The relationship between Medicaid policy and realized access to home- and community-based services

Medicaid funding for home- and community-based services (HCBS) has increased substantially in recent decades. Prior research has investigated the effects of this expansion on outcomes for individuals as well as costs to Medicaid, often using state policy as a proxy for access to HCBS or implicitly assuming that more generous policies affect outcomes through access, an assumption that may not hold. In this study, using survey data linked to Medicaid claims, we assess the extent to which common measures of state Medicaid HCBS generosity correspond to increased individual use of HCBS among older adults with potential needs. We find several measures to have strong predictive power, but only with relatively large changes in policy generosity. Our findings imply that increased funding of HCBS is not sufficient to ensure access to services and that researchers should be careful when using state policy generosity as a proxy for access.

Effectiveness of different treatments for odontogenic keratocyst: a network meta-analysis

Odontogenic keratocysts (OKC) are benign but aggressive lesions. As there is a lack of well randomized clinical studies assessing the effectiveness of the different treatment options for OKC, a network meta-analysis (NMA) was performed to identify the best treatment option with the lowest recurrence rate. An electronic search was performed following the PRISMA guidelines to identify all clinical studies comparing treatment options against enucleation alone. The outcome variable was recurrence. The predictor variables were treatments. The eight included treatments were: enucleation with peripheral ostectomy/curettage (E + PO/curettage); enucleation with cryotherapy (E + CRYO); enucleation with/without PO followed by modified Carnoy's solution (E ± PO+MCS); enucleation with PO and with topical 5-fluorouracil (E + PO+5FU); enucleation with/without PO followed by original Carnoy's solution (E ± PO+CS); marsupialization alone (MARS); marsupialization followed by secondary enucleation with/without PO (MARS+2°E ± PO); and resection. The odds ratio was used to estimate the recurrence rate. A frequentist NMA was performed using Stata software. A total of 2989 patients in 40 studies were included. Both direct pairwise meta-analysis and NMA showed that E + 5FU+PO was significantly superior to E ± PO+MCS. However, no statistically significant difference was found between E ± PO+CS vs E + 5FU+PO, E ± PO+MCS, and resection, respectively (all very low quality evidence). The three most effective treatments in reducing the recurrence rate were E + PO+ 5FU (98.1%; very low quality evidence), resection (83.5%; very low quality evidence), and E ± PO+CS (63.8%; moderate quality evidence). The findings from this study suggest that CS remains the most effective fixative agent after enucleation and PO until proven otherwise. Additionally, 5FU appears to be an effective method with promising results that needs further research. Finally, the efficacy of MCS remains controversial; further in vivo and in vitro studies are required to determine new protocols. As this NMA included retrospective studies, the results should be interpreted with great caution (level of evidence: type III).

Snapping Hip Syndrome: A Comprehensive Update

Purpose of review

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.

Recent Findings

Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.

Summary

SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Ketamine for the Treatment of Chronic Pain: A Comprehensive Review

Background

Chronic pain significantly worsens the quality of life. Unlike neuropathic, musculoskeletal, postoperative pain, and cancer pain, chronic primary pain cannot be explained by an underlying disease or condition, making its treatment arduous.

Objectives

This manuscript intends to provide a comprehensive review of the use of ketamine as a treatment option for specific chronic pain conditions.

Study Design

A review article.

Setting

A review of the literature.

Methods

A search was done on PubMed for relevant articles.

Results

A comprehensive review of the current understanding of chronic pain and the treatment of specific chronic pain conditions with ketamine.

Limitations

Literature is scarce regarding the use of ketamine for the treatment of chronic pain.

