"Endless opportunities": A qualitative exploration of facilitators and barriers to scale-up of two-way texting follow-up after voluntary medical male circumcision in Zimbabwe

In Zimbabwe, the ZAZIC consortium employs two-way, text-based (2wT) follow-up to strengthen post-operative care for voluntary medical male circumcision (VMMC). 2wT scaled nationally with evidence of client support and strengthened follow-up. However, 2wT uptake among healthcare providers remains suboptimal. Understanding the gap between mobile health (mHealth) potential for innovation expansion and scale-up realization is critical for 2wT and other mHealth innovations. Therefore, we conducted an exploratory qualitative study with the objective of identifying 2wT program strengths, challenges, and suggestions for scale up as part of routine VMMC services. A total of 16 in-depth interviews (IDIs) with diverse 2wT stakeholders were conducted, including nurses, monitoring & evaluation teams, and technology partners-a combination of perspectives that provide new insights. We used both inductive and deductive coding for thematic analysis. Among 2wT drivers of expansion success, interviewees noted: 2wT care benefits for clients; effective hands-on 2wT training; ease of app use for providers; 2wT saved time and money; and 2wT strengthened client/provider interaction. For 2wT scale-up challenges, staff shortages; network infrastructure constraints; client costs; duplication of paper and electronic reporting; and complexity of digital tools integration. To improve 2wT robustness, respondents suggested: more staff training to offset turnover; making 2wT free for clients; using 2wT to replace paper VMMC reporting; integrating with routine VMMC reporting systems; and expanding 2wT to other health areas. High stakeholder participation in app design, implementation strengthening, and evaluation were appreciated. Several 2wT improvements stemmed from this study, including enrollment of multiple people on one number to account for phone sharing; 2wT inclusion of minors ages 15+; clients provided with $1 to offset SMS costs; and reduced SMS messages to clients. Continued 2wT mentoring for staff, harmonization of 2wT with Ministry e-health data systems, and increased awareness of 2wT's client and provider benefits will help ensure successful 2wT scale-up.

Adults with CHD balancing motivations and concerns in pregnancy decision-making

BACKGROUND

While the incidence of pregnancy has increased among individuals with adult CHD, little has been described about considerations and experiences of patients with adult CHD regarding pregnancy.

OBJECTIVE

We aimed to explore patients' motivations, concerns, and decision-making processes regarding pregnancy.

METHODS

In April 2019-January 2020, we conducted in-depth telephone interviews with patients (n = 25) with simple, moderate, or complex adult CHD, who received prenatal care at the University of Washington during 2010-2019 and experienced a live birth. Transcripts were analysed using thematic analysis.

RESULTS

Participants described motivations for pregnancy as both internal desires (motherhood, marriage fulfillment, biological connection, fetal personhood, self-efficacy) and external drivers (family or community), as well as concerns for the health and survival of themselves and the fetus. Factors that enabled their decision to maintain a pregnancy included having a desire that outweighed their perceived risk, using available data to guide their decision, planning for contingencies and knowing their beliefs about termination, plus having a trusted healthcare team, social support, and resources. Factors that led to insurmountable risk in subsequent pregnancies included desire having been fulfilled by the first pregnancy, compounding risk with age and additional pregnancies, new responsibility to an existing child, and reduced healthcare team and social support.

CONCLUSIONS

Understanding individuals' motivations and concerns, and how they weigh their decisions to become or remain pregnant, can help clinicians better support patients with adult CHD considering pregnancy. Clinician education on patient experiences is warranted.

Stakeholder Perspectives on Returning Nonactionable Apolipoprotein L1 (APOL1) Genetic Results to African American Research Participants

The ethics of returning nonactionable genetic research results to individuals are unclear. Apolipoprotein L1 (APOL1) genetic variants are nonactionable, predominantly found in people of West African ancestry, and contribute to kidney disease disparities. To inform ethical research practice, we interviewed researchers, clinicians, and African American community members (n  =  76) about the potential risks and benefits of returning APOL1 research results. Stakeholders strongly supported returning APOL1 results. Benefits include reciprocity for participants, community education and rebuilding trust in research, and expectation of future actionability. Risks include analytic validity, misunderstanding, psychological burdens, stigma and discrimination, and questionable resource tradeoffs.

Conclusions: APOL1 results should be offered to participants. Responsibly fulfilling this offer requires careful identification of best communication practices, broader education about the topic, and ongoing community engagement.

Experience With Advance Care Planning Discussions Among Pregnant Women With Congenital Heart Disease

CONTEXT

Women with adult congenital heart disease (ACHD) have an increased risk of adverse events during pregnancy. Advance care planning may therefore be an appropriate component of prenatal care.

