Public perception of participation in low-risk clinical trials in critical care using waived consent: a Canadian national survey.

PURPOSE: The acceptability of waiver of consent for participation in clinical research in intensive care unit (ICU) settings is uncertain. We sought to survey the Canadian public to assess levels of support, comfort, and acceptability for waived consent for low-risk clinical trials. METHODS: We performed a prospective cross-sectional survey of the Canadian public aged 18 yr or older. The survey was conducted by Ipsos between 19 and 23 November 2020. The survey content was derived from a literature review and in consultation with a patient and family partnership committee. The survey focused on attitudes and beliefs on waived consent for participation in low-risk clinical trials in ICU settings. The survey contained 35 items focused on sociodemographics, general health status, participation in medical research, and levels of support and comfort with research and with waived consent. The survey used a case study of a low-risk clinical trial intervention in ICU patients. Analysis was descriptive. RESULTS: We included 2,000 participants, 38% of whom reported experience with ICU and 16% with medical research. Participation in medical research was more common among those with postsecondary education, those with chronic disease, and those who were employed in health care. Most (80%) would support a model of waived consent for low-risk clinical trials, citing medical benefits (36%) and low perceived risk (34%). Most (77%) were comfortable with personally participating in a low-risk clinical trial. Most (80%) believed waived consent approaches were acceptable. Half (52%) believed the waived consent process should provide information about the research and include the option of opting out. When asked whether participants should always give full informed consent, regardless of the practicality or level of risk, 74% and 72% agreed, respectively. CONCLUSIONS: There is public support for models of waived consent for participation in low-risk pragmatic clinical trials in ICU settings in Canada; however, this is not universal. This information can inform and guide education, ethics, policy, and legal discussion on consent models.

RéSUMé: OBJECTIF: L'acceptabilité de la renonciation au consentement pour la participation à la recherche clinique à l'unité de soins intensifs (USI) est incertaine. Nous avons cherché à sonder la population canadienne afin d'évaluer les niveaux de soutien, de confort et d'acceptabilité de la renonciation au consentement pour les études cliniques à faible risque. MéTHODE: Nous avons réalisé un sondage transversal prospectif auprès de la population canadienne âgée de 18 ans et plus. Le sondage a été réalisé par Ipsos entre le 19 et le 23 novembre 2020. Le contenu du sondage a été élaboré à partir d'une revue de la littérature et en consultation avec un comité de partenariat composé de patient·es et de familles. Le sondage portait sur les attitudes et les croyances à l'égard de la renonciation au consentement pour participer à des études cliniques à faible risque dans les unités de soins intensifs. Le sondage comportait 35 questions axées sur les données sociodémographiques, l'état de santé général, la participation à la recherche médicale et les niveaux de soutien et de confort à l'égard de la recherche et de la renonciation au consentement. Le sondage s'est appuyé sur une étude de cas d'une intervention d'étude clinique à faible risque chez des patient·es des soins intensifs. L'analyse était descriptive. RéSULTATS: Nous avons inclus 2000 personnes, dont 38 % ont déclaré avoir eu des expériences en soins intensifs et 16 % en recherche médicale. La participation à la recherche médicale était plus fréquente chez les personnes ayant fait des études postsecondaires, celles atteintes de maladies chroniques et celles qui travaillaient dans le domaine des soins de santé. La plupart d'entre elles (80 %) appuieraient un modèle de renonciation au consentement pour les études cliniques à faible risque, citant les avantages médicaux (36 %) et le faible risque perçu (34 %). La majorité des personnes répondantes (77 %) étaient à l'aise à l'idée de participer personnellement à une étude clinique à faible risque. La plupart d'entre elles (80 %) croyaient que les approches fondées sur la renonciation au consentement étaient acceptables. La moitié (52 %) estimaient que le processus de renonciation au consentement devrait fournir des renseignements sur la recherche et inclure la possibilité de se retirer. Lorsqu'on leur a demandé si les participant·es devraient toujours donner un consentement éclairé complet, quel que soit l'aspect pratique ou le niveau de risque, 74 % et 72 % ont répondu par l'affirmative, respectivement. CONCLUSION: Il y a un appui public pour les modèles de renonciation au consentement quant à la participation à des études cliniques pragmatiques à faible risque dans les unités de soins intensifs au Canada; cet appui n'est toutefois pas universel. Ces renseignements peuvent éclairer et orienter l'éducation, l'éthique, les politiques et les discussions juridiques sur les modèles de consentement.

