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Background: Infravesical obstruction leads to kidney and bladder dysfunction in a significant proportion of boys. The aim of this review is to determine the value of diagnostic tests for ascertainment of infravesical obstruction in boys. Methodology: We searched PubMed and EMBASE databases until January 1, 2013, to identify papers that described original diagnostic accuracy research for infravesical obstruction in boys. We extracted information on (1) patient characteristics and clinical presentation of PUV and (2) diagnostic pathway, (3) diagnostic accuracy measures and (4) assessed risk of bias. Principal Findings: We retrieved 15 studies describing various diagnostic pathways in 1,189 boys suspected for infravesical obstruction. The included studies reflect a broad clinical spectrum of patients, but all failed to present a standardised approach to confirm the presence and severity of obstruction. The risk of bias of included studies is rather high due to work-up bias and missing data. Conclusions: As a consequence of low quality of methods of the available studies we put little confidence in the reported estimates for the diagnostic accuracy of US, VCUG and new additional tests for ruling in or ruling out infravesical obstruction. To date, firm evidence to support common diagnostic pathways is lacking. Hence, we are unable to draw conclusions on diagnostic accuracy of tests for infravesical obstruction. In order to be able to standardise the diagnostic pathway for infravesical obstruction, adequate design and transparent reporting is mandatory. [ABSTRACT FROM AUTHOR]

Background: Increasing active travel (primarily walking and cycling) has been widely advocated for reducing obesity levels and achieving other population health benefits. However, the strength of evidence underpinning this strategy is unclear. This study aimed to assess the evidence that active travel has significant health benefits. Methods: The study design was a systematic review of (i) non-randomised and randomised controlled trials, and (ii) prospective observational studies examining either (a) the effects of interventions to promote active travel or (b) the association between active travel and health outcomes. Reports of studies were identified by searching 11 electronic databases, websites, reference lists and papers identified by experts in the field. Prospective observational and intervention studies measuring any health outcome of active travel in the general population were included. Studies of patient groups were excluded. Results: Twenty-four studies from 12 countries were included, of which six were studies conducted with children. Five studies evaluated active travel interventions. Nineteen were prospective cohort studies which did not evaluate the impact of a specific intervention. No studies were identified with obesity as an outcome in adults; one of five prospective cohort studies in children found an association between obesity and active travel. Small positive effects on other health outcomes were found in five intervention studies, but these were all at risk of selection bias. Modest benefits for other health outcomes were identified in five prospective studies. There is suggestive evidence that active travel may have a positive effect on diabetes prevention, which may be an important area for future research. Conclusions: Active travel may have positive effects on health outcomes, but there is little robust evidence to date of the effectiveness of active transport interventions for reducing obesity. Future evaluations of such interventions should include an assessment of their impacts on obesity and other health outcomes. [ABSTRACT FROM AUTHOR]

Background: Accurate data on coverage of key maternal, newborn, and child health (MNCH) interventions are crucial for monitoring progress toward the Millennium Development Goals 4 and 5. Coverage estimates are primarily obtained from routine population surveys through self-reporting, the validity of which is not well understood. We aimed to examine the validity of the coverage of selected MNCH interventions in Gongcheng County, China. Method and Findings: We conducted a validation study by comparing women’s self-reported coverage of MNCH interventions relating to antenatal and postnatal care, mode of delivery, and child vaccinations in a community survey with their paper- and electronic-based health care records, treating the health care records as the reference standard. Of 936 women recruited, 914 (97.6%) completed the survey. Results show that self-reported coverage of these interventions had moderate to high sensitivity (0.57 [95% confidence interval (CI): 0.50–0.63] to 0.99 [95% CI: 0.98–1.00]) and low to high specificity (0 to 0.83 [95% CI: 0.80–0.86]). Despite varying overall validity, with the area under the receiver operating characteristic curve (AUC) ranging between 0.49 [95% CI: 0.39–0.57] and 0.90 [95% CI: 0.88–0.92], bias in the coverage estimates at the population level was small to moderate, with the test to actual positive (TAP) ratio ranging between 0.8 and 1.5 for 24 of the 28 indicators examined. Our ability to accurately estimate validity was affected by several caveats associated with the reference standard. Caution should be exercised when generalizing the results to other settings. Conclusions: The overall validity of self-reported coverage was moderate across selected MNCH indicators. However, at the population level, self-reported coverage appears to have small to moderate degree of bias. Accuracy of the coverage was particularly high for indicators with high recorded coverage or low recorded coverage but high specificity. The study provides insights into the accuracy of self-reports based on a population survey in low- and middle-income countries. Similar studies applying an improved reference standard are warranted in the future. [ABSTRACT FROM AUTHOR]

France implemented a comprehensive smoke-free law in two phases: Phase 1 (February 2007) banned smoking in workplaces, shopping centres, airports, train stations, hospitals, and schools; Phase 2 (January 2008) banned smoking in hospitality venues (bars, restaurants, hotels, casinos, nightclubs). This paper evaluates France’s smoke-free law based on the International Tobacco Control Policy Evaluation Project in France (the ITC France Project), which conducted a cohort survey of approximately 1,500 smokers and 500 non-smokers before the implementation of the laws (Wave 1) and two waves after the implementation (Waves 2 and 3). Results show that the smoke-free law led to a very significant and near-total elimination of observed smoking in key venues such as bars (from 94–97% to 4%) and restaurants (from 60–71% to 2–3%) at Wave 2, which was sustained four years later (6–8% in bars; 1–2% in restaurants). The reduction in self-reported smoking by smoking respondents was nearly identical to the effects shown in observed smoking. Observed smoking in workplaces declined significantly after the law (from 41–48% to 18–20%), which continued to decline at Wave 3 (to 14–15%). Support for the smoke-free laws increased significantly after their implementation and continued to increase at Wave 3 (p<.001 among smokers for bars and restaurants; p<.001 among smokers and p = .003 for non-smokers for workplaces). The findings demonstrate that smoke-free policies that are implemented in ways consistent with the Guidelines for Article 8 of the WHO Framework Convention on Tobacco Control (WHO FCTC) lead to substantial and sustained reductions in indoor smoking while also leading to high levels of support by the public. Moreover, contrary to arguments by opponents of smoke-free laws, smoking in the home did not increase after the law was implemented and prevalence of smoke-free homes among smokers increased from 23.2% before the law to 37.2% 5 years after the law. [ABSTRACT FROM AUTHOR]

Background: This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon. Methods: Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1st, 2004 and September 30th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months. Results: Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions. Conclusion: A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum. [ABSTRACT FROM AUTHOR]