OBJECTIVE

The aim of this study was to describe the perspectives of women with ACHD surrounding advance care planning during pregnancy.

METHODS

We conducted a thematic analysis of 25 semi-structured interviews with women with ACHD who had been pregnant. Purposive sampling was used to gain diversity in ACHD lesion complexity, race, age at pregnancy, and marital status.

RESULTS

Mean age at pregnancy was 29 years (range 15-41 years), and ACHD was classified as simple (24%), moderate (44%), or complex (32%). We identified three primary themes: 1) the role of advance care planning in being prepared and providing security for family; 2) reasons for avoiding advance care planning, including its lower priority among more pressing concerns and the impact it might have on their current psychological state; and 3) varied openness to advance care planning discussions during pregnancy.

CONCLUSION

Advance care planning is not a routine part of prenatal care in ACHD, and its role in this population requires further assessment.

At the Research-Clinical Interface: Returning Individual Genetic Results to Research Participants

Whether individual results of genetic research studies ought to be disclosed to study participants has been debated in recent decades. Previously, the prevailing expert view discouraged the return of individual research results to participants because of the potential lack of analytic validity, questionable clinical validity and medical actionability, and questions about whether it is the role of research to provide participants with their data. With additional knowledge of participant perspectives and shifting views about the benefits of research and respect for participants, current expert consensus is moving toward support of returning such results. Significant ethical controversies remain, and there are many practical questions left to address, including appropriate procedures for returning results and the potential burden to clinicians when patients seek guidance about the clinical implications of research results. In this review, we describe current views regarding the return of genetic research results, including controversies and practical challenges, and consider the application of these issues to research on apolipoprotein L1 (APOL1), a gene recently associated with health disparities in kidney disease. Although this case is unique, it illustrates the complexities involved in returning results and highlights remaining questions.

Organizational readiness to implement population-based screening and genetic service delivery for hereditary cancer prevention and control

Despite clinical guidelines, programs conducting population-based screening and genetic service delivery for hereditary cancer prevention and control are rare in practice. We interviewed individuals (n = 13) instrumental in implementing seven unique clinical programs conducting either universal tumor screening for Lynch Syndrome or routine family history screening and provision of genetic services for hereditary breast and ovarian cancer in the United States. To characterize determinants of readiness to implement population-based cancer genetic service delivery models, interviews and deductive codes drew on Weiner's theory of organizational readiness for change. Qualitative analysis identified themes across programs. The degree to which organizational stakeholders valued moving to a population-based genetic service delivery model depended on the existence of aligned clinical guidelines at the time of program implementation. However, judgments of implementation capacity within the organization, particularly with respect to task demands and resource concerns, were more often barriers to readiness. Program champions were essential to facilitating readiness, frequently taking on substantial uncompensated work. These data suggest that developing interventions targeting change efficacy and cultivating practice change champions may be two promising ways to increase uptake of population-based hereditary cancer screening and genetic service delivery in clinical practice.

Apolipoprotein L1 Testing in African Americans: Involving the Community in Policy Discussions

BACKGROUND

Apolipoprotein A1 (APOL1) gene variants occurring in people of West African descent contribute to the greater burden of kidney disease among African Americans. These variants are associated with increased risk of nondiabetic nephropathy, more rapid progression of chronic kidney disease, and shorter survival of donor kidneys after transplantation. However, only a minority of people with APOL1-associated risk develops kidney disease and specific clinical measures to address APOL1-associated risk are lacking. Given these uncertainties, we sought to engage members of the African American public in discussions with other stakeholders about the appropriate use of APOL1 testing.

METHODS

Formative interviews with community members, researchers, and clinicians in Seattle WA, Nashville TN, and Jackson MS, provided baseline information about views toward APOL1 testing and informed the design of 3 community-based deliberations among African Americans. A national meeting held in March 2018 included 13 community members, 7 scientific advisors and 26 additional researchers, clinicians, bioethicists, patient advocates, and representatives from professional organizations and federal funding agencies. Using small break-out and plenary discussion, the group agreed on recommendations based on current knowledge about APOL1-associated risk.

RESULTS

Meeting outcomes included recommendations to develop educational materials about APOL1 for community members and clinicians; to offer APOL1 research results to participants; and on the use of APOL1testing in kidney transplant programs. The group recommended against the routine offer of APOL1 testing in clinical care. Areas of disagreement included whether kidney transplant programs should require APOL1 testing of prospective living donors or bar individuals with APOL1 risk from donating kidneys and whether testing should be available on request in routine clinical care.

