Injuries to the anterior cruciate ligament (ACL) are immediately disabling and are associated with long-term consequences, such as posttraumatic osteoarthritis. It is important to have a comprehensive understanding of all possible risk factors for ACL injury to identify individuals who are at risk for future injuries and to provide an appropriate level of counseling and programs for prevention.
This review, part 2 of a 2-part series, highlights what is known and still unknown regarding hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors for ACL injury.
Studies were identified from MEDLINE (1951–March 2011) using the MeSH terms anterior cruciate ligament, knee injury, and risk factors. The bibliographies of relevant articles and reviews were cross-referenced to complete the search.
Prognostic case-control and prospective cohort study designs to evaluate risk factors for ACL injury were included in this review.
A total of 50 case-control and prospective cohort articles were included in parts 1 and 2. Twenty-one focused on hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors.
Several risk factors are associated with increased risk of suffering ACL injury—such as female sex, prior reconstruction of the ACL, and familial predisposition. These risk factors most likely act in combination with the anatomic factors reviewed in part 1 of this series to influence the risk of suffering ACL injury.
anterior cruciate ligament (ACL); knee injury; risk factors
Research using electronic health records (EHRs) relies heavily on coded clinical data. Due to variation in coding practices, it can be difficult to aggregate the codes for a condition in order to define cases. This paper describes a methodology to develop ‘indicator markers’ found in patients with early rheumatoid arthritis (RA); these are a broader range of codes which may allow a probabilistic case definition to use in cases where no diagnostic code is yet recorded.
We examined EHRs of 5,843 patients in the General Practice Research Database, aged ≥30y, with a first coded diagnosis of RA between 2005 and 2008. Lists of indicator markers for RA were developed initially by panels of clinicians drawing up code-lists and then modified based on scrutiny of available data. The prevalence of indicator markers, and their temporal relationship to RA codes, was examined in patients from 3y before to 14d after recorded RA diagnosis.
Indicator markers were common throughout EHRs of RA patients, with 83.5% having 2 or more markers. 34% of patients received a disease-specific prescription before RA was coded; 42% had a referral to rheumatology, and 63% had a test for rheumatoid factor. 65% had at least one joint symptom or sign recorded and in 44% this was at least 6-months before recorded RA diagnosis.
Indicator markers of RA may be valuable for case definition in cases which do not yet have a diagnostic code. The clinical diagnosis of RA is likely to occur some months before it is coded, shown by markers frequently occurring ≥6 months before recorded diagnosis. It is difficult to differentiate delay in diagnosis from delay in recording. Information concealed in free text may be required for the accurate identification of patients and to assess the quality of care in general practice.
Based on studies in mice and humans, cohesin loss from chromosomes during the period of protracted meiotic arrest appears to play a major role in chromosome segregation errors during female meiosis. In mice, mutations in meiosis-specific cohesin genes cause meiotic disturbances and infertility. However, the more clinically relevant situation, heterozygosity for mutations in these genes, has not been evaluated. We report here evidence from the mouse that partial loss of gene function for either Smc1b or Rec8 causes perturbations in the formation of the synaptonemal complex (SC) and affects both synapsis and recombination between homologs during meiotic prophase. Importantly, these defects increase the frequency of chromosomally abnormal eggs in the adult female. These findings have important implications for humans: they suggest that women who carry mutations or variants that affect cohesin function have an elevated risk of aneuploid pregnancies and may even be at increased risk of transmitting structural chromosome abnormalities.
Chromosome segregation errors during meiosis are the leading cause of birth defects and miscarriages in humans. While the basis for these errors is unknown, recent studies suggest that defective sister chromatid cohesion may be an important contributor. Accordingly, we tested the hypothesis that partial loss of gene function for either of two meiosis-specific cohesins, Smc1b or Rec8, might adversely affect synapsis or recombination between homologs during meiotic prophase. Our analyses of different mouse models demonstrate cohesin dosage effects on meiosis in both males and females. Importantly, reduced gene function led to an increase the frequency of chromosomally abnormal eggs in the adult female, suggesting that, in humans, women carrying cohesin mutations may be at an increased risk of chromosomally abnormal pregnancies.
