Bicycle helmet campaigns and head injuries among children. Does poverty matter?

Objectives   To assess the impact of a community-based bicycle helmet programme aimed at children aged 5–12 years (about 140 000) from poor and well-off municipalities.
Methods   A quasi-experimental design, including a control group, was used. Changes in the risk of bicycle-related head injuries leading to hospitalization were measured, using rates ratios.
Results   Reductions in bicycle-related head injuries were registered in both categories of municipalities. Compared with the pre-programme period, the protective effect of the programme during the post-programme period was as significant among children from poor municipalities (RR 0.45; 95% CI 0.26–0.78) as among those from richer municipalities (RR 0.55; 95% CI 0.41–0.75).
Conclusion   Population-based educational programmes may have a favourable impact on injury risks in poor areas despite lower adoption of protective behaviours.     

The physical environment as a fall risk factor in older adults: Systematic review and meta-analysis of cross-sectional and cohort studies

Background/aim:  Evidence that the physical environment is a fall risk factor in older adults is inconsistent. The study evaluated and summarised evidence of the physical environment as a fall risk factor.
Methods:  Eight databases (1985–2006) were searched. Investigators evaluated quality of two categories (cross-sectional and cohort) of studies, extracted and analysed data.
Results:  Cross-sectional: falls occur in a variety of environments; gait aids were present in approximately 30% of falls.
Cohort:  Home hazards increased fall risk (odds ratio (OR) = 1.15; 95% confidence interval (CI): 0.97–1.36) although not significantly. When only the high quality studies were included, the OR = 1.38 (95% CI: 1.03–1.87), which was statistically significant. Use of mobility aids significantly increased fall risk in community (OR = 2.07; 95% CI: 1.59–2.71) and institutional (OR = 1.77; 95% CI: 1.66–1.89) settings.
Conclusions:  Home hazards appear to be a significant risk factor in older community-dwelling adults, although they may present the greatest risk for persons who fall repeatedly. Future research should examine relationships between mobility impairments, use of mobility aids and falls.     

Mentorship in postgraduate training programmes: views of Canadian programme directors

Objectives  Many academic training programmes have developed mentorship programmes for postgraduate doctors in training, but little is known about the factors that influence their establishment.
Methods  Canadian postgraduate training directors were surveyed to determine views on mentorship and factors associated with the establishment of these programmes.
Results  A total of 199 of 344 (58%) programme directors completed an online survey. Overall, 65% of respondents reported that their training programmes had a mentorship programme and 40% felt there was a need for more structured mentorship in training programmes. Univariate analysis showed that mentorship programmes were present significantly more often in larger programmes, internal medicine-based training programmes, and in programmes where the acting programme director had either been part of a mentorship programme during his or her own training or felt that mentorship had played an important role in his or her professional development. In adjusting for covariates using a logistic regression analysis, only those factors directly attributable to a programme director's personal mentoring experiences remained significantly associated with having a mentorship programme. Those who felt that mentorship had played a role in their own careers ( P  = 0.008, odds ratio [OR] = 3.3, 95% confidence interval [CI] 1.7–6.6) or who had been part of a mentorship programme during their own training ( P  = 0.01, OR = 6.6, 95% CI 1.4–30.1) were more likely to have an active mentorship programme at their institution.
Conclusions  A need for more structured mentorship was identified for many training programmes. Overall, programme directors' previous mentoring experiences were independently associated with having a mentorship programme.     

The Effect of Waiting Time on Health-Related Quality of Life, Pain, and Physical Function in Patients Awaiting Primary Total Hip Replacement: A Randomized Controlled Trial

