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The objective of this paper was to document contraceptive dynamics and associated correlates of contraceptive method switching and discontinuation in Myanmar during the COVID-19 pandemic. We conducted a secondary analysis of panel data collected between August 2020 and March 2021 among married women of reproductive age of households registered for a strategic purchasing project in Yangon. Statistical analysis included descriptive statistics, bivariate tests of association and adjusted log-Poisson models with generalised estimating equations to examine relative risks and 95% confidence intervals. Among the study sample, 28% of women reported method switching and 20% method discontinuation at least once during the study period. Difficulties accessing resupply/removal/insertion of contraception due to COVID-19 and method type at baseline were identified as correlates of method switching and discontinuation. Women who reported difficulty obtaining their method due to COVID-19 had an increased risk of method switching (RR adj : 1.85, 95%CI: 1.27, 2.71). Women who reported injectables as their initial contraceptive method at baseline had an increased risk of method switching (RR adj :1.71, 95%CI: 1.06, 2.76) and method discontinuation (RR adj : 2.16, 95%CI: 1.16, 4.02) compared to non-injectable users. As Myanmar evaluates its public health response to COVID-19, the country should consider innovative service delivery models that allow women to have sustained access to their method of choice during a health emergency. (211).

Background: Identifying risk factors for metachronous colorectal cancer (CRC) and metachronous advanced neoplasia could be useful for guiding surveillance. We conducted a systematic review and meta-analysis to investigate risk factors for metachronous CRC and advanced neoplasia., Methods: Searches were conducted in MEDLINE, Embase, Web of Science and Cochrane Central Registry of Controlled Trials for articles (searching period: 1945 to Feburary, 2021) that reported the results of an association between any factor and metachronous advanced neoplasia or metachronous CRC. There were no restrictions on the publication date or language. Random effects models were fitted to estimate the combined association between the risk factors and metachronous CRC or advanced neoplasia. The Risk of Bias In Non-Randomised Studies of Interventions tool (ROBINS-I) was used to assess the risk of bias of included studies., Results: In total, 22 observational studies with 625,208 participants were included in the systematic review and meta-analysis. Of these, 13 studies investigated risk factors for metachronous CRC and 9 for advanced neoplasia. The risks of metachronous CRC or advanced neoplasia were higher if the first CRC was diagnosed in the presence of a synchronous advanced lesion (pooled risk ratio (RR) from 3 studies: 3.61, 95% confidence interval (CI): 1.44-9.05; and pooled RR from 8 studies: 2.77, 95% CI: 2.23-3.43, respectively). The risk of metachronous CRC was lower, but the risk of metachronous advanced neoplasia was higher if the first CRC was distal (compared with proximal) (pooled RR from 3 studies: 0.48, 95% CI: 0.23-0.98; and pooled RR from 2 studies: 2.99, 95% CI: 1.60-5.58 respectively). The risk of metachronous advanced neoplasia increased with age (pooled RR from 3 studies: 1.07 per year of age, 95% CI: 1.03-1.11). There was no evidence that any lifestyle risk factors studied were associated with the risk of metachronous CRC or advanced neoplasia., Conclusions: The identified risk factors for metachronous CRC and advanced neoplasia might be useful to tailor the existing surveillance guidelines after the first CRC. There were potential limitations due to possible misclassification of the outcome, confounding and risk of bias, and the findings cannot be generalised to high-risk genetic syndrome cases., (© 2023. The Author(s).)

Background: Migrant populations are at an increased risk of exposure to malaria due to their nature of work and seasonal migration. This study aimed to compare malaria prevention behaviours and care-seeking practices among worksite migrant workers and villagers in the malaria-at-risk areas of Eastern Myanmar close to the China border., Methods: A mixed method study was conducted in March 2019. The malaria-at-risk worksites in the four targeted townships, and villages located the nearest to these worksites were approached. Key stakeholders, such as worksite managers and village leaders, were interviewed., Results: A total of 23 worksites, which employed 880 migrants and 447 locals, and 20 villages, which were homes for 621 migrants and 9731 locals, were successfully interviewed. Regarding malaria prevention behaviours, sleeping under a bed net was common among both worksites (74%) and villages (85%). In contrast, insecticide-treated nets/long-lasting insecticidal nets (ITN/LLIN) usage was much lower in the worksites than in the villages (39% vs 80%). Regarding care-seeking practices for febrile illness, self-medication was a popular choice for both worksite workers and villagers owing to the easy availability of western medicine. Moreover, local-belief-driven traditional practices were more common among villagers. For occasions in which fever was not relieved, both would seek health care from rural health centres, private clinics, or public hospitals. As for barriers, villagers mostly cited language barriers, which often lead to misunderstanding between health providers and them. In contrast, most of the worksites cited logistics issues as they were in remote areas with devastated road conditions and the routes to formal health facilities were not secure due to frequent armed conflicts., Conclusion: This study demonstrated that site-workers and villagers had different malaria prevention behaviours and care-seeking practices even though they resided in the same geographic area. Hence, it is important to recognize such differences for more effective intervention approaches., (© 2022. The Author(s).)