Injuries to the anterior cruciate ligament (ACL) of the knee are immediately debilitating and can cause long-term consequences, including the early onset of osteoarthritis. It is important to have a comprehensive understanding of all possible risk factors for ACL injury to identify individuals who are at risk for future injuries and to provide an appropriate level of counseling and programs for prevention.
This review, part 1 of a 2-part series, highlights what is known and still unknown regarding anatomic and neuromuscular risk factors for injury to the ACL from the current peer-reviewed literature.
Studies were identified from MEDLINE (1951–March 2011) using the MeSH terms anterior cruciate ligament, knee injury, and risk factors. The bibliographies of relevant articles and reviews were cross-referenced to complete the search.
Prognostic studies that utilized the case-control and prospective cohort study designs to evaluate risk factors for ACL injury were included in this review.
A total of 50 case-control and prospective cohort articles were included in the review, and 30 of these studies focused on neuromuscular and anatomic risk factors.
Several anatomic and neuromuscular risk factors are associated with increased risk of suffering ACL injury—such as female sex and specific measures of bony geometry of the knee joint, including decreased intercondylar femoral notch size, decreased depth of concavity of the medial tibial plateau, increased slope of the tibial plateaus, and increased anterior-posterior knee laxity. These risk factors most likely act in combination to influence the risk of ACL injury; however, multivariate risk models that consider all the aforementioned risk factors in combination have not been established to explore this interaction.
Anterior Cruciate Ligament; knee injury; risk factors
The purpose of this study was to describe the resource use and associated direct costs of diabetes care for patients with type 2 diabetes mellitus in the 6 months before and after initiation of insulin therapy.
INSTIGATE is a prospective, noninterventional, multicenter study of patients with type 2 diabetes who were initiating insulin for the first time as part of their usual care in 2006. The study was conducted in France, Germany, Greece, Spain, and the UK, and observed the course of diabetes therapy for up to 6 months. Direct medical costs were evaluated from the national health care system (third-party payer) perspective at 2006 prices.
Of the 1153 patients with type 2 diabetes, 1051 (91.2%) had follow-up visits in the 6 months after insulin initiation and were included in the cost analysis. In all countries in our study, mean total direct costs per patient increased in the 6-month follow-up period, compared with the 6-month period prior to insulin initiation, and ranged from €577 in Greece to €1402 in France. The incremental cost of adding insulin treatment ranged from €81 in France to €471 in Spain.
In all countries, the mean total direct cost of care for diabetes increased after starting insulin. The breakdown of total direct costs by expenditure category varied considerably across countries, reflecting differences in resource use patterns, prices of medical resources, and different health care systems.
type 2 diabetes mellitus; costs; resource use; insulin
To examine changes in insulin regimens and glycemic control during the 24 months after initiation of insulin in patients with type 2 diabetes mellitus.
Data were collected over a 24-month period from patients requiring insulin initiation as part of usual care, in a prospective, observational study. Changes in insulin regimens and hemoglobin A1c (HbA1c) were examined within countries (Germany, Greece, Spain) and overall.
Prandial insulin only was most commonly initiated in Germany, while basal or premixed formulations were initiated in Greece and Spain. In Germany, compared with Greece or Spain, the patients were slightly younger and had a shorter diabetes duration when initiating insulin. For patients overall, 76.1% did not change their insulin regimen between initiation and 24 months. The most obvious change was a shift from prandial to basal/bolus in Germany, with almost doubling of mean daily insulin dose; in Greece and Spain, more patients stopped using insulin and the trend to more complex regimens was not seen. Overall, mean (SD) HbA1c decreased from baseline (9.4 [1.7]%) to 6 months (7.2 [1.0]%), but with little further change through 24 months (7.2 [1.1]%). HbA1c change with basal/bolus insulin (−2.6 [2.0]%, baseline 10.1%) was greater than with basal only (−2.0 [1.8]%, baseline 9.3%). Mean HbA1c less than 7% was achieved and maintained over 24 months in Germany, but was not achieved at any time in Greece or Spain.
