Surgical sexism in Canada: structural bias in reimbursement of surgical care for women

BACKGROUND

It is well established that female physicians in Canada are reimbursed at lower rates than their male counterparts. To explore if a similar discrepancy exists in reimbursement for care provided to female and male patients, we addressed this question: Do Canadian provincial health insurers reimburse physicians at lower rates for surgical care provided to female patients than for similar care provided to male patients?

METHODS

Using a modified Delphi process, we generated a list of procedures performed on female patients, which we paired with equivalent procedures performed on male patients. We then collected data from provincial fee schedules for comparison.

RESULTS

In 8 out of 11 Canadian provinces and territories studied, we found that surgeons were reimbursed at significantly lower rates (28.1% [standard deviation 11.1%]) for procedures performed on female patients than for similar procedures performed on male patients.

CONCLUSION

The lower reimbursement of the surgical care of female patients than for similar care provided to male patients represents double discrimination against both female physicians and their female patients, as female providers predominate in obstetrics and gynecology. We hope our analysis will catalyze recognition and meaningful change to address this systematic inequity, which both disadvantages female physicians and threatens the quality of care for Canadian women.

Comparing Self-Reported Pain During Intercourse and Pain During a Standardized Gynecological Exam at 12- and 24-Month Postpartum

BACKGROUND

There is limited information about the physical indicators and biopsychosocial predictors of self-reported pain during intercourse and pain during a gynecological examination at 12- and 24-month following childbirth.

AIM

This longitudinal study aimed to (i) Compare the findings from gynecological exams at 12- and 24-month postpartum for women with minimal vs clinically significant pain during intercourse; (ii) Assess the biomedical and psychosocial correlates of self-reported pain during intercourse and the vestibular pain index (VPI) from the cotton-swab test at 12- and 24-month postpartum; (iii) Establish the relationship between self-reported pain during intercourse and the cotton-swab test.

METHODS

Women (N = 97 at 12 months postpartum and N = 44 at 24-month postpartum) recruited from a local women's hospital completed online surveys in their first trimester of pregnancy and at 12- and 24-month postpartum to assess pain during intercourse and biopsychosocial variables. Those with clinically significant (pain ≥4/10 on a visual analogue scale) were matched with those reporting minimal pain (pain <3/10) and underwent a gynecological exam including a cotton-swab test. Descriptive analyses, multiple regressions, and bivariate correlations were conducted to address each of the study aims, respectively.

MAIN OUTCOME MEASURES

(i) Findings from the gynecological examination (ii) Numerical rating scale for the VPI; (iii) Visual analogue scale of pain during intercourse.

RESULTS

The majority of women in both pain groups had normal physical findings in the gynecological exam. Greater sexual distress and pain catastrophizing at 12- and 24-month postpartum were significantly associated with greater pain during intercourse at each time-point, respectively. Greater pain catastrophizing at 12 months postpartum was significantly associated with greater pain during the cotton-swab test at that time-point. Lower relationship satisfaction at 12 months postpartum was associated with greater VPI ratings at 24 months postpartum. Pain during intercourse and the VPI were moderately and positively correlated.

CLINICAL IMPLICATIONS

Addressing psychosocial variables may interrupt the maintenance of postpartum pain. Following an initial assessment, self-reported pain intensity may be a suitable proxy for repeated examinations.

STRENGTHS & LIMITATIONS

This study is the first to describe the physical findings and psychosocial predictors of pain during intercourse and the VPI at 12- and 24-month postpartum. The homogenous and small sample may limit generalizability.

CONCLUSION

There were no observable physical indicators of clinically significant postpartum pain during intercourse. Psychosocial variables were linked to women's greater postpartum pain during intercourse and VPI ratings.

73 THE NEW CHRONIC DISEASE MANAGEMENT PROGRAMME FOR GENERAL PRACTITIONERS: MAKING THE CASE FOR ITS REVISION TO INCLUDE DEMENTIA

Background

A significant component of the new contract for general practitioners is the chronic disease management programme (CDMP for GPs). Although dementia can be framed as a chronic disease, it was not included in this programme. Its exclusion raises a number of questions including: Should dementia be framed as a chronic disease? Is it feasible to include dementia in a future revised CDMP for GPs? What are the likely benefits and potential risks?

