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Background: The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades.Methods: We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods.Results: Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI -36% to -30%) for ambulatory primary care visits, by 22% (95% CI -27% to -16%) for mammography and by 27% (95% CI -40% to -23%) for injury hospitalizations.Interpretation: Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations. [ABSTRACT FROM AUTHOR]

Introduction: Interventions that increase physical activity behavior can reduce morbidity and prolong life, but long-term effects in large populations are unproven. This study investigates the association of medical fitness facility membership and frequency of attendance with all-cause mortality and rate of hospitalization.Methods: A propensity weighted retrospective cohort study was conducted by linking individuals who attended medical fitness facilities in Winnipeg, Canada to provincial health administrative databases. Members aged ≥18 years who had ≥1 year of provincial health coverage from their index date between January 1, 2005 and December 31, 2015 were included. Controls were assigned a pseudo-index date at random on the basis of the frequency distribution of index dates in the intervention group. Members were stratified into low-frequency attenders (<1 weekly visit), moderate-frequency attenders (1-3 weekly visits), and high-frequency attenders (>3 weekly visits). The primary outcomes were time to all-cause mortality and rate of hospitalizations. Statistical analyses were performed between 2018 and 2020.Results: Among 19,300 adult members and 515,810 controls, members had a 60% lower risk of all-cause mortality during the first 651 days and 48% after 651 days. Membership was associated with a 13% lower risk of hospitalizations. A dose-response effect was apparent because higher weekly attendance was associated with a lower risk of hospitalizations (low frequency: 9%, moderate frequency: 20%, high frequency: 39%).Conclusions: Membership at a medical fitness facility was associated with a reduced risk of all-cause mortality and hospitalizations. Healthcare systems should consider the medical fitness model as a preventative public health strategy to encourage physical activity participation. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to determine primary prescription adherence for obstructive lung diseases (e.g., asthma, COPD) in an adult primary care patient population over a 3-year period. Methods: A retrospective analysis of electronic medical record and administrative data was performed to determine primary adherence, defined as dispensation of a new prescription within 90 days of the date the prescription was written. Multivariable logistic regression models were used to test predictors of prescription primary adherence. Results: Of 13,220 prescriptions for obstructive airway disease, 75.9% (N = 10,038) were filled. In multivariate analysis, depression, certain age groups (18–44 years), higher income quartile were associated with reduced prescription adherence. However, 1–2 ER visits in the previous year (compared to no ER visits), number of ambulatory visits in the previous year, and number of hospitalizations in the previous year, did not increase the likelihood of prescription adherence. Interpretation: This study provides important insights about factors associated with prescription nonadherence and is the first study examining primary medication adherence with medications for obstructive lung disease in adults, providing indications of prescription nonadherence patterns among a broad population. [ABSTRACT FROM AUTHOR]

SpaceOAR, an absorbable polyethylene glycol hydrogel, increases the space between the prostate and rectum to reduce the radiation received by the rectum during prostate cancer radiation therapy. The objective of this systematic review was to evaluate controlled studies on the dosimetric and clinical outcomes of SpaceOAR in men undergoing external beam radiation therapy for localized prostate cancer. Eight studies were included in the review. All of the studies showed SpaceOAR to reduce the radiation dose volume to the rectum over numerous dosimetry levels. Of the four studies that assessed toxicity, one reported SpaceOAR to significantly decrease acute Grade 1 diarrhoea and two reported SpaceOAR to significantly decrease late Grade 1 and Grade ≥2 rectal toxicities. Two studies assessed cumulative incidence of toxicity at 3 years in which one reported SpaceOAR to significantly decrease urinary incontinence and Grade ≥1 and Grade ≥2 rectal toxicities, and the other reported SpaceOAR to significantly decrease Grade 1 diarrhoea and Grade 2 proctitis. Moreover, one study reported that fewer SpaceOAR patients experienced 10-point declines in bowel quality of life at 3 years, but another study reported no significant difference in 10-point declines in bowel quality of life between the SpaceOAR and control groups at 5 years. With the current research available, SpaceOAR may be beneficial to those who did not meet the standard rectal dose-volume criteria, have higher risk factors of developing rectal toxicities post-radiation, or wish to decrease the length and costs of radiotherapy by increasing the dose of radiation per fraction. [ABSTRACT FROM AUTHOR]

Background: Primary care provides an opportunity to introduce prevention strategies and identify risk behaviours. Algorithmic information technology such as the Risk Factor Identification Tool (RFIT) can support primary care counseling. This study explores the integration of the tablet-based RFIT in primary care clinics to support exploration of patient risk factor information. Methods: Qualitative study to explore patients' perspectives of RFIT. RFIT was implemented in two primary care clinics in Manitoba, Canada. There were 207 patients who completed RFIT, offered to them by eight family physicians. We conducted one-on-one patient interviews with 86 patients to capture the patient's perspective. Responses were coded and categorized into five common themes. Results: RFIT had a completion rate of 86%. Clinic staff reported that very few patients declined the use of RFIT or required assistance to use the tablet. Patients reported that the tablet-based RFIT provided a user-friendly interface that enabled self-reflection while in the waiting room. Patients discussed the impact of RFIT on the patient-provider interaction, utility for the clinician, their concerns and suggested improvements for RFIT. Among the patients who used RFIT 12.1% smoked, 21.2% felt their diet could be improved, 9.3% reported high alcohol consumption, 56.4% reported less than 150 min of PA a week, and 8.2% lived in poverty. Conclusion: RFIT is a user-friendly tool for the collection of patient risk behaviour information. RFIT is particularly useful for patients lacking continuity in the care they receive. Information technology can promote self-reflection while providing useful information to the primary care clinician. When combined with practical tools and resources RFIT can assist in the reduction of risk behaviours. [ABSTRACT FROM AUTHOR]

Adenocarcinoma ex-goblet carcinoid (ADA ex-GCC) is a rare and aggressive subtype of goblet cell carcinoid, a distinct tumor of the appendix characterized by both neuroendocrine and glandular differentiation. Patients often present with chronic abdominal pain or symptoms of acute appendicitis. Right hemicolectomy is the primary mode of treatment, and prophylactic salpingo-oophorectomy and hysterectomy is recommended in post-menopausal women due to the tumor's propensity of transcoelemic spread, especially to the ovaries. In this case report, we describe a patient with ADA ex-GCC who was found to have oligometastic disease in the pelvis and treated with hypofractionated stereotactic body radiation therapy (HSRT). She initially underwent a right hemicolectomy followed by adjuvant capecitabine four years prior when her tumor was incidentally discovered on colonoscopy. She subsequently had a salpingo-oophorectomy for gynecologic tract metastatic disease and declined further chemotherapy. The patient was again discovered to have oligometastatic disease in the right pelvis adjacent to the rectum on a Gallium-68 dotatate PET/MRI, and was subsequently treated with HSRT to 39 Gy in 6.5 Gy daily fractions. The patient tolerated her radiation course without notable radiation-related toxicity, and she remains without disease progression nine months later. [ABSTRACT FROM AUTHOR]

