Cohort-based income gradients in obesity among U.S. adults.

OBJECTIVES: No studies have focused on socioeconomic disparities in obesity within and between cohorts. Our objectives were to examine income gradients in obesity between birth-cohorts (inter-cohort variations) and within each birth-cohort (intra-cohort variations) by gender and race/ethnicity. METHODS: Our sample includes 56,820 white and black adults from pooled, cross-sectional National Health and Nutrition Examination Surveys (1971-2012). We fit a series of logistic hierarchical Age-Period-Cohort models to control for the effects of age and period, simultaneously. Predicted probabilities of obesity by poverty-to-income ratio were estimated and graphed for 5-year cohort groups from 1901-1990. We also stratified this relationship for four gender and racial/ethnic subgroups. RESULTS: Obesity disparities due to income were weaker for post-World War I and II generations, specifically the mid-1920s and the mid-1940s to 1950s cohorts, than for other cohorts. In contrast, we found greater income gradients in obesity among cohorts from the 1930s to mid-1940s and mid-1960s to 1970s. Moreover, obesity disparities due to income across cohorts vary markedly by gender and race/ethnicity. White women with higher income consistently exhibited a lower likelihood of obesity than those with lower income since early 1900s cohorts; whereas, black men with higher income exhibited higher risks of obesity than those with lower income in most cohorts. CONCLUSIONS: Our findings suggest that strategies that address race and/or gender inequalities in obesity should be cognizant of significant historical factors that may be unique to cohorts. Period-based approaches that ignore life-course experiences captured in significant cohort-based experiences may limit the utility of policies and interventions.

Factors associated with continued participation in a matched monetary incentive programme at local farmers' markets in low-income neighbourhoods in San Diego, California.

OBJECTIVE: The Farmers' Market Fresh Fund Incentive Program is a policy, systems and environmental intervention to improve access to fresh produce for participants on governmental assistance in the USA. The current study examined factors associated with ongoing participation in this matched monetary incentive programme. DESIGN: Relationship of baseline factors with number of Fresh Fund visits was assessed using Poisson regression. Mixed-effects modelling was used to explore changes in consumption of fruits and vegetables and diet quality. SETTING: San Diego, California. SUBJECTS: Recipients of Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Supplemental Security Income (SSI) who attended participating farmers' markets from 2010 to 2012 (n 7298). RESULTS: Among those with participation for ≤6 months, factors associated with increased visits included reporting more daily servings of fruits and vegetables (F&V) at baseline, being Vietnamese or Asian/Pacific Islander, and eligibility because of SNAP/CalFresh or SSI (v. WIC). Among those who came for 6-12 months, being Asian/Pacific Islander, eligibility because of SNAP/CalFresh and enrolling in the autumn, winter or spring were associated with a greater number of Fresh Fund visits. Among those who came for >12 months, being male and eligibility because of SSI were associated with a greater number of visits. Overall, the odds of increasing number of servings of F&V consumed increased by 2 % per month, and the odds of improved perception of diet quality increased by 10 % per month. CONCLUSIONS: Sustaining and increasing Fresh Fund-type programme operations should be a top priority for future policy decisions concerning farmers' market use in low-income neighbourhoods.

"One Scar Too Many:" The Associations Between Traumatic Events and Psychological Distress Among Undocumented Mexican Immigrants.

Undocumented immigration often presents with multiple stressors and contextual challenges, which may diminish mental health. This study is the first to provide population-based estimates for the prevalence of traumatic events and its association to clinically significant psychological distress among undocumented Mexican immigrants in the United States. This cross-sectional study used respondent-driven sampling to obtain and analyze data from clinical interviews with 248 undocumented Mexican immigrants residing in high-risk neighborhoods near the California-Mexico border. Overall, 82.7% of participants reported a history of traumatic events, with 47.0% of these meeting the criteria for clinically significant psychological distress. After controlling for relevant covariates, having experienced material deprivation, odds ratio (OR) = 2.26, 95% CI [1.18, 4.31], p = .013, and bodily injury, OR = 2.96, 95% CI [1.50, 5.83], p = .002, and not having a history of deportation, OR = 0.36, 95% CI [0.17, 0.79], p = .011, were associated with clinically significant psychological distress. These results support the need to revisit health and immigration policies and to devise solutions grounded in empirical evidence aimed at preventing the negative effects of trauma and psychological distress in this population.

