. Abstract and title screening, and full-text screening were conducted by single reviewers. Data were extracted by a single reviewer and verified by a second. Results were synthesized narratively.

Results

Database searches identified 3,428 articles; an additional 16 articles were identified through other sources. Ninety-four studies underwent full-text review, of which 27 reported a direct connection between GI toxicities and HRQoL (n = 11) and economic burden (n = 19). Some studies reported both HRQoL and economic data.

Patients identified treatment-related adverse events (AEs), such as GI events, as an important aspect of treatment that can affect therapy choice, discontinuation, and switching. Generally, patients with mBC had lower HRQoL than other BC groups, and increasing toxicity was associated with a greater degree of HRQoL impairment. When patients were asked to rank which AEs they most wanted to avoid, only pain ranked higher than nausea and vomiting. In a willingness to pay study, women with mBC were willing to pay $3,894 (2014 USD) per year to avoid severe diarrhea and $3,211 to avoid severe nausea.

Gastrointestinal events were among the costliest class of AEs, with mean costs as high as $4,809 (2016 USD) per episode; costs increased by 24% if events were persistent or recurrent.

Conclusions

Gastrointestinal toxicities are common in patients with aBC/mBC and have significant consequences for HRQoL and system-level economic outcomes. Frequency and implications of GI effects of treatment regimens should be considered carefully during patient counseling,, prescribing and coverage decisions in metastatic breast cancer.

Citation Format: Disher T, Siddiqui M, Mitra D, Cameron C, Zhan L, Iyer S. GI toxicities in metastatic breast cancer: A comprehensive literature review [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-33.

Guselkumab for the Treatment of Moderate-to-Severe Plaque Psoriasis During Induction Phase: A Systematic Review and Network Meta-Analysis

Background:

Guselkumab is an interleukin-23 inhibitor indicated for treatment of moderate-to-severe plaque psoriasis.

Objective:

The objective was to determine the relative efficacy and safety of guselkumab compared to other biologics.

Methods:

A systematic review was performed to identify randomized controlled trials (RCTs). Bayesian network meta-analyses (NMAs) were conducted using meta-regression analyses that adjusted for cross-trial differences and risk differences. The primary outcome was Psoriasis Area and Severity Index (PASI) 90 response. Other efficacy and safety outcomes were considered. Several meta-regressions were performed to account for variations in patient and study characteristics: baseline risk adjustment (ie, control group response), prior biologic use, duration of psoriasis, weight, age, race, and baseline PASI/dermatology life quality index scores. The best-fitting model using predefined criteria was selected.

Results:

Forty-five RCTs were identified. Patient and study characteristics differed between RCTs as reflected in variations in control group response. Both the baseline risk-adjusted NMA and the risk-difference NMA fit the data best and suggested guselkumab has one of the highest PASI 90 responses. Pairwise comparisons from the baseline risk-adjusted PASI 90 NMA suggested guselkumab has comparable efficacy with ixekizumab (relative risk [RR]: 0.999, 95% credible intervals [CrIs]: 0.89-1.13) and brodalumab (RR: 1.04, 95% CrIs: 0.91-1.17) and superior efficacy versus all other treatments in the network (RR range, 1.20 to 43.22). Guselkumab was superior or comparable to other therapies for other efficacy outcomes and had a more favorable safety profile than most.

Conclusions:

Guselkumab has one of the highest PASI 90 responses among psoriasis treatments; similar findings were observed for other efficacy outcomes. Guselkumab has a favorable benefit–risk balance compared to moderate-to-severe psoriasis therapies.

Cost-impact study of rotavirus vaccination programme in Scotland

Aim: In July 2013, the Scottish Government introduced a rotavirus vaccination programme into the childhood immunisation schedule. The aim of this research was to estimate the cost-impact of this programme. Methods: Data for rotavirus-related resource use were identified including laboratory reports, hospitalisations, attendances at accident and emergency departments (A&E), general practice consultations (GP), calls to the National Health Service telephone helpline (NHS24) and prescriptions for common rehydration treatments. We used an interrupted time series analysis approach to assess the impact on resource utilisation in all categories. Appropriate costs were added to the models and predicted pre-and post-vaccination mean annual costs were estimated. The cost of the vaccination programme was estimated using costs from the literature. Results: The vaccination programme was associated with a reduction in utilisation in all measured healthcare resource categories. These reductions were all statistically significant (at the 95% level) with p-values less than 0.001. Reductions ranged from 18% in calls to NHS24 to 73% in positive laboratory reports. The vaccination programme was associated with a reduction in annual healthcare resource costs of 38% (£595,000 per 100,000 infants < 5 years old) in our measured categories (including £495,000 from a reduction in hospital stays). The annual overall cost-impact of the rotavirus vaccination programme (the cost of delivering the programme minus the reduction in resource costs) was estimated at approximately £435,000 per 100,000 infants < 5 years old. Conclusion: The rotavirus vaccination programme was associated with a reduction in all measured categories of rotavirus-related resource use by infants < 5 years old.

