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Traditional cancer treatments based on chemo- and/or radiotherapy effectively kill only differentiated cancer cells, while metastasis and recurrences are caused by surviving cancer resistant cells (CRC) or a special subpopulation of cancer cells known as cancer stem cells (CSC). Both of these cell types compromise anticancer treatment through various mechanisms, including withdrawal of the anticancer drug through ATP-binding cassette transporters, increased expression of DNA repair genes, or transition to a quiescent phenotype. In contrast to many cancers, where energy consumption is due to glycolysis (Warburg effect), the bioenergetics of CSC and CRC is most often related to oxidative phosphorylation, that is, dependent on mitochondrial function. Therefore, compounds that induce mitochondrial dysfunction (MDF), such as some antibiotics, may represent an alternative approach to anticancer therapy. This review summarizes the major recent works on the use of antibiotics to target tumors via CSC and suggests next steps for developing this approach.

Purpose Incretin-based medications are a novel class of agents for the treatment of type-2 diabetes mellitus (DM2). The safety profile of these medications is not firmly established, and concerns have been raised about their potential carcinogenicity. The objective of our study was to produce new evidence on the effect of incretin-based medications on cancer risk in patients with DM2. Methods We conducted a "retrospective cohort" study with data from the Clinical Practice Research Datalink and the Hospital Episodes Statistics in the UK. New users of either an incretin-based medication (n = 18 885) or a sulfonylurea medication (n = 36 929) between 2007 and 2013 were identified and followed for up to 8 years. Cox proportional-hazards models were used to estimate the quasi-intention-to-treat and quasi-per-protocol hazard-ratios for the association between incretin-based medications with cancer while adjusting for potential confounders. Results The adjusted hazard ratio (95% confidence interval) for use of incretin-based medications versus use of sulfonylurea medications for the overall-cancer outcome was 0.97 (0.90, 1.05) in the quasi-intention-to-treat analysis and 0.90 (0.81, 1.00) in the quasi-per-protocol analysis. In both analyses, the hazard-ratio functions over the 8-year follow-up seemed fairly constant, and the 8-year cumulative-risk functions in the two subcohorts were similar. Conclusions Our study suggests that the use of incretin-based medications in patients with DM2 does not increase the risk of cancer relative to the use of sulfonylurea medications, at least in the first several years of the use. Further research is needed to assess long-term effects of the use of incretin-based medications on cancer risk.

Introduction The few population-based studies that investigate the association between cannabis use and adiposity are inconclusive possibly because nicotine moderates the effect of cannabis on adiposity. The objective was to test the hypotheses that the association between cannabis use and adiposity in young men and women is modified by cigarette smoking. Methods Data were drawn from the Nicotine Dependence in Teens (NDIT) study, a 13-year prospective cohort investigation of the natural course of nicotine dependence. A total of 271 males and 319 females aged 12–13 years at cohort inception provided data on past-year cannabis use and number of cigarettes smoked per day in the past three months, at age 20 years. Outcomes included change in body mass index (BMI) and in waist circumference (WC) from ages 17 to 24 years. The hypothesis was tested in multiple linear regression models that included interaction terms for cannabis use and cigarette smoking and controlled for physical activity, sedentary behavior, alcohol use, and level of the outcome at baseline. Results The association between cannabis use and change in adiposity was U-shaped in male non-smokers and in females, and an inverted U-shape in male smokers. In males, the interaction between cannabis use and cigarette smoking was significant in both the models for change in BMI (p = 0.004; n = 271) and change in WC (p = 0.04; n = 250). In females, the interaction between cannabis use and cigarette smoking was not significant. Conclusion Smoking cigarettes appears to modify the association between cannabis use and adiposity in young men.

