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Nawar Alotaibi,1 Brigitte M Borg,2,3 Michael J Abramson,3 Eldho Paul,3 Nicholas Zwar,4 Grant Russell,5 Sally Wilson,1,6 Anne E Holland,2,7 Billie Bonevski,8 Ajay Mahal,9 Johnson George1,3 1Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia; 2Respiratory Medicine, Alfred Health, Melbourne, VIC, Australia; 3School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia; 4Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia; 5Department of General Practice, Monash University, Melbourne, VIC, Australia; 6Department of Infrastructure Engineering, The University of Melbourne, Melbourne, VIC, Australia; 7Central Clinical School, Monash University, Melbourne, VIC, Australia; 8College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia; 9The Nossal Institute for Global Health, The University of Melbourne, Melbourne, VIC, AustraliaCorrespondence: Johnson George, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia, Email Johnson.George@monash.eduAim: Diagnosis of COPD in primary care is hindered by underuse of spirometry. Case finding using validated symptom and health status questionnaires, and simple handheld devices in high-risk populations may improve diagnosis. This study aimed to determine the best combination of measures to optimise COPD diagnosis in the primary care setting.Methods: We recruited 335 current or ex-smokers, including those with an established diagnosis of COPD from general practices. Participants’ FEV1 and FEV6 were measured using a handheld spirometry device (COPD-6®). Each completed the COPD assessment test (CAT), a modified Medical Research Council (mMRC) dyspnoea scale, St George’s Respiratory Questionnaire (SGRQ) and smoking history questionnaire. From these data we calculated the predictive validity for spirometry-confirmed diagnosis of COPD. Area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated for each. Kappa coefficient was used to measure the agreement between the Fixed-Ratio (FR) and Lower Limit of Normal (LLN) spirometric criteria in diagnosing COPD.Results: FEV1/FEV6 < 0.70 alone showed significant association (p< 0.0001) with COPD diagnosis and good predictive accuracy (AUROC=0.725). However, no further improvement was found after combining SGRQ, CAT and mMRC with FEV1/FEV6. FEV1/FEV6 < 0.70 using the COPD-6® handheld device had moderate sensitivity (65.7%) and high PPV (90.1%), high specificity (79.3%) and NPV (44.8%). There was good agreement between FR and LLN definitions (κ=0.70).Conclusion: Handheld micro-spirometers can facilitate case finding of COPD in smokers and ex-smokers attending general practice. The fixed ratio criterion currently recommended by COPD-X guidelines offers the simplest method for diagnosing COPD in Australian primary care.Keywords: case finding, COPD, diagnosis, primary care

We present results from a 3.1 kg-day target exposure of two charge-coupled devices (CCDs), each with 24 megapixels and skipper readout, deployed in the DAMIC (DArk Matter In CCDs) setup at SNOLAB. With a reduction in pixel readout noise of a factor of 10 relative to the previous detector, we investigate the excess population of low-energy bulk events previously observed above expected backgrounds. We address the dominant systematic uncertainty of the previous analysis through a depth fiducialization designed to reject surface backgrounds on the CCDs. The measured bulk ionization spectrum confirms with higher significance the presence of an excess population of low-energy events in the CCD target with characteristic rate of ${\sim}7$ events per kg-day and electron-equivalent energies of ${\sim}80~$eV, whose origin remains unknown., 8 pages, 4 figures

ImportanceRecognizing the association between timely treatment and less myocardial injury for patients with ST-segment elevation myocardial infarction (STEMI), US national guidelines recommend specific treatment-time goals.ObjectiveTo describe these process measures and outcomes for a recent cohort of patients.Design, Setting, and ParticipantsCross-sectional study of a diagnosis-based registry between the second quarter of 2018 and the third quarter of 2021 for 114 871 patients with STEMI treated at 648 hospitals in the Get With The Guidelines–Coronary Artery Disease registry.ExposuresSTEMI or STEMI equivalent.Main Outcomes and MeasuresTreatment times, in-hospital mortality, and adherence to system goals (75% treated ≤90 minutes of first medical contact if the first hospital is percutaneous coronary intervention [PCI]-capable and ≤120 minutes if patients require transfer to a PCI-capable hospital).ResultsIn the study population, median age was 63 (IQR, 54-72) years, 71% were men, and 29% were women. Median time from symptom onset to PCI was 148 minutes (IQR, 111-226) for patients presenting to PCI-capable hospitals by emergency medical service, 195 minutes (IQR, 127-349) for patients walking in, and 240 minutes (IQR, 166-402) for patients transferred from another hospital. Adjusted in-hospital mortality was lower for those treated within target times vs beyond time goals for patients transported via emergency medical services (first medical contact to laboratory activation ≤20 minutes [in-hospital mortality, 3.6 vs 9.2] adjusted OR, 0.54 [95% CI, 0.48-0.60], and first medical contact to device ≤90 minutes [in-hospital mortality, 3.3 vs 12.1] adjusted OR, 0.40 [95% CI, 0.36-0.44]), walk-in patients (hospital arrival to device ≤90 minutes [in-hospital mortality, 1.8 vs 4.7] adjusted OR, 0.47 [95% CI, 0.40-0.55]), and transferred patients (door-in to door-out time Conclusions and RelevanceThis study of patients with STEMI included in a US national registry provides information on changes in process and outcomes between 2018 and 2021.

This case series shows how the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization can be used to decide between revascularization or optimal medical therapy to reduce mortality or cardiovascular events in selected subsets of patients with stable ischemic heart disease and complex coronary disease with or without left ventricular dysfunction. (Level of Difficulty: Advanced.), Graphical abstract

Implementation Costs of Technology-Enhanced Transitional Palliative Care for Rural Caregivers by Brystana G. Kaufman, Diane E. Holland, Catherine E. Vanderboom, Cory Ingram, Ellen M. Wild, Ann Marie Dose, Carole Stiles, Allison M. Gustavson, Alice Chun, Erica Langan, Henry A. Baer-Benson, Jay Mandrekar, and Joan M. Griffin in American Journal of Hospice and Palliative Medicine

Additional file 3. Thematic analyses from free-text items.

Additional file 5. Comparison of participants reporting not being satisfied with the care they received during the pandemic compared to those more satisfied with the care received.

Additional file 1. COVID-19 Specific questionnaire.

Additional file 4. Comparison of participants reporting less likely to seek medical assistance during the pandemic compared to those more or equally as likely to seek care.

Additional file 2. Responses to COVID-specific questionnaire.