Within 24 months of insulin initiation, the majority of patients with type 2 diabetes remained on the same insulin regimen initially instigated, despite the well-established progressive loss of prandial and basal endogenous insulin secretion. Adequate glycemic control was best achieved where insulin dosage adjustments and insulin intensification took place.
Basal/bolus insulin; Glycemic control; Insulin therapy; Insulin regimen; Prandial insulin; Type 2 diabetes
High maternal mortality in India is a serious public health challenge. Demand side financing interventions have emerged as a strategy to promote access to emergency obstetric care. Two such state run programs, Janani Suraksha Yojana (JSY)and Chiranjeevi Yojana (CY), were designed and implemented to reduce financial access barriers that preclude women from obtaining emergency obstetric care. JSY, a conditional cash transfer, awards money directly to a woman who delivers in a public health facility. This will be studied in Madhya Pradesh province. CY, a voucher based program, empanels private obstetricians in Gujarat province, who are reimbursed by the government to perform deliveries of socioeconomically disadvantaged women. The programs have been in operation for the last seven years.
The study outlined in this protocol will assess and compare the influence of the two programs on various aspects of maternal health care including trends in program uptake, institutional delivery rates, maternal and neonatal outcomes, quality of care, experiences of service providers and users, and cost effectiveness. The study will collect primary data using a combination of qualitative and quantitative methods, including facility level questionnaires, observations, a population based survey, in-depth interviews, and focus group discussions. Primary data will be collected in three districts of each province. The research will take place at three levels: the state health departments, obstetric facilities in the districts and among recently delivered mothers in the community.
The protocol is a comprehensive assessment of the performance and impact of the programs and an economic analysis. It will fill existing evidence gaps in the scientific literature including access and quality to services, utilization, coverage and impact. The implementation of the protocol will also generate evidence to facilitate decision making among policy makers and program managers who currently work with or are planning similar programs in different contexts.
India; Demand side financing; Maternal morality; Chiranjeevi yojana; Janani suraksha yojana
This study explored the psychometric properties (internal consistency, construct validity, discriminative ability) of the Juniper Mini Asthma Quality of Life Questionnaire (Mini AQLQ-J) and the Sydney Asthma Quality of Life Questionnaire (AQLQ-S).
One hundred fourty-six adults (18–45 years) with asthma requiring regular inhaled corticosteroids were recruited to a trial of written emotional disclosure. Correlational analyses were performed to understand the relationship of the two measures with each other, with symptoms, lung function, asthma control, asthma bother and generic quality of life. Median quality of life scores were compared according to gender, health care usage and levels of asthma severity.
AQLQ-J and AQLQ-S total scores correlated strongly with each other (rho = −0.80) and moderately with the EuroQol Current Health Status Scale (AQLQ-J: rho = 0.35; AQLQ-S: rho = −0.40). Domain score correlations between AQLQ-J and AQLQ-S were mostly moderate (0.50 < rho < 0.80).
Both QoL measures were significantly correlated with symptom score. Correlations with the symptom score asthma module (AQLQ-J: rho = −0.69; AQLQ-S: rho = 0.50) were stronger compared with the total symptom score and the symptom score rhinitis module (AQLQ-J: rho = −0.41; AQLQ-S: rho =0.31).
Neither QoL measure was significantly correlated with FEV1, % predicted at the total or the domain level.
Total scores of both measures were significantly correlated with subjective asthma control (AQLQ-J: rho = 0.68; AQLQ-S: rho = −0.61) and asthma bother (AQLQ-J: rho = −0.73; AQLQ-M: rho = 0.73).
Total AQLQ-J score and total AQLQ-S score were significantly associated with perceived asthma severity (AQLQ-J: p=0.004, AQLQ-S: p=0.002) and having visited a GP in the past four months (AQLQ-J: p=0.003, AQLQ-S: p=0.002).
This study provides further evidence for the validity of the AQLQ-J and the AQLQ-S in a British population of adult patients with asthma managed in primary care. Correlations with lung function parameters were weak or absent. Correlations with generic quality of life were moderate, those with asthma symptoms, asthma control and asthma bother were strong. Both measures are able to discriminate between levels of asthma severity and health care usage.