Community BMI Surveillance Using an Existing Immunization Registry in San Diego, California.

This study examines the demographic representativeness of the County of San Diego Body Mass Index (BMI) Surveillance System to determine if the BMI estimates being obtained from this convenience sample of individuals who visited their healthcare provider for outpatient services can be generalized to the general population of San Diego. Height and weight were transmitted from electronic health records systems to the San Diego Immunization Registry (SDIR). Age, gender, and race/ethnicity of this sample are compared to general population estimates by sub-regional area (SRA) (n = 41) to account for regional demographic differences. A < 10% difference (calculated as the ratio of the differences between the frequencies of a sub-group in this sample and general population estimates obtained from the U.S. Census Bureau) was used to determine representativeness. In 2011, the sample consisted of 352,924 residents aged 2-100 years. The younger age groups (2-11, 12-17 years) and the oldest age group (≥65 years) were representative in 90, 75, and 85% of SRAs, respectively. Furthermore, at least one of the five racial/ethnic groups was represented in 71% of SRAs. This BMI Surveillance System was found to demographically represent some SRAs well, suggesting that this registry-based surveillance system may be useful in estimating and monitoring neighborhood-level BMI data.

Testing the Invariance of the National Health and Nutrition Examination Survey's Sexual Behavior Questionnaire Across Gender, Ethnicity/Race, and Generation.

Federal and state policies are based on data from surveys that examine sexual-related cognitions and behaviors through self-reports of attitudes and actions. No study has yet examined their factorial invariance--specifically, whether the relationship between items assessing sexual behavior and their underlying construct differ depending on gender, ethnicity/race, or age. This study examined the factor structure of four items from the sexual behavior questionnaire part of the National Health and Nutrition Examination Survey (NHANES). As NHANES provided different versions of the survey per gender, invariance was tested across gender to determine whether subsequent tests across ethnicity/race and generation could be done across gender. Items were not invariant across gender groups so data files for women and men were not collapsed. Across ethnicity/race for both genders, and across generation for women, items were configurally invariant, and exhibited metric invariance across Latino/Latina and Black participants for both genders. Across generation for men, the configural invariance model could not be identified so the baseline models were examined. The four item one factor model fit well for the Millennial and GenerationX groups but was a poor fit for the baby boomer and silent generation groups, suggesting that gender moderated the invariance across generation. Thus, comparisons between ethnic/racial and generational groups should not be made between the genders or even within gender. Findings highlight the need for programs and interventions that promote a more inclusive definition of "having had sex."

Predictors of treatment failure in young patients undergoing in vitro fertilization.

PURPOSE: The purpose of the study was to evaluate whether routinely collected clinical factors can predict in vitro fertilization (IVF) failure among young, "good prognosis" patients predominantly with secondary infertility who are less than 35 years of age. METHODS: Using de-identified clinic records, 414 women <35 years undergoing their first autologous IVF cycle were identified. Logistic regression was used to identify patient-driven clinical factors routinely collected during fertility treatment that could be used to model predicted probability of cycle failure. RESULTS: One hundred ninety-seven patients with both primary and secondary infertility had a failed IVF cycle, and 217 with secondary infertility had a successful live birth. None of the women with primary infertility had a successful live birth. The significant predictors for IVF cycle failure among young patients were fewer previous live births, history of biochemical pregnancies or spontaneous abortions, lower baseline antral follicle count, higher total gonadotropin dose, unknown infertility diagnosis, and lack of at least one fair to good quality embryo. The full model showed good predictive value (c = 0.885) for estimating risk of cycle failure; at ≥80 % predicted probability of failure, sensitivity = 55.4 %, specificity = 97.5 %, positive predictive value = 95.4 %, and negative predictive value = 69.8 %. CONCLUSION: If this predictive model is validated in future studies, it could be beneficial for predicting IVF failure in good prognosis women under the age of 35 years.

