Reasons and suggestions for improving low immunization uptake among children living in low socioeconomic status communities in Northern Alberta, Canada - A qualitative study.

OBJECTIVE: Under-immunization increases the risk of acquiring vaccine-preventable diseases in children and the community. The targeted coverage rate for routine childhood immunization in Alberta, especially in disadvantaged communities in rural and remote geographic areas, has not been achieved for many years. This study was conducted to identify reasons for under-immunization in children in low socioeconomic status (SES) communities and propose suggestions to address issues/concerns identified by low SES parents for improving immunization coverage in their communities. METHODS: Fourteen semi-structured phone interviews of low SES parents with under-immunized children living in rural and remote geographic areas in Northern Alberta were conducted. Transcripts were analyzed to identify relevant themes. RESULTS: Busy lifestyles of many parents prevented them from taking their children to clinics for immunization, which were exacerbated by long distances to clinics, transportation issues, operating hours of clinics, and lack of reminders. Many disadvantaged parents also exhibited varying levels of vaccine hesitancy due to safety concerns, especially about newer vaccines, thereby causing some parents to delay immunizing their child intentionally. CONCLUSION: Implementing procedures to alleviate access issues, such as offering extended operating hours, opening drop-in clinics/satellite clinics in distant areas, nurse visits to their homes, updating contact information of parents, frequent reminder options and addressing safety and effectiveness concerns about vaccines in plain language using evidence-based communication strategies can promote timely immunization among children of low SES parents.

Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida.

BACKGROUND: Primary cesarean deliveries are a major contributor to the large increase in cesarean delivery rates in the United States over the past 2 decades and are an essential focus for the reduction of related morbidity and costs. Studies have shown that primary cesarean delivery rates among low-risk women in the United States vary 3-fold across hospitals and are not explained by differences in patient case-mix. However, the extent to which maternal vs hospital characteristics contribute to this variation remains poorly understood because previous studies were limited in scope and did not assess the influence of factors such as maternal ethnicity subgroups or prepregnancy obesity. OBJECTIVE: We assessed the contribution of individual- and hospital-level risk factors to the hospital variation in primary cesarean delivery rates among low-risk women in Florida. STUDY DESIGN: Our population-based retrospective cohort study used Florida's linked birth certificate and hospital discharge records for the period of 2004-2011. The study population was comprised of 412,192 nulliparous, singleton, vertex, live births with labor at 37-40 weeks gestation in 122 nonmilitary delivery hospitals. Data were analyzed with logistic mixed-effects regression with cesarean delivery as the outcome. This approach provided adjusted risk estimates at an individual and hospital level and the estimated percent of hospital variation statewide that was explained by these factors. RESULTS: The primary cesarean delivery rate in the study population was 23.9%, with hospital-specific estimates that ranged from 12.8-47.3%. Leading risk factors for cesarean delivery were maternal age ≥35 years (adjusted relative risk, 2.22), prepregnancy obesity (body mass index, ≥30 kg/m(2); adjusted relative risk, 1.73), medical risk conditions (adjusted relative risk, 1.72), labor induction (adjusted relative risk, 1.52), and delivery in hospitals located in Miami-Dade County (adjusted relative risk, 1.73). Hospital geographic location was a significant effect modifier for prepregnancy obesity, medical conditions, and labor induction (P < .05), with a tendency towards lower adjusted relative risks for these factors in Miami-Dade County relative to other Florida regions. Conversely, Miami-Dade County had an increased prevalence of higher-risk ethnic subgroups, such as Cuban or Puerto Rican mothers, and also substantially higher adjusted relative risks that were associated with practice-related factors, such as delivery during weekday hours. Whereas hospital geographic location contributed to 39.6% of the observed variation statewide, the estimated contribution of maternal ethnicity ranged from 1.6-15.7% among Florida regions. CONCLUSIONS: Hospital geographic location contributes to hospital variation in primary cesarean delivery rates among low-risk women in Florida. In contrast to previous studies, our findings suggest that individual level risk factors such as maternal ethnicity also contribute to some of this variation, with differing extent by region. These individual factors likely interact with practice factors and add to the variation. This study was limited by not including maternal Bishop score before induction or obstetrics provider in the analysis. These were not available on the dataset but likely contribute to the variation. Our findings suggest potential issues to consider in quality improvement efforts, such as the need for future qualitative research that focuses on mothers in higher-risk ethnic subgroups and providers in high-rate hospitals, particularly those in Miami-Dade County. These studies may help to identify potential cultural differences in maternal beliefs and expectations for delivery and maternal reasons for differences in obstetrics practices.

A genome-wide investigation of microRNA expression identifies biologically-meaningful microRNAs that distinguish between high-risk and low-risk intraductal papillary mucinous neoplasms of the pancreas.

BACKGROUND: Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic ductal adenocarcinoma (PDAC) precursors. Differentiating between high-risk IPMNs that warrant surgical resection and low-risk IPMNs that can be monitored is a significant clinical problem, and we sought to discover a panel of mi(cro)RNAs that accurately classify IPMN risk status. METHODOLOGY/PRINCIPAL FINDINGS: In a discovery phase, genome-wide miRNA expression profiling was performed on 28 surgically-resected, pathologically-confirmed IPMNs (19 high-risk, 9 low-risk) using Taqman MicroRNA Arrays. A validation phase was performed in 21 independent IPMNs (13 high-risk, 8 low-risk). We also explored associations between miRNA expression level and various clinical and pathological factors and examined genes and pathways regulated by the identified miRNAs by integrating data from bioinformatic analyses and microarray analysis of miRNA gene targets. Six miRNAs (miR-100, miR-99b, miR-99a, miR-342-3p, miR-126, miR-130a) were down-regulated in high-risk versus low-risk IPMNs and distinguished between groups (P<10-3, area underneath the curve (AUC) = 87%). The same trend was observed in the validation phase (AUC = 74%). Low miR-99b expression was associated with main pancreatic duct involvement (P = 0.021), and serum albumin levels were positively correlated with miR-99a (r = 0.52, P = 0.004) and miR-100 expression (r = 0.49, P = 0.008). Literature, validated miRNA:target gene interactions, and pathway enrichment analysis supported the candidate miRNAs as tumor suppressors and regulators of PDAC development. Microarray analysis revealed that oncogenic targets of miR-130a (ATG2B, MEOX2), miR-342-3p (DNMT1), and miR-126 (IRS-1) were up-regulated in high- versus low-risk IPMNs (P<0.10). CONCLUSIONS: This pilot study highlights miRNAs that may aid in preoperative risk stratification of IPMNs and provides novel insights into miRNA-mediated progression to pancreatic malignancy. The miRNAs identified here and in other recent investigations warrant evaluation in biofluids in a well-powered prospective cohort of individuals newly-diagnosed with IPMNs and other pancreatic cysts and those at increased genetic risk for these lesions.