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To evaluate whether contraceptive insurance coverage for women who present for an abortion is associated with obtaining long-acting reversible contraception or depot medroxyprogesterone acetate (DMPA) on the day the abortion is completed.We conducted a prospective cohort study of women presenting for medical or surgical abortion at a single health center in North Carolina. Eligible women were 18 years or older and fluent in English or Spanish. Data were from participant questionnaires, medical charts, and financial records. Our main exposure was whether the woman had insurance coverage for contraception at clinic intake. Our primary outcome was receiving DMPA, an intrauterine device, or a contraceptive subdermal implant on the same day of their surgical abortion or at the visit that determined their medication abortion was complete. We used univariable, bivariable, and multivariable analysis to report our findings.Five hundred seventy-five women enrolled in our cohort between September 2015 and April 2016. One hundred twenty-eight (22%) had insurance coverage and 447 (78%) did not. In the group with insurance coverage for contraception, 38% (49/128) received a long-acting reversible contraception method or DMPA compared with 7% (33/447) in the group without insurance coverage for contraception. After adjusting for confounding, women with contraceptive coverage were more than five times as likely to receive immediate postabortion contraception with one of these methods compared with women without coverage (relative risk 5.6, 95% confidence interval 3.8-8.3).Women with contraceptive insurance coverage on the day of their abortion were more likely to leave the abortion clinic with an intrauterine device or implant in place or receive DMPA injection compared with women without coverage.

Concurrent with fire exclusion, shortleaf pine × loblolly pine hybrids have increased throughout the southeastern USA and may threaten the genetic integrity of shortleaf pine. Historically, fire favored shortleaf pine over other southern pine species, especially loblolly pine, with which it shares a broad sympatric natural range. Shortleaf pine seedlings have a morphological adaptation (basal crook) that lowers dormant buds to the soil surface where they are presumably protected from fire to facilitate resprouting after topkill. To evaluate this presumption, we tested (1) the functional role of the basal crook in protecting dormant buds by measuring resprouting after exposing the lower stem of shortleaf pine to fire and protecting from fire the lower stem (and dormant buds) of loblolly pine (which lacks a basal crook) and (2) the occurrence and importance of the basal crook morphological adaptation in F1 shortleaf × loblolly pine seedlings by comparing morphology and post-fire resprouting of the hybrids to both parents. Fire exposure of shortleaf pine seedling dormant buds caused seedling mortality, while protecting loblolly pine dormant buds facilitated resprouting. Hybrid pines have basal crooks intermediate to the strong crook of shortleaf pine and loblolly pine’s non-crooked stem. Fire top-killed loblolly pine and shortleaf × loblolly pine seedlings, and they did not resprout, while 57% of shortleaf pine resprouted after topkill during two dormant season and one growing season burns. This highly significant difference shows that the basal crook is important for shortleaf pine resprouting after topkill by fire. Fire is an important tool to reduce shortleaf × loblolly pine hybrids, and to provide a competitive advantage to shortleaf pine relative to loblolly pine, for ecosystem restoration and maintaining the genetic integrity of shortleaf pine.

Across much of the globe, fire is a major disturbance agent of forest and grassland communities. The removal of fire from previously fire-maintained ecosystems, which has occurred in many areas, changes species composition, favoring later less fire tolerant species over fire-adapted ones. A recent measured increase in the rate of hybridization between the fire-adapted shortleaf pine (Pinus echinata) and less fire-adapted loblolly pine (P. taeda) suggests that introgression may be an emerging threat to shortleaf pine as a genetically distinct species. We used 25 microsatellite markers on seedlings and saplings to test how the use of frequent fire affects the survival of hybrids between the two species by contrasting species makeup and hybridity in regularly burned areas (every 2 years) to that in neighboring unburned areas, both with mixed canopies of loblolly pine, shortleaf pine, and hybrids. The results show that frequent prescribed fire selects against loblolly pine and hybrids, restoring the community to one dominated by shortleaf pine. These results are the first to indicate that frequent fire can resist introgression between two co-occurring native species and that fire exclusion as a land management policy may be having unrecognized deleterious effects on the genetic integrity of species previously isolated from one another based on fire tolerance.

BackgroundAs the population ages, older adults are seeking meaningful, and impactful, post-retirement roles. As a society, improving the health of people throughout longer lives is a major public health goal. This paper presents the design and rationale for an effectiveness trial of Experience Corps™, an intervention created to address both these needs. This trial evaluates (1) whether senior volunteer roles within Experience Corps™ beneficially impact children's academic achievement and classroom behavior in public elementary schools and (2) impact on the health of volunteers.MethodsDual evaluations of (1) an intention-to-treat trial randomizing eligible adults 60 and older to volunteer service in Experience Corps™, or to a control arm of usual volunteering opportunities, and (2) a comparison of eligible public elementary schools receiving Experience Corps™ to matched, eligible control schools in a 1:1 control:intervention school ratio.OutcomesFor older adults, the primary outcome is decreased disability in mobility and Instrumental Activities of Daily Living (IADL). Secondary outcomes are decreased frailty, falls, and memory loss; slowed loss of strength, balance, walking speed, cortical plasticity, and executive function; objective performance of IADLs; and increased social and psychological engagement. For children, primary outcomes are improved reading achievement and classroom behavior in Kindergarten through the 3rd grade; secondary outcomes are improvements in school climate, teacher morale and retention, and teacher perceptions of older adults.SummaryThis trial incorporates principles and practices of community-based participatory research and evaluates the dual benefit of a single intervention, versus usual opportunities, for two generations: older adults and children.