CONCLUSION

We recommend continued discussion among stakeholders and concerted efforts to ensure active and informed participation of members of the affected community to guide research on APOL1 and kidney disease.

Responsible Research With Urban American Indians and Alaska Natives

American Indian and Alaska Native (AI/AN) communities harbor understandable mistrust of research. Outside researchers have historically controlled processes, promulgating conclusions and recommended policies with virtually no input from the communities studied. Reservation-based communities can apply sovereignty rights conferred by the federal government to change this research trajectory. Many tribes now require review and approval before allowing research activities to occur, in part through the development of regulatory codes and oversight measures. Tribal oversight ensures that research is directed toward questions of importance to the community and that results are returned in ways that optimize problem solving. Unfortunately, tribal governance protections do not always extend to AI/ANs residing in urban environments. Although they represent the majority of AI/ANs, urban Indians face an ongoing struggle for visibility and access to health care. It is against this backdrop that urban Indians suffer disproportionate health problems. Improved efforts to ensure responsible research with urban Indian populations requires attention to community engagement, research oversight, and capacity building. We consider strategies to offset these limitations and develop a foundation for responsible research with urban Indians.

Identifying "ownership" through role descriptions to support implementing universal colorectal cancer tumor screening for Lynch syndrome

Purpose

Lynch Syndrome cases are under-identified, and universal colorectal cancer tumor screening for Lynch Syndrome (UTS) has been recommended. UTS implementation is challenging and few successful examples exist to date, and colorectal cancer patients and at-risk family members exhibit low uptake of genetic services. This study sought to identify the elements that could guide the choice of specialties to implement UTS through three main stages: initiating the screen, returning positive screen results, and providing follow-up.

Methods

To understand stakeholder views on the UTS process, twenty semi-structured interviews were conducted with clinicians from six medical specialties crucial for implementing UTS. Data were analyzed using directed content analysis and additional thematic analysis across content categories.

Results

Several clinical specialties could fill necessary roles at each of the main stages of UTS implementation. Participants suggested owners based on attributes of specialty roles, clinical settings, and the routes patients take through the system.

Conclusion

UTS is considered possible in a range of healthcare settings, with tailoring. Health systems need to choose who best fills the role’s needs based on local resources and processes. These results offer implementation guidance based on role needs, not clinical specialty, in resolving the issue of UTS “ownership.”

Found in translation: Decoding local understandings of genetics and heredity in a Yup'ik Eskimo community

The Center for Alaska Native Health Research is a community-based participatory research center that conducts studies involving genetic research with Yup'ik Eskimo community members in Southwest Alaska, where Yup'ik remains the first language for most residents. Cultural equivalents are needed to communicate results of these studies among all partners and members of the participating communities, since many scientific terms have no direct translation in Yup'ik. To inform that effort, we examined local understandings of genetics and heredity in one community. Here, we report results from back-translated Yup'ik interviews, and identify working genetic concepts shared by participants from interviews and focus groups. We suggest issues involved in, and some potential steps toward, developing a concise, scientifically accurate and culturally relevant term for "genetics" and other health concepts.

dbGaP data access requests: a call for greater transparency

The scientific and public health benefits of mandatory data-sharing mechanisms must be actively demonstrated. To this end, we manually reviewed 2724 data access requests approved between June 2007 and August 2010 through the U.S. National Center for Biotechnology Information database of genotypes and phenotypes (dbGaP). Our analysis demonstrates that dbGaP enables a wide range of secondary research by investigators from academic, governmental, and nonprofit and for-profit institutions in the United States and abroad. However, limitations in public reporting preclude the tracing of outcomes from secondary research to longer-term translational benefit.

Enhanced delayed-type hypersensitivity and diminished immediate-type hypersensitivity in mice lacking the inducible VPAC(2) receptor for vasoactive intestinal peptide