Access to care may be implicated in disparities between men and women in death after acute coronary syndrome, especially among younger adults. We aimed to assess sex-related differences in access to care among patients with premature acute coronary syndrome and to identify clinical and gender-related determinants of access to care.We studied 1123 patients (18-55 yr) admitted to hospital for acute coronary syndrome and enrolled in the GENESIS-PRAXY cohort study. Outcome measures were door-to-electrocardiography, door-to-needle and door-to-balloon times, as well as proportions of patients undergoing cardiac catheterization, reperfusion or nonprimary percutaneous coronary intervention. We performed univariable and multivariable logistic regression analyses to identify clinical and gender-related determinants of timely procedures and use of invasive procedures.Women were less likely than men to receive care within benchmark times for electrocardiography (≤ 10 min: 29% v. 38%, p = 0.02) or fibrinolysis (≤ 30 min: 32% v. 57%, p = 0.01). Women with ST-segment elevation myocardial infarction (MI) were less likely than men to undergo reperfusion therapy (primary percutaneous coronary intervention or fibrinolysis) (83% v. 91%, p = 0.01), and women with non-ST-segment elevation MI or unstable angina were less likely to undergo nonprimary percutaneous coronary intervention (48% v. 66%, p0.001). Clinical determinants of poorer access to care included anxiety, increased number of risk factors and absence of chest pain. Gender-related determinants included feminine traits of personality and responsibility for housework.Among younger adults with acute coronary syndrome, women and men had different access to care. Moreover, fewer than half of men and women with ST-segment elevation MI received timely primary coronary intervention. Our results also highlight that men and women with no chest pain and those with anxiety, several traditional risk factors and feminine personality traits were at particularly increased risk of poorer access to care.

Background Recent cross-sectional studies suggest some adolescents who have never smoked cigarettes experience nicotine dependence (ND) symptoms and that exposure to second-hand smoke, social exposure to smoking, and alcohol use are plausible correlates. The aim of this study was to replicate and extend these findings by investigating possible predictors of ND symptoms longitudinally. Method Participants included 847 secondary school students who had never smoked cigarettes enrolled in the Nicotine Dependence in Teens Study. Adolescents completed self-report questionnaires measuring smoking status, ND symptoms, and risk factors for ND in smokers (i.e., socio-demographic indicators, social exposure to smoking, psychosocial indicators, and substance use) in 20 survey cycles from 7 to 11th grade. Generalized estimating equations, which account for repeated measures within individuals, were used to test the predictors of ND symptoms. Results Consistent with previous research, 7.8% of never-smokers across all cycles endorsed at least one ND symptom. Younger age ( p ≤ .001), country of birth ( p ≤ .05), peer smoking ( p ≤ .001), teacher smoking ( p ≤ .05), depression ( p ≤ .05), stress ( p ≤ .001), lower self-esteem ( p ≤ .05), impulsivity ( p ≤ .05), and alcohol use ( p ≤ .001) predicted greater ND symptoms in multivariable modeling. Conclusions Replicating previous cross-sectional findings, peer smoking and alcohol use predicted ND symptoms among never-smoking adolescents. Extending these findings, previous predictors only observed among ever-smokers, including socio-demographic and psychosocial indicators, also predicted ND symptoms. This longitudinal investigation demonstrated the temporal relation of the predictors preceding ND symptoms. Future research should consider longer prospective studies with younger children to capture early onset of ND symptoms and with longer follow-up to detect eventual smoking uptake.

Summary Background Around 90% of deaths from ovarian cancer are due to high-grade serous cancer (HGSC), which is frequently diagnosed at an advanced stage. Several cancer organisations made a joint recommendation that all women with specified symptoms of ovarian cancer should be tested with the aim of making an early diagnosis. In the Diagnosing Ovarian Cancer Early (DOvE) study we investigated whether open-access assessment would increase the rate of early-stage diagnosis. Methods Between May 1, 2008, and April 30, 2011, we enrolled women who were aged 50 years or older and who had symptoms of ovarian cancer. They were offered diagnostic testing with cancer antigen (CA-125) blood test and transvaginal ultrasonography (TVUS) at a central and a satellite open-access centre in Montreal, QC, Canada. We compared demographic characteristics of DOvE patients with those of women in the same age-group in the general population of the area, and compared indicators of disease burden with those in patients with ovarian cancer referred through the usual route to our gynaecological oncology clinic (clinic patients). Findings Among 1455 women assessed, 402 (27·6%) were in the highest-risk age group (≥65 years). 239 (16·4%) of 1455 required additional investigations. 22 gynaecological cancers were diagnosed, 11 (50%) of which were invasive ovarian cancers, including nine HGSC. The prevalence of invasive ovarian cancer, therefore, was one per 132 women (0·76%), which is ten times higher than that reported in screening studies. DOvE patients were significantly younger, more educated, and more frequently English speakers than were women in the general population. They also presented with less tumour burden than did the 75 clinic patients (median CA-125 concentration 72 U/mL, 95% CI 12–1190 vs 888 U/mL, 440–1936; p=0·010); Eight (73%) tumours were completely resectable in DOvE patients, compared with 33 (44%) in clinic patients (p=0·075). Seven (78%) of the HGSC in the DOvE group originated outside the ovaries and five were associated with only slightly raised CA-125 concentrations and minimal or no ovarian abnormalities on TVUS. Interpretation The proportion of HGSC that originated outside the ovaries in this study suggests that early diagnosis programmes should aim to identify low-volume disease rather than early-stage disease, and that diagnostic approaches should be modified accordingly. Although testing symptomatic women may result in earlier diagnosis of invasive ovarian cancer, large-scale implementation of this approach is premature. Funding Canadian Institutes of Health Research, Montreal General Hospital Foundation, Royal Victoria Hospital Foundation, Cedar's Cancer Institute, and La Fondation du Cancer Monique Malenfant-Pinizzotto.