The reliability of tweets as a supplementary method of seasonal influenza surveillance.

BACKGROUND: Existing influenza surveillance in the United States is focused on the collection of data from sentinel physicians and hospitals; however, the compilation and distribution of reports are usually delayed by up to 2 weeks. With the popularity of social media growing, the Internet is a source for syndromic surveillance due to the availability of large amounts of data. In this study, tweets, or posts of 140 characters or less, from the website Twitter were collected and analyzed for their potential as surveillance for seasonal influenza. OBJECTIVE: There were three aims: (1) to improve the correlation of tweets to sentinel-provided influenza-like illness (ILI) rates by city through filtering and a machine-learning classifier, (2) to observe correlations of tweets for emergency department ILI rates by city, and (3) to explore correlations for tweets to laboratory-confirmed influenza cases in San Diego. METHODS: Tweets containing the keyword "flu" were collected within a 17-mile radius from 11 US cities selected for population and availability of ILI data. At the end of the collection period, 159,802 tweets were used for correlation analyses with sentinel-provided ILI and emergency department ILI rates as reported by the corresponding city or county health department. Two separate methods were used to observe correlations between tweets and ILI rates: filtering the tweets by type (non-retweets, retweets, tweets with a URL, tweets without a URL), and the use of a machine-learning classifier that determined whether a tweet was "valid", or from a user who was likely ill with the flu. RESULTS: Correlations varied by city but general trends were observed. Non-retweets and tweets without a URL had higher and more significant (P<.05) correlations than retweets and tweets with a URL. Correlations of tweets to emergency department ILI rates were higher than the correlations observed for sentinel-provided ILI for most of the cities. The machine-learning classifier yielded the highest correlations for many of the cities when using the sentinel-provided or emergency department ILI as well as the number of laboratory-confirmed influenza cases in San Diego. High correlation values (r=.93) with significance at P<.001 were observed for laboratory-confirmed influenza cases for most categories and tweets determined to be valid by the classifier. CONCLUSIONS: Compared to tweet analyses in the previous influenza season, this study demonstrated increased accuracy in using Twitter as a supplementary surveillance tool for influenza as better filtering and classification methods yielded higher correlations for the 2013-2014 influenza season than those found for tweets in the previous influenza season, where emergency department ILI rates were better correlated to tweets than sentinel-provided ILI rates. Further investigations in the field would require expansion with regard to the location that the tweets are collected from, as well as the availability of more ILI data.

Monetary matched incentives to encourage the purchase of fresh fruits and vegetables at farmers markets in underserved communities.

INTRODUCTION: Farmers market programs may increase access to more healthful foods and reduce the high prevalence of obesity in low-income communities. The objective of this study was to examine outcomes of the Fresh Fund farmers market program serving low-income neighborhoods in San Diego, California. METHODS: Through its Farmers Market Fresh Fund Incentive Program, the County of San Diego Health and Human Services Agency offered monetary incentives to government nutrition assistance recipients to purchase fresh produce at 5 farmers markets. Participants enrolled at participating markets from June 1, 2010, through December 31, 2011; they completed baseline and follow-up surveys of daily consumption and weekly spending on fruits and vegetables. We examined enrollment, participation, participant health perceptions, and vendor revenue. RESULTS: During the study period, 7,298 eligible participants enrolled in Fresh Fund; most (82%) had previously never been to a farmers market. Among 252 participants with matched surveys at baseline and 12-month follow-up, the proportion who reported their diet to be "healthy" or "very healthy" increased from 4% to 63% (P < .001); nearly all (93%) stated that Fresh Fund was "important" or "very important" in their decision to shop at the farmers market. Vendors reported that 48% of all market revenue they received was received through the Fresh Fund program. At 2 markets, revenue from June 1, 2011, through January 31, 2012, increased by 74% and 68% compared with revenue from June 1, 2010, through January 31, 2011. CONCLUSION: Participants in the Fresh Fund program self-reported increases in daily consumption and weekly spending on fruits and vegetables, and vendors at participating farmers markets also increased their revenue.

