Gender equality, zero hunger and healthy lives and well-being for all, are three of the Sustainable Development Goals (SDGs) that underpin Fiji's National Development Plan. Work towards each of these ...goals contributes to the reduction of non-communicable diseases (NCDs). There are gender differences in NCD burden in Fiji. It is, however, unclear whether a gender lens could be more effectively included in nutrition and health-related policies. This study consisted of three components: (i) a policy content analysis of gender inclusion in nutrition and health-related policies (n = 11); (ii) policy analysis using the WHO Gender Analysis tool to identify opportunities for strengthening future policy; and (iii) informant interviews (n = 18), to understand perceptions of the prospects for gender considerations in future policies. Gender equality was a goal in seven policies (64%); however, most focused on women of reproductive age. One of the policies was ranked as gender responsive. Main themes from key informant interviews were: 1) a needs-based approach for the focus on specific population groups in policies; 2) gender-related roles and responsibilities around nutrition and health; 3) what is considered "equitable" when it comes to gender, nutrition, and health; 4) current considerations of gender in policies and ideas for further gender inclusion; and 5) barriers and enablers to the inclusion of gender considerations in policies. Informants acknowledged gender differences in the burden of nutrition-related NCDs, yet most did not identify a need for stronger inclusion of gender considerations within policies. There is considerable scope for greater inclusion of gender in nutrition and health-related policies in Fiji. This could be done by: 1) framing gender considerations in ways that are actionable and inclusive of a range of gender identities; 2) undertaking advocacy through actor networks to highlight the need for gender-responsive nutrition and health-related policies for key stakeholder groups; 3) ensuring that data collected to monitor policy implementation is disaggregated by sex and genders; and 4) promoting equitable participation in nutrition related issues in communities and governance processes. Action on these four areas are likely critical enablers to more gender equitable NCD reduction in Fiji.
Herpes zoster (HZ) and HZ-associated pain greatly affect patients' quality of life, particularly in older and immunocompromised adults, for whom comorbidities and polypharmacy are often reported. ...Three phase III, randomized, placebo-controlled clinical trials have reported the adjuvanted recombinant zoster vaccine (RZV) as highly efficacious in preventing HZ and reducing pain severity in healthy adults ≥50 years old (Zoster Efficacy Study ZOE-50 study, NCT01165177) and ≥70 years old (ZOE-70; NCT01165229) and in immunocompromised adults ≥18 years old undergoing autologous hematopoietic stem cell transplantation (ZOE-HSCT; NCT01610414). Here, we investigated efficacy of RZV in reducing (i) the duration of clinically significant pain (Zoster Brief Pain Inventory pain score ≥3) and (ii) HZ-associated pain medication use and duration of use in participants with confirmed HZ ("breakthrough cases") from the 3 studies. Recombinant zoster vaccine effectively reduced the duration of clinically significant HZ-associated pain during HZ episodes by 38.5% ( P -value: 0.010) in the ZOE-HSCT study. Although a similar trend was observed in the ZOE-50 and ZOE-70 studies, the results were not statistically significant because of the high vaccine efficacy (VE) against HZ resulting in rare breakthrough cases. VE in reducing pain medication use (39.6%; P -value: 0.008) and duration of medication use (49.3%, P -value: 0.040) was reported in the ZOE-70 study; corresponding positive VE estimates were observed in the ZOE-50 and ZOE-HSCT studies but were not statistically significant. Data reported here demonstrate efficacy of RZV in reducing HZ-associated pain duration and pain medication use in breakthrough cases, thereby improving quality of life of those with HZ.
Objective
To determine whether amyloid imaging with the positron emission tomography (PET) agent Pittsburgh compound B (PiB) can detect vascular β‐amyloid (Aβ) in the essentially pure form of ...cerebral amyloid angiopathy associated with the Dutch‐type hereditary cerebral amyloid angiopathy (D‐CAA) mutation.