Objective This study aimed to evaluate the cost-effectiveness of a screening program for breast cancer from the health care payers' perspective. Methods A Markov model was used to compare costs and effects of an annual screening program using clinical breast examination (CBE) with the absence of screening on a cohort of 4,103,285 asymptomatic women aged 40 years. The model was analyzed over the cohort's lifetime under the assumption that women participated in the screening program annually for 15 years. The model integrated both epidemiological and cost data for breast cancer from prior Vietnamese studies. Costs were measured in 2008 US dollars. Costs and effects were discounted annually at 3%. The incremental cost-effectiveness ratio (ICER) was defined as the difference in cost per life-years saved (LYS). One-way and probabilistic sensitivity analyses were implemented to assess the uncertainty of inputs. Results The ICER for the breast cancer screening program with CBE was US $994.96 per LYS compared with the absence of screening. Earlier initiation of the program at age 35 years increased the ICER to US $1196.68 per LYS, while extending the duration of time screened to age 60 years decreased the ICER. Changing the participation rate to 70%, reducing the specificity of CBE testing, and increasing the cost of the screening program by 30% raised ICER estimates to US $1419.32, US $1124.15, and US $1292.03 per LYS, respectively. Conclusion Breast cancer screening with CBE for women aged 40 to 55 years is considered very cost-effective in Vietnam according to the World Health Organization criteria.

The natural range of shortleaf pine encompasses 22 states from New York to Texas, second only to eastern white pine in the eastern United States. It is a species of minor and varying occurrence in most of these states usually found in association with other pines, but it is the only naturally occurring pine in the northwestern part of its range in Oklahoma, Arkansas, and Missouri. Over the whole of this area, it is apparent that shortleaf pine hybridizes with loblolly pine, including areas of species overlap (sympatry) and nonoverlap (allopatry). In this study, we used 25 DNA markers to measure the levels of hybridization and introgression in populations of juvenile and mature shortleaf pine from a wilderness area within the allopatric range of shortleaf pine that bordered loblolly pine plantings. Frequency of hybrids ranged from 9.2 to 24.0% among the populations sampled, and we found that levels of hybridization correlates with distances to the nearest loblolly pine plantations. However, the rates of hybridization and introgression apparently remained the same among the parent and juvenile populations.

Hybrids between shortleaf pine (Pinus echinata Mill.) and loblolly pine (Pinus taeda L.) have increased since the 1950s throughout the southeastern USA. Previously, greater sprouting capacity and the formation of a basal crook that lowers the height of dormant buds may have favored pure shortleaf pine populations on fire prone sites. The objective of this study was to determine how seasonal timing of topkill by both fire and topclipping affect sprouting of shortleaf × loblolly pine F1 hybrids compared to their parent open-pollinated populations during their third growing season. A factorial combination of top-clipping (hand pruners) and girdling by fire (propane torch) was conducted on November 2010, January, March, and April 2011 and sprouting response was measured after the growing season. Survival of topkilled shortleaf pine (94 %) was greatest followed by hybrid (78 %) and loblolly pine (35 %). However, species effects varied with topkill treatment and treatment date because survival was relatively lower for loblolly and hybrid pines in the burn-only as well as the November and April treatment dates while survival of shortleaf pine was consistently high. The number of sprouts was greatest for shortleaf (32.3) intermediate for hybrid (23.8) and lowest for loblolly pine (12.0). Overall, 83 % of shortleaf pine, 35 % of hybrid pine, and 5 % of loblolly pine exhibited a basal crook. The height from ground line to the lowest sprout was shortest for shortleaf (3.5 mm), intermediate for hybrids (7.7 mm), and largest for loblolly pine (21.3 mm). While the hybrid saplings exhibited intermediate performance in survival, sprouting capacity, and crooking, pure shortleaf pine were superior and are probably better suited to recover from fire.

Shortleaf pine (Pinus echinata Mill.) is an important commercial timber resource and forest ecosystem component in the southeastern USA. The species occurs in mainly drier sites as an early- to mid-successional species, is fire-adapted, and it plays an important role in the fire ecology of the region. However, shortleaf pine genetics are not well-studied, especially in this era of molecular genetics and genomics. Most genetics research about the species has focused on provenance testing. Generally, shortleaf pine performs well in colder areas, when compared to loblolly pine (Pinus taeda L.), a close relative, which is faster growing and the most common plantation species in the region. Though not as advanced in genetic improvement as loblolly pine, tree breeders have improved shortleaf pine in one to two generations of selection, and diverse, genetically improved shortleaf pine materials are available to foresters and landowners throughout the southeastern USA. Researchers have also studied the genetic variation of shortleaf pine using various molecular markers and have found that shortleaf pine is generally a prolific outcrosser, a trait it shares with other non-isolated members of the family Pinaceae. In recent years, however, it has shared less genetic material across long ranges, probably because of habitat fragmentation. Various anthropogenic factors also affect shortleaf pine’s future, as recent studies show that shortleaf pine introgression with loblolly pine puts the species—and the resiliency of southeastern forests—at risk. Importantly, fire exclusion is a likely cause of the increase in introgression. Herein, we provide further details and up-to-date genetic information and resources for foresters and ecologists interested in the restoration and management of shortleaf pine.

Hybridization between loblolly pine and shortleaf pine has been shown in sympatric and allopatric portions of the species native ranges. In this study, we used 25 microsatellite markers to determine the hybrid status of 165 and 151 loblolly pine and shortleaf pine trees sampled across their ranges, respectively, and to estimate population differentiation within these species. Estimated differentiation (Φ PT) for these current-day samples was significantly higher in both species—0.115 in loblolly pine and 0.146 in shortleaf pine—than for trees planted from seed collected from the same locations in the 1950s. These increases are likely due to anthropogenic causes such as habitat fragmentation. In addition, the proportion of hybrids rose dramatically in both species: 27.3% hybrids in loblolly pine populations and 46.7% hybrids in shortleaf pine populations compared to rates of 4.5% and 3.3%, respectively, in the 1950s populations. Our results suggest that shortleaf pine and remnant naturally regenerated loblolly pine are at risk.