Conclusion

First-line treatment for many chronic pain conditions includes NSAIDs, antidepressants, anticonvulsants, and opioids. However, these treatment methods are unsuccessful in a subset of patients. Ketamine has been explored in randomized controlled trials (RCTs) as an alternative treatment option, and it has been demonstrated to improve pain symptoms, patient satisfaction, and quality of life. Conditions highlighted in this review include neuropathic pain, fibromyalgia, complex regional pain syndrome (CRPS), phantom limb pain (PLP), cancer pain, and post-thoracotomy pain syndrome. This review will discuss conditions, such as neuropathic pain, fibromyalgia, complex regional pain syndrome, and more and ketamine's efficacy and its supplementary benefits in the chronic pain patient population. As the opioid crisis in the United States continues to persist, this review aims to understand better multimodal analgesia, which can improve how chronic pain is managed.

First Annotated Genome of a Mandibulate Moth, Neomicropteryx cornuta, Generated Using PacBio HiFi Sequencing

We provide a new, annotated genome assembly of Neomicropteryx cornuta, a species of the so-called mandibulate archaic moths (Lepidoptera: Micropterigidae). These moths belong to a lineage that is thought to have split from all other Lepidoptera more than 300 Ma and are consequently vital to understanding the early evolution of superorder Amphiesmenoptera, which contains the order Lepidoptera (butterflies and moths) and its sister order Trichoptera (caddisflies). Using PacBio HiFi sequencing reads, we assembled a highly contiguous genome with a contig N50 of nearly 17 Mb. The assembled genome length of 541,115,538 bp is about half the length of the largest published Amphiesmenoptera genome (Limnephilus lunatus, Trichoptera) and double the length of the smallest (Papilio polytes, Lepidoptera). We find high recovery of universal single copy orthologs with 98.1% of BUSCO genes present and provide a genome annotation of 15,643 genes aided by resolved isoforms from PacBio IsoSeq data. This high-quality genome assembly provides an important resource for studying ecological and evolutionary transitions in the early evolution of Amphiesmenoptera.

Hydantoin-bridged medium ring scaffolds by migratory insertion of urea-tethered nitrile anions into aromatic C-N bonds

Bicyclic or tricyclic nitrogen-containing heterocyclic scaffolds were constructed rapidly by intramolecular nucleophilic aromatic substitution of metallated nitriles tethered by a urea linkage to a series of electronically unactivated heterocyclic precursors. The substitution reaction constitutes a ring expansion, enabled by the conformationally constrained tether between the nitrile and the heterocycle. Attack of the metallated urea leaving group on the nitrile generates a hydantoin that bridges the polycyclic products. X-ray crystallography reveals ring-dependant strain within the hydantoin.

Orthostatic Hypotension and Urine Specific Gravity Among Collegiate Athletes

Introduction The purpose of this study is to describe orthostatic blood pressure (BP) and urine specific gravity (USG) among collegiate athletes and then to examine if correlations between these variables could support use of orthostatic hypotension (OH) measures to screen for dehydration. Methods A prospective observational study was performed using a sample of convenience of collegiate athletes. Athlete's sex and sport were recorded in addition to height, weight, seated and standing BP and USG measured at a pre- and post-season encounter. An OH response was defined as either the systolic BP decreasing ≥ 15 mmHg or the diastolic BP decreasing ≥ 7 mmHg when transitioning from sit to stand. The USG was considered positive for dehydration if >1.020. Descriptive statistics, pairwise t-tests, and the Spearman version of the correlation coefficient were used with statistical significance set at p < 0.05. Results Eighty athletes met inclusion criteria. Six athletes had an OH response during pre-season and three during post-season. Increased frequencies of athletes testing positive for dehydration were identified during the post-season compared to pre-season measures. No significant association was identified between OH and elevated USG. A secondary analysis identified significant associations between athletes with increased height and OH responses and correlations between higher BP and USG. Conclusion This study identified collegiate athletes with pre- and post-season OH as well as athletes with USG measures meeting the threshold for dehydration. While no correlation between OH and USG was identified, findings suggest screening of both BP and hydration status among collegiate athletes may be warranted.