The complex relationship of realspace events and messages in cyberspace: case study of influenza and pertussis using tweets.

BACKGROUND: Surveillance plays a vital role in disease detection, but traditional methods of collecting patient data, reporting to health officials, and compiling reports are costly and time consuming. In recent years, syndromic surveillance tools have expanded and researchers are able to exploit the vast amount of data available in real time on the Internet at minimal cost. Many data sources for infoveillance exist, but this study focuses on status updates (tweets) from the Twitter microblogging website. OBJECTIVE: The aim of this study was to explore the interaction between cyberspace message activity, measured by keyword-specific tweets, and real world occurrences of influenza and pertussis. Tweets were aggregated by week and compared to weekly influenza-like illness (ILI) and weekly pertussis incidence. The potential effect of tweet type was analyzed by categorizing tweets into 4 categories: nonretweets, retweets, tweets with a URL Web address, and tweets without a URL Web address. METHODS: Tweets were collected within a 17-mile radius of 11 US cities chosen on the basis of population size and the availability of disease data. Influenza analysis involved all 11 cities. Pertussis analysis was based on the 2 cities nearest to the Washington State pertussis outbreak (Seattle, WA and Portland, OR). Tweet collection resulted in 161,821 flu, 6174 influenza, 160 pertussis, and 1167 whooping cough tweets. The correlation coefficients between tweets or subgroups of tweets and disease occurrence were calculated and trends were presented graphically. RESULTS: Correlations between weekly aggregated tweets and disease occurrence varied greatly, but were relatively strong in some areas. In general, correlation coefficients were stronger in the flu analysis compared to the pertussis analysis. Within each analysis, flu tweets were more strongly correlated with ILI rates than influenza tweets, and whooping cough tweets correlated more strongly with pertussis incidence than pertussis tweets. Nonretweets correlated more with disease occurrence than retweets, and tweets without a URL Web address correlated better with actual incidence than those with a URL Web address primarily for the flu tweets. CONCLUSIONS: This study demonstrates that not only does keyword choice play an important role in how well tweets correlate with disease occurrence, but that the subgroup of tweets used for analysis is also important. This exploratory work shows potential in the use of tweets for infoveillance, but continued efforts are needed to further refine research methods in this field.

Abscess and self-treatment among injection drug users at four California syringe exchanges and their surrounding communities.

This study aimed to identify the prevalence and determinants of soft tissue infections and self-treatment among injection drug users (IDUs) in California. The study interviewed 864 IDUs in California using computer-assisted personal interview (CAPI) from 2003 to 2005. Multiple logistic regression analyses were performed to examine adjusted associations for recent abscess and abscess self-treatment. In these analyses, Latinos had higher odds than African Americans to self-treat, while IDUs reporting a usual place of health care had lower odds of self-treatment. Findings suggest an expansion of wound care facilities to mitigate the self-treatment of abscesses, with special consideration to Latinos.

Prenatal alcohol exposure patterns and alcohol-related birth defects and growth deficiencies: a prospective study.