Methods
PiB retention in a cortical composite of frontal, lateral, and retrosplenial regions (FLR) was measured by PiB‐PET in 19 D‐CAA mutation carriers (M+; 13 without neurologic symptoms, 6 with prior lobar intracerebral hemorrhage) and 17 mutation noncarriers (M−). Progression of PiB retention was analyzed in a subset of 18 serially imaged individuals (10 asymptomatic M+, 8 M−). We also analyzed associations between PiB retention and cerebrospinal fluid (CSF) Aβ concentrations in 17 M+ and 11 M− participants who underwent lumbar puncture and compared the findings to PiB‐PET and CSF Aβ in 37 autosomal dominant Alzheimer disease (ADAD) mutation carriers.
Results
D‐CAA M+ showed greater age‐dependent FLR PiB retention (p < 0.001) than M−, and serially imaged asymptomatic M+ demonstrated greater longitudinal increases (p = 0.004). Among M+, greater FLR PiB retention associated with reduced CSF concentrations of Aβ40 (r = −0.55, p = 0.021) but not Aβ42 (r = 0.01, p = 0.991). Despite comparably low CSF Aβ40 and Aβ42, PiB retention was substantially less in D‐CAA than ADAD (p < 0.001).
Interpretation
Increased PiB retention in D‐CAA and correlation with reduced CSF Aβ40 suggest this compound labels vascular amyloid, although to a lesser degree than amyloid deposits in ADAD. Progression in PiB signal over time suggests amyloid PET as a potential biomarker in trials of candidate agents for this untreatable cause of hemorrhagic stroke. ANN NEUROL 2019;86:616–625
Introduction
pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance ...testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery.
Methods
Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome.
Results
We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (
p
= 0.01) and Toupet fundoplication (vs. Nissen;
p
= 0.03) were independently associated with greater improvement in GERD-HRQL.
Conclusions
Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.
Enhanced prenatal/postnatal care home visiting programs for Medicaid-insured women have significant positive impacts on care and health outcomes. However, enhanced prenatal care participation rates ...are typically low, enrolling <30% of eligible women. This study investigates the impacts of a population-based systems approach on timely enhanced prenatal care participation and other healthcare utilization.
This quasi-experimental, population-based, difference-in-differences study used linked birth certificates, Medicaid claims, and enhanced prenatal care data from complete statewide Medicaid birth cohorts (2009 to 2015), and was analyzed in 2019–2020. The population-based system intervention included cross-agency leadership and work groups, delivery system redesign with clinical–community linkages, increased enhanced prenatal care–Community Health Worker care, and patient empowerment. Outcomes included enhanced prenatal care participation and early participation, prenatal care adequacy, emergency department contact, and postpartum care.
Enhanced prenatal care (7.4 percentage points, 95% CI=6.3, 8.5) and first trimester enhanced prenatal care (12.4 percentage points, 95% CI=10.2, 14.5) increased among women served by practices with established clincial-community linkages, relative to that among the comparator group. First trimester enhanced prenatal care improved in the county (17.9, 95% CI=15.7, 20.0), emergency department contact decreased in the practices (−11.1, 95% CI= −12.3, −9.9), and postpartum care improved in the county (7.1, 95% CI=6.0, 8.2). Enhanced prenatal care participation for Black women served by the practices improved (4.4, 95% CI=2.2, 6.6) as well as early enhanced prenatal care (12.3, 95% CI=9.0, 15.6) and use of postpartum care (10.4, 95% CI=8.3, 12.4).
A population systems approach improved selected enhanced prenatal care participation and service utilization for Medicaid-insured women in a county population, those in practices with established clinical-community linkages, and Black women.
