Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis

Importance

Alcohol use disorder affects more than 28.3 million people in the United States and is associated with increased rates of morbidity and mortality.

Objective

To compare efficacy and comparative efficacy of therapies for alcohol use disorder.

Data Sources

PubMed, the Cochrane Library, the Cochrane Central Trials Registry, PsycINFO, CINAHL, and EMBASE were searched from November 2012 to September 9, 2022 Literature was subsequently systematically monitored to identify relevant articles up to August 14, 2023, and the PubMed search was updated on August 14, 2023.

Study Selection

For efficacy outcomes, randomized clinical trials of at least 12 weeks' duration were included. For adverse effects, randomized clinical trials and prospective cohort studies that compared drug therapies and reported health outcomes or harms were included.

Data Extraction and Synthesis

Two reviewers evaluated each study, assessed risk of bias, and graded strength of evidence. Meta-analyses used random-effects models. Numbers needed to treat were calculated for medications with at least moderate strength of evidence for benefit.

Main Outcomes and Measures

The primary outcome was alcohol consumption. Secondary outcomes were motor vehicle crashes, injuries, quality of life, function, mortality, and harms.

Results

Data from 118 clinical trials and 20 976 participants were included. The numbers needed to treat to prevent 1 person from returning to any drinking were 11 (95% CI, 1-32) for acamprosate and 18 (95% CI, 4-32) for oral naltrexone at a dose of 50 mg/d. Compared with placebo, oral naltrexone (50 mg/d) was associated with lower rates of return to heavy drinking, with a number needed to treat of 11 (95% CI, 5-41). Injectable naltrexone was associated with fewer drinking days over the 30-day treatment period (weighted mean difference, -4.99 days; 95% CI, -9.49 to -0.49 days) Adverse effects included higher gastrointestinal distress for acamprosate (diarrhea: risk ratio, 1.58; 95% CI, 1.27-1.97) and naltrexone (nausea: risk ratio, 1.73; 95% CI, 1.51-1.98; vomiting: risk ratio, 1.53; 95% CI, 1.23-1.91) compared with placebo.

Conclusions and Relevance

In conjunction with psychosocial interventions, these findings support the use of oral naltrexone at 50 mg/d and acamprosate as first-line pharmacotherapies for alcohol use disorder.

Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review

IMPORTANCE

Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities.

OBJECTIVE

To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity.

EVIDENCE REVIEW

Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity).

FINDINGS

Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences.

CONCLUSIONS AND RELEVANCE

In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.

Screening for Depression and Suicide Risk in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide.

Objective

To review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF).

Data Sources

PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.

Study Selection

English-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Test accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events.

Results

Twenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, -0.58 [95% CI, -0.83 to -0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, -2.25 [95% CI, -4.09 to -0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children's Depression Rating Scale-Revised mean difference, -3.76 [95% CI, -5.95 to -1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children's Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, -2.35 [95% CI, -4.06 to -0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different.

Conclusion and Relevance

Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.

Screening for Anxiety in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions.

Objective

To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force.

Data Sources

PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.

Study Selection

English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration-approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events.

Results

Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement-mean difference (Pediatric Anxiety Rating Scale mean difference, -4.0 [95% CI, -5.5 to -2.5]; n = 726; 5 studies; and Clinical Global Impression-Severity scale mean difference, -0.84 [95% CI, -1.13 to -0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)-but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different.

Conclusions and Relevance

Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.

Screening for Hypertension in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Childhood hypertension can result in adverse outcomes during adulthood; identifying and treating primary and secondary childhood hypertension may reduce such risks.

OBJECTIVE

To update the evidence on screening and treatment of hypertension in childhood and adolescence for the US Preventive Services Task Force.

DATA SOURCES

PubMed, Cochrane Library, International Pharmaceutical Abstracts, EMBASE, and trial registries through September 3, 2019; bibliographies from retrieved articles, experts, and surveillance of the literature through October 6, 2020.

STUDY SELECTION

Fair- or good-quality English-language studies evaluating diagnostic accuracy of blood pressure screening; cohort studies assessing the association of hypertension in childhood and adolescence with blood pressure or other intermediate outcomes in adulthood; randomized clinical trials (RCTs) or meta-analyses of pharmacological and lifestyle interventions.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently assessed titles/abstracts and full-text articles, extracted data, and assessed study quality; the evidence was synthesized qualitatively.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity, and measures of association between childhood and adulthood blood pressure; reduction of childhood blood pressure; adverse effects of treatments.

RESULTS

Forty-two studies from 43 publications were included (N>12 400). No studies evaluated the benefits or harms of screening and the effect of treating childhood hypertension on outcomes in adulthood. One study reported a sensitivity of 0.82 and a specificity of 0.70 for 2 office-based blood pressure measurements. Twenty observational studies suggested a significant association between childhood hypertension and abnormal blood pressure in adulthood (odds ratios, 1.1-4.5; risk ratios, 1.45-3.60; hazard ratios, 2.8-3.2). Thirteen placebo-controlled RCTs and 1 meta-analysis assessed reductions in systolic (SBP) and diastolic blood pressure from pharmacological treatments. Pooled reductions of SBP were -4.38 mm Hg (95% CI, -7.27 to -2.16) for angiotensin-converting enzyme inhibitors and -3.07 mm Hg (95% CI, -4.99 to -1.44) for angiotensin receptor blockers. Candesartan reduced SBP by -6.56 mm Hg (P < .001; n = 240). β-Blockers, calcium channel blockers, and mineralocorticoid receptor antagonists did not achieve significant reductions over 2 to 4 weeks. SBP was significantly reduced by exercise over 8 months (-4.9 mm Hg, P ≤ .05; n = 69), by dietary approaches to stop hypertension over 3 months (-2.2 mm Hg, P < .01; n = 57), and by a combination of drug treatment and lifestyle interventions over 6 months (-7.6 mm Hg; P < .001; n = 95). Low-salt diet did not achieve reductions of blood pressure.

CONCLUSIONS AND RELEVANCE

Observational studies indicate an association between hypertension in childhood and hypertension in adulthood. However, the evidence is inconclusive whether the diagnostic accuracy of blood pressure measurements is adequate for screening asymptomatic children and adolescents in primary care.

Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review

BACKGROUND

As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia.

METHODS

We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis.

RESULTS

We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline.

CONCLUSIONS

Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

Cigarette Smoking Among Inmates by Race/Ethnicity: Impact of Excluding African American Young Adult Men From National Prevalence Estimates

INTRODUCTION

Cigarette smoking prevalence is more than two times greater among incarcerated adults, a population usually excluded from national health surveys. African American young adult (18-25) men are less likely to smoke cigarettes than their white counterparts. However, they are two and a-half-times more likely to be incarcerated. This study estimated smoking prevalence with noninstitutionalized and incarcerated samples combined to determine if excluding incarcerated adults impacts smoking prevalence for certain populations.

METHODS

The Bureau of Justice Statistics last fielded the Survey of Inmates in State and Federal Correction Facilities in 2003-2004. We combined data from Survey of Inmates in State and Federal Correction Facilities (n = 17 910) and the 2003 and 2004 National Health Interview Survey (n = 61 470) to calculate combined cigarette smoking estimates by race/ethnicity, sex, and age.

RESULTS

Inmates represented the greatest proportion of smokers among African American men. Among African American young adult men, inmates represented 15.2% of all smokers in the combined population, compared to 2.0% among white young adult men. Cigarette smoking prevalence was 17.6% in the noninstitutionalized population of young adult African American men and 19.7% in the combined population. Among white young adult men, cigarette smoking prevalence was 29.8% in the noninstitutionalized population, and 30.2% in the combined population. There was little difference in estimates among women.