Objective:  This prospective randomized study assessed the effect of waiting time (WT) on health outcomes in Finnish patients admitted to hospital for primary total hip replacement (THR).
Methods:  A total of 395 consecutive patients with a need for a primary THR because of osteoarthritis and who were placed on the waiting list between August 2002 and November 2003. After placement on the waiting list, the patients were randomly assigned to a short WT (≤3 months) group (n = 174) or a nonfixed WT group (n = 221). The patients completed self-administered questionnaires at the time of placing on the waiting list and at hospital admission. Health-related quality of life was measured by the generic 15D instrument. Hip pain and function were measured by the patient self-report Harris hip score (HHS).
Results:  Of the 395 patients, 312 (79%) completed the follow-up (140 patients with short and 172 with nonfixed WT). At admission, the mean 15D scores for patients with short and nonfixed WT were 0.784 and 0.783, respectively. In the intention-to-treatment analysis, the difference between the groups (Δ0.001, 95% confidence interval [CI]: –0.019 to 0.021) was not statistically significant or clinically important. The mean self-report HHS in patients with short WT was 43.5, and among those with nonfixed WT was 41.9. The difference (Δ1.6, 95% CI: –1.77 to 4.87) was not statistically significant.
Conclusions:  Both generic and disease-specific measures revealed that longer WTs did not result in poorer health status at admission.     

Influences on participation in a community-based colorectal neoplasia screening program by virtual colonoscopy in Australia

Objective : To determine the effect of certain personal and health behaviour characteristics on participation in a community-based colorectal neoplasia (CRN) screening program using virtual colonoscopy.
Methods : The study population comprised randomly selected subjects from the State electoral roll; screening by virtual colonoscopy was offered through letter of invitation. For non-responders, a further invitation was sent a month later. Non-response after a further month led to subjects being considered non-participants. Non-participants were contacted by letter to complete a structured questionnaire; participants completed a similar questionnaire immediately after their screening virtual colonoscopy.
Results : Discussing the invitation to screening with someone else increased the likelihood of participation by 63% (prevalence ratio 1.63, 95% CI 1.38–1.93); knowing someone with cancer increased the likelihood of participation by 23% (PR 1.23, 95% CI 1.07–1.42). Among participants who discussed screening with another individual, the spouse was the most common (71%). Subjects who were single were less likely to participate (PR 0.79, 95% CI 0.67–0.94). The strongest reported influence for participation was information provided in the letter of invitation (29.8%). The most common reasons for non-participation were lack of time and perceived good health.
Conclusions and Implications : This study suggests that a simple strategy to facilitate participation is to encourage subjects to discuss screening with others; further, to recognise that this may be most difficult for those who are single. Information provided to subjects prior to screening positively contributes to participation.     

Psychiatric symptoms and disorders in adolescents with low birthweight

Objective   To evaluate the prevalence of psychiatric symptoms and disorders associated with low birthweight.
Design/study groups   A population-based follow-up study of 56 very low birthweight (VLBW: birthweight ≤1500 g), 60 term small for gestational age (SGA: birthweight <10th centile), and 83 term control (birthweight ≥10th centile) children at 14 years of age.
Outcome measures   Schedule for affective disorders and schizophrenia for school-aged children, attention deficit/hyperactivity disorder (ADHD) rating scale IV, autism spectrum screening questionnaire, and children's global assessment scale.
Results   VLBW adolescents had a higher prevalence of psychiatric symptoms (46%) than controls (13%) [odds ratio (OR) 5.7, 95% confidence interval (CI) 2.5–13.0] and, more psychiatric disorders (25%) than controls (7%) (OR 4.3, 95% CI 1.5–12.0), especially anxiety disorders. Although 25% of the VLBW adolescents had attention problems, ADHD was diagnosed in only 7%. Four VLBW adolescents had symptoms of Asperger's disorder, and the VLBW group had a higher sum score than controls on the autism spectrum screening questionnaire. Although more SGA adolescents had psychiatric symptoms than controls (23% vs. 13%), the difference was not statistically significant. Results remained essentially the same when adolescents with low estimated intelligence quotient were excluded, and persisted after possible psychosocial confounders had been controlled for.
Conclusion   VLBW, but not SGA adolescents, have a high risk of developing psychiatric symptoms and disorders by the age of 14, especially attention deficit, anxiety symptoms and relational problems.     

