Household donations of time and money in response to a health shock

Donations play a critical role in supporting the provision of public goods, yet how donating behaviour changes in response to health shocks is poorly understood. We investigate how the household's joint decision to donate time (volunteer) and money changes following a health shock. Using data from the United States Panel Study of Income Dynamics, and a within-household design that captures the dynamics of a post-health shock response, we find no overall change in the probability of households donating money but an overall reduction in the probability of donating time following a health shock. This is driven by a significant shift from donating both money and time to donating only money after a health shock. The shift away from donating time occurs for both the individual who experienced the health shock and their spouse, though the reduction is greater for the spouse. We examine the role of labour market responses to health shocks in explaining donating behaviour and find that consistent with the added worker effect, spouses of those who experience a health shock increase their work hours, constraining their time available for volunteering.

Long-term health effects of a school construction program

Non-communicable diseases (NCDs) disproportionately affect people in low- and middle-income countries (LMICs), yet context-specific evidence on policies that impact NCD risk factors is lacking. We estimate the impact of a massive Indonesian primary school expansion program in the 1970s on NCD risk factors in later life using data from two surveys with very large sample sizes. We find that in non-Java regions of Indonesia, the program led to significant increases in the likelihood of overweight and high waist circumference among women, but not among men. The increase for women can be partly explained by increased consumption of high-calorie packaged and take-away meals. We find no meaningful impacts on high blood pressure for either sex. Despite the increase in body weight, the program had a negligible impact on diabetes and cardiovascular disease diagnosis. It led to an improvement in women's self-reported health outcomes in their early-40s, but these benefits largely disappeared once they reached their mid-40s.

Exploring the impacts of a fresh produce market program: a realist economic evaluation

OBJECTIVE

To determine the contexts under which a fresh food market program is cost-effective in improving dignified access to nutritious food for food-insecure individuals.

METHODS

A realist economic evaluation was employed. Purported cost related theories about how the program may function, known as context-mechanism-outcome configurations were developed. In-depth interviews with key stakeholders (program developers, funder, local food relief agencies, volunteers) involved in the program (n=19) as well Photovoice with focus groups with market attendees (n=8) were conducted and coded for contexts, mechanisms and outcomes. A cost-effectiveness analysis of the program was calculated whereby the cost inputs associated with operating the program were compared to the quantity and value of produce distributed. Alternative cost scenarios were evaluated in a sensitivity analysis. The cost-effectiveness analysis was used together with qualitative data to refine theory.

RESULTS

Food insecure individuals attending a partnership fresh food market with a small fee, experienced improved, yet infrequent access to nutritious food through community connections and support a more dignified, viable access to fresh nutritious food.

CONCLUSIONS

Food relief should consider alternative models.

IMPLICATIONS FOR PUBLIC HEALTH

More dignified food relief programs that support local connections may be part of the solution to addressing food insecurity.

Social acceptability of standard and behavioral economic inspired policies designed to reduce and prevent obesity

The obesity epidemic is a significant public policy issue facing the international community, resulting in substantial costs to individuals and society. Various policies have been suggested to reduce and prevent obesity, including those informed by standard economics (a key feature of which is the assumption that individuals are rational) and behavioral economics (which identifies and harness deviations from rationality). It is not known which policy interventions taxpayers find acceptable and would prefer to fund via taxation. We provide evidence from a discrete choice experiment on an Australian sample of 996 individuals to investigate social acceptability of eight policies: mass media campaign; traffic light nutritional labeling; taxing sugar sweetened beverages; prepaid cards to purchase healthy food; financial incentives to exercise; improved built environment for physical activity; bans on advertising unhealthy food and drink to children; and improved nutritional quality of food sold in public institutions. Latent class analysis revealed three classes differing in preferences and key respondent characteristics including capacity to benefit. Social acceptability of the eight policies at realistic levels of tax increases was explored using post-estimation analysis. Overall, 78% of the sample were predicted to choose a new policy, varying from 99% in those most likely to benefit from obesity interventions to 19% of those least likely to benefit. A policy informed by standard economics, traffic light labeling was the most popular policy, followed by policies involving regulation: bans on junk food advertising to children and improvement of food quality in public institutions. The least popular policies were behaviorally informed: prepaid cards for the purchase of only healthy foods, and financial incentives to exercise.

Whose mental health declines during economic downturns?

Prior research shows that economic downturns are associated with increases in mental illness. However, we know little about whose mental health is most negatively affected. Is it the young or old, men or women, employed or non-employed, rich or poor? Using an 18-year panel dataset of Australians, we contribute to this understanding by estimating the impact of changes in unemployment on mental health, separately by population subgroups. Our mental health measure captures psychological distress and emotional difficulties, which are often missed by infrequent event indicators such as suicides. We find that young women suffer most during economic downturns. Men and women of older ages are not significantly affected. The effects for young women are driven by those in insecure employment, and those from low socioeconomic backgrounds. Our results suggest that public health programs should emphasize the mental health of young women during economic downturns.

P–394 Intralipid infusion at time of embryo transfer in women with history of recurrent implantation failure: a systematic review and meta-analysis

Study question

What is the effectiveness of IV Intralipid (IVI) in improving pregnancy rates in women undergoing IVF with history of Recurrent implantation failure (RIF) to improve reproductive outcomes.