Methods

This presentation focuses on two elements of a larger mixed-methods study, namely: (i) in-depth analysis of the CDMP for GPs, involving a review of the programme’s three main components to test the feasibility of extending it to incorporate dementia; and (ii) qualitative content analysis of data from semi-structured interviews with 12 stakeholders whose expertise is in dementia, chronic disease or both. Both elements were informed by a literature review.

Results

No consensus was found about whether dementia should be framed as a chronic disease. Results showed that it is feasible to extend the annual preventative programme of the CDMP for GPs to include additional modifiable dementia risk factors. While opportunistic case finding for identifying undiagnosed dementia cannot be recommended, a tool is available that would enable GPs identify people with dementia for enrolment on the structured treatment programme. Expected benefits from including dementia in the CDMP for GPs include integrated care pathways, better GP access and record-keeping and greater emphasis on primary and secondary prevention. Expected risks include excessive costs, caregiver burden, increased GP workload and sub-optimal care due to lack of specialist dementia training.

Conclusion

There is a compelling case to support dementia risk reduction in the CDMP for GPs. However, the programme’s current emphasis on self-management and rigidly planned visits could prove problematic for people with dementia and would need substantial revision.

Admission to long-stay residential care and mortality among people with and without dementia living at home but on the boundary of residential care: a competing risks survival analysis

BACKGROUND

Health policy in many countries is underpinned by a commitment to support dependent older people to remain in their own home for as long as possible and practicable. This study explores factors affecting both admission to long-stay residential care (LSRC) and mortality among people with and without dementia who are currently living at home with intensive formal care support.

METHODS

This is a cross-sectional study based on administrative data collected on 429 dependent older people in Ireland, 269 of whom were people with dementia. A cause-specific hazard model was used to investigate the hazard of admission to LSRC, while accounting for mortality as a competing risk and vice versa.

RESULTS

Admission to LSRC was higher for people with dementia relative to people without and for those receiving lower amounts of informal care. The hazard of mortality was significantly higher for older people aged 85+, whereas it was lower for individuals with a medium level of dependency relative to those with high levels of dependency. The hazard of mortality was also influenced by the amount of informal care provision.

CONCLUSION

People with dementia are more likely to be admitted to LSRC than people without. Care for people with dementia needs to be more specialised and personal, and intensity of provision should not be equated to the number of care hours on offer. Informal care provision may help to prevent admission to LSRC. Advanced age, physical dependency and informal care provision affect mortality, raising interesting issues in relation to resource allocation.

Clinical Conundrum: Neisseria meningitidis Septic Abortion

Septic shock after abortion is an important cause of global maternal mortality but is rarely encountered in developed countries. We describe a case of septic abortion with a novel associated pathogen: Neisseria meningitidis. A 30-year-old multiparous woman presented in septic shock after an incomplete spontaneous abortion. She received empiric antibiotics and vasopressors, underwent an urgent dilatation and curettage, and was admitted to the intensive care unit. Her blood cultures and endometrial tissue were positive for N. meningitidis. Antibiotics were adjusted based on culture, and the patient recovered. Septic shock requires prompt identification, antibiotic administration, and source control. Here, we identify an uncommon pathogen associated with septic abortion and highlight the importance of broad empiric and subsequent culture-guided antibiotic choice to ensure coverage.

Raisonnement clinique : Avortement septique à Neisseria meningitidis

Le choc septique post-avortement est une cause mondiale importante de mortalité maternelle, mais on l'observe rarement dans les pays développés. Nous décrivons ici un cas d'avortement septique associé à un nouvel agent pathogène : Neisseria meningitidis. Une femme multipare de 30 ans s'est trouvée en choc septique après un avortement spontané incomplet. Elle a reçu un traitement empirique par antibiotiques et vasopresseurs, a subi une dilatation-aspiration d'urgence et a été admise à l'unité de soins intensifs. L'hémoculture et l'analyse de tissus endométriaux se sont révélées positives à la bactérie N. meningitidis. L'antibiothérapie a été ajustée en fonction de la culture et la patiente s'est rétablie. Il importe de reconnaître le choc septique, d'administrer l'antibiothérapie et de neutraliser la source d'infection dans les plus brefs délais. Ici, nous décrivons un cas d'avortement septique associé à un agent pathogène inhabituel. Nous soulignons aussi l'importance d'utiliser une antibiothérapie empirique à large spectre suivie d'une antibiothérapie spécifique aux résultats de culture pour obtenir la meilleure couverture possible.