Regulation of bile acid metabolism in biliary atresia: reduction of FGF19 by Kasai portoenterostomy and possible relation to early outcome

BACKGROUND

Fibroblast growth factor 19 (FGF19) is produced in the small intestine and is involved in suppression of hepatic bile acid (BA) synthesis. FGF19 is also expressed in the liver and serum levels are elevated in adults with cholestatic liver disease. This may reflect a rescue mechanism to dampen liver injury caused by increased intrahepatic BAs.

OBJECTIVES

To examine circulating FGF19 at early stages of biliary atresia and at short-term follow-up post-Kasai portoenterostomy (KPE) in relation to noncholestatic infants. The relationship between FGF19, BAs and markers for BA synthesis and hepatic gene expression of factors involved in BA metabolism were also evaluated.

METHODS

Liver tissue, portal and peripheral blood samples were obtained from fifteen patients at KPE; additional blood was collected 4-6 months after surgery. Two control groups were included; to examine possible changes related to surgery and to compare FGF19 in biliary atresia to noncholestatic infants.

RESULTS

Circulating FGF19 levels correlated to its hepatic gene expression at time of KPE in biliary atresia and levels were elevated compared to noncholestatic infants. At follow-up, FGF19 levels were markedly reduced, and the decline coincided with reductions in bilirubin and conjugated chenodeoxycholic acid and with increased levels of the BA synthesis marker C4.

CONCLUSION

Elevated circulating FGF19 in biliary atresia is of hepatic origin and reduced following KPE. Changes in serum FGF19 may reflect the level of restoration of the enterohepatic circulation, and this warrants further long-term studies on the role of FGF19 in the cholestatic liver.

Constitutive AKT Activity Predisposes Lung Fibrosis by Regulating Macrophage, Myofibroblast and Fibrocyte Recruitment and Changes in Autophagy

The etiology and pathogenesis of pulmonary fibrosis is poorly understood. We and others reported that M-CSF/CSF-1, M-CSF-R and downstream AKT activation plays an important role in lung fibrosis in mice models and in IPF patients. To understand potential molecular pathways used by M-CSF-R activation to direct lung fibrosis, we used a novel transgenic mouse model that expresses a constitutively-active form of AKT, myristoylated AKT (Myr-Akt), driven by the c-fms (M-CSF-R) promoter. We were particularly interested in the basal immune state of the lungs of these Myr-Akt mice to assess M-CSF-R-related priming for lung fibrosis. In support of a priming effect, macrophages isolated from the lungs of unchallenged Myr-Akt mice displayed an M2-tropism, enhanced co-expression of M-CSF-R and α-SMA, reduced autophagy reflected by reduced expression of the key autophagy genes Beclin-1, MAP1-Lc3a(Lc3a), and MAP1-Lc3b(Lc3b), and increased p62/STSQM1 expression compared with littermate WT mice. Furthermore, Myr-Akt mice had more basal circulating fibrocytes than WT mice. Lastly, upon bleomycin challenge, Myr-Akt mice showed enhanced collagen deposition, increased F4/80+ and CD45+ cells, reduced autophagy genes Beclin-1, Lc3a, and Lc3b expression, and a shorter life-span than WT littermates. These data provide support that M-CSF-R/AKT activation may have a priming effect which can predispose lung tissue to pulmonary fibrosis.

Abstract P1-15-02: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Schwab R, Clark A, Yau C, Wolf D, Chien AJ, Majure M, Ewing C, Wallace A, Roesch E, Helsten T, Forero A, Stringer-Reasor E, Vaklavas C, Nanda R, Jaskowiak N, Boughey J, Haddad T, Han H, Lee C, Albain K, Isaacs C, Elias A, Ellis E, Shah P, Lang J, Lu J, Tripathy D, Kemmer K, Yee D, Haley B, Korde L, Edmiston K, Northfelt D, Viscusi R, Khan Q, I-SPY 2 Consortium, Symmans WF, Perlmutter J, Hylton N, Rugo H, Melisko M, Wilson A, Singhrao R, Asare S, van't Veer L, DeMichele A, Berry D, Esserman L. Withdrawn [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 P1-15-02.