In Myanmar, transgender women (TGW) have historically been grouped into the men who have sex with men (MSM) population in program and surveillance data. There is no direct translation for the term transgender in Myanmar language, and there are no data on HIV prevalence or HIV-related risk behaviors among TGW. Therefore, this study aimed to explore how TGW identify and express themselves in Myanmar and their HIV-related risk behaviors. This qualitative study consisted of 11 key informant interviews with service providers and 20 in-depth interviews with TGW participants in Yangon in 2017. All participants said that TGW in Myanmar were assigned male at birth, but none identified as men; they all self-identified as women or another gender, such as trans. Such identity emerged from an internal sense of being a woman or an alternative gender. In addition, many participants reported that TGW changed their appearance through changes in clothing or mannerisms. TGW are particularly vulnerable to violence: Often reported during transition, transgender women were exposed to transphobia, violence and discrimination from their family, relatives or workplace. Many participants reported TGW being the receptive partner during sex and engaged in high-risk sexual behaviors, such as sex with multiple partners, group sex, and condomless sex. Our findings can help to define this population in the Myanmar context and assess needs for health services., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The role of community drug shops in providing primary care has been recognized as important in Myanmar as in other countries. The contribution by private community drug shops to National Tuberculosis case notifications and National Malaria testing and positive cases is significant. Population Services International Myanmar (PSI/Myanmar) has been successfully training and engaging community drug shops to screen presumptive Tuberculosis to make referrals to public health clinics and perform malaria rapid diagnostic tests (mRDT) to malaria fever cases and provide management accordingly., Objectives: The study aims to identify barriers to service provision of the trained providers at the drug shops that are currently engaged in PSI/Myanmar Tuberculosis and malaria programs. Exploring their needs enabled us to identify and address barriers, to provide evidence for better linkage with the primary care system., Method: A mixed method study was conducted with the service providers at the drug shops. A quantitative follow up survey was done with 177 trained Tuberculosis service providers and 65 trained malaria service providers. A total of 32 qualitative in-depth interviews were completed. Seventeen Tuberculosis trained providers and 15 malaria trained providers participated in individual interviews. Content analysis approach was used to generate themes for the data analysis., Results: From the survey, the majority of drug shops reported that they performed appropriate first steps, particularly referring symptomatic Tuberculosis cases and offering mRDT testing to fever cases. Nevertheless, in-depth interviews with them revealed they did not adhere to the national guidelines for every client. There was a need to emphasize the importance of following the national guidelines for referring patients with prolonged cough and fever cases management. For those who were trained in Tuberculosis case referral, support from program staff was needed to make smooth referrals. Those who were trained in malaria often considered differential diagnosis of fever other than malaria and did not test with malaria rapid diagnostic test due to declining numbers of malaria cases., Conclusion: The study findings highlighted that the drug shops trained in Tuberculosis referral seemed to have the potential to fully engage into the primary care health system if provided with suitable support and supervision. On the other hand, those trained in malaria case management might be less motivated to engage in the era of declining malaria endemicity., (© 2021. The Author(s).)

