Lessons learned from U.S. rapid antiretroviral therapy initiation programs

BACKGROUND

Rapid antiretroviral therapy initiation (R-ART) for treatment of HIV has been recommended since 2017, however it has not been adopted widely across the US.

PURPOSE

The study purpose was to understand facilitators and barriers to R-ART implementation in the U.S.

RESEARCH DESIGN

This was a qualitative design involving semi-structured interviews.

STUDY SAMPLE

The study sample was comprised of the medical leadership of nine US HIV clinics that were early implementers of R-ART.

DATA COLLECTION AND ANALYSIS

In-depth, semi-structured interviews were performed. The Consolidated Framework for Implementation Research (CFIR) was used to guide thematic analysis.

RESULTS

We identified three main content areas: strong scientific rationale for R-ART, buy-in from multiple key stakeholders, and the condensed timeline of R-ART. The CFIR construct of Evidence Strength and Quality was cited as an important factor in R-ART implementation. Buy-in from key stakeholders and immediate access to medications ensured the success of R-ART implementation. Patient acceptance of the condensed timeline for ART initiation was facilitated when presented in a patient-centered manner, including empathetic communication and addressing other patient needs concurrently. The condensed timeline of R-ART presented logistical challenges and opportunities for the development of intense patient-provider relationships.

CONCLUSIONS

Results from the analysis showed that R-ART implementation should address the following: 1) logistical planning to implement HIV treatment with a condensed timeline 2) patients' mixed reactions to a new HIV diagnosis and 3) the high cost of HIV medications.

Predicting Breastfeeding Intentions: A Test and Extension of the Theory of Normative Social Behavior with African American Social Identity

Breastfeeding is a health promoting social behavior but statistics suggest a persistent disparity of lower rates among African American mothers. The Theory of Normative Social Behavior (TNSB) explains when and how norms influence behaviors, but has produced inconsistent results with respect to proposed moderators group identity and injunctive norms (IN), limiting its predictive value in diverse cultural groups. Cultural norms are one of many influences on breastfeeding behaviors, yet little is known about their mechanisms of influence. The TNSB has not been tested in the breastfeeding context or within an exclusively African American cultural group. Given this knowledge gap, a survey of 528 African American mothers in the Washington, D.C. area was conducted to test the moderating effects of IN and subjective norms (SN) and social identity on the descriptive norms (DN) to intentions relationship as predicted by the TNSB. Structural equation modeling was used to show that when controlling for education and breastfeeding history, norms significantly predicted 26.4% of the variance in breastfeeding intentions. SN and DN interacted negatively to enhance breastfeeding intentions. Latent profile analysis using ethnic pride, collectivism, and religiosity scales detected four profiles of African American social identity. Social identity profile membership was a significant moderator on the DN to intentions pathway in the structural equation model. Profiles with the highest ethnic pride were significantly influenced by DN to intend to breastfeed. Implications from this study for public health intervention and communication messaging are discussed.

Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia

BACKGROUND

Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic.

METHODS

A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews.

RESULTS

All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data.

CONCLUSION

Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

GAPEWORM (SYNGAMUS SPP.) PREVALENCE IN WISCONSIN GREATER PRAIRIE CHICKENS (TYMPANUCHUS CUPIDO PINNATUS)

Under Wisconsin state law, the greater prairie chicken (GRPC; Tympanuchus cupido pinnatus) has been listed as a threatened species since 1976. In 2014-15, we conducted a pilot study to determine the prevalence and intensity of gapeworms (Syngamus spp.) in female Wisconsin GRPCs collected from 2 monitored populations. We captured 62 female GRPCs using walk-in-style traps for females and night lighting for juveniles ≥45 days of age. From these individuals, we collected 15 carcasses of radio-marked birds, most of whom died due to predation events. Through dissection, we identified gapeworm in 20% of examined carcasses and report an intensity ranging between 4 and 74 worms.