Highlights • Some breast cancer patients survive > 10 years after oligometastasis-directed HSRT. • Oligometastatic tumor burden (lesion volume and number) impacts risk of recurrence. • Patients with oligometastatic bone-only breast cancer had better clinical outcomes. Abstract Background The clinical state of oligometastases describes metastases limited in number and extent, amenable to metastasis-directed therapy. We sought to analyze long-term outcomes and characterize potential prognostic factors, in women with breast cancer (BC) oligometastases treated with hypofractionated stereotactic radiation (HSRT) therapy on a prospective phase II protocol. Methods Forty-eight women with 1–5 extracranial BC oligometastases received HSRT to all radiographically apparent sites of disease. Various dose-fractionation schedules were used. Most (n = 27) received 10 daily fractions, typically ≥50 Gy (n = 17). Results BC patients with bone-only oligometastases (BO, n = 12) vs. all other patients (non-BO; n = 36) were significantly younger, more likely to present with oligometastases at the time of primary BC diagnosis (i.e., synchronous), and significantly more likely to have had hormone receptor-positive disease. The 5-year and 10-year overall survival (OS) rates after HSRT were 83% and 75%, respectively, for BO patients vs. 31% and 17%, respectively, for non-BO patients (p = 0.002). BO patients experienced a significantly (p = 0.018) greater freedom from widespread metastases (FFWM). Among non-BO patients, net oligometastatic GTV >25 cc (reflecting disease burden) was a significant factor for freedom from local recurrence (p = 0.047) and FFWM (p = 0.028). The number of oligometastatic lesions (p = 0.007) and organs (p = 0.001) involved were also significant factors for FFWM in non-BO patients. Conclusions Some patients with BC oligometastases treated with HSRT can survive >10 years. Tumor burden (volume and number of lesions) appears to impact risk of recurrence. Further research is needed to help better identify BC patients most likely to benefit from metastasis-directed radiotherapy. [ABSTRACT FROM AUTHOR]

Purpose: In primary care, there is increasing recognition of the difficulty of treating patients' immediate health concerns when their overall well-being is shaped by underlying social determinants of health. We assessed the association of social complexity factors with the quality of care patients received in primary care settings.Methods: Eleven social complexity factors were defined using administrative data on poverty, mental health, newcomer status, and justice system involvement from the Manitoba Population Research Data Repository. We measured the distribution of these factors among primary care patients who made at least 3 visits during 2010-2013 to clinicians in Manitoba, Canada. Using generalized linear mixed modeling, we measured 26 primary care indicators to compare the quality of care received by patients with 0 to 5 or more social complexity factors.Results: Among 626,264 primary care patients, 54% were living with at least 1 social complexity factor, and 4% were living with 5 or more. Social complexity factors were strongly associated with poorer outcomes with respect to primary care indicators for prevention (eg, breast cancer screening; odds ratio [OR] = 0.77; 99% CI, 0.73-0.81), chronic disease management (eg, diabetes management; OR = 0.86; 99% CI, 0.79-0.92), geriatric care (eg, benzodiazepine prescriptions; OR = 1.63; 99% CI, 1.48-1.80), and use of health services (eg, ambulatory visits; OR = 1.09; 99% CI, 1.08-1.09).Conclusions: Linking health and social data demonstrates how social determinants are associated with primary care service provision. Our findings provide insight into the social needs of primary care populations, and may support the development of focused interventions to address social complexity in primary care. [ABSTRACT FROM AUTHOR]

Background: The Community Health Outreach Work to Prevent AIDS (CHOW) Project is the first and longest-standing statewide integrated and funded needle and syringe exchange program (SEP) in the US. Initiated on O'ahu in 1990, CHOW expanded statewide in 1993. The purpose of this study is to estimate the prevalences of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection, and to characterize risk behaviors associated with infection among clients of a long-standing SEP through the analysis of the 2012 CHOW evaluation data.Methods: A cross-sectional sample of 130 CHOW Project clients was selected from January 1, 2012 through December 31, 2012. Questionnaires captured self-reported exposure information. HIV and HCV antibodies were detected via rapid, point-of-care FDA-approved tests. Log-binomial regressions were used to estimate prevalence proportion ratios (PPRs). A piecewise linear log-binomial regression model containing 1 spline knot was used to fit the age-HCV relationship.Results: The estimated seroprevalence of HCV was 67.7% (95% confidence interval [CI]=59.5-75.8%). HIV seroprevalence was 2.3% (95% CI=0-4.9%). Anti-HCV prevalence demonstrated age-specific patterns, ranging from 31.6% through 90.9% in people who inject drugs (PWID) <30 to ≥60 years respectively. Age (continuous/year) prior to spline knot at 51.5 years (adjusted PPR [APPR]=1.03; 95% CI=1.02-1.05) and months exchanging syringes (quartiles) (APPR=1.92; 95% CI=1.3-3.29) were independently associated with anti-HCV prevalence.Conclusion: In Hawai'i, HCV prevalence among PWID is hyperendemic demonstrating age- and SEP duration-specific trends. Relatively low HIV prevalence compared with HCV prevalence reflects differences in transmissibility of these 2 blood-borne pathogens and suggests much greater efficacy of SEP for HIV prevention. [ABSTRACT FROM AUTHOR]

Background. The Centers for Disease Control and Prevention (CDC) currently recommends dual therapy with ceftriaxone and azithromycin for gonorrhea to ensure effective treatment and slow emergence of antimicrobial resistance. Since 2013, the prevalence of reduced azithromycin susceptibility increased in the United States; however, these strains were highly susceptible to cephalosporins. We identified a cluster of Neisseria gonorrhoeae isolates with high-level azithromycin resistance, several of which also demonstrated decreased ceftriaxone susceptibility. Methods. Eight N. gonorrhoeae isolates collected from 7 patients on Oahu, Hawaii, seen 21 April 2016 through 10 May 2016 underwent routine Etest antimicrobial susceptibility testing by the Hawaii Department of Health. All demonstrated elevated azithromycin minimum inhibitory concentrations (MICs) >256 μg/mL and elevated ceftriaxone MICs (≥0.125 μg/mL). Isolates were sent to the University of Washington and CDC for confirmatory agar dilution testing; sequence data were sent to CDC for analysis. All patients were interviewed and treated, and when possible, partners were interviewed, tested, and treated. Results. All isolates had azithromycin MICs >16 μg/mL and 5 had ceftriaxone MICs = 0.125 μg/mL by agar dilution. All isolates were β-lactamase positive and were resistant to penicillin, tetracycline, and ciprofloxacin. Genomic analysis revealed genetic relatedness. No patients reported recent travel or antibiotic use, and no male patients reported male sex partners. All patients were successfully treated. Conclusions. This cluster of genetically related gonococcal isolates with decreased ceftriaxone susceptibility and high-level azithromycin resistance may bring the threat of treatment failure in the United States with the current recommended dual therapy one step closer. [ABSTRACT FROM AUTHOR]

Purpose: The patient medical home (PMH) model aims to improve patient satisfaction and health outcomes in Canada, but since its introduction in 2009, there has been no evaluation of the extent to which primary care conforms with PMH attributes. Our objective was to compare current primary care across Canada with the 10 goals of the PMH model.Methods: A cross-sectional survey of primary care organization and delivery was conducted in Canadian provinces to evaluate the PMH-based attributes of primary care practices. Family physician and patient responses were mapped to the 10 goals of the PMH model. We used regression models to describe the provinces' success in meeting the goals, taking specific practice characteristics into account. We created a PMH composite score by weighting each goal equally for each practice and aggregating these by province. The PMH score is the sum of the values for each goal, which were scored from 0 to 1; a score of 10 indicates that all 10 goals of the PMH model were achieved.Results: Seven hundred seventy-two primary care practices and 7,172 patients participated in the survey. The average national PMH score was 5.36 (range 4.75-6.23) of 10. Ontario was the only province to score significantly higher than Canada as a whole, whereas Québec, Newfoundland/Labrador, and New Brunswick/Prince Edward Island scored below the national average. There was little variation, however, among provinces in achieving the 10 PMH goals.Conclusions: Provincial PMH scores indicate considerable room for improvement if the PMH goals are to be fully implemented in Canada. [ABSTRACT FROM AUTHOR]