Large cytomegalovirus (CMV)-specific CD8 T-cell responses are observed in both young and, somewhat more often, old people. Frequent CMV reactivation is thought to exhaust these cells and render them dysfunctional so that larger numbers of them are needed to control CMV. Expansions of CMV-specific CD4 T cells are also seen but are less well studied. In this study, we examined the T-cell response to the dominant CMV pp65 and IE-1 antigens in healthy CMV-infected people across a wide age range (20 to 84 years) by using multicolor flow cytometry. CMV-specific T cells were characterized by the activation markers CD40 ligand (CD40L), interleukin-2 (IL-2), tumor necrosis factor alpha (TNF-α), and gamma interferon (IFN-γ) and the memory markers CD27 and CD45RA. The proportions of effector memory T cells increased in large responses, as did the proportions of polyfunctional CD8 (IFN-γ+ IL-2+/− TNF-α+) and CD4 (CD40L+/− IFN-γ+ IL-2+ TNF-α+) T-cell subsets, while the proportion of naïve T cells decreased. The bigger the CD4 or CD8 T-cell response to pp65, the larger was the proportion of T cells with an advanced memory phenotype in the entire (including non-CMV-specific) T-cell compartment. In addition, the number of activation markers per cell correlated with the degree of T-cell receptor downregulation, suggesting increased antigen sensitivity in polyfunctional cells. In summary, our findings show that polyfunctional CMV-specific T cells were not superseded by dysfunctional cells, even in very large responses. At the same time, however, the memory subset composition of the entire T-cell compartment correlated with the size of the T-cell response to CMV pp65, confirming a strong effect of CMV infection on the immune systems of some, but not all, infected people.
Health policy makers now have access to a greater number and variety of systematic reviews to inform different stages in the policy making process, including reviews of qualitative research. The inclusion of mixed methods studies in systematic reviews is increasing, but these studies pose particular challenges to methods of review. This article examines the quality of the reporting of mixed methods and qualitative-only studies.
We used two completed systematic reviews to generate a sample of qualitative studies and mixed method studies in order to make an assessment of how the quality of reporting and rigor of qualitative-only studies compares with that of mixed-methods studies.
Overall, the reporting of qualitative studies in our sample was consistently better when compared with the reporting of mixed methods studies. We found that mixed methods studies are less likely to provide a description of the research conduct or qualitative data analysis procedures and less likely to be judged credible or provide rich data and thick description compared with standalone qualitative studies. Our time-related analysis shows that for both types of study, papers published since 2003 are more likely to report on the study context, describe analysis procedures, and be judged credible and provide rich data. However, the reporting of other aspects of research conduct (i.e. descriptions of the research question, the sampling strategy, and data collection methods) in mixed methods studies does not appear to have improved over time.
Mixed methods research makes an important contribution to health research in general, and could make a more substantial contribution to systematic reviews. Through our careful analysis of the quality of reporting of mixed methods and qualitative-only research, we have identified areas that deserve more attention in the conduct and reporting of mixed methods research.
To examine substance use and mental health disparities between sexual minority girls and heterosexual girls.
Data from the Pittsburgh Girls Study were analyzed. All girls were 17 years old. Girls were included if they were not missing self-reported sexual orientation and mental health data (N = 527). Thirty-one girls (6%) endorsed same-sex romantic orientation/identity or current same-sex attraction. Bivariate analyses were conducted to test group differences in the prevalence of substance use and suicidal behavior, and group differences in depression, anxiety, borderline personality disorder (BPD), oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms.
Compared with heterosexual girls, sexual minority girls reported higher past-year rates of cigarette, alcohol, and heavy alcohol use, higher rates of suicidal ideation and self-harm, and higher average depression, anxiety, BPD, ODD, and CD symptoms.
Sexual minority girls are an underrepresented group in the health disparities literature, and compared with heterosexual girls, they are at higher risk for mental health problems, most likely because of minority stress experiences such as discrimination and victimization. The disparities found in this report highlight the importance of discussing sexual orientation as part of a comprehensive preventive care visit.