The effect of screen time during secondary school on percent body fat was examined in a cohort of 744 Canadian adolescents aged 12-13 years at baseline. Participants completed self-reported questionnaires on television viewing and computer use in 19 survey cycles over 57 months from 1999 to 2005. Triceps skinfold thickness and subscapular skinfold thickness were measured in survey cycles 1 and 19. Four screen-time trajectory groups identified in growth mixture modeling included steady-low screen time (73% of the sample), steady-high (10%), increasers (9%), and decreasers (8%). The effect of screen-time trajectory on percent body fat at survey cycle 19 was modeled in boys and girls separately by using linear regression, adjusting for baseline percent body fat and physical activity. Relative to that of steady-low screen-time trajectory group boys, percent body fat was 2.9 (95% confidence interval: 0.7, 5.0) and 2.4 (95% confidence interval: 0.5, 4.2) percentage units higher on average among "increasers" and "steady-high" trajectory group boys, respectively. There was no evidence that screen time has an effect on percent body fat in girls overall, although physical activity modified the association between screen time and percent body fat in both sexes. Efforts to prevent obesity in youth should emphasize reducing screen time.

Few prospective studies of smoking initiation have investigated a wide range of time-varying and invariant predictor variables at the individual and contextual levels concurrently. In this study (1999-2005), 877 Canadian students (mean age = 12.7 years) who had never smoked at baseline completed self-report questionnaires on cigarette smoking and 32 predictor variables in 20 survey cycles during secondary school. Height and weight were measured in survey cycles 1, 12, and 19. School administrators completed questionnaires on school tobacco control policies/activities, and trained observers collected data on access to tobacco products in commercial establishments near schools. Younger age, single-parent family status, smoking by parents, siblings, friends, and school staff, stress, impulsivity, lower self-esteem, feeling a need to smoke, not doing well at school, susceptibility to tobacco advertising, alcohol use, use of other tobacco products, and attending a smoking-tolerant school were independent determinants of smoking initiation. Independent determinants of daily smoking onset among initiators of nondaily smoking included smoking by siblings and friends, feeling a need to smoke, susceptibility to tobacco advertising, use of other tobacco products, and self-perceived mental and physical addiction. Adolescent tobacco control programs should address multiple individual and contextual-level risk factors. Strategies that address nicotine dependence symptoms are also needed for adolescents who have already initiated smoking.

Purpose To study the effect of cigarette use on height and adiposity in adolescents. Methods Data on cigarette use were collected every 3 months for 5 years from adolescents initially 12–13 years of age. Height, weight, and triceps skinfold thickness were measured in survey cycles 1, 12, and 19. Multivariate linear regression models were fitted to estimate the association between cigarette use and the anthropometric measures in a dataset that pooled data over two time periods, from survey cycles 1–12 and from survey cycles 12–19. Results Data were available for 451 boys and 478 girls. Seven percent of boys and 14% of girls smoked ≥30 cigarettes per month on average during the first time period; 9% of boys and 18% of girls smoked ≥30 cigarettes per month on average during the second time period. In boys, a 100-cigarette per month increment in cigarette use over the preceding 2.5 years was independently associated with lower body mass index (−0.4 kg/m 2 ) and shorter height (−0.7 cm). In girls, cigarette use was not associated with height or adiposity. Conclusions While there was no relation in girls, cigarette use appears to decrease body mass index and height in boys. Young girls may be less likely to take up cigarette smoking if tobacco control messages emphasize that cigarette use may not be associated with reduced weight in adolescent females.