CONCLUSIONS

The exclusion of incarcerated African American young adult men may result in a small underestimation of cigarette smoking prevalence in this population. Increasing access to smoking cessation support among inmates may reduce smoking prevalence in disproportionately incarcerated segments of the US population.

IMPLICATIONS

The exclusion of incarcerated adults from national survey data should be considered when examining differences in cigarette smoking prevalence estimates between African American and white young adult men. Approximately one in six African American young adult men who smoke were incarcerated. Increasing access to smoking cessation support among inmates may reduce smoking prevalence among disproportionately incarcerated segments of the population.

Modes of ever marijuana use among adult tobacco users and non-tobacco users-Styles 2014

BACKGROUND

Tobacco and marijuana use are related behaviors; therefore, it is important to identify how users consume marijuana, and how it varies with tobacco use status. We estimated the modes of ever marijuana use among current, former, and never adult tobacco users.

METHODS

Weighted data were analyzed for 4181 adults from 2014 Styles, an online consumer panel survey of US adults, to estimate proportions for modes of ever marijuana use. Differences in modes of ever marijuana use between categories of tobacco use status were assessed (p-value <0.05).

RESULTS

More than half of current (56.6%) and former tobacco users (50.9%) had ever used marijuana, whereas only 13.0% of never tobacco users had ever used marijuana. Among ever marijuana users, joint use was the most common mode of use among current (86.4%), former (92.5%), and never (79.8%) tobacco users. Similarly, other modes of marijuana use were significantly higher in current and former tobacco users compared to never tobacco users.

CONCLUSIONS

Prevalence of all modes of ever marijuana use was higher in current and former tobacco users. These findings underscore the importance of considering the relationship between marijuana and tobacco use when developing programs and policies aimed at preventing and reducing marijuana use.

Not Just Cigarettes: A More Comprehensive Look at Marijuana and Tobacco Use Among African American and White Youth and Young Adults

INTRODUCTION

Cigarettes, cigars, and marijuana have generally been studied in isolation yet their use does not occur in isolation. Focus on cigarette smoking may overstate the observation that African American youth and young adults are less likely to smoke any combustible product compared with their white counterparts. Assessing cigarette, cigar, and marijuana use trends may help identify the extent of this difference.

METHODS

Data from the 2002-2012 National Survey on Drug Use and Health (N = 25 541 to N = 28 232) were used to investigate past 30-day cigarette, cigar, and marijuana use trends among African American and white youth (12-17) and young adults (18-25). Logistic regressions assessed trends in combustible tobacco (cigarettes and cigars) and marijuana use, alone and in combination.

RESULTS

From 2002-2012, the absolute difference in cigarette smoking prevalence between African American and white youth (9.6%-4.2%) and young adults (19.0%-10.5%) narrowed. Any combustible tobacco/marijuana use was significantly lower among African Americans than whites but, relative to cigarettes, the absolute difference was much smaller among youth (7.2%-2.2%) and young adults (15.8%-5.6%). Among any combustible tobacco/marijuana users, using two or more substances ranged from 31.4% to 40.3% among youth and 29.1% to 39.8% among young adults.

CONCLUSION

Any combustible tobacco/marijuana use trends suggest the smoking prevalence difference between African American and white youth and young adults is real, but less pronounced than when assessing cigarette smoking alone. Policies and programs addressing smoking behaviors may benefit from broadening focus to monitor and address cigar and marijuana use as well.

IMPLICATIONS

Trends in any use of cigarettes, cigars, and/or marijuana suggest the difference in smoking prevalence between African American and white youth and young adults is real, but less pronounced than when cigarette smoking is assessed alone. In 2012, more than 10% of African American and white youth, more than a third of African American young adults, and nearly half of white young adults reported past 30-day use of cigarette, cigars, and/or marijuana. Public health programs aimed at reducing these behaviors among youth and young adults could be informed by considering detailed, race-specific information regarding tobacco and marijuana use patterns.

National Surveys and Tobacco Use Among African Americans: A Review of Critical Factors

INTRODUCTION

Beginning in the 1970s, US national surveys showed African American youth having a lower prevalence of cigarette smoking than white youth. Yet, during adulthood, African Americans have a smoking prevalence comparable to white adults. Data sources chosen can contribute in different ways to understanding tobacco use behaviors among African American youth and adults; this article is a review of national and/or state-based health surveys to examine their methodology, racial and ethnic classifications, and tobacco-use related measures.

METHODS

Eleven national and/or state based surveys were selected for review. Eight surveys were multitopic and included questions on tobacco use and three surveys were tobacco specific. Survey methods included telephone (4), household (3), and school (4). Three major characteristics examined for each survey were: (1) survey design and methods, (2) racial and ethnic background classification, and (3) selected tobacco smoking questions. Within these three characteristics, 15 factors considered to be important for examining tobacco use behaviors by African Americans were identified a priori using previously published reviews and studies.

RESULTS

Within survey design and methods, the majority of surveys (≥7) oversampled African Americans and did not use proxy respondents for tobacco questions. All surveys used Office of Management and Budget standard classification for race/ethnicity classification. The majority of surveys (≥7) captured five of the seven tobacco-related smoking questions.

CONCLUSIONS

Programmatic objectives and/or research questions should guide the selection of data sources for tobacco control programs and researchers examining African American tobacco use behaviors.

IMPLICATIONS

This review of 11 national and state tobacco-related surveys shows that these surveys provide much needed estimates of tobacco use behaviors. However, as tobacco programs and researchers seek to examine tobacco use behaviors among African Americans, it is important to consider multiple surveys as each can contribute to informing the tobacco experience in African Americans. Most importantly, programmatic objectives and/or research questions should guide the selection of data sources for tobacco control programs and researchers examining African American tobacco use behaviors.

Tobacco and Marijuana Initiation Among African American and White Young Adults

INTRODUCTION

African American youth use marijuana at similar rates and tobacco at lower rates compared with white youth; however, in adulthood, tobacco use is similar. Tobacco and marijuana use are closely associated; differing initiation patterns may contribute to observed racial differences in tobacco prevalence by age. Therefore, it is important to assess tobacco and marijuana initiation patterns by race.

METHODS

Data were obtained from 56,555 adults aged 18-25 who completed the 2005-2012 National Survey on Drug Use and Health. The analysis was restricted to those who reported ever use of marijuana and combustible tobacco (cigarettes and/or cigars). Three mutually exclusive categories of initiation patterns were evaluated: use of marijuana before tobacco; marijuana and tobacco at the same age; and tobacco before marijuana. Multivariable regression models were used to assess changes over time and compare these outcomes by race while controlling for sociodemographics, risk perceptions, and current substance use.

RESULTS

In 2005, 26.6% of African American and 14.3% of white young adults used marijuana before tobacco, compared with 41.5% of African American and 24.0% of white young adults in 2012 (P < .001). Overall, African American young adults had greater odds of using marijuana before tobacco (AOR = 1.79; 95% CI: 1.67, 1.91) compared with whites.

CONCLUSION

African American young adults were more likely than whites to use marijuana before tobacco and both groups were increasingly likely to use marijuana before tobacco over time. A greater understanding of how marijuana initiation interacts with tobacco initiation could inform more effective tobacco and marijuana use prevention efforts.

IMPLICATIONS

Among ever users of combustible tobacco and marijuana, greater proportions of African American young adults used marijuana before tobacco or at the same age than their white counterparts. Moreover, both African Americans and whites were more likely to use marijuana before tobacco in 2012 compared with 2005. Tobacco control policy may benefit from a broader understanding of the patterns of initiation to tobacco and marijuana use. Some public health interventions aimed at preventing and reducing combustible tobacco use among African American young adults may be strengthened by considering marijuana use.