LGBT health; Sexual minority girls; Adolescent substance use; Adolescent mental health disparities
Cases of polio in India declined after the implementation of the polio eradication programme especially in these recent years. The programme includes surveillance of acute flaccid paralysis (AFP) to detect and diagnose cases of polio at early stage. Under this surveillance, over 40,000 cases of AFP are reported annually since 2007 regardless of the number of actual polio cases. Yet, not much is known about these children. We conducted a qualitative research to explore care and support for children with AFP after their diagnosis.
The research was conducted in a district of western Uttar Pradesh classified as high-risk area for polio. In-depth interviews with parents of children with polio (17), with non-polio AFP (9), healthcare providers (40), and key informants from community including international and government officers, religious leaders, community leaders, journalists, and academics (21) were performed.
Minimal medicine and attention were provided at government hospitals. Therefore, most parents preferred private-practice doctors for their children with AFP. Many were visited at homes to have stool samples collected by authorities. Some were visited repetitively following the sample collection, but had difficulty in understanding the reasons for these visits that pertained no treatment. Financial burden was a common concern among all families. Many parents expressed resentment for their children's disease, notably have been affected despite receiving multiple doses of polio vaccine. Both parents and healthcare providers lacked information and knowledge, furthermore poverty minimised the access to available healthcare services. Medicines, education, and transportation means were identified as foremost needs for children with AFP and residual paralysis.
Despite the high number of children diagnosed with AFP as part of the global polio eradication programme, we found they were not provided with sufficient medical support following their diagnosis. Improvement in the quality and sufficiency of the healthcare system together with integration of AFP surveillance with other services in these underprivileged areas may serve as a key solution.
Acute flaccid paralysis; AFP Surveillance; Healthcare; India; Poliomyelitis; Pulse Polio Programme; Residual paralysis
Post-exposure prophylaxis (PEP) following sexual exposure to HIV has been recommended as a method of preventing HIV infection in the UK. Men who have sex with men (MSM) are the group most affected by HIV in the UK and their sexual risk taking behaviour is reported to be increasing. One-to-one behavioural interventions, such as motivational interviewing (MI) have been recommended to reduce HIV in high risk groups. The Information, Motivation and Behavioral skills (IMB) model has been shown to provide a good basis for understanding and predicting HIV-relevant health behaviour and health behaviour change, however the IMB has yet to be applied to PEP after risky sexual exposure. The primary aim of this trial is to examine the impact of MI augmented with information provision and behavioural skills building (informed by the IMB Model), over and above usual care, on risky sexual behaviour in MSM prescribed PEP after potential sexual exposure. A secondary aim of this research is to examine the impact of the intervention on adherence to PEP. This study will also provide estimates of the cost-effectiveness of the intervention.
A manualised parallel group randomised controlled trial with economic evaluation will be conducted. The primary outcome is the proportion of risky sexual practices. Secondary outcomes include: i) Levels of adherence to PEP treatment; ii) Number of subsequent courses of PEP; iii) Levels of motivation to avoid risky sexual behaviours; iv) Levels of HIV risk-reduction information/knowledge; v) Levels of risk reduction behavioural skills; vi) Diagnosis of anal gonorrhoea, Chlamydia and/or HIV. 250 participants will be asked to self-complete a questionnaire at four time points during the study (at 0,3,6,12 months). The intervention will consist of a two-session, fixed duration, telephone administered augmented MI intervention based on the IMB model. A newly developed treatment manual will guide the selection of persuasive communication strategies as appropriate for each participant and will be based on underlying change mechanisms specified by the IMB theoretical framework. Information provision and skills building will also be included in the intervention package through the use of information leaflets and tailored action plans. Fidelity of intervention delivery will be assessed.
The results from this NIHR funded study will identify whether it is appropriate and cost-effective to intervene using one-to-one telephone calls with MSM seeking PEP. If the intervention is effective, further work will be needed on training staff to deliver the intervention competently.