Service Utilization and Health-Care Costs in the Advanced Elderly

Objectives:  Despite their increasing importance, the advanced elderly are often neglected in service utilization and costing studies. The purpose of this study was to analyze from societal perspective service utilization and direct health-care costs and its predictors in the advanced elderly population.
Methods:  A bottom-up costing study was conducted using a cross-sectional primary care sample aged 75+ (n = 452) in Germany. The main instruments were a questionnaire of service utilization and costs administered by an interviewer and the chronic disease score (CDS). Predictors were derived by means of multivariate regression models.
Results:  Respondents caused mean direct costs of €3730 (95% CI 3203–4257) in prices of 2004/2005. This included inpatient care 34%, pharmaceuticals 29%, outpatient physician services 15%, nursing care 10%, medical supply and dentures 6%, outpatient nonphysician providers 5%, assisted living 1%, and transportation 2%. A shift from lower to middle education and a one-point increase in CDS were associated with an increase of €1678 (95% CI 250–3369) and €482 (95% CI 316–654), respectively. Total mean direct costs did not differ significantly between sexes. Ischemic heart disease and diabetes mellitus were associated with excess costs of €711 and €290, both being not significant. Altogether 55% of the respondents accounted for 90% of total direct costs.
Conclusions:  Advanced elderly used a wide range of health services. Our study still underestimates the true costs to society. Further research should focus on economic evaluation of new health-care programs for this increasingly important age group.     

Motor skills in adolescents with low birthweight

Background   Minor motor problems have been reported in low birthweight children, but few studies have assessed motor skills in adolescents.
Objective   To examine the prevalence of motor problems in adolescents with low birthweight.
Methods   Fifty-four very low birthweight (VLBW: birth weight ≤1500 g), 59 term small for gestational age (SGA: birthweight <10th centile), and 83 control (birthweight ≥10th centile at term) children were assessed with the movement assessment battery for children (Movement ABC) at the age of 14 in a population-based study.
Results   One in four VLBW children [odds ratio (OR) 9.3, 95% confidence interval (CI) 2.5–34.5] and one in six SGA children (OR 4.7, 95% CI 1.2–18.4) had motor problems compared with controls (3.7%). There were no sex differences in motor problems in the VLBW group, and the increased risk was consistent across the continuum of the Movement ABC. For SGA children, the increased risk of motor problems was particularly in manual dexterity in boys.
Conclusion   VLBW and SGA adolescents have increased risk of motor problems compared with control children.     

A Longitudinal Analysis of Outcomes Associated with Abciximab and Eptifibatide in a Consecutive Series of 3074 Percutaneous Coronary Interventions

Background:  Although the efficacy of platelet glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa) in reducing complication rates during percutaneous coronary intervention (PCI) is well established, comparative studies assessing currently approved agents as administered in current practice are limited. We studied the clinical and length of stay (LOS) outcomes of patients undergoing PCI who received either abciximab or eptifibatide.
Methods:  All patients undergoing elective, urgent, or emergency PCI at Mayo Clinic Rochester between November 17, 2000 and August 31, 2004 who received either abciximab or eptifibatide were included. Clinical, angiographic, and follow-up data were prospectively recorded in the Mayo Clinic PCI Registry; administrative data recorded LOS. We used logistic and Cox proportional hazard models to estimate the risk of adverse events and generalized linear modeling to predict LOS. Propensity score and standard risk adjustments were used to account for baseline differences.
Results:  A total of 2123 PCI patients received eptifibatide and 951 received abciximab. The adjusted odds ratio for in-hospital death and myocardial infarction (MI) with eptifibatide was 0.80 (95% CI 0.56–1.14, P  = 0.21) versus abciximab. Adjusted hazard ratios for death and MI and for death, MI, or target vessel revascularization during a median follow-up of 24.6 months were 0.84 (95% CI 0.68–1.02, P  = 0.08) and 0.95 (95% CI 0.81–1.11, P  = 0.53), respectively. Adjusted postprocedural LOS was similar at 3.4 days.
Conclusion:  This large observational study found no evidence of a clinical or LOS advantage to physician choice of either abciximab or eptifibatide during PCI in contemporary practice.     