Although related to inflammatory markers in adults, little is known about the association between cigarette smoking and C-reactive protein (CRP) in adolescent smokers. We examined the association between high-sensitivity CRP (hs-CRP) concentrations and smoking in youth. We used data from a cross-sectional, province-wide survey of a representative sample of youth conducted in Quebec, Canada, in 1999. Data were collected in self-report questionnaires completed by participants and their parents. Participants provided a fasting blood sample, and anthropometric measures were undertaken by trained technicians. The present analysis pertains to 1,501 adolescents aged 13 and 16 years who completed questionnaires and for whom blood samples were available. The independent association between a six-category indicator of smoking status and elevated hs-CRP, defined as a value at least in the 90th percentile of the age- and sex-specific CRP distribution, was assessed in multiple logistic regression analyses controlling for potential confounders. Relative to never-smokers, the odds ratios (95% confidence intervals) for puffers (i.e., never smoked a whole cigarette), those who smoked but not in the past month, light past-month smokers, moderate past-month smokers, and heavy past-month smokers were 1.04 (0.55-1.98), 1.76 (1.06-2.94), 1.39 (0.70-2.76), 2.07 (0.96-4.42), and 2.40 (1.18-4.88), respectively. Our data suggest a positive association between smoking status and elevated CRP in adolescents, and in particular among heavier past-month smokers. Damage related to cigarette smoking may begin soon after tobacco use initiation, reinforcing the preventive message that no level of smoking is safe in youth.

Therapeutic approaches in systemic lupus erythematosus (SLE) have evolved over the last few decades, but their impact on prevention of organ damage is unknown. The objective of this study was to compare new cumulative damage in SLE patients across different calendar periods. Patients from a large SLE cohort were divided into two subcohorts; the first diagnosed and followed between 1978 and 1988 (cohort #1, n = 100) and the second between 1989 and 1999 (cohort #2, n = 51). Initial Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI) scores, and changes in scores over the observation intervals, were compared for the two groups. Logistic regression estimated adjusted odds ratios (OR) comparing damage accrual between the two cohorts. Medication exposures were noted. Baseline characteristics were similar between the two groups. At first assessment, the adjusted OR for a SLICC/ACR DI score ≥1 was 1.79 (95% CI 0.82, 3.88) for cohort #1 versus cohort #2. At the end of the observation interval, the adjusted OR for a SLICC/ACR DI score ≥1 was 1.22 (0.58, 2.55) for cohort #1 versus cohort #2. The adjusted OR for accruing damage over the observation interval in cohort #1 versus cohort #2 was 0.94 (0.39, 2.44). Increased medication exposure was evident for cohort #2 compared to cohort #1. Despite increased therapeutic measures used for patients in more recent periods, our data do not establish a clear difference in damage accrual. This emphasizes the need for strategies to effectively treat lupus-specific manifestations, while minimizing side effects and comorbidities.

The purpose of this study was to develop and evaluate the psychometric properties of the Parent Adherence Report Questionnaire, a measure of adherence to treatment recommendations in juvenile idiopathic arthritis (JIA). Forty-one primary caregivers of children with JIA (age 1.5 to 18 years) completed a series of measures over a 3-month period. Demographic and disease-related information were obtained at baseline. To measure adherence, caregivers completed bi-weekly diaries on treatment adherence, the general adherence scale (GAS) monthly, and the PARQ at the end of 3 months. The PARQ was reassessed 2 weeks later. Medical charts were reviewed to compare bi-weekly diary reports to actual prescriptions. Intraclass correlation coefficients and kappa coefficients used to assess reproducibility indicated moderate to substantial levels of agreement for PARQ items across time. Construct validity was supported through: (1) significant correlations between the GAS and the PARQ for both exercise and medication; (2) fair agreement between the PARQ-medication and diary reports on medication-related behaviors, and (3) a significant positive correlation between the PARQ-exercise and diary reports on exercise-related behaviors. The study provides preliminary evidence of the reliability and validity of the PARQ.