Few Versus Many-Body Physics of an Impurity Immersed in a Superfluid of Spin 1/2 Attractive Fermions

In this Letter we investigate the properties of an impurity immersed in a superfluid of strongly correlated spin 1/2 fermions and we calculate the beyond-mean-field corrections to the energy of a weakly interacting impurity. We show that these corrections are divergent and have to be regularized by properly accounting for three-body physics in the problem and that our approach naturally provides a unifying framework for Bose and Fermi polaron physics.

Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair

OBJECTIVE

To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS.

OPTIONS

Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies.

OUTCOMES

The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth.

EVIDENCE

Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.

Female genital cutting

OBJECTIVE

To strengthen the national framework for care of adolescents and women affected by female genital cutting (FGC) in Canada by providing health care professionals with: (1) information intended to strengthen their knowledge and understanding of the practice; (2) directions with regard to the legal issues related to the practice; (3) clinical guidelines for the management of obstetric and gynaecological care, including FGC related complications; and (4) guidance on the provision of culturally competent care to adolescents and women with FGC.

EVIDENCE

Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and keywords (e.g., female genital mutilation, clitoridectomy, infibulation). We also searched Social Science Abstracts, Sociological Abstracts, Gender Studies Database, and ProQuest Dissertations and Theses in 2010 and 2011. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Female genital cutting is internationally recognized as a harmful practice and a violation of girls' and women's rights to life, physical integrity, and health. (II-3) 2. The immediate and long-term health risks and complications of female genital cutting can be serious and life threatening. (II-3) 3. Female genital cutting continues to be practised in many countries, particularly in sub-Saharan Africa, Egypt, and Sudan. (II-3) 4. Global migration patterns have brought female genital cutting to Europe, Australia, New Zealand, and North America, including Canada. (II-3) 5. Performing or assisting in female genital cutting is a criminal offense in Canada. (III) 6. Reporting to appropriate child welfare protection services is mandatory when a child has recently been subjected to female genital cutting or is at risk of being subjected to the procedure. (III) 7. There is concern that female genital cutting continues to be perpetuated in receiving countries, mainly through the act of re-infibulation. (III) 8. There is a perception that the care of women with female genital cutting is not optimal in receiving countries. (III) 9. Female genital cutting is not considered an indication for Caesarean section. (III) Recommendations 1. Health care professionals must be careful not to stigmatize women who have undergone female genital cutting. (III-A) 2. Requests for re-infibulation should be declined. (III-B) 3. Health care professionals should strengthen their understanding and knowledge of female genital cutting and develop greater skills for the management of its complications and the provision of culturally competent care to adolescents and women who have undergone genital cutting. (III-A) 4. Health care professionals should use their knowledge and influence to educate and counsel families against having female genital cutting performed on their daughters and other family members. (III-A) 5. Health care professionals should advocate for the availability of and access to appropriate support and counselling services. (III-A) 6. Health care professionals should lend their voices to community-based initiatives seeking to promote the elimination of female genital cutting. (III-A) 7. Health care professionals should use interactions with patients as opportunities to educate women and their families about female genital cutting and other aspects of women's health and reproductive rights. (III-A) 8. Research into female genital cutting should be undertaken to explore women's perceptions and experiences of accessing sexual and reproductive health care in Canada. (III-A) The perspectives, knowledge, and clinical practice of health care professionals with respect to female genital cutting should also be studied. (III-A). 9. Information and guidance on female genital cutting should be integrated into the curricula for nursing students, medical students, residents, midwifery students, and students of other health care professions. (III-A) 10. Key practices in providing optimal care to women with female genital cutting include: a. determining how the woman refers to the practice of female genital cutting and using this terminology throughout care; (III-C) b. determining the female genital cutting status of the woman and clearly documenting this information in her medical file; (III-C) c. ensuring the availability of a well-trained, trusted, and neutral interpreter who can ensure confidentiality and who will not exert undue influence on the patient-physician interaction when providing care to a woman who faces language challenges; (III-C) d. ensuring the proper documentation of the woman's medical history in her file to minimize the need for repeated medical histories and/or examinations and to facilitate the sharing of information; (III-C) e. providing the woman with appropriate and well-timed information, including information about her reproductive system and her sexual and reproductive health; (III-C) f. ensuring the woman's privacy and confidentiality by limiting attendants in the room to those who are part of the health care team; (III-C) g. providing woman-centred care focused on ensuring that the woman's views and wishes are solicited and respected, including a discussion of why some requests cannot be granted for legal or ethical reasons; (III-C) h. helping the woman to understand and navigate the health system, including access to preventative care practices; (III-C) i. using prenatal visits to prepare the woman and her family for delivery; (III-C) j. when referring, ensuring that the services and/or practitioners who will be receiving the referral can provide culturally competent and sensitive care, paying special attention to concerns related to confidentiality and privacy. (III-C).