Association between folate, vitamin B6 and vitamin B12 intake and depression in the SUN cohort study

Background:  An association between low blood levels of folate, vitamins B₆ and B₁₂ and a higher prevalence of depressive symptoms has been reported in several epidemiological studies. The present study aimed to assess the association between folate, vitamins B₆ and B₁₂ intake and depresion prevalence in the SUN cohort study.
Methods:  The study comprised a cross-sectional analysis of 9670 participants. A validated semi-quantitative food frequency questionnaire was used to ascertain vitamin intake. The association between the baseline intake of folate, vitamins B₆ and B₁₂ categorised in quintiles and the prevalence of depression was assessed. The analyses were repeated after stratifying by smoking habits, alcohol intake, physical activity and personality traits.
Results:  Among women, odds ratios (OR) [95% confidence interval (CI)] for the third to fifth quintile for vitamin B₁₂ intake were 0.58 (0.41–0.84), 0.56 (0.38–0.82) and 0.68 (0.45–1.04), respectively. Among those men with a low level of anxiety and current smokers, a significant positive association between low folate intake and the prevalence of depression was found. The OR (95% CI) for the first quintile of intake was 2.85 (1.49–5.45) and 2.18 (1.08–4.38), respectively, compared to the upper quintiles of intake (Q2–Q5) considered as a group.
Conclusion:  Low folate intake was associated with depression among currently smoking men and men with low anxiety levels. Low intake of vitamin B₁₂ was associated with depression among women. No significant associations were found for vitamin B₆ intake.     

Mortality among participants and non-participants in a prospective cohort study

Socioeconomic position and lifestyle often affect participation in scientific studies. The authors investigated differences in overall and cause-specific mortality between participants and non-participants in the prospective Danish cohort study “Diet, Cancer and Health” and the association between non-participation and mortality by socioeconomic position. A total of 80,996 men and 79,729 women aged 50–64?years, were invited. The authors obtained register data on education, income, death and cause-specific mortality for participants and non-participants and used survival curves to examine differences in overall mortality. Poisson regression models were used to estimate the mortality rate ratio (MRR) by socioeconomic group and by cause of death of participants and non-participants. After a median follow-up of 13?years (5–95 percentiles, 5–14?years), the MRRs for overall mortality among non-participants were 2.09 (95?% CI 1.99–2.14) and 2.29 (95?% CI 2.19–2.40) among men and women, respectively compared with participants. After adjusting for socioeconomic position, the MRRs changed to 1.73 (95?% CI 1.66–1.79) and 2.10 (95?% CO 2.01–2.20) among men and women, respectively. The MRRs did not level out after up to 15?years of follow-up. The MRRs were all significantly increased and ranged from 1.51 to 4.28 for men, depending on the cause of death, and from 1.60 to 3.99 for women. Clear differences in mortality from all investigated causes of death were found between participants and non-participants, which persisted after up to 15?years of follow-up. Socioeconomic position had little effect on this result.     

Characteristics of non-participants in comprehensive health examinations ("Otasha-kenshin") among an urban community dwelling elderly: basic research for prevention of the geriatric syndrome and a bed-ridden state

PURPOSE: The present study was conducted to identify the characteristics of non-participants in secondary comprehensive health examinations among community-dwelling elderly. METHODS: The subjects were 728 men and 984 women aged 70 years and over who had participated in comprehensive health examinations in 2002. Multiple logistic regression analysis was performed to assess the characteristics associated with non-participation in comprehensive health examinations after 2 years (in 2004). RESULTS: The rates of participation in follow-up health examinations were 66.3% for men and 67.3% for women. Logistic regression analysis showed that male non-participants had low cognitive function (odds ratio (OR) = 2.19, 95% confidence interval (CI) = 1.07-4.49), low education (OR = 1.58, 95% CI = 1.22-2.22), and suffered from health problems (OR = 1.82, 95% CI = 1.27-2.59), and that female non-participants had low cognitive function (OR = 2.01, 95% CI 1.13-3.59), tended to be smokers (OR = 2.05, 95%, CI = 1.13-3.72), and had no hobby (OR = 0.68, 95% CI = 0.50-0.92). CONCLUSION: Poor cognitive function, health problems, and unfavorable lifestyle factors are related to non-participation in comprehensive health examinations. PROPOSAL: It is necessary to devise various approaches to encourage participation of such individuals.     