Most existing coronary risk assessment methods are based on baseline data only. The authors compared the predictive ability of coronary multivariable risk scores based on updated versus baseline risk factors and investigated the optimal frequency of updating. Data from 16 biennial examinations of 4,962 subjects from the original Framingham Heart Study (1948-1978) were used. The predictive ability of three multivariable risk scores was evaluated through 10-fold cross-validation. The baseline-only multivariable risk score was computed using baseline values of coronary risk factors applied to a Cox model estimated from baseline data. The two other approaches relied on updated risk factors and included them in the models estimated from, respectively, baseline and updated data. All analyses were stratified by sex and age. For 30, 14, and 10 years of follow-up, the predictive ability of the baseline-only multivariable risk score was substantially poorer than that of the models using updated risk factors. Between the two latter models, the one estimated from updated data ensured better prediction than the one estimated from baseline data for 30 years of follow-up among younger subjects only. The results suggest that coronary risk assessment can be improved by utilizing updated risk factors and that the optimal frequency of updating may vary across subpopulations.

Objectives: To conduct a systematic review of the literature on the determinants of hospital emergency department (ED) visits by elders, using a modification of the Andersen behavioral model of health services, adapted to explain ED utilization. Methods: Relevant articles were identified through MEDLINE and a search of reference lists and personal files. Studies of populations aged 65 or older in which ED visits were a study outcome were included if they were: original, not restricted to a particular medical condition, written in English or French, and investigated one or more determinants. Data were abstracted and checked by two authors using a standard protocol. Results: Fourteen studies (reported in 15 articles) were reviewed, 10 community-based and four using clinical samples. Among ten studies that measured multiple determinants, determinants reported from multivariate analyses included measures of need (perceived and evaluated health status, prior utilization), predisposing factors (health beliefs and sociodemographic variables), and enabling factors (physician availability, regular source of care, family resources, geographical access to services). Conclusions: Need is usually the primary determinant of ED visits in older people. Controlling for need, predisposing and enabling factors that promote access to primary medical care are associated with reduced ED utilization.

Importance Little is known about whether sex differences in acute coronary syndrome (ACS) presentation exist in young patients and what factors determine absence of chest pain in ACS presentation. Objectives To evaluate sex differences in ACS presentation and to estimate associations between sex, sociodemographic, gender identity, psychosocial and clinical factors, markers of coronary disease severity, and absence of chest pain in young patients with ACS. Design, setting, participants We conducted a prospective cohort study of 1015 patients (30% women) 55 years or younger, hospitalized for ACS and enrolled in the GENESIS PRAXY (Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome) study (January 2009-September 2012). Main outcomes and measures The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey was administered during hospitalization. Results The median age for both sexes was 49 years. Women were more likely to have non-ST-segment elevation myocardial infarction (37.5 vs 30.7; P = .03) and present without chest pain compared with men (19.0% vs 13.7%; P = .03). Patients without chest pain reported fewer symptoms overall and no discernable pattern of non-chest pain symptoms was found. In the multivariate model, being a woman (odds ratio [OR], 1.95 [95% CI, 1.23-3.11]; P = .005) and tachycardia (OR, 2.07 [95% CI, 1.20-3.56]; P = .009) were independently associated with ACS presentation without chest pain. Patients without chest pain did not differ significantly from those with chest pain in terms of ACS type, troponin level elevation, or coronary stenosis. Conclusions and relevance Chest pain was the most common ACS symptom in both sexes. Although women were more likely to present without chest pain than men, absence of chest pain was not associated with markers of coronary disease severity. Strategies that explicitly incorporate assessment of common non-chest pain symptoms need to be evaluated.