Breastfeeding in Context: African American Women's Normative Referents, Salient Identities, and Perceived Social Norms

The purpose of this study was to describe social norms and salient social identities related to breastfeeding intentions among African American mothers in Washington, D.C. Five focus groups were held with 30 mothers who gave birth to a child between 2016 and 2019. Two coders conducted pragmatic thematic analysis. This study demonstrated that women hold different identities relevant to making infant feeding decisions, with mother being primary and race/ethnicity, age, and relationship status factoring into how they define themselves. Mothers drew their perceptions of what is common and accepted from family, friends, the "Black community," and what they perceived visually in their geographic area and heard from their health care providers. Mothers believed breastfeeding to be increasing in popularity and acceptability in African American communities in Washington, D.C., but not yet the most common or accepted mode of feeding, with some variability by socioeconomic status group. Implications for public health communication and social marketing are discussed.

Descriptive Analysis of a Telephone Based Community Monitoring Service for COVID-19

The coronavirus disease (COVID-19) pandemic has required health services to rapidly respond to the needs of people diagnosed with the virus. Over 80% of people diagnosed with COVID-19 experience a mild illness and there is a need for community management to support these people in their home. In this paper we present, a telephone based COVID-19 community monitoring service developed in an Australian public health network, and we describe the rapid implementation of the service and the demographic and clinical characteristics of those enrolled. A retrospective mixed methods evaluation of the COVID-19 community monitoring service using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Eight hundred and fifty COVID-19 positive patients were enrolled, 54% female, 45% male, mean age 34 years SD 17. Four hundred and nine (48%) patients were born outside Australia. Among the 850 patients, 305 (36%) were classified as having a high risk of serious illness from COVID-19. The most prevalent risk factors were cardiovascular disease (37%), lung disease (30%) and age over 60 years (26%). The most common reported ongoing symptoms were fatigue (55%), breathing issues (26%) and mental health issues such as low mood (19%). There were no deaths in patients that participated in the service. The process of risk stratification undertaken with telephone triage was effective in determining risk of prolonged illness from COVID-19. Telephone monitoring by trained health professionals has a strong potential in the effective management of patients with a mild COVID-19 illness.

The pre-exposure prophylaxis (PrEP) consciousness of black college women and the perceived hesitancy of public health institutions to curtail HIV in black women

Background

Consistent use of Pre-Exposure Prophylaxis (PrEP), a biomedical intervention for HIV seronegative persons, has been shown to significantly decrease HIV acquisition. Black women are a viable population segment to consider for PrEP use as their HIV incidence is overwhelmingly higher than all other women groups.

Methods

We developed and piloted a cultural- and age- appropriate PrEP education intervention to determine Black college women’s: 1) perceptions of and receptivity to PrEP use; and 2) preferences for PrEP information delivery.

Results

We recruited N = 43 Black college women. Most of our sample were sophomore and Juniors of whom identified as heterosexual (83%) and single (67%). Over 50% of young women had never been HIV tested and only 28% had been tested in the last 6 months; however, 100% of the women believed their HIV status was negative. Prior to participating in the study, most Black college women (67%) had not heard about PrEP and were unsure or apprehensive (72%) to initiate PrEP. The Black college women indicated that our educational intervention was extremely helpful (67%) for understanding and learning about PrEP. Post participating in our PrEP education module, regardless of delivery modality, participants reported being likely (62.55–70%) to initiate PrEP in the future.

Conclusions

Results indicate that Black college women would strongly consider PrEP when provided with basic knowledge, regardless of delivery modality. Participants also showed greater appreciation for in-person delivery and found it to be significantly more helpful and of greater quality for learning about PrEP; comprehension or perceived usefulness of PrEP-related content was relatively the same between groups. PrEP content delivery -- via in-person or online methods – is contingent on learning style and presentation.

Trial registration

This study has been registered under the ISRCTN Registry as of July 6, 2020. The trial registration number is ISRCTN14792715. This study was retrospectively registered.