Angela T Burge,1– 3 Carla Malaguti,1,4 Mariana Hoffman,1 Alan Shiell,5 Christine F McDonald,3,6,7 David J Berlowitz,3,6,7 Anne E Holland1– 3 1Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, VIC, Australia; 2Physiotherapy Department, Alfred Health, Melbourne, VIC, Australia; 3Institute for Breathing and Sleep, Heidelberg, VIC, Australia; 4Faculty of Physiotherapy, Federal University of Juiz de Fora, Juiz de Fora, Brazil; 5Department of Public Health, La Trobe University, Bundoora, VIC, Australia; 6Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia; 7Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, AustraliaCorrespondence: Angela T Burge, Respiratory Research@Alfred, Central Clinical School, Monash University, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia, Tel +61 3 9903 0176, Fax +61 3 9903 0556, Email angela.burge@monash.eduBackground: Pulmonary rehabilitation is an effective intervention for people with chronic obstructive pulmonary disease (COPD). People with COPD undertake repeat programs, but synthesis of evidence regarding such practice has not been undertaken. The aim of this systematic review was to establish the effects of repeating pulmonary rehabilitation subsequent to an initial program in people with COPD.Methods: Studies where participants with COPD undertook > 1 pulmonary rehabilitation program were included, incorporating RCT (randomized controlled trial) and non-randomized studies. Electronic database searches were undertaken. Two authors independently undertook study identification, data extraction and risk of bias assessment. The primary outcome was health-related quality of life (HRQoL); secondary outcomes were exercise capacity, hospitalizations and exacerbations, adherence, mortality and adverse events. Narrative synthesis was undertaken for clinically heterogeneous trials. Data from RCTs and non-randomized studies were not combined for analysis.Results: Ten included studies (2 RCTs) involved 907 participants with COPD (n=653 had undertaken > 1 program). The majority of studies were at high risk of bias. One RCT (n=33) reported no difference in HRQol after a repeat program vs usual care following exacerbation (Chronic Respiratory Disease Questionnaire dyspnea domain score MD 0.4, 95% CI − 0.5 to 3). In stable patients, clinically important and statistically significant improvements in HRQoL and exercise capacity were reported after repeat programs, but of a smaller magnitude than initial programs. There was evidence for reductions in exacerbations and hospitalizations, and shorter hospital length of stay for patients who repeated a program twice in 12 months compared to those who repeated once. No data for mortality or adverse events were available.Conclusion: This systematic review provides limited evidence for benefits of repeating pulmonary rehabilitation in people with COPD, including improved HRQoL and exercise capacity, and reduced hospitalizations. However, most studies have high risk of bias, which reduces the certainty of these conclusions.Study Registration: PROSPERO (CRD42020215093).Keywords: COPD, repeat pulmonary rehabilitation, systematic review

4H-Silicon Carbide, when considered as a material for the fabrication of Low Gain Avalanche Detectors for particle timing and position measurement, offers potential advantages over Silicon. We discuss an ongoing study of this material aimed at the fabrication and test of prototype fast timing sensors. This work is well aligned with technical directions identified in the recent Department of Energy study, Basic Research Needs for High Energy Physics Detector Research and Development., Submitted to Snowmass 2021

We use a science-grade skipper charge-coupled device (skipper CCD) operating in a low-radiation background environment to develop a semiempirical model that characterizes the origin of single-electron events in CCDs. We identify, separate, and quantify three independent contributions to the single-electron events, which were previously bundled together and classified as "dark counts": dark current, amplifier light, and spurious charge. We measure a dark current, which depends on exposure, of (5.89±0.77)×10-4e-/pix/day, and an unprecedentedly low spurious charge contribution of (1.52±0.07)×10-4e-/pix, which is exposure independent. In addition, we provide a technique to study events produced by light emitted from the amplifier, which allows the detector's operation to be optimized to minimize this effect to a level below the dark-current contribution. Our accurate characterization of the single-electron events allows one to greatly extend the sensitivity of experiments searching for dark matter or coherent neutrino scattering. Moreover, an accurate understanding of the origin of single-electron events is critical to further progress in ongoing research and development efforts of skipper and conventional CCDs.

The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Recent clinical practice guidelines provide clinicians with guidance; however, decisions regarding treatment for individual patients can still be difficult. The American College of Cardiology's Cardiac Surgery Team and Interventional Council joined together to develop a practical approach to the treatment of LM CAD, taking into account randomized clinical trial, meta-analyses, and clinical practice guidelines. The various presentations of LM CAD based on anatomy and physiology are presented. Recognizing the complexity of LM CAD, which rarely presents isolated and is often in combination with multivessel disease, a treatment algorithm with medical therapy alone or in conjunction with percutaneous coronary intervention or coronary artery bypass grafting is proposed. A heart team approach is recommended that accounts for clinical, procedural, operator, and institutional factors, and features shared decision-making that meets the needs and preferences of each patient and their specific clinical situation.

BACKGROUND: Physical activity levels are known to decline following hospitalisation for people with cystic fibrosis (pwCF). However, optimal physical activity promotion strategies are unclear. This study investigated the effect of a web-based application (ActivOnline) in promoting physical activity in young pwCF. METHODS: Multicentre randomised controlled trial with assessor blinding and qualitative evaluation. People with CF (12-35 years) admitted to hospital for a respiratory cause were eligible and randomised to the 12-week ActivOnline intervention (AO) or usual care (UC). The primary outcome was change in device-based time spent in moderate-to-vigorous physical activity (MVPA) from baseline to post-intervention. Follow-up was at 6 months from hospital discharge when qualitative evaluation was undertaken. RESULTS: 107 participants were randomised to AO (n=52) or UC (n=55). Sixty-three participants (59%) contributed to the intention-to-treat analysis. Mean (SD) age was 21 (6) years (n=46

Hydroperoxymethyl thioformate (HPMTF), is a newly identified major oxidation product of dimethyl sulfide (DMS). It is speculated that it could act as a major reservoir of marine sulfur, but its fate in the atmosphere is currently unknown. In this study we have investigated the formation of HPMTF through the oxidation of DMS by OH, NO3 and Cl radicals and its losses through photolysis, OH oxidation, dry deposition and wet deposition using the global 3-dimensional chemical transport model, STOCHEM-CRI. The model results suggest that the distribution of loss processes for HPMTF are photolysis (46%) and wet deposition (31%) with additional contributions from dry deposition (13%) and OH-oxidation (10%). The global burden and the tropospheric lifetime of HPMTF are found to be 0.052 Tg and 0.5 days, respectively. The model integrations agree well with both aircraft derived measurements of HPMTF over the ocean surface between 80oN and 85oS latitudes and ground-based measurements made in the central Amazon. These ground-based data reveal a clear diurnal cycle with a maximum during midday, consistent with other recently reported data and possibly due to the dominance of the photochemical production rather than the photolytic loss. Accounting for HPMTF chemistry results in a significant decrease in boundary layer levels of SO2 and H2SO4 but increases in sulfate aerosol in the upper troposphere. We suggest that these changes could have important consequences on pre-industrial to present-day radiative forcing from sulfate aerosol.

We present experimental results using a single-electron resolution Skipper-CCD running above ground level to demonstrate the potential of this technology for its use in reactor neutrino observations and other low-energy particle interaction experiments. Operating conditions and event-selection criteria are provided to decouple most of the background rate at low energies. Our final results for events with energies as low as $5$ ionized electron-hole pairs show that the exponentially increasing rate of events seen in other technologies is not present in our data. This demonstrates that the Skipper CCD proves to be among the best options to measure low energy and weakly interacting particles at ground level.