Background: Cobalamin and folate are essential micronutrients and are important in DNA and RNA synthesis, cell proliferation, growth, hematopoiesis, and cognitive function. However, data on cobalamin and folate status are lacking particularly from young children residing in low and middle income countries. Objective: To measure cobalamin and folate status and identifies their predictors among 6 to 35 months old children presenting with acute diarrhea. Design: This was a cross-sectional study in 823 children presenting with acute diarrhea. We measured plasma cobalamin, folate, methylmalonic acid and total homocysteine who sought treatment for acute diarrhea between June 1998 and August 2000. Results: The mean (SD) plasma concentrations of cobalamin, folate, total homocysteine and methylmalonic acid were 206 (124) pmol/L, 55 (32) nmol/L, 11.4 (5.6) µmol/L and 0.79 (1.2) µmol/L, respectively. The prevalence of low plasma cobalamin (<150 pmol/L) was 41% but less than 2% (15) children had low folate concentration (<10 nmol/L). Plasma homocysteine and methylmalonic acid concentrations were negatively associated with cobalamin concentration but not associated with folate status. The prevalence of cobalamin deficiency was higher in breastfed than non-breastfed children (44% vs 24%; p = <0.001). The prevalence of hyperhomocysteinemia (>10 µmol/L) and elevated methylmalonic acid (>0.28 µmol/L) were 73% and 52%, respectively. In the regression analyses, the plasma cobalamin concentration was positively associated with age, and introduction of animal or formula milk. Conclusions: Our study indicated that poor cobalamin status was common particularly among breastfed children. Folate deficiency was virtually none existent. Possible consequences of cobalamin deficiency in young children need to be explored. [ABSTRACT FROM AUTHOR]

Background: Sexually transmitted infections (STIs), including Hepatitis B and C virus, are emerging public health risks in China, especially among men who have sex with men (MSM). This study aims to assess the magnitude and risks of STIs among Chinese MSM. Methods: Chinese and English peer-reviewed articles were searched in five electronic databases from January 2000 to February 2013. Pooled prevalence estimates for each STI infection were calculated using meta-analysis. Infection risks of STIs in MSM, HIV-positive MSM and male sex workers (MSW) were obtained. This review followed the PRISMA guidelines and was registered in PROSPERO. Results: Eighty-eight articles (11 in English and 77 in Chinese) investigating 35,203 MSM in 28 provinces were included in this review. The prevalence levels of STIs among MSM were 6.3% (95% CI: 3.5–11.0%) for chlamydia, 1.5% (0.7–2.9%) for genital wart, 1.9% (1.3–2.7%) for gonorrhoea, 8.9% (7.8–10.2%) for hepatitis B (HBV), 1.2% (1.0–1.6%) for hepatitis C (HCV), 66.3% (57.4–74.1%) for human papillomavirus (HPV), 10.6% (6.2–17.6%) for herpes simplex virus (HSV-2) and 4.3% (3.2–5.8%) for Ureaplasma urealyticum. HIV-positive MSM have consistently higher odds of all these infections than the broader MSM population. As a subgroup of MSM, MSW were 2.5 (1.4–4.7), 5.7 (2.7–12.3), and 2.2 (1.4–3.7) times more likely to be infected with chlamydia, gonorrhoea and HCV than the broader MSM population, respectively. Conclusion: Prevalence levels of STIs among MSW were significantly higher than the broader MSM population. Co-infection of HIV and STIs were prevalent among Chinese MSM. Integration of HIV and STIs healthcare and surveillance systems is essential in providing effective HIV/STIs preventive measures and treatments. Trial Registration: PROSPERO No: CRD42013003721 [ABSTRACT FROM AUTHOR]

Background: The rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. We present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers (CHWs) in Malawi. Methods and Findings: Government-employed community health workers in Malawi are responsible for maintaining a Village Health Register, in which they record births and deaths that occur in their catchment area. We expanded on this system to provide additional training, supervision and incentives. We tested the equivalence between child mortality rates obtained from data on births and deaths collected by 160 randomly-selected and trained CHWs over twenty months in two districts to those computed through a standard household mortality survey. CHW reports produced an under-five mortality rate that was 84% (95%CI: [0.71,1.00]) of the household survey mortality rate and statistically equivalent to it. However, CHW data consistently underestimated under-five mortality, with levels of under-estimation increasing over time. Under-five deaths were more likely to be missed than births. Neonatal and infant deaths were more likely to be missed than older deaths. Conclusion: This first test of the accuracy and completeness of vital events data reported by CHWs in Malawi as a strategy for monitoring child mortality shows promising results but underestimated child mortality and was not stable over the four periods assessed. Given the Malawi government's commitment to strengthen its vital registration system, we are working with the Ministry of Health to implement a revised version of the approach that provides increased support to CHWs. [ABSTRACT FROM AUTHOR]

Objective: Obesity is a risk factor for chronic kidney disease (CKD) and cardiovascular disease. The association between waist to height ratio (WheiR) and CKD is unclear. This study evaluated the association between WheiR and CKD. Design and Methods: In this longitudinal cohort study, 4841 Japanese workers (3686 males, 1155 females) 18 to 67 years of age in 2008 were followed up until 2011. CKD was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m2 (by the Modification of Diet in Renal Disease equation for Japanese) or dipstick proteinuria (≥1+). Cox proportional hazards models were used to examine the relationship between WheiR and development of CKD. Results: A total of 384 (7.9%) participants (300 men and 84 women) were found to have new CKD. The incidence of CKD was 13.7, 24.2, 37.9 and 43.7 per 1000 person-years of follow-up in the lowest, second, third and highest quartiles of WheiR, respectively. After adjustment for potential confounders, the adjusted hazard ratios (95% confidence interval) for CKD were 1.00 (reference), 1.23 (0.85, 1.78), 1.59 (1.11, 2.26) and 1.62 (1.13, 2.32) through the quartiles of WheiR, respectively. WheiR had a significant predictive value for the incidence of both proteinuria and low estimated glomerular filtration rate. After subdivision according to gender, the relationship between WheiR and the incidence of CKD was statistically significant in the unadjusted model. However, after adjusting for potential confounders, WheiR was significantly associated with the incidence of CKD in females, whereas it was not significant in males. Conclusions: WheiR, which is commonly used as an index of central obesity, is associated with CKD. There was a significant gender difference in the relationship between CKD and WheiR. [ABSTRACT FROM AUTHOR]

Introduction: Findings regarding the association between overweight and all-cause mortality range from significantly lower to higher risk, compared with body-mass-index (BMI) within the “normal” range. Methods: We examined empirically potential methodological explanations for these apparently conflicting results using questionnaire and linked mortality data from 246,314 individuals aged ≥45 years in the Australian 45 and Up Study (11,127 deaths; median follow-up 3.9 years). Hazard ratios (HR) for all-cause mortality associated with BMI were modelled according to different methods of accounting for illness at baseline, finer versus broader gradations of BMI and choice of reference group, adjusting for potential confounders. Results: In analyses using the broad World Health Organization (WHO) categories, the all-cause mortality HR was significantly lower in the overweight category (25.0–29.99 kg/m2), than the normal weight (18.5–24.99 kg/m2) category. However, in analyses accounting for baseline illness, which excluded those with pre-existing illness at baseline, ever-smokers and the first 2 years of follow up, absolute age-standardised mortality rates varied up to two-fold between finer BMI categories within the WHO normal weight category; rates were lowest at 22.5–24.99 kg/m2 and mortality HRs increased steadily for BMI above (ptrend<0.02) and below (ptrend<0.003) this reference category. Hence, the breadth of the BMI categories used and whether or not baseline illness is accounted for explain the apparent discrepancies between reported BMI-mortality associations. Conclusion: Using fine BMI categories and the category with the lowest absolute rates as the reference group and accounting for the potential confounding effects of baseline illness is likely to yield the most reliable risk estimates for establishing the independent relationship of BMI to all-cause mortality. These results and those of other studies indicate that a BMI of 22.5–24.99 kg/m2, not the broad “overweight” category of 25–29.99 kg/m2, was associated with the most favourable mortality risk. [ABSTRACT FROM AUTHOR]