Background Pelvic inflammatory disease (PID) is a notifiable disease in Hawaii with legal implications for noncompliance. A previous study comparing PID diagnoses in Hawaii's hospitals and state surveillance data confirmed underreporting in Hawaii. Reasons for noncompliance and underreporting are not well understood. Methods All licensed primary care physicians in Hawaii were mailed a survey addressing PID diagnosis and reporting attitudes and practices. Hierarchical logistic regression was used to determine if physician characteristics, PID knowledge, or attitudes related to the diagnosis or reporting of PID, increased the odds of diagnosing and reporting PID. Results Among survey respondents (486 of 1,062; response rate of 45.8%), 104 (21.4%) had diagnosed PID. The PID reporting rate was 55.8% (58 of 104). The majority of physicians who diagnosed PID reported that PID reporting was time consuming. In hierarchical regression, obstetrician/gynecologists and family practitioners had the highest odds of diagnosing PID and internists had the lowest odds of reporting PID, those 15 years or longer since residency were less likely to report PID than those fewer than 15 years since residency, and increased PID diagnosing and reporting knowledge increased the odds of PID reporting by 1.63 times. Conclusion Our findings suggest the need for training of all physicians on reportable diagnoses on a regular basis. There is a need to simplify the reporting process, because the time burden of reporting may present a modifiable barrier to reporting. Increased PID-related communication between local health departments and physicians is essential, and physicians should be provided technical assistance with reporting. [ABSTRACT FROM AUTHOR]

Abstract: A case of congenital syphilis due to multiple missed opportunities, highlights the challenges of treating syphilis during pregnancy. Although cases are increasing in the United States, congenital syphilis, a disease with devastating consequences, is preventable. [ABSTRACT FROM AUTHOR]

Introduction: Childhood vaccination rates in Manitoba populations with low socioeconomic status (SES) fall significantly below the provincial average. This study examined the impact of a pay-for-performance (P4P) program called the Physician Integrated Network (PIN) on health inequity in childhood vaccination rates. Methods: The study used administrative data housed at the Manitoba Centre for Health Policy. We included all children born in Manitoba between 2003 and 2010 who were patients at PIN clinics receiving P4P funding matched with controls at non-participating clinics. We examined the rate of completion of the childhood primary vaccination series by age 2 across income quintiles (Q1-Q5). We estimated the distribution of income using the Gini coefficient, and calculated concentration indices for vaccination to determine whether the P4P program altered SES-related differences in vaccination completion. We compared these measures between study cohorts before and after implementation of the P4P program, and over the course of the P4P program in each cohort. Results: The PIN cohort included 6,185 children. Rates of vaccination completion at baseline were between 0.53 (Q1) and 0.69 (Q5). Inequality in income distribution was present at baseline and at study end in PIN and control cohorts. SES-related inequity in vaccination completion worsened in non-PIN clinics (difference in concentration index 0.037; 95 % CI 0.013, 0.060), but remained constant in P4P-funded clinics (difference in concentration index 0.006; 95 % CI 0.008,0.021). Conclusions: The P4P program had a limited impact on vaccination rates and did not address health inequity. [ABSTRACT FROM AUTHOR]

The author reflects on the need for family physicians to engage with patients about mammography. Topics discussed include informed consent and shared decision-making as the fundamental components of a healthy therapeutic relationship, patients' demand in terms of patient-centered care, and the first four European Breast Guidelines' screening recommendations launched by the European Commission on Breast Cancer in November 2016.

Background: Adults with chronic disease are the most frequent users of the primary healthcare system. In Manitoba, patients are allowed to seek ambulatory (outpatient) care from the provider of their choosing (primary care physician or specialist), with referrals to specialists preferred but not always required. Some patients receive their routine care from specialists. We conducted this study to determine the patterns by which adults with chronic disease access ambulatory care as a prelude to exploring the impact these patterns may have on the quality of care received. Methods: Physician claims for all visits between 2007/8-2009/10 were extracted from the Data Repository at the Manitoba Centre for Health Policy. Patients included in the analysis made at least four ambulatory visits to a primary care physician or specialist within the study period, and met the definition criteria for at least one of six chronic diseases: diabetes mellitus; congestive heart failure; mood disorders; ischemic heart disease; total respiratory morbidity; and/or hypertension. Patients were "assigned" to the physician they visited most regularly. Physician visit patterns were assessed by dividing visits into nine visit types based on the type of physician patients visited (assigned primary care physician, other primary care physician, or specialist) and whether or not they received a referral. Results: 347,606 patients with 7,662,411 physician visits were included in the analysis. Most visits were to the patients' assigned primary care physician. About 50% of the visits to specialists were by referral from the assigned primary care physician. However, 26-29% of all visits to a primary care physician were not to the assigned primary care physician, and non-assigned physicians were more likely to refer patients to specialists than assigned primary care physicians. Conclusion: The findings suggest that the current primary care system in Manitoba may not adequately support coordination of ambulatory care. Ambulatory visits to a primary care provider who is not the patient's regular provider may represent a lost opportunity for coordination and continuity of care, and may affect the quality of care patients receive. Primary care renewal initiatives in this province should address this challenge to service provision. [ABSTRACT FROM AUTHOR]

Heavy episodic drinking among college students is a serious health concern. The purpose of this study was to identify factors associated with heavy episodic drinking behaviors amongst a predominately Asian undergraduate college student population in the United States. A survey measuring alcohol use behaviors was completed by a random sample of 18-24 year old undergraduates during April, 2011. A multivariate logistic regression analysis was conducted to determine factors associated with students' heavy episodic drinking behavior. Independent factors associated with heavy episodic drinking included living on campus, ethnicity, perceived drinking behavior among peers, and a belief that alcohol is a central part of one's social life. Heavy episodic drinking was also associated with poor academic performance. Campus-wide educational strategies to reduce heavy episodic drinking among college undergraduates should incorporate accurate information regarding alcohol use norms to correct students' perceived over estimation of their peers alcohol consumption rates and the under estimation of students protective alcohol use behaviors. These efforts should focus in on-campus residence halls where a higher occurrence of heavy episodic drinking is often found. [ABSTRACT FROM AUTHOR]