To assess the socioeconomic, geographical and demographic inequities in the use of postnatal health-care services in low- and middle-income countries.We searched Medline, Embase and Cochrane Central databases and grey literature for experimental, quasi-experimental and observational studies that had been conducted in low- and middle-income countries. We summarized the relevant studies qualitatively and performed meta-analyses of the use of postnatal care services according to selected indicators of socioeconomic status and residence in an urban or rural setting.A total of 36 studies were included in the narrative synthesis and 10 of them were used for the meta-analyses. Compared with women in the lowest quintile of socioeconomic status, the pooled odds ratios for use of postnatal care by women in the second, third, fourth and fifth quintiles were: 1.14 (95% confidence interval, CI : 0.96-1.34), 1.32 (95% CI: 1.12-1.55), 1.60 (95% CI: 1.30-1.98) and 2.27 (95% CI: 1.75-2.93) respectively. Compared to women living in rural settings, the pooled odds ratio for the use of postnatal care by women living in urban settings was 1.36 (95% CI: 1.01-1.81). A qualitative assessment of the relevant published data also indicated that use of postnatal care services increased with increasing level of education.In low- and middle-income countries, use of postnatal care services remains highly inequitable and varies markedly with socioeconomic status and between urban and rural residents.تقييم حالات الإجحاف الاجتماعية والاقتصادية والجغرافية والديمغرافية في الاستفادة من خدمات الرعاية الصحية بعد الولادة في البلدان المنخفضة الدخل والبلدان المتوسطة الدخل.أجرينا بحثاً في قواعد بيانات Medline وEmbase وكوكرين المركزية والمؤلفات غير الرسمية عن الدراسات التجريبية وشبه التجريبية والدراسات القائمة على الملاحظة التي تم إجراؤها في البلدان المنخفضة الدخل والبلدان المتوسطة الدخل. وقمنا بتلخيص الدراسات ذات الصلة من حيث النوع وأجرينا تحليلات وصفية للاستفادة من خدمات رعاية ما بعد الولادة وفقاً للمؤشرات المحددة للوضع الاجتماعي والاقتصادي والإقامة في بيئة حضرية أو ريفية.تم إدراج ما مجموعه 36 دراسة في الملخص السردي وتم استخدام 10 منها لإجراء التحليلات الوصفية. ومقارنة بالنساء في الفئة الخميسية الأدنى للوضع الاجتماعي والاقتصادي، كانت نسب الاحتمال المجمعة لاستفادة النساء في الفئات الخميسية الثانية والثالثة والرابعة والخامسة من رعاية ما بعد الولادة على النحو التالي: 1.14 (فاصل الثقة 95 %، فاصل الثقة: من 0.96 إلى 1.34) و1.32 (فاصل الثقة: 95 %، فاصل الثقة: من 1.12 إلى 1.55) و1.60 (فاصل الثقة: 95 %، فاصل الثقة: من 1.30 إلى 1.98) و2.27 (فاصل الثقة: 95 %، فاصل الثقة: من 1.75 إلى 2.93)، على التوالي. ومقارنة بالنساء اللاتي يعشن في المناطق الريفية، كانت نسبة الاحتمال المجمعة لاستفادة النساء اللاتي يعشن في المناطق الحضرية من رعاية ما بعد الولادة 1.36 (فاصل الثقة: 95 %، فاصل الثقة: من 1.01 إلى 1.81). وأشار تقييم نوعي للبيانات المنشورة ذات الصلة كذلك إلى ازدياد الاستفادة من خدمات رعاية ما بعد الولادة بازدياد مستوى التثقيف.مازال هناك إجحاف كبير في البلدان المنخفضة الدخل والبلدان المتوسطة الدخل في الاستفادة من خدمات رعاية ما بعد الولادة، ويتباين ذلك بتباين الوضع الاجتماعي والاقتصادي وبين سكان المناطق الحضرية والريفية.评估中低收入国家在使用产后卫生保健服务的社会经济学、地理学与人口学方面的不平等现象。.我们搜索了Medline、Embase、Cochrane Central数据库及灰色文献，查找在中低收入国家执行的试验、类试验和观察性研究。我们定性地总结了相关研究，并根据社会经济地位以及城市或农村居住等选定指标进行产后护理服务使用的综合分析。.总共36项研究被列入叙述合成，其中10项被用作荟萃分析。与社会经济地位五等分位数最低等的女性相比，排在第二、三、四、五等分位数的女性使用产后护理的合并优势比分别是：1.14（95%置信区间，CI：0.96-1.34）、1.32（95% CI：1.12-1.55）、1.60（95% CI：1.30-1.98）和2.27（95% CI：1.75-2.93）。与居住在农村环境的女性相比，居住在城市的女性使用产后护理的合并优势比是1.36（95% CI：1.01-1.81）。对相关公布数据的定性评估同样表明，产后护理服务使用的增加与教育程度成正比。.在中低收入国家，产后护理服务的使用依然处于极度不平等的阶段，因社会经济地位与城乡居民间的差异，产后护理的使用也明显不同。.Évaluer les inégalités socio-économiques, géographiques et démographiques en matière d'utilisation des soins de santé postnatals dans les pays à revenu faible et à revenu intermédiaire.Nous avons effectué une recherche bibliographique dans les bases de données Medline, Embase et Cochrane Central, ainsi que dans la littérature grise, pour trouver les études expérimentales, quasi-expérimentales et observationnelles qui ont été menées dans les pays à revenu faible et à revenu intermédiaire. Nous avons fait la synthèse qualitative des études pertinentes et effectué des méta-analyses de l'utilisation des services de soins postnatals en fonction des indicateurs choisis pour le statut socio-économique et la résidence dans les zones urbaines ou rurales.Un total de 36 études ont été incluses dans la synthèse narrative et 10 d'entre elles ont été utilisées pour les méta-analyses. Par rapport aux femmes du quintile de statut socio-économique