To assess the impact of disease and treatment on patients with advanced non-small cell lung cancer (NSCLC), we set out to determine a clinically meaningful change (CMC) on the Lung Cancer Subscale ...(LCS) and the Trial Outcome Index (TOI) of the Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire. We used data from Eastern Cooperative Oncology Group study 5592 (E5592), a randomized trial comparing three chemotherapeutic regimens in 599 advanced NSCLC patients. Patients completed the FACT-L at baseline (pretreatment), 6 weeks, 12 weeks, and 6 months. Comparing across baseline performance status (0 vs. 1), prior weight loss (<5% vs. ⩾5%), and primary disease symptoms (⩽1 vs. >1), LCS and TOI score differences ranged from 2.4 to 3.6 and 6.5 to 9.2, respectively (all Ps < .001). Mean improvement in LCS score from baseline to 12 weeks was 2.4 points in patients who had responded to treatment versus 0.0 points in patients who had progressive disease. Twelve-week LCS change scores for patients progressing early were 3.1 points worse than those of patients progressing later (mean = −1.2 vs.1.9, respectively). Similarly, the average TOI change score from baseline to 12 weeks was −6.1 for patients who had progressive disease versus −0.8 points for patients who had responded to treatment. Twelve-week TOI change scores for patients progressing early (mean = −8.1) were 5.7 points worse than those of patients progressing later (mean = −8.1 vs. −2.4, respectively). Analyses assuming nonrandom missing data resulted in slightly larger differences. Clinically relevant change scores were estimated as two to three points for the LCS and five to seven points for the TOI, setting upper limits for minimal CMCs. These values were comparable to suggested distribution-based criteria of a minimally important difference. These results support use of a two to three point change in the LCS and five to six point change on the TOI of the FACT-L as a CMC, and offer practical direction for inclusion of important patient-based endpoints in lung cancer clinical trials.
Children born extremely preterm are at risk for cognitive difficulties and disability. The relative prognostic value of neonatal brain MRI and cranial ultrasound (CUS) for school-age outcomes remains ...unclear. Our objectives were to relate near-term conventional brain MRI and early and late CUS to cognitive impairment and disability at 6 to 7 years among children born extremely preterm and assess prognostic value.
A prospective study of adverse early and late CUS and near-term conventional MRI findings to predict outcomes at 6 to 7 years including a full-scale IQ (FSIQ) <70 and disability (FSIQ <70, moderate-to-severe cerebral palsy, or severe vision or hearing impairment) in a subgroup of Surfactant Positive Airway Pressure and Pulse Oximetry Randomized Trial enrollees. Stepwise logistic regression evaluated associations of neuroimaging with outcomes, adjusting for perinatal-neonatal factors.
A total of 386 children had follow-up. In unadjusted analyses, severity of white matter abnormality and cerebellar lesions on MRI and adverse CUS findings were associated with outcomes. In full regression models, both adverse late CUS findings (odds ratio OR 27.9; 95% confidence interval CI 6.0-129) and significant cerebellar lesions on MRI (OR 2.71; 95% CI 1.1-6.7) remained associated with disability, but only adverse late CUS findings (OR 20.1; 95% CI 3.6-111) were associated with FSIQ <70. Predictive accuracy of stepwise models was not substantially improved with the addition of neuroimaging.
Severe but rare adverse late CUS findings were most strongly associated with cognitive impairment and disability at school age, and significant cerebellar lesions on MRI were associated with disability. Near-term conventional MRI did not substantively enhance prediction of severe early school-age outcomes.
PURPOSE:Recent studies have demonstrated that patients who attend more cardiac rehabilitation (CR) sessions have lower subsequent mortality rates than those who attend fewer sessions.
METHODS:We ...analyzed the impact of several phased-in policy and process changes implemented to increase patient participation in CR. In March 2010, our CR program changed from a policy of individualizing the recommended number of CR sessions per patient to a policy that recommended all 36 CR sessions. In October 2010, we introduced a 7-minute video describing the benefits of CR. In August 2011, we introduced a motivational program that rewarded patients after every sixth CR session. The number of CR sessions attended was determined through review of billing records. Enrollment and completion were defined as attending ≥1 session and ≥30 sessions, respectively.
