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Objective(s) We studied women's experiences seeking and receiving second-trimester abortion care in two geographically and legislatively different settings to inform ways to improve abortion care access and services. Study design We conducted in-depth interviews with women who obtained second-trimester abortion care. Themes from the interviews were then used to inform a self-administered survey, which was completed by 108 women who received second-trimester abortion care in the Northeast and Midwest. We calculated descriptive statistics and used chi-squared and t-tests to compare responses. Results We interviewed eight women and surveyed 108 women. Most interviewees and 65.2% of survey respondents reported difficulties accessing care. Although most interview and survey respondents had insurance, a slight majority reported difficulty funding care. All interviewees and 57.9% of survey respondents reported positive experiences with providers, with many interviewees and 62.0% of survey respondents saying their abortion care was better than their usual health care. Most interviewees and 75.8% of survey respondents reported pain as low to moderate, and the majority of participants reported it was the same or less than expected. Knowledge about abortion restrictions was low. Most interviewees and 68.4% survey respondents disagreed with restrictions on insurance coverage of abortion. Common recommendations to improve experiences were to ensure travel and financial support and to decrease wait times at clinics. There were few regional differences among outcomes. Conclusion(s) Women seeking second-trimester abortion in these locations reported positive abortion experiences. However, they had to overcome significant obstacles to obtain care. Implications This is the first study to systematically research women's second-trimester care experiences in two different regions of the United States. Regardless of location, women experienced barriers due to policies that impose gestational age restrictions, limit provider availability (consequently increasing wait times), and increase costs. Policy change to reduce these barriers is critical to improve access to and experiences with second trimester abortion care.

Objective: Following a California law expanding pharmacists’ scope of practice to include directly providing self-administered hormonal contraception to patients pursuant to a statewide protocol, this study aimed to assess California pharmacists’ intentions to provide this new service prior to the protocol development and implementation. Design: Descriptive, nonexperimental, cross-sectional study. Setting: California between August and September 2014. Participants: California pharmacists working in community pharmacies. Intervention: Invitations to participate in the online survey were sent to 1774 pharmacists. Main Outcome Measures: Main outcomes included pharmacists’ current practices, intentions to prescribe hormonal contraception, comfort performing various activities, knowledge about contraceptive methods, training needs, and barriers to prescribing. Results: A total of 257 responses (14.5% response rate) were received. Of those, 121 respondents met inclusion criteria and were included in the analysis. About half of the respondents (49.6%) reported working in a community chain pharmacy, 46.3% in an independent pharmacy, and 4.1% in other community pharmacy settings. The majority (72.7%) of pharmacists reported that they would likely provide this new service. Respondents reported being comfortable educating patients on short-acting (94.2%) and long-acting reversible contraception (81.7%), as well as identifying drug interactions with hormonal contraception (96.7%). Respondents indicated time constraints (74.4%), lack of reimbursement (63.6%), and liability concerns (62.0%) as barriers to prescribing hormonal contraception. Conclusions: California pharmacists expressed strong intentions and comfort in prescribing hormonal contraception. Pharmacists’ additional training needs and barriers should be addressed for successful implementation. This new service has great potential to increase access to contraception, potentially fostering increased use and adherence.

Despite a relatively low fertility rate, maternal mortality in Ghana still remains high. According to the Ghana Demographic and Health Surveys, about 22% of Ghanaian women of reproductive age currently use contraception. We analyzed contraceptive use among a representative sample of women in Accra, Ghana, to better understand contraceptive use patterns. We used data from two cross-sectional surveys of a representative cohort of women in Accra. In 2003, 28.9% of sexually active women used a contraceptive method. In 2008, 31.5% of sexually active women used a contraceptive method. Additionally, we observed high rates of discontinuation—from 64.1% among those using longer-acting methods to 82.1% among those using traditional methods—between years. Further research on women’s contraceptive decision-making is needed to explain these patterns and to ensure that family planning interventions meet the needs of women in Ghana. (Afr. J Reprod Health 2016; 20[4]: 22-36).

Two experiments were conducted to evaluate the effects of the level of corn dry distillers grains with solubles (CDDGS) supplementation on growing performance, blood metabolites, digestion characteristics and ruminal fermentation patterns in steers grazing dormant forage. In Exp. 1, of growth performance, 120 steers (204±5 kg initial body weight [BW]) were distributed randomly into 3 groups (each of 40 steers), which were provided with the following levels of CDDGS supplement: 0%, 0.25%, or 0.50% BW. All groups of steers were grazed for 30 days in each of 3 grazing periods (March, April, and May). Approximately 1,000 ha of the land was divided with electric fencing into 3 equally sized pastures (333 ha in size). Blood samples were collected monthly from 20 steers in each grazing group for analysis of glucose (G), urea-nitrogen (UN) and non-esterified fatty acids. Final BW, average daily gain (ADG) and supplement conversion (CDDGS-C) increased with increasing levels of CDDGS supplementation (p