Summary answer

The evidence to support the use of IVI at the time of embryo transfer in women with RIF is limited. More RCTs are needed. What is known already: Optimising the implantation process following embryo transfer remains a clinical challenge with 10% of couples undergoing IVF affected by (RIF). Immunotherapy could help to optimise endometrial receptivity and increase the chances for successful conception in women with history of RIF. Intra-venous Intralipid (IVI), a fat-based emulsion of soybean oil, glycerine, phospholipids, egg, and polyunsaturated fatty acids, has been evaluated in several trials as a potential intervention to downregulate the uNK cells and macrophages as well as inhibit the pro-inflammatory mediators including T1 helper cells. Evidence synthesis is needed to evaluate the effectiveness of this intervention.

Study design, size, duration

We performed this systematic review using a prospectively registered protocol (CRD42019148517) and reported in accordance with the PRISMA guidelines. Participants/materials, setting, methods: We searched MEDLINE, EMBASE and CENTRAL for any randomised trials evaluating the use of IVI at the time of embryo transfer in women undergoing assisted conception until September 2020. We extracted data in duplicate and assessed risk of bias using the Cochrane Risk of Bias tools. We meta-analysed data using a random effect model and reported on dichotomous outcomes using risk ratio (RR) and 95% confidence interval (CI).

Main results and the role of chance

We included five randomised trials reporting on 843 women with an overall moderate risk of bias. All trials used 20% IVI solution at the time of embryo transfer compared to normal saline infusion or no intervention (routine care). The IVI group had a higher chance of clinical pregnancy (172 vs 119, RR 1.55, 95%CI 1.16–2.07, I2 44.2%) and live birth (132 vs 73, RR 1.83, 95%CI 1.42–2.35, I2 0%) post treatment compared to no intervention.

Limitations, reasons for caution

Our findings are limited by the small sample size and the variations in treatment protocols and population characteristics.

Wider implications of the findings: Our meta-analysis offers an overview on the value of IVI to help women affected by RIF. Given the limitations and the quality of included trials, adopting the use of IVI a-la-carte to couples undergoing IVF remains immature. IVI should not be offered until larger RCTs demonstrate a persistent benefit.

Trial registration number

CRD42019148517

Association between density of gaming venues in a geographical area and prevalence of insolvency: longitudinal evidence from Australia

BACKGROUND AND AIMS

Problem gambling can lead to a myriad of harmful consequences, including unmanageable amounts of debt and serious financial problems. The aim of this study was to examine whether changes in the number of electronic gaming machine (EGM) venues within a local area (due to venue openings and closings) are associated with changes in the rates of serious financial problems.

DESIGN

Area-level longitudinal multivariate regressions controlling for possible confounders (fixed and time-varying local area characteristics).

SETTING

Australia's three largest states (New South Wales, Victoria, Queensland), during the period 2011-18.

PARTICIPANTS

A total of 225 local areas (Statistical Area 3 level) within the three states.

MEASUREMENTS

Serious financial problems were measured by administrative data on total number of personal insolvencies (bankruptcies, debt agreements and insolvency agreements) in each local area per annum. The number of EGM venues in each local area was the regressor of primary interest. Area-level covariates included the number of non-gaming pubs and clubs, unemployment rate, population count, local area dummies, local area linear time trends and a separate set of state dummies for each year.

FINDINGS

A one-venue decrease over time within a local area decreased the number of personal insolvencies by 1.8 per year [95% confidence interval (CI) = 0.4-3.2]. The result is robust to alternative specifications, including allowing for geographical spillovers (β = 2.2, 95% CI = 0.7-3.7), temporal lagged effects (β = 1.6, 95% CI = 0.6-2.8) and the spatial variability of venues within areas (β = 2.7, 95% CI = 0.9-4.5).

CONCLUSIONS

There is a positive association between the number of gaming venues in a local geographic area and the number of personal insolvencies in that area. Reducing the number or accessibility of gaming venues could help to reduce financial harms associated with problem gambling.

Proxy reporting of health-related quality of life for people with dementia: a psychometric solution

Background

The growing move towards personalised health and social care systems means that every effort needs to be made to generate patient-reported outcome data. However, the deteriorating nature of dementia can make it difficult for people with dementia to complete self-reported questionnaires and it is often necessary to rely on a family member (proxy) to report on their behalf. There is little evidence to guide how the difference between self- and proxy-reports of health reported quality of life (HRQL) in dementia can be interpreted.

Methods

We recruited people with dementia and their family carers from 78 memory Assessment Services in the UK. We used Rasch measurement methods to investigate whether a HRQL questionnaire known as DEMQOL (self-reported by the person with dementia) and DEMQOL-Proxy (proxy-reported by a family carer) can be placed on the same continuum and whether a revised scoring algorithm, based on this equated model, can be developed that takes account of the relationship between self- and proxy-reports.

Results

In a sample of 1434 patients and 1030 carers, our findings supported equating DEMQOL/DEMQOL-Proxy (overall fit to the model; no mis-fitting items) after addressing specific issues (eight disordered items requiring re-scoring, four pairs locally dependent items, and five items showing DIF). Cross walk tables have been produced.