Vasoactive intestinal peptide (VIP) and its G protein-coupled receptors, VPAC(1)R and VPAC(2)R, are prominent in the immune system and regulate many aspects of T cell-dependent immunity. In mouse T cells, VPAC(1)R is expressed constitutively, whereas VPAC(2)R is induced by immune stimuli. VPAC(2)R-null (VPAC(2)R(-/-)) mice on a C57BL/6 background are shown here to have normal basic immune characteristics, including serum Ig concentrations, blood levels of all leukocytes, and spleen number of total T cells (CD3(+)) and T cells bearing CD4, CD8, and CD28. Hapten-evoked cutaneous delayed-type hypersensitivity (DTH) was significantly enhanced in VPAC(2)R-null mice compared with age- and sex-matched wild-type mice. In contrast, generation of IgE anti-hapten antibodies and active cutaneous anaphylaxis were > or =70% lower in VPAC(2)R-null mice than in wild-type controls. Cytokine production by splenic CD4(+) T cells, stimulated with adherent anti-CD3 plus anti-CD28 antibodies, revealed higher levels of IL-2 (mean = 3-fold) and IFN-gamma (mean = 3-fold), and lower levels of IL-4 (mean = one-fifth) in VPAC(2)R-null mice than wild-type controls. Loss of VIP-VPAC(2)R maintenance of the normal ratio of Th2/Th1 cytokines thus leads to a state of enhanced DTH and depressed immediate-type hypersensitivity, which may alter both host defense and susceptibility to immune-mediated diseases.

The VIP2 receptor: molecular characterisation of a cDNA encoding a novel receptor for vasoactive intestinal peptide

We have cloned and sequenced a cDNA (RPR4) encoding a new member of the secretin/calcitonin/parathyroid hormone (PTH) receptor family. RPR4 was identified by PCR of rat pituitary cDNA, and a full-length clone was isolated from a rat olfactory bulb cDNA library. When RPR4 was functionally expressed in COS 7 cells, cyclic adenosine monophosphate (cAMP) production was stimulated by vasoactive intestinal peptide (VIP), pituitary adenylate cyclase activating peptides (PACAP-38 and PACAP-27) and helodermin, with equal potency. Peptide histidine isoleucine (PHI) and rat growth hormone releasing hormone (rGHRH) also stimulated cAMP production at lower potency. This suggests that RPR4 encodes a novel VIP receptor which we have designated the VIP2 receptor. In situ hybridisation showed that mRNA for this receptor was present mainly in the thalamus, hippocampus and in the suprachiasmatic nucleus.

Molecular cloning and expression of a cDNA encoding a receptor for pituitary adenylate cyclase activating polypeptide (PACAP)

We have cloned and sequenced a novel cDNA (RPR7) encoding a receptor for pituitary adenylate cyclase activating polypeptide (PACAP). RPR7 was identified by PCR of rat pituitary cDNA, and full-length clones were isolated from a rat olfactory bulb cDNA library. When expressed in COS cells, RPR7 was functionally coupled to increases in intracellular cyclic adenosine monophosphate (cAMP) in response to stimulation by PACAP-38, PACAP-27, vasoactive intestinal peptide (VIP) and peptide histidine isoleucine (PHI). The order of potency of these ligands was PACAP-38-PACAP-27 > VIP > PHI, suggesting that the receptor corresponds to the pharmacologically characterised PACAP Type I receptor.

Reactive oxygen species and human spermatozoa: analysis of the cellular mechanisms involved in luminol- and lucigenin-dependent chemiluminescence

We have shown that human spermatozoa generate and release reactive oxygen species that can be detected by chemiluminescence techniques. Analysis of the cellular mechanisms responsible for this activity suggests that the probe, luminol, undergoes an intracellular dioxygenation reaction mediated by hydrogen peroxide and a sperm peroxidase located within the acrosome. Support for this model included the following observations: (1) the luminol-dependent signal could be suppressed with peroxidase inhibitors, phenylhydrazine and sodium azide; (2) this suppression could be reversed by the addition of an azide-insensitive peroxidase, horse radish peroxidase (HRP); (3) inhibition of intracellular superoxide dismutase (SOD) with potassium cyanide (KCN) suppressed the luminol signal; (4) peroxidase activity could be detected in purified populations of human spermatozoa with 3,3',5,5' tetramethylbenzidine (TMB); (5) this peroxidase was active at the pH prevailing within the acrosomal vesicle; and (6) peroxidase activity and luminol-dependent chemiluminescence were minimal in spermatozoa exhibiting a congenital absence of acrosomes. Human spermatozoa could also generate lucigenin-dependent chemiluminescent signals that could neither be suppressed with peroxidase inhibitors nor enhanced by the addition of peroxidase. However, these signals could be enhanced by suppression of intracellular SOD with KCN or inhibited by exogenous SOD, suggesting that lucigenin was responding to superoxide anion released into the extracellular space. The ability of chemiluminescent techniques to detect and discriminate the production of superoxide and hydrogen peroxide by spermatozoa should facilitate the further analysis of reactive oxygen species as mediators of normal and abnormal human sperm function.