Relationship Between Hyperglycemia and Heart Transplant Rejection

PURPOSE

Hyperglycemia increases risks of kidney and liver transplant rejection. To determine whether perioperative and subsequent glycemic control was associated with increased risk of heart transplant rejection over the year after transplantation, we performed a retrospective analysis of glycemic control and rejection rates in heart transplantation patients.

METHODS

Perioperative glucose levels were analyzed in 157 patients undergoing transplantation at Northwestern Memorial Hospital from June 2005 to December 2012 and compared in patients with and without rejection found on routine follow-up biopsy specimens.

RESULTS

Grade ≤1R rejection on biopsy was observed in 116 patients and grade ≥2R rejection (grade requiring increased anti-rejection treatment) in 41 patients. Although no significant differences in the preoperative fasting or inpatient mean glucose levels were found, the mean glucose levels from discharge to 1 year trended higher in those with grade ≥2R compared to grade ≤1R (128.8 ± 40.9 versus 142.2 ± 46.6 mg/dL, P = .084). In a multivariable logistic regression model, neither the lowest nor highest quartile of glucose levels had significantly different odds ratios (ORs) for the development of ≥2R compared to the middle 50% glucose levels. Older age (OR 0.96, P = .020) and higher body mass index levels (OR 0.86, P = .004) were significantly associated with lower odds of developing grade ≥2R.

CONCLUSIONS

Although the glucose trend regarding rejection was not statistically significant, we cannot exclude the possibility that much higher glucose levels would influence rejection rates.

Comparative trends in incident fracture rates for all long-term care and community-dwelling seniors in Ontario, Canada, 2002-2012

SUMMARY

In this population-based study, we compared incident fracture rates in long-term care (LTC) versus community seniors between 2002 and 2012. Hip fracture rates declined more rapidly in LTC than in the community. An excess burden of fractures occurred in LTC for hip, pelvis, and humerus fractures in men and hip fractures only in women.

INTRODUCTION

This study compares trends in incident fracture rates between long-term care (LTC) and community-dwelling seniors ≥65 years, 2002-2012.

METHODS

This is a population-based cohort study using administrative data. Measurements were age/sex-adjusted incident fracture rates and rate ratios (RR) and annual percent change (APC).

RESULTS

Over 11 years, hip fracture rates had a marked decline occurring more rapidly in LTC (APC, -3.49 (95% confidence interval (CI), -3.97, -3.01)) compared with the community (APC, -2.93 (95% CI, -3.28, -2.57); p < 0.05 for difference in slopes). Humerus and wrist fracture rates decreased; however, an opposite trend occurred for pelvis and spine fractures with rates increasing over time in both cohorts (all APCs, p < 0.05). In 2012, incident hip fracture rates were higher in LTC than the community (RRs: women, 1.55 (95% CI, 1.45, 1.67); men, 2.18 (95% CI, 1.93, 2.47)). Higher rates of pelvis (RR, 1.48 (95% CI, 1.22, 1.80)) and humerus (RR, 1.40 (95% CI, 1.07, 1.84)) fractures were observed in LTC men, not women. In women, wrist (RR, 0.76 (95% CI, 0.71, 0.81)) and spine (RR, 0.52 (95% CI, 0.45, 0.61)) fracture rates were lower in LTC than the community; in men, spine (RR, 0.75 (95% CI, 0.57, 0.98) but not wrist fracture (RR, 0.91 (95% CI, 0.67, 1.23)) rates were significantly lower in LTC than the community.

CONCLUSION

Previous studies in the community have shown declining hip fracture rates over time, also demonstrated in our study but at a more rapid rate in LTC. Rates of humerus and wrist fractures also declined. An excess burden of fractures in LTC occurred for hip fractures in women and for hip, pelvis, and humerus fractures in men.