Background: Only few longitudinal studies on the course of asthma among adults have been carried out. Objective: The aim of the present prospective study, carried out between 2000 and 2009 in Italy, is to assess asthma remission and control in adults with asthma, as well as their determinants. Methods: All the subjects with current asthma (21–47 years) identified in 2000 in the Italian Study on Asthma in Young Adults in 6 Italian centres were followed up. Asthma remission was assessed at follow-up in 2008–2009 (n = 214), asthma control at baseline and follow-up. Asthma remission and control were related to potential determinants by a binomial logistic and a multinomial logistic model. Separate models for remission were used for men and women. Results: The estimate of the proportion of subjects who were in remission was 29.7% (95%CI: 14.4%;44.9%). Men who were not under control at baseline had a very low probability of being in remission at follow-up (OR = 0.06; 95%CI:0.01;0.33) when compared to women (OR = 0.40; 95%CI:0.17;0.94). The estimates of the proportion of subjects who were under control, partial control or who were not under control in our sample were 26.3% (95%CI: 21.2;31.3%), 51.6% (95%CI: 44.6;58.7%) and 22.1% (95%CI: 16.6;27.6%), respectively. Female gender, increasing age, the presence of chronic cough and phlegm and partial or absent asthma control at baseline increased the risk of uncontrolled asthma at follow-up. Conclusion: Asthma remission was achieved in nearly 1/3 of the subjects with active asthma in the Italian adult population, whereas the proportion of the subjects with controlled asthma among the remaining subjects was still low. [ABSTRACT FROM AUTHOR]

The 1986 accident at the Chernobyl nuclear power plant remains the most serious nuclear accident in history, and excess thyroid cancers, particularly among those exposed to releases of iodine-131 remain the best-documented sequelae. Failure to take dose-measurement error into account can lead to bias in assessments of dose-response slope. Although risks in the Ukrainian-US thyroid screening study have been previously evaluated, errors in dose assessments have not been addressed hitherto. Dose-response patterns were examined in a thyroid screening prevalence cohort of 13,127 persons aged <18 at the time of the accident who were resident in the most radioactively contaminated regions of Ukraine. We extended earlier analyses in this cohort by adjusting for dose error in the recently developed TD-10 dosimetry. Three methods of statistical correction, via two types of regression calibration, and Monte Carlo maximum-likelihood, were applied to the doses that can be derived from the ratio of thyroid activity to thyroid mass. The two components that make up this ratio have different types of error, Berkson error for thyroid mass and classical error for thyroid activity. The first regression-calibration method yielded estimates of excess odds ratio of 5.78 Gy−1 (95% CI 1.92, 27.04), about 7% higher than estimates unadjusted for dose error. The second regression-calibration method gave an excess odds ratio of 4.78 Gy−1 (95% CI 1.64, 19.69), about 11% lower than unadjusted analysis. The Monte Carlo maximum-likelihood method produced an excess odds ratio of 4.93 Gy−1 (95% CI 1.67, 19.90), about 8% lower than unadjusted analysis. There are borderline-significant (p = 0.101–0.112) indications of downward curvature in the dose response, allowing for which nearly doubled the low-dose linear coefficient. In conclusion, dose-error adjustment has comparatively modest effects on regression parameters, a consequence of the relatively small errors, of a mixture of Berkson and classical form, associated with thyroid dose assessment. [ABSTRACT FROM AUTHOR]

Globally, influenza infection is a major cause of morbidity and mortality in the elderly, who are suggested to be the major target group for trivalent influenza vaccine (TIV) vaccination by World Health Organization. In spite of an increasing trend in vaccine coverage rates in many countries, the effect of vaccination among the elderly in reducing hospitalization and mortality remains controversial. In this study, we conducted a historical cohort study to evaluate the temporal pattern of influenza-associated morbidity among persons older than 64 years over a decade. The temporal patterns of influenza-associated morbidity rates among the elderly older than 64 years indicated that Taiwan's elderly P&I outpatient visits have been decreasing since the beginning of the 1999–2000 influenza season; however, hospitalization has been increasing despite significant increases in vaccine coverage. The propensity score logistic regression model was implemented to evaluate the source of bias and it was found that the TIV-receiving group had a higher propensity score than the non-receiving group (P<0.0001). In order to investigate the major factors affecting the temporal pattern of influenza-associated morbidity, we then used the propensity score as a summary confounder in a multivariate Poisson regression model based on the trimmed data. Our final models suggested that the factors affected the temporal pattern of morbidity differently. The variables including co-morbidity, vaccination rate, influenza virus type A and B isolation rate were associated with increased outpatient visits and hospitalization (p<0.05). In contrast, variables including high propensity score, increased 1°C in temperature, matching vaccine strains of type A/H1N1 and type B were associated with decreased outpatient visits and hospitalization (p<0.05). Finally, we assessed the impact of early appearance of antigenic-drifted strains and concluded that an excess influenza-associated morbidity substantial trends toward higher P&I hospitalization, but not outpatient visits, during the influenza season with early appearance of antigenic-drifted strains. [ABSTRACT FROM AUTHOR]

In the absence of reliable systems for registering rare types of vital events large surveys are required to measure changes in their rates. However some events such as maternal deaths are widely known about in the community. This study examined the utility of asking respondents about events in their neighbourhood as an efficient method for measuring relative rates of rare health events such as maternal and infant deaths. A survey was conducted in the health and demographic surveillance system (HDSS) in Matlab, Bangladesh, which includes two areas with different health care regimes. Adult women were asked about any maternal deaths; multiple births; infant deaths, live births and some other events they knew of in a small specified area around their home. Agreement between HDSS records and survey responses was moderate or better (kappa≥0.44) for all the events and greatest for maternal deaths (kappa = 0.77) with 84% being reported. Most events were more likely to be reported if they were recent (p<0.05). Infant mortality rate in one area was 0.56 times that in the other which was well reflected by the ratio of survey results (0.53). Simulations were used to study the ability of the method to detect differences in maternal mortality ratio. These suggested that a sample size around 5000 would give 80% power to detect a 50% decrease from a baseline of 183 which compared well with an estimated sample size around 10 times larger using the direct sisterhood method. The findings suggest that the Neighbourhood Method has potential for monitoring relative differences between areas or changes over time in the rates of rare demographic events, requiring considerably smaller sample sizes than traditional methods. This raises the possibility for interventions to demonstrate real effects on outcomes such as maternal deaths where previously this was only feasible by indirect methods. [ABSTRACT FROM AUTHOR]