RESULTS:We identified 1103 patients sequentially enrolled in CR between May 2009 and January 2012. Overall, the median number of sessions per patient improved from 12 to 20 (P < .001). Completion rate improved from 14% to 39% (P < .001). The motivational program increased attendance by a median of 3 sessions per patient (P = .04), but this effect was limited to local CR participants. Financial analysis suggested that for every $100 spent on motivational rewards, patients attended an additional 6.6 (95% CI, −1 to 14) sessions of CR.
CONCLUSIONS:Quality improvement activities significantly increased CR participation. Wide implementation of such programs may favorably impact patient participation in CR and potentially decrease the rate of subsequent cardiac events.
Log and core data document gas saturations as high as 90% in a coarse‐grained turbidite sequence beneath the gas hydrate stability zone (GHSZ) at south Hydrate Ridge, in the Cascadia accretionary ...complex. The geometry of this gas‐saturated bed is defined by a strong, negative‐polarity reflection in 3D seismic data. Because of the gas buoyancy, gas pressure equals or exceeds the overburden stress immediately beneath the GHSZ at the summit. We conclude that gas is focused into the coarse‐grained sequence from a large volume of the accretionary complex and is trapped until high gas pressure forces the gas to migrate through the GHSZ to seafloor vents. This focused flow provides methane to the GHSZ in excess of its proportion in gas hydrate, thus providing a mechanism to explain the observed coexistence of massive gas hydrate, saline pore water and free gas near the summit.
Enterovirus D68 (EV-D68) has been infrequently reported historically, and is typically associated with isolated cases or small clusters of respiratory illness. Beginning in August, 2014, increases in ...severe respiratory illness associated with EV-D68 were reported across the USA. We aimed to describe the clinical, epidemiological, and laboratory features of this outbreak, and to better understand the role of EV-D68 in severe respiratory illness.
We collected regional syndromic surveillance data for epidemiological weeks 23 to 44, 2014, (June 1 to Nov 1, 2014) and hospital admissions data for epidemiological weeks 27 to 44, 2014, (June 29 to Nov 1, 2014) from three states: Missouri, Illinois and Colorado. Data were also collected for the same time period of 2013 and 2012. Respiratory specimens from severely ill patients nationwide, who were rhinovirus-positive or enterovirus-positive in hospital testing, were submitted between Aug 1, and Oct 31, 2014, and typed by molecular sequencing. We collected basic clinical and epidemiological characteristics of EV-D68 cases with a standard data collection form submitted with each specimen. We compared patients requiring intensive care with those who did not, and patients requiring ventilator support with those who did not. Mantel-Haenszel χ(2) tests were used to test for statistical significance.
Regional and hospital-level data from Missouri, Illinois, and Colorado showed increases in respiratory illness between August and September, 2014, compared with in 2013 and 2012. Nationwide, 699 (46%) of 1529 patients tested were confirmed as EV-D68. Among the 614 EV-D68-positive patients admitted to hospital, age ranged from 3 days to 92 years (median 5 years). Common symptoms included dyspnoea (n=513 84%), cough (n=500 81%), and wheezing (n=427 70%); 294 (48%) patients had fever. 338 59% of 574 were admitted to intensive care units, and 145 (28%) of 511 received ventilator support; 322 (52%) of 614 had a history of asthma or reactive airway disease; 200 (66%) of 304 patients with a history of asthma or reactive airway disease required intensive care compared with 138 (51%) of 270 with no history of asthma or reactive airway disease (p=0·0004). Similarly, 89 (32%) of 276 patients with a history of asthma or reactive airway disease required ventilator support compared with 56 (24%) of 235 patients with no history of asthma or reactive airway disease (p=0·039).
In 2014, EV-D68 caused widespread severe respiratory illness across the USA, disproportionately affecting those with asthma. This unexpected event underscores the need for robust surveillance of enterovirus types, enabling improved understanding of virus circulation and disease burden.
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