The epidemiology of invasive group A streptococcal disease in Victoria, Australia

OBJECTIVE: To estimate the incidence and severity of invasive group A streptococcal infection in Victoria, Australia. DESIGN: Prospective active surveillance study. SETTING: Public and private laboratories, hospitals and general practitioners throughout Victoria. PATIENTS: People in Victoria diagnosed with group A streptococcal disease notified to the surveillance system between 1 March 2002 and 31 August 2004. MAIN OUTCOME MEASURE: Confirmed invasive group A streptococcal disease. RESULTS: We identified 333 confirmed cases: an average annual incidence rate of 2.7 (95% CI, 2.3-3.2) per 100,000 population per year. Rates were highest in people aged 65 years and older and those younger than 5 years. The case-fatality rate was 7.8%. Streptococcal toxic shock syndrome occurred in 48 patients (14.4%), with a case-fatality rate of 23%. Thirty cases of necrotising fasciitis were reported; five (17%) of these patients died. Type 1 (23%) was the most frequently identified emm sequence type in all age groups. All tested isolates were susceptible to penicillin and clindamycin. Two isolates (4%) were resistant to erythromycin. CONCLUSION: The incidence of invasive group A streptococcal disease in temperate Australia is greater than previously appreciated and warrants greater public health attention, including its designation as a notifiable disease.     

Deficient inflammatory response to UV radiation in neonatal mice

Mechanisms of juvenile susceptibility to cancer are not well understood. The immune response in neonates favors nonresponsiveness or T(H)2-dominant responses, raising the question of a role for neonatal immunity in this susceptibility. We have investigated the postulate that the inflammatory response differs in neonatal and adult skin. We found no inflammatory infiltrate into neonatal mouse skin in response to UV irradiation as a function of time, dose, or wavelength, although UV-induced DNA damage was readily detected. In contrast, UV irradiation of adult mice initiated a dose- and time-dependent influx of inflammatory cells, chiefly CD11b(+)Ly6G(+) neutrophils, into the skin, detected by immunohistochemistry and quantitated by FACS analysis. This inflammatory response was initiated by UVB (290-320 nm) but not by UVA (320-400 nm). Further, in neonates, in contrast to adults, neither topical trinitrochlorobenzene (TNCB) nor i.p. thioglycollate initiated an inflammatory infiltrate. Conversely, topical TNCB applied to neonates was tolerogenic, resulting in a subsequent antigen-specific decrease of the contact-hypersensitivity response in adults. Neonatal blood contained abundant neutrophils, which exhibited impaired chemotaxis to the chemokine growth-related oncogene-alpha but efficient chemotaxis to the bacterial product fMLP, concomitant with decreased expression of CXCR2 but normal levels of CD11b. We propose this neonatal deficiency in the inflammatory response is a significant, previously unrecognized factor in neonatal immune tolerance and may contribute to neonatal susceptibility to cancer, including melanoma and other UV-induced cancers.     

Psychological factors associated with ratings of portion size: relevance to the risk profile for obesity

The ability to assess accurately the relative size of food portions is highly variable in the population. This study was designed to identify salient individual differences that correlate with this variation since estimation errors are seen as a barrier to the control of food intake and a detriment to many obesity treatment strategies. Healthy weight and obese adult women were assessed on a self-report measure of food amount ratings. We predicted that a high sensitivity to reward, symptoms of binge eating, and a preference for fat foods would relate positive to scores on this rating scale, and that weight status might moderate these relationships. As expected, a preference for high-fat food was associated with the tendency to under-estimate portion sizes. A significant interaction between weight status and reward sensitivity indicated that high values on the latter were correlated with ratings reflecting under-estimation of food amounts--but only among obese individuals. This study identified important factors that may influence estimation biases in food amount ratings-information of direct relevance to research and treatment protocols that use food diaries and focus on efforts to normalize eating behaviours.     

The informed decisions toolbox: tools for knowledge transfer and performance improvement

In recent years, spurred by developments in evidence-informed medicine, a movement to strengthen evidence-informed managerial decision making in healthcare organizations has emerged in the United States and in other countries. The drivers of this movement include demands by payers and consumer groups for improved quality of care, increased operational efficiency, and greater accountability from healthcare organizations. But numerous barriers to managers' use of evidence in decision making exist, including time pressures, perceived threats to autonomy, preference for colloquial knowledge based on individual experiences, difficulty accessing the relevant evidence base, reliance on external consultants (and others) to determine the quality of the information, and lack of resources. To help managers overcome these barriers, we developed the Informed Decisions Toolbox. It provides tools to help managers efficiently perform the six key steps in the evidence-informed approach to decision making: (1) framing the management question, (2) finding sources of information, (3) assessing the accuracy of the information, (4) assessing the applicability of the information, (5) assessing the actionability of the evidence, and (6) determining if the information is adequate. To build an organizational environment conducive to evidence-informed decision making, we suggest four leadership-driven strategies: (1) recognize and respond to the growing demand for accountability as a strategic issue, (2) establish organizational structures and processes for knowledge transfer, (3) build a questioning organizational culture, and (4) build organizational research capabilities. With organizational support, managers who use the tools presented in the Informed Decisions Toolbox will be able to take control of the decision-making process, will be less reliant on colloquial evidence and consultants, and will be better able to improve the performance of their organizations.     