Since 2017, Population Services International Myanmar (PSI/Myanmar) has been running Strategic Purchasing (SP) clinics in Hlegu and Shwepyithar townships in Yangon, Myanmar. In the project, Population Services International Myanmar simulated the role of a purchaser and contracted SP clinics through a capitation payment scheme. The project aimed to reduce the health-related financial burden of poor populations in the catchment area, by having them registered under respective SP clinics for access to a package of essential health services for a minimal fixed co-payment, as a replacement for usual fee-for-service payments. Four longitudinal surveys of households registered under SP clinics were conducted in 2017, 2018 and 2019. Among 2506 registered households, 867 households sought some health care in all surveys, resulting in 3468 observations. Multivariable linear mixed-effect regression model was used to analyse the changes in out-of-pocket expenditure for health care in relation to household capacity to pay (OOPCTP). The utilization of SP clinics increased over time, and the rates were much higher in Hlegu (20.5% in baseline to 61.9% in round three) compared with those in Shwepyithar (0.2 to 7.9%). Compared with the baseline assessment, household OOPCTP decreased significantly during and after the implementation (0.76 times in round one, 0.80 in round two and 0.82 in round three; P < 0.001). Households in Shwepyithar with less utilization of SP clinics had 1.8 times higher OOPCTP compared with those in Hlegu (1.82, 95% CI 1.58, 2.09; P < 0.001). Household direct expenditures on care-seeking and family planning were up to 50% lower among those who used SP clinics. Our study highlighted that capitation-based health financing schemes could successfully lower out-of-pocket health expenditures among the poor. Optimal utilization of services was paramount in the successful implementation of such programmes. Therefore, for the effective scale-up of new health financing schemes, service utilization rates should be carefully monitored as one of the critical indicators., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Mammograms contain information that predicts breast cancer risk. We developed two novel mammogram-based breast cancer risk measures based on image brightness (Cirrocumulus) and texture (Cirrus). Their risk prediction when fitted together, and with an established measure of conventional mammographic density (Cumulus), is not known. We used three studies consisting of: 168 interval cases and 498 matched controls; 422 screen-detected cases and 1197 matched controls; and 354 younger-diagnosis cases and 944 controls frequency-matched for age at mammogram. We conducted conditional and unconditional logistic regression analyses of individually- and frequency-matched studies, respectively. We estimated measure-specific risk gradients as the change in odds per standard deviation of controls after adjusting for age and body mass index (OPERA) and calculated the area under the receiver operating characteristic curve (AUC). For interval, screen-detected and younger-diagnosis cancer risks, the best fitting models (OPERAs [95% confidence intervals]) involved: Cumulus (1.81 [1.41-2.31]) and Cirrus (1.72 [1.38-2.14]); Cirrus (1.49 [1.32-1.67]) and Cirrocumulus (1.16 [1.03 to 1.31]); and Cirrus (1.70 [1.48 to 1.94]) and Cirrocumulus (1.46 [1.27-1.68]), respectively. The AUCs were: 0.73 [0.68-0.77], 0.63 [0.60-0.66], and 0.72 [0.69-0.75], respectively. Combined, our new mammogram-based measures have twice the risk gradient for screen-detected and younger-diagnosis breast cancer (P ≤ 10 -12 ), have at least the same discriminatory power as the current polygenic risk score, and are more correlated with causal factors than conventional mammographic density. Discovering more information about breast cancer risk from mammograms could help enable risk-based personalised breast screening., (© 2020 UICC.)

Interval breast cancers (those diagnosed between recommended mammography screens) generally have poorer outcomes and are more common among women with dense breasts. We aimed to develop a risk model for interval breast cancer. We conducted a nested case-control study within the Melbourne Collaborative Cohort Study involving 168 interval breast cancer patients and 498 matched control subjects. We measured breast density using the CUMULUS software. We recorded first-degree family history by questionnaire, measured body mass index (BMI) and calculated age-adjusted breast tissue aging, a novel measure of exposure to estrogen and progesterone based on the Pike model. We fitted conditional logistic regression to estimate odds ratio (OR) or odds ratio per adjusted standard deviation (OPERA) and calculated the area under the receiver operating characteristic curve (AUC). The stronger risk associations were for unadjusted percent breast density (OPERA = 1.99; AUC = 0.66), more so after adjusting for age and BMI (OPERA = 2.26; AUC = 0.70), and for family history (OR = 2.70; AUC = 0.56). When the latter two factors and their multiplicative interactions with age-adjusted breast tissue aging (p = 0.01 and 0.02, respectively) were fitted, the AUC was 0.73 (95% CI 0.69-0.77), equivalent to a ninefold interquartile risk ratio. In summary, compared with using dense breasts alone, risk discrimination for interval breast cancers could be doubled by instead using breast density, BMI, family history and hormonal exposure. This would also give women with dense breasts, and their physicians, more information about the major consequence of having dense breasts-an increased risk of developing an interval breast cancer., (© 2019 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Introduction: For women of the same age and body mass index, increased mammographic density is one of the strongest predictors of breast cancer risk. There are multiple methods of measuring mammographic density and other features in a mammogram that could potentially be used in a screening setting to identify and target women at high risk of developing breast cancer. However, it is unclear which measurement method provides the