Over the past few decades, advances in the pharmacologic, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions (AMI). However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of AMI. The most commonly encountered mechanical complications are acute mitral regurgitation (MR) secondary to papillary muscle rupture, ventricular septal defect (VSD), pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care which mainly depends on local expertise and available resources. In this American Heart Association Scientific Statement, we: (1) define the epidemiology of mechanical complications of AMI; (2) propose contemporary best medical, interventional, and surgical management practice considerations; (3) consider best practices in clinical decisions and supportive care, and (4) outline specific research gaps for future investigation to improve overall cardiovascular care and post-discharge outcomes for this high acuity and complex patient population.

ispartof: ANNALS OF THE AMERICAN THORACIC SOCIETY vol:18 issue:5 pages:737-748 status: published

Supplemental material, sj-pdf-1-aar-10.1177_21526567211010728 for Community Response to the Impact of Thunderstorm Asthma Using Smart Technology by Ala AlQuran MPH Mehak Batra MDS Susanto Harry Nugroho PhD Anne E. Holland PhD Janet M. Davies PhD in Allergy & Rhinology

We use a science-grade Skipper Charge Coupled Device (Skipper-CCD) operating in a low-radiation background environment to develop a semi-empirical model that characterizes the origin of single-electron events in CCDs. We identify, separate, and quantify three independent contributions to the single-electron events, which were previously bundled together and classified as "dark counts": dark current, amplifier light, and spurious charge. We measure a dark current, which depends on exposure, of (5.89+-0.77)x10^-4 e-/pix/day, and an unprecedentedly low spurious charge contribution of (1.52+-0.07)x10^-4 e-/pix, which is exposure-independent. In addition, we provide a technique to study events produced by light emitted from the amplifier, which allows the detector's operation to be optimized to minimize this effect to a level below the dark-current contribution. Our accurate characterization of the single-electron events allows one to greatly extend the sensitivity of experiments searching for dark matter or coherent neutrino scattering. Moreover, an accurate understanding of the origin of single-electron events is critical to further progress in ongoing R&D efforts of Skipper and conventional CCDs., 9 pages, 6 figures, 4 tables

In addition to the overview of diversity in soil sensing technologies, this chapter presents four case studies to illustrate the practical use of these technologies to enhance precision agriculture in Canada, the United Kingdom, Sweden and Papua New Guinea. These studies represent investigations of different instruments, field conditions and targeted soil properties. However, in all four cases, proximal soil sensing was used to predict selected soil properties to generate relatively accurate maps that could help to implement site-specific crop management successfully.

Students with disabilities are educated in general physical education classes with their same aged peers more now than ever before (Governmental Accountability Office [GAO], 2010), yet little is known about how those with orthopedic impairments experience these integrated classes. Additionally, while a plethora of strategies are described as promoting ‘inclusion’, very few ‘inclusive’ strategies have been problematized. This dissertation followed a two-study format. The first study explored the lived experiences of students with orthopedic impairments in integrated physical education classes, and the second study examined how students with orthopedic impairments experienced strategies identified in the literature to support ‘inclusion’. An interpretative phenomenological analysis research approach was used in each, and six students with orthopedic impairments (age 10-14 years) served as participants. Data sources included semi-structured, audiotaped interviews, reflective interview notes, and a written prompt. Based on data analysis, three themes developed in the first study: “Without it, they probably would like, just treat me normal”: visibility, disclosure, and expectations; “I sit out”: limited participation and a lack of modifications/accommodations; and “PE doesn’t feel great”: social interactions and perception of self; and four themes arose in the second study: “It’s kind of embarrassing”: experiences with support; “I don’t want to be different”: equipment, activity, and rule modifications; “I like to be a part of the conversation”: autonomy and choice in PE; and “I would rather be like the other students”: discussing disability. The themes highlight the marginalization and lack of access that the participants encountered during their integrated physical education classes, indicating that physical education professionals may benefit from reflecting on personal biases, as well as their instructional practices in an effort to improve the quality of physical education experiences for their students. Further, the differential effects of these explicated ‘inclusive’ strategies were emphasized, whereas each strategy contributed to feelings of inclusion, as well as marginalization. The findings indicate that ‘inclusive’ strategies should not be considered as blanket recommendations; instead, attempts to promote ‘inclusion’ of students with disabilities should start with a reflexive look at the unique needs of each individual student.

No abstract available. published

The COVID-19 pandemic has caused significant shifts in patient care including a steep decline in ambulatory visits and a marked increase in the use of telemedicine. Infantile hemangiomas (IH) can require urgent evaluation and risk stratification to determine which infants need treatment and which can be managed with continued observation. For those requiring treatment, prompt initiation decreases morbidity and improves long-term outcomes. The Hemangioma Investigator Group has created consensus recommendations for management of IH via telemedicine. FDA/EMA-approved monitoring guidelines, clinical practice guidelines, and relevant, up-to-date publications regarding initiation and monitoring of beta-blocker therapy were used to inform the recommendations. Clinical decision-making guidelines about when telehealth is an appropriate alternative to in-office visits, including medication initiation, dosage changes, and ongoing evaluation, are included. The importance of communication with caregivers in the context of telemedicine is discussed, and online resources for both hemangioma education and propranolol therapy are provided.

Supplement_19June for Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: A rapid review by Anne E Holland, Carla Malaguti, Mariana Hoffman, Aroub Lahham, Angela T Burge, Leona Dowman, Anthony K May, Janet Bondarenko, Marnie Graco, Gabriella Tikellis, Joanna YT Lee and Narelle S Cox in Chronic Respiratory Disease

Additional file 1: Supplemental Table 1. Technology-Enhanced Transitional Palliative Care for Family World Health Organization Trial Registration Data Set Information.

Additional file 1: Supplementary Table 1. Participant features associated with feasibility of self-reported healthcare utilisation data. Supplementary Table 2. Participant features associated with accurate reporting of general practitioner visits. Supplementary Table 3. Participant features associated with accurate reporting of medical specialist appointments. Supplementary Table 4. Participant features associated with accurate reporting of emergency department presentations. Supplementary Table 5. Participant features associated with accurate reporting of hospital admissions.

Supplement_A_-_SemiStructured_interviews_and_quotes-PhaseI_R1 for Early home-based pulmonary rehabilitation following acute exacerbation of COPD: A feasibility study using an action research approach by Bruna Wageck, Narelle S Cox, Janet Bondarenko, Monique Corbett, Amanda Nichols, Rosemary Moore and Anne E Holland in Chronic Respiratory Disease

Supplement_B_-_SemiStructured_interviews_R1 for Early home-based pulmonary rehabilitation following acute exacerbation of COPD: A feasibility study using an action research approach by Bruna Wageck, Narelle S Cox, Janet Bondarenko, Monique Corbett, Amanda Nichols, Rosemary Moore and Anne E Holland in Chronic Respiratory Disease

Gabriel Izbicki,1,2 Valerie Teo,1,3 Jenifer Liang,4 Grant M Russell,5 Anne E Holland,6 Nicholas A Zwar,7 Billie Bonevski,8 Ajay Mahal,9 Paula Eustace,10 Eldho Paul,1 Kirsten Phillips,11 Sally Wilson,4,12 Johnson George,1,4 Michael J Abramson1 1School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; 2Shaare Zedek Medical Center and The Hebrew University Hadassah Medical School, Jerusalem, Israel; 3National Healthcare Group Polyclinics, Singapore; 4Centre For Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia; 5Southern Academic Primary Care Research Unit, Department of General Practice, Monash University, Notting Hill, Australia; 6Discipline of Physiotherapy, La Trobe University and Alfred Health, Melbourne, Australia; 7Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia; 8School of Medicine and Public Health, University of Newcastle, Callaghan, Australia; 9The Nossal Institute For Global Health, University of Melbourne, Melbourne, Australia; 10Eastern Melbourne PHN (EMPHN), Box Hill, Australia; 11Lung Foundation Australia (LFA), Milton, Australia; 12Department of Infrastructure Engineering, The University of Melbourne, Melbourne, AustraliaCorrespondence: Michael J AbramsonSchool of Public Health & Preventive Medicine, 553 St Kilda Road, Melbourne, VIC 3004, AustraliaTel +61 3 9903 0573Fax +61 3 9903 0556Email michael.abramson@monash.eduPurpose: Many older adults with a history of smoking and asthma develop clinical features of both asthma and COPD, an entity sometimes called asthma-COPD overlap (ACO). Patients with ACO may be at higher risk of poor health outcomes than those with asthma or COPD alone. However, understanding of ACO is limited in the primary care setting and more information is needed to better inform patient management. We aimed to compare the characteristics of patients with ACO or COPD in Australian general practices.Patients and methods: Data were from the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial, an intervention study of an interdisciplinary community-based model of care. Baseline demographic and clinical characteristics, pre- and post-bronchodilator spirometry, dyspnoea and St. George’s Respiratory Questionnaire scores were compared between 60 ACO patients and 212 with COPD alone.Results: Pre-bronchodilator Forced Expiratory Volume in 1 second (mean±SD 58.4±14.3 vs 67.5±20.1% predicted) and Forced Vital Capacity (mean 82.1±16.9 v 91.9±17.2% predicted) were significantly lower in the ACO group (p