Smoke-free policies in U.S. Prisons and jails: A review of the literature

INTRODUCTION

Despite progress in limiting exposure to secondhand smoke (SHS) in the United States, little is known about the impact of smoke-free polices in prisons and jails. SHS exposure in this setting may be great, as smoking prevalence among inmates is more than three times higher than among non-incarcerated adults. To inform the implementation of smoke-free policies, this article reviews the literature on the extent, nature, and impact of smoke-free policies in U.S. prisons and jails.

METHODS

We systematically searched PubMed, Embase, EconLit, and Social Services Abstracts databases. We examined studies published prior to January 2014 that described policies prohibiting smoking tobacco in adult U.S. correctional facilities.

RESULTS

Twenty-seven studies met inclusion criteria. Smoke-free policies in prisons were rare in the 1980s but, by 2007, 87% prohibited smoking indoors. Policies reduced SHS exposure and a small body of evidence suggests they are associated with health benefits. We did not identify any studies documenting economic outcomes. Non-compliance with policies was documented in a small number of prisons and jails, with 20%-76% of inmates reporting smoking in violation of a policy. Despite barriers, policies were implemented successfully when access to contraband tobacco was limited and penalties were enforced.

CONCLUSION

Smoke-free policies have become increasingly common in prisons and jails, but evidence suggests they are not consistently implemented. Future studies should examine the health and economic outcomes of smoke-free policies in prisons and jails. By implementing smoke-free policies, prisons and jails have an opportunity to improve the health of staff and inmates.

Annual healthcare spending attributable to cigarette smoking: an update

BACKGROUND

Fifty years after the first Surgeon General's report, tobacco use remains the nation's leading preventable cause of death and disease, despite declines in adult cigarette smoking prevalence. Smoking-attributable healthcare spending is an important part of overall smoking-attributable costs in the U.S.

PURPOSE

To update annual smoking-attributable healthcare spending in the U.S. and provide smoking-attributable healthcare spending estimates by payer (e.g., Medicare, Medicaid, private insurance) or type of medical services.

METHODS

Analyses used data from the 2006-2010 Medical Expenditure Panel Survey linked to the 2004-2009 National Health Interview Survey. Estimates from two-part models were combined to predict the share of annual healthcare spending that could be attributable to cigarette smoking. The analysis was conducted in 2013.

RESULTS

By 2010, 8.7% (95% CI=6.8%, 11.2%) of annual healthcare spending in the U.S. could be attributed to cigarette smoking, amounting to as much as $170 billion per year. More than 60% of the attributable spending was paid by public programs, including Medicare, other federally sponsored programs, or Medicaid.

CONCLUSIONS

These findings indicate that comprehensive tobacco control programs and policies are still needed to continue progress toward ending the tobacco epidemic in the U.S. 50 years after the release of the first Surgeon General's report on smoking and health.

Tobacco use among middle and high school students--United States, 2013

Tobacco use is the leading preventable cause of disease and death in the United States, and nearly all tobacco use begins during youth and young adulthood. Among U.S. youths, cigarette smoking has declined in recent years; however, the use of some other tobacco products has increased, and nearly half of tobacco users use two or more tobacco products. CDC analyzed data from the 2013 National Youth Tobacco Survey to determine the prevalence of ever (at least once) and current (at least 1 day in the past 30 days) use of one or more of 10 tobacco products (cigarettes, cigars, hookahs, smokeless tobacco, electronic cigarettes [e-cigarettes], pipes, snus, bidis, kreteks, and dissolvable tobacco) among U.S. middle school (grades 6-8) and high school (grades 9-12) students. In 2013, 22.9% of high school students reported current use of any tobacco product, and 12.6% reported current use of two or more tobacco products; current use of combustible products (i.e., cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs) was substantially greater (20.7%) than use of other types of tobacco. Also, 46.0% of high school students reported having ever tried a tobacco product, and 31.4% reported ever trying two or more tobacco products. Among middle school students, 3.1% reported current use of cigars, and 2.9% reported current use of cigarettes, with non-Hispanic black students more than twice as likely to report current use of cigars than cigarettes. Monitoring the prevalence of the use of all available tobacco products, including new and emerging products, is critical to support effective population-based interventions to prevent and reduce tobacco use among youths as part of comprehensive tobacco prevention and control programs.

Clinical interventions to reduce secondhand smoke exposure among pregnant women: a systematic review

OBJECTIVE

To conduct a systematic review of clinical interventions to reduce secondhand smoke (SHS) exposure among non-smoking pregnant women.

DATA SOURCES

We searched 16 databases for publications from 1990 to January 2013, with no language restrictions.

STUDY SELECTION

Papers were included if they met the following criteria: (1) the study population included non-smoking pregnant women exposed to SHS, (2) the clinical interventions were intended to reduce SHS exposure at home, (3) the study included a control group and (4) outcomes included either reduced SHS exposure of non-smoking pregnant women at home or quit rates among smoking partners during the pregnancy of the woman.

DATA EXTRACTION

Two coders independently reviewed each abstract or full text to identify eligible papers. Two abstractors independently coded papers based on US Preventive Services Task Force criteria for study quality (good, fair, poor), and studies without biochemically-verified outcome measures were considered poor quality.

DATA SYNTHESIS

From 4670 papers, we identified five studies that met our inclusion criteria: four focused on reducing SHS exposure among non-smoking pregnant women, and one focused on providing cessation support for smoking partners of pregnant women. All were randomised controlled trials, and all reported positive findings. Three studies were judged poor quality because outcome measures were not biochemically-verified, and two were considered fair quality.

CONCLUSIONS

Clinical interventions delivered in prenatal care settings appear to reduce SHS exposure, but study weaknesses limit our ability to draw firm conclusions. More rigorous studies, using biochemical validation, are needed to identify strategies for reducing SHS exposure in pregnant women.

Population-based surveillance of asthma among workers in British Columbia, Canada

Introduction

Population-based health databases were used for the surveillance of asthma among workers in British Columbia for the period 1999 to 2003. The purpose was to identify high-risk groups of workers with asthma for further investigation, education and prevention.

Methods

Workers were identified using an employer-paid health premium field in the provincial health registry, and were linked to their physician visit, hospitalization, workers' compensation and pharmaceutical records; asthma cases were defined by the presence of an asthma diagnosis (International Classification of Diseases [ICD]-9-493) in these health records. Workers were assigned to an ''at-risk'' exposure group based on their industry of employment.

Results

For males, significantly higher asthma rates were observed for workers in the Utilities, Transport/Warehousing, Wood and Paper Manufacturing (Sawmills), Health Care/Social Assistance and Education industries. For females, significantly higher rates were found for those working in the Waste Management/Remediation and Health Care/ Social Assistance industries.

Conclusion

The data confirm a high prevalence of active asthma in the working population of British Columbia, and in particular, higher rates among females compared to males and in industries with known respiratory sensitizers such as dust and chemical exposures.

Population-based surveillance of asthma among workers in British Columbia, Canada

INTRODUCTION

Population-based health databases were used for the surveillance of asthma among workers in British Columbia for the period 1999 to 2003. The purpose was to identify high-risk groups of workers with asthma for further investigation, education and prevention.

METHODS

Workers were identified using an employer-paid health premium field in the provincial health registry, and were linked to their physician visit, hospitalization, workers' compensation and pharmaceutical records; asthma cases were defined by the presence of an asthma diagnosis (International Classification of Diseases [ICD]-9-493) in these health records. Workers were assigned to an ''at-risk'' exposure group based on their industry of employment.