Conclusions

We have established for the first time that DEMQOL and DEMQOL-Proxy can be placed on the same continuum and that patients and carer proxies are reporting on the same construct when they complete these questionnaires. Where possible both DEMQOL and DEMQOL-Proxy should still be administered together, using the improved scoring algorithm reported here. Where only DEMQOL-Proxy is available, the cross walk tables provide an estimate of DEMQOL for a particular person from their DEMQOL-Proxy score.

Can Memory Assessment Services (MAS) in England be categorized? A national survey

Background

The effectiveness and efficiency of memory assessment services (MASs) is unknown. Our aim was to determine if a typology can be constructed, based on shared structural and process characteristics, as a basis for a non-randomized evaluation of their effectiveness and cost-effectiveness.

Methods

Survey of random sample of 73 MASs in 2015; comparison of characteristics and investigation of inter-correlation.

Results

It was not possible to group characteristics to form the basis of a typology of MASs. However, there was considerable variation in staff numbers (20-fold), new patients per whole-time equivalent (WTE) staff (20-fold), skill mix and the nurse:doctor ratio (1-10). The operational performance also varied: first appointments (50-120 minutes); time for first follow-up (2-12 weeks); frequency of follow-up in first year (1-5). These differences were not associated with the number of new patients per WTE staff or the accreditation status of the MAS. Post diagnosis, all MASs provided pharmacological treatment but the availability of non-pharmacological support varied, with half providing none or only one intervention while others providing four or more.

Conclusions

In the absence of any clear typology, evaluation of MASs will need to focus on the impact of individual structural and process characteristics on outcomes.

Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review

Background

Care bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice. However, there is variation in the design and implementation of care bundles, which may impact on the fidelity of delivery and subsequently their clinical effectiveness.

Methods

A scoping review was carried out using the Arksey and O’Malley framework to identify the literature reporting on the design, implementation and evaluation of care bundles. The Embase, CINAHL, Cochrane and Ovid MEDLINE databases were searched for manuscripts published between 2001 and November 2017; hand-searching of references and citations was also undertaken. Data were initially assessed using a quality assessment tool, the Downs and Black checklist, prior to further analysis and narrative synthesis. Implementation strategies were classified using the Expert Recommendations for Implementing Change (ERIC) criteria.

Results

Twenty-eight thousand six hundred ninety-two publications were screened and 348 articles retrieved in full text. Ninety-nine peer-reviewed quantitative publications were included for data extraction. These consisted of one randomised crossover trial, one randomised cluster trial, one case-control study, 20 prospective cohort studies and 76 non-parallel cohort studies. Twenty-three percent of studies were classified as poor based on Downs and Black checklist, and reporting of implementation strategies lacked structure.

Negative associations were found between the number of elements in a bundle and compliance (Spearman’s rho = − 0.47, non-parallel cohort and − 0.65, prospective cohort studies), and between the complexity of elements and compliance (p < 0.001, chi-squared = 23.05). Implementation strategies associated with improved compliance included evaluative and iterative approaches, development of stakeholder relationships and education and training strategies.

Conclusion

Care bundles with a small number of simple elements have better compliance rates. Standardised reporting of implementation strategies may help to implement care bundles into clinical practice with high fidelity.

Trial Registration

This review was registered on the PROSPERO database: CRD 42015029963 in December 2015.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0894-2) contains supplementary material, which is available to authorized users.

TBX18 overexpression enhances pacemaker function in a rat subsidiary atrial pacemaker model of sick sinus syndrome

KEY POINTS

The sinoatrial node (SAN) is the primary pacemaker of the heart. SAN dysfunction, or 'sick sinus syndrome', can cause excessively slow heart rates and pauses, leading to exercise limitation and syncope, currently treated by implantation of an electronic pacemaker. 'Biopacemaking' utilises gene therapy to restore pacemaker activity by manipulating gene expression. Overexpressing the HCN pacemaker ion channel has been widely used with limited success. We utilised bradycardic rat subsidiary atrial pacemaker tissue to evaluate alternative gene targets: the Na+ /Ca2+ exchanger NCX1, and the transcription factors TBX3 and TBX18 known to be involved in SAN embryonic development. TBX18 overexpression restored normal SAN function, as assessed by increased rate, improved heart rate stability and restoration of isoprenaline response. TBX3 and NCX1 were not effective in accelerating the rate of subsidiary atrial pacemaker tissue. Gene therapy targeting TBX18 could therefore have the potential to restore pacemaker function in human sick sinus syndrome obviating electronic pacemakers.