Risk factors associated with the mental health of fathers of children with an intellectual disability in Australia

BACKGROUND

Raising a child with a disability places considerable demands and stress on parents, which can contribute to mental health difficulties. Research has primarily focused on mothers' mental health, and our understanding of the effects on fathers remains limited. The factors that place fathers at increased risk of mental health difficulties are also poorly understood. This study aimed to redress these gaps by reporting on the mental health of a large sample of fathers of children with an intellectual disability (ID) (aged 3-15 years), comparing this to published Australian norms and mothers of children with ID. The second aim of the study was to explore risk factors associated with fathers' mental health.

METHOD

The data for this study come from 315 Australian fathers of children (aged 3-15 years) with ID, who participated in the large-scale evaluation of the Signposts for building better behaviour programme. Fathers completed a range of self-report questionnaires at baseline including the Depression Anxiety Stress Scale (DASS).

RESULTS

Fathers in the present sample reported significantly more symptoms of depression and stress than the Australian normative data, with approximately 6-8% reporting symptoms in the severe to extremely severe range. The strongest predictors of fathers' mental health difficulties were children's behaviour problems, daily stress arising from fathers' own needs and children's care needs, and low parenting satisfaction. Socio-economic factors did not predict mental health difficulties.

CONCLUSION

This study is among one of the first to report the mental health of fathers of children with a disability in Australia. Findings highlight that some fathers of children with ID are at heightened risk of experiencing mental health difficulties, underscoring the importance of the provision of information and interventions to promote their mental health.

Asteroseismology. Echography of young stars reveals their evolution

We demonstrate that a seismic analysis of stars in their earliest evolutionary phases is a powerful method with which to identify young stars and distinguish their evolutionary states. The early star that is born from the gravitational collapse of a molecular cloud reaches at some point sufficient temperature, mass, and luminosity to be detected. Accretion stops, and the pre-main sequence star that emerges is nearly fully convective and chemically homogeneous. It will continue to contract gravitationally until the density and temperature in the core are high enough to start nuclear burning of hydrogen. We show that there is a relationship for a sample of young stars between detected pulsation properties and their evolutionary status, illustrating the potential of asteroseismology for the early evolutionary phases.

Methods of weaning preterm babies <30 weeks gestation off CPAP: a multicentre randomised controlled trial

BACKGROUND

Controversy exists whether different continuous positive airway pressure (CPAP) weaning methods influence time to wean off CPAP, CPAP duration, oxygen duration, Bronchopulmonary Dysplasia (BPD) or length of admission.

AIMS

In a multicentre randomised controlled trial, the authors have primarily compared CPAP weaning methods impact on time to wean off CPAP and CPAP duration and secondarily their effect on oxygen duration, BPD and time of admission.

METHODS

Between April 2006 and October 2009, 177 infants <30 weeks gestational age (GA) who fulfilled stability criteria on CPAP were randomised to one of the three CPAP weaning methods (M). M1: Taken 'OFF' CPAP with the view to stay 'OFF'. M2: Cycled on and off CPAP with incremental time 'OFF'. M3: As with m(2), cycled on and off CPAP but during 'OFF' periods were supported by 2 mm nasal cannula at a flow of 0.5 l/min.

RESULTS

Based on intention to treat analysis, there was no significant difference in mean GA or birthweight between the groups (27.1 ± 1.4, 26.9 ± 1.6 and 27.3 ± 1.5 (weeks ± 1SD) and 988 ± 247, 987 ± 249 and 1015 ± 257 (grams ± 1SD), respectively). Primary outcomes showed M1 produced a significantly shorter time to wean from CPAP (11.3 ± 0.8, 16.8 ± 1.0, 19.4 ± 1.3 (days ± 1SE) p<0.0001, respectively) and CPAP duration (24.4 ± 0.1, 38.6 ± 0.1, 30.5 ± 0.1 (days ± 1SE) p<0.0001, respectively). All the secondary outcomes were significantly shorter with M1, (oxygen duration: 24.1 ± 1.5, 45.8 ± 2.2, 34.1 ± 2.0 (days ± 1SE) p<0.0001, BPD: 7/56 (12.5%), 29/69 (42%), 10/52 (19%) p=0.011 and length of admission: 58.5 ± 0.1, 73.8 ± 0.1 69.5 ± 0.1 (days ± 1SE) p<0.0001, respectively).

CONCLUSION

Method 1 significantly shortens CPAP weaning time, CPAP duration, oxygen duration, BPD and admission time.