A Practical Guide for Navigating the Design,Build, and Clinical Integration of Electronic Patient-Reported Outcomes in the Radiation Oncology Department

The development and integration of electronic patient-reported outcomes (ePROs) into the radiation oncology clinic workflow provide novel opportunities, accompanied by unique design considerations and implementation challenges. The processes required for implementation of ePROs are entirely distinct from standard paper-based surveys, with the majority of time devoted to conception and design before initiating questionnaire build, detailed workflow process mapping including development of new workflows, comprehensive communication of the vision between providers and the information technology team, and quality assurance. Based on our experience with implementation of ePROs in our radiation oncology department, we developed a stepwise framework for approaching ePRO conceptual design, build, workflow integration, and the electronic health record interface. Here, we provide a guide for the numerous considerations, decision points, and solutions associated with the implementation of ePROs in the radiation oncology department setting. Although various ePRO tools and electronic health record capabilities impose different requirements, opportunities, and limitations, the conceptual processes and many of the electronic build considerations are broadly applicable.     

Association between the decline in workers' compensation claims and workforce composition and job characteristics in Ontario, Canada

We examined associations between workforce demographics and job characteristics, grouped by industrial sector, and declines in workers' compensation claim rates in Ontario, Canada, between 1990 and 2003. Gender, age, occupation, and job tenure were predictors for claim rates in 12 industrial sectors. The decline in claims was significantly associated with a decline in the proportion of employment in occupations with high physical demands. These findings should generate interest in economic incentives and regulatory policies designed to encourage investment in safer production processes.     

Hard to handle: understanding mothers' handwashing behaviour in Ghana

While handwashing with soap (HWWS) has been identified as a major pathway to reducing the risk of diarrhoeal diseases, and respiratory infections, rates of HWWS remain low across the globe. The current study, a national survey of Ghanaian mothers, found that as few as 4% of mothers engaged in HWWS after defecation, and only 2% after cleaning a child's bottom. In a multivariate analysis, we explored the determinants of handwashing at these key junctures, with and without soap. After defecation, mother's education, knowledge of important times to handwash with soap, the age of her children, and a measure of the quality of child care were all associated with handwashing (in any form). However, only the latter two variables also predicted soap use amongst handwashers. After cleaning a child's bottom, education, knowledge of important times to handwash with soap, and child care quality were associated with handwashing (in any form), yet only one variable, a measure of disgust sensitivity, showed any possible relationship with soap use. While this study has several important limitations, failure to explain much of the observed variance, despite a large range of potential determinants explored, suggests that we need to continue complementing quantitative surveys with in-depth qualitative studies if we are to better understand the motivations for, and constraints to, HWWS in community settings.     

Workplace injury or “part of the job”?: Towards a gendered understanding of injuries and complaints among young workers

Epidemiological studies have found that teenage workers have higher occupational injury rates than adult workers, and that young males are a particularly high-risk subgroup. However, there have been few studies to date that have explored qualitatively young workers' everyday understandings and experiences of occupational health risks. Based on focus groups conducted with Canadian urban and suburban teenagers aged 16-18 years, this paper explores young workers' understandings and experiences of occupational health risks, and their gendered nature. The respondents were employed in a diverse range of jobs. The findings suggest that young workers experience a number of minor injuries and physical complaints related to their work. These injuries were typically seen as "part of the job" because they happened frequently and were of low severity. Also, the experience of these injuries as "part of the job" was informed by the young workers' perceived lack of control to improve or alter the conditions of their work. Furthermore, young workers' complaints and concerns were systematically discounted and this happened in a gendered fashion. Whereas the females emphasized how their complaints were actively disregarded by their superiors, males (and some females in male-dominated work settings) described how they stifled their complaints in order to appear mature among their (older) co-workers. Comparisons with qualitative studies of adult workers suggest that accepting some risks and injuries as "part of the job" is not peculiar to young workers. The implications of these findings for improving workplace safety for young workers are discussed.     

Construction of an Exome‐Wide Risk Score for Schizophrenia Based on a Weighted Burden Test

Polygenic risk scores obtained as a weighted sum of associated variants can be used to explore association in additional data sets and to assign risk scores to individuals. The methods used to derive polygenic risk scores from common SNPs are not suitable for variants detected in whole exome sequencing studies. Rare variants, which may have major effects, are seen too infrequently to judge whether they are associated and may not be shared between training and test subjects. A method is proposed whereby variants are weighted according to their frequency, their annotations and the genes they affect. A weighted sum across all variants provides an individual risk score. Scores constructed in this way are used in a weighted burden test and are shown to be significantly different between schizophrenia cases and controls using a five‐way cross‐validation procedure. This approach represents a first attempt to summarise exome sequence variation into a summary risk score, which could be combined with risk scores from common variants and from environmental factors. It is hoped that the method could be developed further.