Trial registration numbers
UKCRN ID:11436; ISRCTN00746242.
Sexual behaviour; HIV; Motivational interviewing; Post-exposure-prophylaxis; Intervention
Pain assessment in children can be extremely challenging. Most professional bodies recommend that parents or carers should be involved with their child's pain assessment; but the evidence that parents can accurately report pain on behalf of their children is mixed. Our objective was to examine whether there were differences in post-operative pain score ratings between the child, nurse and parent or carer after surgery. Cognitively intact children aged four upwards, undergoing all surgical procedures, whose parents were present in the post-anaesthetic recovery unit (PACU), were studied. Thirty-three children were included in the study. The numerical rating scale was used to rate the child's pain by the child, nurse and parent on arrival to the PACU and prior to discharge. We found strong correlations between children's, nurses' and parent's pain scores on admission and discharge from PACU. The intraclass correlation coefficient of pain scores reported by children, nurses and parents was 0.94 (95% confidence intervals 0.91-0.96, P<0.0001). In cognitively intact children, it is adequate to manage pain based upon the assessment of children's and nurses' pain scores alone. The numerical rating scale appeared to be suitable for younger children. Whilst there are benefits of parents being present in recovery, it is not essential for optimizing the assessment of pain.
pain measurement; nursing; postoperative diagnosis; child behavior; parents; psychology.
The prevalence of complementary and alternative medicine (CAM) use among women in the United States is high. Little is known about how CAM use may differ based on sexual orientation. Study aims were to measure the prevalence of CAM use in a community sample of women, explore differences in CAM use patterns by sexual orientation, and identify correlates of CAM use.
Analyses were based on women (Total N = 879; n = 479 lesbians) enrolled in the Epidemiologic STudy of HEalth Risk in Women (ESTHER) Project, a cross-sectional heart-disease risk-factor study.
Data were collected through convenience sampling of adult females in Pittsburgh, PA (2003–2006).
Main outcome measures included lifetime and past 12-month CAM use, and types of CAM modalities used in the past 12 months.
The prevalence of having ever used CAM was 49.8%, with 42% having reported CAM use within the past 12 months. Lesbians had greater odds of having ever used CAM (adjusted odds ratio [AOR] = 1.68 [95% confidence interval (CI): 1.23, 2.28]) and of having used CAM in the past 12 months (AOR = 1.44 [CI: 1.06, 1.97]) than heterosexuals. In multivariate analyses, correlates of lifetime and past 12-month CAM use included being lesbian, white, higher educated, and a large-city resident; experiencing perceived discrimination in a health care setting; and having a greater spirituality rating and a history of a diagnosed mental health disorder. Past 12-month CAM use was also associated with having a provider of usual health care. Among women who used CAM within the past 12 months, heterosexuals had significantly higher yoga participation rates than lesbians.
Sexual orientation is important in understanding lifetime and past 12-month CAM use. Because of the high prevalence of CAM use found in this study, medical practitioners should inquire about the CAM practices of female patients, particularly lesbians.
Mesenchymal stem cells (MSCs) have anti-inflammatory and immunosuppressive properties and may be useful in the therapy of diseases such as arteriosclerosis. MSCs have some ability to traffic into inflamed tissues, however to exploit this therapeutically their migratory mechanisms need to be elucidated. This study examines the interaction of murine MSCs (mMSCs) with, and their migration across, murine aortic endothelial cells (MAECs), and the effects of chemokines and shear stress. The interaction of mMSCs with MAECs was examined under physiological flow conditions. mMSCs showed lack of interaction with MAECs under continuous flow. However, when the flow was stopped (for 10min) and then started, mMSCs adhered and crawled on the endothelial surface, extending fine microvillous processes (filopodia). They then spread extending pseudopodia in multiple directions. CXCL9 significantly enhanced the percentage of mMSCs adhering, crawling and spreading and shear forces markedly stimulated crawling and spreading. CXCL9, CXCL16, CCL20 and CCL25 significantly enhanced transendothelial migration across MAECs. The transmigrated mMSCs had down-regulated receptors CXCR3, CXCR6, CCR6 and CCR9. This study furthers the knowledge of MSC transendothelial migration and the effects of chemokines and shear stress which is of relevance to inflammatory diseases such as arteriosclerosis.