The Ontario Osteoporosis Strategy: implementation of a population-based osteoporosis action plan in Canada

In the last decade, there have been a number of action plans published to highlight the importance of preventing osteoporosis and related fractures. In the province of Ontario Canada, the Ministry of Health provided funding for the Ontario Osteoporosis Strategy. The goal is to reduce morbidity, mortality, and costs from osteoporosis and related fractures through an integrated and comprehensive approach aimed at health promotion and disease management. This paper describes the components of the Ontario Osteoporosis Strategy and progress on implementation efforts as of March 2009. There are five main components: health promotion; bone mineral density testing, access, and quality; postfracture care; professional education; and research and evaluation. Responsibility for implementation of the initiatives within the components is shared across a number of professional and patient organizations and academic teaching hospitals with osteoporosis researchers. The lessons learned from each phase of the development, implementation, and evaluation of the Ontario Osteoporosis Strategy provides a tremendous opportunity to inform other jurisdictions embarking on implementing similar large-scale bone health initiatives.

Cost-utility analysis of proton pump inhibitors and other gastro-protective agents for prevention of gastrointestinal complications in elderly patients taking nonselective nonsteroidal anti-inflammatory agents

BACKGROUND

The use of proton pump inhibitors (PPIs) among elderly patients using nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) has increased; the price of PPIs is higher than that of majority of alternative treatment strategies.

AIM

To evaluate the cost-effectiveness of nsNSAIDS + PPIs relative to alternative gastroprotective regimens in the prevention of GI complications among elderly patients (aged > or = 65 years).

METHODS

An incremental cost-utility analysis, comparing PPIs with alternative gastroprotective regimens was conducted using a decision analytical model. Clinical outcomes, costs and utilities were derived from recently published studies. Probabilistic and deterministic sensitivity analyses were performed to test the robustness of the results to variation in model inputs and assumptions.

RESULTS

The incremental cost-utility ratio (ICUR) of PPIs, relative to nsNSAID alone, was $206,315 per QALY gained or were more costly and less effective. Other co-prescribed treatment options had higher costs per QALY gained. In patients with a history of a complicated or uncomplicated ulcer, PPIs had ICURs of $24,277 and $40,876, respectively.

CONCLUSIONS

Use of PPIs in all elderly patients taking nsNSAIDs is unlikely to represent an efficient use of finite healthcare resources. Co-prescribing PPIs, however, to elderly patients taking nsNSAIDs who have a history of complicated or uncomplicated ulcers appears to be economically attractive.

A demonstration project of a multi-component educational intervention to improve integrated post-fracture osteoporosis care in five rural communities in Ontario, Canada

This study evaluated a multi-component intervention (educational materials and outreach visits) to increase knowledge and improve post-fracture care management in five rural communities in Canada. One hundred and twenty-five patients pre- intervention and 149 post-intervention were compared. No significant improvement in post-fracture care was documented suggesting that a more targeted intervention is needed.

INTRODUCTION

Currently, the majority of patients with a low trauma fracture are under-investigated and under-treated for osteoporosis. We set out to evaluate an educational intervention on increasing knowledge of post-fracture care among health care professionals (HCPs) and fracture patients and on improving post-fracture management.

METHODS

We studied five rural communities in Ontario, Canada, using a multi-component intervention ("Behind the Break"), including educational material for HCPs and patients and educational outreach visits to physicians. The study had a historical control, non-equivalent pre/post design. Telephone surveys were carried out with individuals > or =40 years of age who had a low trauma fracture in 2003 (n = 125) or in 2005 (n = 149). Family physicians and emergency department staff were also surveyed.

RESULTS

A total of 4,207 educational packages were distributed. Seventy-three percent of family physicians had an outreach visit. Two-thirds indicated that they received enough information about post-fracture follow-up to incorporate it into their practice. Despite this, no significant improvement in post-fracture care was documented (32% in the "pre" group had a bone mineral density test and 25% in the "post" group). Of those diagnosed with osteoporosis, the majority were prescribed a bone-sparing medication (63% "pre" and 80% "post").

CONCLUSION

A more targeted intervention linking fracture patients to their physician needs to be evaluated in rural communities.