Background: Evaluation of the effectiveness of a patient decision aid (nurse-managed telephone support line and/or colorectal cancer screening website), distributed to patients by their family physician, in improving fecal occult blood test (FOBT) colorectal cancer screening rates. Methods: A pragmatic, two arm, cluster randomized controlled trial in Winnipeg, Manitoba, Canada (39 medical clinic clusters; 79 fee-for-service family physicians; 2,395 average risk patients). All physicians followed their standard clinical screening practice. Intervention group physicians provided a fridge magnet to patients that facilitated patient decision aid access. Primary endpoint was FOBT screening rate within four months. Multi-level logistic regression to determine effect of cluster, physician, and patient level factors on patient FOBT completion rate. ICC determined. Results: Family physicians were randomized to control (n = 39) and intervention (n = 40) groups. Compared to controls (56.9%; n = 663/1165), patients receiving the intervention had a higher FOBT completion rate (66.6%; n = 805/1209; OR of 1.47; 95% confidence interval 1.06 to 2.03; p < 0.02). Patient aid utilization was low (1.1%; 13/1,221) and neither internet nor telephone access affected screening rates for the intervention group. FOBT screening rates differed among clinics and physicians (p < 0.0001). Patients whose physician promoted the FOBT were more likely to complete it (65%; n = 1140/1755) compared to those whose physician did not (51.1%; n = 242/470; p < 0.0001; OR of 1.54 and 95% CI of 1.23 to 1.92). Patients reporting they had done an FOBT in the past were more likely to complete the test (70.6%; n = 1141/1616; p < 0.0001; 95% CI 2.51 to 3.73) than those who had not (43%; n = 303/705). Patients 50-59 years old had lower screening rates compared to those over 60 (p < 0.0001). 75% of patients completing the test did so in 34 days. Conclusion: Despite minimal use of the patient aid, intervention group patients were more likely to complete the FOBT. Powerful strategies to increase colorectal cancer screening rates include a recommendation to do the test from the family physician and focusing efforts on patients age 50-59 years to ensure they complete their first FOBT. [ABSTRACT FROM AUTHOR]

Background: Evaluation of the effectiveness of a patient decision aid (nurse-managed telephone support line and/or colorectal cancer screening website), distributed to patients by their family physician, in improving fecal occult blood test (FOBT) colorectal cancer screening rates. Methods: A pragmatic, two arm, cluster randomized controlled trial in Winnipeg, Manitoba, Canada (39 medical clinic clusters; 79 fee-for-service family physicians; 2,395 average risk patients). All physicians followed their standard clinical screening practice. Intervention group physicians provided a fridge magnet to patients that facilitated patient decision aid access. Primary endpoint was FOBT screening rate within four months. Multi-level logistic regression to determine effect of cluster, physician, and patient level factors on patient FOBT completion rate. ICC determined. Results: Family physicians were randomized to control (n = 39) and intervention (n = 40) groups. Compared to controls (56.9%; n = 663/1165), patients receiving the intervention had a higher FOBT completion rate (66.6%; n = 805/1209; OR of 1.47; 95% confidence interval 1.06 to 2.03; p < 0.02). Patient aid utilization was low (1.1%; 13/1,221) and neither internet nor telephone access affected screening rates for the intervention group. FOBT screening rates differed among clinics and physicians (p < 0.0001). Patients whose physician promoted the FOBT were more likely to complete it (65%; n = 1140/1755) compared to those whose physician did not (51.1%; n = 242/470; p < 0.0001; OR of 1.54 and 95% CI of 1.23 to 1.92). Patients reporting they had done an FOBT in the past were more likely to complete the test (70.6%; n = 1141/1616; p < 0.0001; 95% CI 2.51 to 3.73) than those who had not (43%; n = 303/705). Patients 50-59 years old had lower screening rates compared to those over 60 (p < 0.0001). 75% of patients completing the test did so in 34 days. Conclusion: Despite minimal use of the patient aid, intervention group patients were more likely to complete the FOBT. Powerful strategies to increase colorectal cancer screening rates include a recommendation to do the test from the family physician and focusing efforts on patients age 50-59 years to ensure they complete their first FOBT. [ABSTRACT FROM AUTHOR]

Background Stereotactic Body Radiotherapy (SBRT) has excellent control rates for low- and intermediate-risk prostate carcinoma.The role of SBRT for high-risk disease remains less studied. We present long-term results on a cohort of patients with NCCN-defined high-risk disease treated with SBRT. Methods We retrospectively studied 97 patients treated as part of prospective trial from 2006-2010 with SBRT alone (n = 52) to dose of 35-36.25 Gy in 5 fractions, or pelvic radiation to 45 Gy followed by SBRT boost of 19-21 Gy in 3 fractions (n = 45). 46 patients received Androgen Deprivation Therapy. Quality of life and bladder/bowel toxicity was assessed using the Expanded Prostate Index Composite (EPIC) and RTOG toxicity scale. Results Median followup was 60 months. 6-year biochemical disease-free survival (bDFS) was 69%. On multivariate analysis, only PSA remained significant (P < 0.01) for bDFS. Overall toxicity was mild, with 5% Grade 2-3 urinary and 7% Grade 2 bowel toxicity. Use of pelvic radiotherapy was associated with significantly higher bowel toxicity (P = .001). EPIC scores declined for the first six months and then returned towards baseline. Conclusions SBRT appears to be a safe and effective treatment for high-risk prostate carcinoma. Our data suggests that SBRT alone may be the optimal approach. Further followup and additional studies is required to corroborate our results. [ABSTRACT FROM AUTHOR]

Background: Historically, emergency gallbladder surgery in elderly patients has been associated with high rates of morbidity and mortality. Recent studies have described much lower complication rates that may still overestimate morbidity. The purpose of this study was to determine the true population morbidity and mortality rates after gallbladder surgery in the elderly. Methods: All elderly patients (defined as age 65 years or older) admitted to the hospital with a principle diagnosis related to benign gallbladder disease in the Province of Manitoba from January 1, 1995 to December 31, 2008 were identified by using administrative claims data. Outcomes after emergency gallbladder surgery, including complication rates and their predictors, were compared with outcomes after elective surgery and after nonoperative treatment for gallbladder-related hospital admissions. Results: A total of 9,936 patients were included: 2,355 had emergency or urgent surgery and 4,901 had elective procedures, whereas 2,680 patients were treated without surgery. Emergency gallbladder surgery was associated with a mortality rate of 0.7 %, compared with 1.6 % for elective cases and 5.6 % for patients treated nonoperatively. Complication rates were 16.2, 17.7, and 25 % respectively. Independent predictors of 30-day mortality were age, male gender, increasing comorbidity, surgeon experience, and surgical treatment. Conclusions: Emergency gallbladder surgery in the elderly was not associated with higher mortality or complication rate compared with the elective setting. Elderly patients with gallbladder-related emergencies should be offered urgent surgery when feasible. [ABSTRACT FROM AUTHOR]

Background: Stereotactic body radiotherapy (SBRT) may yield disease control for prostate cancer in a brief, hypofractionated treatment regimen without increasing treatment toxicity. Our report presents a 6-year update from 304 low- (n = 211), intermediate- (n = 81), and high-risk (n = 12) prostate cancer patients who received CyberKnife SBRT. Methods: The median PSA at presentation was 5.8 ng/ml. Fifty-seven patients received neoadjuvant hormonal therapy for up to one year. The first 50 patients received a total dose of 35 Gy in 5 fractions of 7 Gy. The subsequent 254 patients received a total dose of 36.25 Gy in 5 fractions of 7.25 Gy. Toxicity was assessed with the Expanded Prostate Cancer Index Composite questionnaire and the Radiation Therapy Oncology Group urinary and rectal toxicity scale. Biochemical failure was assessed using the nadir + 2 definition. Results: No patients experienced Grade III or IV acute complications. Fewer than 5% of patients experienced any acute Grade II urinary or rectal toxicities. Late urinary Grade II complications were observed in 4% of patients treated to 35 Gy and 9% of patients treated to 36.25 Gy. Five (2%) late Grade III urinary toxicities occurred in patients who were treated with 36.25 Gy. Late Grade II rectal complications were observed in 2% of patients treated to 35 Gy and 5% of patients treated to 36.25 Gy. Bowel and urinary quality of life (QOL) scores initially decreased, but later returned to baseline values. An overall decrease of 20% in the sexual QOL score was observed. QOL in each domain was not differentially affected by dose. For patients that were potent prior to treatment, 75% stated that they remained sexually potent. Actuarial 5-year biochemical recurrence-free survival was 97% for low-risk, 90.7% for intermediate-risk, and 74.1% for high-risk patients. PSA fell to a median of 0.12 ng/ml at 5 years; dose did not influence median PSA levels. Conclusions: In this large series with long-term follow-up, we found excellent biochemical control rates and low and acceptable toxicity, outcomes consistent with those reported for from high dose rate brachytherapy (HDR BT). Provided that measures are taken to account for prostate motion, SBRT's distinct advantages over HDR BT include its noninvasiveness and delivery to patients without anesthesia or hospitalization. [ABSTRACT FROM AUTHOR]