Among adult women an association between childhood sexual abuse (CSA) and obesity has been observed. Research with lesbian women has consistently identified high rates of obesity as well as frequent reports of CSA, but associations between sexual abuse and obesity have not been fully explored. Our aim was to investigate the relationship between sexual abuse (SA) history and obesity among heterosexual (n = 392) and lesbian (n = 475) women (age 35–64) who participated in the Epidemiologic STudy of HEalth Risk in Women (ESTHER) Project in Pittsburgh, Pennsylvania.
Obesity was defined as body mass index (BMI) ≥30. Covariates included self-reported SA, sexual orientation, demographic factors, and history of a depression or anxiety diagnosis. SA history was assessed by three factors: (1) SA experienced under the age of 18 by a family member or (2) by a nonfamily member and (3) forced, unwanted sexual experience(s) at age ≥18. Data were analyzed using chi-square tests and logistic regression models.
Multiple logistic regression analyses revealed that obesity was associated with African American race, lesbian sexual orientation, intrafamilial CSA, and history of mental health diagnosis. Protective factors were having a household income of at least $75,000 and having a bachelor's degree or higher.
Results suggest that lesbian women may be at greater risk of obesity than heterosexual women and that intrafamilial CSA—regardless of sexual orientation—may play a role in the development of obesity.
Dipsticks are one of the most commonly used near-patient tests in primary care, but few clinical or dipstick algorithms have been rigorously developed.
To confirm whether previously documented clinical and dipstick variables and algorithms predict laboratory diagnosis of urinary tract infection (UTI).
Design of study
A total of 434 adult females with suspected lower UTI had bacteriuria assessed using the European Urinalysis Guidelines.
Sixty-six per cent of patients had confirmed UTI. The predictive values of nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) were confirmed (independent multivariate odds ratios = 5.6, 3.5, and 2.1 respectively). The previously developed dipstick rule — based on presence of nitrite, or both leucocytes and blood — was moderately sensitive (75%) but less specific (66%; positive predictive value [PPV] 81%, negative predictive value [NPV] 57%). Predictive values were improved by varying the cut-off point: NPV was 76% for all three dipstick results being negative; the PPV was 92% for having nitrite and either blood or leucocyte esterase. Urine offensive smell was not found to be predictive in this sample; for a clinical score using the remaining three predictive clinical features (urine cloudiness, dysuria, and nocturia), NPV was 67% for none of the features, and PPV was 82% for three features.
A clinical score is of limited value in increasing diagnostic precision. Dipstick results can modestly improve diagnostic precision but poorly rule out infection. Clinicians need strategies to take account of poor NPVs.
algorithms, clinical scoring; diagnosis, urinary tract infection; primary care; urinalysis
Charging for tuberculosis (TB) treatment could reduce completion rates, particularly in the poor. We identified and synthesised studies that measure costs of TB treatment, estimates of adherence and the potential impact of charging on treatment completion in China.
Inclusion criteria were primary research studies, including surveys and studies using qualitative methods, conducted in mainland China. We searched MEDLINE, PUBMED, EMBASE, Science Direct, HEED, CNKI to June 2010; and web pages of relevant Chinese and international organisations. Cost estimates were extracted, transformed, and expressed in absolute values and as a percentage of household income.
Low income patients, defined at household or district level, pay a total of US$ 149 to 724 (RMB 1241 to 5228) for medical costs for a treatment course; as a percentage of annual household income, estimates range from 42% to 119%. One national survey showed 73% of TB patients at the time of the survey had interrupted or suspended treatment, and estimates from 9 smaller more recent studies showed that the proportion of patients at the time of the survey who had run out of drugs or were not taking them ranged from 3 to 25%. Synthesis of surveys and qualitative research indicate that cost is the most cited reason for default.