RESULTS

For males, significantly higher asthma rates were observed for workers in the Utilities, Transport/Warehousing, Wood and Paper Manufacturing (Sawmills), Health Care/Social Assistance and Education industries. For females, significantly higher rates were found for those working in the Waste Management/Remediation and Health Care/Social Assistance industries.

CONCLUSION

The data confirm a high prevalence of active asthma in the working population of British Columbia, and in particular, higher rates among females compared to males and in industries with known respiratory sensitizers such as dust and chemical exposures.

Characterizing the geometry of InAs nanowires using mirror electron microscopy

Mirror electron microscopy (MEM) imaging of InAs nanowires is a non-destructive electron microscopy technique where the electrons are reflected via an applied electric field before they reach the specimen surface. However strong caustic features are observed that can be non-intuitive and difficult to relate to nanowire geometry and composition. Utilizing caustic imaging theory we can understand and interpret MEM image contrast, relating caustic image features to the properties and parameters of the nanowire. This is applied to obtain quantitative information, including the nanowire width via a through-focus series of MEM images.

Direct-to-participant feedback and awareness of bone mineral density testing results in a population-based sample of mid-aged Canadians

This population-based study of mid-aged Canadians assessed awareness of diagnosis by bone mineral density (BMD) following dual-energy X-ray absorptiometry (DXA) testing and compared the effects of feedback only to the physician with direct-to-participant feedback. Poor recall of osteoporosis results was observed irrespective of the feedback destination, but direct-to-participant feedback improved recall of borderline or normal results.

INTRODUCTION

BMD testing provides information about fracture risk. This study assessed whether awareness of results, in a random population sample of mid-aged Canadians, differed if results were provided to physicians only or directly to participants.

METHODS

Prospective cohort study of 2,678 women and men aged 40-60 years from the Canadian Multicentre Osteoporosis Study. Participants completed hip and spine DXA and interviewer-administered questionnaires regarding demographics and osteoporosis risk factors. Lateral spine X-rays were conducted on those > or =50 years of age. All test results were reported to the participant, the family physician or both. Associations between BMD results, feedback destination and correct self-report results, 3 years later, were assessed using logistic regression while adjusting for potential confounders.

RESULTS

Only 25% of men and 33% of women correctly reported their osteoporosis diagnoses. Direct-to-participant vs. physician-only reports did not improve recall of osteoporosis diagnosis but improved recall of borderline or normal BMD. Older (vs. younger) men and men with prevalent vertebral fractures demonstrated better recall of their osteoporosis diagnosis.

CONCLUSIONS

Recall of low BMD results was poor, despite direct-to-participant feedback and even in the presence of other osteoporosis risk factors. Direct-to-participant feedback may improve awareness of borderline or normal BMD results.

The Role of Plasmalemmal-Cortical Anchoring on the Stability of Transmembrane Electropores

The structure of eukaryotic cells is maintained by a network of filamentous actin anchored subjacently to the plasma membrane. This structure is referred to as the actin cortex. We present a locally constrained surface tension model for electroporation in order to address the influence of plasmalemmal-cortical anchoring on electropore dynamics. This model predicts that stable electropores are possible under certain conditions. The existence of stable electropores has been suggested in several experimental studies. The electropore radius at which stability is achieved is a function of the characteristic radii of locally constrained regions about the plasma membrane. This model opens the possibility of using actin-modifying compounds to physically manipulate cortical density, thereby manipulating electroporation dynamics. It also underscores the need to improve electroporation models further by incorporating the influence of trans-electropore ionic and aqueous flow, cortical flexibility, transmembrane protein mobility, and active cellular wound healing mechanisms.

Early changes in respiratory health in trades' apprentices and physician visits for respiratory illnesses later in life

OBJECTIVES

An inception cohort of trades' apprentices had rapid declines in lung function (forced expiratory volume in 1 s (FEV(1))) and rapid increases in bronchial responsiveness ( upward arrowBR) over the first 2 years of employment. We used physician visit data to assess respiratory health over the following 13 years.

METHODS

Construction painter, electrician, insulator and machinist apprentices beginning at a British Columbia trade school in 1988 were invited to participate and were followed up 2 years later. Subjects were linked to provincial medical databases to examine physician visits for asthma and other respiratory illnesses for the 13 years following. Multivariable models with rapid decline in FEV(1) and rapid increase in BR from years 1 to 3 were constructed. Respiratory symptoms were also examined as predictors of visit rates and meeting a case definition (for asthma or other respiratory illness).

RESULTS

The cohort included 281 apprentices (97% are men). Sixteen subjects met the asthma case definition (>or=2 visits coded as asthma in 1 year) and 20 met the other respiratory illness case definition (>or=3 visits for bronchitis, emphysema, respiratory symptoms in 1 year). In models controlling for demographic factors and smoking, subjects with bronchitis symptoms at baseline were more likely to develop other respiratory illness during follow-up (RR 4.4, 95% CI 1.6 to 11.9). Apprentices who developed asthma symptoms over the first 2 years were approximately six times more likely to become asthma cases (95% CI 1.9 to 18.8). Those with a rapid increase in BR were at increased risk of becoming asthma cases (RR 5.5, 95% CI 1.9 to 16.1), as well as having higher asthma visit rates (RR 6.5). Subjects with rapid decline in FEV(1) were 3.2 times more likely to become asthma cases (95% CI 0.8 to 12.1).

CONCLUSIONS

Changes in respiratory health early in adulthood, especially increased BR, are associated with respiratory physician visits. These findings are important for workplace screening and prevention and also suggest that physician visit databases are promising research tools in respiratory epidemiology.

Risks for the development of outcomes related to occupational allergies: an application of the asthma-specific job exposure matrix compared with self-reports and investigator scores on job-training-related exposure

BACKGROUND AND AIM

Risks for development of occupational sensitisation, bronchial hyper-responsiveness, rhinoconjunctival and chest symptoms at work associated with continued exposure to high molecular weight (HMW) allergens were estimated with three exposure assessment methods.

METHODS

A Cox regression analysis with adjustment for atopy and smoking habit was carried out in 408 apprentices in animal health technology, pastry making, and dental hygiene technology with an 8-year follow-up after training. The risk of continued exposure after training, estimated by the asthma-specific job exposure matrix (JEM), was compared with self-reports and investigator scores on job-training-related exposure. Associations between outcomes and work duration in job(s) related to training were also evaluated.

RESULTS

Exposure to animal-derived HMW allergens, subsequent to the apprenticeship period, as estimated by the JEM, was associated with a significantly increased risk for occupational sensitisation (hazard ratio (HR) 6.4; 95% CI 2.3 to 18.2) and rhinoconjunctival symptoms at work (HR 2.6; 95% CI 1.1 to 6.2). Exposure to low molecular weight (LMW) agents significantly increased the risk of developing bronchial hyper-responsiveness (HR 2.3; 95% CI 1.1 to 5.4). Exposure verification appeared to be important to optimise the sensitivity and the specificity, as well as HRs produced by the JEM. Self-reports and investigator scores also indicated that further exposure to HMW allergens increased the risk of developing occupational allergies. The agreement between self-reports, investigator scores, and the JEM were moderate to good. There was no significant association between respiratory outcomes and work duration in jobs related to training.

CONCLUSION

The asthma-specific JEM could estimate the risk of various outcomes of occupational allergies associated with exposure to HMW and LMW allergens, but it is relatively labour intensive. Exposure verification is an important integrated step in the JEM that optimised the performance of the matrix.