Integrating HIV Pre-Exposure Prophylaxis into Family Planning Care: A RE-AIM Framework Evaluation

We aimed to systematically evaluate the feasibility of integrating HIV prevention services, including pre-exposure prophylaxis (PrEP), into a family planning setting in a high-prevalence community. We used the RE-AIM Framework (Reach, Efficacy, Adoption, Implementation, Maintenance) to evaluate the integration of HIV prevention services into a family planning clinic over 6 months. Before the integration, PrEP was not offered. We implemented a staff training program on HIV PrEP. We determined the proportion of women presenting to the clinic who were screened, eligible for, and initiated PrEP through chart review. We assessed staff comfort with PrEP pre- and post-integration. We compared planned and actual implementation, interviewed staff to determine barriers and facilitators, and tracked systems adaptations. We assessed maintenance of PrEP after the study concluded. There were 640 clinical encounters for 515 patients; the rate of HIV counseling and PrEP screening was 50%. The rate was 10% in month 1 and peaked to 65% in month 3. Nearly all screened patients were eligible for PrEP (98.4%) and 15 patients (6%) initiated PrEP. Staff knowledge and comfort discussing PrEP improved after education. Facilitators included partnering with local experts, continuing education, clinical tools for providers, and patient education materials. Barriers included competing priorities during clinical encounters, limited woman-centered patient education materials, and insurance-related barriers. Embedding HIV prevention services in the family planning setting was feasible in this pilot. The proportion of women screened for PrEP rapidly increased. In this high HIV prevalence community, nearly all screened women were eligible and 6% initiated PrEP.

The upgraded Polaris powder diffractometer at the ISIS neutron source

This paper describes the design and operation of the Polaris time-of-flight powder neutron diffractometer at the ISIS pulsed spallation neutron source, Rutherford Appleton Laboratory, UK. Following a major upgrade to the diffractometer in 2010-2011, its detector provision now comprises five large ZnS scintillator-based banks, covering an angular range of 6° ≤ 2θ ≤ 168°, with only minimal gaps between each bank. These detectors have a substantially increased solid angle coverage (Ω ∼ 5.67 sr) compared to the previous instrument (Ω ∼ 0.82 sr), resulting in increases in count rate of between 2× and 10×, depending on 2θ angle. The benefits arising from the high count rates achieved are illustrated using selected examples of experiments studying small sample volumes and performing rapid, time-resolved investigations. In addition, the enhanced capabilities of the diffractometer in the areas of in situ studies (which are facilitated by the installation of a novel design of radial collimator around the sample position and by a complementary programme of advanced sample environment developments) and in total scattering studies (to probe the nature of short-range atomic correlations within disordered crystalline solids) are demonstrated.

Differences in Medical Mistrust Between Black and White Women: Implications for Patient-Provider Communication About PrEP

Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention method. PrEP uptake has been persistently low among US women, particularly Black women, who account for 61% of new HIV diagnoses among women. Further understanding of barriers to Black women accessing PrEP is needed. This 2017 cross-sectional survey study explored race-based differences in PrEP interest and intention among women and the indirect association between race and comfort discussing PrEP with a healthcare provider through medical mistrust. The sample consisted of 501 adult women (241 Black; 260 White) who were HIV-negative, PrEP-inexperienced, and heterosexually active. Black women reported greater PrEP interest and intention than White women. However, Black women expressed higher levels of medical mistrust, which, in turn, was associated with lower comfort discussing PrEP with a provider. Medical mistrust may operate as a unique barrier to PrEP access among Black women who are interested in and could benefit from PrEP.

Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK

AIMS

To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age.

METHODS

We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes.

RESULTS

Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness.

CONCLUSIONS

The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Expression and Reception: An Analytic Method for Assessing Message Production and Consumption in CMC

This article presents an innovative methodology to study computer-mediated communication (CMC), which allows analysis of the multi-layered effects of online expression and reception. The methodology is demonstrated by combining the following three data sets collected from a widely tested eHealth system, the Comprehensive Health Enhancement Support System (CHESS): 1) a flexible and precise computer-aided content analysis; 2) a record of individual message posting and reading; and 3) longitudinal survey data. Further, this article discusses how the resulting data can be applied to online social network analysis and demonstrates how to construct two distinct types of online social networks - open and targeted communication networks - for different types of content embedded in social networks.