Caesarean section and gastrointestinal symptoms, atopic dermatitis, and sensitization during the first year of life

Aims   To investigate the effect of Caesarean section on gastrointestinal symptoms, atopic dermatitis and sensitization to nutritional allergens in infants.
Methods   A total of 865 healthy full-term neonates with parental history of allergy participating in the prospective German Infant Nutritional Intervention Program (GINI) were exclusively breastfed during the first four months of life and had a one year follow-up. Data were obtained by follow-up visits at age 1, 4, 8, and 12 months, weekly diaries for the first six months, and measurement of total and specific IgE at birth and 12 months.
Results   Infants born by Caesarean section (147/865, 17%) had a greater risk of diarrhoea (OR_adj 1.46, 95% CI 1.022–2.10) and sensitization to food allergens, both in adjusted (OR_adj 2.06, 95% CI 1.123–3.80) and stratified analyses (by cord blood IgE). Caesarean delivery was not associated with colicky pain and atopic dermatitis.
Conclusion   Caesarean delivery might be a risk factor for diarrhoea and sensitization in infants with family history of allergy. Further research in this area seems warranted as choosing Caesarean section becomes increasingly popular.     

Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country

Background   Programmes that promote early psychological development of children in the developed world have been found to be beneficial. However, such programmes are rare in underprivileged parts of the developing world. We adapted one such parent-based programme (Learning Through Play) for a rural Pakistani population and aimed to study if: (1) it was acceptable to community health workers; (2) the programme led to an improvement, after a period of 6 months, in mothers' knowledge and attitudes about early infant development; (3) it led to a reduction in the levels of maternal mental distress in the post-natal period.
Methods   Using a cluster randomized design with villages as unit of randomization, 163 mothers from 24 villages in a rural sub-district of Rawalpindi, Pakistan, received the 'Learning Through Play' programme, whereas 146 mothers from 24 villages acted as controls. Twenty-four community health workers were trained to carry out the programme. Assessments were conducted using a specially developed 15-item Infant Development Questionnaire and the 20-item Self-Reporting Questionnaire (SRQ).
Results   Over 80% of the community health workers trained found the programme to be relevant and were able to integrate it into their routine work. There was a significant increase in mothers' knowledge and positive attitudes about infant development in the intervention group, compared with the control group. Women in the intervention group answered correctly 4.3 (95% CI 3.7–14.9, P  < 0.001) more questions than the control group. There was no difference in levels of mental distress measured by the SRQ.
Conclusions   The 'Learning Through Play' programme was successfully integrated into the existing health system and accepted by community health workers. The programme succeeded in improving the knowledge and attitudes of mothers about infant development.     

Preference-Based Quality of Life of Patients on Renal Replacement Therapy: A Systematic Review and Meta-Analysis

Objectives:  Various utility measures have been used to assess preference-based quality of life of patients with end-stage renal disease (ESRD). The purposes of this study were to summarize the literature on utilities of hemodialysis (HD), peritoneal dialysis (PD), and renal transplantation (RTx) patients, to compare utilities between these patient groups, and to obtain estimates for quality-of-life adjustment in economic analyses.
Methods:  We searched the English literature for studies that reported visual analog scale (VAS), time trade-off (TTO), standard gamble (SG), EuroQol-5D (EQ-5D), and health utilities index (HUI) values of ESRD patients. We extracted patient characteristics and utilities and calculated mean utilities and 95% confidence intervals (CIs) for categories defined by utility measure and treatment modality using random-effects models.
Results:  We identified 27 articles that met the inclusion criteria. VAS articles were too heterogeneous to summarize quantitatively and we found only one study reporting HUI values. Thus, we summarized utilities from TTO, SG, and EQ-5D studies. Mean TTO and EQ-5D-index values were lower for dialysis compared to RTx patients, though not statistically significant for TTO values (TTO values: HD 0.61, 95% CI 0.54–0.68; PD 0.73, 95% CI 0.61–0.85; RTx 0.78, 95% CI 0.63–0.93; EQ-5D-index values: HD 0.56, 95% CI 0.49–0.62; PD 0.58, 95% CI 0.50–0.67; RTx 0.81, 95% CI 0.72–0.90). Mean HD versus PD associated TTO, EQ-5D-index and EQ-VAS values were not statistically significantly different.
Conclusion:  RTx patients tended to have a higher utility than dialysis patients. Among HD and PD patients, there were no statistically significant differences in utility.     