The Impact of Obesity on Success of Immediate Lymphatic Reconstruction for Prevention of Breast Cancer-Related Lymphedema.

BACKGROUND: Breast cancer-related lymphedema (BRCL) is a potential sequela of high-risk breast cancer treatment. Preventive treatment with immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has emerged as the standard of care; however, there is relatively little known about factors that may contribute to procedural failure. METHODS: A retrospectively maintained, institutional review board-approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between May 2018 and May 2023. Patients who presented for at least one follow-up visit in our multidisciplinary lymphedema clinic met the criteria for inclusion. Patients who developed lymphedema despite ILR and potential contributing factors were further explored. RESULTS: 349 patients underwent ILR at our institution between May 2018 and May 2023. 341 of these patients have presented for follow-up in our multidisciplinary lymphedema clinic. 32 (9.4%) patients developed lymphedema despite ILR. This cohort was significantly more likely to be obese (56% vs 35%, P = 0.04). Multivariate logistic regression demonstrates increased odds of procedural failure in patients with a body mass index (BMI) ≥30 kg/m2 (odds ratio 2.6 [1.2-5.5], P = 0.01). CONCLUSION: These data comment upon our institutions outcomes following ILR. Patients who develop lymphedema despite ILR tend to have a higher BMI, with a significantly increased risk in patients with a BMI of 30 or greater. Consideration of these data is critical for preprocedural counseling and may support a BMI cutoff when considering candidacy for ILR going forward, as well as when optimizing failures for secondary lymphedema procedures.

Efficacy of Immediate Lymphatic Reconstruction in Prevention of Breast Cancer-Related Lymphedema.

INTRODUCTION: Breast cancer-related lymphedema (BCRL) is a chronic condition that can negatively affect the quality of life of breast cancer survivors. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection is emerging as a technique for the prevention of BCRL. This study compared the incidence of BRCL in patients who received ILR and those who were not amenable to ILR. METHODS: Patients were identified through a prospectively maintained database between 2016 and 2021. Some patients were deemed nonamenable to ILR due to a lack of visualized lymphatics or anatomic variability (eg, spatial relationships or size discrepancies). Descriptive statistics, independent t test, and Pearson χ 2 test were used. Multivariable logistic regression models were created to assess the association between lymphedema and ILR. A loose age-matched subsample was created for subanalysis. RESULTS: Two hundred eighty-one patients were included in this study (252 patients who underwent ILR and 29 patients who did not). The patients had a mean age of 53 ± 12 years and body mass index of 28.6 ± 6.8 kg/m 2 . The incidence of developing lymphedema in patients with ILR was 4.8% compared with 24.1% in patients who underwent attempted ILR without lymphatic reconstruction ( P = 0.001). Patients who did not undergo ILR had significantly higher odds of developing lymphedema compared with those who had ILR (odds ratio, 10.7 [3.2-36.3], P < 0.001; matched OR, 14.2 [2.6-77.9], P < 0.001). CONCLUSIONS: Our study showed that ILR was associated with lower rates of BCRL. Further studies are needed to determine which factors place patients at highest risk of developing BCRL.

The Epidemiology and Management of Pediatric Maxillary Fractures.