Measurements and computations of the separation and reattachment locations are reported for the steady flow over a SD7003 airfoil at different angles of attack and chord Reynolds number in the range 2 × 10-4 × 10. The experiments are based on multi-line molecular tagging velocimetry, and the computations employ an implicit large eddy simulation approach. Comparisons of experimental results with current computations and previous experiments point to challenges involved in the experimental determination of the separation bubble characteristics. The results also underline the importance of the facility-dependent freestream turbulence level on the experimental data. The collective effect of experimental uncertainty and facility-dependent issues, examined systematically herein, appear to clarify the discrepancy among the various experimental and computational results. The findings also suggest that accurate characterization of the separation bubble over airfoils at low Reynolds number is more difficult than generally recognized and presents a challenge in comparing results between different experiments, and between experiments and computations. Moreover, this complicates the validation of computational data against experiments within this flow regime. [ABSTRACT FROM AUTHOR]

Purpose: We sought to determine efficacy, safety, and outcome of stereotactic hypofractionated radiation therapy (SHORT) as a suitable bridging therapy for patients awaiting liver transplantation (LT) for hepatocellular carcinoma (HCC). We also examined histological response to radiation in the resected or explanted livers. Methods and Materials: Between August 2007 and January 2009, 18 patients with 21 lesions received SHORT. A median total dose of 50 Gy was delivered in 10 fractions. Three patients underwent either chemoembolization (n = 1) or radiofrequency ablation (n = 2) prior to SHORT. Radiographic response was based on computed tomography evaluation at 3 months after SHORT. Histological response as a percentage of tumor necrosis was assessed by a quantitative morphometric method. Results: Six of 18 patients were delisted because of progression (n = 3) or other causes (n = 3). Twelve patients successfully underwent major hepatic resection (n = 1) or LT (n = 11) at a median follow-up of 6.3 months (range, 0.6–11.6 months) after completion of SHORT. No patient developed gastrointestinal toxicity Grade ≥3 or radiation-induced liver disease. Ten patients with 11 lesions were evaluable for pathological response. Two lesions had 100% necrosis, three lesions had ≥50% necrosis, four lesions had ≤50% necrosis, and two lesions had no necrosis. All patients were alive after LT and/or major hepatic resection at a median follow-up of 19.6 months. Conclusions: SHORT is an effective bridging therapy for patients awaiting LT for HCC. It provides excellent in-field control with minimal side effects, helps to downsize or stabilize tumors prior to LT, and achieves good pathological response. [ABSTRACT FROM AUTHOR]

Purpose: To analyze the long-term survival and tumor control outcomes after stereotactic body radiotherapy (SBRT) for metastases limited in number and extent. Methods and Materials: We prospectively analyzed the long-term overall survival (OS) and cancer control outcomes of 121 patients with five or fewer clinically detectable metastases, from any primary site, metastatic to one to three organ sites, and treated with SBRT. Freedom from widespread distant metastasis (FFDM) was defined as metastatic disease not amenable to local therapy (i.e., resection or SBRT). Prognostic variables were assessed using log–rank and Cox regression analyses. Results: For breast cancer patients, the median follow-up was 4.5 years (7.1 years for 16 of 39 patients alive at the last follow-up visit). The 2-year OS, FFDM, and local control (LC) rate was 74%, 52%, and 87%, respectively. The 6-year OS, FFDM, and LC rate was 47%, 36%, and 87%, respectively. From the multivariate analyses, the variables of bone metastases (p = .057) and one vs. more than one metastasis (p = .055) were associated with a fourfold and threefold reduced hazard of death, respectively. None of the 17 bone lesions from breast cancer recurred after SBRT vs. 10 of 68 lesions from other organs that recurred (p = .095). For patients with nonbreast cancers, the median follow-up was 1.7 years (7.3 years for 7 of 82 patients alive at the last follow-up visit). The 2-year OS, FFDM, and LC rate was 39%, 28%, and 74%, respectively. The 6-year OS, FFDM, and LC rate was 9%, 13%, and 65%, respectively. For nonbreast cancers, a greater SBRT target volume was significantly adverse for OS (p = .012) and lesion LC (p < .0001). Patients whose metastatic lesions, before SBRT, demonstrated radiographic progression after systemic therapy experienced significantly worse OS compared with patients with stable or regressing disease. Conclusions: Select patients with limited metastases treated with SBRT are long-term survivors. Future research should address the therapeutic benefit of SBRT for these patients. [Copyright &y& Elsevier]

Introduction: The objective of this study is to explore the associations between national tuberculosis program (NTP) budget allocation and tuberculosis related outcomes in the World Health Organization's 22 high burden countries from 2007-2009. Methods: This ecological study used mixed effects and generalized estimating equation models to identify independent associations between NTP budget allocations and various tuberculosis related outcomes. Models were adjusted for a number of independent variables previously noted to be associated with tuberculosis incidence. Results: Increasing the percent of the NTP budget for advocacy, communication and social mobilization was associated with an increase in the case detection rate. Increasing TB-HIV funding was associated with an increase in HIV testing among TB patients. Increasing the percent of the population covered by the Directly Observed Therapy (DOT) program was associated with an increase in drug susceptibility testing. Laboratory funding was positively associated with tuberculosis notification. Increasing the budgets for first line drugs, management and multi-drug resistant tuberculosis (MDR-TB) was associated with a decrease in smear positive deaths. Conclusion: Effective TB control is a complex and multifaceted challenge. This study revealed a number of budget allocation related factors associated with improved TB outcome parameters. If confirmed with future longitudinal studies, these findings could help guide NTP managers with allocation decisions. [ABSTRACT FROM AUTHOR]