J. Scott Nystrom 1 , John C. Hornberger 2,3 , Gauri R. Varadhachary 4 , Richard J. Hornberger 3 , Hialy R. Gutierrez 3 , W. David Henner 5 , Shawn H. Becker 5 , Mahul B. Amin 6 , and Michael G. Walker 2 1 Department of Medicine, Tufts Medical Center, Boston, MA, USA 2 Department of Medicine, Stanford University, Stanford, CA, USA 3 Cedar Associates LLC, Menlo Park, CA, USA 4 Department of Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA 5 Pathwork Diagnostics, Inc., Redwood City, CA, USA 6 Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA Received: May 22, 2012; Accepted: June 08, 2012; Published: June 9, 2012; Keywords: cancer of unknown primary, diagnosis, genomics, clinical utility, tissue of origin Correspondence: John Hornberger, email: // // Abstract PURPOSE: The primary tissue-site origin in over 4% of cancers remains uncertain despite thorough clinicopathological evaluation. This study assessed the effect of a Food and Drug Administration-cleared 2,000-gene–expression-profiling (GEP) test on primary tissue-site working diagnoses and management for metastatic and poorly differentiated cancers. METHODS: Clinical information was collected from physicians ordering the GEP test for patients with difficult to diagnose cancers. Endpoints included diagnostic procedures, physicians’ working diagnoses and treatment recommendations before and after GEP result availability, and physician reports of the test’s usefulness for clinical decision making. Patient date of death was obtained, with a minimum of one year follow-up from date of biopsy. RESULTS: Sixty-five physicians participated in the study (n=107 patients). Before GEP, patients underwent 3.2 investigations on average (e.g., radiology, endoscopy). Ten immunohistochemistry tests were used per biopsy (SD 5.2). After GEP testing, physicians changed the primary working diagnosis for 50% of patients (95% CI: 43%,58%) and management for 65% of patients (95% CI: 58%,73%). With GEP results, the recommendation for guideline-consistent chemotherapy increased from 42% to 65% of patients, and the recommendation for non-guideline-consistent regimens declined from 28% to 13%. At last follow-up, 69 patients had died, and median survival was 14.0 months (95% CI: 10.2,18.6). Thirty-three percent of patients were alive at 2 years. CONCLUSION: In patients with difficult-to-diagnose cancers, GEP changed the working diagnosis and management for the majority of patients. Patients for whom the GEP test was ordered had longer median survival than that historically reported for patients enrolled in treatment trials for cancer of unknown primary.

A recent phase III trial demonstrated improved progression-free survival (PFS) and overall survival (OS) associated with adding rituximab to fludarabine and cyclophosphamide (R-FC) compared to FC in treatment of previously untreated chronic lymphocytic leukemia (CLL). A cost-effectiveness analysis of R-FC over FC was performed from a US third-party payer perspective over a lifetime horizon in the base case. One-way, two-way and probabilistic sensitivity analyses were conducted to assess the robustness of the results. A secondary analysis was performed by also considering a societal perspective. R-FC was associated with an incremental 1.15 quality-adjusted life-years (QALYs) compared to FC and resulted in an incremental cost-effectiveness ratio of $23 530 per QALY in the base case and $31 513 per QALY considering a societal perspective. Results were most sensitive to time horizon, discount rate and unit drug cost for rituximab. Within the limitations of modeling long-term outcomes, R-FC is cost-effective for previously untreated CLL.

Introduction This paper identifies factors influencing differences in the prevalence of diarrhea, fever and acute respiratory infection (ARI), and health seeking behavior among caregivers of children under age five in rural Tanzania. Methods Using cross-sectional survey data collected in Kilombero, Ulanga, and Rufiji districts, the analysis included 1,643 caregivers who lived with 2,077 children under five years old. Logistic multivariate and multinomial regressions were used to analyze factors related to disease prevalence and to health seeking behavior. Results One quarter of the children had experienced fever in the past two weeks, 12.0 % had diarrhea and 6.7 % experienced ARI. Children two years of age and older were less likely to experience morbidity than children under one year [ORfever = 0.77, 95 % CI 0.61-0.96; ORdiarrhea = 0.26, 95 % CI 0.18-0.37; ORARI = 0.60 95 % CI 0.41-0.89]. Children aged two and older were more likely than children under one to receive no care or to receive care at home, rather than to receive care at a facility [RRRdiarrhea = 3.47, 95 % CI 1.19-10.17 for “No care”]. Children living with an educated caregiver were less likely to receive no care or home care rather than care at a facility as compared to those who lived with an uneducated caregiver [RRRdiarrhea = 0.28, 95 % CI 1.10-0.79 for “No care”]. Children living in the wealthiest households were less likely to receive no care or home care for fever as compared to those who lived poorest households. Children living more than 1 km from health facility were more likely to receive no care or to receive home care for diarrhea rather than care at a facility as compared to those living less than 1 km from a facility [RRRdiarrhea = 3.50, 95 % CI 1.13-10.82 for “No care”]. Finally, caregivers who lived with more than one child under age five were more likely to provide no care or home care rather than to seek treatment at a facility as compared to those living with only one child under five. Conclusions Our results suggest that child age, caregiver education attainment, and household wealth and location may be associated with childhood illness and care seeking behavior patterns. Interventions should be explored that target children and caregivers according to these factors, thereby better addressing barriers and optimizing health outcomes especially for children at risk of dying before the age of five.