ABSTRACT

The sinoatrial node (SAN) is the primary pacemaker of the heart. Disease of the SAN, sick sinus syndrome, causes heart rate instability in the form of bradycardia and pauses, leading to exercise limitation and syncope. Biopacemaking aims to restore pacemaker activity by manipulating gene expression, and approaches utilising HCN channel overexpression have been widely used. We evaluated alternative gene targets for biopacemaking to restore normal SAN pacemaker physiology within bradycardic subsidiary atrial pacemaker (SAP) tissue, using the Na+ /Ca2+ exchanger NCX1, and the transcription factors TBX3 and TBX18. TBX18 expression in SAP tissue restored normal SAN function, as assessed by increased rate (SAN 267.5 ± 13.6 bpm, SAP 144.1 ± 8.6 bpm, SAP-TBX18 214.4 ± 14.4 bpm; P < 0.001), improved heart rate stability (standard deviation of RR intervals fell from 39.3 ± 7.2 ms to 6.9 ± 0.8 ms, P < 0.01; root mean square of successive differences of RR intervals fell from 41.7 ± 8.2 ms to 6.1 ± 1.2 ms, P < 0.01; standard deviation of points perpendicular to the line of identity of Poincaré plots (SD1) fell from 29.5 ± 5.8 ms to 7.9 ± 2.0 ms, P < 0.05) and restoration of isoprenaline response (increases in rates of SAN 65.5 ± 1.3%, SAP 28.4 ± 3.4% and SAP-TBX18 103.3 ± 10.2%; P < 0.001). These changes were driven by a TBX18-induced switch in the dominant HCN isoform in SAP tissue, with a significant upregulation of HCN2 (from 1.01 × 10-5  ± 2.2 × 10-6 to 2.8 × 10-5  ± 4.3 × 10-6 arbitrary units, P < 0.001). Biophysically detailed computer modelling incorporating isoform-specific HCN channel electrophysiology confirmed that the measured changes in HCN abundance could account for the observed changes in beating rates. TBX3 and NCX1 were not effective in accelerating the rate of SAP tissue.

The effect of school sports facilities on physical activity, health and socioeconomic status in adulthood

This paper focuses on the long-term impacts of attending a high school with inadequate sports facilities. We use prospective data from the British National Child Development Study, a continuing panel of a cohort of 17,634 children born in Great Britain during a single week of March 1958. Our empirical approach exploits the educational system they were exposed to: children were sorted by educational ability at age 11, but conditional on educational ability, attended their closest school. This produces quasi-random variation in the quality of the school sports facilities across respondents. We use this variation between cohort members residing within the same local authority area, and focus on outcome measures of physical activity, health, health-related lifestyle activities, and socioeconomic status, collected at ages between 33 and 50 years. We control for any potential links between the inadequacy of sports facilities and inadequacy of other facility types, and test that allocation to school type is random with respect to pre-high school observables. We find that attending a school with inadequate sports facilities led to a statistically significant, modest decrease in the likelihood of physical activity participation during adulthood. In contrast, we find no evidence that inadequate sports facilities worsened adulthood measures of physical and mental health, lifestyle or socioeconomic status.

The health care costs of childhood obesity in Australia: An instrumental variables approach

The effect of childhood obesity on medical costs incurred by the Australian Government is estimated using five waves of panel data from the Longitudinal Study of Australian Children, which is linked to public health insurance administrative records from Medicare Australia. Instrumental variables estimators are used to address concerns about measurement error and selection bias. The additional annual medical costs due to overweight and obesity among 6 to 13 year olds is about $43 million (in 2015 AUD). This is driven by a higher utilisation of general practitioner and specialist doctors. The results suggest that the economic consequences of childhood obesity are much larger than previously estimated.

For richer, for poorer: the relationship between adolescent obesity and future household economic prosperity

Adolescent obesity not only has serious long-term health implications, but also the potential to lead to a socioeconomic trajectory of lower earnings and household income. However, the magnitude and mechanisms of such outcomes across the life course are poorly understood. Using birth cohort data from the British National Child Development Study (1958 to 2008), we examined the relationship between adolescent obesity (at age 16) and future household income, employment, wages, marriage and spousal earnings when individuals were in their 30s, 40s and 50s. We additionally investigated the role of obesity persistence from childhood (age 11) through to adulthood (age 33). After adjusting for a rich set of childhood characteristics, compared to normal weight, obesity at age 16 was associated with significantly lower levels of future household income for women (by approximately 14%), but not men. This household income penalty was greater for women with obesity in both childhood and adulthood. The household income penalty for women appeared to be driven by a lower likelihood of marriage and lower spousal earnings for those who were married, and not by their own wage penalty in the labour market. The spousal earnings penalty occurred even when obesity did not persist into adulthood.

Differential item functioning in quality of life measurement: An analysis using anchoring vignettes

Systematic differences in the ways that people use and interpret response categories (differential item functioning, DIF) can introduce bias when using self-assessments to compare health or quality of life across heterogeneous groups. This paper reports on an exploratory analysis involving the use of anchoring vignettes to identify DIF in a commonly used measure for assessing health-related quality of life - namely the EQ-5D. Using data from a bespoke (i.e. custom) survey that recruited a representative sample of 4300 respondents from the general Australian population in 2014 and 2015, we find that the assumptions of response consistency (RC) and vignette equivalence (VE) hold in a sub-sample of respondents aged 55-65 years (n = 914), which demonstrates that vignettes can appropriately identify DIF in EQ-5D reporting for this age group. We find that the EQ-5D is indeed subject to DIF, and that failure to account for DIF can lead to conclusions that are misleading when using the instrument to compare health or quality of life across heterogeneous groups. We also provide several important insights in terms of the identifying assumptions of RC and VE. We conclude that the implications of DIF could be of considerable importance, not only for outcomes research, but for funding decisions in healthcare more broadly given the strong reliance on patient-reported outcome measures in economic evaluations for health technology assessment.