Background: The potential to use data on family history of premature disease to assess disease risk is increasingly recognised, particularly in scoring risk for coronary heart disease (CHD). However the quality of family health information in primary care records is unclear. Aim: To assess the availability and quality of family history of CHD documented in electronic primary care records Design: Cross-sectional study Setting: 537 UK family practices contributing to The Health Improvement Network database. Method: Data were obtained from patients aged 20 years or more, registered with their current practice between 1st January 1998 and 31st December 2008, for at least one year. The availability and quality of recorded CHD family history was assessed using multilevel logistic and ordinal logistic regression respectively. Results: In a cross-section of 1,504,535 patients, 19% had a positive or negative family history of CHD recorded. Multilevel logistic regression showed patients aged 50–59 had higher odds of having their family history recorded compared to those aged 20–29 (OR:1.23 (1.21 to 1.25)), however most deprived patients had lower odds compared to those least deprived (OR: 0.86 (0.85 to 0.88)). Of the 140,058 patients with a positive family history recorded (9% of total cohort), age of onset was available in 45%; with data specifying both age of onset and relative affected available in only 11% of records. Multilevel ordinal logistic regression confirmed no statistical association between the quality of family history recording and age, gender, deprivation and year of registration. Conclusion: Family history of CHD is documented in a small proportion of primary care records; and where positive family history is documented the details are insufficient to assess familial risk or populate cardiovascular risk assessment tools. Data capture needs to be improved particularly for more disadvantaged patients who may be most likely to benefit from CHD risk assessment. [ABSTRACT FROM AUTHOR]

Background and Objectives: Following the 2010 earthquake in Haiti, infant and young child feeding was identified as a priority nutrition intervention. A new approach to support breastfeeding mothers and distribute ready-to-use infant formula (RUIF) to infants unable to breastfeed was established. The objective of the evaluation was to assess the implementation of infant feeding programs using RUIF in displaced persons camps in Port-au-Prince, Haiti during the humanitarian response. Methods: A retrospective record review was conducted from April–July, 2010 to obtain data on infants receiving RUIF in 30 baby tents. A standardized data collection form was created based on data collected across baby tents and included: basic demographics, admission criteria, primary caretaker, feeding practices, and admission and follow-up anthropometrics. Main Findings: Orphans and abandoned infants were the most frequent enrollees (41%) in the program. While the program targeted these groups, it is unlikely that this is a true reflection of population demographics. Despite programmatic guidance, admission criteria were not consistently applied across programs. Thirty-four percent of infants were undernourished (weight for age Z score <−2) at the time of admission. Defaulting accounted for 50% of all program exits and there was no follow-up of these children. Low data quality was a significant barrier. Conclusions: The design, implementation and magnitude of the ‘baby tents’ using RUIF was novel in response to infant and young child feeding (IYCF) in emergencies and presented multiple challenges that should not be overlooked, including adherence to protocols and the adaption of emergency programs to existing programs. The implementation of IYCF programs should be closely monitored to ensure that they achieve the objectives set by the humanitarian community and national government. IYCF is an often overlooked component of emergency preparedness; however to improve response, generic protocols and pre-emergency training and preparedness should be established for humanitarian agencies. [ABSTRACT FROM AUTHOR]

Objectives: There is no agreed-upon definition for severe obesity (Sev-OB) in children. We compared estimates of Sev-OB as defined by different cut-points of body mass index (BMI) from the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO) curves and the ability of each set of cut-points to screen for the presence of cardiometabolic risk factors. Research Design and Methods: Cross-sectional, multicenter study involving 3,340 overweight/obese young subjects. Sev-OB was defined as BMI ≥99th percentile or ≥1.2 times the 95th percentile of the CDC or the WHO curves. High blood pressure, hypertriglyceridemia, low High Density Lipoprotein -cholesterol and impaired fasting glucose were considered as cardiometabolic risk factors. Results: The estimated prevalence of Sev-OB varied widely between the two reference systems. Either using the cut-point ≥99th percentile or ≥1.2 times the 95th percentile, less children were defined as Sev-OB by CDC than WHO (46.8 vs. 89.5%, and 63.3 vs. 80.4%, respectively p<0.001). The CDC 99th percentile had lower sensitivity (58.5 vs 94.2), higher specificity (57.6 vs 12.3) and higher positive predictive value (34.4 vs 28.9) than WHO in identifying obese children with ≥2 cardiometabolic risk factors. These differences were mitigated using the 1.2 times the 95th percentile (sensitivity 73.9 vs. 88.1; specificity 40.7 vs. 22.5; positive predictive value 32.1 vs. 30.1). Substantial agreement between growth curves was found using the 1.2 times the 95th percentile, in particular in children ≤10 years. Conclusions: Estimates of Sev-OB and cardiometabolic risk as defined by different cut-points of BMI are influenced from the reference systems used. The 1.2 times the 95th percentile of BMI of either CDC or WHO standard has a discriminatory advantage over the 99th percentile for identifying severely obese children at increased cardiometabolic risk, particularly under 10 years of age. [ABSTRACT FROM AUTHOR]

Background: Microalbuminuria is associated with increased risk of renal disease and cardiovascular diseases even in non-diabetic subjects. High incidence rates of microalbuminuria have been found in a number of population-based studies. However, the prevalence and risk factors associated with microalbuminuria in the general population in Korea are unclear. Objectives: The present study was performed to estimate the prevalence of microalbuminuria and investigate the associated risk factors in the general adult population using the Fifth Korea National Health and Nutrition Examination Survey (KNHANES V-2) data from 2011. Methods: A total of 5,202 participants (mean age, 45.6 years; men, 2,337; women, 2,865) were included in the analysis. Microalbuminuria was evaluated in participants of KNHANES V-2 based on the urine albumin–creatinine ratio. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease study equation. Results: The weighted prevalence of microalbuminuria was 5.2% (95% CI, 4.4–6.1) in the general population. The prevalence of albuminuria is increased with age. After adjustment for age and sex, the presence of albuminuria was associated with increased waist circumference, systolic and diastolic blood pressure, aspartate aminotransferase, triglyceride, fasting plasma glucose, and the presence of hypertension and diabetes. In logistic regression analyses, older age, female sex, diabetes, hypertension, and serum aspartate aminotransferase were independently associated with the presence of albuminuria. Conclusion: The prevalence of microalbuminuria was found to be 5.2%, and conventional risk factors for cardiovascular diseases are closely related to the presence of microalbuminuria in Korea. Microalbuminuria may be a useful marker to identify individuals with increased risk of cardiovascular disease. [ABSTRACT FROM AUTHOR]

Objective: The abuse of antimicrobials is a serious concern in China. Several measures have been taken to improve the rational use of antimicrobials, including the establishment of a national surveillance network for antimicrobial use. This study describes the dynamic changes in antimicrobial use in China between 2001 and 2010, with the scope of identifying targets to improve the prescription of antimicrobials. Methods: Five point prevalence surveys were performed in hospitals across mainland China in 2001, 2003, 2005, 2008, and 2010. All inpatients who were admitted for at least 24 hours were included in the study. Details regarding antimicrobial use by these patients and the collection of samples for bacterial culture from inpatients administered therapeutic antimicrobials were recorded. Results: The surveys encompassed tertiary hospitals from all 31 provinces of mainland China. Antimicrobial use prevalence decreased from 54.79% in 2001 to 46.63% in 2010. While this decline was observed in most hospital departments, antimicrobial use remained stable or increased in others. Antimicrobial use prevalence was relatively high in the Pediatrics departments and general intensive care units, whereas it was lower in the Obstetrics (Neonatal group) departments in each survey. The proportion of patients administered a single antimicrobial increased from 60.78% in 2001 to 70.16% in 2010, while the proportion of administration of two or more antimicrobials declined. The bacterial culture rate increased from 25.22% in 2003 to 34.71% in 2010. Antimicrobial use prevalence (47.96% vs 46.16%), bacterial culture rate (36.40% vs 34.19%), and the proportion of administration of a single antimicrobial (71.41% vs 67.33%) were higher in teaching hospitals than in nonteaching hospitals in 2010. Conclusion: Although measures for enhancing the rational use of antimicrobials have been effective, further improvements are required. The findings from this study can promote such improvements. [ABSTRACT FROM AUTHOR]