BACKGROUND: The physical features of fetal alcohol syndrome include smooth philtrum, thin vermillion border, short palpebral fissures, microcephaly, and growth deficiencies on weight and height. However, little is known about the specific quantities of alcohol exposure, pattern of drinking, timing of exposure, and magnitude of risk for each of these features. METHODS: Using data on 992 subjects collected prospectively in California between 1978 and 2005, we examined the patterns and timing of alcohol exposure in relation to these features. Structural features were assessed by a dysmorphologist who performed a blinded physical examination of all infants. Patterns of drinking were evaluated by drinks per day, number of binge episodes, and maximum number of drinks. Timing of exposure was evaluated 0 to 6 weeks postconception, 6 to 12 weeks postconception, first trimester, second trimester, and third trimester. RESULTS: Higher prenatal alcohol exposure in every pattern was significantly associated with the incidence of smooth philtrum but not with short palpebral fissures. The strongest associations were with timing of exposure in the second half of the first trimester (RR 1.25, 95% CI 1.14 to 1.36 for average number of drinks per day; RR 1.17, 95% CI 1.09 to 1.26 for maximum number of drinks in 1 episode). Similarly, thin vermillion border was most strongly associated with exposure in the second half of the first trimester. Findings with respect to timing of exposure were similar for microcephaly and reduced birth weight. However, reduced birth length was increased with exposure in any trimester. These associations were linear, and there was no evidence of a threshold. CONCLUSIONS: Reduced birth length and weight, microcephaly, smooth philtrum, and thin vermillion border are associated with specific gestational timing of prenatal alcohol exposure and are dose-related without evidence of a threshold. Women should continue to be advised to abstain from alcohol consumption from conception throughout pregnancy.

Patterns of prenatal alcohol exposure and associated non-characteristic minor structural malformations: a prospective study.

The characteristic facial features of the more severe end of Fetal Alcohol Spectrum Disorders (FASD) include smooth philtrum, thin vermillion of the upper lip, and short palpebral fissures. A systematic evaluation of a comprehensive list of minor structural defects in association with varying patterns of prenatal exposure to alcohol has not been performed. We examined the patterns and timing of prenatal alcohol exposure to minor structural malformations occurring in at least 5% of the sample. Patterns of drinking were evaluated by drinks per day, number of binge episodes, and maximum number of drinks. Timing of exposure was evaluated 0-6 weeks post-conception, 6-12 weeks post-conception, first trimester, second trimester, and third trimester. Naevus flammeus neonatorum is significantly associated with various patterns of drinking during the second half of the first trimester (RR 1.14, 95% CI 1.04, 1.24 for average number of drinks per day; RR 1.04, 95% CI 1.02, 1.07 for number of binge episodes; RR 1.08, 95% CI 1.01, 1.15 for maximum number of drinks in one episode) and similar for number of binge episodes in all categories of timing of exposure and in the second trimester for average number of drinks per day. Other minor malformations occurring in at least 5% of the sample were not found to be significantly associated with prenatal alcohol exposure. Expected minor malformations were not found to be significantly associated with prenatal alcohol exposure. Naevus flammeus neonatorum appears to be part of the spectrum of features associated with prenatal alcohol exposure.

Increasing hookah use in California.

Hookah use is gaining popularity nationwide. We determined the correlates and trends for hookah use from the California Tobacco Survey. Between 2005 and 2008 hookah use increased more than 40%, and in 2008, 24.5% of young men reported ever using a hookah. Hookah use was more common among the young (18-24 years), the educated, the non-Hispanic Whites, and the cigarette smokers. Hookah use is increasing in California, especially among young adults, and in 2008 reached the highest prevalence ever reported for both genders.

Determinants of hookah use among high school students.