Summary objective To generate community-based estimates of the public (paid by the government) and private (paid by households) costs of blood culture-confirmed typhoid fever in Hechi, China; North Jakarta, Indonesia; Kolkata, India; Karachi, Pakistan and Hue, Vietnam. methods To measure out-of-pocket costs of illness and lost earnings, families with culture-proven cases were surveyed 7, 14 and 90 days after onset of illness. Public costs of treatment were measured at local health facilities using a micro costing (bottom-up) method. results The costs of hospitalized cases ranged from USD 129 in Kolkata to USD 432 in North Jakarta (hospitalization rates varied from 2% in Kolkata to 40% in Hechi) and the costs of non-hospitalized cases ranged from USD 13 in Kolkata to USD 67 in Hechi. Where costs were highest (Hechi, North Jakarta and Karachi), the bulk of the costs of hospitalized cases was borne by families, comprising up to 15% of annual household income. conclusion Although these estimates may understate true costs due to the fact that higher quality treatment may have been provided earlier-than-usual, this multi-country community-based study contributes to evidence on the public and private costs of typhoid fever in developing countries. These cost estimates were used in a cost-effectiveness analysis of typhoid vaccines and will help policymakers respond to World Health Organization’s updated typhoid fever immunization recommendations.

Loblolly pine and shortleaf pine are known to naturally hybridize. In this study, we used 42 microsatellite markers and isocitrate dehydrogenase isozyme to create genetic profiles of 202 loblolly and shortleaf pine trees grown from seed collected in the 1950s for the Southwide Southern Pine Seed Source Study. Estimated ΦPT was low in both loblolly (0.061) and shortleaf (0.080) pines, indicating that most of the diversity is accounted for within seed sources. However, both loblolly and shortleaf pines showed significant correlations between seed sources’ genetic and geographic distances, with R2 of 0.43 and 0.17, respectively. The hybridization rate was 4.0%, with more hybrids west of the Mississippi River (8.1%) than east of the river (2.1%). Additionally, about the same proportion of both species (4.5% of loblolly and 3.3% of shortleaf pine) were identified as hybrids. These results are consistent with prior studies on these two species but do contrast with the results from an amplified fragment length polymorphism (AFLP) analysis of the same samples. For example, the AFLP study concluded that 6.3% of the trees were hybrids, or 1.4 times higher than determined by this study. Of the 12 hybrids identified in the AFLP study, six were not identified as hybrids here, and of the eight hybrids identified here, only four were identified in the AFLP study. Although similar in overall results, we suggest that the microsatellite analysis is more convincing than the AFLP analysis because microsatellites provide more information per genetic locus than do AFLPs.

Ignoring the indirect effects of vaccination has led to two types of inaccuracies in cholera vaccine policy analysis in endemic settings. First, when herd protection is ignored, the social benefits and cost-effectiveness of vaccination programs are underestimated, such that the programs are rarely considered to be a wise use of scarce public health resources. Once vaccine herd protection is included, use of the vaccine can satisfy both social welfare objectives and benchmark cost effectiveness criteria. Second, design recommendations to implement programs considered most attractive without accounting for the effect of herd protection may not allow the capture of the greatest social benefits. The analysis summarized in this paper demonstrates that it is possible to account for herd protection in both cost-effectiveness and cost-benefit calculations. In the former case, however, it does pose significant interpretation challenges. When herd protection is incorporated into a cost-effectiveness model, cost-effectiveness measures such as costs per DALY avoided become a function of vaccination coverage. When this is the case, there is no obvious decision objective in a cost-effectiveness analysis. Cost-benefit metrics, on the other hand, provide a clear economic argument for when to pursue vaccination efforts and how to design them. More sophisticated measurements of the economic benefits of vaccination should therefore become standard practice when evaluating the potential of vaccination programs.

There are five different core types of Escherichia coli lipopolysaccharide (LPS), and enterohaemorrhagic E. coli tend to have the R3 core type. It has been hypothesized that increased carriage of bacteria with a specific core type will induce higher levels of antibodies and protect against disease caused by bacteria carrying that specific LPS core. Approximately 320 isolates of E. coli, half from healthy human faeces and half from healthy bovine faeces have been core typed both by core-specific monoclonal antibodies, and by PCR for genes encoding the enzymes responsible for the biosynthesis of the specific core structures. Results showed that E. coli possessing R1 core LPS were most frequently detected in both human and cattle populations (63 and 49 %, respectively). Compared to the human isolates a significantly higher level of bacteria with R3 core LPS was detected among the bovine commensal E. coli (11 % compared to 4 %; P < 0.05). Antibody levels to each of the specific core types were measured in serum samples from healthy humans (n = 91) and healthy cattle (n = 39). In each population the highest level of antibody detected was reactive to the R4 core. In cattle the level of anti-R3 core antibody was significantly higher than the level of anti-R1, -R2 and -K12 antibodies (P < 0.01). In summary there was a greater proportion of E. coli with R3 core type in cattle, together with a corresponding higher anti-R3 antibody level. This suggests that cattle may have greater immunity to E. coli strains with an LPS of R3 core type.

The data presented show the ability of subinhibitory concentrations of plant essential oils to influence the production of enterotoxins A and B and alpha-toxin by Staphylococcus aureus. Subinhibitory concentrations of the oils of bay, clove, cinnamon, nutmeg and thyme had no significant effect on the overall quantity of extracellular protein produced. Haemolysis due to alpha-toxin was significantly reduced after culture with all five plant essential oils. This reduction was greatest with the oils of bay, cinnamon and clove. These three oils also significantly decreased the production of enterotoxin A; the oils of clove and cinnamon also significantly decreased the production of enterotoxin B.

Utilisation of healthcare facilities is low in many developing areas. One possible explanation is that treatment costs, in time or money, are high. Another is that parents perceive treatment benefits to be low. We combine Philippines DHS data with a subsequent facilities survey in order to examine these issues with respect to treatment for respiratory infections and diarrhoea in young children. Controlling statistically for the selectivity of the initiating illness, we find that the staffing level of nearby health facilities is a determinant of the probability that parents take their ill children for curative care.