Supplemental material, TRA879326 Supplemental Material for Measurement of mobility and physical function in hospitalised trauma patients: A systematic review of instruments and their measurement properties by Sara Calthorpe, Lara A Kimmel, Melissa J Webb, Belinda J Gabbe and Anne E Holland in Trauma

Supplemental material, TRA879326 Supplemental Material for Measurement of mobility and physical function in hospitalised trauma patients: A systematic review of instruments and their measurement properties by Sara Calthorpe, Lara A Kimmel, Melissa J Webb, Belinda J Gabbe and Anne E Holland in Trauma

This study describes physical activity levels and factors associated with physical activity at the end of stroke rehabilitation. Primary stroke survivors were assessed at completion of physical rehabilitation. Outcomes included physical activity (e.g. step count, moderate-vigorous physical activity duration) and sedentary time measured with the Sensewear Armband, gait speed, and cognition. The number of participants meeting physical activity recommendations was calculated. Differences in physical activity were examined between household ambulators (gait speed 0.8 m/s). The influence of age, cognition, and gait speed on physical activity was determined by multiple regression. Seventy-nine stroke survivors participated. Twenty-one participants achieved 30 min/day of moderate-vigorous physical activity accumulated in 10 min bouts. Unlimited community ambulators took more steps/day (median 4975 vs. 469 limited, 355 household, p p p p = 0.001); adding employment status to the model predicted 57.3% of the variance in step count (p Physical activity is low following stroke and should be a target for treatment, particularly in those with gait speeds ≤0.8 m/s.Implications for rehabilitationSeventy-three percent of stroke survivors performed ≥30 minutes of moderate to vigorous physical activity throughout the day.Twenty-seven percent of stroke survivors accumulated ≥30 minutes of moderate to vigorous physical activity in 10 minute bouts.Despite relatively good physical ability, daily step count was low in this sample.Those with gait speeds ≤0.8 m/s had lower physical activity levels and higher sedentary time. Seventy-three percent of stroke survivors performed ≥30 minutes of moderate to vigorous physical activity throughout the day. Twenty-seven percent of stroke survivors accumulated ≥30 minutes of moderate to vigorous physical activity in 10 minute bouts. Despite relatively good physical ability, daily step count was low in this sample. Those with gait speeds ≤0.8 m/s had lower physical activity levels and higher sedentary time.

Supplemental Material, Supplement_multimorbidity_usual_care_Final for A rehabilitation programme for people with multimorbidity versus usual care: A pilot randomized controlled trial by Kathryn Barker, Anne E Holland, Annemarie L Lee, Kathryn Ritchie, Claire Boote, Stephanie Lowe, Fiona Pazsa, Lee Thomas, Monica Turczyniak, and Elizabeth H Skinner in Journal of Comorbidity

The research presented herein seeks to utilise Keith Muckelroy’s body of theory regarding maritime archaeology while also investigating alternate methodologies deemed useful and appropriate for the re-investigation of known shipwreck sites that are considered to be discontinuous, disturbed, and/or scattered. These previously investigated sites have varying levels of preservation and, as a result, varying levels of perceived interpretive value. It is the goal of this research to assess these sites, identify previously untapped datasets, and suggest potential management strategies going forward, in order to determine if these sites are too fragmentary to yield new research avenues.The key output of this research is the development of an integrated complex of tools for the study of previously investigated shipwreck sites. A secondary output is the development of a glossary of terms relevant to all aspects of the analyses included within this research. A third output is to recommend the application and use of the phrases shipwreck biography and site transformation processes as of importance when analysing the variety of cultural and non-cultural processes at work on shipwreck sites. The final output is the conceptual distinction and application of life histories and shipwreck biographies on a series of previously investigated shipwreck sites, as an avenue to identifying new management directions for each of these sites.The author suggests that the complex of tools utilised within has successfully identified additional research avenues for each of the three case study sites, beyond those that have been previously documented as a result of previous investigations. The shipwreck biographies generated are the product of the compilation of the following datasets: shipwreck histories; artefact distribution maps, where possible with current research; assessment of site formation and transformation processes, including all documented environmental analyses conducted on the sites to date; execution of tracer artefact studies on two of the three study sites; and, lastly, combination of all datasets into unified shipwreck biographies. The synthesis of the current environmental conditions, known historical information about the ship, the wrecking event, and the previous documentation of the archaeological site have been effectively combined to provide the link between the past and present environment, between the ship as a cultural entity and the shipwreck as an archaeological site, between the artefact on the seabed, the current site interpretation, and recommendations for ongoing management practices.

OBJECTIVES: To compare patients who accepted ("acceptors") post acute care services (PAC) with those who were offered services and refused ("refusers") in terms of their sociodemographic and clinical characteristics, quality of life, health-related problems, and unmet needs; and to examine the association between refusing PAC services and the risk for 30- and 60-day readmission. STUDY DESIGN: Secondary data analysis from a cross-sectional study. METHODS: Bivariate analysis and logistic regressions were used to examine the association between refusing PAC services and 30- and 60-day readmission. RESULTS: A convenience sample of 495 PAC-referred patients 55 years and older discharged from 2 large academic medical centers in the northeastern United States completed the study questionnaires, with a resulting 28% (n = 139) that refused PAC services. Refusers were significantly younger (average age 68 years vs 73 years; P

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. A growing body of evidence shows that individuals with COPD have important deficits in balance control that may be associated with an increased risk of falls. Pulmonary rehabilitation (PR) is a key therapeutic intervention for individuals with COPD; however, current international guidelines do not include balance training and fall prevention strategies. Objective: The primary aim of this trial is to determine the effects of PR with balance training compared to PR with no balance training on the 12-month rate of falls in individuals with COPD. Secondary aims are to determine the effects of the intervention on balance, balance confidence, and functional lower body strength, and to estimate the cost-effectiveness of the program. Methods: A total of 400 individuals from nine PR centers across Canada, Europe, and Australia will be recruited to participate in a randomized controlled trial. Individuals with COPD who have a self-reported decline in balance, a fall in the last 2 years, or recent near fall will be randomly assigned to an intervention or control group. The intervention group will undergo tailored balance training in addition to PR and will receive a personalized home-based balance program. The control group will receive usual PR and a home program that does not include balance training. All participants will receive monthly phone calls to provide support and collect health care utilization and loss of productivity data. Both groups will receive home visits at 3, 6, and 9 months to ensure proper technique and progression of home exercise programs. The primary outcome will be incidence of falls at 12-month follow-up. Falls will be measured using a standardized definition and recorded using monthly self-report fall diary calendars. Participants will be asked to record falls and time spent performing their home exercise program on the fall diary calendars. Completed calendars will be returned to the research centers in prepaid envelopes each month. Secondary measures collected by a blinded assessor at baseline (pre-PR), post-PR, and 12-month follow-up will include clinical measures of balance, balance confidence, functional lower body strength, and health status. The cost-effectiveness of the intervention group compared with the control group will be evaluated using the incremental cost per number of falls averted and the incremental cost per quality-adjusted life years gained. Results: Recruitment for the study began in January 2017 and is anticipated to be complete by December 2019. Results are expected to be available in 2020. Conclusions: Findings from this study will improve our understanding of the effectiveness and resource uses of tailored balance training for reducing falls in individuals with COPD. If effective, the intervention represents an opportunity to inform international guidelines and health policy for PR in individuals with COPD who are at risk of falling. Trial Registration: ClinicalTrials.gov NCT02995681; https://clinicaltrials.gov/ct2/show/NCT02995681 (Archived by WebCite at http://www.webcitation.org/6ukhxgAsg) [JMIR Res Protoc 2017;6(11):e228]