Sperm penetration into a hyaluronic acid polymer as a means of monitoring functional competence

The diagnostic significance of sperm penetration assays based on a commercially available hyaluronate preparation (Sperm Select) has been investigated in the male partners of 77 couples characterized by a normal female partner. Sperm penetration into hyaluronate was highly correlated with the ability of the same sperm populations to penetrate bovine cervical mucus and, moreover, depended on the same attributes of semen quality, including the morphology of the spermatozoa, their number, and their motility as reflected by their mean path velocity. Stepwise multiple regression analyses employing these independent variables generated r values of 0.821 to 0.931, depending on the criterion of hyaluronate penetration used; path velocity was consistently the most informative variable according to the standardized regression coefficients. The relationship between hyaluronate penetration and sperm movement was so close that multiple regression equations could be generated that were capable of accounting for up to 76% of the variance in sperm velocity measurements obtained with a computerized image analysis system. Regression equations could also be generated using the hyaluronate penetration data that could account for 65% of the variance observed in an A23187-enhanced zona-free hamster oocyte penetration test, including the successful identification of the subpopulation of patients in whom 0% oocyte penetration had been recorded. Within the same data set, independent variables based on bovine cervical mucus penetration could only account for 43.5% of the variance in sperm-oocyte fusion. Hyaluronate penetration therefore appears to offer a simple, objective means of generating information on the functional competence of human spermatozoa that should find a role in routine diagnostic services where the more specialized tests are not available.

Analysis of the relationship between reactive oxygen species production and leucocyte infiltration in fractions of human semen separated on Percoll gradients

We have shown previously that the reactive oxygen species generated by washed human ejaculates originate from cells which can be isolated in the low density region of discontinuous Percoll gradients. In this study we have used a simplified two-step (40/80%) Percoll gradient to separate human ejaculates (n = 109) into two populations of spermatozoa, exhibiting either a high or a low capacity for reactive oxygen species generation. We have then examined the relationships between this activity and other properties of the isolated fractions, with particular emphasis on the presence of leucocytes, which we have quantified using a monoclonal antibody directed against the common leucocyte antigen. The low-density cells recovered from the 40%/80% interface of the Percoll gradients, differed from the high-density fraction in exhibiting significantly reduced sperm motility, poorer sperm morphology, and a considerably enhanced capacity for reactive oxygen species production (P less than 0.001). In six cases the elevated levels of reactive oxygen species generation were associated with leucocyte concentrations in excess of 1 x 10(6) per 10(7) sperm, suggesting that leucocytes enter the seminal compartment in an activated, oxygen-radical generating, state. However, in the majority of cases exhibiting high levels of reactive oxygen species production, leucocyte numbers were low or absent and the semen profiles were unremarkable, except that seminal sperm concentrations tended to be low. These results suggest that the oxidative stress responsible for defective sperm function involves reactive oxygen species originating from two sources; the sperm and infiltrating leucocytes.

Relevance to prenatal diagnosis of the identification of a human Y/autosome translocation by Y-chromosome-specific in situ hybridisation

Routine cytogenetic analysis of an amniotic fluid sample revealed a large brightly fluorescent region in the short arm of chromosome 14 in an otherwise normal male karyotype (46,XY,14p+ + +). This site was also present in the paternal karyotype. In situ hybridisation to a Y-chromosome-specific DNA probe confirmed that the father had a Y/14 translocation. The incidence of two hybridisation bodies (large hybridisation sites), detecting both the translocated Y chromatin and the normal Y chromosome, was lower in interphase nuclei (44.3%) than in metaphase spreads (95.2%). The relevance of these observations to the potential use of in situ hybridisation to interphase nuclei for prenatal diagnosis is discussed.

Sexing the human fetus and identification of polyploid nuclei by DNA-DNA in situ hybridisation in interphase nuclei

Samples of human adult lymphocytes, fetal lymphocytes, amniotic fluid cells, and chorionic villus cells were sexed independently by cytogenetics and DNA-DNA in situ hybridisation to a tritiated Y probe. For the in situ hybridisation analysis, the presence of Y bodies (hybridisation bodies) in 100 interphase nuclei were scored after autoradiography. In all, 82/83 samples were sexed in this way (one technical failure) and 78/82 were sexed by both in situ hybridisation and cytogenetics. There was complete agreement between the two methods. There was a considerable variation (40-100%) in the percentage of interphase nuclei with a hybridisation body among the male samples, but very few nuclei from female samples showed significant hybridisation. In situ hybridisation could be used to sex the conceptus when males but not females are at risk for various X-linked genetic disorders and may also be useful for detecting 45,X/46,XY mosaicism or polyploid/diploid mosaicism. This would be particularly useful for direct preparations of chorionic villus samples, which often prove difficult to analyse cytogenetically but offer the best means of avoiding maternal contamination. Some interphase nuclei had more than one hybridisation body, and this was most commonly found among amniotic fluid cells. Comparison of sizes of nuclei with one or two hybridisation bodies strongly suggested that most of the amniotic fluid cell nuclei with two hybridisation bodies were tetraploid.