Does depression diagnosis and antidepressant prescribing vary by location? Analysis of ethnic density associations using a large primary-care dataset

BACKGROUND

Studies have linked ethnic differences in depression rates with neighbourhood ethnic density although results have not been conclusive. We looked at this using a novel approach analysing whole population data covering just over one million GP patients in four London boroughs.

METHOD

Using a dataset of GP records for all patients registered in Lambeth, Hackney, Tower Hamlets and Newham in 2013 we investigated new diagnoses of depression and antidepressant use for: Indian, Pakistani, Bangladeshi, black Caribbean and black African patients. Neighbourhood effects were assessed independently of GP practice using a cross-classified multilevel model.

RESULTS

Black and minority ethnic groups are up to four times less likely to be newly diagnosed with depression or prescribed antidepressants compared to white British patients. We found an inverse relationship between neighbourhood ethnic density and new depression diagnosis for some groups, where an increase of 10% own-ethnic density was associated with a statistically significant (p < 0.05) reduced odds of depression for Pakistani [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.70-0.93], Indian (OR 0.88, CI 0.81-0.95), African (OR 0.88, CI 0.78-0.99) and Bangladeshi (OR 0.94, CI 0.90-0.99) patients. Black Caribbean patients, however, showed the opposite effect (OR 1.26, CI 1.09-1.46). The results for antidepressant use were very similar although the corresponding effect for black Caribbeans was no longer statistically significant (p = 0.07).

CONCLUSION

New depression diagnosis and antidepressant use was shown to be less likely in areas of higher own-ethnic density for some, but not all, ethnic groups.

In situ neutron powder diffraction study of the reaction M2O3 ↔ M3O4 ↔ MO, M = (Fe0.2Mn0.8): implications for chemical looping with oxygen uncoupling

The structural properties of (Fe_0.2Mn_0.8)_xO_y as a function of temperature under differing oxidizing and reducing atmospheres have been investigated using thermal gravimetric analysis and neutron powder diffraction techniques.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study

PURPOSE

People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.

METHODS

E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.

RESULTS

In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).

CONCLUSIONS

There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Congenital high myopia and central macular atrophy: a report of 3 families

AIMS

To report the clinical phenotype in a series of four children from three families with the rare association of high myopia, central macular atrophy, and normal full-field electroretinography (ERG).

METHODS

Four male patients were ascertained with reduced vision, nystagmus, and atrophy of the macula from early childhood. Patients underwent full ophthalmic examination, electrophysiological testing, and retinal imaging.

RESULTS

Minimum duration of follow-up was 8 years. At last review, visual acuity ranged from 0.22 to 1.20 logMAR (6/9.5-6/95 Snellen) at a mean age of 10.5 years (median 9.5 years, range 9-14 years). Refractive error ranged from a spherical equivalent of -7.40 D to -24.00 D. Three had convergent squint. Fundus examination and imaging demonstrated bilateral macular atrophy in all patients that varied from mild atrophy of the retinal pigment epithelium (RPE) to well-demarcated, punched-out atrophic lesions of retina, RPE, and choroid. Flash ERG was normal under photopic and scotopic conditions in all patients. Pattern ERG, performed in three patients, was consistent with mild to severe macular dysfunction. Progression of the area of atrophy was evident in one patient and of the myopia in two patients but all patients had stable visual acuity.

CONCLUSIONS

Patients with congenital high myopia and macular atrophy present in infancy with reduced visual acuity and nystagmus. The macular atrophic lesions vary in size and severity but electrophysiological testing is consistent with dysfunction confined to the macula. There was no deterioration in visual acuity over 8-10 years of monitoring.

Order/disorder phenomena in Zn1-xMnxGa2Se4 ordered vacancy compounds: high temperature neutron powder diffraction experiments