ST-segment elevation myocardial infarction (STEMI) is considered a cardiology emergency requiring immediate recognition and treatment aimed at successful and early reperfusion to ensure optimal outcomes. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have issued guidelines for the diagnosis and management of patients with acute myocardial infarction since 1990. These guidelines are based on clinical research exploring reperfusion modalities and adjunctive therapies. They are further supported by expert opinion where randomized trial evidence is lacking. In January 2013, the ACCF/AHA released the most recent guidelines for the management of patients with STEMI. This review focuses on the newest and most important recommendations taken from the 2013 ACCF/AHA Guidelines for the Management of STEMI and highlight important new studies that have emerged over the past year.

This systematic review examined the measurement properties of the 6-min walk test (6MWT), incremental shuttle walk test (ISWT) and endurance shuttle walk test (ESWT) in adults with chronic respiratory disease. Studies that report the evaluation or use of the 6MWT, ISWT or ESWT were included. We searched electronic databases for studies published between January 2000 and September 2013. The 6-min walking distance (6MWD) is a reliable measure (intra-class correlation coefficients ranged from 0.82 to 0.99 in seven studies). There is a learning effect, with greater distance walked on the second test (pooled mean improvement of 26 m in 13 studies). Reliability was similar for ISWT and ESWT, with a learning effect also evident for ISWT (pooled mean improvement of 20 m in six studies). The 6MWD correlates more strongly with peak work capacity (r=0.59-0.93) and physical activity (r=0.40-0.85) than with respiratory function (r=0.10-0.59). Methodological factors affecting 6MWD include track length, encouragement, supplemental oxygen and walking aids. Supplemental oxygen also affects ISWT and ESWT performance. Responsiveness was moderate to high for all tests, with greater responsiveness to interventions that included exercise training. The findings of this review demonstrate that the 6MWT, ISWT and ESWT are robust tests of functional exercise capacity in adults with chronic respiratory disease. The realisation of this systematic review would not have been possible without the financial support of the European Respiratory Society and American Thoracic Society. Sally J. Singh is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands (CLAHRC EM), and work took place at the University Hospitals of Leicester NHS Trust. Support was also provided by the NIHR Leicester Respiratory Biomedical Research Unit. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Dept of Health.