Oxygen-induced leakage of spin polarization in Overhauser-enhanced magnetic resonance imaging: Application for oximetry in tumors

Overhauser-enhanced Magnetic Resonance Imaging (OMRI) is a double resonance technique applied for oxygen imaging in aqueous samples and biological tissues. In this report, we present an improved OMRI approach of oxygen measurement using the single line "Finland" trityl spin probe. Compared to a traditional approach, we introduced an additional mechanism of leakage of spin polarization due to an interaction of a spin system with oxygen. The experimental comparison of the new approach with an oxygen-dependent leakage factor to a traditional approach performed in phantom samples in vitro, and mouse tumor model in vivo, shows improved accuracy of determination of oxygen and contrast agent concentrations.

Abstract AP30: PHASE IB/II WITH EXPANSION OF PATIENTS AT THE MTD STUDY OF OLAPARIB PLUS WEEKLY (METRONOMIC) CARBOPLATIN AND PACLITAXEL IN RELAPSED OVARIAN CANCER PATIENTS

BACKGROUND: We established the olaparib tablet maximum tolerated dose (MTD) at 150 mg bid, dose limiting toxicities (DLT's) and response to therapy or carboplatin, paclitaxel and olaparib tablet given simultaneously, reported at ASCO 2014. This abstract will include data from both the phase 1b and the phase 2 expansion.

METHODS: A total of 54 subjects were evaluated in this trial, 14 in phase 1b and 40 in phase 2. Eligibility required measurable disease, adequate organ function and ECOG performance status of ~ 2. Subjects had to have failed first line platinum containing chemotherapy. BRCA testing was conducted as available. Subjects received the metronomic therapy of paclitaxel 60mg/m2 IV and carboplatin AUC 2 IV weekly, 3 weeks out of 4, and olaparib tablets at 150 mg bid administered orally for 3 consecutive days (D1-D3) every week for each cycle. Subjects were assessed for toxicity and response according to the protocol. Subjects that reached a confirmed complete remission were transitioned to olaparib tablets only, 300 mg bid until disease progression.

RESULTS: Median age was 58 and median number of prior regimens was 4. There have been no deaths due to the study regimen. One patient had grade 4 neutropenia and an allergic reaction to carboplatin. The common grade 3/4 toxicities were caused by the chemotherapy (neutropenia. anemia and thrombocytopenia). Two patients had mild GI toxicities. One patient had a skin rash. There was no evidence of cardiac, hepatic, or pulmonary toxicities in any of these patients. 25% of subjects had a complete remission (CR), 31% had PR, 23% had SD and 21% had

PD. Of the 13 CRs, 4 were BRCA negative. PFS median for BRCA positive subjects is 12.6 months vs 4.8 months for BRCA negative subjects. OS median for BRCA positive subjects is 24 months vs 16 months for BRCA negative subjects. All of the CR's are alive.

CONCLUSION: Olaparib tablet can be safely administered simultaneously with a weekly regimen of carboplatin and paclitaxel in heavily pretreated ovarian cancer patients. Olaparib appears to be highly effective in BRCA positive subjects. This is the first successful combination of olaparib tablets with carboplatin and paclitaxel that has been well tolerated.

Citation Format: Rivkin SE, Moon J, Iriarte D, Sloan H, Wiseman C, Klee M, Ference K, Drescher C, Veljovich D, Bondurant A, Peters W, Jiang P, Goodman G, Park M, Fer M, Shah C, Johnston E, Kaplan H, Wahl T, Ellis E. PHASE IB/II WITH EXPANSION OF PATIENTS AT THE MTD STUDY OF OLAPARIB PLUS WEEKLY (METRONOMIC) CARBOPLATIN AND PACLITAXEL IN RELAPSED OVARIAN CANCER PATIENTS [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr AP30.