Toll-like receptor 4 (TLR4)-mediated recognition of lipopolysaccharide (LPS) is required for efficient recognition of Gram-negative bacterial infections. Two commonly occurring mutations in the human TLR4 gene (Asp299Gly and Thr399Ile) have recently been shown to be associated with blunted physiological responses to inhaled LPS, and with increased risk of Gram-negative bacteraemia in sepsis patients and reduced risk of atherosclerosis in an Italian population. Here we show that monocytes from individuals heterozygous for both mutations in the TLR4 gene exhibit no deficit in recognition of LPS of Escherichia coli, Neisseria meningitidis, Bacteroides fragilis, Yersinia pestis, Chlamydia trachomatis, Porphyromonas gingivalis, or Pseudomonas aeruginosa. We propose that the relatively high frequency of these mutations in the Caucasian population may reflect modified responses of carriers to alternative TLR4 agonists.

Successful infection by Listeria monocytogenes is dependent upon a range of bacterial extracellular proteins including a cytolysin termed listeriolysin O and phosphatidylcholine-specific phospholipase C. Five plant essential oils – bay, clove, cinnamon, nutmeg and thyme – significantly reduced the production of listeriolysin O by L. monocytogenes. The greatest change was observed after culture with oil of thyme, which reduced haemolysis to 52.1 haemolytic units (HU)/ml compared with 99.85muHU/ml observed with the control. Oil of clove was the only oil that also significantly reduced phosphatidylcholine-specific phospholipase C activity. These changes were observed despite the oils causing no change to the final bacterial concentration or total extracellular protein concentration.

A vaccine that induces humoral immunity to lipopolysaccharide (LPS), while remaining non-pyrogenic should be beneficial, as high levels of antibodies against LPS are associated with a reduced risk of adverse outcome. However, pure LPS or bacteria expressing LPS are generally considered too toxic to be used as vaccines. Recently, a novel, immunogenic complete core lipopolysaccharide vaccine has been described, which has been designed to prevent endotoxin-related inflammatory reactions in surgical and high-risk hospitalized patients. In vivo studies have shown that while administration of the vaccine to rabbits results in no toxicity over 7 days, it does induce significantly enhanced antibody responses towards a broad range of clinically relevant Gram-negative LPSs. Here we show that encapsulation of the four complete core LPS types Escherichia coli K12, Escherichia coli R1, Bacteroides fragilis and Pseudomonas aeruginosa into liposomes greatly reduces the ability of a given amount of LPS to induce TNF-α production in vitro from human monocytes. In contrast to previous studies of liposomal LPS, we demonstrate a reduction in activity of approximately 100,000-fold; a reduction approximately 100—1,000-fold more than that previously described. The signalling by the liposomal LPS appears to be entirely dependent on serum factors, though this can be partially restored by soluble CD14 or, to a lesser extent, by lipopolysaccharide binding protein. Time-course experiments reveal that liposomal LPS signalling shows similar kinetics to pure LPS signalling. Therefore, as well as inducing specific antibody responses, liposomal LPS demonstrates characteristics suitable for use as a vaccine to be used in human beings.

Investigations were carried out to assess the efficiency of four plant essential oils; bay, clove, cinnamon and thyme as natural food preservatives. The effect of the plant essential oils at concentrations of 0·1, 0·5 and 1% was studied in low-fat and full-fat soft cheese against Listeria monocytogenes and Salmonella enteritidis at 4° and 10°C respectively, over a 14-day period. The composition of the cheese was shown to be an important factor in determining the effectiveness of the plant essential oils. In the low-fat cheese, all four oils at 1% reduced L. monocytogenes to ≤1·0 log 10 cfu ml −1 . In contrast, in the full-fat cheese, oil of clove was the only oil to achieve this reduction. Oil of thyme proved ineffective against S. enteritidis in the full-fat cheese, yet was equally as effective as the other three oils in the low-fat cheese, reducing S. enteritidis to ≤1·0 log 10 cfu ml −1 from day 4 onwards. It is concluded that selected plant essential oils can act as potent inhibitors of L. monocytogenes and S. enteritidis in a food product.

The decline in the prevalence and duration of breast‐feeding in less developed countries and the accompanying increase in bottle feeding is a concern. Little research has been done tracing the links from infant food marketing to infant and child health outcomes. In this study, Philippine mothers’ feeding decisions and infantile diarrhoeal morbidity rates are modelled and jointly estimated using semiparametric estimation methods. The data clearly support the hypothesis that infant feeding practices are important determinants of diarrhoeal morbidity and that breast‐feeding reduces the incidence of diarrhoea. Our results also show that marketing activities have affected infant feeding choices.

This study describes inhibitory properties of combinations of oil of fennel and paraben (methyl, ethyl or propyl) against C. albicans, E. coli and S. aureus. Bacteria or yeast were cultured in broth at 25°C and viable counts were measured over a period of 24 h. E. coli was particularly sensitive to inhibition by each combination where there was

The antimicrobial properties of 21 plant essential oils and two essences were investigated against five important food-borne pathogens, Campylobacter jejuni, Salmonella enteritidis, Escherichia coli, Staphylococcus aureus and Listeria monocytogenes. The oils of bay, cinnamon, clove and thyme were the most inhibitory, each having a bacteriostatic concentration of 0.075% or less against all five pathogens. In general, Gram-positive bacteria were more sensitive to inhibition by plant essential oils than the Gram-negative bacteria. Campylobacter jejuni was the most resistant of the bacteria investigated to plant essential oils, with only the oils of bay and thyme having a bacteriocidal concentration of less than 1%. At 35 degrees C, L. monocytogenes was extremely sensitive to the oil of nutmeg. A concentration of less than 0.01% was bacteriostatic and 0.05% was bacteriocidal, but when the temperature was reduced to 4 degrees, the bacteriostatic concentration was increased to 0.5% and the bacteriocidal concentration to greater than 1%.

This study describes inhibitory properties of combinations of oil of fennel, oil of anise or oil of basil with either benzoic acid or methyl-paraben against Listeria monocytogenes and Salmonella enteriditis. Micro-organisms were cultured at 37 degrees C in broth and viable counts measured over a 48-h period. S. enteriditis was particularly sensitive to inhibition by a combination of oil of anise, fennel or basil with methyl-paraben where there was < 10 CFU/ml after 1 h. L. monocytogenes was less sensitive to inhibition by each combination however there was a significant reduction in growth of 4-8 log by combinations of all oils and methyl-paraben at 8, 24 and 48 h. Synergistic inhibition by one or more combinations was evident against each micro-organism.