Background: Fecal occult blood test screening in Canada is sub-optimal. Family physicians play a central role in screening and are limited by the time constraints of clinical practice. Patients face multiple barriers that further reduce completion rates. Tools that support family physicians in providing their patients with colorectal cancer information and that support uptake may prove useful. The primary objective of the study is to evaluate the efficacy of a patient decision aid (nurse-managed telephone support line and/or colorectal cancer screening website) distributed by community-based family physicians, in improving colorectal cancer screening rates. Secondary objectives include evaluation of (dis)incentives to patient FOBT uptake and internet use among 50 to 74 year old males and females for health-related questions. Challenges faced by family physicians in engaging in collaborative partnerships with primary healthcare researchers will be documented. Methods/design: A pragmatic, two-arm, randomized cluster controlled trial conducted in 22 community-based family practice clinics (36 clusters) with 76 fee-for-service family physicians in Winnipeg, Manitoba, Canada. Each physician will enroll 30 patients attending their periodic health examination and at average risk for colorectal cancer. All physicians will follow their standard clinical practice for screening. Intervention group physicians will provide a fridge magnet to each patient that contains information facilitating access to the study-specific colorectal cancer screening decision aids (telephone help-line and website). The primary endpoint is patient fecal occult blood test completion rate after four months (intention to treat model). Multi-level analysis will include clinic, physician and patient level variables. Patient Personal Health Identification Numbers will be collected from those providing consent to facilitate analysis of repeat screening behavior. Secondary outcome data will be obtained through the Clinic Characterization Form, Patient Tracking Form, In-Clinic Patient Survey, Post-Study Follow-Up Patient Survey, and Family Physician Survey. Study protocol approved by The University of Manitoba HealthResearch Ethics Board. Discussion: The study intervention has the potential to increase patient fecal occult blood test uptake, decrease colorectal cancer mortality and morbidity, and improve the health of Manitobans. If utilization of the website and/or telephone support line result in clinically significant increases in colorectal cancer screening uptake, changes in screening at the policy- and system-level may be warranted. Trial registration: Clinical trials.gov identifier NCT01026753 [ABSTRACT FROM AUTHOR]

Background: As the long-term efficacy of stereotactic body radiation therapy (SBRT) becomes established and other prostate cancer treatment approaches are refined and improved, examination of quality of life (QOL) following prostate cancer treatment is critical in driving both patient and clinical treatment decisions. We present the first study to compare QOL after SBRT and radical prostatectomy, with QOL assessed at approximately the same times pre- and post-treatment and using the same validated QOL instrument. Methods: Patients with clinically localized prostate cancer were treated with either radical prostatectomy (n = 123 Spanish patients) or SBRT (n = 216 American patients). QOL was assessed using the Expanded Prostate Cancer Index Composite (EPIC) grouped into urinary, sexual, and bowel domains. For comparison purposes, SBRT EPIC data at baseline, 3 weeks, 5, 11, 24, and 36 months were compared to surgery data at baseline, 1, 6, 12, 24, and 36 months. Differences in patient characteristics between the two groups were assessed using Chi-squared tests for categorical variables and t-tests for continuous variables. Generalized estimating equation (GEE) models were constructed for each EPIC scale to account for correlation among repeated measures and used to assess the effect of treatment on QOL. Results: The largest differences in QOL occurred in the first 1-6 months after treatment, with larger declines following surgery in urinary and sexual QOL as compared to SBRT, and a larger decline in bowel QOL following SBRT as compared to surgery. Long-term urinary and sexual QOL declines remained clinical significantly lower for surgery patients but not for SBRT patients. Conclusions: Overall, these results may have implications for patient and physician clinical decision making which are often influenced by QOL. These differences in sexual, urinary and bowel QOL should be closely considered in selecting the right treatment, especially in evaluating the value of non-invasive treatments, such as SBRT. [ABSTRACT FROM AUTHOR]

Hawaii currently ranks first among states for chlamydia screening of young women based on recent Healthcare Effectiveness Data and Information Set (HEDIS) measures and has consistently ranked in the top ten states in the US for annual reported chlamydia rates since 2002. A statewide provider survey was conducted in October 2007 and March 2008 to assess chlamydia screening practices and beliefs and identify potential barriers to screening. The overall reported screening rate for 15-19 year old females was 66.9% with significant differences by practice specialty (obstetrician/gynecologists were more likely to screen than family practitioners or pediatricians) and practice setting (higher rates of screening in non-private practice settings). Providers who were unaware of health plan reimbursement for screening and those who targeted screening only for clients perceived to be at 'high risk' were significantly less likely to routinely provide screening. The Hawaii State Department of Health is currently working in consort with health care providers and the state's dominant health insurance carriers to address these issues through targeted provider educational interventions. [ABSTRACT FROM AUTHOR]

Although infrequently diagnosed in the United States, leptospirosis is a notable reemerging infectious disease throughout developing countries. Until 1995, when the disease was eliminated from the US list of nationally notifiable diseases, Hawaii led the nation in reported annual incidence rates. Leptospirosis remains a notifiable disease in Hawaii. To ascertain the status of leptospirosis in Hawaii since the most recent US report in 2002, we reviewed 1999-2008 data obtained from case investigation reports by the Hawaii State Department of Health. Of the 345 case reports related to in-state exposures, 198 (57%) were laboratory confirmed. Our findings indicate a change in seasonal disease occurrence from summer to winter and in the infective serogroup from Icterohemorrhagiae to Australis. Also, during the past 20 years, recreational exposures have plateaued, while occupational exposures have increased. Ongoing surveillance is needed to clarify and track the dynamic epidemiology of this widespread zoonosis. [ABSTRACT FROM AUTHOR]

This study examined factors associated with adverse sexual outcomes among 24,963, 18-24 year old undergraduate college students participating in the Spring, 2004 National College Health Assessment Survey. Alcohol use, mental health problems, and higher rates of perceived peer sexual activity were associated with increased odds of sexually transmitted infections (STIs) and unintended pregnancy. In contrast, living on campus reduced students' odds for STI acquisition, and high grade point average was associated with reduced odds for unintended pregnancies. Results suggest that factors associated with college students' sexual health behaviors are complex and often interrelated and deserve further and more in-depth study. [ABSTRACT FROM AUTHOR]

A recent case investigation of secondary syphilis in a 27-year-old heterosexual Micronesian male and his 19-year-old chlamydia and syphilis co-infected female partner, conducted by the Hawaii State Department of Health, June to August 2007, identified a cluster of 13 case-patients with undiagnosed syphilis, chlamydia, and gonorrhea. The social network of Micronesians uncovered was characterized by having transient accommodations but a central gathering place. The critical factor in gaining access to this network was the establishment of a trusting relationship with a key social network member. Field interviews and the application of field diagnostic techniques helped to identify case-patients who otherwise would not have presented to a traditional office or clinic setting. Micronesians in Hawaii represent an at-risk population for adverse health indices including sexually transmitted diseases, based on their socioeconomic status. [ABSTRACT FROM AUTHOR]

Purpose: To characterize oligometastases in patients enrolled on two prospective pilot studies, treating oligometastases with hypofractionated stereotactic body radiotherapy and stereotactic radiosurgery to cranial lesions. Methods and Materials: We describe the characteristics and local control (LC) of 293 lesions in 121 patients with five or fewer metastases treated with stereotactic body radiation and/or cranial stereotactic radiosurgery. For each lesion, the primary cancer site, tumor histology, site of metastasis, gross tumor volume, and prescribed dose were ascertained. The prescribed dose is expressed by the biologically effective dose in 2-Gy fractions (BED2), calculated using the linear quadratic model, assuming an α/β ratio of 10. Results: Lung lesions were significantly smaller than other lesions in our cohort, whereas liver lesions were significantly larger, possibly reflecting a detection and/or referral bias. The 2-year and 4-year tumor LC rates were 77% and 73% respectively. A larger gross tumor volume was significantly (p < 0.0001) correlated with worse lesion LC. Lesions originating from primary pancreatic, biliary or liver cancer exhibited significantly poorer LC, as did lesions from colorectal cancer. Lesions from breast cancer were better controlled. A higher BED2 did not correlate with improved tumor control. Conclusions: Stereotactic body radiation to aggressively treat oligometastatic lesions results in good local tumor control. Bulkier lesions are more difficult to control and may benefit from dose escalation. [Copyright &y& Elsevier]

The article discusses a study which examined the use of curative-intent stereotactic body radiation therapy in patients diagnosed with oligometastatic lesions. The study included 121 patients found to have lower than five metastases between 2001 and 2006. Patients with breast cancer were found to have better overall survival, local control and progression-free survival. It concluded that oligometastatic disease is a curable state of cancer spread.