De Novo Donor-Specific HLA Antibody Formation in Two Patients With Crigler-Najjar Syndrome Type I Following Human Hepatocyte Transplantation With Partial Hepatectomy Preconditioning

Clinical hepatocyte transplantation is hampered by low engraftment rates and gradual loss of function resulting in incomplete correction of the underlying disease. Preconditioning with partial hepatectomy improves engraftment in animal studies. Our aim was to study safety and efficacy of partial hepatectomy preconditioning in clinical hepatocyte transplantation. Two patients with Crigler-Najjar syndrome type I underwent liver resection followed by hepatocyte transplantation. A transient increase of hepatocyte growth factor was seen, suggesting that this procedure provides a regenerative stimulus. Serum bilirubin was decreased by 50%, and presence of bilirubin glucuronides in bile confirmed graft function in both cases; however, graft function was lost due to discontinuation of immunosuppressive therapy in one patient. In the other patient, serum bilirubin gradually increased to pretransplant concentrations after ≈600 days. In both cases, loss of graft function was temporally associated with emergence of human leukocyte antigen donor-specific antibodies (DSAs). In conclusion, partial hepatectomy in combination with hepatocyte transplantation was safe and induced a robust release of hepatocyte growth factor, but its efficacy on hepatocyte engraftment needs to be evaluated with additional studies. To our knowledge, this study provides the first description of de novo DSAs after hepatocyte transplantation associated with graft loss.

Appalachian mountaintop mining particulate matter induces neoplastic transformation of human bronchial epithelial cells and promotes tumor formation

Epidemiological studies suggest that living near mountaintop coal mining (MTM) activities is one of the contributing factors for high lung cancer incidence. The purpose of this study was to investigate the long-term carcinogenic potential of MTM particulate matter (PMMTM) exposure on human bronchial epithelial cells. Our results show that chronic exposure (3 months) to noncytotoxic, physiological relevant concentration (1 μg/mL) of PMMTM, but not control particle PMCON, induced neoplastic transformation, accelerated cell proliferation, and enhanced cell migration of the exposed lung cells. Xenograft transplantation of the PMMTM-exposed cells in mice caused no apparent tumor formation, but promoted tumor growth of human lung carcinoma H460 cells, suggesting the tumor-promoting effect of PMMTM. Chronic exposure to the main inorganic chemical constituent of PMMTM, molybdenum but not silica, similarly induced cell transformation and tumor promotion, suggesting the contribution of molybdenum, at least in part, in the PMMTM effects. These results provide new evidence for the carcinogenic potential of PMMTM and support further risk assessment and implementation of exposure control for PMMTM.

The effect of lung compliance and experience on manual hyperinflation

This study was designed to investigate the factors which affect the safe and effective performance of manual hyperinflation by physiotherapists. To determine this, experienced and student physiotherapists were requested to deliver manual hyperinflations at tidal volumes of 1000mLorpeak inspiratory pressures of 15cm H2O during a series of trials with variations in lung compliance. These hyperinflations were delivered into an artificial lung system. Subjects were blind to random changes in lung compliance and were only allowed the feel of the bag for feedback during testing. It was found that compliance had a significant effect on the tidal volumes and pressures generated, and bothgroups of subjects allowed peak inspiratory pressure to rise significantly when lung compliance was low. Experience, hand size and grip strength of individuals did not influence these results.