Quantification of electroporative uptake kinetics and electric field heterogeneity effects in cells

We have conducted experiments quantitatively investigating electroporative uptake kinetics of a fluorescent plasma membrane integrity indicator, propidium iodide (PI), in HL60 human leukemia cells resulting from exposure to 40 mus pulsed electric fields (PEFs). These experiments were possible through the use of calibrated, real-time fluorescence microscopy and the development of a microcuvette: a specialized device designed for exposing cell cultures to intense PEFs while carrying out real-time microscopy. A finite-element electrostatic simulation was carried out to assess the degree of electric field heterogeneity between the microcuvette's electrodes allowing us to correlate trends in electroporative response to electric field distribution. Analysis of experimental data identified two distinctive electroporative uptake signatures: one characterized by low-level, decelerating uptake beginning immediately after PEF exposure and the other by high-level, accelerating fluorescence that is manifested sometimes hundreds of seconds after PEF exposure. The qualitative nature of these fluorescence signatures was used to isolate the conditions required to induce exclusively transient electroporation and to discuss electropore stability and persistence. A range of electric field strengths resulting in transient electroporation was identified for HL60s under our experimental conditions existing between 1.6 and 2 kV/cm. Quantitative analysis was used to determine that HL60s experiencing transient electroporation internalized between 50 and 125 million nucleic acid-bound PI molecules per cell. Finally, we show that electric field heterogeneity may be used to elicit asymmetric electroporative PI uptake within cell cultures and within individual cells.

Considering risks to healthcare workers from glutaraldehyde alternatives in high-level disinfection

Due to concerns over glutaraldehyde's toxicity, two substitutes have recently been introduced; ortho-phthalaldehyde (OPA), and a mixture of hydrogen peroxide and peracetic acid. There is limited information about the health effects for employees from these products. This study assesses the current practices regarding the use of high-level disinfectants in British Columbian hospitals and predicts the relative toxicities of each product. Industry practices were compiled using a comprehensive survey of current practices and decision processes in all hospitals in British Columbia. Of 95 hospitals, 64 returned surveys; 80% of these used high-level disinfection. Among user hospitals, 49% used glutaraldehyde alone and 51% had introduced alternatives. Concern about staff health was the most common reason for substituting, but this was frequently not considered when choosing specific alternatives. Hospitals that involved occupational health, infection control or regional staff in high-level disinfectant decisions used glutaraldehyde alternatives less often. In most hospitals, it was difficult to find individuals who were knowledgeable about the use of disinfectants. Potential health effects associated with each type of high-level disinfectant were assessed by review of the published literature and available manufacturers' data along with qualitative structure-activity relationship analysis. Results indicated that although all products irritate the skin and respiratory tract, OPA is a potential dermal and respiratory sensitizer but hydrogen peroxide and peracetic acid do not cause allergic reactions. Despite little being known about the risks to employees from glutaraldehyde alternatives, their use is widespread. The potential risks of all high-level disinfectants are serious; thus regulators and users are faced with important risk management decisions before and after they have been introduced into the workplace.

Interpreting and reporting results

Creating and disseminating knowledge is the goal of research. This is accomplished through critical analysis of systematically collected and clearly reported information. Critical analysis begins with the simple step of looking at the data collected prior to applying complex statistical analysis to make comparisons. Statistical analysis is approached in a standardised manner, depending on the type of data that has been collected. When a careful, stepwise standardised approach is applied to comparisons needed to address the research question, new knowledge is created and erroneous conclusions avoided. Following careful examination and analysis of the data, critical review is an important additional step to ensure that conclusions are correctly drawn. The process of peer review involved in publishing the research in the scientific literature is an important step to disseminating the new knowledge and ensuring its quality. Research is never complete without submitting it for publication in the peer-reviewed literature.

Conducting research: practical steps

Developing a research protocol and obtaining funding for carrying out the research are only the first steps in doing research. Understanding the means to conduct the research is equally important. As research is a joint effort of a team, a mechanism of collaboration must be developed to engage all those with an interest in the research. This includes the community in which the research is to be undertaken, representatives of those who will participate in the research, the academic community who will be involved in the research, and those who will sponsor the research. These individuals can be formed into a 'steering committee' to guide the development, conduct, analysis and communication of the research. Careful consideration must be given to the benefits and risks of the research. These must be precisely spelled out in the research protocol, and all aspects of the research must be independently evaluated for technical competence, accuracy, communication and liability for injury by an ethics review committee. The research must follow precisely the protocol developed. Administrative procedures, including recruitment and management of staff, outlining standard procedures and quality assurance procedures must be clearly outlined and followed. Carefully handling the information collected in a research project is vital to ensuring the quality and validity of the research.

Measurement in epidemiology

Data (information) are the building blocks of epidemiological research. Careful measurement, recording and handling of information are crucial to the research process. The nature of the data required must be precisely defined and its collection requires the use of reliable tools or instruments. Standardisation of definitions and procedures used in measurement helps to ensure comparability. Care in undertaking measurements and rigorous training of personnel carrying out the measurements help to ensure precision. Special care is necessary to ensure completeness and accuracy in recording the data. Information may be obtained from routine or especially designed forms and evaluated by counting deaths or cases of disease or measures of dysfunction. Questionnaires are a frequently used instrument for collecting information. They should include data identifying the individual being studied, followed by specific questions concerning diseases and determinants. To be useful, such questionnaires must be carefully structured. Diseases are usually compared by calculating 'rates' or 'risks', consisting of numerators (cases, events) and denominators (population). Prevalence and incidence are standard measures of 'risk'. The collection of high quality information (data) and its use to construct estimates of 'risk' or risk ratios form the basis of epidemiology.

Choosing a research study design and selecting a population to study

Epidemiological studies have been standardised into a group of 'designs'. The descriptive study describes disease by time, place and person and can develop hypotheses about associations between disease and possible determinants. The analytic study tests these hypotheses. The cross-sectional study measures the disease and determinants at a single point in time. The cohort study identifies those within a group with or without a determinant, and observes the occurrence of disease in the two groups. The case-control study identifies a group of patients with a disease and selects a group of persons from the same population who do not have the disease, comparing the presence of a determinant in the two groups. The experimental study, a type of cohort study, is one in which the investigator 'assigns' the determinant (a treatment) to one subgroup in a population and compares the occurrence of a disease between those with and those without the determinant. All such studies must ensure that the comparisons made have relevance to a defined population. This is done by selecting a 'representative' sample from that population. Carefully selecting a study design and population facilitates the creation of new knowledge while avoiding, as far as possible, important errors.

Getting started in research: the research protocol

To be efficient and precise, research needs a 'road map', called the 'research protocol', which follows a standard format. It includes an abstract, study description, ethical considerations, significance of the study, the budget and a description of the investigators. Study description spells out the study question, the rationale for the study, including previous studies on the subject, the objectives, hypotheses and aims, design and methods, project management, strengths and limitations and a list of references. The objectives, hypotheses and aims are developed by outlining a general research topic (the objective), developing a hypothesis from the broad objective, translating it into the null hypothesis and then listing the steps by which the null hypothesis will be refuted or accepted (the aims). The design and methods describe the type of study to be undertaken, the population in which the study is carried out, including the sample size and statistical power, the selection of subjects, the methods of data collection, and outline of data management and statistical analysis. The detail of the protocol ensures that the study will be carried out successfully and is essential for all health research.

Point-of-sale glass bottle recycling: indoor airborne exposures and symptoms among employees

AIMS

To assess the impact of newly introduced point-of-sale glass bottle recycling on indoor air quality and employee health.