Measurement of thyroid stimulating immunoglobulins using a novel thyroid stimulating hormone receptor-guanine nucleotide-binding protein, (GNAS) fusion bioassay

Hyperthyroidism, defined by overproduction of thyroid hormones, has a 2-3% prevalence in the population. The most common form of hyperthyroidism is Graves' disease. A diagnostic biomarker for Graves' disease is the presence of immunoglobulins which bind to, and stimulate, the thyroid stimulating hormone receptor (TSHR), a G-protein coupled receptor (GPCR). We hypothesized that the ectopically expressed TSHR gene in a thyroid stimulating immunoglobulin (TSI) assay could be engineered to increase the accumulation of the GPCR pathway second messenger, cyclic AMP (cAMP), the molecule measured in the assay as a marker for pathway activation. An ectopically expressing TSHR-mutant guanine nucleotide-binding protein, (GNAS) Chinese hamster ovary (CHO) cell clone was constructed using standard molecular biology techniques. After incubation of the new clone with sera containing various levels of TSI, GPCR pathway activation was then quantified by measuring cAMP accumulation in the clone. The clone, together with a NaCl-free cell assay buffer containing 5% polyethylene glycol (PEG)6000, was tested against 56 Graves' patients, 27 toxic thyroid nodule patients and 119 normal patients. Using receiver operating characteristic analysis, when comparing normal with Graves' sera, the assay yielded a sensitivity of 93%, a specificity of 99% and an efficiency of 98%. Total complex precision (within-run, across runs and across days), presented as a percentage coefficient of variation, was found to be 7·8, 8·7 and 7·6% for low, medium and high TSI responding serum, respectively. We conclude that the performance of the new TSI assay provides sensitive detection of TSI, allowing for accurate, early detection of Graves' disease.

Using a birth cohort to study ageing: representativeness and response rates in the National Survey of Health and Development

Britain's oldest birth cohort study, the MRC National Survey of Health and Development (NSHD) provides data to explore life time influences on ageing. The latest data collection was undertaken between 2006 and 2011 when study members were aged 60-64 and consisted of postal and pre-assessment questionnaires to eligible study members, followed by invitation to attend one of six clinical research facilities (CRFs) across the UK for clinical assessments, and dietary diaries and activity monitors in the days following the CRF visit. The option of a home visit for clinical assessments was provided if the study member refused or was unable to attend the CRF. We examined response and attrition, here describing rates overall and for postal and clinical assessment modes of data collection, identifying socioeconomic and health-related predictors of response, and assessing the continued representativeness of the sample. In total, 2,661 (84 % of the target sample) responded. Lower educational attainment, lower childhood cognition and lifelong smoking independently predicted lower likelihood of both overall response and CRF cooperation. At 53 years, not owning one's home and not being married predicted lower likelihood of overall response whereas manual social class and obesity predicted lower likelihood of CRF cooperation. Providing for collection of biomedical data in the home and use of assessment instruments and modes to retain study members with lower education attainment, lower cognition and poorer health behaviours should be priorities for helping reduce attrition amongst vulnerable ageing study members.

Contemporary management and outcomes for infants born with oesophageal atresia

Background

Reports on the management and outcome of rare conditions, such as oesophageal atresia, are frequently limited to case series reporting single-centre experience over many years. The aim of this study was to identify all infants born with oesophageal atresia in the UK and Ireland to describe current clinical practice and outcomes.

Methods

This was a prospective multicentre cohort study of all infants born with oesophageal atresia and/or tracheo-oesophageal fistula in 2008–2009 in the UK and Ireland to record current clinical management and early outcomes.

Results

A total of 151 infants admitted to 28 paediatric surgical units were identified. Some aspects of perioperative management were universal, including oesophageal decompression, operative technique and the use of transanastomotic tubes. However, there were a number of areas where clinical practice varied considerably, including the routine use of perioperative chest drains, postoperative contrast studies and antireflux medication, with each of these being employed in 30–50 per cent of patients. There was a trend towards routine postoperative ventilation.

Conclusion

The prospective methodology used in this study can help identify practices that all surgeons employ and also those that few surgeons use. Areas of clinical equipoise can be recognized and avenues for further research identified.