Background: Prospective studies have consistently reported lower colorectal cancer risks associated with higher intakes of total dairy products, total milk and dietary calcium. However, less is known about whether the inverse associations vary for individual dairy products with differing fat contents. Materials and Methods: In the European Prospective Investigation into Cancer and Nutrition (EPIC), we investigated the associations between intakes of total milk and milk subtypes (whole-fat, semi-skimmed and skimmed), yoghurt, cheese, and dietary calcium with colorectal cancer risk amongst 477,122 men and women. Dietary questionnaires were administered at baseline. Multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models, adjusted for relevant confounding variables. Results: During the mean 11 years of follow-up, 4,513 incident cases of colorectal cancer occurred. After multivariable adjustments, total milk consumption was inversely associated with colorectal cancer risk (HR per 200 g/day 0.93, 95% CI: 0.89–0.98). Similar inverse associations were observed for whole-fat (HR per 200 g/day 0.90, 95% CI: 0.82–0.99) and skimmed milk (HR per 200 g/day 0.90, 95% CI: 0.79–1.02) in the multivariable models. Inverse associations were observed for cheese and yoghurt in the categorical models; although in the linear models, these associations were non-significant. Dietary calcium was inversely associated with colorectal cancer risk (HR per 200 mg/day 0.95, 95% CI: 0.91–0.99); this association was limited to dairy sources of calcium only (HR per 200 mg/day 0.95, 95% CI: 0.91–0.99), with no association observed for non-dairy calcium sources (HR per 200 mg/day 1.00, 95% CI: 0.81–1.24). Conclusions: Our results strengthen the evidence for a possible protective role of dairy products on colorectal cancer risk. The inverse associations we observed did not differ by the fat content of the dairy products considered. [ABSTRACT FROM AUTHOR]

Background: Research on the co-occurrence of unhealthy lifestyles has tended to focus mainly upon the demographic and socioeconomic characteristics of individuals. This study investigated the relevance of neighborhood socioeconomic circumstance for multiple unhealthy lifestyles. Method: An unhealthy lifestyle index was constructed for 206,457 participants in the 45 and Up Study (2006–2009) by summing binary responses on smoking, alcohol, physical activity and five diet-related variables. Higher scores indicated the co-occurrence of unhealthy lifestyles. Association with self-rated health, quality of life; and risk of psychological distress was investigated using multilevel logistic regression. Association between the unhealthy lifestyle index with neighborhood characteristics (local affluence and geographic remoteness) were assessed using multilevel linear regression, adjusting for individual-level characteristics. Results: Nearly 50% of the sample reported 3 or 4 unhealthy lifestyles. Only 1.5% reported zero unhealthy lifestyles and 0.2% had all eight. Compared to people who scored zero, those who scored 8 (the ‘unhealthiest’ group) were 7 times more likely to rate their health as poor (95%CI 3.6, 13.7), 5 times more likely to report poor quality of life (95%CI 2.6, 10.1), and had a 2.6 times greater risk of psychological distress (95%CI 1.8, 3.7). Higher scores among men decreased with age, whereas a parabolic distribution was observed among women. Neighborhood affluence was independently associated with lower scores on the unhealthy lifestyle index. People on high incomes scored higher on the unhealthy lifestyle index if they were in poorer neighborhoods, while those on low incomes had fewer unhealthy lifestyles if living in more affluent areas. Interpretation: Residents of deprived neighborhoods tend to report more unhealthy lifestyles than their peers in affluent areas, regardless of their individual demographic and socioeconomic characteristics. Future research should investigate the trade-offs of population-level versus geographically targeted multiple lifestyle interventions. [ABSTRACT FROM AUTHOR]

Background: Anemia and vitamin D deficiency are both important health issues; however, the nature of the association between vitamin D and either hemoglobin or anemia remains unresolved in the general population. Methods: Data on 11,206 adults were obtained from the fifth Korean National Health and Nutritional Examination Survey. A generalized additive model was used to examine the threshold level for relationship between serum 25-hydroxyvitamin D [25(OH)D] and hemoglobin levels. A multivariate logistic regression for anemia was conducted according to 25(OH)D quintiles. All analyses were stratified according to sex and menstrual status. Results: The generalized additive model confirmed a threshold 25(OH)D level of 26.4 ng/mL (male, 27.4 ng/mL; premenopausal females, 11.8 ng/mL; postmenopausal females, 13.4 ng/mL). The threshold level affected the pattern of association between 25(OH)D and anemia risk: the odds ratio of the 1st quintile but not the 2nd, 3rd, and 4th quintiles were significantly different from the 5th quintile in both premenopausal and postmenopausal females, however there was no obvious trend in males. Conclusions: This population-based study demonstrated a non-linear relationship with a threshold effect between serum 25(OH)D and hemoglobin levels in females. Further interventional studies are warranted to determine whether the appropriate level of hemoglobin can be achieved by the correction of vitamin D deficiency. [ABSTRACT FROM AUTHOR]

Background: Human immunodeficiency virus (HIV) and mental illness are interlinked health problems; mental illness may pose a risk for contracting HIV and HIV-positive individuals are at higher risk of mental illness. However, in countries with high HIV prevalence, the main focus of HIV-related health programmes is usually on prevention and treatment of somatic complications of HIV, and mental illness is not given high priority. We examined HIV prevalence, uptake of HIV services, and HIV-related risk behaviour among people attending a mental health clinic in rural Malawi. Methodology: Semi-structured interviews were performed with patients capable to consent (94%), and with those accompanied by a capable caregiver who consented. HIV counselling and testing was offered to participants. Findings: Among 174 participants, we collected 162 HIV test results (91%). HIV prevalence was 14.8%. Women were three times as likely to be HIV-positive compared to men. Two-thirds of participants reported having been tested for HIV prior to this study. The uptake of HIV-services among HIV-positive patients was low: 35% did not use recommended prophylactic therapy and 44% of patients not receiving antiretroviral treatment (ART) had never been assessed for ART eligibility. The reported rate of sexual activity was 61%, and 9% of sexually active participants had multiple partners. Inconsistent condom use with stable (89%) and occasional (79%) sexual partners, and absence of knowledge of the HIV status of those partners (53%, 63%) indicate high levels of sexual risk behaviour. Conclusions: HIV-prevalence among persons attending the clinic, particularly men, was lower than among the general population in a population survey. The rate of HIV testing was high, but there was low uptake of preventive measures and ART. This illustrates that HIV-positive individuals with mental illness or epilepsy constitute a vulnerable population. HIV programmes should include those with neuropsychiatric illness. [ABSTRACT FROM AUTHOR]