BACKGROUND: Most literature regarding traumatic Le Fort or maxillary fractures exists in the adult population, with limited information regarding the epidemiology and management of pediatric fractures. The purpose of this study was to evaluate fracture mechanism, surgical management, and associated injuries in pediatric patients with Le Fort fractures. METHODS: A retrospective chart analysis of all pediatric patients age ≤18 years diagnosed with facial fractures at a single level 1 trauma center over a 10-year period (January 2006-December 2015) was performed. Demographics, fracture location, mechanism of injury, and hospital course were abstracted as well as associated injuries and need for operative management. RESULTS: A total of 1274 patients met inclusion criteria. Sixty-nine (5.4%) presented with Le Fort fractures. Factors associated with Le Fort fractures included motor vehicle collisions (P < 0.001), increased age (P < 0.001), and traumatic brain injury (P < 0.04). Patients with Le Fort fractures were more likely to need intensive care unit admission (P < 0.001), surgical management (P < 0.001), transfusions (P < 0.001), secondary fixation surgery (P < 0.001), and have a longer length of stay (P < 0.001). Multivariate showed increased odds for increased age (OR 1.1; 95%CI 1.04-1.17) and concomitant orbit fractures (OR 8.33; 95%CI 4.08-19.34). Decreased odds were associated for all mechanisms of injury other than motor vehicle collisions (Other blunt trauma: OR 0.36; 95%CI 0.2-0.6. Penetrating trauma: OR 0.13; 95%CI 0.01-0.6). CONCLUSION: Maxillary or Le Fort fractures represent a small portion of pediatric facial fractures but require high rates of operative management. The high velocity required to create this fracture type is associated with significant traumatic comorbidities, which can complicate the hospital course.

International networking guidelines for nurses.

ABSTRACT: Basic guidelines are necessary for international networking in nursing. This article outlines the benefits of and strategies for networking, highlights the social and behavioral considerations of social networking, and presents potential guidelines for further discourse.

Are We Out of the Woods Yet? The Aftermath of Resuscitative Thoracotomy.

BACKGROUND: After traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU. MATERIALS AND METHODS: We conducted a retrospective review (January 1, 2012-June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome. RESULTS: Over 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center. CONCLUSIONS: After resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.

Cervical Spine Injuries in Pediatric Maxillofacial Trauma: An Under-Recognized Problem.

Pediatric cervical spine injuries (CSI) are uncommon events, but can be devastating injuries. Facial fractures have been associated with injuries to the cervical spine in children, but may be deemed isolated facial fractures and bypass the standard trauma pathway. The objective of this study is to describe the mechanisms, associated injuries and outcomes of pediatric cervical spine injuries in patients with known maxillofacial trauma at a level 1 trauma center. An analysis was performed of all patients under the age of 18 with maxillofacial trauma admissions to a single level 1 trauma center, from 2006 to 2015. Patients were stratified based on the presence or absence of a cervical spine injury. Data was abstracted to include demographic, mechanism and clinical outcomes data. There were 1274 patients who were admitted with maxillofacial trauma during the study period. Of these, 72 (5.7%) experienced a cervical spine injury. Factors associated with cervical spine injuries include older age and penetrating mechanism. Cervical spine injuries were associated with concomitant traumatic brain injuries and skull fractures. Patients with spine injuries were more like to experience a longer length of stay and death. On multivariate analysis, only increased age predicted CSI. Our database demonstrated a 5.7% incidence of pediatric cervical spine injuries in patients with maxillofacial trauma. This incidence is higher than previously published reports of smaller cohorts. Clinicians must take care to stabilize the cervical spine in any patient with facial fractures, especially during work up and diagnostic maneuvers performed before spinal injuries are ruled out.

Factors Associated With Surgical Management for Pediatric Facial Fractures at a Level One Trauma Center.