Justification bias in self-reported disability: New evidence from panel data

The relationship between health and work is frequently investigated using self-assessments of disability from social surveys. The complication is that respondents may overstate their level of disability to justify non-employment and welfare receipt. This study provides new evidence on the existence and magnitude of justification bias by exploiting a novel feature of a large longitudinal survey: each wave respondents are asked identical disability questions twice; near the beginning and end of the face-to-face interview. Prior to answering the second disability question, respondents are asked a series of questions that increase the salience of their employment and welfare circumstances. Justification bias is identified by comparing the variation between the two measures within-individuals over time, with the variation in employment status over time. Results indicate substantial and statistically significant justification bias; especially for men and women who receive disability pensions.

Response-Scale Heterogeneity in the EQ-5D

This paper discusses two types of response-scale heterogeneity, which may impact upon the EQ-5D. Response-scale heterogeneity in reporting occurs when individuals systematically differ in their use of response scales when responding to self-assessments. This type of heterogeneity is widely observed in relation to other self-assessed measures but is often overlooked with regard to the EQ-5D. Analogous to this, preference elicitation involving the EQ-5D could be subject to a similar type of heterogeneity, where variations across respondents may occur in the interpretations of the levels (response categories) being valued. This response-scale heterogeneity in preference elicitation may differ from variations in preferences for health states, which have been observed in the literature. This paper explores what these forms of response-scale heterogeneity may mean for the EQ-5D and the potential implications for researchers who rely on the instrument as a measure of health and quality of life. We identify situations where they are likely to be problematic and present potential avenues for overcoming these issues. Copyright © 2016 John Wiley & Sons, Ltd.

3D-printed pediatric endoscopic ear surgery simulator for surgical training

INTRODUCTION

Surgical simulators are designed to improve operative skills and patient safety. Transcanal Endoscopic Ear Surgery (TEES) is a relatively new surgical approach with a slow learning curve due to one-handed dissection. A reusable and customizable 3-dimensional (3D)-printed endoscopic ear surgery simulator may facilitate the development of surgical skills with high fidelity and low cost. Herein, we aim to design, fabricate, and test a low-cost and reusable 3D-printed TEES simulator.

METHODS

The TEES simulator was designed in computer-aided design (CAD) software using anatomic measurements taken from anthropometric studies. Cross sections from external auditory canal samples were traced as vectors and serially combined into a mesh construct. A modified tympanic cavity with a modular testing platform for simulator tasks was incorporated. Components were fabricated using calcium sulfate hemihydrate powder and multiple colored infiltrants via a commercial inkjet 3D-printing service.

RESULTS

All components of a left-sided ear were printed to scale. Six right-handed trainees completed three trials each. Mean trial time (n = 3) ranged from 23.03 to 62.77 s using the dominant hand for all dissection. Statistically significant differences between first and last completion time with the dominant hand (p < 0.05) and average completion time for junior and senior residents (p < 0.05) suggest construct validity.

CONCLUSIONS

A 3D-printed simulator is feasible for TEES simulation. Otolaryngology training programs with access to a 3D printer may readily fabricate a TEES simulator, resulting in inexpensive yet high-fidelity surgical simulation.

Sex-specific genetic determinants for arterial stiffness in Dahl salt-sensitive hypertensive rats

Background

Arterial stiffness is an independent predictor of cardiovascular outcomes in hypertensive patients including myocardial infarction, fatal stroke, cerebral micro-bleeds which predicts cerebral hemorrhage in hypertensive patients, as well as progression to hypertension in non-hypertensive subjects. The association between arterial stiffness and various cardiovascular outcomes (coronary heart disease, stroke) remains after adjusting for age, sex, blood pressure, body mass index and other known predictors of cardiovascular disease, suggesting that arterial stiffness, measured via carotid-femoral pulse wave velocity, has a better predictive value than each of these factors. Recent evidence shows that arterial stiffening precedes the onset of high blood pressure; however their molecular genetic relationship (s) and sex-specific determinants remain uncertain. We investigated whether distinct or shared genetic determinants might underlie susceptibility to arterial stiffening in male and female Dahl salt-sensitive rats. Thus, we performed a genome-wide scan for quantitative trait loci (QTLs) affecting arterial stiffness in six-week old F2 (Dahl S x R)-intercross male and female rats characterized for abdominal aortic pulse wave velocity and aortic strain by high-resolution ultrasonography.

Results

We detected five highly significant QTLs affecting aortic stiffness: two interacting QTLs (AS-m1 on chromosome 4 and AS-m2 on chromosome16, LOD 8.8) in males and two distinct interacting QTLs (AS-f1 on chromosome 9 and AS-f2 on chromosome11, LOD 8.9) in females affecting pulse wave velocity. One QTL (AS-1 on chromosome 3, LOD 4.3) was found to influence aortic strain in a sex-independent manner. None of these arterial stiffness QTLs co-localized with previously reported blood pressure QTLs detected in equivalent genetic intercrosses.