Purpose: To evaluate the feasibility and efficacy of hypofractionated stereotactic body radiation therapy (SBRT) for the treatment of liver metastases. Methods and Materials: The records of 69 patients with 174 metastatic liver lesions treated with SBRT between April 2001 and October 2004 were reviewed. The most common primary tumors were colorectal (n = 20), breast (n = 16), pancreas (n = 9), and lung (n = 5). The mean number of lesions treated per patient was 2.5 (range, 1-6). The longest diameter of the lesions ranged in size from 0.6 to 12.2 cm (median, 2.7 cm). Dose per fraction ranged from 2 Gy to 6 Gy, with a median total dose of 48 Gy (range, 30-55 Gy). Dose was prescribed to the 100% isodose line (IDL), with the 80% IDL covering the gross tumor volume with a minimum margin of 7 mm. Results: The median follow up was 14.5 months. Sixty patients were evaluable for response based on an abdominal computed tomography scan obtained at a minimum of 3 months after completion of SBRT. The actuarial overall infield local control rate of the irradiated lesions was 76% and 57% at 10 and 20 months, respectively. The median overall survival time was 14.5 months. The progression-free survival rate was 46% and 24% at 6 and 12 months, respectively. None of the patients developed Grade 3 or higher toxicity. Conclusion: Hypofractionated SBRT provides excellent local control with minimal side effects in selected patients with limited hepatic metastases. [ABSTRACT FROM AUTHOR]

Objective. To explore the feasibility of using administrative data to develop process indicators for measuring quality in primary care. Data Sources/Study Setting. The Population Health Research Data Repository (Repository) housed at the Manitoba Centre for Health Policy which includes physician claims, hospital discharge abstracts, pharmaceutical use (Drug Program Information Network (DPIN)), and the Manitoba Immunization Monitoring Program (MIMS) for all residents of Manitoba, Canada who used the health care system during the 2001/02 fiscal year. Family physicians were identified from the Physician Resource Database. Indicators were developed based on a literature review and focus group validation. Data Collection/Extraction Methods. Data files were extracted from administrative data available in the Repository. We extracted data based on the ICD-9-CM codes and ATC-class drugs prescribed and then linked them to the Physician Resource Database. Physician practices were defined by allocating patients to their most responsible physician. Every family physician in Manitoba that met the inclusion criteria (having either 5 or 10 eligible patients depending on the indicator) was ‘scored’ on each indicator. Physicians were then grouped according to the proportion of the patients allocated to their practice who received the recommended care for the specific indicator. Principal Findings. Using administrative health data we were able to develop and measure eight indicators of quality of care covering both preventive care services and chronic disease management. The number of eligible physicians and patients varied for each indicator as did the percent of patients with recommended care, per physician. For example, the childhood immunization indicator included 544 physicians who, on average, provided immunization for 65 percent of their patients. Conclusions. Quality of care provided by family physicians can be measured using administrative data. Despite the limitations addressed in this paper, this work establishes a practical methodology to measure quality of care provided by family physicians that can be used for quality improvement initiatives. [ABSTRACT FROM AUTHOR]

The purpose of this study is to assess the objective knowledge of mental health professionals in Hawaii related to evidence-based early psychological interventions for victims of mass trauma as well as their perceived response readiness to a bio terrorism associated event. During June and July 2004 an anonymous survey was mailed as many as three times to a random sample of licensed psychologists and social workers residing in Hawaii (n = 273). The response rate for deliverable surveys was 68 percent (176 of 257). Only 10 percent of respondents reported prior bio terrorism preparedness training. Less than 50 percent felt able to identify and manage populations exhibiting the normal range of stress reactions to a bioterrorist event, and only 19 percent felt able to distinguish psychological illness from the organic sequelae of a bioterrorist event. However, 75 percent expressed willingness to provide assistance in the state's bio terrorism response and control efforts. Respondents who were retired or inactive scored significantly lower than their actively employed peers on the objective knowledge questions. These finding indicate that more attention needs to be focused on bio terrorism preparedness training of mental health professionals to improve their ability to respond effectively. [ABSTRACT FROM AUTHOR]

The authors and associates conducted a social norms-based intervention targeting high-risk sexual behaviors among undergraduate students at 4 college campuses. Social norms theory predicts that widely held misperceptions may encourage risky behavior in a misguided attempt to conform to perceived norms and that information correcting these misperceptions will lead to a decrease in such behaviors. Students overestimated their peers' levels of sexual activity, numbers of partners, incidence of sexually transmitted infections, and rates of unintended pregnancies, but underestimated rates of condom use. Rates of HIV test taking, however, were accurately estimated. Although some components of sexual risk behaviors lend themselves well to social norms-based interventions, others, specifically inconsistent condom use and avoiding HIV tests, do not. Although no changes in reported beliefs or practices were apparent at the end of a 9-month intervention period, longer or modified interventions may be needed to make a fair assessment of the efficacy of this approach. [ABSTRACT FROM AUTHOR]

Background: Current perceptions of family physician (FP) shortages in Canada have prompted policies to expand medical schools. Our objective was to assess how FP supply, work-loads and access to care have changed over the past decade. Methods: We used an anonymized physician and population registry and administrative health service data from Winnipeg for the period 1991/92 to 2000/01. We calculated the following measures of supply and workload: ratios of FPs to population, of population to FPs and of FP full-time equivalents (FTEs) to population, as well as FP activity ratios (sum of FTEs/number of FPs), annual number of visits per FP and visits per FP per full-time day of work. Trends in FP remuneration were analyzed by age and sex. We also measured standardized visit rates and stratified the analysis by populations deemed at risk of needing FP services. Results: In 2000/01 FPs between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously. Conversely, FPs 60 to 69 years of age (11% of the workforce) provided 33% more visits per year than the corresponding group a decade earlier. On a per capita basis, the number of FPs declined by 5%, from 97 per 100 000 population in 1991/92 to 92 per 100 000 population in 2000/01, which paralleled changes in national estimates of FP supply. Per capita visit rates among Winnipeg citizens (3.5 per year in 2000/01) and average workloads among FPs (4193 visits per year in 2000/01) were stable over the decade. Interpretation: Despite relative homeostasis in aggregate FP supply and use, there have been substantial temporal shifts in the volume of services provided by FPs of different age groups. Younger FPs are providing many fewer visits and older FPs are providing many more visits than their same-age predecessors did 10 years ago, a finding that was independent of physician sex. Given these data, the perpetual focus of policy-makers and care provides on... [ABSTRACT FROM AUTHOR]