Pediatric facial fractures present and are managed differently than the adult population. This study describes the pattern and mechanism of facial fractures in children and identifies factors associated with need for surgical management. An IRB-approved retrospective chart analysis of all pediatric patients age ≤ 18 years diagnosed with facial fractures at our level 1 trauma center over a 10-year period (January 2006-December 2015) was performed. Demographics, fracture location, mechanism of injury, concomitant head and neck injuries, and surgical management were reviewed. Statistical analysis was then performed comparing surgical and nonsurgical cohorts using univariate and multivariate analyses. One thousand two hundred seventy-four patients were diagnosed with facial fractures. Five hundred seventeen (40.6%) underwent surgical management. Two thousand one hundred seventy-two total facial fractures were recorded. Orbit fractures (29%) were the most commonly recorded, observed in 49% of patients presenting. Increased age was associated with increased odds of surgical management (OR 1.13; 95% CI 1.09-1.16). Mandible (OR 9.28; 95% CI 6.88-12.51) and Le Fort fractures (OR 19.73; 95% CI 9.78-39.77) had increased odds of surgical management. Patients with traumatic brain injury had reduced odds (OR 0.54; 95% CI 0.35-0.83) of surgical management for their facial fractures. Older pediatric patients may be more likely to require surgical management of their facial fractures, especially those with mandible or Le Fort fractures. Patients with traumatic brain injury are likely to sustain life threatening injuries, deferring repair of their facial fractures. Patient education and counseling, as well as predictive models, can be improved to reflect these data.

The Trends of Pediatric Facial Fractures Due to Violence in a Level One Trauma Population.

INTRODUCTION: Pediatric facial fractures due to intentionally violent mechanisms represent a unique subset of facial fractures. The objective of our research is to identify how violence affects patterns of facial fractures and their management in pediatric patients. METHODS: An IRB approved, retrospective study of our institution's pediatric patients ≤18 years of age who presented with ≥1 facial fracture due to violence from January 2006 to December 2015 was performed. Violence was defined as trauma intended to hurt another or self. Demographics, fractures, mechanism, concomitant injuries, and management were analyzed. RESULTS: The 1274 patients were diagnosed with facial fractures, with 235 of these due to violence (18%). These patients of violence (POV) had 332 fractures, with an average fracture per patient of 1.4 ±â€Š.0.8. The majority (86%) were male, Non-Hispanic African American (35%), and the average age was 15.9 ±â€Š2.8 years. The most common fracture was the mandible (50% of patients) and most common mechanism was assault (76%). The POV were older, male, and of minority race/ethnic groups when compared to patients of non-violence (PONV) (P <0.01). The POV presented with fewer concomitant injuries, were less likely to be admitted to the intensive care unit, and more often surgically managed when compared to the PONV (P <0.01). CONCLUSION: This study represents the largest US, single institution, Level 1 trauma center study of pediatric facial fractures. Pediatric patients with facial fractures due to a violent mechanism represent a distinct category of trauma patients with a unique profile of injuries.

Assessing Burden of Care in the Patient With Cleft Lip and Palate: Factors Influencing Completion and Noncompletion of Nasoalveolar Molding.

OBJECTIVE: Evaluate the factors that influence caregiver-reported completion of nasoalveolar molding (NAM) therapy for patients with cleft lip and palate. DESIGN: An IRB-approved 30-question survey. SETTING: Outpatient clinic for patients with cleft lip. PATIENTS: Patients with unilateral or bilateral cleft lip treated with NAM therapy. INTERVENTIONS: Survey of previous experiences. MAIN OUTCOME MEASURE(S): Rate of noncompletion for patients initiating NAM therapy and identifiable causes. RESULTS: Of 94 patients who underwent NAM, 13 (13.8%) failed to complete NAM therapy. Reasons for incomplete treatment included: obstructive sleep apnea, device intolerance, tape issues, and lack of support. Patients who did not complete NAM therapy were less likely to have primary caregivers >30-year old (P = .045) and more likely to be the first child for the family (P = .021) and have a bilateral cleft (P = .03). Caregivers of NAM patients were less satisfied with the outcome (P < .001) when they did not complete therapy. CONCLUSION: This study shows that a high number of parents fail to complete this therapy for many reasons, personal and medical. More data are needed to elucidate true prevalence of NAM noncompletion and to establish evidence-based guidelines to reduce barriers to care for completing NAM treatment.