Background Service Provision Assessment (SPA) surveys have been conducted to gauge primary health care and family planning clinical readiness throughout East and South Asia as well as sub-Saharan Africa. Intended to provide useful descriptive information on health system functioning to supplement the Demographic and Health Survey data, each SPA produces a plethora of discrete indicators that are so numerous as to be impossible to analyze in conjunction with population and health survey data or to rate the relative readiness of individual health facilities. Moreover, sequential SPA surveys have yet to be analyzed in ways that provide systematic evidence that service readiness is improving or deteriorating over time. Methods This paper presents an illustrative analysis of the 2006 Tanzania SPA with the goal of demonstrating a practical solution to SPA data utilization challenges using a subset of variables selected to represent the six building blocks of health system strength identified by the World Health Organization (WHO) with a focus on system readiness to provide service. Principal Components Analytical (PCA) models extract indices representing common variance of readiness indicators. Possible uses of results include the application of PCA loadings to checklist data, either for the comparison of current circumstances in a locality with a national standard, for the ranking of the relative strength of operation of clinics, or for the estimation of trends in clinic service quality improvement or deterioration over time. Results Among hospitals and health centers in Tanzania, indices representing two components explain 32 % of the common variance of 141 SPA indicators. For dispensaries, a single principal component explains 26 % of the common variance of 86 SPA indicators. For hospitals/HCs, the principal component is characterized by preventive measures and indicators of basic primary health care capabilities. For dispensaries, the principal component is characterized by very basic newborn care as well as preparedness for delivery. Conclusions PCA of complex facility survey data generates composite scale coefficients that can be used to reduce indicators to indices for application in comparative analyses of clinical readiness, or for multi-level analysis of the impact of clinical capability on health outcomes or on survival. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1203-7) contains supplementary material, which is available to authorized users.

Lessons learned by countries that have successfully implemented coverage schemes for health services may be valuable for other countries, especially low- and middle-income countries (LMICs), which likewise are seeking to provide/expand coverage. The research team surveyed experts in population health management from LMICs for information on characteristics of health care coverage schemes and factors that influenced decision-making processes. The level of coverage provided by the different schemes varied. Nearly all the health care coverage schemes involved various representatives and stakeholders in their decision-making processes. Maternal and child health, cardiovascular diseases, cancer, and HIV were among the highest priorities guiding coverage development decisions. Evidence used to inform coverage decisions included medical literature, regional and global epidemiology, and coverage policies of other coverage schemes. Funding was the most commonly reported reason for restricting coverage. This exploratory study provides an overview of health care coverage schemes from participating LMICs and contributes to the scarce evidence base on coverage decision making. Sharing knowledge and experiences among LMICs can support efforts to establish systems for accessible, affordable, and equitable health care.

Importance Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. Objectives To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. Design We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. Results US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. Conclusions and Relevance From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.