Piecing the puzzle together: foreign-born tuberculosis in an immigrant-receiving country

In major immigrant-receiving countries, annual foreign-born tuberculosis (TB) case counts and rates are relatively constant. Why this is so, and who might be a high-yield target for screening for latent TB infection, remain open questions. Foreign-born TB in Canada during 1986-2002 was retrospectively examined using national TB and immigration data as well as census data. Case counts and rates were analysed in relation to demographics, immigration period and time since arrival. Pre-1986 immigrants (n=3,860,853) and 1986-2002 immigrants (n=3,463,283) contributed 8,662 and 9,613 TB cases, respectively. Immigrants arriving ≤ 5 yrs ago and those arriving >10 yrs ago contributed almost equally to the annual foreign-born TB case count despite a 3.5-fold difference in in-country person-yrs. Remarkably stable and relatively low TB incidence was observed among immigrants >10 yrs post-arrival. Conversely, TB incidence within 5 yrs of arrival was dynamic, demonstrating a strong inverse association with time since arrival and higher sensitivity to changes in immigration level than shifts toward higher incidence source countries. Relative constancy in foreign-born TB incidence is explained by a complex convergence of several factors. Immigrants born in high-incidence countries who arrived ≤ 2 yrs ago and were aged 15-34 yrs upon arrival constitute high-yield targets for preventive therapy.

Diabetes outpatient care before and after admission for diabetic foot complications

OBJECTIVE

To assess the number of patients admitted with a diabetic foot complication to a regional teaching hospital over a 12-month period (July 2005 to June 2006) and determine the percentage that went though an optimal diabetes outpatient management pathway before and after this admission.

METHOD

Diabetic inpatients with foot ulcers and infections were identified through the relevant International Classification of Diseases (ICD) codes. Both inpatient and outpatient data were obtained through the local electronic patient management system and review of clinical notes.

RESULTS

Forty-nine patients were admitted to hospital with diabetic foot ulcers or infections during the audit period. Median age was 66 years and 67% were male. The most common admitting speciality was vascular surgery. The main associated procedure was toe amputation. In the six month period before and after the index admission, 63% of patients were seen by a health professional at the diabetes centre before or after the admission. 45% of patients were seen at the diabetes centre before and after the admission; 33% were seen by a podiatrist before and after the admission. However, 37% had no contact with the diabetes Centre and 51% did not see a podiatrist from the diabetes centre at any time during the six months before and after their admission.

CONCLUSION

Despite the availability of a multidisciplinary high risk foot clinic, only 45% of patients admitted to our regional hospital during the audit period followed an interdisciplinary pathway that included specialist diabetes input of some form and only 33% were assessed by a specialist diabetes podiatrist both before and after their hospital admission. A formalised patient pathway is likely to improve clinical management and may minimise further admissions. In this way it will help reduce morbidity and mortality in this high-risk patient group. In the future, this might best be achieved using an electronic referral and decision support system.

Demographic, laboratory and clinical characteristics of HIV-positive tuberculosis cases in Canada

BACKGROUND

Human immunodeficiency virus (HIV) is an important risk factor for the global incidence and mortality of tuberculosis (TB) and has had a tremendous impact on the epidemiology and the control of the disease. The purpose of this study was to determine the demographic, laboratory and clinical characteristics of HIV-positive TB cases in Canada as compared to HIV-negative cases.

METHODS

TB cases reported to the Canadian TB Reporting System (CTBRS) from 1997 to 2006 were retrospectively reviewed and for those with known HIV serostatus, the distributions of age, sex, country of birth, smear and culture positivity, drug resistance, site of disease and treatment outcome were compared.

RESULTS

2710 TB cases had a report of an HIV test with a 12.9% positivity rate. HIV-positive cases were more likely to be 30-44 years old, male, Canadian born non-Aboriginal or African born. Sputum and lymph node biopsies were significantly more likely to be smear-positive and sputum was more likely to be culture positive. Anti-TB drug resistant rates were similar, except for lower streptomycin resistance in new HIV-positive cases. HIV-positive cases were significantly more likely to present with miliary or central nervous system TB, to have multi-system disease, to have lower treatment success rates (66.4% versus 88.5%) and to have a 5.6 higher case-fatality rate.