Conclusions

These data reveal sex-specific genetic determinants for aortic pulse wave velocity and suggest distinct polygenic susceptibility for arterial stiffness and salt-sensitive hypertension in Dahl rats based upon reported blood pressure QTLs in equivalent (Dahl S x R)-intercrosses.

Childhood Obesity and Cognitive Achievement

Obese children tend to perform worse academically than normal-weight children. If poor cognitive achievement is truly a consequence of childhood obesity, this relationship has significant policy implications. Therefore, an important question is to what extent can this correlation be explained by other factors that jointly determine obesity and cognitive achievement in childhood? To answer this question, we exploit a rich longitudinal dataset of Australian children, which is linked to national assessments in math and literacy. Using a range of estimators, we find that obesity and body mass index are negatively related to cognitive achievement for boys but not girls. This effect cannot be explained by sociodemographic factors, past cognitive achievement or unobserved time-invariant characteristics and is robust to different measures of adiposity. Given the enormous importance of early human capital development for future well-being and prosperity, this negative effect for boys is concerning and warrants further investigation.

Views of the chairs of Scottish health boards on engagement with quality management and comparisons with English trusts

OBJECTIVE

To describe the views of the chairs of Scottish health boards on the engagement of their boards with healthcare quality and to compare them with the views of the chairs of boards of English acute trusts. The focus of the Scottish Health Boards is on providing and commissioning care, while in England the acute trusts only provide care.

METHODS

We mailed a questionnaire, based on one used in England, to the 14 health board chairs in NHS Scotland in January 2011. The results were compared with the results of a similar questionnaire given to English acute trust chairs in 2009.

RESULTS

Most chairs in Scotland (67%) prioritised oversight of quality. Quality is considered at most Board meetings (92%), taking over 20% of time for 69% of chairs. Most boards have local quality targets and feedback quality data to staff. Compared with England, boards in Scotland meet less frequently and focus less on quality (shorter discussions, less frequent data review, fewer local targets) but they are more optimistic about their board's performance.

CONCLUSIONS

Although most chairs of Scottish boards view quality as a priority, they pay less attention to it than chairs in England, possibly due to their additional role in commissioning care.

Socioeconomic differences in patient-reported outcomes after a hip or knee replacement in the English National Health Service

BACKGROUND

We investigated socioeconomic differences in patient-reported outcomes after a hip or knee replacement and the contribution of health differences beforehand.

METHODS

Our sample included 121 983 patients in England who had an operation in 2009-2011. Socioeconomic status was measured with quintiles of the ranking of areas by the English Index of Multiple Deprivation. Outcomes at 6 months were the Oxford hip or knee score (OHS or OKS) that measure pain and disability on a scale from 0 (worst) to 48 (best), and the percentage reporting no improvement in problems. Adjustment was made for age, sex, ethnicity, comorbidity, general health, revision surgery, primary diagnosis, preoperative OHS or OKS and having longstanding problems.

RESULTS

Comparing the most- with the least-deprived group, the mean OHS was 5.0 points lower and the OKS 5.4 lower. Adjusted differences, reflecting the differences in improvement in the condition, were 2.8 [95% confidence interval (CI): 2.5-3.0] on OHS and 2.4 (95% CI: 2.2-2.7) on OKS. Adjusted odds ratios for reporting no improvement were 1.4 (1.2-1.6) for the hip and 1.4 (1.3-1.5) for the knee.

CONCLUSIONS

On average, patients living in socioeconomically deprived areas had worse outcomes after surgery, partly related to preoperative differences in health and disease severity and partly to less postoperative improvement.

Relationship between patients' reports of complications and symptoms, disability and quality of life after surgery

BACKGROUND

Patient-reported complications are increasingly being used to compare the performance of surgical departments. The objectives of this study were to explore the validity of patient-reported complications and to determine their influence on patients' reports of the benefits of surgery (health gain).

METHODS

This was an observational study of patients in England who underwent hip replacement (68,391), knee replacement (77,705), inguinal hernia repair (48,199) or varicose vein surgery (16,535) during 2009-2011. Health gain was assessed with condition-specific measures of symptoms and disability (Oxford Hip Score, Oxford Knee Score, Aberdeen Varicose Vein Questionnaire), health-related quality of life (EQ-5D™ index) and a single item on the success of surgery. Adverse outcomes included four complications, readmission and further surgery.

RESULTS

There was evidence that patient-reported complications were valid. Patients with three or more co-morbid conditions reported more complications, whereas age, sex and socioeconomic status (adjusted for co-morbidity) had little, or no association. Complications were strongly associated with readmission and further surgery. Among patients reporting a complication, the Oxford Hip Score or Oxford Knee Score was about 3 points (or 15 per cent) lower than the value in patients not reporting a complication. The EQ-5D™ score was about 0·07 lower for joint replacement, 0·06 lower for hernia repair and 0·04 lower for varicose vein surgery.

CONCLUSION

Patients' reports of complications can be used for statistical comparisons of surgical departments. If the relationship between complications and health gain is causal, there is scope for improving health gain indicators after surgery by minimizing the risk of a complication.

Sociodemographic differences in the severity and duration of disease amongst patients undergoing hip or knee replacement surgery

BACKGROUND

Differences in the use of hip and knee replacement by sex, age, ethnicity or socioeconomic status may lead to differences in disease severity between those who have surgery.