Influenza A/H1N1v in pregnancy: an investigation of the characteristics and management of affected women and the relationship to pregnancy outcomes for mother and infant

BACKGROUND

In April 2009 a novel influenza A virus (AH1N1v) of swine origin (swine flu) emerged, spreading rapidly and achieving pandemic status in June 2009. Pregnant women were identified as being at high risk of severe influenza-related complications and as a priority group for vaccination against AH1N1v. Limited information was available about the maternal and fetal risks of AH1N1v infection or of antiviral drug or AH1N1v vaccine use in pregnancy.

OBJECTIVES

To assess rates of and risk factors for adverse outcomes following AH1N1v infection in pregnancy and to assess the adverse effects of the antiviral drugs and vaccines used in prevention and management.

METHODS

Prospective national cohort studies were conducted to identify pregnant women who were (1) suspected to be infected with AH1N1v or being treated with antiviral medication in primary care; (2) vaccinated against AH1N1v; and (3) admitted to hospital with confirmed AH1N1v. Characteristics of women with influenza-like illness (ILI) in primary care were compared with those of women without symptoms accepting or declining immunisation. Characteristics of women admitted to hospital with confirmed AH1N1v infection in pregnancy were compared with a historical cohort of over 1200 women giving birth in the UK who were uninfected with AH1N1v. Outcomes examined in hospitalised women included maternal death, admission to an intensive care unit, perinatal mortality and preterm birth. Risk factors for hospital and intensive care unit admission were examined in a full regression model.

RESULTS

The weekly incidence of ILI among pregnant women averaged 51/100,000 over the study period. Antiviral drugs were offered to 4.8% [95% confidence interval (CI) 4.0% to 5.9%] and vaccination to 64.8% (95% CI 64.7% to 68.9%) of registered pregnant women. Ninety pregnant women with ILI presenting in primary care were reported to the research team, 55 of whom were prescribed antiviral drugs and in 42 (76%) cases this was within 2 days of symptom onset. After comparison with 1329 uninfected pregnant women offered vaccination, pre-existing asthma was the only maternal factor identified as increasing risk of ILI presentation [adjusted odds ratio (OR) 2.0, 95% CI 1.0 to 3.9]. Maternal obesity and smoking during pregnancy were also associated with hospital admission with AH1N1v infection. Overall, 241 pregnant women were admitted to hospital with laboratory-confirmed AH1N1v infection. Eighty-three per cent of these women were treated with antiviral agents, but only 6% received antiviral treatment before hospital admission. Treatment within 2 days of symptom onset was associated with an 84% reduction in the odds of admission to an intensive therapy unit (OR 0.16, 95% CI 0.08 to 0.34). Women admitted to hospital with AH1N1v infection were more likely to deliver preterm; a three times increased risk was suggested compared with an uninfected population cohort (OR 3.1, 95% CI 2.1 to 4.5).

CONCLUSIONS

Earlier treatment with antiviral agents is associated with improved outcomes for pregnant women and further actions are needed in future pandemics to ensure that antiviral agents and vaccines are provided promptly to pregnant women, particularly in the primary care setting. Further research is needed on longer-term outcomes for infants exposed to AH1N1v influenza, antiviral drugs or vaccines during pregnancy.

Critical illness with AH1N1v influenza in pregnancy: a comparison of two population-based cohorts

OBJECTIVE

To compare admissions to intensive care units (ICUs) with confirmed AH1N1v influenza in pregnancy in Australia, New Zealand and the UK.

DESIGN

National cohort studies.

SETTING

ICUs in Australia, New Zealand and the UK.

POPULATION

Fifty-nine women admitted to ICUs in Australia and New Zealand in June-August 2009, and 57 women admitted to ICUs in the UK in September 2009-January 2010.

METHODS

Comparison of cohort data.

MAIN OUTCOME MEASURES

Incidence of ICU admission, comparison of characteristics and outcomes.

RESULTS

There was a significantly higher ICU admission risk in Australia and New Zealand than in the UK (risk ratio 2.59, 95% CI 1.75-3.85). Indigenous women from Australia and women with Maori/Pacific Island backgrounds from New Zealand had the highest admission risk (29.7 admissions per 10 000 maternities, 95% CI 17.9-46.3). Women admitted in Australia and New Zealand were significantly more likely to have a pre-existing medical condition (51% versus 21%, P = 0.001), but were less likely to receive antiviral treatment (80% versus 93%, P = 0.038) than women admitted in the UK. Women admitted in the UK had a longer length of hospital stay (median 21 days, range 3-128 days) than women admitted in Australia and New Zealand (median 12 days, range 3-66 days), but there were no other differences in maternal or pregnancy outcomes.