INTERPRETATION

HIV-positive cases have a different demographic profile, present with more advanced and severe forms of disease, have poorer treatment outcomes and higher mortality. All TB cases should be tested for HIV so as to offer appropriate case management and treatment.

Choice of secondary prevention improves risk factors after acute coronary syndrome: 1-year follow-up of the CHOICE (Choice of Health Options In prevention of Cardiovascular Events) randomised controlled trial

OBJECTIVE

To determine the effect of a new CHOICE (Choice of Health Options In prevention of Cardiovascular Events) programme on cardiovascular risk factors in acute coronary syndrome (ACS) survivors.

DESIGN

Single-blind randomised controlled trial.

SETTING

Tertiary referral hospital in Sydney Australia.

PATIENTS

144 ACS survivors who were not accessing standard cardiac rehabilitation. Data were also collected on a further 64 ACS survivors attending standard cardiac rehabilitation.

INTERVENTION

The CHOICE group (n = 72) participated in a brief, patient-centred, modular programme comprising a clinic visit plus telephone support, encompassing mandatory cholesterol lowering and tailored preferential risk modification. The control group (n = 72) participated in continuing conventional care but no centrally coordinated secondary prevention.

MAIN OUTCOME MEASURES

Values for total cholesterol, systolic blood pressure, smoking status and physical activity.

RESULTS

CHOICE and control groups were well matched at baseline. At 12 months, the CHOICE group (n = 67) had significantly better risk factor levels than controls (n = 69) for total cholesterol (TC) (mean (SEM) 4.0 (0.1) vs 4.7 (0.1) mmol/l, p<0.001), systolic blood pressure (131.6 (1.8) vs 143.9 (2.3) mm Hg, p<0.001), body mass index (28.9 (0.7) vs 31.2 (0.7) kg/m(2), p = 0.025) and physical activity (1369.1 (167.2) vs 715.1 (103.5) METS/kg/min, p = 0.001) as well as a better knowledge of risk factor targets. Also at 1 year, fewer CHOICE participants (21%) had three or more risk factors above widely recommended levels then controls (72%) (p<0.001).

CONCLUSIONS

Participation in a brief CHOICE programme significantly improved the modifiable risk profiles and risk factor knowledge of ACS survivors over 12 months. CHOICE is an effective alternative for dealing with the widespread underuse of existing secondary prevention programmes.

TRIAL REGISTRATION NUMBER

ISRCTN42984084.

Physical activity and health: evidence from a study of deprived communities in England

This study aims to explore the relationship between physical activity levels and the self-reported health status of residents living in deprived communities in England. A cross-sectional interview survey was conducted in communities in receipt of funding from the New Deal for Communities (NDC) regeneration programme. A sample of 848 addresses was selected by random sampling from within each of the 39 NDC areas, and one adult from each household was selected for interview. A total of 19 574 residents were interviewed between July and October 2002. The main outcome measures were physical activity level and health status assessed using four self-reported health measures: health in the last 12 months, health change in the last 12 months, long-standing illness or disability and a mental health-related quality-of-life score. There are large regional and demographic variations in respect of NDC residents' physical activity levels. The areas with the lowest levels of physical activity are mainly located in northern industrial towns. Residents who did little or no physical activity were more than twice as likely to feel that their health was not good (adjusted OR 2.54, 95% CI 2.35-2.75).

Reducing inequalities in access to health care: developing a toolkit through action research

PROBLEM

Healthcare organisations are expected both to monitor inequalities in access to health services and also to act to improve access and increase equity in service provision.

DESIGN

Locally developed action research projects with an explicit objective of reducing inequalities in access.

SETTING

Eight different health care services in the Yorkshire and Humber region, including community based palliative care, general practice asthma care, hospital based cardiology clinics, and termination of pregnancy services.

KEY MEASURES FOR IMPROVEMENT

Changes in service provision, increasing attendance rates in targeted groups.