The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia.

This corrects the article DOI: 10.1038/bjc.2017.310.

The Effect of Vasectomy Reversal on Prostate Cancer Risk: International Meta-Analysis of 684,660 Vasectomized Men.

PURPOSE: Evidence of the effect of vasectomy on prostate cancer is conflicting with the issue of detection bias a key criticism. We examined the effect of vasectomy reversal on prostate cancer risk in a cohort of vasectomized men. Evidence of a protective effect would be consistent with a harmful effect of vasectomy on prostate cancer risk while nullifying the issue of detection bias. MATERIALS AND METHODS: Data were sourced from a total of 5 population level linked health databases in Australia, Canada and the United Kingdom. Cox proportional hazards regression analysis was used to compare the risk of prostate cancer in 9,754 men with vasectomy reversal to the risk in 684,660 with vasectomy but no reversal. Data from each jurisdiction were combined in a meta-analysis. RESULTS: The combined analysis showed no protective effect of vasectomy reversal on the incidence of prostate cancer compared to that in men with vasectomy alone (HR 0.92, 95% CI 0.70-1.21). CONCLUSIONS: These results align with those of previous studies showing no evidence of a link between vasectomy and prostate cancer.

The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia.

BACKGROUND: Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia. METHODS: 2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control. PRIMARY OUTCOME: total diagnostic interval (TDI). RESULTS: 1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI -0.06-0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI -0.18-0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI. CONCLUSIONS: This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis.

Value of Pathology Review in a Population-based Series of Ovarian Tumors.

Ovarian neoplasia comprises a heterogenous group of tumors with distinct clinicopathologic and molecular features and therefore assessment of potential risk factors should be tumor subtype specific. As part of ongoing epidemiological investigations of ovarian neoplasia in Western Australia, we performed an initial review of original pathology reports followed, in selected cases, by reassessment of histology material to optimize accurate diagnosis. Additional immunohistochemistry, often using antibodies unavailable at the time of initial assessment, was also performed as required. From an initial cohort of 1660 cases identified through the Western Australia Cancer Registry, benign, nonepithelial, nonovarian, miscellaneous, and indeterminate cases were excluded. Also excluded were 33 cases that were reclassified as ovarian metastases rather than primary ovarian tumors. Following exclusions there remained 1321 borderline and malignant epithelial neoplasms. The diagnosis was considered accurate in 1186 cases (89.8%) based upon information in the initial pathology reports and clinical follow-up data but uncertain in 135 cases (10.2%). Histologic review was possible in 92 of the latter tumors leading to an amended diagnosis in 63 cases (68.5%). The most common types of diagnostic amendment were the reclassification of high-grade carcinomas of undifferentiated, endometrioid, or transitional appearance as high-grade serous carcinoma, and the reclassification of most carcinomas of mixed epithelial type as "pure" carcinomas. This review illustrated specific pitfalls in the diagnosis of ovarian epithelial neoplasia and helped to maintain the accuracy of the Western Australia Cancer Registry. Accurate diagnosis will optimize further epidemiological studies assessing risk factors in specific subtypes of ovarian neoplasia.

Green tea consumption and glutathione S-transferases genetic polymorphisms on the risk of adult leukemia.