Free love in the far north: plural breeding and polyandry of arctic foxes (Alopex lagopus) on Bylot Island, Nunavut

Molecular studies show that canid breeding systems are more complex than field data have sometimes suggested. For example, microsatellite DNA fingerprints of offspring and adults within their social group indicate that many canid species thought to form monogamous pairs engage in polygyny, polyandry, and plural breeding. In many areas, arctic foxes ( Alopex lagopus (L., 1758)) are considered monogamous, with the complexity of their social systems increasing as population isolation increases. We combined a genetic approach with spatial data of arctic foxes on Bylot Island, Nunavut, Canada, to investigate breeding patterns in a population less isolated than many previously studied. As in previous field studies, single breeding pairs were most common, but one case of plural breeding and one case of polyandry with multiple paternity were also observed. Reproductive output in arctic foxes is closely tied to the productivity of their habitat in a given year; we support the hypothesis that abundant resources at our study site have also contributed to complex breeding patterns among resident foxes. We also suggest that increased genetic variation among offspring of multiply mated females may provide an additional adaptive advantage to species in uncertain environments.

Genetic linkage and association analysis in type 1 von Willebrand disease: results from the Canadian type 1 VWD study

BACKGROUND

von Willebrand disease (VWD) is the most common bleeding disorder known in humans, with type 1 VWD representing the majority of cases. Unlike the other variant forms of VWD, type 1 disease represents a complex genetic trait, influenced by both genetic and environmental factors.

AIM

To evaluate the contribution of the von Willebrand factor (VWF) and ABO blood group loci to the type 1 VWD phenotype, and to assess the potential for locus heterogeneity in this condition, we have performed genetic linkage and association studies on a large, unselected type 1 VWD population.

METHOD

We initially collected samples from 194 Canadian type 1 VWD families for analysis. After the exclusion of families found to have either type 2 or type 3 VWD, and pedigrees with samples from single generations, linkage and association analysis was performed on 155 type 1 VWD families.

RESULTS AND CONCLUSION

The linkage study has shown a low heterogeneity LOD score of 2.13 with the proportion of families linked to the VWF gene estimated to be 0.41. Linkage was not detected to the ABO locus in this type 1 VWD population. In the family-based association test, significant association was found between the type 1 VWD phenotype, the quantitative traits, VWF:Ag, VWF:RCo, and FVIII:C and the ABO 'O' and 'A' alleles and the VWF codon 1584 variant. There was also weak association with the -1185 promoter polymorphism and VWF:Ag, VWF:RCo, and FVIII:C plasma levels. These studies provide further evidence to support the role for genetic loci other than VWF and ABO in the pathogenesis of type 1 VWD.

Introduction of pneumococcal conjugate vaccine to the UK childhood immunisation programme, and changes to the meningitis C and Hib schedules

Changes to vaccinations in the United Kingdom (UK) childhood immunisation programme will be implemented later this year [1].

Development of an integrated-care delivery model for post-fracture care in Ontario, Canada

INTRODUCTION

The purpose of this study was to develop an integrated-care model for patients at highest risk for osteoporosis, those with a low-trauma fracture. Specific objectives were to describe the current processes and patterns of post-fracture care in hospitals in Ontario; to examine health-care professional and patient awareness of osteoporosis and the roles and responsibilities of various organizations and health care professionals; and to identify barriers and facilitators and obtain feedback on the model.

METHODS

In 2002, questionnaires were completed for 178 eligible hospitals.

RESULTS

Only 65% of hospitals inform primary-care physicians of a fracture for all patients and only 4% indicated that they provide information about osteoporosis. The main themes that emerged from the four patient focus groups (n=21) were lack of continuity of care, the absence of a link between the fracture and osteoporosis by both patients and health care providers, and need for information. Most participants agreed that something was needed to prompt their primary-care physician to investigate for osteoporosis. The four physician focus groups (n=26) identified a role for orthopaedic surgeons to flag cases.

CONCLUSIONS

From 34 key informant interviews with community-based organizations, we found a lack of integration between health care professionals who provide fracture care and those who provide osteoporosis management and fall prevention. Based on these data, we developed an integrated local-resource-based post-fracture care model, which we obtained feedback on at a stakeholder consultation workshop. The model focuses on improving emergency department/fracture clinic communication, emphasizes the need for follow-up investigation by family physicians for osteoporosis, and incorporates other health care professionals and a telemedicine multidisciplinary osteoporosis clinic. We are currently evaluating whether this model leads to an increase in appropriate investigation of and treatment for osteoporosis in patients with low-trauma fractures.