CONCLUSIONS

The difference in admission risk may reflect a second phase effect from successful clinical and public health interventions, as well as differences in population characteristics between the countries. The overall severity of the AH1N1v influenza infection in pregnancy is evident, and emphasises the importance of an ongoing immunisation programme in pregnant women in both northern and southern hemispheres.

Ethnic inequalities in access to and outcomes of healthcare: analysis of the Health Survey for England

BACKGROUND

Ethnic/racial inequalities in access to and quality of healthcare have been repeatedly documented in the USA. Although there is some evidence of inequalities in England, research is not so extensive. Ethnic inequalities in use of primary and secondary health services, and in outcomes of care, were examined in England.

METHODS

Four waves of the Health Survey for England were analysed, a representative population survey with ethnic minority oversamples. Outcome measures included use of primary and secondary healthcare services and clinical outcomes of care (controlled, uncontrolled and undiagnosed) for three conditions - hypertension, raised cholesterol and diabetes.

RESULTS

Ethnic minority respondents were not less likely to use GP services. For example, the adjusted odds ratios for Indian, Pakistani and Bangladeshi versus white respondents were 1.29 (95% confidence intervals 1.07 to 1.54), 1.32 (1.10 to 1.58) and 1.35 (1.10 to 1.65) respectively. Similarly, there were no ethnic inequalities for the clinical outcomes of care for hypertension and raised cholesterol, and, on the whole, no inequalities in outcomes of care for diabetes. There were ethnic inequalities in access to hospital services, and marked inequalities in use of dental care.

CONCLUSION

Ethnic inequalities in access to healthcare and the outcomes of care for three conditions (hypertension, raised cholesterol and diabetes), for which treatment is largely provided in primary care, appear to be minimal in England. Although inequalities may exist for other conditions and other healthcare settings, particularly internationally, the implication is that ethnic inequalities in healthcare are minimal within NHS primary care.

Identification of functional transport in non lactating breast epithelium and its relationship to parity and menstrual cycle

Abstract #4084

Background: The electrophysiological properties of breast epithelia have not been extensively studied in non-lactating women. Furthermore, it is known that parity is protective against breast cancer, but it is unknown how parity may influence the functional characteristics of breast epithelia and whether there is a carry over effect after childbirth.&#x2028; Patients and Methods: With IRB and patient consent, electrical contact with ductal epithelium was established non-invasively, using a specially designed nipple sensor in 15 normal women under the age of 40 with no risk factors for breast cancer. The transepithelial potential (TEP) and resistance of the skin were abolished with sonopheresis. TEP was measured across the breast epithelium using an isolated millivoltmeter. In a separate study isolated mammary epithelial cells were obtained from 14 women undergoing surgery to identify the origins of transepithelial potential in non-lactating epithelia. Cultures were established in media permissive for epithelial cells, which were immunomagnetically purified and mounted on porous substrates. Ion transport was measured in an Ussing chamber coupled to a voltage clamp apparatus. Data were analyzed using t-test, Mann-Whitney test, or ANOVA as appropriate.&#x2028; Results: Nulliparous women (n=8) had an open circuit potential of -56 ± 2 mV (mean ± SEM), -55 ± 1 mV, -56 ± 2 mV and -57 ± 2 mV during weeks 1-4 for 64 observations weekly through 2 complete menstrual cycles. Parous women (n=7) had open circuit potentials which were hyperpolarized compared to nulliparous women with values of -64 ± 1 mV (p &lt; 0.001), -65 ± 1 mV (p &lt; 0.001), -60 ± 2 mV (p n.s.) and -63 ± 2 mV (p&lt;0.005) during weeks 1-4 for 56 observations weekly through 2 menstrual cycles. Therefore the transepithelial potential was 6-10 mV hyperpolarized in parous women compared to nulliparous women except in the 3rd week of menstrual cycle. Primary cultures of human mammary epithelial cells, which thrived in culture and matured successfully into competent (&gt; 200 Ω.cm2) monolayers (50%), upregulated transepithelial ion movement in response to adrenergic stimulus (10uM norepinephrine). These currents were sensitive to pharmacologic inhibitors of ENaC (electrogenic sodium transport), NKCC (Na,K,2Cl) and Na/K ATPase. These findings suggest electrogenic sodium and chloride transport are responsible for the TEP observed in vivo. Post partum modulation of the activity of one of these functioning elements identified in non-cancerous monolayers may be responsible for the observed differences in TEP observed in this study.&#x2028; Discussion: Parity appears to make the epithelium functionally competent so that it maintains a higher transepithelial potential, and is “primed for lactation”. Depolarization of the epithelium throughout cycle (as in the nulliparous group) may make it more susceptible to proliferative signals. Epithelial depolarization may represent a biomarker of breast cancer risk, the ionic basis of which remains to be elucidated.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4084.