STRATEGIES FOR CHANGE

Local teams identified the population concerned and appropriate interventions using both published and grey literature. Where change to service provision was achieved, local data were collected to monitor the impact of service change.

EFFECTS OF CHANGE

A number of evidence based changes to service provision were proposed and implemented with variable success. Service uptake increased in some of the targeted populations.

LESSONS LEARNT

Interventions to improve access must be sensitive to local settings and need both practical and managerial support to succeed. It is particularly difficult to improve access effectively if services are already struggling to meet current demand. Key elements for successful interventions included effective local leadership, identification of an intervention which is both evidence based and locally practicable, and identification of additional resources to support increased activity. A "toolkit" has been developed to support the identification and implementation of appropriate changes.

Complications of rigid internal fixation for mandibular fractures

The application of rigid internal fixation to maxillofacial trauma is among the truly great advances that have been made in the field. The use of rigid internal fixation techniques has resulted in many advantages for the patient. Unfortunately, complications have occurred with this technology that are often devastating in their consequences for treatment outcomes. This article addresses some of the problems that stem from the use/misuse of rigid fixation devices in the treatment of mandibular fractures. It presents the most common complications and their management, including malunion, fibrous union, infection/osteitis, and impalement of the tooth roots and/or inferior alveolar canal.

Treatment methods for fractures of the mandibular angle

Fractures of the mandibular angle are plagued with the highest rate of complication of all mandibular fractures. Over the past 8 years, the following six accepted forms of treatment for these fractures were performed on an indigent inner-city population: closed reduction or intra-oral open reduction and nonrigid fixation; extraoral open reduction and internal fixation with an AO/ASIF reconstruction bone plate; and intraoral open reduction and internal fixation using either two 2.0 mm minidynamic compression plates, two 2.4 mm mandibular dynamic compression plates, two noncompression miniplates, or a single noncompression miniplate. This article reviews the results of those treatment modalities when used for the same patient population at one hospital. Results show that the use of either an extraoral open reduction and internal fixation with the AO/ASIF reconstruction plate or intraoral open reduction and internal fixation using a single miniplate was associated with the fewest complications.

Lag screw fixation of mandibular fractures

The lag screw is the simplest means of rigid internal fixation. By virtue of its ability to compress bone fragments without the use of a bone plate, it has wide application and achieves great stability. This article presents techniques to apply lag screws to fractures of the mandibular symphysis, the mandibular body, and the mandibular angle. Results are reviewed in studies of 315 patients whom the author has treated with lag screw fixation. The advantages of the lag screw technique over bone-plate fixation, such as a more rapid application, obviation of the need to adapt a bone plate, minimal displacement of bone segments, and the rapid application of fixation without diminishing the rigidity of the fracture reduction, are discussed, as are the technique's contraindications.

GH is a regulator of IGF2 promoter-specific transcription in human liver

The regulation of the insulin-like growth factor-II gene (IGF2) is complex and involves the usage of four promoters resulting in different 5' untranslated regions, but with a common translated product. The IGF2 gene product is a mitogenic and survival factor that has been suggested to be important for a normal fetal development and cancer. In this paper we present evidence suggesting that the human IGF2 gene is regulated by GH, and that this regulation occurs in a promoter-specific way. Three lines of evidence support this finding. First, in vivo data from patients treated with GH (one injection or daily injections for 5 consecutive days) showed an increase in the IGF2 P2 promoter derived transcript after acute treatment, and of the P4 promoter transcript after short-term treatment while the P1 promoter derived transcript did not show any significant change. Secondly, isolated human liver cells treated with GH for 2 h displayed an upregulation of the P2 promoter derived transcript. Thirdly, employing transfection experiments in GH-receptor positive CHO cells with P2 and P4 promoter-luciferase constructs, an upregulation by GH was evident, while a P1 promoter construct was unresponsive. We suggest that GH may be a physiological regulator of IGF2 in humans.