Limited studies have shown high rates of gonorrheal and chlamydial infections among incarcerated adolescents, however, this population has not been routinely targeted for sexually transmitted disease (STD) screening. This study was done to ascertain the feasibility of screening females for STDs at a juvenile detention facility in Honolulu, Hawaii, and to determine the prevalence of chlamydial and gonorrheal infections in this population. Between January 2000 and December 2001, pelvic examination-based STD screening was offered to all female detainees, on selected dates. Specimens from multiple anatomical sites were cultured for Neisseria gonorrhoeae. Endocervical swabs were tested for Chlamydia trachomatis using a DNA probe (GenProbe®). One-hundred one of 204 (50%) eligible females were screened. Fourteen of 101 (13.9%) females were screen positive for chlamydial infection, while six of 101 (5.9%) were culture positive for infection with N. gonorrhoeae. Three females were co-infected with both organisms. The high STD rates justify the institution of a routine screening program for this high risk and previously underserved group. [ABSTRACT FROM AUTHOR]

To date, the usage of exercise echocardiography in patients with pulmonary or congenital heart disease has been limited despite its potential for broader applications in different clinical scenarios. Exercise echocardiography can be utilized to determine the extent of pulmonary vascular damage in patients with chronic obstructive pulmonary disease by demonstrating the presence of exertional pulmonary hypertension in subjects with normal pulmonary artery pressures (PAPs) at rest. It is also useful in patients with connective tissue disease to screen for lung involvement by identifying exertional pulmonary hypertension, and in patients with established pulmonary hypertension to choose and monitor the effects of therapeutic interventions on the PAPs. Moreover, the measurement of aortic flow velocity and acceleration by exercise echocardiography may be helpful in the study of dyspnea in patients at risk for both pulmonary disease and congestive heart failure. In patients with congenital heart disease, the measurement of PAP and ventricular function both at rest and during exercise by echocardiography is the cornerstone in the investigation of the etiology of exercise intolerance in these individuals. Lastly, exercise echocardiography can also screen for residual narrowing in patients after repair of the coarctation of the aorta by detecting a significant diastolic gradient in the descending aorta during exercise provocation. (ECHOCARDIOGRAPHY, Volume 21, July 2004) [ABSTRACT FROM AUTHOR]

Background: Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are a widely used class of therapy in the treatment of chronic pain and inflammation. The drugs are effective and can be relatively inexpensive thanks to available generic versions. Unfortunately the traditional NSAIDs are associated with gastrointestinal complications in a small proportion of patients, requiring costly co-therapy with gastro-protective agents. Recently, a new class of non-steroidal anti-inflammatory agents known as coxibs has become available, fashioned to be safer than the traditional NSAIDs but priced considerably higher than the traditional generics. To help physicians choose appropriately and cost-effectively from the expanded number of anti-inflammatory therapies, scientific bodies have issued clinical practice guidelines and third party payers have published restricted reimbursement policies. The objective of this study is to determine whether an educational intervention can prompt physicians to adjust their prescribing in accordance with these expert recommendations. Methods: This is an ongoing, randomized controlled trial. All primary care physicians in Manitoba, Canada have been randomly assigned to a control group or an intervention study group. The educational intervention being evaluated consists of an audit and feedback mechanism combined with optional participation in a Continuing Medical Education interactive workshop. The primary outcome of the study is the change, from pre-to post-intervention, in physicians' appropriate prescribing of non-steroidal anti-inflammatory therapies for patients requiring chronic treatment. Three classes of non-steroidal anti-inflammatory therapies have been identified: coxib therapy, traditional NSAID monotherapy, and traditional NSAID therapy combined with gastro-protective agents. Appropriate prescribing is defined based on international clinical practice guidelines and the provincial drug reimbursement policy in Manitoba. [ABSTRACT FROM AUTHOR]

Methamphetamine abuse is epidemic in Hawaii, but the extent of use among pregnant women is unknown. We sought to define the prevalence of use during pregnancy. We conducted a cross-sectional study of consecutive births between November and December 1999, and determined that the prevalence of drug metabolites in meconium were fatty acid ethyl esters: 72 (17.1%); cotinine: 33 (7.7%); opiates: 4 (0.9%); delta-9 tetrahydrocannabinal: 1 (0.2%); and methamphetamine: 3 (0.7%). Including three positives discovered solely through forensic testing, the overall prevalence of methamphetamine exposure during pregnancy was 1.4% (6/443). The prevalence of methamphetamine was Iow compared to the prevalence of fatty acid ethyl esters, reportedly indicative of ethanol exposure, and cotinine, a tobacco metabolite. In Hawaii, more attention should be directed towards alcohol and tobacco use during pregnancy. [ABSTRACT FROM AUTHOR]

Summary Laboratory confirmation of leptospirosis is usually accomplished serologically, without isolates, using the microscopic agglutination test (MAT). However, optimal performance of the MAT is dependent on the knowledge of enzootic serogroups and serovars so that an appropriate MAT antigen testing battery can be established. Infecting leptospiral serogroups can be identified serologically without isolates, using the MAT, or by serogrouping of isolates, but little information is available regarding the correlation between these methods. The identification of infecting serogroups for 53 culture-confirmed leptospirosis cases, diagnosed in Hawaii between 1979 and 1998, using serology and culture isolates were compared. The overall agreement between the two methods was good (κ = 0.71, 95% CI: 0.56, 0.86). However, the agreement varied between serogroups from 0 to 100%. In establishing the prevalence of serogroups, results obtained via MAT serology (in the absence of serogrouped isolates) should be considered presumptive rather than definitive. [ABSTRACT FROM AUTHOR]

PURPOSE: For surveillance purposes, the Centers for Disease Control and Prevention and Council of State and Territorial Epidemiologists (CDC/CSTE) have defined two case classifications for leptospirosis: “confirmed” and “probable.” The objective of this study was to provide data to refine the current surveillance case classifications.METHODS: All reported leptospirosis infections from exposures within the State of Hawaii, 1974 to 1998 meeting CDC/CSTE “confirmed” and “probable” case classifications were compared on a number of clinical and epidemiologic parameters.RESULTS: Confirmed cases (n = 276) had more severe clinical manifestations than probable cases (n = 180); however, probable cases with higher peak microscopic agglutination test (MAT) titers (&ges;1:800) were clinically and epidemiologically comparable to confirmed cases. In addition, 77 cases demonstrating fourfold or greater MAT titer increases in paired serum collected less than two weeks apart (currently excluded from the “confirmed” case classification) were also comparable to confirmed cases.CONCLUSIONS: Our findings support amending the current CDC/CSTE surveillance confirmed case classification to include demonstration of a fourfold or greater MAT titer increase in paired serum, irrespective of the interval between specimen collection. Consideration should also be given to including single MAT titer &ges;1:800 as a criterion for “confirmation.” These changes would both simplify and expedite the surveillance confirmation of leptospirosis. [Copyright &y& Elsevier]

Presents a study that assessed the clinical presentation and treatment of confirmed leptospirosis cases in Hawaii from 1974-1998. Reason for misdiagnosis of the disease; Regions in which the disease is common; Information on how the disease is contacted by humans.

Investigates the history of sexual abuse in a sample of women attending a Canadian community health center with a substantial aboriginal population. Methods; Results; Suggestion that sexual abuse may be associated with clinical, lifestyle and reproductive consequences, beyond specific physical and psychosocial disorders; Aboriginal and non-aboriginal women showing differences in their health and health-related behaviors.

The author reflects on the diagnosis of a bacterial zoonotic disease called Leptospirosis using real-time quantitative polymerase chain reaction (qPCR) assays. The disease has been identified as a re-emerging infectious disease by the U.S. Centers for Disease Control and Prevention. There are several diagnostic approaches to Leptospirosis, but high sensitivity and ability to detect low leptospire levels of qPCR makes it one of the most convincing techniques for leptospirosis.