Sub-epithelial impedance: a new non-invasive method to measure mammographic density

Abstract #4075

Background: Breast density is possibly the strongest risk factor for breast cancer after genetic predisposition. Estimation of mammographic density can be highly subjective. More accurate volumetric approaches to measure density using mammography are under development, but require x-ray exposure. Dense breast stroma has a lower electrical resistance, which becomes increased as the stroma is replaced with fat. We have previously reported that the impedance of breast stroma correlates with age, obesity and inversely with position in menstrual cycle. It is unknown whether mammographic density also correlates with stromal impedance. When a high frequency sine wave is used to interrogate the breast the impedance of the overlying skin and the breast epithelium are significantly reduced with most of the remaining impedance being due to the stromal tissue and is defined as the sub-epithelial impedance (Zsub).&#x2028; Patients and Methods: With IRB and patient consent, electrical contact with ductal epithelium was established non-invasively, using a specially designed nipple sensor in 288 women. Measurements were made between the nipple sensor and skin surface electrodes placed in each of 4 quadrants of the breast. Zsub was measured at 60 KHz using a frequency response analyzer, and sine-wave correlation technique. Data were analyzed using a t-test, Mann-Whitney test, ANOVA, Pearson Moment Correlation, and stepwise regression as appropriate. In a subset of 112 women, in whom mammograms were available, a blinded review was performed to estimate the percent density averaged for two views of each breast.&#x2028; Results: Zsub correlated with age of the patients (n = 288), (0.58 Correlation Coefficient (CC), p &lt; 0.0001). Zsub was elevated in women who underwent a biopsy demonstrating breast cancer (n = 52) or proliferative breast disease (n = 27) with values of 211 ± 19Ω (median ± SEM), and 216 ± 18Ω respectively, compared with women with benign biopsies (n = 75) and values of 131 ± 15Ω (p &lt; 0.01). In a subset of patients (n=112) Zsub was inversely correlated with mammographic density (-0.68 CC, p &lt; 0.0001). Body mass index (BMI) increased with age (0.20 CC, p &lt; 0.05), Zsub (0.48 CC, p &lt; 0.00001) and inversely with mammographic density (-0.51 CC, p &lt; 0.0001). Using stepwise regression, mammographic density was predicted by a linear combination of age, BMI and Zsub with a coefficient of 150.22 ± 11.98 (SE), Age -0.64 ± 0.20 (p &lt; 0.002), BMI -1.43 ± 0.42 (p &lt; 0.001) and Zsub -0.21 ± 0.04 (p &lt; 0.001).&#x2028; Discussion: Mammographic breast density decreases with increasing age and BMI because of replacement of stromal tissue with fat, which likely also affects the sub-epithelial electrical impedance of the breast. Breast density can be estimated non-invasively and objectively using measurements of Zsub. Increased impedance of the breast parenchyma may represent a novel biomarker of breast cancer risk associated with mammographic breast density.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4075.

Indoor air pollutants: limited-resource households and child care facilities

This paper reports on a study of indoor air quality in homes and child care facilities in non-metropolitan counties of New York State. Specific pollutants examined were lead, radon, carbon monoxide, asbestos, and mold. Some homes had high levels of pollutants, and certain pollutants were significantly and negatively correlated with household income. High levels of pollutants also were observed in many child care facilities, which raises questions about constant exposure of children to pollutants. Recommendations are made for lowering pollutant levels in low-income households and child care facilities.