METHODS

Airborne exposures and both chronic and acute respiratory and somatic symptoms were surveyed among 226 employees at 36 randomly selected liquor stores with bottle recycling and in-house glass breaking. Each store was visited twice; between visits glass breaking was discontinued for one month in half the stores (selected at random), although bottles were still collected and stored on site. Rates of chronic symptoms were compared to an external, unexposed control population.

RESULTS

Geometric mean exposure levels were 0.18 mg/m3 for inhalable particulate matter and 3.6 EU/m3 for endotoxin (270 personal samples); 1064 CFU/m3 for viable fungi (648 area samples). Fungal levels were associated with visibly mouldy bottles being broken, outdoor fungal counts, and uncovered glass bins. Exposures were not altered by the intervention of shutting down glass breaking machinery. Compared to controls, employees reported more work related chronic chest tightness and chronic nasal symptoms. Acute chest symptoms were associated with breaking visibly mouldy bottles, but not with measured fungal counts. Inhalable particulate matter levels >0.2 mg/m3 were associated with acute upper airway irritation. Somatic symptoms were associated with measures of psychosocial job strain.

CONCLUSION

Results suggest that this type of recycling programme may generate fungal exposures sufficient to elicit upper airway and chest symptoms.

Research methods for promotion of lung health

The goal of health research is to develop new knowledge for action to improve health. Relevant health research includes study of diseases, their causes and their treatment/prevention as well as structure and utilisation of health services and policies to improve lung health. As resources are not infinite, priorities must be established. These are determined by the relative frequency of a condition, how much dysfunction or disability it produces and whether there are cost-effective means to deal with it. Epidemiology is the discipline used to address these issues. Using it, one can describe the distribution and relative importance of a condition (the descriptive study), identify determinants and define its natural history (the analytical study), assess methods of prevention, cure and amelioration (the experimental study) and evaluate the process and outcome of services (health services or operational research). Epidemiology addresses itself to determining causation among associated variables. Characteristics associated with causation include consistency, strength of association, specificity, dose response, temporal relationship, coherence, and experimental evidence. Epidemiology can truly be described as the 'basic science of public health.' When used strategically, it can create the new knowledge that is the cornerstone for improving the health of the whole population.

Expression and prognostic relevance of Mcl-1 in breast cancer

BACKGROUND

Bcl-2, an anti-apoptotic protein, is frequently associated with favourable prognosis in breast cancer. The potential role of mcl-1, another bcl-2 family member, in breast cancer has not yet been defined.

PATIENTS AND METHODS

This study examined the expression of mcl-1 and bcl-2 in 170 cases of invasive primary breast carcinoma, using reverse-transcriptase polymerase chain reaction and immunohistochemical analyses.

RESULTS

Expression of bcl-2 mRNA and protein were found to be favourably associated with outcome for patients, supporting a prognostic role for bcl-2 in breast cancer, whereas mcl-1 expression, at the mRNA or protein level, did not correlate with tumour size, grade, lymph node or ER status, age of patient at diagnosis, or disease outcome.

CONCLUSION

As these analyses of mcl-1 expression may have co-detected mcl-1(S/deltaTM) (a more recently identified, shorter variant, that may be pro-apoptotic) with the anti-apoptotic wild-type of mcl-1, it is possible that future studies may indicate some significant clinical correlations if the isoforms can be independently investigated.

An evaluation of the influence of practitioner-led hand clinics on rupture rates following primary tendon repair in the hand

Practitioner-led hand clinics were introduced in our unit in the year 2000 as a response to the high and increasing number of postoperative hand trauma patients coming to consultant clinics. The aim of this study was to evaluate the influence of these clinics on rupture rates following primary tendon repair in the hand. The study specifically examined:zone II flexor tendon repairsflexor pollicis longus (FPL) tendon repairsextensor pollicis longus (EPL) tendon repairs. Prospective data collection were undertaken for these particular operations over a 17-month study period. Prior to the introduction of the practitioner-led hand clinics previous audits had demonstrated rupture rates of 30% zone II flexor tendon repairs, 16% for FPL repairs and 5% for EPL repairs. Rupture rates after the introduction of practitioner-led hand clinics fell in all of the study categories-to 17% for zone II flexor tendon repairs, 4% for FPL repairs and 0% for EPL repairs. It is suggested that improved continuity of care by experienced hand therapists may have contributed to the observed improvements in outcome.

Prognostic importance of survivin in breast cancer

Survivin is a member of the inhibitor of apoptosis (IAP) family, and is also involved in the regulation of cell division. Survivin is widely expressed in foetal tissues and in human cancers, but generally not in normal adult tissue. This study examined the expression of surviving protein in a series of 293 cases of invasive primary breast carcinoma. Survivin immunoreactivity was assessed using two different polyclonal antibodies, and evaluated semiquantitatively according to the percentage of cells demonstrating distinct nuclear and/or diffuse cytoplasmic staining. Overall, 60% of tumours were positive for survivin: 31% demonstrated nuclear staining only, 13% cytoplasmic only, and 16% of tumour cells demonstrated both nuclear and cytoplasmic staining. Statistical analysis revealed that survivin expression was independent of patient's age, tumour size, histological grade, nodal status, and oestrogen receptor status. In multivariate analysis, nuclear survivin expression was a significant independent prognostic indicator of favourable outcome both in relapse-free and overall survival (P<0.001 and P=0.01, respectively). In conclusion, our results show that survivin is frequently overexpressed in primary breast cancer. Nuclear expression is most common and is an independent prognostic indicator of good prognosis.

Morphometrics and estimates of force generation by the chelae of a North American population of the invasive green crab,Carcinus maenas(L.)

The European green crab, Carcinus maenas, is an invasive species in eastern North America and has the potential to significantly impact wild and aquaculture shellfish in the southern Gulf of St. Lawrence, Canada. To examine potential predation effects on local shellfish and assess the appropriateness of extrapolating results from studies conducted elsewhere, the morphometry of chelae from a recently established population of C. maenas in Nova Scotia was examined for comparison with the presumed founding (European) population, and forces generated by the chelae over a range of crab sizes were estimated. The Nova Scotia population was found to be morphologically very similar to European populations with respect to chela structure. Force generation by the chelae was found to scale with isometry in the female crab and with positive allometry in the male. Estimated forces compare well with previously reported forces, and force generation is calculated to increase in a nonlinear manner proceeding from the chela tips proximally toward the fulcrum. The calculated forces generated by the chelae are clearly sufficient for outright crushing of some shells (e.g., Mya arenaria), even for small crabs, but appear to be too low for crushing those of other molluscs. There is a complex interplay between gape and maximum force along the length of the dactyl that allows great variability in force application, and thus also in the size of prey consumed and prey-handling behaviour. We suggest that for such a lever system, the gape angle of the chelae, which does not change with crab size, is optimal with respect to the resultant force generated.

Granulomatous appendicitis revisited: report of a case

BACKGROUND

Isolated granulomatous appendicitis is uncommon and previously was considered to be a form of localised Crohn's disease. However more recent series have noted that relapse is rare after appendicectomy and concluded that the condition is a distinct entity unrelated to Crohn's disease. Following a case of granulomatous appendicitis at St. Vincent's University Hospital Dublin, the condition was reviewed and the results are detailed herein.

METHODS

A case of granulomatous appendicitis is presented with discussion of 4 previous cases encountered in our practice and the literature is reviewed.

RESULTS

The clinical presentation was sub-acute appendicitis with a mass palpable in the right iliac fossa. At operation an enlarged, inflamed appendix with a broad base was noted and appendicectomy performed. Histopathology showed numerous granulomata on microscopic examination. The yersinia serology tests were negative. Review of computerised histopathology records in the hospital for the last 7 years showed 4 additional cases of granulomatous appendicitis. This is a total of 5 of 1,615 appendectomies (an incidence of 0.31%). In all cases, the post-operative course was uneventful and the patients have had no further complaints.

