Tularemia in Germany: the tip of the iceberg?

SUMMARYTularemia is a rare, notifiable zoonosis in Germany. Since November 2004, several lines of evidence including outbreaks in humans or animals and confirmed infections in indigenous hare and rodent populations have indicated a re-emergence of tularemia in different German federal states. Unfortunately, reliable basic information on the seroprevalence in different geographical regions, permitting the identification of risk factors, does not exist. Combining a sensitive screening assay with a highly specific confirmative immunoblot test, we performed a serological investigation on 2416 sera from a population-based, cross-sectional health survey of the city population of Leutkirch, Baden-Wuerttemberg. A total of 56 sera gave positive results indicating a seroprevalence of 2.32%. Thus, the seroprevalence is tenfold higher than that previously reported in a nationwide study in 2004. Francisella tularensis can cause a wide variety of clinical syndromes including severe, sometimes fatal disease. Missing epidemiological data on its spatial and temporal distribution in an endemic country complicate an appropriate risk assessment necessary for public health authorities to be prepared for an adequate outbreak management. This is of special concern regarding the extraordinary potential of F. tularensis as an agent of bioterrorism. Our investigation performed in a presumed low-risk area demonstrated that tularemia might be seriously underestimated in Germany and probably in other central European countries as well.     

Histoplasmosis in eastern India: the tip of the iceberg?

Systemic histoplasmosis has various clinical presentations and is of especially concern in immunocompromised patients. A high index of suspicion is required for its diagnosis. A total of 38 cases had been reported from India up to 1996. The most frequent occurrence of cases was around Calcutta in eastern India where the previous case was detected 20 years earlier. However, we have diagnosed 5 cases in the past 2 years from eastern India which are reported here. These cases may indicate under-diagnosis and under-reporting of histoplasmosis in India. All 5 patients had disseminated disease with multisystem involvement including 2 with bilateral adrenal enlargement. Two were diabetic and only 1 patient was infected with HIV.     

Public skepticism in Canadian healthcare: the real cause of inertia in the system?

Although Canada has not examined issue related to public trust in as much depth as the United States, we can assume that despite improvements in life expectancy, quality of life and infant mortality rates during the past 30 years, Canadians perceive their healthcare to have deteriorated over the last two decades. Should we worry about this phenomenon, and can anything be done about it?     

Variations in occurrences of nutrition-related diseases in Sub-Saharan Africans in stages of transition: what of the future?

In many Sub-Saharan African populations, in particular urban dwellers, there have been marked rises in the prevalences of obesity in women, hypertension, diabetes, and cerebral vascular disease. Yet there have been only slight rises in coronary heart disease. To learn more of the roles of the various influencing factors in the puzzling situations described, some aspects of the past and present occurrences of these diseases are described and discussed, with comparisons being made with corresponding situations in African Americans, as well as in certain white populations. Despite increases in the knowledge of influencing factors, such fail to explain fully the epidemiologic situations described. As to the future, judging from the experiences of other populations, despite continuing indigence, within the next generation significant rises in coronary heart disease in certain African populations seem to be inevitable. However, in many of those populations, in particular those in the South, the extent of changes, apart from those linked with level of socioeconomic state, will be strongly affected by the rising epidemic of human immunodeficiency virus and acquired immunodeficiency syndrome.     

Aspirin in the primary prevention of cardiovascular disease in the Women’s Health Study: Effect of noncompliance

Randomized evidence for aspirin in the primary prevention of cardiovascular disease (CVD) among women is limited and suggests at most a modest effect for total CVD. Lack of compliance, however, can null-bias estimated effects. We used marginal structural models (MSMs) to estimate the etiologic effect of continuous aspirin use on CVD events among 39,876 apparently healthy female health professionals aged 45 years and older in the Women's Health Study, a randomized trial of 100 mg aspirin every other day versus placebo. As-treated analyses and MSMs controlled for time-varying determinants of aspirin use and CVD. Predictors of aspirin use differed by randomized group and prior use and included medical history, CVD risk factors, and intermediate CVD events. Previously reported intent-to-treat analyses found small non-significant effects of aspirin on total CVD (hazard ratio (HR) = 0.91, 95 % confidence interval (CI) = 0.81-1.03) and CVD mortality (HR = 0.95, 95 % CI = 0.74-1.22). As-treated analyses were similar for total CVD with a slight reduction in CVD mortality (HR = 0.88, 95 % CI = 0.67-1.16). MSMs, which adjusted for non-compliance, were similar for total CVD (HR = 0.93; 95 % CI: 0.81, 1.07) but suggested lower CVD mortality with aspirin use (HR = 0.76; 95 % CI: 0.54, 1.08). Adjusting for non-compliance had little impact on the estimated effect of aspirin on total CVD, but strengthened the effect on CVD mortality. These results support a limited effect of low-dose aspirin on total CVD in women, but potential benefit for CVD mortality.     