strongest predictor of breast cancer risk., Methods and Analysis: The measurement challenge has been established as an international resource to offer a common set of anonymised mammogram images for measurement and analysis. To date, full field digital mammogram images and core data from 1650 cases and 1929 controls from five countries have been collated. The measurement challenge is an ongoing collaboration and we are continuing to expand the resource to include additional image sets across different populations (from contributors) and to compare additional measurement methods (by challengers). The intended use of the measurement challenge resource is for refinement and validation of new and existing mammographic measurement methods. The measurement challenge resource provides a standardised dataset of mammographic images and core data that enables investigators to directly compare methods of measuring mammographic density or other mammographic features in case/control sets of both raw and processed images, for the purposes of the comparing their predictions of breast cancer risk., Ethics and Dissemination: Challengers and contributors are required to enter a Research Collaboration Agreement with the University of Melbourne prior to participation in the measurement challenge. The Challenge database of collated data and images are stored in a secure data repository at the University of Melbourne. Ethics approval for the measurement challenge is held at University of Melbourne (HREC ID 0931343.3)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Population Services International (PSI) Myanmar's social franchise network of general practitioners, known as Sun Quality Health Clinics (SQHC), provided tuberculosis (TB) diagnosis and treatment with Direct Observed Treatment Short course (DOTs) across Myanmar since 2004, with a total of 898 clinics across the country. People who sought TB treatment from these SQHC by themselves were regarded as walk-in patients. To augment TB case notification, PSI Myanmar developed two treatment seeking channels: Community Health Services Providers (CHSP) and Interpersonal Communicators (IPC). They actively sought people who were suspected to have TB and referred them to SQH clinics. In this study, we compared the loss to follow-up rates of TB patients across three treatment seeking channels; and investigated risk-factors for loss to follow-up., Methods and Findings: A retrospective cohort design was applied using TB client records between 2012 and 2016. Outcome was defined as loss to follow-up in comparison to successful TB treatment (completed or cured). Multivariate Poisson regression was conducted to estimate incidence rate ratio of loss to follow-up. Of the 62,664 TB patients registered at the SQHC, around 10% each were actively screened by the CHSP and the IPC, and 78.9% were walk-in patients. Overall cumulative incidence for loss to follow-up rate was significantly higher in the IPC channel (14.2%, 95% CI 13.4-15.1%) than walk-in patients (8.9%, 95% CI 8.6-9.1%) and the CHSP channel (5.5%, 95% CI 5.0-6.1%) (p<0.001). The median time after which patients were lost to follow-up from treatment was 4.04 months. We found that patients with older age, male sex, patients residing in hilly region, unknown smear status, retreated cases, HIV co-infection, and unknown HIV status were risk-factors for loss to follow-up in the continuation phase of treatment; whereas patients with higher initial body weight, patients who received travel support and patients taking treatment in older providers were less likely to be lost to follow-up., Conclusions: Based on these findings, we recommend that implementation strategies for improving case notification and treatment seeking should carefully consider retention strategies in parallel, and the identified influencing factors for loss to follow-up should be taken account for such consideration., Competing Interests: The authors have declared that no competing interests exist.

Background: Case-control studies show that mammographic density is a better risk factor when defined at higher than conventional pixel-brightness thresholds. We asked if this applied to interval and/or screen-detected cancers., Method: We conducted a nested case-control study within the prospective Melbourne Collaborative Cohort Study including 168 women with interval and 422 with screen-detected breast cancers, and 498 and 1197 matched controls, respectively. We measured absolute and percent mammographic density using the Cumulus software at the conventional threshold (Cumulus) and two increasingly higher thresholds (Altocumulus and Cirrocumulus, respectively). Measures were transformed and adjusted for age and body mass index (BMI). Using conditional logistic regression and adjusting for BMI by age at mammogram, we estimated risk discrimination by the odds ratio per adjusted standard deviation (OPERA), calculated the area under the receiver operating characteristic curve (AUC) and compared nested models using the likelihood ratio criterion and models with the same number of parameters using the difference in Bayesian information criterion (ΔBIC)., Results: For interval cancer, there was very strong evidence that the association was best predicted by Cumulus as a percentage (OPERA = 2.33 (95% confidence interval (CI) 1.85-2.92); all ΔBIC > 14), and the association with BMI was independent of age at mammogram. After adjusting for percent Cumulus, no other measure was associated with risk (all P > 0.1). For screen-detected cancer, however, the associations were strongest for the absolute and percent Cirrocumulus measures (all ΔBIC > 6), and after adjusting for Cirrocumulus, no other measure was associated with risk (all P > 0.07)., Conclusion: The amount of brighter areas is the best mammogram-based measure of screen-detected breast cancer risk, while the percentage of the breast covered by white or bright areas is the best mammogram-based measure of interval breast cancer risk, irrespective of BMI. Therefore, there are different features of mammographic images that give clinically important information about different outcomes.