INTRODUCTION: Hookah use is increasing among young people, but there are limited data on its use among high school-age populations. We examined hookah use initiation, prevalence, cessation, and psychosocial risk factors of hookah use among high school students. METHODS: A cross-sectional survey of 689 students from three high schools in San Diego County was used to compare characteristics of hookah ever-users to nonusers and factors associated with current and former hookah use. RESULTS: Hookah ever-use in the study population was 26.1%, previous month hookah use was 10.9%, and current hookah use was 10.3%. Most students first learned about hookah from friends (50.3%) or saw a hookah lounge (20.9%). Students believed hookah to be more socially acceptable than cigarettes and less harmful than cigarettes, cigars, and smokeless tobacco. Hookah ever-users were significantly more likely than nonusers to have smoked cigarettes, to know of a hookah lounge in their community, and to believe hookah is safer and more socially acceptable than cigarettes. In comparison to former users, current users were more likely to have recently smoked a cigarette, to know of a hookah lounge in their community, and to believe hookah is more socially acceptable than cigarettes. CONCLUSIONS: Hookah use is becoming a commonly acceptable behavior among adolescents, and risk perception is a significant factor. Presence of hookah lounges are associated with increased hookah use among high school students and should be a target of further regulation.

Prevalence and psychological correlates of traumatic brain injury in operation iraqi freedom.

OBJECTIVE: To describe the prevalence and psychological correlates of traumatic brain injury (TBI) among injured male combatants in the Iraq conflict. PARTICIPANTS: A total of 781 men injured during military combat between September 2004 and February 2005. MAIN OUTCOME MEASURES: Mental health diagnosis (ICD-9 290-319), particularly posttraumatic stress disorder and mood/anxiety disorders, assigned through November 2006. RESULTS: 15.8% met criteria for TBI (13.4% mild, 2.4% moderate-severe TBI), 35.0% other head injury, and 49.2% non-head injury. Multivariate logistic regression suggested lower rates of posttraumatic stress disorder and mood/anxiety disorders among those with mild and moderate-severe TBI. CONCLUSIONS: These findings could reflect a problem with differential diagnosis or, conversely, a low rate of self-presentation for symptoms. Further research is needed to elucidate the psychological consequences, clinical implications, and overall impact of TBI among military combat veterans.

Psychological correlates of battle and nonbattle injury among Operation Iraqi Freedom veterans.

Limited research exists on the relationship between physical injury and PTSD within military populations. The present study assessed postinjury rates of PTSD and other psychological correlates among battle and non-battle injuries. A total of 1,968 men (831 battle injuries and 1,137 nonbattle injuries) injured between September 2004 and February 2005 during Operation Iraqi Freedom (OIF) composed the study sample. Patients were followed through November 2006 for mental health diagnosis (ICD-9 290-319). Compared with nonbattle injuries, those with battle injuries had a greater risk of PTSD and other mental health diagnosis, and there was a positive association with injury severity. Self-reported mental health symptoms were significantly higher for both minor and moderate-severe battle injury in comparison to nonbattle injury and previous population estimates from an earlier OIF period. More research is needed to further define this relationship by examining potential mechanisms and addressing the possible contributing effect of combat exposure.

Periodontal disease and its connection to systemic biomarkers of cardiovascular disease in young American Indian/Alaskan natives.

BACKGROUND: Periodontal disease has been shown to be associated with cardiovascular disease (CVD). No known studies evaluate the relationship between periodontal disease status and biomarkers of CVD risk in the American Indian/Alaskan Native (AI/AN) population despite their disproportionately high rates of poor oral health and cardiovascular disease-related outcomes. This study compared levels of interleukin (IL)-6 and C-reactive protein (CRP) across increasing severity of periodontal disease status among younger adults between the ages of 21 and 43 years. METHODS: Plasma levels of IL-6 and CRP were measured in adult participants (ages 21 to 43 years) as part of a study of periodontal disease and CVD risk among an AI/AN population in southern California (n = 59). Periodontal evaluations were performed and disease status was classified into three categories based on highest probing depth (none/mild: < 3 mm; moderate: 4 to 5 mm; severe: ≥6 mm). Participants with known systemic disease or active infection were excluded. RESULTS: Severe periodontitis was significantly associated with increased levels of IL-6 compared with those with none or mild periodontitis before controlling for other variables (P = 0.02), but lacked significance after controlling for sex, BMI, smoking status, and high-density lipoprotein (P = 0.09). Moderate periodontal disease was positively associated with IL-6 levels after controlling for potential confounders (P = 0.01). Periodontal status was not associated with CRP, before or after adjusting for covariates. CONCLUSIONS: In this otherwise healthy AI/AN adult sample, moderate periodontal disease compared with none or mild periodontal disease was associated with increased levels of IL-6. High levels of CRP found in this population warrant further research.