There is no question that the stigma and discrimination associated with HIV and AIDS can be reduced through intervention. The inclusion of stigma and discrimination reduction as a critical component of achieving an AIDS-free generation in recent UNAIDS, UN and PEPFAR political initiatives is promising. Yet national governments need evidence on effective interventions at the individual, community and societal levels in order to strategically incorporate stigma and discrimination reduction into national AIDS plans. Currently, the heterogeneity of stigma and discrimination reduction approaches and measurement makes it challenging to compare and contrast evaluated interventions. Moving forward, it is critical for the research community to: (1) clearly link intervention activities to the domains of stigma to be shifted; (2) assess the stigma domains in a consistent manner; and (3) link stigma and discrimination reduction with HIV prevention, care and treatment outcomes (e.g., uptake, adherence and retention of ART). These steps would further advance the scientific evidence base of stigma and discrimination reduction and allow for the identification of effective interventions that could be scaled up by national governments., Introduction Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. Methods We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. Results Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants’ ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ 2=7.7; p=0.005). Conclusions We found that HIV-related stigma compromised participants’ abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence., Introduction HIV-related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response. Methods We conducted a systematic review of studies and reports that assessed the effectiveness of interventions to reduce HIV stigma and discrimination between 1 January 2002 and 1 March 2013. Databases searched for peer-reviewed articles included PubMed, Scopus, EBSCO Host –CINAHL Plus, Psycinfo, Ovid, Sociofile and Popline. Reports were obtained from the www.HIVAIDSClearinghouse.eu, USAID Development Experience Clearinghouse, UNESCO HIV and AIDS Education Clearinghouse, Google, WHO and UNAIDS. Ancestry searches for articles included in the systematic review were also conducted. Studies of any design that sought to reduce stigma as a primary or secondary objective and included pre- and post-intervention measures of stigma were included. Results Of 2368 peer-reviewed articles and reports identified, 48 were included in our review representing 14 different target populations in 28 countries. The majority of interventions utilized two or more strategies to reduce stigma and discrimination, and ten included structural or biomedical components. However, most interventions targeted a single socio-ecological level and a single domain of stigma. Outcome measures lacked uniformity and validity, making both interpretation and comparison of study results difficult. While the majority of studies were effective at reducing the aspects of stigma they measured, none assessed the influence of stigma or discrimination reduction on HIV-related health outcomes. Conclusions Our review revealed considerable progress in the stigma-reduction field. However, critical challenges and gaps remain which are impeding the identification of effective stigma-reduction strategies that can be implemented by national governments on a larger scale. The development, validation, and consistent use of globally relevant scales of stigma and discrimination are a critical next step for advancing the field of research in this area. Studies comparing the effectiveness of different stigma-reduction strategies and studies assessing the influence of stigma reduction on key behavioural and biomedical outcomes are also needed to maximize biomedical prevention efforts., Introduction Global scale up of antiretroviral therapy is changing the context of HIV-related stigma. However, stigma remains an ongoing concern in many countries. Groups of people living with HIV can contribute to the reduction of stigma. However, the pathways through which they do so are not well understood. Methods This paper utilizes data from a qualitative study exploring the impact of networked groups of people living with HIV in Jinja and Mbale districts of Uganda. Participants were people living with HIV (n=40), members of their households (n=10) and their health service providers (n=15). Data were collected via interviews and focus group discussions in 2010, and analyzed inductively to extract key themes related to the approaches and outcomes of the groups’ anti-stigma activities. Results Study participants reported that HIV stigma in their communities had declined as a result of the collective activities of groups of people living with HIV. However, they believed that stigma remained an ongoing challenge. Gender, family relationships, social and economic factors emerged as important drivers of stigma. Challenging stigma collectively transcended individual experiences and united people living with HIV in a process of social renegotiation to achieve change. Groups of people living with HIV provided peer support and improved the confidence of their members, which ultimately reduced self-stigma and improved their ability to deal with external stigma when it was encountered. Conclusions Antiretroviral therapy and group-based approaches in the delivery of HIV services are opening up new avenues for the collective participation of people living with HIV to challenge HIV stigma and act as agents of social change. Interventions for reducing HIV stigma should be expanded beyond those that aim to increase the resilience and coping mechanisms of individuals, to those that build the capacity of groups to collectively cope with and challenge HIV stigma. Such interventions should be gender sensitive and should respond to contextual social, economic and structural factors that drive stigma., Introduction HIV stigma and discrimination are major issues affecting people living with HIV in their everyday lives. In Thailand, a project was implemented to address HIV stigma and discrimination within communities with four activities: (1) monthly banking days; (2) HIV campaigns; (3) information, education and communication (IEC) materials and (4) “Funfairs.” This study evaluates the effect of project interventions on reducing community-level HIV stigma. Methods A repeated cross-sectional design was developed to measure changes in HIV knowledge and HIV-related stigma domains among community members exposed to the project. Two cross-sectional surveys were implemented at baseline (respondent n=560) and endline (respondent n=560). T-tests were employed to assess changes on three stigma domains: fear of HIV infection through daily activity, shame associated with having HIV and blame towards people with HIV. Baseline scales were confirmed at endline, and each scale was regressed on demographic characteristics, HIV knowledge and exposure to intervention activities. Results No differences were observed in respondent characteristics at baseline and endline. Significant changes were observed in HIV transmission knowledge, fear of HIV infection and shame associated with having HIV from baseline to endline. Respondents exposed to three specific activities (monthly campaign, Funfair and IEC materials) were less likely to exhibit stigma along the dimensions of fear (3.8 points lower on average compared to respondents exposed to none or only one intervention; 95% CI: −7.3 to −0.3) and shame (4.1 points lower; 95% CI: −7.7 to −0.6), net of demographic controls and baseline levels of stigma. Personally knowing someone with HIV was associated with low fear and shame, and females were less likely to possess attitudes of shame compared to males. Conclusions The multivariate linear models suggest that a combination of three interventions was critical in shifting community-level stigma – monthly campaign, Funfair and IEC materials. This is especially important given Thailand's new national AIDS strategy to reduce HIV-related stigma and discrimination by half by 2016. Knowing which interventions to invest in for HIV stigma reduction is crucial for country-wide expansion and scale-up of intervention activities., Introduction Globally, HIV-related stigma is prevalent in healthcare settings and is a major barrier to HIV prevention and treatment adherence. Some intervention studies have showed encouraging outcomes, but a gap continues to exist between what is known and what is actually delivered in medical settings to reduce HIV-related stigma. Methods This article describes the process of implementing a stigma reduction intervention trial that involved 1760 service providers in 40 hospitals in China. Guided by Diffusion of Innovation theory, the intervention identified and trained about 15–20% providers as popular opinion leaders (POLs) to disseminate stigma reduction messages in each intervention hospital. The intervention also engaged governmental support in the provision of universal precaution supplies to all participating hospitals in the trial. The frequency of message diffusion and reception, perceived improvement in universal precaution practices and reduction in the level of stigma in hospitals were measured at 6- and 12-month follow-up assessments. Results Within the intervention hospitals, POL providers reported more frequent discussions with their co-workers regarding universal precaution principles, equal treatment of patients, provider-patient relationships and reducing HIV-related stigma. Service providers in the intervention hospitals reported more desirable intervention outcomes than providers in the control hospitals. Our evaluation revealed that the POL model is compatible with the target population, and that the unique intervention entry point of enhancing universal precaution and occupational safety was the key to improved acceptance by service providers. The involvement of health authorities in supporting occupational safety was an important element for sustainability. Conclusions This report focuses on explaining the elements of our intervention rather than its outcomes. Lessons learned from the intervention implementation will enrich the development of future programs that integrate this or other intervention models into routine medical practice, with the aim of reducing HIV-related stigma and improving HIV testing, treatment and care in medical settings., Introduction Stigma associated with HIV has been documented as a barrier for accessing quality health-related services. When the stigma manifests in the healthcare setting, people living with HIV receive substandard services or even be denied care altogether. Although the consequences of HIV stigma have been documented extensively, efforts to reduce these negative attitudes have been scarce. Interventions to reduce HIV stigma should be implemented as part of the formal training of future healthcare professionals. The interventions that have been tested with healthcare professionals and published have several limitations that must be surpassed (i.e., lack of comparison groups in research designs and longitudinal follow-up data). Furthermore, Latino healthcare professionals have been absent from these intervention efforts even though the epidemic has affected this population disproportionately. Methods In this article, we describe an intervention developed to reduce HIV stigma among medical students in Puerto Rico. A total of 507 medical students were randomly introduced into our intervention and control conditions. Results The results show statistically significant differences between the intervention and control groups; intervention group participants had lower HIV stigma levels than control participants after the intervention. In addition, differences in HIV stigma levels between the groups were sustained for a 12-month period. Conclusions The results of our study demonstrate the efficacy of the modes of intervention developed by us and serve as a new training tool for future healthcare professionals with regard to stigma reduction., Introduction Within healthcare settings, HIV-related stigma is a recognized barrier to access of HIV prevention and treatment services and yet, few efforts have been made to scale-up stigma reduction programs in service delivery. This is in part due to the lack of a brief, simple, standardized tool for measuring stigma among all levels of health facility staff that works across diverse HIV prevalence, language and healthcare settings. In response, an international consortium led by the Health Policy Project, has developed and field tested a stigma measurement tool for use with health facility staff. Methods Experts participated in a content-development workshop to review an item pool of existing measures, identify gaps and prioritize questions. The resulting questionnaire was field tested in six diverse sites (China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis). Respondents included clinical and non-clinical staff. Questionnaires were self- or interviewer-administered. Analysis of item performance across sites examined both psychometric properties and contextual issues. Results The key outcome of the process was a substantially reduced questionnaire. Eighteen core questions measure three programmatically actionable drivers of stigma within health facilities (worry about HIV transmission, attitudes towards people living with HIV (PLHIV), and health facility environment, including policies), and enacted stigma. The questionnaire also includes one short scale for attitudes towards PLHIV (5-item scale, α = 0.78). Conclusions Stigma-reduction programmes in healthcare facilities are urgently needed to improve the quality of care provided, uphold the human right to healthcare, increase access to health services, and maximize investments in HIV prevention and treatment. This brief, standardized tool will facilitate inclusion of stigma measurement in research studies and in routine facility data collection, allowing for the monitoring of stigma within healthcare facilities and evaluation of stigma-reduction programmes. There is potential for wide use of the tool either as a stand-alone survey or integrated within other studies of health facility staff., Introduction In Kenya, human rights violations have a marked impact on the health of people living with HIV. Integrating legal literacy and legal services into healthcare appears to be an effective strategy to empower vulnerable groups and address underlying determinants of health. Methods We carried out an evaluation to collect evidence about the impact of legal empowerment programmes on health and human rights. The evaluation focused on Open Society Foundation-supported legal integration activities at four sites: the Academic Model of Providing Access to Healthcare (AMPATH) facility, where the Legal Aid Centre of Eldoret (LACE) operates, in Eldoret; Kenyatta National Hospital's Gender-based Violence Recovery Centre, which hosts the COVAW legal integration program; and Christian Health Association of Kenya (CHAK) facilities in Mombasa and Naivasha. In consultation with the organizations implementing the programs, we designed a conceptual logic model grounded in human rights principles, identified relevant indicators and then coded structure, process and outcome indicators for the rights-related principles they reflect. The evaluation included a resource assessment questionnaire, a review of program records and routine data, and semi-structured interviews and focus group discussions with clients and service providers. Data were collected in May–August 2010 and April–June 2011. Results Clients showed a notable increase in practical knowledge and awareness about how to access legal aid and claim their rights, as well as an enhanced ability to communicate with healthcare providers and to improve their access to healthcare and justice. In turn, providers became more adept at identifying human rights violations and other legal difficulties, which enabled them to give clients basic information about their rights, refer them to legal aid and assist them in accessing needed support. Methodological challenges in evaluating such activities point to the need to strengthen rights-oriented evaluation methods. Conclusions Legal empowerment programmes have the potential to promote accountability, reduce stigma and discrimination and contribute to altering unjust structures and systems. Given their apparent value as a health and human rights intervention, particularly for marginalized populations, further rigorous evaluations are called for to support the scale-up of such programmes., Introduction HIV stigma inflicts hardship and suffering on people living with HIV (PLHIV) and interferes with both prevention and treatment efforts. Health professionals are often named by PLHIV as an important source of stigma. This study was designed to examine rates and drivers of stigma and discrimination among doctors, nurses and ward staff in different urban healthcare settings in high HIV prevalence states in India. Methods This cross-sectional study enrolled 305 doctors, 369 nurses and 346 ward staff in both governmental and non-governmental healthcare settings in Mumbai and Bengaluru, India. The approximately one-hour long interviews focused on knowledge related to HIV transmission, personal and professional experiences with PLHIV, instrumental and symbolic stigma, endorsement of coercive policies, and intent to discriminate in professional and personal situations that involve high and low risk of fluid exposure. Results High levels of stigma were reported by all groups. This included a willingness to prohibit female PLHIV from having children (55 to 80%), endorsement of mandatory testing for female sex workers (94 to 97%) and surgery patients (90 to 99%), and stating that people who acquired HIV through sex or drugs “got what they deserved” (50 to 83%). In addition, 89% of doctors, 88% of nurses and 73% of ward staff stated that they would discriminate against PLHIV in professional situations that involved high likelihood of fluid exposure, and 57% doctors, 40% nurses and 71% ward staff stated that they would do so in low-risk situations as well. Significant and modifiable drivers of stigma and discrimination included having less frequent contact with PLHIV, and a greater number of transmission misconceptions, blame, instrumental and symbolic stigma. Participants in all three groups reported high rates of endorsement of coercive measures and intent to discriminate against PLHIV. Stigma and discrimination were associated with multiple modifiable drivers, which are consistent with previous research, and which need to be targeted in future interventions. Conclusions Stigma reduction intervention programmes targeting healthcare providers in urban India need to address fear of transmission, improve universal precaution skills, and involve PLHIV at all stages of the intervention to reduce symbolic stigma and ensure that relevant patient interaction skills are taught., Introduction The African American church is a highly influential institution with the potential to greatly increase the reach of HIV prevention interventions and address HIV-related stigma in US African American communities. However, there are few studies on HIV-related stigma and African American church populations. This study explored HIV-related stigma among church and community members participating in an HIV education and testing intervention pilot study in African American churches, named Taking It to the Pews. Methods Four African American churches located in Kansas City, MO and KS, were randomized to either intervention or comparison groups. Churches assigned to the intervention group received religiously tailored HIV education, testing and compassion messages/activities (e.g., sermons, brochures/church bulletins, testimonials) via the Taking It to the Pews HIV Tool Kit. Comparison churches received non-religiously tailored HIV information. HIV-related stigma was assessed with 543 church members and with community members served through church outreach services (e.g., food/clothing pantries, social services) in the four churches. Participants completed surveys at baseline, 6 months and 12 months to assess their HIV-related stigma beliefs, exposure to intervention components and satisfaction with the study. Results At baseline, HIV-related stigma beliefs were similar across experimental groups and were quite low. Mean HIV-related stigma scores were not significantly different between experimental groups at 6 months (p=0.92) or at 12 months (p=0.70). However, mean HIV-related stigma scores within both groups showed decreasing trends at six months, which approached significance. Analysis of previously studied HIV-related stigma factors (e.g., age, gender, income, HIV knowledge, religiosity) did not yield changes in the null findings. Intervention group participants were highly exposed to several intervention components (sermons, HIV resource tables, posters, brochures/church bulletins). Overall, participants were highly satisfied with the intervention pilot study. Conclusions African American churches may be well positioned to increase the reach of HIV prevention interventions to church and community members and could serve an important role in addressing HIV-related stigma in their church communities. Future research is needed on measuring HIV-related stigma beliefs and on testing intensive, scalable, religiously tailored HIV interventions to impact HIV-related stigma in African American churches., Introduction Men who have sex with men (MSM) often face socially sanctioned disapproval of sexual deviance from the heterosexual “normal.” Such sexual stigma can be internalized producing a painful affective state (i.e., shame). Although shame (e.g., addiction) can predict risk-taking (e.g., alcohol abuse), sexual shame's link to sexual risk-taking is unclear. Socially Optimized Learning in Virtual Environments (SOLVE) was designed to reduce MSM's sexual shame, but whether it does so, and if that reduction predicts HIV risk reduction, is unclear. To test if at baseline, MSM's reported past unprotected anal intercourse (UAI) is related to shame; MSM's exposure to SOLVE compared to a wait-list control (WLC) condition reduces MSM's shame; and shame-reduction mediates the link between WLC condition and UAI risk reduction. Methods HIV-negative, self-identified African American, Latino or White MSM, aged 18–24 years, who had had UAI with a non-primary/casual partner in the past three months were recruited for a national online study. Eligible MSM were computer randomized to either WLC or a web-delivered SOLVE. Retained MSM completed baseline measures (e.g., UAI in the past three months; current level of shame) and, in the SOLVE group, viewed at least one level of the game. At the end of the first session, shame was measured again. MSM completed follow-up UAI measures three months later. All data from 921 retained MSM (WLC condition, 484; SOLVE condition, 437) were analyzed, with missing data multiply imputed. Results At baseline, MSM reporting more risky sexual behaviour reported more shame (r s=0.21; p, Introduction Same-sex practices and orientation are both stigmatized and criminalized in many countries across sub-Saharan Africa. This study aimed to assess the relationship of fear of seeking healthcare and disclosure of same-sex practices among a sample of men who have sex with men (MSM) in Swaziland with demographic, socio-economic and behavioural determinants. Methods Three hundred and twenty-three men who reported having had anal sex with a man in the past year were recruited using respondent-driven sampling and administered a structured survey instrument. Asymptotically unbiased estimates of prevalence of stigma and human rights abuses generated using the RDSII estimator are reported with bootstrapped confidence intervals (CIs). Weighted simple and multiple logistic regressions of fear of seeking healthcare and disclosure of same-sex practices to a healthcare provider with demographic, social and behavioural variables are reported. Results Stigma was common, including 61.7% (95% CI=54.0–69.0%) reporting fear of seeking healthcare, 44.1% (95% CI=36.2–51.3%) any enacted stigma and 73.9% (95% CI=67.7–80.1%) any perceived social stigma (family, friends). Ever disclosing sexual practices with other men to healthcare providers was low (25.6%, 95% CI=19.2–32.1%). In multiple logistic regression, fear of seeking healthcare was significantly associated with: having experienced legal discrimination as a result of sexual orientation or practice (aOR=1.9, 95% CI=1.1–3.4), having felt like you wanted to end your life (aOR=2.0, 95% CI=1.2–3.4), having been raped (aOR=11.0, 95% CI=1.4–84.4), finding it very difficult to insist on condom use when a male partner does not want to use a condom (aOR=2.1, 95% CI=1.0–4.1) and having a non-Swazi nationality at birth (aOR=0.18, 95% CI=0.05–0.68). In multiple logistic regression, disclosure of same-sex practices to a healthcare provider was significantly associated with: having completed secondary education or more (aOR=5.1, 95% CI=2.5–10.3), having used a condom with last casual male sexual partner (aOR=2.4, 95% CI=1.0–5.7) and having felt like you wanted to end your life (aOR=2.1, 95% CI=1.2–3.8). Conclusions MSM in Swaziland report high levels of stigma and discrimination. The observed associations can inform structural interventions to increase healthcare seeking and disclosure of sexual practices to healthcare workers, facilitating enhanced behavioural and biomedical HIV-prevention approaches among MSM in Swaziland., Introduction HIV infection may be affected by multiple complex socioeconomic status (SES) factors, especially individual socioeconomic disadvantage and community-level inequality. At the same time, stigma towards HIV and marginalized groups has exacerbated persistent concentrated epidemics among key populations, such as persons who inject drugs (PWID) in Vietnam. Stigma researchers argue that stigma fundamentally depends on the existence of economic power differences in a community. In rapidly growing economies like Vietnam, the increasing gap in income and education levels, as well as an individual's absolute income and education, may create social conditions that facilitate stigma related to injecting drug use and HIV. Methods A cross-sectional baseline survey assessing different types of stigma and key socioeconomic characteristics was administered to 1674 PWID and 1349 community members living in physical proximity throughout the 32 communes in Thai Nguyen province, Vietnam. We created four stigma scales, including HIV-related and drug-related stigma reported by both PWID and community members. We then used ecologic Spearman's correlation, ordinary least-squares regression and multi-level generalized estimating equations to examine community-level inequality associations, individual-level SES associations and multi-level SES associations with different types of stigma, respectively. Results There was little urban–rural difference in stigma among communes. Higher income inequality was marginally associated with drug-related stigma reported by community members (p=0.087), and higher education inequality was significantly associated with higher HIV-related stigma reported by both PWID and community members (p