Background: Breast cancer is becoming a public health problem in Vietnam. The mortality to incidence ratio of the disease was ranked second among the most common cancers in women. This study estimates the survival probability at 1, 3, and 5 years following diagnosis and determines prognostic factors for breast cancer mortality in Vietnam. Methods: A survival analysis was conducted based on retrospective data from Hue Central Hospital and the Cancer Registry in Ho Chi Minh City. Using the Kaplan-Meier method, the survival probability of patients with breast cancer was estimated at 1, 3, and 5 years following diagnosis. The covariates among prognostic factors for survival time were studied using an extended Cox proportion hazards model, including timedependent predictors. Results: Overall survival rates at 1, 3, and 5 years following diagnosis were 0.94, 0.83 and 0.74 respectively. Marital status, education level, stage at diagnosis, and hormone therapy were prognostic factors for mortality. For the stage at diagnosis, the relation to the risk of death for breast cancer was 1.32 (95% CI, 1.22-1.41). Married women faced a risk of death nearly 1.59 times higher than unmarried women (95% CI, 1.09-2.33). Women with higher levels of education and who received hormone therapy had approximately 10% (hazard ratio [HR]: 0.92; 95% CI, 0.89-0.96) and 80% (HR: 0.22; 95% CI, 0.12-0.41) risk reduction of death respectively, compared with those classified as illiterate and those without hormone therapy. Conclusions: The 5-year survival probability of breast cancer was lower in Vietnam than in countries with similar distributions of the stage at diagnosis. Screening programs and related support policies should be developed to increase the life expectancy of women with breast cancer in Vietnam. Keywords: breast cancer; survival; prognostic factors; Vietnam (Published: 17 January 2013) Citation: Glob Health Action 2013, 6 : 18860 - http://dx.doi.org/10.3402/gha.v6i0.18860 This paper is part of the Cluster Public health in Vietnam: here's the data, where's the action? - more papers from this cluster can be found here .

Sera obtained from 106 children following an outbreak of Neisseria meningitidis (B:4:P1.15) were screened for bactericidal antibodies against isolates of meningococci and Neisseria lactamica. Most had high titres of antibodies to N. lactamica and N. meningitidis NG:4:- but not to capsulate isolates: B:4:P1.15; B:15:P1.16; B:4:-; C:4:-. Bactericidal activity was higher for both carriers and secretors but the differences were not significant. Bactericidal activity was not associated with total or specific IgA or IgM. Carriers had significantly higher levels of IgG to N. lactamica but not to NG:4:- in sera with bactericidal activity for each of the capsulate strains. Among non-carriers, higher levels of IgG to N. lactamica were associated with killing of B:4:P1.15 and B:4:-. Secretors' sera with bactericidal activity had significantly higher levels of IgG to N. lactamica compared with sera that were not bactericidal. This was not observed among non-secretors. Antibodies to the outbreak strain were adsorbed by all Neisseria isolates tested and absorption of sera with N. lactamica alone completely removed the bactericidal activity against the outbreak strain.

Researchers applied February 1983-April 1986 data from the Metropolitan Cebu (Philippines) Longitudinal Survey to a modified basic household production model of the mothers decision-making process to determine the effect of marketing activities of the infant food industry on mothers infant feeding decisions through the first 6 months of an infants life. The marketing activities were apparently directed to the most educated mothers rather than the less educated mothers. For example more highly educated than poorly educated mothers recalled an infant formula brand name (98.8% vs. 79%) and were more likely to receive a free formula sample (49.6% vs. 9.1%). The lower free sample distribution among poorly educated mothers was due to the fact that they did not deliver at health facilities. Formula advertising increased mixed feeding with commercial milk substitutes from less than 10% to 20% among the least educated mothers. For the least educated mothers past marketing activities predicted a 3% reduction in all breast feeding infants at 2 months a 3.5% reduction at 4 months and 4% at 6 months. Had advertising and free sample distribution been more widespread among the least educated mothers large reductions in breast feeding supplemented with other foods would have occurred and breast feeding supplemented with commercial milks would have replaced breast feeding supplemented with other foods. These findings suggest that infant food marketing activities adversely change infant feeding patterns in the Philippines.

There is a scarcity of data regarding medical hospitalizations for breast cancer. The aim was to determine whether the burden of inpatient care for breast cancer was declining.A retrospective study was conducted of all admissions to a single medical oncology inpatient unit in 1996 and 2006 related to the treatment of breast cancer. The total number of hospitalizations, patients' length of stay in hospital, clinical indications for hospitalization and utilization of inpatient services were determined. Data analysis involved pairwise comparisons between the cohorts.The total number of breast cancer hospitalizations was similar in 1996 and 2006. However, the number of hospitalizations for adjuvant treatment complications was 50% lower in 2006, attributable to a lower rate of chemotherapy-associated febrile neutropenia. Acute clinical problems necessitating inpatient care differed between 1996 and 2006. Fewer hospitalizations for symptomatic hypercalcemia, uncontrolled pain and chemotherapy toxicity were required in 2006 but a significant increase was seen in central nervous system complications. Recent practice involved greater inpatient consultation of other medical and surgical teams. There was a trend towards a shorter duration of admissions in 2006 in both adjuvant and metastatic patients.Although total annual breast cancer admission numbers and length of stay did not change significantly, hospitalization for treatment-related complications was less frequent in 2006. The clinical manifestations of metastatic breast cancer appear to be changing, and in our institution are being managed with broader multidisciplinary care.