Was there a disparity in age appropriate infant immunization uptake in the theatre of war in the North of Sri Lanka at the height of the hostilities?: a cross-sectional study in resettled areas in the Kilinochchi district

Background

It was long speculated that there could be under-immunized pockets in the war affected Northern part of Sri Lanka relative to other areas. With the cessation of hostilities following the military suppression of the rebellion, opportunities have arisen to appraise the immunization status of children in areas of re-settlement in former war ravaged districts.

Methods

We conducted a cross-sectional study to describe the coverage and age appropriateness of infant vaccinations in a former conflict district during the phase of re-settlement. The target population comprised all children of re-settled families in the age group of 12 – 23 months in the district. We selected a study sample of 300 children from among the target population using the WHO’s 30 cluster EPI survey method. Trained surveyors collected data using a structured checklist. The infant vaccination status was ascertained by reviewing vaccination records in the Child Health Development Record or any other alternative documentary evidence.

Results

The survey revealed that the proportion of fully vaccinated children in the district was 91%. For individual vaccines, it ranged from 92% (measles) to 100% (BCG, DPT/OPV1). However, the age appropriateness of vaccination was less than 50% for all antigens except for BCG (94%). The maximum number of days of delay of vaccinations ranged from 21 days for BCG to 253 days for measles. Age appropriate vaccination rates significantly differed for DPT/OPV1-3 and measles during the conflict and post-conflict stages while it did not for the BCG. Age appropriate vaccination rates were significantly higher for DPT/OPV1-3 during the conflict while for the measles it was higher in the post conflict stage.

Conclusions

Though the vaccination coverage for infant vaccines in the war affected Kilinochchi district was similar to other districts in the country, it masked a disparity in terms of low age-appropriateness of infant immunizations given in field settings. This finding underscores the need for investigation of underlying reasons and introduction of remedial measures in the stage of restoring Primary Health Care services in the ex-conflict zone.

     

Participative observation: standing in the shoes of others?

This article argues that participant observation is more than mere method and in need of greater theoretical attention. This is particularly true for its more participative forms, which are inseparable from assumptions about the role of the body in the generation of knowledge. Drawing on fieldwork experience, parallels are noted between participative observation and the clinical practice of nursing, for example, their reliance on physical involvement, their claims to experiential knowledge, and the associated theoretical assumptions they share, such as a reciprocity of perspective between subject and object. Such assumptions need to be examined if the knowledge learnt through participation is to carry-weight.     

Empowered parents: the role of self-efficacy in parental mediation of children’s smartphone use in the United States

This study examines how different types of self-efficacy – media competency, perceived parenting abilities, and perceived control over parental mediation practices – influence the extent to which parents mediate their children’s use of smartphones. A survey conducted with parents of young smartphone users aged 10–17 in the United States (N = 304) reveals that parents who feel confident about their own smartphone skills view themselves as good parents and believe that they have control over their parental mediation practices and are more likely to engage in parental mediation of children’s smartphone use. The findings also indicate that when parents are less confident about their smartphone skills, those with higher parenting competencies are more likely to engage in discussion-based active mediation than those with lower parenting competencies.     