BACKGROUND: The vascular and gastrointestinal effects of non-steroidal anti-inflammatory drugs (NSAIDs), including selective COX-2 inhibitors (coxibs) and traditional non-steroidal anti-inflammatory drugs (tNSAIDs), are not well characterised, particularly in patients at increased risk of vascular disease. We aimed to provide such information through meta-analyses of randomised trials. METHODS: We undertook meta-analyses of 280 trials of NSAIDs versus placebo (124,513 participants, 68,342 person-years) and 474 trials of one NSAID versus another NSAID (229,296 participants, 165,456 person-years). The main outcomes were major vascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death); major coronary events (non-fatal myocardial infarction or coronary death); stroke; mortality; heart failure; and upper gastrointestinal complications (perforation, obstruction, or bleed). FINDINGS: Major vascular events were increased by about a third by a coxib (rate ratio [RR] 1·37, 95% CI 1·14-1·66; p=0·0009) or diclofenac (1·41, 1·12-1·78; p=0·0036), chiefly due to an increase in major coronary events (coxibs 1·76, 1·31-2·37; p=0·0001; diclofenac 1·70, 1·19-2·41; p=0·0032). Ibuprofen also significantly increased major coronary events (2·22, 1·10-4·48; p=0·0253), but not major vascular events (1·44, 0·89-2·33). Compared with placebo, of 1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not significantly increase major vascular events (0·93, 0·69-1·27). Vascular death was increased significantly by coxibs (1·58, 99% CI 1·00-2·49; p=0·0103) and diclofenac (1·65, 0·95-2·85, p=0·0187), non-significantly by ibuprofen (1·90, 0·56-6·41; p=0·17), but not by naproxen (1·08, 0·48-2·47, p=0·80). The proportional effects on major vascular events were independent of baseline characteristics, including vascular risk. Heart failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs 1·81, 1·17-2·81, p=0·0070; diclofenac 1·89, 1·16-3·09, p=0·0106; ibuprofen 3·97, 2·22-7·10, p