Background: Faced with a massive shortfall in meeting sanitation targets, some governments have implemented campaigns that use subsidies focused on latrine construction to overcome income constraints and rapidly expand coverage. In settings like rural India where open defecation is common, this may result in sub-optimal compliance (use), thereby continuing to leave the population exposed to human excreta. Methods: We conducted a cross-sectional study to investigate latrine coverage and use among 20 villages (447 households, 1933 individuals) in Orissa, India where the Government of India’s Total Sanitation Campaign had been implemented at least three years previously. We defined coverage as the proportion of households that had a latrine; for use we identified the proportion of households with at least one reported user and among those, the extent of reported use by each member of the household. Results: Mean latrine coverage among the villages was 72% (compared to <10% in comparable villages in the same district where the Total Sanitation Campaign had not yet been implemented), though three of the villages had less than 50% coverage. Among these households with latrines, more than a third (39%) were not being used by any member of the household. Well over a third (37%) of the members of households with latrines reported never defecating in their latrines. Less than half (47%) of the members of such households reported using their latrines at all times for defecation. Combined with the 28% of households that did not have latrines, it appears that most defecation events in these communities are still practiced in the open. Conclusion: A large-scale campaign to implement sanitation has achieved substantial gains in latrine coverage in this population. Nevertheless, gaps in coverage and widespread continuation of open defecation will result in continued exposure to human excreta, reducing the potential for health gains. [ABSTRACT FROM AUTHOR]

Background: Information on dietary supplement (DS) use during pregnancy is largely lacking. Besides, little is known about the share of DS use as self-medication versus such use following a physician's advice/prescription. Our aim was to evaluate DS use and its socioeconomic, lifestyle and dietary correlates among pregnant women participating in the French NutriNet-Santé cohort study. Method: Data were collected by self-administered web-based questionnaires. Food intake was assessed by repeated 24 h dietary records. 903 pregnant women provided data on their DS use (both “regular” DS and medication containing mainly vitamins/minerals). Supplement users were compared to non-users by unconditional logistic regression. Results: DS use—in general and as regards folic acid in particular—was positively correlated with age, being primiparous, having higher income and belonging to a higher socioprofessional category. DS users had significantly higher dietary intakes of most vitamins and minerals. The proportion of DS users (e.g., those reporting use at least three days a week) increased significantly with the trimester of pregnancy (58.0%, 62.2% and 74.5%, respectively). 50.2% of women in their 1st trimester used folic acid. The proportion of iron users tripled from the 1st to the 3rd trimester (18.5 to 63.9%). DS use was prescribed or recommended by a physician in 86.7% of the cases. Conclusion: This study provided new and detailed information on DS use and its correlates during pregnancy. Even in this relatively well-educated population, folic acid supplementation at the beginning of pregnancy was inadequate and was associated with socioeconomic and demographic disparities. [ABSTRACT FROM AUTHOR]

Objective: Children with Down syndrome, the most common genetic cause of intellectual disability, are prone to multiple and varied health-related problems. This study describes patterns of hospitalisations for children and young people with Down syndrome in Western Australia. Methods: Birth records were linked to the Western Australian population-based Intellectual Disability database to identify all children born with Down syndrome in Western Australia between 1 January, 1983 and 31 December, 1999. These records were linked to the Hospital Morbidity Data System to provide information on all hospitalisations up to 31 December, 2004. Hospitalisation data, coded using ICD-9CM or ICD-10 (v0.5) were grouped into clinically relevant categories using the primary diagnosis. Rates of hospital admission for all and specific diagnoses were expressed in 1000-person-years at-risk and median age at first admission and length of stay were calculated. Results: Of the 405 children, 395 had one or more hospital admissions, totalling 3786 admissions for all children and an estimated 39.5 person-years in hospital. On average, children were admitted 9.7 times, with an estimated rate of 757.2 admissions per 1000pyr (95% CI: 680, 843). A quarter of all admissions occurred in the first year of life. The average hospital length of stay was 3.8 days (95% CI: 3.7, 4.1). Upper respiratory tract conditions affected the most children (58.5%) and accounted for 12.1% of all admissions. Other disorders which affected a high percentage of children were ear/hearing conditions (50.6%), disorders of the oral cavity (38.0%) and lower respiratory tract conditions (37.5%). Overall, children with Down syndrome were hospitalised at a rate five times (95% CI = 4.3–6.2) that of the general population. Conclusion: Children with Down syndrome are at increased risk of morbidity for varied causes underlining the importance of comprehensive and targeted primary care for this group. [ABSTRACT FROM AUTHOR]

Background: Acute alcohol-related dysfunctional behaviours, such as hangover, are predictive of poor health and mortality. Although much is known about the association of education with alcohol consumption, little is known about its association with these dysfunctional behaviours. Methods: The study population was 1,705 male drinkers aged 25–54 years resident in the city of Izhevsk, Russia who participated in a cross-sectional survey (2003–6). Structural equation modelling was used to examine the relationships between education, beverage and non-beverage alcohol intake, drinking patterns, and acute alcohol-related dysfunction score among these drinkers. Results: Dysfunction was related to all other drinking variables, with the strongest predictors being spirit intake, non-beverage alcohol consumption and drinking patterns. There was a strong relationship between education and acute dysfunction which was not explained by adjusting for alcohol intake and drinking patterns (mean adjusted dysfunction score 0.35 SD (95% CI 0.10, 0.61) lower in men with higher versus secondary education). Conclusions: Although by definition one or more aspects of alcohol consumption should explain the educational differences in alcohol-related dysfunction, detailed information on drinking only partly accounted for the observed patterns. Thus beyond their intrinsic interest, these results illustrate the challenges in constructing statistical models that convincingly identify the pathways that link educational differences to health-related outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Using a world-wide, population-based dataset of adults, we sought to determine the frequency of far visual difficulty and its associated risk factors. Methods: The World Health Survey (WHS) was conducted in 70 countries throughout the world in 2003 using a random, multi-stage, stratified, cluster sampling design of adults ages 18 years and older. Far vision was assessed by asking “In the last 30 days, how much difficulty did you have in seeing and recognizing a person you know across the road (i.e. from a distance of about 20 meters)?”. Responses included none, mild, moderate, severe, or extreme/unable. The income status of countries was estimated using gross national income per capita data from 2003 from the World Bank. Prevalence and regression estimates were adjusted to account for the complex sample design. Results: 21% of adults reported any visual difficulty. The rate varied by the income status of the country with the percentage who had any visual difficulty being 24%, 23%, and 13% in low, middle, and high income countries, respectively. Five percent of people reported severe or extreme visual difficulty with rates in low, middle, and high income countries of 6%, 5%, and 2% respectively. Risk factors for visual difficulty included older age, female sex, poorer socioeconomic status, little to no formal education, and diabetes (P<0.05). Conclusions: One out of five adults in the WHS reported some degree of far visual difficulty. Given the importance of vision to living an independent life, better access to quality eye care services and life course factors affecting vision health (e.g. repeated eye infections, diet lacking vitamin A) must receive adequate attention and resources, especially in low and middle income countries. [ABSTRACT FROM AUTHOR]