SUMMARYEconomic analyses of cholera immunization programmes require estimates of the costs of cholera. The Diseases of the Most Impoverished programme measured the public, provider, and patient costs of culture-confirmed cholera in four study sites with endemic cholera using a combination of hospital- and community-based studies. Families with culture-proven cases were surveyed at home 7 and 14 days after confirmation of illness. Public costs were measured at local health facilities using a micro-costing methodology. Hospital-based studies found that the costs of severe cholera were US$32 and US$47 in Matlab and Beira. Community-based studies in North Jakarta and Kolkata found that cholera cases cost between US$28 and US$206, depending on hospitalization. Patients' cost of illness as a percentage of average monthly income were 21% and 65% for hospitalized cases in Kolkata and North Jakarta, respectively. This burden on families is not captured by studies that adopt a provider perspective.

To generate community-based estimates of the public (paid by the government) and private (paid by households) costs of blood culture-confirmed typhoid fever in Hechi, China; North Jakarta, Indonesia; Kolkata, India; Karachi, Pakistan and Hue, Vietnam.To measure out-of-pocket costs of illness and lost earnings, families with culture-proven cases were surveyed 7, 14 and 90 days after onset of illness. Public costs of treatment were measured at local health facilities using a micro costing (bottom-up) method.The costs of hospitalized cases ranged from USD 129 in Kolkata to USD 432 in North Jakarta (hospitalization rates varied from 2% in Kolkata to 40% in Hechi) and the costs of non-hospitalized cases ranged from USD 13 in Kolkata to USD 67 in Hechi. Where costs were highest (Hechi, North Jakarta and Karachi), the bulk of the costs of hospitalized cases was borne by families, comprising up to 15% of annual household income.Although these estimates may understate true costs due to the fact that higher quality treatment may have been provided earlier-than-usual, this multi-country community-based study contributes to evidence on the public and private costs of typhoid fever in developing countries. These cost estimates were used in a cost-effectiveness analysis of typhoid vaccines and will help policymakers respond to World Health Organization's updated typhoid fever immunization recommendations.

SUMMARYIt has been suggested that individuals might be more readily colonized with bacteria that cause meningitis through enhanced binding of the bacteria to virusinfected epithelial cells. As respiratory syncytial virus (RSV) affects infants and children in the age group also susceptible to bacterial meningitis, we tested the hypothesis that infection of HEp-2 cells by RSV might enhance binding ofNeisseria meningitidisorHaemophilus influenzaetype b (Hib). Attachment of fluorescein-labelled bacteria to HEp-2 cells was measured by flow cytometry, and RSV-infected cells bound significantly more meningococci (P< 0·001) and Hib (P< 0·01) than uninfected cells. Although the isolates expressed different antigenic characteristics (3 meningococci and 5 Hib), all showed a similar pattern of binding. The results are discussed with reference to the methods used for detection of bacterial binding and to interactions that might explain the increased binding to RSV-infected cells.

Although it is desirable to identify the interactions between endotoxin/LPS and the innate immune mechanism, it is often not possible to isolate these interactions from other cell wall-related structures of protein or polysaccharide origin. There is no universally accepted method to extract different LPSs from different bacteria, and their natural state will be influenced by their interactions with the associated molecules in the bacterial outer membrane. It is now believed that Toll-like receptor (TLR) 4 is the main signal transducer of classical LPS (i.e.Escherichia coliLPS), while TLR2 is used by certain non-classical LPSs. There are contradictory reports as to whetherBacteroides fragilisLPS, a non-classical LPS, signals primarily through TLR2 or TLR4. This study was designed to address this problem. Different non-purified and purifiedB. fragilisLPSs extracted by different methods together with different heat-killed, whole-cell populations ofB. fragiliswere used to elucidate the TLR specificity. All of theseB. fragilispreparations showed a significant signalling specificity for TLR2 but not for TLR4. This indicates that changing the extraction methods, with or without applying a repurification procedure, and varying the cell populations do not alter the TLR specificity ofB. fragilisLPS.

There has been much controversy about the impact of the health sector and the infant food industry on breast-feeding behavior. This study links causal factors to breast-feeding decisions, using a longitudinal survey of more than 3,000 Filipino mother-infant pairs. Most factors decreasing the likelihood that mothers will breast-feed seem to be related to family economics. Delivery in a private hospital, urban residence, high income, absence of spouse, and having worked for wages affect adversely the initiation of breast-feeding. Formula advertising and distribution of samples appear to have relatively little impact on feeding decisions.

The amount of H antigens on buccal epithelial cells (BEC) of secretors and non-secretors was measured by flow cytometry. H type 1 and H type 2 on BEC were detected with fluorescein-labelled Ulex europaeus lectin, and H type 2 was measured with mouse monoclonal antibody. Between 3.5 and 6 times more H antigen was detected on cells from secretors compared with cells from non-secretors. The level of H type 2 was the same on BEC of secretors and non-secretors. Adsorption of H type 1 antigen from secretor saliva onto non-secretors BEC was demonstrated. A simple and sensitive ELISA method was developed for the determination of H in saliva with biotin-labelled Ulex lectin. This system provides a simple means for measuring the amount of H present in saliva and for the determination of secretor status.

Non-secretion of ABO blood group substances in body fluids is associated with susceptibility to some bacterial infections. Non-secretors were previously found to be over-represented in patients with ankylosing spondylitis (AS) (49%) compared to controls (27%). Re-evaluation of secretor status in a population of 92 AS patients and 103 controls revealed identical proportions of non-secretors (28%). Of 43 patients studied in both surveys, 6/22 typed initially as non-secretors proved to be secretors using both haemagglutination inhibition assay (HAI) and enzyme-linked immunosorbent assay (ELISA) techniques. Loss of secreted blood group antigens in the saliva is the cause of this mis-typing. Careful attention to the method of collection, handling and preservation of saliva specimens is essential for accurate assessment of secretor status. Therefore, there is no link between secretor status and AS.