le plus bas, les rapports des cotes regroupés pour l'utilisation des soins postnatals par les femmes dans le deuxième, troisième quatrième et cinquième quintiles étaient de: 1,14 (intervalle de confiance à 95%, IC: 0,96-1,34) et 1,32 (IC à 95%: 1,12-1,55) et 1,60 (IC à 95%: 1,30-1,98) et 2,27 (IC à 95%: 1,75-2,93), respectivement. Par rapport aux femmes vivant en zones rurales, le rapport des cotes regroupé pour l'utilisation des soins postnatals par les femmes vivant en zones urbaines était de 1,36 (IC à 95%: 1,01-1,81). Une évaluation qualitative des données publiées pertinentes a également indiqué que l'utilisation des services de soins postnatals augmentait avec l’augmentation du niveau d'éducation.Dans les pays à revenu faible et à revenu intermédiaire, l'utilisation de services de soins postnatals reste très inéquitable et varie manifestement avec le statut socio-économique et entre les résidents urbains et ruraux.Оценить социально-экономическое, географическое и демографическое неравенство в получении услуг по уходу в постнатальном периоде в странах с низким и средним уровнем доходов.Мы изучили базы данных Medline, Embase и Cochrane Central, а также не индексированную в медицинских базах данных литературу, посвященную экспериментальным, квазиэкспериментальным и обсервационным исследованиям, которые проводились в странах с низким и средним уровнем доходов. Мы обобщили качественные результаты соответствующих исследований и выполнили метаанализ использования услуг по уходу в постнатальном периоде в соответствии с отобранными показателями социально-экономического статуса и проживания в городской или сельской местности.В нарративный синтез было включено в общей сложности 36 исследований; 10 из них использовались для метаанализа. Сравнив показатели женщин, входящих в нижний квинтиль социально-экономического статуса, мы получили следующие обобщенные отношения шансов на получение услуг по уходу в постнатальном периоде для женщин, входящих во второй, третий, четвертый и пятый квинтили: 1,14 (доверительный интервал (ДИ) 95%: 0,96–1,34), 1,32 (ДИ 95%: 1,12–1,55), 1,60 (ДИ 95%: 1,30–1,98) и 2,27 (ДИ 95%: 1,75–2,93) соответственно. По сравнению с женщинами, проживающими в сельской местности, обобщенные отношения шансов на получение услуг по уходу в постнатальном периоде для женщин, проживающих в городской местности, составили 1,36 (ДИ 95%: 1,01–1,81). Результаты качественной оценки соответствующих опубликованных данных также свидетельствуют о том, частота использования услуг по уходу в постнатальном периоде уменьшается с понижением уровня образования.В странах с низким и средним уровнем доходов сохраняется существенное неравенство в получении услуг по уходу в постнатальном периоде, которое зависит главным образом от социально-экономического статуса и отличается среди городских и сельских жителей.Evaluar las desigualdades socioeconómicas, geográficas y demográficas en el uso de los servicios de salud de atención posnatal en países de ingresos bajos y medianos.Se buscaron estudios experimentales, cuasiexperimentales y observacionales que se habían llevado a cabo en países de ingresos bajos y medianos en las bases de datos Medline, Embase y Cochrane Central, así como en la literatura gris. Se resumieron los estudios relevantes cualitativamente y se realizaron metaanálisis sobre el uso de los servicios de atención posnatal según indicadores seleccionados del nivel socioeconómico y residencia en un entorno urbano o rural.Se incluyó un total de 36 estudios en la síntesis narrativa, 10 de los cuales se utilizaron para los metaanálisis. En comparación con las mujeres del quintil más bajo del nivel socioeconómico, las razones de posibilidades agrupadas del uso de atención posnatal de las mujeres en el segundo, tercer, cuarto y quinto quintiles fueron: 1,14 (intervalo de confianza del 95 %, IC: 0,96–1,34), 1,32 (IC del 95 %: 1,12–1,55), 1,60 (IC del 95 %: 1,30–1,98) y 2,27 (IC del 95 %: 1,75–2,93), respectivamente. En comparación con las mujeres que viven en entornos rurales, la razón de posibilidades agrupada del uso de atención posnatal por mujeres que viven en entornos urbanos fue 1,36 (IC del 95 %: 1,01–1,81). Una evaluación cualitativa de los datos relevantes publicados indicó además que el uso de servicios de atención posnatal ha aumentado mediante el aumento del nivel de educación.En los países de ingresos bajos y medianos, el uso de servicios de atención posnatal sigue siendo muy desigual y varía notablemente con el nivel socioeconómico y entre los residentes urbanos y rurales.