METHODS

Analyses used data collected from 117,736 patients in 2009-10 via the Patient Reported Outcome Measures (PROMs) programme in England. Adjusted differences were estimated in the Oxford Hip Score (OHS) or the Oxford Knee Score (OKS), both expressed on a scale from 0 to 48, and the proportion with longstanding problems (>5 years), expressed as odds ratios (ORs).

RESULTS

Women had more severe pain and disability than men on average (difference OHS 2.3 and OKS 3.3), but less often longstanding problems. Compared with white patients, average severity was higher in South Asian patients (difference OHS 2.7 and OKS 3.0) and in black patients (difference OHS 0.9 and OKS 1.6), who also more often had longstanding problems (OR 1.40 for hip and 1.54 for knee). Patients from deprived areas had more severe disease (difference OHS 3.6 and OKS 3.3 between least and most deprived quintile).

CONCLUSIONS

There is evidence that non-white and deprived patients tend to have hip and knee replacement surgery at a later stage in the course of their disease.

Outcomes of elective surgery undertaken in independent sector treatment centres and NHS providers in England: audit of patient outcomes in surgery

OBJECTIVE

To compare characteristics of patients and outcomes after elective surgery in independent sector treatment centres (ISTCs) and NHS providers.

DESIGN

Follow-up study with outcomes reported by patients three to six months after surgery.

SETTING

25 ISTCs and 72 NHS providers in England. Population Consecutive patients undergoing hip or knee replacement (5671 in ISTCs and 14,292 in NHS), inguinal hernia repair (640 and 2023, respectively), or surgery for varicose veins (248 and 1336, respectively).

MAIN OUTCOMES

Symptoms and disability reported by patients (Oxford hip and knee scores on a 48 point scale; Aberdeen varicose vein questionnaire) and quality of life (EuroQol EQ-5D score).

RESULTS

Patients in ISTCs were healthier than those in NHS providers, had less severe preoperative symptoms, and were more affluent, though the differences were small. With adjustment, patients undergoing joint replacements in NHS providers had poorer outcomes: difference of -1.7 (95% confidence interval -2.5 to -0.9) on the Oxford hip score and -0.9 (-1.6 to -0.2) on the Oxford knee score. They more often reported complications: odds ratio 1.3 (95% confidence interval 1.1 to 1.5) for hip and 1.4 (1.2 to 1.6) for knee. There were no significant differences in outcomes after surgery for hernia or varicose veins, except that NHS patients more often reported poor results after hernia repair (1.4, 1.0 to 1.9) and additional surgery after varicose vein surgery (2.8, 1.2 to 6.8).

CONCLUSION

Patients undergoing surgery in ISTCs were slightly healthier and had less severe conditions than those undergoing surgery in NHS providers. Some outcomes were better in ISTCs, but differences were small compared with the impact ISTCs could have on the provision of elective services.

Is there value in routine screening for Cushing's syndrome in patients with diabetes?

CONTEXT

Subclinical Cushing's syndrome has been described among diabetic populations in recent years, but no consensus has emerged about the value of screening.

METHODS

We enrolled 201 consecutive patients attending our diabetes clinic and 79 controls. Patients with at least two of the following three criteria were offered screening using a 2300 h salivary cortisol test: glycosylated hemoglobin of at least 7%, body mass index of at least 25 kg/m(2), and a history of hypertension or blood pressure of at least 140/90 mm Hg. Results are expressed as mean +/- sem.

RESULTS

Mean nighttime salivary cortisol levels were similar in the two groups (8.5 +/- 1.0 nmol/liter for diabetic patients vs. 5.8 +/- 1.0 nmol/liter for controls). Forty-seven patients (23%) had a value of at least 10 nmol/liter, which was set as a conservative threshold above which further investigation would be performed. Thirty-five (75%) agreed to further testing with a 1-mg overnight dexamethasone test. Of the remaining 12 patients, 10 were followed up clinically for at least 1 yr, and no evidence was found of the syndrome evolving. In 28 patients, serum cortisol suppressed to 60 nmol/liter or less. Of the seven patients who failed this test, four agreed to a 2 mg/d 48-h dexamethasone test, with serum cortisol suppressing to 60 nmol/liter or less in all four. Three declined this test but had normal 24-h urinary free cortisol levels. No patient had clinical features of hypercortisolism.

CONCLUSIONS

The 1-3% detection rates of three recently published series have not been realized at our center where we studied a group using criteria making patients more likely to have hypercortisolism. Our results do not support the validity of screening patients without clinical features of Cushing's syndrome in the diabetes clinic.

The decision making process on public health measures related to passenger ships: the example of influenza pandemic 2009

BACKGROUND

Public health measures at sea ports have posed a challenge for public health competent authorities, especially in the context of the influenza pandemic of 2009. This paper discusses the response of authorities to notifications of infectious diseases on passenger ships and the importance of assessing the risks related to cases of influenza. It further provides options for health measures and considerations for decision making during a pandemic such as the influenza pandemic of 2009.

DISCUSSION

Prevention and control of influenza have included action taken by both competent port authorities and ships' crews. Assessing the public health risk of each event reported from ships to competent authorities at ports is important before advice is given on implementation of control measures. Public health risk assessment involves appraisal of threats to passengers and crew on board the ship as well as to the population in the community.