Recognition of bacterial lipopolysaccharide (LPS) is critical in the host defence against Gram-negative infection. While enterobacterial LPS signals via Toll-like receptor 4 (TLR4), it has recently been reported that the LPS of Leptospira interrogans, Legionella pneumophila, Rhizobium species Sin-1 and at least one strain of Porphyromonas gingivalis are capable of signalling via TLR2. Using a TLR transfection assay and measurement of an NF-kappaB-sensitive promoter region, the results show that the LPS of Bacteroides fragilis NCTC-9343, Chlamydia trachomatis LGV-1 and Pseudomonas aeruginosa PAC-611 also signal via TLR2 and it is pointed out that all TLR2-signalling LPS discovered to date demonstrate relatively weak endotoxicity in some models and structural features distinct from those LPS shown to signal via TLR4.

This paper uses Cote d’Ivoire and Nigeria survey data on both supply and demand characteristics to examine how structural and demographic factors influence family planning provision and cost. The model, which takes into account the endogenous influence of service provision on average cost, explains provision well but poorly explains what influences service cost. We show that both size and specialization matter. In both countries, vertical (exclusive family planning) facilities provide significantly more contraception than integrated medical establishments. In the Nigeria sample, larger facilities also offer services at lower average cost. Since vertical facilities tend to be large, they at most incur no higher unit costs than integrated facilities. These results are consistent across most model specifications, and are robust to corrections for endogenous facility placement in Nigeria. Model results and cost recovery information point to the relative efficiency of the International Planned Parenthood Federation, which operates large, mostly vertically organized facilities.

Previous studies have shown enteral nutritional solutions (ENS) contaminated with large numbers of microorganisms from the environment or gastrointestinal (GI) tract of patients have caused respiratory infections, acute and chronic enteritis, and septicemia. The introduction of "closed" enteral feeding systems has been used to prevent contaminating organisms from entering enteral feeding systems in large numbers. However, there is some discussion as to whether this has been an effective measure in reducing ENS-related infections because there is anecdotal evidence to suggest that disease processes resulting from enteral feeding are still commonplace in the hospital and home. This is because there is very little information about the growth of microorganisms in ENS and whether growth in ENS may affect the virulence and pathogenicity of microorganisms. This study shows that Escherichia coli and Pseudomonas aeruginosa may grow at 25 degrees C from either high or low initial numbers to up to 9.2 log colony-forming units per mL in a range of milk-based ENS. However, these organisms did not grow in the fruit-based ENS. The effect on the lipopolysaccharide (LPS) of culturing E. coli and P. aeruginosa in milk-based ENS as opposed to standard laboratory media was examined using polyacrylamide gel electrophoresis. We found that there were significant qualitative changes in the phenotype of O-polysaccharide side chains of the LPS from these organisms. O-polysaccharide is known to mediate in the complement, antibiotic and bile resistance, and affect adherence. Therefore, changes in the virulence and pathogenicity of these microorganisms when cultured in ENS may be indicated. Thus, the study provides further evidence for reevaluating the microbiologic and immunologic effects of enteral feeding, especially on the microbial flora of the GI tract.

Background: In recent years, cases of breast cancer have been on the rise in Vietnam. To date, there has been no study on the financial burden of the disease. This study estimates the direct medical cost of a 5-year treatment course for women with primary breast cancer in central Vietnam. Methods: Retrospective patient-level data from medical records at the Hue Central Hospital between 2001 and 2006 were analyzed. Cost analysis was conducted from the health care payers’ perspective. Various direct medical cost categories were computed for a 5-year treatment course for patients with breast cancer. Costs, in US dollars, discounted at a 3% rate, were converted to 2010 after adjusting for inflation. For each cost category, the mean, standard deviation, median, and cost range were estimated. Median regression was used to investigate the relationship between costs and the stage, age at diagnosis, and the health insurance coverage of the patients. Results: The total direct medical cost for a 5-year treatment course for breast cancer in central Vietnam was estimated at $975 per patient (range: $11.7-$3,955). The initial treatment cost, particularly the cost of chemotherapy, was found to account for the greatest proportion of total costs (64.9%). Among the patient characteristics studied, stage at diagnosis was significantly associated with total treatment costs. Patients at later stages of breast cancer did not differ significantly in their total costs from those at earlier stages however, but their survival time was much shorter. The absence of health insurance was the main factor limiting service uptake. Conclusion: From the health care payers’ perspective, the Government subsidization of public hospital charges lowered the direct medical costs of a 5-year treatment course for primary breast cancer in central Vietnam. However, the long treatment course was significantly influenced by out-of-pocket payments for patients without health insurance. Keywords: breast cancer; direct medical cost; health care payer; Vietnam (Published: 4 February 2013) Citation: Glob Health Action 2013, 6 : 18872 - http://dx.doi.org/10.3402/gha.v6i0.18872 This paper is part of the thematic cluster Public health in Vietnam: here's the data, where's the action? - more papers from this cluster can be found here .

PURPOSE: To establish the toxicity profile of simultaneously administered postoperative radiation therapy and CMF chemotherapy as a prelude to a randomized controlled study addressing the sequencing of the two modalities. METHODS AND MATERIALS: One hundred and thirty eight breast cancer patients at high risk of locoregional, as well as systemic relapse, who were referred to three centers in Australia and New Zealand were treated with postoperative radiation therapy and chemotherapy simultaneously. Acute toxicity and dose modifications in these patients were compared with 83 patients treated over the same time frame with chemotherapy alone. In a separate study the long-term radiation and surgical effects in 24 patients treated simultaneously with radiation therapy and chemotherapy at Newcastle (Australia) following conservative surgery were compared with 23 matched patients treated at Newcastle with radiation therapy alone. RESULTS: Myelotoxicity was increased in patients treated simultaneously with radiation therapy and chemotherapy. The effect was not great, but may have contributed to chemotherapy dose reductions. Lymphopenia was observed to be the largest factor in total white cell depressions caused by the simultaneous administration of radiation therapy. Postsurgical appearances were found to so dominate long-term treatment effects on the treated breast that the effect of radiation therapy dose and additional chemotherapy was difficult to detect. CONCLUSION: Studies addressing the sequencing of radiation therapy and chemotherapy will necessarily be large because adverse effects from administering the two modalities simultaneously are not great. The present study has endorsed the importance in future studies of stratification according to the extent and type of surgery and adherence to a single strict policy of chemotherapy dose modification.