To conduct a systematic review of the literature on the determinants of hospital emergency department (ED) visits by elders, using a modification of the Andersen behavioral model of health services, adapted to explain ED utilization.Relevant articles were identified through MEDLINE and a search of reference lists and personal files. Studies of populations aged 65 or older in which ED visits were a study outcome were included if they were: original, not restricted to a particular medical condition, written in English or French, and investigated one or more determinants. Data were abstracted and checked by two authors using a standard protocol.Fourteen studies (reported in 15 articles) were reviewed, 10 community-based and four using clinical samples. Among ten studies that measured multiple determinants, determinants reported from multivariate analyses included measures of need (perceived and evaluated health status, prior utilization), predisposing factors (health beliefs and sociodemographic variables), and enabling factors (physician availability, regular source of care, family resources, geographical access to services).Need is usually the primary determinant of ED visits in older people. Controlling for need, predisposing and enabling factors that promote access to primary medical care are associated with reduced ED utilization.

Objectives The association between depression and cardiovascular disease severity in younger patients has not been assessed, and sex differences are unknown. We assessed whether major depression and depressive symptoms were associated with worse cardiovascular disease severity in patients with premature acute coronary syndrome, and we assessed sex differences in these relationships. Methods We enrolled 1023 patients (aged ≤55 years) hospitalized with acute coronary syndrome from 26 centers in Canada, the United States, and Switzerland, through the GENdEr and Sex determInantS of cardiovascular disease: From bench to beyond-Premature Acute Coronary Syndrome study. Left ventricular ejection fraction, Killip class, cardiac troponin I, and Global Registry of Acute Coronary Events score data were collected through chart review. Results The sample comprised 248 patients with major depression and 302 women. In univariate analyses, major depression was associated with a lower likelihood of having an abnormal left ventricular ejection fraction (odds ratio, 0.70; 95% confidence interval, 0.51-0.97; P = . 03) and lower troponin I levels (estimate, −4.04; 95% confidence interval, −8.01 to −0.06; P = .05). After adjustment for sociodemographic and clinical characteristics, neither major depression nor depressive symptoms were associated with disease severity indices, and there were no sex differences. Conclusion The increased risk of adverse events in depressed patients with premature acute coronary syndrome is not explained by disease severity.

Background The American Academy of Pediatrics advocates that pediatricians should be involved in tobacco counseling and has developed guidelines for counseling. We present a prognostic tool for use by health care practitioners in both clinical and non-clinical settings, to identify adolescents at risk of becoming daily smokers. Methods Data were drawn from the Nicotine Dependence in Teens (NDIT) Study, a prospective investigation of 1293 adolescents, initially aged 12-13 years, recruited in 10 secondary schools in Montreal, Canada in 1999. Questionnaires were administered every three months for five years. The prognostic tool was developed using estimated coefficients from multivariable logistic models. Model overfitting was corrected using bootstrap cross-validation. Goodness-of-fit and predictive ability of the models were assessed by R2, the c-statistic, and the Hosmer-Lemeshow test. Results The 1-year and 2-year probability of initiating daily smoking was a joint function of seven individual characteristics: age; ever smoked; ever felt like you needed a cigarette; parent(s) smoke; sibling(s) smoke; friend(s) smoke; and ever drank alcohol. The models were characterized by reasonably good fit and predictive ability. They were transformed into user-friendly tables such that the risk of daily smoking can be easily computed by summing points for responses to each item. The prognostic tool is also available on-line at http://episerve.chumontreal.qc.ca/calculation_risk/daily-risk/daily_smokingadd.php. Conclusions The prognostic tool to identify youth at high risk of daily smoking may eventually be an important component of a comprehensive tobacco control system.