In vivo high-resolution video-rate spectral-domain optical coherence tomography of the human retina and optic nerve

An ultra-high-speed spectral-domain optical coherence tomography system (SD-OCT) was developed for imaging the human retina and optic nerve in vivo at a sustained depth profile (A-line) acquisition speed of 29 kHz. The axial resolution was 6 microm in tissue and the system had shot-noise-limited performance with a maximum sensitivity of 98.4 dB. 3-dimensional data sets were collected in 11 and 13 seconds for the macula and optic nerve head respectively and are presented to demonstrate the potential clinical applications of SD-OCT in ophthalmology. Additionally, a 3-D volume of the optic nerve head was constructed from the acquired data and the retinal vascular network was visualized.

The GP perspective: problems experienced in providing diabetes care in UK general practice

AIMS

To describe the problems and barriers perceived by general practitioners (GPs) whilst providing diabetes care in primary care in England and Wales and to identify those health authorities (HAs) in which primary care reported the most and least difficulty.

DESIGN

Descriptive postal survey using a self-administered questionnaire.

SUBJECTS

One thousand eight hundred and seventy-three randomly sampled GP practices (one in five practices).

RESULTS

One thousand three hundred and twenty (70%) responded. Getting patients to alter their lifestyles was perceived as causing the most difficulty in managing individual patients, followed by lack of time, patients' nonattendance, noncompliance with medical regimens and poor communication with secondary care. The greatest barriers to practices providing desirable care were lack of time/under-funding and keeping up to date in the area of diabetes, followed by lack of space, inadequate chiropody, dietetics, ophthalmology and access to secondary care. There are important differences between HAs in the difficulties experienced by primary care teams and we have ranked the HAs accordingly.

CONCLUSION

The study has identified what problems need tackling in order to assist primary care to deliver good quality diabetes care, and has highlighted HAs where primary care needs further help, and HAs where examples of good practice may be found and useful lessons learnt. This should form the basis of a needs-based research and development programme for diabetes in primary care.

A survey of diabetes care in general practice in Northern Ireland

We aimed to describe some key features of diabetes care carried out in primary care settings in Northern Ireland using a descriptive postal questionnaire survey sent to every general practice in Northern Ireland. 252 (70%) of practices responded. Of these 92% of practices have active registers of people with diabetes, identifying 1.9% of their population as having diabetes and 85% of practices use these registers for call/recall visits. Seventy five per cent of practices held diabetes clinics run by the general practitioner and nurse (63%) or a nurse alone (32%). Only 47% of practices felt they received adequate support from the acute diabetes team; with 29% meeting with them this team regularly and only 19% having a shared care protocol. Overall practices provided most of the routine care for 60% of their diabetic patients. The majority of GPs and practice nurses had received some diabetes education in the previous year. There has been a considerable change in the delivery of routine diabetes care in Northern Ireland. A large proportion of diabetes care now takes place in the community, much of it delivered by practice nurses. The organisational infrastructure necessary for the delivery of care is in place. Many practices have special interest in diabetes but the survey highlights a need for better communication and cooperation with secondary care. General practitioners recognise their educational needs in diabetes. They should also be aware of their practice nurses' needs, which should be addressed. There should be initiatives to improve the primary-secondary care interface in Northern Ireland.

A clinical informaticist to support primary care decision making

OBJECTIVES

To develop and evaluate an information service in which a "clinical informaticist" (a GP with training in evidence-based medicine) provided evidence-based answers to questions posed by GPs and nurse practitioners.

DESIGN

Descriptive pilot study with systematic recording of the process involved in searching for and critically appraising literature. Evaluation by questionnaire and semi-structured interview.

SETTING

General practice.

PARTICIPANTS

34 clinicians from two London primary care groups (Fulham and Hammersmith).

MAIN OUTCOME MEASURES

Number and origin of questions; process and time involved in producing summaries; satisfaction with the service.

RESULTS

All 100 clinicians in two primary care groups were approached. Thirty four agreed to participate, of whom 22 asked 60 questions over 10 months. Participants were highly satisfied with the summaries they received. For one third of questions the clinicians stated they would change practice in the index patient, and for 55% the participants stated they would change practice in other patients. Answering questions thoroughly was time consuming (median 130 minutes). The median turnaround time was 9 days; 82% of questions were answered within the timeframe specified by the questioner. Without the informaticist, one third of questions would not have been pursued.

CONCLUSION

The clinical informaticist service increased access to evidence for busy clinicians. Satisfaction was high among users and clinicians stated that changes in practice would occur. However, uptake of the service was lower than expected (22% of those offered the service). Further research is needed into how this method of increasing access to evidence compares with other strategies, and whether it results in improved health outcomes for patients.