We present a study of order-disorder phenomena in the series of tetrahedral ordered vacancy compounds Zn1-xMnxGa2Se4 by means of time-of-flight neutron diffraction at high temperature together with dc magnetic susceptibility, Raman spectroscopy, differential thermal analysis and optical absorption experiments. Samples of nominal composition x = 0, 0.24, 0.5, 0.77 and 1 have been studied. An order-disorder phase transition has been detected, with Tc ranging from 472 to 610 ° C, which involves a structural change from a defect chalcopyrite phase, with I4 space group (s.g.) and three different cation sites, to a partially disordered defect stannite, in which Zn, Mn and half of the Ga ions share the 4d site in I42m s.g. Neither the vacancies nor the Ga ions occupying site 2a are involved in the phase transition. An additional ordering process is observed on approaching the phase transition from below, which is attributed to several factors: the activation of cation diffusion at ∼300 ° C, the partially disordered cation distribution exhibited by the as-grown single crystals and the preference of Mn atoms for the 2d crystallographic site in the I4 structure. The reversibility of the phase transition is analysed with the aid of magnetic, optical and Raman experiments.

Neutron powder diffraction and molecular dynamics study of superionic SrBr2

The nature of the dynamic ionic disorder within the high-temperature superionic phase of strontium bromide, β-SrBr2, has been investigated using reverse Monte Carlo (RMC) modelling of neutron powder diffraction data and complementary ab initio molecular dynamics (MD) simulations. The RMC and MD results are in good agreement and indicate the presence of extensive dynamic disorder within the Br(-) sublattice of the cubic fluorite structure. Rapid anion diffusion predominantly occurs as hops between nearest neighbour sites in the 〈100〉 directions, though the trajectories are markedly curved and pass through the peripheries of the octahedral voids in the cation sublattice. In addition, there are extensive correlations between the motions of individual Br(-), often leading to the formation of a short-lived square antiprism co-ordination environment around the Sr(2+). Such polyhedra are observed within the (ambient temperature) ordered tetragonal crystal structure of α-SrBr2. The nature of the ionic disorder in SrBr2 is of particular interest because it is the only known example of a Br(-)-ion superionic. Owing to the large size of this anion, a comparison with the behaviour of other superionic phases gives an insight into the role of ionic size on the conducting properties within these materials.

Total scattering analysis of cation coordination and vacancy pair distribution in Yb substituted δ-Bi2O3

Reverse Monte Carlo (RMC) modelling of neutron total scattering data, combined with conventional Rietveld analysis of x-ray and neutron data, has been used to describe the cation coordination environments and vacancy pair distribution in the oxide ion conducting electrolyte Bi3YbO6. The thermal variation of the cubic fluorite unit cell volume, monitored by variable temperature x-ray and neutron experiments, reveals significant curvature, which is explained by changes in the oxide ion distribution. There is a significant increase in tetrahedral oxide ion vacancy concentration relative to δ-Bi2O3, due to the creation of Frenkel defects associated with the Yb(3+) cation. The tetrahedral oxide ion vacancy concentration increases from room temperature to 800 °C, but little change is observed in the vacancy pair distribution with temperature. The vacancy pair distributions at both temperatures are consistent with a favouring of [100] vacancy pairs.

Progression of chronic kidney disease in a multi-ethnic community cohort of patients with diabetes mellitus

AIMS

Ethnicity is a risk factor for the prevalence of severe chronic kidney disease among patients with diabetes. We studied the effect of ethnicity on progression of chronic kidney disease in people with diabetes managed in community settings.

METHODS

A 5-year retrospective, community-based cohort study of 3855 people with diabetes mellitus of white, black or South Asian ethnicity with an estimated glomerular filtration rate of < 60 ml min⁻¹ 1.73 m⁻² was undertaken. From 135 general practices in east London, all cases with at least 3 years clinical data were included. Using repeated-measures analysis, the annual decline in estimated glomerular filtration rate was calculated. Comparisons between the rate of decline in the three main ethnic groups, with and without proteinuria at baseline, were made.

RESULTS

The annual adjusted decline in estimated glomerular filtration rate for this cohort was 0.85 ml min⁻¹ 1.73 m⁻². The rate of chronic kidney disease progression was significantly greater in South Asian groups (-1.01 ml min⁻¹ 1.73 m⁻²) compared with white groups (-0.70 ml min⁻¹ 1.73 m⁻²) (P = 0.001). For those with proteinuria at baseline, the annual decline was greater at 2.05 ml min⁻¹ 1.73 m⁻², with both South Asian and black groups having a significantly faster rate of decline than white groups.