Purpose To compare three mammographic density measures defined by different pixel intensity thresholds as predictors of breast cancer risk for two different digital mammographic systems. Materials and Methods The Korean Breast Cancer Study included 398 women with invasive breast cancer and 737 control participants matched for age at mammography (±1 year), examination date, mammographic system, and menopausal status. Mammographic density was measured by using the automated Laboratory for Individualized Breast Radiodensity Assessment (LIBRA) software and the semiautomated Cumulus software at the conventional threshold (Cumulus) and at increasingly higher thresholds (Altocumulus and Cirrocumulus, respectively). Measures were Box-Cox-transformed and adjusted for age, body mass index, and menopausal status. Conditional logistic regression was used to estimate risk associations. For calculation of measures of predictive value, the change in odds per standard deviation (OPERA) and the area under the receiver operating characteristic curve (AUC) were used. Results For dense area, with use of the direct conversion system the OPERAs were 1.72 (95% confidence interval [CI]: 1.38, 2.15) for LIBRA, 1.58 (95% CI: 1.27, 1.97) for Cumulus, 2.04 (95% CI: 1.60, 2.59) for Altocumulus, and 3.48 (95% CI: 2.45, 4.47) for Cirrocumulus (P < .001). The corresponding AUCs were 0.70, 0.69, 0.76, and 0.89, respectively. With use of the indirect conversion system, the corresponding OPERAs were 1.50 (95% CI: 1.28, 1.76), 1.36 (95% CI: 1.16, 1.59), 1.40 (95% CI: 1.19, 1.64), and 1.47 (95% CI: 1.25, 1.73) (P < .001) and the AUCs were 0.64, 0.60, 0.61, and 0.63, respectively. Conclusion It is possible that mammographic density defined by higher pixel thresholds could capture more risk-predicting information with use of a direct conversion mammographic system; the mammographically bright, rather than white, regions are etiologically important. © RSNA, 2017.

Background: Mammographic density defined by the conventional pixel brightness threshold, and adjusted for age and body mass index (BMI), is a well-established risk factor for breast cancer. We asked if higher thresholds better separate women with and without breast cancer., Methods: We studied Australian women, 354 with breast cancer over-sampled for early-onset and family history, and 944 unaffected controls frequency-matched for age at mammogram. We measured mammographic dense area and percent density using the CUMULUS software at the conventional threshold, which we call Cumulus , and at two increasingly higher thresholds, which we call Altocumulus and Cirrocumulus , respectively. All measures were Box-Cox transformed and adjusted for age and BMI. We estimated the odds per adjusted standard deviation (OPERA) using logistic regression and the area under the receiver operating characteristic curve (AUC)., Results: Altocumulus and Cirrocumulus were correlated with Cumulus (r ∼ 0.8 and 0.6 , respectively) . For dense area, the OPERA was 1.62, 1.74 and 1.73 for Cumulus, Altocumulus and Cirrocumulus , respectively (all P  < 0.001). After adjusting for Altocumulus and Cirrocumulus , Cumulus was not significant ( P  > 0.6). The OPERAs for percent density were less but gave similar findings. The mean of the standardized adjusted Altocumulus and Cirrocumulus dense area measures was the best predictor; OPERA = 1.87 [95% confidence interval (CI): 1.64-2.14] and AUC = 0.68 (0.65-0.71)., Conclusions: The areas of higher mammographically dense regions are associated with almost 30% stronger breast cancer risk gradient, explain the risk association of the conventional measure and might be more aetiologically important. This has substantial implications for clinical translation and molecular, genetic and epidemiological research., (© The Author 2016. Published by Oxford University Press on behalf of the International Epidemiological Association)