CONCLUSION

This small series provides further evidence that granulomatous appendicitis is a distinct clinical entity unrelated to Crohn's disease and is cured by appendicectomy. It should be suspected when there is a sub-acute onset of appendicitis and an enlarged, broad-based appendix is found at operation.

Immunocytochemical detection of Fcgamma receptors in human atherosclerotic lesions

Much evidence indicates that atherosclerotic lesions are largely of an inflammatory nature. Activated macrophages and macrophage-derived foam cells laden with cholesterol esters are a major constituent of these lesions and can influence lesion formation via several potential mechanisms. One such mechanism is Fcgamma receptor activation and/or Fcgamma receptor-mediated clearance of immune complexes containing cholesterol, such as lipoprotein immune complexes. That this mechanism contributes to lesion formation would be further supported if Fcgamma receptor expression in arterial lesions were demonstrated. We therefore used monoclonal antibodies and immunocytochemical methods to analyze frozen sections of human arterial lesions for expression of each of the three primary classes of mononuclear phagocyte Fcgamma receptors. Approximately 800 sections of aorta, carotid, and coronary arteries obtained from five elderly donors were analyzed. The presence of macrophages was determined by assaying reactivity of a monoclonal antibody specific to CD163, which is expressed only on cells of the human mononuclear phagocyte lineage. Results indicate that highly cellular preatheromatous lesions contained numerous macrophages in the zone of proliferation that expressed each class of Fcgamma receptor (FcgammaRIA, FcgammaRIIA, and FcgammaRIIIA). Fcgamma receptor-positive cells were also present in medial and adventitial areas. Fcgamma receptor staining was both punctate and diffuse, the latter suggesting that soluble receptors were present in the extracellular matrix. These data further support that Fcgamma receptor-mediated clearance of immune complexes can occur in arterial lesions during atherogenesis. Expression of both the high affinity (FcgammaRIA) and lower affinity (FcgammaRIIA/FcgammaRIIIA) receptors indicates that mono- and multivalent IgG-containing immune complexes could engage Fcgamma receptors and influence lesion formation through several different inflammatory mechanisms triggered by receptor activation.

Respiratory health of automobile workers and exposures to metal-working fluid aerosols: lung spirometry

BACKGROUND

Despite substantial evidence that workers exposed to metal-working fluids (MWF) have increased respiratory morbidity, the few studies of chronic effects on lung function have not been conclusive.

METHODS

Lung spirometry was measured and both current and past exposures to metal-working fluid (MWF) aerosols were estimated in this cross-sectional cohort of 1,811 male automobile workers. Satisfactory exposure data were available for 1,745 (96%): 239 assemblers (never-exposed to MWF), 487 assemblers (previously exposed), 352 machinists currently exposed to straight oils, 441 to soluble oils, and 226 to synthetic fluids. Operations were classified as either grinding or non-grinding machining.

RESULTS

Current exposure was not found to be associated with either forced expiratory volume in 1 second (FEV(1)) or forced ventilatory capacity (FVC). Nor was past exposure to water-based fluids (soluble or synthetic MWF) related to pulmonary function. Past exposure to straight oils, however, was significantly associated with FVC. This association was more obvious among older workers and among workers who had never transferred from MWF exposed jobs to assembly.

CONCLUSIONS

The magnitude of the association between FVC and lifetime exposure to straight MWF was slightly larger than the estimated cigarette effect, suggesting that the impact of an additional year of exposure to 1 mg/m(3) of mineral oil particulate in the thoracic particle size range, has the same impact on FVC as smoking one pack per day for one more year.

Development of an asthma specific job exposure matrix and its application in the epidemiological study of genetics and environment in asthma (EGEA)

OBJECTIVES

To develop a method suitable for estimating exposure risks in population studies of asthma from job titles and international codes, by combining a new job exposure matrix (JEM) with the expert judgement approach. The method was applied in the French epidemiological study of the genetics and environment in asthma (EGEA).

METHODS

The JEM contains 22 exposure groups including 18 high risk groups based on known risk factors for occupational asthma, divided into high molecular weight agents, low molecular weight agents, and mixed environments. After applying the JEM to job codes, exposure estimates for each subject were re-evaluated by examining job title texts. Three high risk exposure estimates for asthma were compared: firstly, applying the JEM to original codes (from different coders in each study centre); secondly, applying the JEM to revised codes (from one experienced coder); and thirdly, after reviewing JEM exposure estimates in the light of job title texts.

RESULTS

The study comprised 173 cases with asthma and 285 controls (age 18-65). Odds ratios (ORs) for asthma for high risk jobs were 1.0 (95% confidence interval (95% CI) 0.6 to 1.7), applying the JEM to original codes; 1.4 (95% CI 0.8 to 2.3), applying the JEM to revised codes; and 1.7 (95% CI 1.1 to 2.7), applying the JEM and subsequently re-evaluating exposure estimates from job title texts. Asthma ORs were 1.4 (95% CI 0.6 to 2.9) for high molecular weight agents, 2.3 (95% CI 1.2 to 4.4) for low molecular weight agents, and 2.1 (95% CI 0.9 to 5.2) for mixed environments.

CONCLUSIONS

This asthma JEM, when enhanced by expert re-evaluation of exposure estimates from job title texts, may be a useful tool in general population studies of asthma. In this study, a 1.7-fold increase in prevalence odds of high risk exposures was found among asthmatic workers compared with controls, with risk magnitude varying for different classes of exposure.

Exposure to dust, resin acids, and monoterpenes in softwood lumber mills

A study to assess exposure to potential respiratory hazards in a large lumber mill processing spruce (Picea engelmannii and glauca), pine (Pinus contorta), and fir (Abies lasiocarpa) used a random sampling strategy to assess exposures for all jobs in the sawmill, planer mills, and yard. Personal samples for inhalable particulate were collected to measure exposure to dust and resin acids (abietic acid and pimaric acid). To estimate wood dust exposure, rather than overall dust, the resin acid content within dust was used in combination with observations of job tasks and proximity to dust sources. Passive dosimeters were used to measure exposure to alpha-pinene, beta-pinene, delta3-carene, and other unidentified wood volatiles suspected to be monoterpenes. The GM of the 220 inhalable particulate samples was 1.0 mg/m3 whereas the mean abietic acid, pimaric acid, and estimated wood dust levels were 7.2 microg/m3, 0.6 microg/m3, and 0.5 mg/m3, respectively. The GMs of the 222 monoterpene samples were 0.1 mg/m3 for alpha-pinene, 0.3 mg/m3 for beta-pinene, 0.1 mg/m3 for delta3-carene, and 0.5 mg/m3 for the unidentified wood volatiles. Monoterpene exposures were much lower than those observed in other studies conducted in Sweden and Finland. The results of this exposure assessment highlight the importance of considering the content of airborne particulates in lumber mills as well as potential exposure to wood chemicals.