CONCLUSIONS

For patients with diabetes and chronic kidney disease managed in primary care, the annual decline of renal function is less than previously thought and approximates the age-related annual decline of 1 ml min⁻¹ 1.73 m⁻². Patients with proteinuria and those of South Asian and Black ethnicity need additional monitoring as they are at greater risk of rapid chronic kidney disease progression.

Periosteal muscle anchoring for large angle incomitant squint

PURPOSE

To describe a surgical technique for correcting very large angle exodeviations and determine long term outcomes leading to the evolution of surgical technique.

METHODS

A consecutive series of seven patients with large angle, incomitant squint were operated on at Moorfields Eye Hospital over a five-year period using periosteal anchoring by a joint Strabismus/Adnexal team. All patients underwent anchoring of the insertion of the medial rectus (MR) muscle to the periosteum of the medial orbital wall via a retrocaruncular approach, with or without lateral rectus (LR) disinsertion and suturing to the lateral orbital rim connective tissue. Retrospective analysis of notes assessed previous procedures, prism dioptre (PD) deviations and complications.

RESULTS

Included were seven eyes (five right, two left) of seven patients (two female, five male). Median age at first anchoring procedure was 25 years (range 4-57). Mean follow up was 34 months (range 8-66). Six patients had long-standing third nerve palsy, one patient had Moebius syndrome. Pre-operative exotropia ranged from 45 to 115 PDs (mean 76, median 75). At the final follow up, all patients had reduced horizontal deviations ranging from 0 to 80 PDs (mean 34, median 30). Further surgery was required in three patients all of whom did not undergo release of the LR muscle at the first procedure.

CONCLUSION

Large angle incomitant divergent squints present a particularly difficult surgical challenge. We advocate a combined bi-rectus fixation approach to hold the globe in the primary position.

Cancer information scanning and seeking in the general population

The amount of cancer-related information available in the media and other sources continues to increase each year. We wondered how people make use of such content in making specific health decisions. We studied both the information they actively seek ("seeking") and that which they encounter in a less purposive way ("scanning") through a nationally representative survey of adults aged 40-70 years (n = 2,489) focused on information use around three prevention behaviors (dieting, fruit and vegetable consumption, and exercising) and three screening test behaviors (prostate-specific antigen, colonoscopy, mammogram). Overall, respondents reported a great deal of scanning and somewhat less seeking (on average 62% versus 28% for each behavior), and they used a range of sources including mass media, interpersonal conversations, and the Internet, alongside physicians. Seeking was predicted by female gender, age of 55-64 vs. 40-44, higher education, Black race and Hispanic ethnicity, and being married. Scanning was predicted by older age, female gender, and education. Respondents were fairly consistent in their place on a typology of scanning and seeking across behaviors. Seeking was associated with all six behaviors, and scanning was associated with three of six behaviors.

The effect of ethnicity on the prevalence of diabetes and associated chronic kidney disease

BACKGROUND

The effect of ethnicity on the prevalence of diabetes mellitus (DM) and associated chronic kidney disease (CKD) is unknown.

AIM

To establish the impact of ethnicity on the prevalence and severity of diabetes mellitus and associated CKD.

DESIGN

Cross-sectional study of 34 359 adult diabetic patients in three primary care trusts in the UK.

METHODS

Read coded data from general practice computers was used to analyse the relationship between ethnicity, DM and CKD.

RESULTS

The prevalence of DM was 3.5% for Whites, 11% for South Asians and 8% for Black groups. The prevalence of CKD (stages 3-5) among diabetics was 18%. CKD stage 3 was more prevalent in Whites compared to South Asians--OR 0.79 (95% CI: 0.71-0.87) and Blacks--OR 0.49 (95% CI: 0.43-0.57). Among all CKD patients severity (CKD stages 4, 5) was associated with Black (OR 1.39, 95% CI: 1.06-1.81) and South Asian (OR 1.54, 95% CI: 1.26-1.88) ethnicity compared to Whites. Less than 50% of diabetics with CKD met the target blood pressure (BP) of 130/80 mmHg. The prevalence of a blood pressure > 150/90 mmHg in diabetics with CKD was South Asian 15.6%, White 13.9%, Black 21.8% (P < 0.001). Proteinuria was present in 8.6% of all diabetic patients. However, this increased to 18.6% in patients with CKD, and was more frequent in Black (22.6%) and South Asian (21%) patients compared to White patients (14.1%) (P < 0.001).