Background: Serrated polyposis syndrome (SPS) is associated with an increased risk of colorectal cancer (CRC) and an evolving management approach. The aims of this study were to assess the polyp burden reduction over time, and the incidence of CRC in serrated polyposis patients undergoing community surveillance., Methods: This is an observational study based on prospectively collected data. A total of 96 SPS patients with no personal history of CRC were prospectively enrolled in a surveillance program under the guidance of a tertiary center. Patients underwent surveillance colonoscopy in multiple centres across New Zealand., Results: Patients underwent a median of four colonoscopies with a median interval of 15 months over a median follow-up period of 4.8 years. Five of 96 patients (5%) were referred for surgery, and the remaining 91 were managed by colonoscopy alone. In patients referred for surgery, 92% of the surveillance intervals to the fourth colonoscopy had been ≤12 months compared to 33% (P<0.001) in the colonoscopy only group, and all five (100%) had ≥20 pancolonic polyps after four procedures compared with only 5/91 (5%) in those managed by colonoscopy alone. In patients successfully managed by colonoscopy, 86% had <10 pancolonic polyps, >75% no longer had polyps ≥10mm and >90% no longer had proximal serrated polyps ≥10mm after the fourth colonoscopy. No patients were found to develop CRC during the study time period., Conclusions: Patients with SPS were managed by proactive surveillance colonoscopy in wider hospital settings under tertiary centre guidance, with only 5% requiring surgical management. No CRC was diagnosed in any patient during surveillance., Competing Interests: Dr Burt reports personal fees from Thetis Pharma outside the submitted work.

Background: Myanmar has the highest burden of malaria in the Greater Mekong. However, there is limited information on ownership and use of insecticide-treated nets (ITNs) in areas of Myanmar most severely affected by malaria. We describe ownership and use of ITNs among people in the malaria-endemic eastern parts of Myanmar and factors associated with ITN use., Methods: A cross-sectional household survey using a multi-stage cluster design was conducted in malaria-endemic townships in eastern Myanmar during the high malaria season of August to September, 2014. An effective ITN was defined as 1) a long-lasting insecticide-treated net obtained within the past three years, or 2) any net treated with insecticide within the past year., Results: In 4,679 households, the average number of ITNs per household was higher in rural compared to urban areas (0.6 vs. 0.4, p <0.001) as well as the proportion of households owning at least one ITN (27.3% vs. 15.5%, p<0.001). The proportion of households in which all members slept under an ITN was also higher in rural compared to urban areas (15.3% vs 6.9%, p<0.001). In multivariate analysis, rural households (adjusted odds ratio [aOR] 1.78, 95% CI: 1.43-2.21, p<0.001), households in which respondents knew malaria is transmitted by mosquitoes (aOR 1.35, 95% CI: 1.10-1.65, p = 0.004), and in which respondents knew malaria can be prevented by ITN use (aOR 1.86, 95% CI: 1.28-2.70, p<0.001) were more likely to have all members sleep under an ITN. Compared to the lowest socio-economic quintile, households in the richest quintile were less likely to have all members sleep under an ITN (aOR 0.47; 95% CI: 0.33-0.66, p<0.001). Households in which the main income earner was a skilled worker or a businessman were less likely to have all members sleep under an ITN (aOR, 0.70, 95% CI: 0.52-0.96, p<0.025) compared to those headed by farmers or fishermen. Households in which all children slept under an ITN were more likely to be in rural areas (aOR 1.58, 95% CI: 1.19-2.09, p = 0.002) and have a household head who knew malaria can be prevented by ITN use (aOR 2.13, 95% CI: 1.30-3.50, p = 0.003). Children were less likely to have slept under an ITN in houses headed by skilled workers or businessmen (aOR 0.50, 95% CI: 0.33-0.75, p = 0.001) or unskilled workers (aOR 0.66, 95% CI: 0.49-0.89, p = 0.006) compared to households with farmers or fishermen. Higher socio-economic level was associated with lower ITN use by children (aOR 0.56, 95% CI: 0.36-0.88, p = 0.012, highest vs. lowest quintile)., Conclusions: The study found ownership of ITNs was low in Myanmar in comparison to the goal of one for every two household members. Use of ITNs was low even when present. Findings are of concern given the study areas were part of enhanced efforts to reduce artemisinin-resistant malaria. Nonetheless, groups vulnerable to malaria such as individuals in rural settings, lower socio-economic households, and workers in high mosquito exposure jobs, had higher rates of ITN ownership. Malaria knowledge was linked to effective ITN use suggesting that distribution campaigns should be complemented by behavior change communications., Competing Interests: Three authors (TA, YKA, HSSK) are employees of Population Services International which funds and supports some malaria intervention activities in the study area.