Detection of Y-bearing spermatozoa by DNA-DNA in situ hybridisation

In situ hybridisation of a Y chromosome-specific DNA probe to preparations of decondensed spermatozoa revealed approximately 46.7% labelled spermatozoa among 3,900 scored. This is not significantly different from the 50% expected if only the Y chromosome-bearing spermatozoa are hybridised. Control hybridizations of Escherichia coli DNA and salmon testis DNA to decondensed sperm produced no significant labelling, whereas more than 99% of the spermatozoa were heavily labelled after hybridisation to total human DNA. These controls indicate that the methodology described in this paper renders the chromatin accessible for hybridisation and that the 50% hybridisation observed with the Y chromosome DNA probe was specific. In situ hybridisation with the Y probe therefore identifies the Y-bearing spermatozoa, and the protocol described should prove useful in evaluating methods of separating Y-bearing and X-bearing spermatozoa.

Sexing whole human pre-embryos by in-situ hybridization with a Y-chromosome specific DNA probe

We have used DNA-DNA in-situ hybridization with a DNA probe for the human Y-chromosome to distinguish between male and female human pre-embryos. Both biotinylated and tritiated Y-probes worked well on control cell cultures where 100 interphase nuclei were scored. Morphologically normal pre-embryos could be sexed with confidence with the tritiated Y-probe but the biotin results were less reliable (although only a few pre-embryos were analysed in this way). Early cleavage stage pre-embryos had large nuclei with relatively diffuse Y-bodies and were more difficult to score with the biotinylated Y-probe. Morphologically abnormal pre-embryos often had large nuclei with multiple Y-bodies (presumably polyploid nuclei) or small nuclei with no Y-bodies (possibly fragmenting nuclei). In all, 38 cleaving and two non-cleaving pre-embryos were analysed. The incidence of false positive and false negative cells seen after hybridization of tritiated Y-probes to control lymphocyte cultures suggests that it should normally be possible to distinguish morphologically normal male and female pre-embryos with samples of three to six interphase nuclei.

The role of circulating glucose and triglyceride concentrations and their interactions with other "risk factors" as determinants of arterial disease in nine diabetic population samples from the WHO multinational study

In 9 of the 14 national samples of diabetic patients assembled for the WHO Multinational Study of Vascular Disease in Diabetes additional laboratory data made it possible to relate manifestations of macrovascular disease to blood glucose concentrations as well as to diabetes duration and to other potential determinants. In five of the samples, serum triglyceride concentrations were also measured and were included in simple and multivariate analyses. Ischemic heart disease defined from Minnesota-coded EKGs and standardized WHO questionnaires was more strongly associated with serum triglyceride concentrations than with serum cholesterol concentrations, an association less notable in non-insulin-dependent diabetic patients. Ischemic heart disease was not related to the single fasting plasma glucose estimated for this study. Stroke and amputation were much more strongly related to the known duration of diabetes than was ischemic heart disease, and they were both related to blood glucose concentration measured at the time of study. Despite major variation in arterial disease prevalence rates between collaborating centers, risk for diabetic women appeared to equal that for diabetic men. The major variation in arterial disease prevalence between national groups could be accounted for only in part by the risk factors studied. Other factors, genetic or more likely environmental, are likely to contribute to the variation in arterial disease susceptibility and, if definable, may be potentially preventable.

Interrelationships of microangiopathy, plasma glucose and other risk factors in 3583 diabetic patients: a multinational study

In a multinational study, fasting plasma glucose values in 3583 diabetic patients, aged 34-56 years, were related to the characteristics of these subjects and to the presence and severity of microangiopathy as ascertained by standardised methods. The patients were from nine different populations and ranged in number from 193 to 686 per population (London, Warsaw, Berlin (FRG), New Delhi, Tokyo, Havana, Oklahoma Indians, Arizona Pima Indians, and a national sample in Switzerland). In the total group, mean fasting plasma glucose was 8.1 mmol/l for those on diet alone, 9.7 mmol/l for those on oral agents, and 12.7 mmol/l for insulin-treated patients, of whom 25% had values exceeding 16.5 mmol/l. Since many variables were measured in each patient, it was possible to take into account many confounding factors in evaluating the relationship of plasma glucose levels to retinopathy and nephropathy.