Background: A job-related factor is attracting a growing interest as a possible determinant of body weight gain in shift-workers. Objective: The aim of the study was to reinvestigate the issue of overweight between rotating shift workers and daytime workers, taking into consideration possible confounding covariate factors. Methods: This is a cross-sectional study, conducted by reviewing data from subjects participating in an occupational surveillance program in 2008. Participants answered a self-administered questionnaire to retrieve information about socio-demographic factors and working conditions (job schedule type, job-related physical activity, time in job), subjective health status, health care visits during the previous year, and lifestyle factors (dietary habits, leisure time physical activity, alcohol consumption). Participants underwent a medical examination for measurement of BMI, and acquisition of medical history. Results: Compared to daytime workers (N = 229), rotating shift workers (N = 110) displayed higher BMI (mean BMI was 27.6±3.9 and 26.7±3.6 for shift workers, and daytime workers, respectively; p<0.05). Logistic regression analysis allowed to highlight the role of rotating shift-work as an independent risk factor for increased body weight (OR 1.93, 95%CI 1.01–3.71), being aged between 35 and 54 years was a major determinant of increased BMI (OR 2.39, 95%CI 1.14–5.00). In addition, family history of obesity was the strongest determinant of overweight/obesity (OR 9.79, 95%CI 1.28–74.74). Interestingly, no significant association was found between overweight and other potentially relevant factors, such as diet quality and food choices, alcohol consumption, levels of occupational and leisure-time physical activity. Conclusions: Present findings seem to support the notion that rotating shift work is an independent risk factor for overweight, regardless of workers' dietary habits and physical activity levels. [ABSTRACT FROM AUTHOR]

Background: The relationship between smoking and risk of kidney failure, especially in people of Chinese origin, is not clear. We analyzed data from the Singapore Chinese Health Study to investigate whether smoking increases the risk of kidney failure. Methods: The Singapore Chinese Health Study is a population-based cohort of 63,257 Chinese adults enrolled between 1993 and 1998. Information on smoking status was collected at baseline. Incidence of kidney failure was identified via record linkage with the nationwide Singapore Renal Registry until 2008. Kidney failure was defined by one of the following: 1) serum creatinine level of more than or equal to 500 µmol/l (5.7 mg/dl), 2) estimated glomerular filtration rate of less than 15 ml/min/1.73 m2, 3) undergoing hemodialysis or peritoneal dialysis, 4) undergone kidney transplantation. Cox proportional hazard regression analysis was performed for the outcome of kidney failure after adjusting for age, education, dialect, herbal medications, body mass index, sex, physician-diagnosed hypertension and diabetes mellitus. Results: The mean age of subjects was 55.6 years at baseline, and 44% were men. Overall 30.6% were ever smokers (current or former) at baseline. A total of 674 incident cases of kidney failure occurred during a median follow-up of 13.3 years. Among men, smokers had a significant increase in the adjusted risk of kidney failure [hazard ratio (HR): 1.29; 95% CI: 1.02–1.64] compared to never smokers. There was a strong dose-dependent association between number of years of smoking and kidney failure, (p for trend = 0.011). The risk decreased with prolonged cessation (quitting ≥10 years since baseline). The number of women smokers was too few for conclusive relationship. Limitation: Information on baseline kidney function was not available. Conclusions: Cigarette smoking is associated with increased risk of kidney failure among Chinese men. The risk appears to be dose- and duration-dependent and modifiable after long duration of cessation. [ABSTRACT FROM AUTHOR]

Background: South Asians in England have an increased risk of childhood cancer but incidence by their individual ethnicities using self-assigned ethnicity is unknown. Our objective was to compare the incidence of childhood cancer in British Indians and Whites in Leicester, which has virtually complete, self-assigned, ethnicity data and the largest population of Indians in England. Methods: We obtained data on all cancer registrations from 1996 to 2008 for Leicester with ethnicity obtained by linkage to the Hospital Episodes Statistics database. Age-standardised incidence rates were calculated for childhood cancers in Indians and Whites as well as rate ratios, adjusted for age. Results: There were 33 cancers registered among Indian children and 39 among White children. The incidence rate for Indians was greater compared to Whites for all cancers combined (RR 1.82 (95% CI 1.14 to 2.89); p = 0.01), with some evidence of increased risk of leukaemia (RR 2.20 (0.95 to 5.07); p = 0.07), lymphoma (RR 3.96 (0.99 to 15.84); p = 0.04) and central nervous system tumours (RR 2.70 (1.00 to 7.26); p = 0.05). Rates were also higher in British Indian children compared to children in India. Conclusions: British Indian children in Leicester had an increased risk of developing cancer compared to White children, largely due to a higher incidence of central nervous system and haematological malignancies. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated gaps in achievement of low-density lipoprotein-cholesterol (LDL-C) goals among U.S. individuals at high cardiovascular disease risk; however, recent studies in selected populations indicate improvements. Objective: We sought to define the longitudinal trends in achieving LDL-C goals among high-risk United States adults from 1999–2008. Methods We analyzed five sequential population-based cross-sectional National Health and Nutrition Examination Surveys 1999–2008, which included 18,656 participants aged 20–79 years. We calculated rates of LDL-C goal achievement and treatment in the high-risk population. Results: The prevalence of high-risk individuals increased from 13% to 15.5% (p = 0.046). Achievement of LDL-C <100 mg/dL increased from 24% to 50.4% (p<0.0001) in the high-risk population with similar findings in subgroups with (27% to 64.8% p<0.0001) and without (21.8% to 43.7%, p<0.0001) coronary heart disease (CHD). Achievement of LDL-C <70 mg/dL improved from 2.4% to 17% (p<0.0001) in high-risk individuals and subgroups with (3.4% to 21.4%, p<0.0001) and without (1.7% to 14.9%, p<0.0001) CHD. The proportion with LDL-C ≥130 mg/dL and not on lipid medications decreased from 29.4% to 18% (p = 0.0002), with similar findings among CHD (25% to 11.9% p = 0.0013) and non-CHD (35.8% to 20.8% p<0.0001) subgroups. Conclusion: The proportions of the U.S. high-risk population achieving LDL-C <100 mg/dL and <70 mg/dL increased over the last decade. With 65% of the CHD subpopulation achieving an LDL-C <100 mg/dL in the most recent survey, U.S. LDL-C goal achievement exceeds previous reports and approximates rates achieved in highly selected patient cohorts. [ABSTRACT FROM AUTHOR]

Background: The hospital standardized mortality ratio (HSMR) is developed to evaluate and improve hospital quality. Different methods can be used to standardize the hospital mortality ratio. Our aim was to assess the validity and applicability of directly and indirectly standardized hospital mortality ratios. Methods: Retrospective scenario analysis using routinely collected hospital data to compare deaths predicted by the indirectly standardized case-mix adjustment method with observed deaths. Discharges from Dutch hospitals in the period 2003–2009 were used to estimate the underlying prediction models. We analysed variation in indirectly standardized hospital mortality ratios (HSMRs) when changing the case-mix distributions using different scenarios. Sixty-one Dutch hospitals were included in our scenario analysis. Results: A numerical example showed that when interaction between hospital and case-mix is present and case-mix differs between hospitals, indirectly standardized HSMRs vary between hospitals providing the same quality of care. In empirical data analysis, the differences between directly and indirectly standardized HSMRs for individual hospitals were limited. Conclusion: Direct standardization is not affected by the presence of interaction between hospital and case-mix and is therefore theoretically preferable over indirect standardization. Since direct standardization is practically impossible when multiple predictors are included in the case-mix adjustment model, indirect standardization is the only available method to compute the HSMR. Before interpreting such indirectly standardized HSMRs the case-mix distributions of individual hospitals and the presence of interactions between hospital and case-mix should be assessed. [ABSTRACT FROM AUTHOR]