Objective: The neurotransmitter serotonin is understood to control mood and drug response. Carrying a genetic variant in the serotonin transporter gene (5HTT) may increase the risk of major depressive disorder and alcohol dependence. Previous estimates of the association of the S allele of 5HTTLPR polymorphism with major depressive disorder and alcohol dependence have been inconsistent., Methods: For the systematic review, we used PubMed MEDLINE and Discovery of The University of Melbourne to search for all relevant case-control studies investigating the associations of 5HTTLPR polymorphism with major depressive disorder and alcohol dependence. Summary odds ratios (OR) and their 95% confidence intervals (CI) were estimated. To investigate whether year of publication, study population or diagnostic criteria used were potential sources of heterogeneity, we performed meta-regression analyses. Publication bias was assessed using Funnel plots and Egger's statistical tests., Results: We included 23 studies of major depressive disorder without alcohol dependence containing 3392 cases and 5093 controls, and 11 studies of alcohol dependence without major depressive disorder containing 2079 cases and 2273 controls. The summary OR for homozygote carriers of the S allele of 5HTTLPR polymorphism compared with heterozygote and non-carriers combined (SS vs SL+LL genotype) was 1.33 (95% CI = [1.19, 1.48]) for major depressive disorder and 1.18 (95% CI = [1.01, 1.38]) for alcohol dependence. The summary OR per S allele of 5HTTLPR polymorphism was 1.16 (95% CI = [1.08, 1.23]) for major depressive disorder and 1.12 (95% CI = [1.01, 1.23]) for alcohol dependence. Meta-regression models showed that the associations did not substantially change after adjusting for year of publication, study population and diagnostic criteria used. There was no evidence for publication bias of the studies included in our meta-analysis., Conclusions: Our meta-analysis confirms that individuals with the homozygous S allele of 5HTTLPR polymorphism are at increased risks of major depressive disorder as well as alcohol dependence. Further studies are required to investigate the association between 5HTTLPR polymorphism and the comorbidity of major depressive disorder and alcohol dependence as well as gene × environmental interactions., (© The Royal Australian and New Zealand College of Psychiatrists 2016.)

Introduction: When measured using the computer-assisted method CUMULUS, mammographic density adjusted for age and body mass index predicts breast cancer risk. We asked if new mammographic density measures defined by higher brightness thresholds gave better risk predictions., Methods: The Korean Breast Cancer Study included 213 women diagnosed with invasive breast cancer and 630 controls matched for age at full-field digital mammogram and menopausal status. Mammographic density was measured using CUMULUS at the conventional threshold (Cumulus), and in effect at two increasingly higher thresholds, which we call Altocumulus and Cirrocumulus, respectively. All measures were Box-Cox transformed and adjusted for age, body mass index, menopausal status and machine. We used conditional logistic regression to estimate the change in Odds PER standard deviation of transformed and Adjusted density measures (OPERA). The area under the receiver operating characteristic curve (AUC) was estimated., Results: Corresponding Altocumulus and Cirrocumulus density measures were correlated with Cumulus measures (r approximately 0.8 and 0.6, respectively). Altocumulus and Cirrocumulus measures were on average 25% and 80% less, respectively, than the Cumulus measure. For dense area, the OPERA was 1.18 (95% confidence interval: 1.01-1.39, P = 0.03) for Cumulus; 1.36 (1.15-1.62, P < 0.001) for Altocumulus; and 1.23 (1.04-1.45, P = 0.01) for Cirrocumulus. After fitting the Altocumulus measure, the Cumulus measure was no longer associated with risk. After fitting the Cumulus measure, the Altocumulus measure was still associated with risk (P = 0.001). The AUCs for dense area was 0.59 for the Altocumulus measure, greater than 0.55 and 0.57 for the Cumulus and Cirrocumulus measures, respectively (P = 0.001). Similar results were found for percentage dense area measures., Conclusions: Altocumulus measures perform better than Cumulus measures in predicting breast cancer risk, and Cumulus measures are confounded by Altocumulus measures. The mammographically bright regions might be more aetiologically important for breast cancer, with implications for biological, molecular, genetic and epidemiological research and clinical translation.