Randomized intervention trial on preventive home visits to older people: baseline and follow-up characteristics of participants and non-participants

AIMS: In controlled intervention studies, a selective non-response or refusal to participate at baseline may bias measurable effects of the intervention. The aim of this study was to compare mortality and nursing home admission among older persons who accepted (participants) and older person who declined (non-participants) to join a controlled feasibility trial, and to describe and evaluate defined subgroups of non-participants. METHODS: Prospective controlled three-year intervention study (1999-2001) in 34 Danish municipalities with five-year follow-up. Randomization and intervention (education of municipality employees) was done at municipality level. In total 5,788 home-dwelling 75- and 80-year-olds living in these municipalities were invited to participate in the study. Written consent was obtained from 4,060 persons (participation rate 71%). RESULTS: During five-year follow-up non-participants had a higher mortality rate (survival analysis risk ratio RR = 1.5, 95% CI = 1.3-1.7, p<0.0001) and a higher rate of nursing home admissions (RR = 1.7, 95% CI = 1.3-2.1, p<0.0001) compared with participants. Subgroups of non-participants describing themselves as "too ill" and persons "not reached" had a significantly higher mortality rate and risk of admission to nursing home than participants, whereas the subgroups of non-participants describing themselves as "too healthy" and having "another reason for refusal" did not differ from the participants. There was no difference in mortality rates between non-participants living in intervention municipalities compared with non-participants living in control municipalities. CONCLUSIONS: Mortality and nursing home admissions were higher among non-participants. Selection participation bias was of no clinical importance since subgroups of non-participants eligible for the intervention did not differ from the participants.     

Livelihood outcomes in a cohort of youth with disabilities following participation in an economic empowerment programme in rural Uganda

BackgroundLittle evidence exists on the livelihoods of young people with disabilities in low- and middle-income settings.ObjectiveThis study examined employability and livelihood outcomes among a cohort of youth with disabilities who participated in an economic empowerment programme in rural Uganda.MethodsProspective cohort of youth with disabilities participating in an economic empowerment programme in rural Uganda. Livelihood outcomes of participants were assessed through structured interviews at baseline (n = 297) and again at 12 months (n = 252) and analysed using chi-squared tests and generalized estimating equations.ResultsOf 297 participants at baseline, 144 (48%) were women and the mean age was 21.7 years. At 12 months follow-up, participants were significantly more likely to have a job (OR 3.04, 95% CI 2.10–4.39); to have accessed finance (OR 5.52, 95% CI 3.18–9.56); and experienced community support (OR 2.23, 95% CI 1.51–3.29) compared with baseline. There were no statistically significant changes in having enough money for food or in having experienced community discrimination.ConclusionsThe findings suggest that targeted vocational skills training, apprenticeships scheme and a start-up financial package may improve the livelihoods of young people living with disabilities in rural African settings.     

Student portfolios and the hidden curriculum on gender: mapping exclusion

Context  The hidden curriculum – the norms, values and practices that are transmitted to students through modelling by preceptors and teachers, and decisions about curricular exclusions and inclusions – can be profoundly important in the socialising of trainee doctors. However, tracking the hidden curriculum as it evolves can be challenging for medical schools.
Objectives  This study aimed to explore the content of student e-portfolios on gender issues, a key perspective often taught through a hidden curriculum.
Methods  Online posts for a gender and medicine e-portfolio task completed by two cohorts of students in Year 3 of a 4-year medical course (n = 167, 66% female) were analysed using a grounded theory approach.
Results  A process of gendered 'othering' was applied to both men and women in the medical school using different pedagogical strategies. Curricular emphases on women's health and lack of support for male students to acquire gynaecological examination skills were seen as explicit ways of excluding males. For female medical students, exclusion tended to be implicit, operating through modelling and aphoristic comments about so-called 'female-friendly' career choices and the negative impact of motherhood on career.
Discussion  E-portfolios can be a useful way of tracking the hidden curriculum as it evolves. Responses to gendered exclusion may be developed more readily for the explicit processes impacting on male students than for the implicit processes impacting on female students, which often reflect structural issues related to training and employment.