Background: Maternal complications are morbidities suffered during pregnancy through the postpartum period of 42 days. In Ethiopia, little is known about women's experience of complications and their care-seeking behavior. This study attempted to assess experiences related to obstetric complication and seeking assistance from a skilled provider among women who gave birth in the last 12 months preceding the study. Methods: This study was a cross-sectional survey of women who gave birth within one year preceding the study regardless of their delivery place. The study was carried out in six selected districts in North Gondar Zone, Amhara Region. Data was collected house-to-house in 12 selected clusters (kebeles) using a pretested Amharic questionnaire. During the survey, 1,668 women were interviewed. Data entry was done using Epi Info version 3.5.3 and was exported to SPSS for analysis. Logistic regression was applied to control confounders. Results: Out of the total sample, 476 women (28.5%, 95% CI: 26.4%, 30.7%) reported some kind of complication. The most common complications reported were; excessive bleeding and prolonged labor that occurred mostly at the time of delivery and postpartum period. Out of the total women who faced complications, 248 (52.1%, 95% CI: 47.6%, 56.6%) sought assistance from a skilled provider. Inability to judge the severity of morbidities, distance/transport problems, lack of money/cost considerations and use of traditional options at home were the major reasons for not seeking care from skilled providers. Belonging to a wealthier quintile, getting antenatal care from a skilled provider and agreement of a woman in planning for possible complications were significantly associated with seeking assistance from a skilled provider. Conclusion: Nearly half of the women who faced complications did not use skilled providers at the time of obstetric complications. Cognitive, geographic, economic and cultural barriers were involved in not using skilled maternal care. [ABSTRACT FROM AUTHOR]

Introduction: Few studies are available on the clinical characteristics of patients using emergency medical transports in Japan. In this study, we aimed to investigate reasons for emergency medical transports and their relation to clinical severity. Methods: We conducted a 3-year population-based observational study of patients transported by ambulance to emergency departments (ED) in the capital of Japan, Tokyo, which has a population of about 13 million. Demographic data, reasons for transport, and the severity of initial assessment at ED were recorded. Logistic regression was used to determine the odds of the clinical severity of each reason for transport. Results: The number of emergency medical transports in the three-year study period was 1,832,637. Mean age was 53±26. Males were 976,142 (53%). Overall, 92% of all transported patients were in a mild or moderate medical state and patients with the 17 most frequent reasons for transport occupied 82% (1,506,017) of all transports. Pain was the most frequent reason for transport, followed by traffic accident. Considering all the patients and their reasons for transport, patients whose reason was pain or a traffic accident (29% of all patients) were in a relatively mild state compared with patients with other reasons for transport. Patients in an altered mental state in the prehospital setting (6.8% of all patients) were in a more severe medical state than other patients. Conclusions: In Tokyo, Japan, 92% of transported patients were in a mild or moderate medical state. In particular, most patients from traffic accidents were in a mild state, even though traffic accidents were the second most frequent reason for transport. Patients in an altered mental state were most likely to be in a severe medical state. [ABSTRACT FROM AUTHOR]

We studied the association between OTC pharmaceutical sales and volume of patients with influenza-like-illnesses (ILI) at an urgent care center over one year. OTC pharmaceutical sales explain 36% of the variance in the patient volume, and each standard deviation increase is associated with 4.7 more patient visits to the urgent care center (p<0.0001). Cross-correlation function analysis demonstrated that OTC pharmaceutical sales are significantly associated with patient volume during non-flu season (p<0.0001), but only the sales of cough and cold (p<0.0001) and thermometer (p<0.0001) categories were significant during flu season with a lag of two and one days, respectively. Our study is the first study to demonstrate and measure the relationship between OTC pharmaceutical sales and urgent care center patient volume, and presents strong evidence that OTC sales predict urgent care center patient volume year round. [ABSTRACT FROM AUTHOR]

Background: Birmingham is the largest UK city after London, and central Birmingham has an annual tuberculosis incidence of 80 per 100,000. We examined seasonality and sunlight as drivers of tuberculosis incidence. Hours of sunshine are seasonal, sunshine exposure is necessary for the production of vitamin D by the body and vitamin D plays a role in the host response to tuberculosis. Methods: We performed an ecological study that examined tuberculosis incidence in Birmingham from Dec 1981 to Nov 2009, using publicly-available data from statutory tuberculosis notifications, and related this to the seasons and hours of sunshine (UK Meteorological Office data) using unmeasured component models. Results: There were 9,739 tuberculosis cases over the study period. There was strong evidence for seasonality, with notifications being 24.1% higher in summer than winter (p<0.001). Winter dips in sunshine correlated with peaks in tuberculosis incidence six months later (4.7% increase in incidence for each 100 hours decrease in sunshine, p<0.001). Discussion and Conclusion: A potential mechanism for these associations includes decreased vitamin D levels with consequent impaired host defence arising from reduced sunshine exposure in winter. This is the longest time series of any published study and our use of statutory notifications means this data is essentially complete. We cannot, however, exclude the possibility that another factor closely correlated with the seasons, other than sunshine, is responsible. Furthermore, exposure to sunlight depends not only on total hours of sunshine but also on multiple individual factors. Our results should therefore be considered hypothesis-generating. Confirmation of a potential causal relationship between winter vitamin D deficiency and summer peaks in tuberculosis incidence would require a randomized-controlled trial of the effect of vitamin D supplementation on future tuberculosis incidence. [ABSTRACT FROM AUTHOR]

Background: Many studies have found extreme temperature can increase the risk of mortality. However, it is not clear whether extreme diurnal temperature range (DTR) is associated with daily disease-specific mortality, and how season might modify any association. Objectives: To better understand the acute effect of DTR on mortality and identify whether season is a modifier of the DTR effect. Methods: The distributed lag nonlinear model (DLNM) was applied to assess the non-linear and delayed effects of DTR on deaths (non-accidental mortality (NAD), cardiovascular disease (CVD), respiratory disease (RD) and cerebrovascular disease (CBD)) in the full year, the cold season and the warm season. Results: A non-linear relationship was consistently found between extreme DTR and mortality. Immediate effects of extreme low DTR on all types of mortality were stronger than those of extreme high DTR in the full year. The cumulative effects of extreme DTRs increased with the increment of lag days for all types of mortality in cold season, and they were greater for extreme high DTRs than those of extreme low DTRs. In hot season, the cumulative effects for extreme low DTRs increased with the increment of lag days, but for extreme high DTR they reached maxima at a lag of 13 days for all types of mortality except for CBD(at lag6 days), and then decreased. Conclusions: Our findings suggest that extreme DTR is an independent risk factor of daily mortality, and season is a modifier of the association of DTR with daily mortality. [ABSTRACT FROM AUTHOR]