Viral glycoproteins G and F are expressed on the surface of cells infected with respiratory syncytial virus (RSV). We investigated the role of these proteins in the previously reported enhanced binding of Neisseria meningitidis to RSV-infected HEp-2 cells. Virus particles attached to bacteria were detected by immunofluorescence with flow cytometry. Binding of FITC-labelled bacteria to RSV-infected cells was significantly inhibited by monoclonal antibody against glycoprotein G. Unlabelled bacteria interfered with binding of the anti-G monoclonal antibody to these cells. These interactions were not found with a monoclonal antibody against glycoprotein F. We propose that glycoprotein G of RSV expressed on the surface of infected cells might act as an additional receptor for meningococci.

Carriage of Neisseria meningitidis B:4:P1.15 was higher among non-secretors during a school outbreak of meningitis; non-secretors had lower levels of anti-meningococcal salivary IgM. Flow cytometry was used to assess effects of secretor and non-secretor saliva on binding of B:4:P1.15 to buccal epithelial cells: (1) to assess inhibition by IgA and IgM; and (2) to assess contributions of salivary antibodies to inhibitory activities. Greater inhibition was obtained with secretor saliva: pooled (P = 0.049); fresh (P = 0.0001). Purified IgA (P = 0.02) and IgM (P = 0.03) were equally inhibitory. After absorption of anti-meningococcal antibodies, there was still significant inhibitory activity in the pools: secretors (P = 0.018); non-secretors (P = 0.005). These results indicate that both secretory immunoglobulins and other factors contribute to protection against colonisation by meningococci and might explain the increased carriage of B:4:P1.15 in this population.

SUMMARYToxigenic strains ofStaphylococcus aureushave been suggested to play a role in sudden infant death syndrome (SIDS). In this study we examined two factors that might enhance binding of toxigenic staphylococci to epithelial cells of infants in the age range in which cot deaths are prevalent: expression of the Lewisaantigen and infection with respiratory syncytial virus (RSV). By flow cytometry we demonstrated that binding of three toxigenic strains ofS. aureusto cells from non-secretors was significantly greater than to cells of secretors. Pre-treatment of epithelial cells with monoclonal anti-Lewisaor anti-type-1 precursor significantly reduced bacterial binding (P< 0·01); however, attachment of the bacteria correlated only with the amount of Lewisaantigen detected on the cells (P< 0·01). HEp-2 cells infected with RSV bound significantly more bacteria than uninfected cells. These findings are discussed in context of factors previously associated with SIDS (mother's smoking, bottle feeding and the prone sleeping position) and a hypothesis proposed to explain some cases of SIDS.

This paper has its Genesis in a glib remark made by a stock market analyst in the business press.1 When asked what the bidding war for RJR-Nabisco would mean to a typical citizen, he responded “You'll be paying more for your Oreo cookies.” The analyst's remark seems to be at direct odds with the political and policy rhetoric that accompanied the dramatic wave of mergers and other forms of business reorganization of the 1980's and with the tenants of the weH advertised ascendancy of the Chicago School's “New Orthodoxy” of industrial organization.2

PURPOSE: To assess whether pamidronate can reduce the frequency of skeletal morbidity in women with lytic bone metastases from breast cancer treated with hormone therapy. PATIENTS AND METHODS: Three hundred seventy-two women with breast cancer who had at least one lytic bone lesion and who were receiving hormonal therapy were randomized to receive 90 mg of pamidronate or placebo as a 2-hour intravenous infusion given in double-blind fashion every 4 weeks for 24 cycles. Patients were evaluated for skeletal complications: pathologic fractures, spinal cord compression, irradiation of or surgery on bone, or hypercalcemia. The skeletal morbidity rate (the ratio of the number of skeletal complications to the time on trial) was the primary efficacy variable. Bone pain, use of analgesics, quality of life, performance status, bone tumor response, and biochemical parameters were also evaluated. RESULTS: One hundred eighty-two patients who received pamidronate and 189 who received placebo were assessable. The skeletal morbidity rate was significantly reduced at 12, 18, and 24 cycles in patients treated with 90 mg of pamidronate (P = .028, .023, and .008, respectively). At 24 cycles, the proportion of patients having had any skeletal complication was 56% in the pamidronate group and 67% in the placebo group (P = .027). The time to the first skeletal complication was longer for patients receiving pamidronate than for those given placebo (P = .049). There was no statistical difference in survival or in objective bone response rate. Pamidronate was well tolerated. CONCLUSION: Treatment with 90 mg of pamidronate as a 2-hour intravenous infusion every 4 weeks in addition to hormonal therapy significantly reduces skeletal morbidity from osteolytic metastases.

This study used summaries of case studies and facility surveys to examine the role of vertical and integrated structures and their effectiveness/efficiency in provision of family planning (FP) services in West Africa. Case studies pertain to Cote dIvoire Nigeria Benin Guinea and Ghana. The case studies offer a description of existing FP structures in each country. The analysis of facility-based surveys pertains to Cote dIvoire and Nigeria and detailed data on resource use among providers. The analysis of surveys and case studies focused on vertical and integrated structures as relevant to the implementation of the 1994 Cairo Plan of Action. Vertical programs operated by nongovernmental organizations (NGOs) provided 44% of all couple-years of protection (CYP) in Cote dIvoire and about 25% in Benin and Guinea. In Nigeria only integrated programs had most of the CYP in 1994. Facility surveys indicate that vertical programs have more efficient staff use. In Cote dIvoire private vertical programs had higher utilization rates than government integrated programs. In Nigeria vertical programs in private or public programs had generally higher utilization rates but results were more ambiguous. Local context appears important in determining effectiveness of vertical vs. integrated programs. It is unclear what the role of higher quality services greater organizational dedication or weakness of the government service system are in determining effectiveness. The trend is for vertical NGOs to expand into government facilities and for IPPF affiliates to include non-FP services in their clinics.