CONCLUSION

Significant disparities exist between the major ethnic groups in both disease prevalence and management. Future studies examining the management of CKD need to take variation by ethnicity into account.

A high temperature cell for simultaneous electrical resistance and neutron diffraction measurements

An in situ cell that allows the electrical resistance of a sample pellet to be measured while performing neutron diffraction experiments has been developed at the ISIS pulsed neutron source. The sample is held between two spring loaded platinum electrodes embedded in a boron nitride clamp assembly with the resistance measured using the four-probe method. An outer quartz glass jacket allows the atmosphere within the sample enclosure to be controlled, and the entire device can be accommodated within a standard ISIS neutron furnace for measurements at temperatures up to 1270 K. The operation of this cell is illustrated using data for the structural, magnetic, and electrical properties of chalcopyrite CuFeS(2) collected over the temperature range of 398-873 K on the Polaris powder diffractometer at ISIS.

Ionic diffusion within the α(*) and β phases of Ag(3)SI

The ionic diffusion mechanism of mobile ions within an underlying body-centred cubic (bcc) sublattice of immobile counterions is discussed. In particular, the case of equal numbers of two ionic species forming long-range ordered and disordered bcc arrays is considered, since these form the basis of the cubic perovskite and α-AgI-type crystal structures, respectively. Their structural behaviour, and its influence on the dynamic ionic disorder which characterizes superionic conduction, is illustrated for the case of Ag(+) diffusion within the β and α(*) phases of Ag(3)SI. The calculated behaviour obtained by molecular dynamics (MD) computer simulations is validated with reference to published neutron diffraction and ionic conductivity measurements of Ag(3)SI, and used to examine the preferred diffusion pathways. The relevance of these findings for the anion conduction mechanisms within perovskite structured compounds is briefly discussed.

Neutron Powder Diffraction Study of Pb(HfxTi1-x)O3 Ceramics (0.10 ≤ x ≤ 0.50)

The crystal symmetries of lead hafnate titanate (Pb(HfxTi1-x)O3, PHT) powders with 0.10<or=x<or=0.50 were investigated by high-resolution neutron powder diffraction. Samples with x<or=0.40 were tetragonal (space group P4 mm), while the sample with x=0.50 contained both monoclinic Cm and rhombohedral (modeled using the R3c space group) phases. The role of the B cations (Hf and Ti) and the oxygen octahedra network, in addition to the displacement of Pb ions from their ideal sites, in promoting the phase transformation between the P4 mm and Cm phases was considered. Two types of structural disorder were identified. Diffuse scattering between Bragg reflection peaks was assigned to Pb ion displacement. A second type of structural disorder, revealed by the weak intensities of observed pseudo-cubic 00l reflections with l even and as 00l reflection peak widths significantly broader than the l00 reflection peaks, was observed. This behavior was attributed to disorder in the arrangement of the O-B-O rows parallel to the c axis. For small values of x, this shift was predominantly along the c axis, whereas shifts perpendicular to the c axis increased with increasing x. These features were modeled using an hkl-dependent line-broadening model. The origin of the hkl-dependent line broadening was assigned to the microstrain accompanying a spatial-composition variation. Structural models were tested by computing valence sums and spontaneous polarization values.

Collapsing cristobalitelike structures in silica analogues at high pressure

The cristobalitelike forms of the ternary silica analogues BPO4 and BAsO4 were investigated at high pressure by x-ray diffraction and theoretical methods. The behavior of these compounds represents an extreme case in which the tilt angle of the constituent tetrahedra increases in a spectacular way at high pressure resulting in a major change in topology from a cristobalitelike framework towards a "collapsed cristobalite" structure. These compounds provide the first examples of the collapse of a framework structure to a close-packed form in a continuous manner without an intervening phase transition.