Differential effects of interferon-gamma on metabolism of lipoprotein immune complexes mediated by specific human macrophage Fcgamma receptors

The objectives were to determine whether there are differences in the mechanisms of lipoprotein metabolism associated with different FcgammaRs and how metabolism associated with FcgammaRs compares to that mediated by scavenger receptors (SRA). To analyze lipoprotein metabolism in a receptor-specific manner, bispecific antibodies were used to target low density lipoproteins (LDL) labeled with (125)I or [(3)H]cholesterol linoleate to FcgammaRI or FcgammaRIIA in human macrophages. Interferon-gamma (IFN-gamma), which stimulates expression of FcgammaRI while inhibiting expression of SRA, was used to help delineate differences in metabolism between each receptor. For each receptor, the total amount of lipoprotein degradation paralleled changes in receptor expression induced by IFN-gamma. In particular, while SRA-mediated degradation typically exceeded degradation mediated by FcgammaRI, in IFN-gamma-treated cells degradation associated with FcgammaRI and SRA was similar. Assay of [(3)H]cholesterol linoleate-labeled lipoproteins indicated that total uptake and hydrolysis of [(3)H]cholesterol linoleate was similar for each class of receptor, and inhibited by IFN-gamma. For FcgammaRI versus FcgammaRIIA, in the presence or absence of IFN-gamma, the [(3)H]cholesterol derived from FcgammaRIIA-mediated uptake was preferentially targeted for re-esterification to [(3)H]cholesterol oleate, in comparison to that resulting from hydrolysis of [(3)H]cholesterol linoleate incorporated by selective uptake. For SRA, the formation of [(3)H]cholesterol oleate, which was substantial in control cells, was significantly inhibited in the presence of IFN-gamma. We conclude that there may be differences in cholesterol trafficking with respect to lipoprotein immune complex metabolism mediated by different classes of FcgammaRs.

Performance of population specific job exposure matrices (JEMs): European collaborative analyses on occupational risk factors for chronic obstructive pulmonary disease with job exposure matrices (ECOJEM)

OBJECTIVES

To compare the performance of population specific job exposure matrices (JEMs) and self reported occupational exposure with data on exposure and lung function from three European general populations.

METHODS

Self reported occupational exposure (yes or no) and present occupation were recorded in the three general population surveys conducted in France, The Netherlands, and Norway. Analysis was performed on subjects, aged 25-64, who provided good forced expiratory volume in 1 second (FEV1) tracings and whose occupations were performed by at least two people, in the French (6217 men and 5571 women), the Dutch (men from urban (854) and rural (780) areas), and the Norwegian (395 men) surveys. Two population specific JEMs, based on the percentage of subjects who reported themselves exposed in each job, were constructed for each survey and each sex. The first matrix classified jobs into three categories of exposure according to the proportion of subjects who reported themselves exposed in each job (P10-50 JEM, low < 10%, moderate 10-49%, high > or = 50%). For the second matrix, a dichotomous variable was constructed to have the same statistical power as the self reported exposure--that is, the exposure prevalence (p) was the same with both exposure assessment methods (Pp JEM). Relations between occupational exposure, as estimated by the two JEMs and self reported exposure, and age, height, city, and smoking adjusted FEV1 score were compared.

RESULTS

Significant associations between occupational exposure estimated by the population specific JEM and lung function were found in the French and the rural Dutch surveys, whereas no significant relation was found with self reported exposure. In populations with few subjects in most jobs, exposure cannot be estimated with sufficient precision by a population specific JEM, which may explain the lack of relation in the Norwegian and the Dutch (urban area) surveys.

CONCLUSION

The population specific JEM, which was easy to construct and cost little, seemed to perform better than crude self reported exposures, in populations with sufficient numbers of subjects per job.

Wheat antigen content of inhalable dust in bakeries: modeling and an inter-study comparison

The purposes of this study were (a) to compare wheat antigen content of inhalable bakery dust in Canada and the Netherlands and, (b) to evaluate the validity of dust exposure measurement as a surrogate of specific antigen exposure. Wheat antigen exposure data from the studies of Canadian and Dutch bakeries were used to explore the correlation between dust and antigen levels, and identify factors explaining variability of the antigen content of bakery dust. Direct comparison and pooling of the data were possible because the same antigen assay was used in both studies. Wheat antigen exposure samples totaling 544 were available, all originating from personal full-shift monitoring of bakery workers. The wheat antigen content of bakery dust varied greatly between the two studies and with different products within each study. Bakery dust from the Canadian study had a much higher wheat antigen content. Therefore, the interstudy difference in the wheat antigen content of bakery dust was by far the most significant in undermining the validity of the use of dust levels as a surrogate measures of wheat antigen exposure. The production of croissants, wheat bread and buns, puff pastry, bagels, and cinnamon buns was associated with increased wheat antigen content of bakery dust, while in rye bread production, bakery dust with less wheat antigen content was emitted. Although we can, in part, account for the pattern of variability in the wheat antigen content of bakery dust (explaining 49% of it), we concluded that the effort involved in modeling it accurately would probably exceed that expended in direct measurement of the antigen level. Therefore, for the exposure assessments carried out for the purpose of managing occupational risks of aeroallergen exposure in bakeries, we recommend the use of analytical techniques that can directly measure antigen exposure.

Localization of the gene for autosomal recessive congenital hereditary endothelial dystrophy (CHED2) to chromosome 20 by homozygosity mapping

Congenital hereditary endothelial dystrophy (CHED) is a corneal disorder that presents with diffuse bilateral corneal clouding. Vision may be severely impaired, and many patients require corneal transplantation. Both autosomal dominant (AD) and autosomal recessive (AR) forms of the disorder have been described. The gene responsible for AD CHED (HGMW-approved symbol CHED1) has been mapped to the pericentromeric region of chromosome 20. Investigating a large, consanguineous Irish pedigree with autosomal recessive CHED, we have previously excluded linkage to this AD CHED locus. We now describe a genome-wide search using homozygosity mapping and DNA pooling. Evidence of linkage to chromosome 20p was demonstrated with a maximum lod score of 9.30 at a recombination fraction of 0.0 using microsatellite marker D20S482. A region of homozygosity in all affected individuals was identified, narrowing the disease gene locus to an 8-cM region flanked by markers D20S113 and D20S882. This AR CHED (HGMW-approved symbol CHED2) disease gene locus is physically and genetically distinct from the AD CHED locus.

Determinants of exposure to inhalable particulate, wood dust, resin acids, and monoterpenes in a lumber mill environment

In a lumber mill in the northern inland region of British Columbia, Canada, we measured inhalable particulate, resin acid, and monoterpene exposures, and estimated wood dust exposures. Potential determinants of exposure were documented concurrently, including weather conditions, tree species, wood conditions, jobs, tasks, equipment used, and certain control measures. Over 220 personal samples were taken for each contaminant. Geometric mean concentrations were 0.98 mg/m3 for inhalable particulate, 0.49 mg/m3 for estimated wood dust, 8.04 micrograms/m3 for total resin acids, and 1.11 mg/m3 for total monoterpenes. Multiple regression models for all contaminants indicated that spruce and pine produced higher exposures than alpine fir or mixed tree species, cleaning up sawdust increased exposures, and personnel enclosure was an effective means of reducing exposures. Sawing wood in the primary breakdown areas of the mill was the main contributor to monoterpene exposures, so exposures were highest for the barker operator, the head rig operator, the canter operator, the board edgers, and a roving utility worker in the sawmill, and lowest in the planer mills (after kiln drying of the lumber) and yard. Cleaning up sawdust, planing kiln-dried lumber, and driving mobile equipment in the yard substantially increased exposures to both inhalable particulate and estimated wood dust. Jobs at the front end of the sawmill where primary breakdown of the logs takes place had lower exposures. Resin acid exposures followed a similar pattern, except that yard driving jobs did not increase exposures.

Pilomatrix carcinoma of the eyelid

PURPOSE

To report a case of a recurring mass with an unusual origin on the eyelid of a 34-year-old man.

METHOD

Case report.

RESULT

Histology demonstrated that the mass was a pilomatrix carcinoma.

CONCLUSION

An atypical mass with unusual symptoms or signs needs definitive treatment and diagnostic confirmation with histology.