PURPOSE: Green tea may have a beneficial role of inhibiting leukemia. Glutathione S-transferases (GSTs) are known to detoxify certain carcinogens. We investigated the roles of green tea consumption and polymorphisms of GSTM1, GSTT1 and GSTP1 on the risk of adult leukemia, and to determine whether the associations varied within GSTs genotypes. METHODS: A multicenter case-control study was conducted in China, 2008-2013. It comprised 442 incident, hematologically confirmed adult leukemia cases and 442 outpatient controls, individually matched to cases by gender, birth quinquennium and study site. Data were collected by face-to-face interview using a validated questionnaire. Genetic polymorphisms were assayed by PCR. RESULTS: An inverse association between green tea consumption and adult leukemia risk was observed. Compared with non-tea drinkers, the adjusted odds ratios (95 % confidence intervals) were 0.50 (0.27-0.93), 0.31 (0.17-0.55) and 0.53 (0.29-0.99) for those who, respectively, consumed green tea >20 years, ≥2 cups daily and dried tea leaves >1000 g annually. In assessing the associations by GSTs genotypes, risk reduction associated with green tea consumption was stronger in individuals with the GSTT1-null genotype (OR 0.24; 95 % CI 0.11-0.53) than GSTT1-normal carriers (OR 0.67; 95 % CI 0.42-1.05; P interaction = 0.02). GSTM1 and GSTP1 did not significantly modify the inverse association of leukemia with green tea. CONCLUSIONS: The results suggest that regular daily green tea consumption may reduce leukemia risk in Chinese adults regardless of GSTM1 and GSTP1 polymorphic status. The association between green tea and adult leukemia risk varied with GSTT1 genotype and highlights further study.

Alcohol consumption and risk of myelodysplastic syndromes: a case-control study.

PURPOSE: Epidemiological studies on alcohol consumption and the risk of myelodysplastic syndromes (MDS) have been inconclusive. We evaluated the association between alcohol consumption and MDS risk in a Chinese population. METHODS: A hospital-based case-control study was conducted between 2012 and 2013 in Hangzhou, China. The analysis included 208 case-control pairs. Diagnosis of MDS was confirmed according to the 2008 World Health Organization classification system. Controls were individually matched to the cases by gender, birth quinquennium, and residential locality. Information on habitual alcohol consumption, diet, and lifestyle was sought from face-to-face interview using a validated questionnaire. Odds ratios (ORs) were calculated using conditional logistic regression. RESULTS: Fewer cases (36.5 %) were classified as alcohol drinkers compared with the controls (48.6 %). Compared with abstainers, the adjusted OR for alcohol drinkers was 0.41 (95 % CI 0.21-0.80), and significant reduced risks were found for light alcohol consumption (≤12.5 g/day of ethanol) and for wine consumption, adjusted ORs (95 % CIs) being 0.27 (0.12-0.61) and 0.12 (0.02-0.79), respectively. Compared with individuals who consumed neither alcohol nor cigarettes, the reduced risk associated with light alcohol consumption was only statistically significant among non-smokers (OR 0.19, 95 % CI 0.06-0.60). CONCLUSIONS: The findings suggest a favorable role of light alcohol consumption in MDS, particularly among non-smokers.

Polymorphisms of 5,10-methylenetetrahydrofolate reductase and thymidylate synthase, dietary folate intake, and the risk of leukemia in adults.

The 5,10-methylenetetrahydrofolate reductase (MTHFR) and thymidylate synthase (TS) are critical enzymes in folate metabolism. Previous studies have reported conflicting results on the associations between MTHFR/TS polymorphisms and adult leukemia risk, which may due to the lack of information on folate intake. We investigated the risks of adult leukemia with genetic polymorphisms of folate metabolic enzymes (MTHFR C677T, A1298C, and TS) and evaluated if the associations varied by dietary folate intake from a multicenter case-control study conducted in Chinese. This study comprised 442 incident adult leukemia cases and 442 outpatient controls, individually matched to cases by gender, birth quinquennium, and study site. Genotypes were determined by a polymerase chain reaction (PCR) or PCR-based restriction fragment length polymorphism assay. Dietary folate intake was assessed by face-to-face interviews using a validated food-frequency questionnaire. The MTHFR 677TT genotype conferred a significant higher risk of leukemia in males than in females and exhibited an increased risk of acute myeloid leukemia (AML) but a decreased risk of acute lymphoblastic leukemia (ALL). The MTHFR 1298AC genotype appeared to decrease the risks of leukemia in both genders, in AML and ALL. Stratified analysis by dietary folate intake showed the increased risks of leukemia with the MTHFR 677TT and TS 2R3R/2R2R genotypes were only significant in individuals with low folate intake. A significant interaction between TS polymorphism and dietary folate intake was observed (P = 0.03). This study suggests that dietary folate intake and gender may modify the associations between MTHFR/TS polymorphisms and adult leukemia risk.