A detailed study of risk factors for retinopathy and nephropathy in diabetes

Indexes of retinopathy and nephropathy were studied in a large population of diabetics using standardized methods. In each of 973 subjects, more than 100 other variables were also measured: this made It possible to take into account many confounding factors when we examined the relationships of these variables to microangiopathy.

The most powerful risk factor for microangiopathy was duration of diabetes, but frequency of both retinopathy and nephropathy was impressively related to the level of plasma glucose at the time of examination. This latter relationship was independent of the effects of other variables. Risk of retinopathy was also related to factors that were probably associated with higher previous plasma glucose levels—need for insulin therapy, history of ketonuria, present level of plasma triglyceride, leanness, and younger age of onset of diabetes. In subjects with a systolic blood pressure of less than 170 mm Hg and who did not have proteinuria, no significant relationship was found between blood pressure and frequency of retinopathy, but, when the systolic pressure was greater than 169 mm Hg, rates of retinopathy were excessive, even In those subjects without proteinuria. Several other factors had no significant relationship to retinopathy or nephropathy: these included age, level of education, smoking, and plasma cholesterol. Rates of severe nephropathy were somewhat greater In men than in women, but this difference was not statistically significant. Rates of retinopathy and of mild proteinuria were similar in men and women. After adjustment for duration of diabetes, the risk of retinopathy was no higher in the 102 subjects with two diabetic parents than in the 254 who had no family history of diabetes.

Absence of a relationship between smoking and diabetic microangiopathy

The relationship between cigarette smoking and retinopathy and proteinuria was examined in a group of 973 subjects with diabetes. Other variables known to influence the risk of microangiopathy were also measured in a standardized fashion (e.g., duration of diabetes, blood glucose, blood pressure). The characteristics of smokers and nonsmokers were studied in detail. It was therefore possible to take into account the effects of confounding variables on the relationship between smoking and risk of microangiopathy. Associations between smoking and risk of microangiopathies, previously reported in some of the smaller studies, were not confirmed in this larger study.

Community screening programs for diabetes?

Considerable uncertainty and disagreement now prevail concerning the utility and priority of community screening programs for diabetes. A large majority of diabetologists believe that substantial benefits attend the early discovery of diabetes. Official statements of the American Diabetes Association support the view that mitigation of hyperglycemia lowers risk of morbidity. Much recent evidence indicates that aggressive early treatment often improves beta-cell function, thereby diminishing the severity of diabetes. Even so, some diabetologists and public health specialists question the practical benefits of community screening programs. Indeed, there is considerable evidence that, as previously performed, results sometimes have not justified costs. This article suggests that, when well designed, community screening is stil justified in some circumstances. To a considerable degree, failures of the past are correctable. The American Diabetes Association should neither approve nor disapprove community screening indisciminately. Affiliate organizations and health departments should be free to examine available evidence and local circumstances and, then, to decide whether to undertake screening programs. More care is needed in planning, executing, and critically evaluating these programs, but there is impressive and mounting evidence supporting the potential utility of the early discovery of diabetes.

Standardization of definition, classification, and reporting in diabetes-related epidemiologic studies

This working paper reviews some advantages and disadvantages of various alternative definitions and classification schemes. Certain of these alternatives were discussed by an international group of experts on the epidemiology of diabetes. It was recommended by the conferees that the following terms not be used as standard descriptors in epidemiologic reports: juvenile diabetes, juvenile-type diabetes, maturity-onset diabetes of youth (MODY), latent diabetes, subclinical diabetes, clinical diabetes, chemical diabetes, and J-type (Jamaica) diabetes. Alternative ways of describing these conditions were offered. Some, but not all, conferees favored abandonment or modification of the terms "secondary diabetes" and "pancreatic diabetes." Two alternate approaches are described in classification. One is designed to classify all types of cases in a single scheme. In this system each case is described by indices that include etiology and special etiologic concomitants, fatness, severity, type of treatment, and, if present, special or peculiar manifestations, and morbidity. This system makes it possible to classify all cases by mutually exclusive categories. A disadvantage of this scheme is that the number of combinations of classifying indices and subindices is great. Another approach is to classify cases by syndromes, using in each class a mixture of indices (e.g., etiology, severity, fatness, etc.). The conferees failed to reach a consensus in the specifics of this approach. There was considerable disagreement on how certain terms should be defined, whether they should be used, and on the degree of need for specific definitions. These designations included the terms "insulin-dependent," "idiopathic," "insulin-requiring," and "ketosis-prone." The conferees agreed that in either of the two approaches to classification, the prime indices should be those that can be ascertained by ordinary clinical methods. Much progress could be accomplished, even in the absence of international standardized definitions and classification systems, provided that authors keep in mind the need to describe the major characteristics of their cases and define the sense in which they use terms such as insulin-dependent, ketosis-prone, obese, etc.