Recall of physical activity in the distant past: the 32-year follow-up of the Prospective Population Study of Women in Göteborg, Sweden

It has been of interest to researchers in chronic disease epidemiology to determine whether elderly subjects can accurately recall their physical activity patterns in the distant past. As part of a 32-year follow-up of the Prospective Population Study of Women in G?teborg, Sweden, 433 participants currently aged 70-92 years recalled their leisure-time physical activity at the original examination in 1968, when they had been 38-60 years of age. Using a four-point scale, subjects were originally asked to describe leisure-time activity during the previous 12 months. Identical questions were asked in 2000 describing levels in 1968 and current levels. Subjects were more likely to overestimate their previous activity level than to underestimate it: 43.9% of women classified themselves consistently at both examinations; 48.7% overestimated and 7.4% underestimated their previous activity levels. Using current activity as a proxy for recalled levels did not improve the moderate agreement with activity as originally reported in 1968. The average magnitude of the recall bias (recalled minus original values) amounted to one half of a unit on the four-point scale and was not significantly associated with age or body mass index. In summary, systematic errors were observed in remote physical activity recalls by elderly women, who generally remembered being more active 32 years earlier than they had originally reported. Physical activity recall questionnaires for the distant past should be used with caution, particularly in older populations.     

Following in the footsteps of smallpox: can we achieve the global eradication of measles?

Background  

Although an effective measles vaccine has been available for almost 40 years, in 2000 there were about 30 million measles infections worldwide and 777,000 measles-related deaths. The history of smallpox suggests that achieving measles eradication depends on several factors; the biological characteristics of the organism; vaccine technology; surveillance and laboratory identification; effective delivery of vaccination programmes and international commitment to eradication.     

Geometric analysis of macronutrient intake in humans: the power of protein?

We introduce a state-space, geometrical approach that has previously been derived and tested using non-human animals and aim to demonstrate that it has the potential to generate testable hypotheses and provide novel insights into human nutrition and diet selection. This 'Geometric Framework' is unusual in that it focuses on the interactions between dietary constituents, and thus emphasizes the manner in which organisms regulate the balance of nutrients ingested. We report results from a pilot study, which indicate that protein ingestion is more strongly regulated than carbohydrate+fat. On the basis of these results and a brief survey of other experimental and population-level data, we hypothesize that regulation of protein intake may explain more of the modern human nutritional condition than has previously been appreciated.     

Rural–urban disparities in the utilization of mental health inpatient services in China: the role of health insurance

Reducing rural–urban disparities in health and health care has been a key policy goal for the Chinese government. With mental health becoming an increasingly significant public health issue in China, empirical evidence of disparities in the use of mental health services can guide steps to reduce them. We conducted this study to inform China’s on-going health-care reform through examining how health insurance might reduce rural–urban disparities in the utilization of mental health inpatient services in China. This retrospective study used 10 years (2005–2014) of hospital electronic health records from the Shandong Center for Mental Health and the DaiZhuang Psychiatric Hospital, two major psychiatric hospitals in Shandong Province. Health insurance was measured using types of health insurance and the actual reimbursement ratio (RR). Utilization of mental health inpatient services was measured by hospitalization cost, length of stay (LOS), and frequency of hospitalization. We examined rural–urban disparities in the use of mental health services, as well as the role of health insurance in reducing such disparities. Hospitalization costs, LOS, and frequency of hospitalization were all found to be lower among rural than among urban inpatients. Having health insurance and benefiting from a relatively high RR were found to be significantly associated with a greater utilization of inpatient services, among both urban and rural residents. In addition, an increase in the RR was found to be significantly associated with an increase in the use of mental health services among rural patients. Consistent with the existing literature, our study suggests that increasing insurance schemes’ reimbursement levels could lead to substantial increases in the use of mental health inpatient services among rural patients, and a reduction in rural–urban disparities in service utilization. In order to promote mental health care and reduce rural–urban disparities in its utilization in China, improving rural health insurance coverage (e.g., reducing the coinsurance rate) would be a powerful policy instrument.     

Gastric cancer: risk factors in patients treated in tertiary care services of a municipality in the interior of the state of Sâo Paulo

This study was developed with gastric cancer patients submitted to surgery with the purpose to identify their exposure to risk factors for the disease. Twenty-four clients who had agreed to participate by signing an informed consent term and responding a semi-structured instrument elaborated according to the Health Field perspective were the subjects in the study. The data analysis allowed to identify that 50.1% referred to inadequate diet, smoking, alcoholism and psychological problems as the responsible factors. With regard to the consumption of food considered to be harmful, there was a tendency to larger consumption of canned food, sausages, smoked and barbecued meat and fried food in addition to diets with high sodium content. 66.7% smoke or used to smoke and 70.8% indicated the consumption of alcoholic drinks, preferably beer or distilled types. These data show the need to implement educational programs with the purpose to inform about risk factors aiming at health promotion.