Despite a policy of free drug treatment for TB in China, health services charge all income groups, and costs are high. Adherence measured in cross sectional surveys is often low, and the cumulative failure to adhere is likely to be much higher. These findings may be relevant to those concerned with the development and spread of multi-drug resistant TB. New strategies need to take this into account and ensure patient adherence.
To estimate the prevalence of premenstrual symptoms in women from the general population in Southampton, UK, and examine their association with lifestyle factors and contraceptive usage.
The City of Southampton, UK.
974 women aged 20-34 years (53% of the 1,841 women invited to participate).
Interviews, questionnaires and completion of a prospective six-week menstrual symptom diary recording on a daily basis the presence and severity of eleven common premenstrual symptoms.
Main outcome measures
Premenstrual symptoms were identified from the diaries by two clinicians who reviewed them independently using a pre-defined algorithm to assess the onset and decline of symptoms in relation to the start of menstruation.
24% of the women were considered to have premenstrual symptoms (95% confidence interval [CI] 21% to 27%). Women were less likely to have symptoms if they had higher levels of educational attainment and suffered less from stress. No associations were found between premenstrual symptoms and diet, alcohol or strenuous exercise, nor after adjustment for other factors, with age, smoking or body mass index. Use of any form of hormonal contraceptives was associated with a lower prevalence of premenstrual symptoms (prevalence ratio 0.66 (95%CI:0.52 to 0.84)).
Premenstrual symptoms were common in this cohort. Use of hormonal contraceptive methods was associated with a lower prevalence of these symptoms.
Since the introduction of highly active antiretroviral therapy (HAART) in the late 1990s, individuals with HIV are living longer and beginning to experience the chronic diseases of ageing. Alongside side effects of HAART therapy, these may be better managed in the community by generalists rather than by HIV specialists.
To explore GPs' current perceptions of barriers to their involvement in managing patients with HIV.
Design of study
Practices within a primary care trust in the south of England.
The questionnaire included 24 statements relating to potential structural and attitudinal barriers to GPs' involvement in the care of patients with HIV.
Seventy-one per cent (124/174) of GPs responded; 93% (n = 115) of responders were comfortable managing other illness in HIV patients, and 60% (n = 74) agreed that GPs rather than specialists should manage common chronic problems such as hypertension or diabetes. Specialist prescribing was commonly identified as a barrier, specifically: difficulty keeping up to date, knowledge of HAART side effects, and drug interactions. The majority of responders (67% ) viewed patients as preferring their HIV illness to be managed by specialists.
There is now the opportunity and potential to relocate the management of chronic disease in patients with HIV to GPs. Factors such as lack of time, experience, and training were identified as barriers to caring for patient with HIV in the pre-HAART era; these factors continue to challenge some GPs. Additional barriers are the complexity of HAART regimes and inadequate reimbursement. Addressing these barriers is necessary if services are to be reconfigured for people with HIV.
antiretroviral therapy; family practice; highly active; HIV
cholera; emergence; outbreak; bacteria; Vibrio cholerae O1; New Guinea; letter
Urinary tract infection (UTI) is one of the commonest acute infections presenting to primary care. Little is known of women's experiences of UTI; self-care strategies and key triggers for their consulting behaviour are also little known.
To explore women's experiences of self-care and their journey to GP care, when faced with symptoms of a UTI.
Design of study
Qualitative semi-structured interview study with women recruited to a larger UK trial of different management strategies for UTI.
General practices across four counties in southern England.
Twenty-one women were interviewed about the experiences they had prior to their GP visit, self-care strategies, and triggers for help seeking. Interviews were analysed thematically, using principles of analytic induction.
Women reported a process of evaluation, monitoring, re-evaluation, and, finally, consulting in order to meet their needs. Four key triggers for consulting were identified: failure to alleviate symptoms through self-care; symptom duration and escalation; impeding normal functioning and the fulfilment of social roles; and concern that it may be or become a serious illness.
Although UTI is often self-limiting, when taking patient histories and formulating their management strategies clinicians need to take into account women's often painful experience, their efforts to resolve symptoms prior to consulting, and their fears that the symptoms may indicate something more serious than a UTI.
antibiotics; consultation; urinary tract infection