Substantial differences in the diagnostic criteria used by diabetes experts

A survey of twenty diabetologists revealed that they employ diagnostic criteria differing quite substantially. In some populations, including the general population of the United States, these disparities would result in very major differences in the rates of "diabetes." Under certain common circumstances, some diabetologists would classify as normal more than half of the one- and two-hour values considered to be abnormal by other well-qualified diabetologists.

Library and information services for small hospitals

The quality of medical care is dependent on effective and expeditious information services for physicians and other health workers. Small hospitals have been at a particular disadvantage in this respect, mainly because unit costs of library services have been quite high when delivered on a small scale with traditional resources and methods. The importance of this problem is suggested by the fact that more than half of the US hospitals have less than 100 beds, and that library services have been primitive or nonexistent in most of these institutions. Certain recent developments will permit most of these smaller hospitals to provide creditable information services at modest cost.

Diabetes in American Indians and other native populations of the New World

This is a review of previous and more recent observations on the prevalence and manifestations of diabetes in aboriginal populations of the New World. Rates of diabetes have now been measured or estimated in more than eighty of these groups in the Americas, Greenland, Polynesia, Micronesia and Melanesia. Diabetes was probably uncommon in all these native populations prior to 1940. It is now rife in many of these groups, but still rare in many. Among certain of these populations, rates of diabetes in adults still differ more than tenfold. Among groups of diabetics there are probably significant intertribal differences in the susceptibility to certain manifestations and complications such as retinopathy and coronary disease. There appear to be peculiarities in the insulin secretion patterns of certain of these tribes.

The available evidence does not rule out the possibility that genetic factors play an important role in determining inter-tribal differences in prevalence and manifestations. But it is also clear that environmental factors exert powerful effects. Low rates of diabetes have been observed in Athapascan tribes and in some Shoshonean tribes. Diabetes was also rare prior to 1940 in Athapascan and Shoshonean Indians of Oklahoma. But diabetes has recently become common in these Oklahoma tribes. They were formerly lean and are now fat. The status of the many Oklahoma tribes is of particular interest because they represent seven of the eight major linguistic groups of North American Indians, having originated in very diverse parts of the Continent. Rates are now high in all Oklahoma tribes for which evidence is adequate to permit an estimate of prevalence. This includes fifteen tribes drawn from seven different linguistic groups. In seven additional Oklahoma tribes preliminary evidence, although less complete, suggests the probability that rates are also high.

Studies of the dramatic emergence of diabetes and its manifestations in these aboriginal groups has considerable potential for gaining a better understanding of the genetic and environmental factors which influence risk and pathophysiology of diabetes and its complications.

Sensitivity and specificity of five screening tests for diabetes in ten countries

The sensitivity and specificity of each of five screening tests were estimated in each of three to ten countries by testing subjects drawn from the general populations of adults over thirty-four years of age. This permitted comparisons among countries and among the different tests (fasting, postprandial, and postglucose urine tests, and fasting and postprandial blood glucose values).

Sensitivity and specificity of each test varied widely among populations. For example, the sensitivity of the twohour urine glucose ranged from 17 per cent in Nicaragua to 100 per cent in East Pakistan. Apparently specificity and sensitivity of such tests are influenced by many factors including both the circumstances under which the tests are performed and the characteristics of the population tested. It is, therefore, not possible to predict prevalence rates reliably by extrapolating from the results of screening tests. However, we believe the data for specific populations on the sensitivity and specificity of various tests will provide a rough guide in predicting the cost-effectiveness of alternative approaches to case detection in those particular countries. For instance, these results suggest that roughly 56 per cent of the occult diabetics in Costa Rica in this age group would be detected by a two-hour urine glucose, but only about 41 per cent of those in whom this test was positive would prove to have diabetes.

Even modest changes of criteria in defining either “diabetes” or Department of Medicine, University of Oklahoma School of Medicine, Oklahoma City, Oklahoma 73104.“abnormality” of the screening results produced marked changes in rates of sensitivity and specificity. With few exceptions, tests which were more sensitive were, comparably, less specific, and the reverse was also true. Rates of “diabetes” were markedly influenced by modest changes in diagnostic criteria.