Objetive:\ud To conduct a systematic review of the literature and meta-analyses to fill the gaps in knowledge on potassium intake and health.\ud \ud Data sources:\ud Cochrane Central Register of Controlled Trials, Medline, Embase, WHO International Clinical Trials Registry Platform, Latin American and Caribbean Health Science Literature Database, and the reference lists of previous reviews.\ud \ud Study selection:\ud Randomised controlled trials and cohort studies reporting the effects of potassium intake on blood pressure, renal function, blood lipids, catecholamine concentrations, all cause mortality, cardiovascular disease, stroke, and coronary heart disease were included.\ud \ud Data extraction and synthesis:\ud Potential studies were independently screened in duplicate, and their characteristics and outcomes were extracted. When possible, meta-analysis was done to estimate the effects (mean difference or risk ratio with 95% confidence interval) of higher potassium intake by using the inverse variance method and a random effect model.\ud \ud Results:\ud 22 randomised controlled trials (including 1606 participants) reporting blood pressure, blood lipids, catecholamine concentrations, and renal function and 11 cohort studies (127,038 participants) reporting all cause mortality, cardiovascular disease, stroke, or coronary heart disease in adults were included in the meta-analyses. Increased potassium intake reduced systolic blood pressure by 3.49 (95% confidence interval 1.82 to 5.15) mm Hg and diastolic blood pressure by 1.96 (0.86 to 3.06) mm Hg in adults, an effect seen in people with hypertension but not in those without hypertension. Systolic blood pressure was reduced by 7.16 (1.91 to 12.41) mm Hg when the higher potassium intake was 90-120 mmol/day, without any dose response. Increased potassium intake had no significant adverse effect on renal function, blood lipids, or catecholamine concentrations in adults. An inverse statistically significant association was seen between potassium intake and risk of incident stroke (risk ratio 0.76, 0.66 to 0.89). Associations between potassium intake and incident cardiovascular disease (risk ratio 0.88, 0.70 to 1.11) or coronary heart disease (0.96, 0.78 to 1.19) were not statistically significant. In children, three controlled trials and one cohort study suggested that increased potassium intake reduced systolic blood pressure by a non-significant 0.28 (-0.49 to 1.05) mm Hg.\ud \ud Conclusions:\ud High quality evidence shows that increased potassium intake reduces blood pressure in people with hypertension and has no adverse effect on blood lipid concentrations, catecholamine concentrations, or renal function in adults. Higher potassium intake was associated with a 24% lower risk of stroke (moderate quality evidence). These results suggest that increased potassium intake is potentially beneficial to most people without impaired renal handling of potassium for the prevention and control of elevated blood pressure and stroke.

BACKGROUND: Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time. METHODS: We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden. FINDINGS: In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania. INTERPRETATION: Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children. FUNDING: Bill and Melinda Gates Foundation.

ObjectivesGene-expression profiling (GEP) reliably supplements traditional clinicopathological information on the tissue of origin (TOO) in metastatic or poorly differentiated cancer. A cost-effectiveness analysis of GEP TOO testing versus usual care was conducted from a US third-party payer perspective.MethodsData on recommendation changes for chemotherapy, surgery, radiation therapy, blood tests, imaging investigations, and hospice care were obtained from a retrospective, observational study of patients whose physicians received GEP TOO test results. The effects of chemotherapy recommendation changes on survival were based on the results of trials cited in National Comprehensive Cancer Network and UpToDate guidelines. Drug and administration costs were based on average doses reported in National Comprehensive Cancer Network guidelines. Other unit costs came from Centers for Medicare & Medicaid Services fee schedules. Quality-of-life weights were obtained from literature. Bootstrap analysis estimated sample variability; probabilistic sensitivity analysis addressed parameter uncertainty.ResultsChemotherapy regimen recommendations consistent with guidelines for final tumor-site diagnoses increased significantly from 42% to 65% (net difference 23%; P

397 Background: An important step for a novel test is assessing its clinical utility and real-world effect on diagnosis and patient management. This report describes completed results of a cohort of physicians who have ordered a gene expression profile assay for identification of tumor tissue of origin (Pathwork Tissue of Origin Test) for patients with difficult-to-diagnose primary cancers and their subsequent treatment and survival. Methods: The IRB-approved registry collected data from participating physicians who have ordered the Tissue of Origin test. A detailed interview was conducted using both a web-based questionnaire and a confirmatory telephone interview with the physicians. Chart survey included collection of data on patient demographics, diagnostic procedures including imaging and immunohistochemistry as well as therapy. The physicians were queried regarding their working diagnoses and treatment recommendations prior to and after Tissue of Origin Test result availability. Date of death was also obtained with a minimum of one year follow-up from date of biopsy. Results: One hundred seven patients (61 women) have been studied and 65 participating physicians have completed the interview. Results indicate that most patients underwent extensive evaluation (≥ 10 IHC) prior to gene expression analysis. After receiving test results, physicians changed the primary site diagnosis for 53 patients (50%, CI [43,58%]; p Conclusions: This registry study confirms that in patients with difficult-to-diagnose primary cancers, extensive baseline diagnostics are common and less than half of the patients have an established working diagnosis. Results indicate that the Tissue of Origin Test led to a change in working diagnosis and changed treatment recommendations in over half the patients. Survival outcomes compare favorably to historical controls in treatment trials where median survival is generally less than one year.

e21093 Background: An important step for validating a novel diagnostic is the assessment of its real-world clinical utility. Gene expression profiling (Pathwork Tissue of Origin Test) is recently a...

e16500 Background: R-FC significantly increases progression-free survival (PFS) compared to FC in previously untreated CLL (phase III trial ML 17102-CLL-8). A cost-effectiveness analysis was conduc...