The purpose of the study was to describe the ability of an evidence-based discharge planning (DP) decision support tool to identify and prioritise patients appropriate for early DP intervention. Specifically, we aimed to determine whether patients with a high Early Screen for Discharge Planning (ESDP) score report more problems and continuing care needs in the first few weeks after discharge than patients with low ESDP scores.Improved methods are needed to efficiently and accurately identify hospitalised patients at risk of complex discharge plans.A descriptive cross-sectional study was designed using a quality health outcomes framework.The ESDP was administered to 260 adults hospitalised in an academic health centre who returned home after discharge. Problems and continuing care needs were self-reported on the Problems After Discharge Questionnaire - English Version, mailed 6-10 days after discharge.Patients with high ESDP scores reported significantly more problems [mean, 16·3 (standard deviation ±8·7)] than those with low scores [12·2 (±8·4)]. Within the Problems After Discharge Questionnaire subscales, patients with high ESDP scores reported significantly more problems with personal care, household activities, mobility and physical difficulties than patients with low screen scores. Significantly more of the patients with a high ESDP score received consults to a Discharge Planner and referrals for postacute services than patients with low screen scores.The ESDP is effective as a decision support tool in identifying patients to prioritise for early DP intervention.Use of an evidence-based DP decision support tool minimises biases inherent in decision-making, promotes efficient use of hospital DP resources, and improves the opportunity for patients to access community resources they need to promote successful recovery after hospitalisation.

Improving transitions in care is an international priority. In acute care, this complex process starts upon admission and requires multiple interventions to appropriately transition patients from one setting to the next. Within this multi-step process are two important decision points that warrant standardization and support. Our research teams have developed decision support tools that meet this critical need. The Early Screen for Discharge Planning (ESDP) and the Discharge Decision Support System (D(2)S(2)) bring evidence based, interdisciplinary decision support to two common and important decisions. The purpose of this paper is to share information about "real life" experiences in implementing decision support covering the development and use of the tools, advising about implementation considerations, making suggestions for automating the process, and sharing findings from our recent implementation study.

We describe charge-coupled device (CCD) development activities at the Lawrence Berkeley National Laboratory (LBNL). Back-illuminated CCDs fabricated on 200-300 mu m thick, fully depleted, high-resistivity silicon substrates are produced in partnership with a commercial CCD foundry.The CCDs are fully depleted by the application of a substrate bias voltage. Spatial resolution considerations require operation of thick, fully depleted CCDs at high substrate bias voltages. We have developed CCDs that are compatible with substrate bias voltages of at least 200V. This improves spatial resolution for a given thickness, and allows for full depletion of thicker CCDs than previously considered. We have demonstrated full depletion of 650-675 mu m thick CCDs, with potential applications in direct x-ray detection. In this work we discuss the issues related to high-voltage operation of fully depleted CCDs, as well as experimental results on high-voltage-compatible CCDs.

We have developed fully depleted, back-illuminated CCDs that build upon earlier research and development efforts directed towards technology development of silicon-strip detectors used in high-energy-physics experiments. The CCDs are fabricated on the same type of high-resistivity, float-zone-refined silicon that is used for strip detectors. The use of high-resistivity substrates allows for thick depletion regions, on the order of 200-300 um, with corresponding high detection efficiency for near-infrared andsoft x-ray photons. We compare the fully depleted CCD to thep-i-n diode upon which it is based, and describe the use of fully depleted CCDs in astronomical and x-ray imaging applications.