"It has to be fixed": a qualitative inquiry into perceived ADHD behaviour among affected individuals and parents in Western Australia.

BACKGROUND: The use of stimulant medication for Attention Deficit Hyperactivity Disorder (ADHD) to improve classroom behaviour and sustained concentration is well known. Achieving a better academic grade has been reported as the prime motivation for stimulant use and is an increasingly discussed topic. The proliferation of stimulant use for ADHD has been a cause for public, medical and policy concern in Australia. This paper explores individuals' perceptions of ADHD, the meaning that the diagnosis carries for them and their attitudes to stimulant medication treatment. METHODS: This qualitative study was underpinned by a social constructivist approach and involved semi-structured interviews with eight participants. The participants were parents of children with ADHD or were adults who themselves had been diagnosed with ADHD. Interviews were audiotaped, transcribed verbatim and thematically analysed. RESULTS: There were three interrelated yet contradictory overarching themes: (i) An impairment to achieving success, which can be a double-edged sword, but has to be fixed; (ii) Diagnosis as a relief that alleviates fault and acknowledges familial inheritance; (iii) Responsibility to be normal and to fit in with societal expectations. Collectively, these perceptions and meanings were powerful drivers of stimulant use. CONCLUSIONS: Paying attention to perceptions of ADHD and reasons for seeking or not seeking stimulant treatment is important when planning appropriate interventions for this condition.

Characterization of process air emissions in automotive production plants.

During manufacturing, particles produced from industrial processes become airborne. These airborne emissions represent a challenge from an industrial hygiene and environmental standpoint. A study was undertaken to characterize the particles associated with a variety of manufacturing processes found in the auto industry. Air particulates were collected in five automotive plants covering ten manufacturing processes in the areas of casting, machining, heat treatment and assembly. Collection procedures provided information on air concentration, size distribution, and chemical composition of the airborne particulate matter for each process and insight into the physical and chemical processes that created those particles.

Glass half full: Survival analysis of new rural doctor retention in Western Australia.

OBJECTIVE: To measure the time trends in retention of new rural doctors in Western Australia (WA) and identify factors associated with improved retention. DESIGN: Retrospective inception cohort study of the 1154 doctors first commencing rural practice in WA in 2004-2013, who provided 1222 tours of service consisting of up to eight attachments at different rural practice settings. MAIN OUTCOME MEASURE: Failure of doctor retention as evidenced by an absence from the rural medical workforce of greater than 1 year and analysed using actuarial survival methods and Cox proportional hazards regression. RESULTS: Comparing 2009-2013 with 2004-2008, there was an improvement of 10 percentage points in retention of new rural doctors at 2 years (58% versus 48% ) and 7 percentage points at 5 years (38% versus 31%). The retention failure rate ratio was 0.68 (95% CI, 0.58-0.83). The improvement at 5 years was largely attributable to gains in retention of those who began as GP registrars (37% versus 14%). Failure of doctor retention was lower in those who possessed procedural skills (RR 0.61, 95% CI, 0.47-0.78) and lower in international medical graduates than in those trained in Australia (RR 0.75, 95% CI, 0.59-0.95). CONCLUSIONS: New rural GP retention in WA has improved substantially, an observation at least consistent with government initiatives delivering a positive return. However, it remains the case that the majority of new doctors have left rural practice within 5 years of commencing their tour of service.