SUMMARY

Any public health measures taken should be necessary and proportional to the threat. Measures at ports cannot alone be effective in the prevention of the spread of a disease to the community since other means of transport play a major role. Measures taken on board ships can be effective in containing the disease. Consistent policy based on common protocols and carried out by competent authorities at local, national, European, or international levels are essential.

Risk factors for fecal colonization with multiple distinct strains of Escherichia coli among long-term care facility residents

Of 49 long-term care facility residents, 21 (43%) were colonized with 2 or more distinct strains of Escherichia coli. There were no significant risk factors for colonization with multiple strains of E. coli. These results suggest that future efforts to efficiently identify the diversity of colonizing strains will be challenging.

Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET project communication

Passenger ships carry a large number of people in confined spaces. A case of the new influenza A (H1N1) virus aboard a passenger ship is an expected event and would lead to rapid spread of the virus, if preventive measures are not in place. However, many cruise lines have detailed policies and procedures to deal with cases of influenza like illness (ILI). The EU SHIPSAN and SHIPSAN TRAINET projects include in their objectives guidelines for the prevention and control of communicable diseases aboard passenger ships. A literature review showed that from 1997 to 2005, nine confirmed outbreaks of influenza were linked to passenger ships, with attack rates up to 37%. It is important to establish and maintain a surveillance system for ILI aboard passenger ships, in order to systematically collect data that can help to determine the baseline illness levels. Monitoring these will enable early identification of outbreaks and allow timely implementation of control measures.

Efficient recovery of fluoroquinolone-susceptible and fluoroquinolone-resistant Escherichia coli strains from frozen samples

We assessed the rate of recovery of fluoroquinolone-resistant and fluoroquinolone-susceptible Escherichia coli isolates from culture of frozen perirectal swab samples compared with the results for culture of the same specimen before freezing. Recovery rates for these 2 classes of E. coli were 91% and 83%, respectively. The majority of distinct strains recovered from the initial sample were also recovered from the frozen sample. The strains that were not recovered were typically present only in low numbers in the initial sample. These findings emphasize the utility of frozen surveillance samples.

The T- and L-type calcium channel blocker (CCB) mibefradil attenuates leg edema induced by the L-type CCB nifedipine in the spontaneously hypertensive rat: a novel differentiating assay

Among the L-type calcium channel blockers (CCBs), particularly dihydropyridines like nifedipine [1,4-dihydro-2,6-dimethyl-4-(2-nitrophenyl)-3,5-pyridinedicarboxylic acid dimethyl ester], a common adverse effect is vasodilatory edema. Newer CCBs, such as the T- and L-type CCB, mibefradil [(1S,2S)-2-[2[[3-(2-benzimidazolylpropyl]methylamino]ethyl]-6-fluoro-1,2,3,4-tetrahydro-1-isopropyl-2-naphthyl methoxyacetate dihydrochloride hydrate], demonstrate antihypertensive efficacy similar to that of their predecessors but seem to have a reduced propensity to cause edema. Using a magnetic resonance imaging (MRI) T(2) mapping technique, we investigated the ability of mibefradil to reduce extracellular water accumulation caused by the L-type CCB, nifedipine, in the hindleg skeletal muscle of the spontaneously hypertensive rat. Mibefradil (10 mg/kg i.v.) and nifedipine (1 mg/kg i.v.) lowered mean arterial blood pressure by 97 +/- 5 and 77 +/- 4 mm Hg, respectively. MRI edema index (expressed as percentage increase of integral T(2) over predrug control) was significantly higher with nifedipine (2606 +/- 86%; p < 0.05) than with mibefradil (981 +/- 171%) measured 30 to 60 min after the start of drug infusion. The hindleg edema caused by nifedipine was dose dependently decreased by coadministration of mibefradil (0, 0.3, or 3 mg/kg). The hindleg edema formation was not due to albumin leakage into the interstitial space based on immunostaining. However, a 4.2-fold increase in the arterial L-/T-type CC mRNA expression ratio was observed compared with the venous L/T ratio as shown by quantitative reverse transcription polymerase chain reaction. These results demonstrate the novel utility of MRI to measure extravascular water after acute exposure to CCBs and indicate that T-type CCB activity may reduce L-type CCB-induced vasodilatory edema in the skeletal muscle vasculature, possibly by a differential effect on arteriole and venule dilatation.

Discovering relevance knowledge in data: a growing cell structures approach

Both information retrieval and case-based reasoning systems rely on effective and efficient selection of relevant data. Typically, relevance in such systems is approximated by similarity or indexing models. However, the definition of what makes data items similar or how they should be indexed is often nontrivial and time-consuming. Based on growing cell structure artificial neural networks, this paper presents a method that automatically constructs a case retrieval model from existing data. Within the case-based reasoning (CBR) framework, the method is evaluated for two medical prognosis tasks, namely, colorectal cancer survival and coronary heart disease risk prognosis. The results of the experiments suggest that the proposed method is effective and robust. To gain a deeper insight and understanding of the underlying mechanisms of the proposed model, a detailed empirical analysis of the models structural and behavioral properties is also provided.