Latent classes of polydrug and polyroute use and associations with human immunodeficiency virus risk behaviours and overdose among people who inject drugs in Tijuana, Baja California, Mexico.

INTRODUCTION AND AIMS: Patterns of polydrug use among people who inject drugs (PWID) may be differentially associated with overdose and unique human immunodeficiency virus (HIV) risk factors. Subgroups of PWID in Tijuana, Mexico, were identified based on substances used, route of administration, frequency of use and co-injection indicators. DESIGN AND METHODS: Participants were PWID residing in Tijuana age ≥18 years sampled from 2011 to 2012 who reported injecting an illicit substance in the past month (n = 735). Latent class analysis identified discrete classes of polydrug use characterised by 11 indicators of past 6 months substance use. Multinomial logistic regression examined class membership association with HIV risk behaviours, overdose and other covariates using an automated three-step procedure in mplus to account for classification error. RESULTS: Participants were classified into five subgroups. Two polydrug and polyroute classes were defined by use of multiple substances through several routes of administration and were primarily distinguished from each other by cocaine use (class 1: 5%) or no cocaine use (class 2: 29%). The other classes consisted primarily of injectors: cocaine, methamphetamine and heroin injection (class 3: 4%); methamphetamine and heroin injection (class 4: 10%); and heroin injection (class 5: 52%). Compared with the heroin-only injection class, memberships in the two polydrug and polyroute use classes were independently associated with both HIV injection and sexual risk behaviours. DISCUSSION AND CONCLUSIONS: Substance use patterns among PWID in Tijuana are highly heterogeneous, and polydrug and polyroute users are a high-risk subgroup who may require more tailored prevention and treatment interventions. [Meacham MC, Roesch SC, Strathdee SA, Lindsay S, Gonzalez-Zuniga P, Gaines TL. Latent classes of polydrug and polyroute use and associations with human immunodeficiency virus risk behaviours and overdose among people who inject drugs in Tijuana, Baja California, Mexico. Drug Alcohol Rev 2018;37:128-136].

Orthodontic appliances for reduction and fixation of a mandibular fracture: a case report.

UNLABELLED: A fractured mandible was treated using orthodontic brackets and wires and intra-oral elastics. The occlusion was corrected and the fracture was efficiently and effectively fixed and the need for a general anaesthetic avoided. CLINICAL RELEVANCE: To provide an effective and inexpensive treatment for a fractured mandible avoiding the need for a general anaesthetic.

International chicken trade and increased risk for introducing or reintroducing highly pathogenic avian influenza A (H5N1) to uninfected countries.

Every year billions of chickens are shipped thousands of miles around the globe in order to meet the ever increasing demands for this cheap and nutritious protein source. Unfortunately, transporting chickens internationally can also increase the chance for introducing zoonotic viruses, such as highly pathogenic avian influenza A (H5N1) to new countries. Our study used a retrospective analysis of poultry trading data from 2003 through 2011 to assess the risk of H5N1 poultry infection in an importing country. We found that the risk of infection in an importing country increased by a factor of 1.3 (95% CI: 1.1-1.5) for every 10-fold increase in live chickens imported from countries experiencing at least one H5N1 poultry case during that year. These results suggest that the risk in a particular country can be significantly reduced if imports from countries experiencing an outbreak are decreased during the year of infection or if biosecurity measures such as screening, vaccination, and infection control practices are increased. These findings show that limiting trade of live chickens or increasing infection control practices during contagious periods may be an important step in reducing the spread of H5N1 and other emerging avian influenza viruses.