Sweeping-window arc therapy: an implementation of rotational IMRT with automatic beam-weight calculation

Sweeping-window arc therapy (SWAT) is a variation of intensity-modulated radiation therapy (IMRT) with direct aperture optimization (DAO) that is initialized with a leaf sequence of sweeping windows that move back and forth periodically across the target as the gantry rotates. This initial sequence induces modulation in the dose and is assumed to be near enough to a minimum to allow successful optimization, done with simulated annealing, without requiring excessive leaf speeds. Optimal beam weights are calculated analytically, with easy extension to allow for variable beam weights. In this paper SWAT is tested on a phantom model and clinical prostate case. For the phantom, constant and variable beam weights are used. Although further work (in particular, improving the dose model) is required, the results show SWAT to be a feasible approach to generating deliverable dynamic arc treatments that are optimized.

Effect of fasting on thyroid hormone levels, and TRα and TRβ mRNA accumulation in late-stage embryo and juvenile rainbow trout, Oncorhynchus mykiss

The accumulation of mRNA encoding for hepatic and intestinal T3-receptor (TR) and body and liver masses were measured in fed and 3-week fasted juvenile and swim up stage rainbow trout embryos. Plasma and total body thyroid hormone (TH) levels were measured for juvenile and swim up stages, respectively. Fasted juveniles exhibited a lower hepatosomatic index (HSI), liver mass and plasma T4 and T3 concentrations than fed animals, but there were no changes in body mass or the accumulation of mRNA encoding for either of the TR(alpha) or TR(beta) isoforms in liver or intestine. TR(beta) mRNA accumulation was greater than TR(alpha) mRNA accumulation in both tissues. Fasted embryos had lower whole body TH levels and body, liver and intestinal tract masses, in addition to a lower intestinosomatic index. However, there was no change in HSI. Fasting did not affect whole body or hepatic TR(alpha) and TR(beta) mRNA accumulation, although intestinal tract TR(alpha) and TR(beta) mRNA accumulation was lower in the fasted embryos. The HSI and body mass changes in fasted juvenile and embryo stages, respectively, indicated that both developmental stages were impacted by fasting. Both stages also showed evidence of decreased TH production. The lower TR gene expression in the intestinal tract of fasted embryos may suggest a role for THs in the transitional stage of intestinal development during this period of development.

In the world of Dolly, when does a human embryo acquire respect?

For most of the 20th century, it was possible to regard fertilisation as the identifiable point when life begins, because this moment could be defined unequivocally and was thought to be the single most essential biological step in the establishment of a new human entity. Since the successful reproductive cloning of Dolly and other mammals, it is clear that any human cell has the potential to supply the full genome of an embryo, and hence a person, without going through fertilisation. At what point in time do such embryos acquire the respect accorded to human beings? The authors argue that the time of implantation is the most useful point at which the potential and the intention to create a new person are translated into reality, because from that point a new life develops. Implantation differentiates a somatic cell in culture (which is not due respect) from a human entity that has acquired its own identity and developmental potential. The authors examine the value of quickening or viability as alternative developmental stages in the process of acquiring respect for the Dolly embryo.

Growth hormone secretion from the Arctic charr (Salvelinus alpinus) pituitary gland in vitro: effects of somatostatin-14, insulin-like growth factor-I, and nutritional status

This study investigated the influence of nutritional status on the growth hormone (GH)/insulin-like growth factor-I (IGF-I) axis in Arctic charr (Salvelinus alpinus). The objectives were to study the regulation of GH secretion in vitro by somatostatin-14 (SRIF) and hIGF-I, and to determine whether pituitary sensitivity to these factors is dependent upon nutritional status. Arctic charr were fed at three different ration levels (0, 0.35, and 0.70% BWd(-1)), and pituitary glands were harvested at 1, 2, and 5 weeks for in vitro study. Both SRIF and hIGF-I inhibited GH secretion from Arctic charr pituitary tissue in long-term (18 h) static hemipituitary culture, as well as after acute exposure in a pituitary fragment perifusion system. This response appeared to be dose-dependent for SRIF in static culture over the range of 0.01-1 nM, but not for hIGF-I. The acute inhibitory action of hIGF-I on GH release in the perifusion system suggests an action that is initially independent of any effects on GH gene expression or protein synthesis. Nutritional status did not affect the sensitivity of Arctic charr pituitary tissue to either SRIF or hIGF-I in vitro, indicating that changes in abundance of pituitary SRIF or IGF-I receptors may not explain the alterations in plasma GH levels found during dietary restriction.