Invasive and in situ squamous cell carcinoma of the skin: a nationwide study in Iceland.

BACKGROUND: The worldwide incidence of cutaneous squamous cell carcinoma (cSCC) is increasing. OBJECTIVES: To evaluate the tumour burden of in situ and invasive cSCC in Iceland, where the population is exposed to limited ultraviolet radiation. METHODS: This whole-population study used the Icelandic Cancer Registry, which contains records of all in situ and invasive cSCC cases from 1981 to 2017. Incidence of cSCC was evaluated according to age, anatomical location, residence and multiplicity, and trends were assessed using joinpoint analysis. Age-standardized rates (WSR) and age-specific incidence rates per 100 000 person-years were calculated, along with cumulative and lifetime risks. RESULTS: Between 1981 and 2017, in situ cSCC WSR increased from 1·2 to 19·1 for men and from 2·0 to 22·3 for women. Invasive cSCC WSR rose from 4·6 to 14 for men and from 0·3 to 13·2 for women. The average number of in situ cSCC lesions was 1·71 per woman and 1·39 per man. Women developed more in situ cSCCs than invasive cSCCs in almost all anatomical locations, whereas men developed more invasive cSCCs, mostly on the head and neck. The rates of in situ cSCC were higher in Reykjavik compared with rural areas. Furthermore, women more commonly developed multiple in situ lesions. For lip cSCCs, invasive lesions occurred more frequently than in situ lesions among both sexes. Joinpoint analysis showed that in situ cSCC in women exhibited the most rapid incidence increase. CONCLUSIONS: cSCC has become an increasingly significant public health problem in Iceland. Tanning bed use and travelling abroad may contribute to skin cancer development. Public health efforts are needed to stem the behaviours leading to this rapid rise in cSCC.

Using bivalve chronologies for quantifying environmental drivers in a semi-enclosed temperate sea.

Annual growth increments formed in bivalve shells are increasingly used as proxies of environmental variability and change in marine ecosystems, especially at higher latitudes. Here, we document that well-replicated and exactly dated chronologies can also be developed to capture oceanographic processes in temperate and semi-enclosed seas, such as the Mediterranean. A chronology is constructed for Glycymeris pilosa from a shallow embayment of the northern Adriatic and extends from 1979 to 2016. The chronology significantly (p < 0.05) and positively correlates to winter sea surface temperatures, but negatively correlates to summer temperatures, which suggests that extreme winter lows and extreme summer highs may be limiting to growth. However, the strongest and most consistent relationships are negative correlations with an index of the Adriatic-Ionian Bimodal Oscillating System (BiOS) for which positive values indicate the inflow of the ultraoligotrophic Eastern Mediterranean waters to the Adriatic. In contrast, the substantial freshwater flows that discharge into the Adriatic do not correlate to the bivalve chronology, emphasizing the importance of remote oceanographic processes to growth at this highly coastal site. Overall, this study underscores the potential of bivalve chronologies to capture biologically relevant, local- to regional-scale patterns of ocean circulation in mid-latitude, temperate systems.

Differences in dermatology training abroad: A comparative analysis of dermatology training in the United States and in India.

Dermatology residency training is not standardized internationally, and each country dictates how training is conducted within its own borders. This article highlights the types of variability in training that can occur from country to country by comparing dermatology residency training programs in the United States and India. This article specifically analyzes the differences that pertain to application and selection, residency program structure, and post-residency opportunities.

Supernova 2007bi as a pair-instability explosion.

Stars with initial masses such that 10M[symbol: see text] or= 140M[symbol: see text] (if such exist) develop oxygen cores with masses, M(core), that exceed 50M[symbol: see text], where high temperatures are reached at relatively low densities. Conversion of energetic, pressure-supporting photons into electron-positron pairs occurs before oxygen ignition and leads to a violent contraction which triggers a nuclear explosion that unbinds the star in a pair-instability supernova. Transitional objects with 100M[symbol: see text] < M(initial) < 140M[symbol: see text] may end up as iron-core-collapse supernovae following violent mass ejections, perhaps as a result of brief episodes of pair instability, and may already have been identified. Here we report observations of supernova SN 2007bi, a luminous, slowly evolving object located within a dwarf galaxy. We estimate the exploding core mass to be M(core) approximately 100M[symbol: see text], in which case theory unambiguously predicts a pair-instability supernova. We show that >3M[symbol: see text] of radioactive (56)Ni was synthesized during the explosion and that our observations are well fitted by models of pair-instability supernovae. This indicates that nearby dwarf galaxies probably host extremely massive stars, above the apparent Galactic stellar mass limit, which perhaps result from processes similar to those that created the first stars in the Universe.

Vaginal delivery after cesarean section: is the risk acceptable?

Recent studies and commentary have questioned the safety of vaginal births after cesarean sections (VBACs). The history of VBACs is reviewed and a framework to continue the safe practice of trials of labor in women with a prior uterine scar is presented.

A population-based assessment of human rights abuses committed against ethnic Albanian refugees from Kosovo.

OBJECTIVES: This study assessed patterns of displacement and human rights abuses among Kosovar refugees in Macedonia and Albania. METHODS: Between April 19 and May 3, 1999, 1180 ethnic Albanian refugees living in 31 refugee camps and collective centers in Macedonia and Albania were interviewed. RESULTS: The majority (68%) of participants reported that their families were directly expelled from their homes by Serb forces. Overall, 50% of participants saw Serb police or soldiers burning the houses of others, 16% saw Serb police or soldiers burn their own home, and 14% witnessed Serb police or soldiers killing someone. Large percentages of participants saw destroyed mosques, schools, or medical facilities. Thirty-one percent of respondents reported human rights abuses committed against their household members, including beatings, killings, torture, forced separation and disappearances, gunshot wounds, and sexual assault. CONCLUSIONS: The present findings confirm that Serb forces engaged in a systematic and brutal campaign to forcibly expel the ethnic Albanian population of Kosovo. In the course of these mass deportations, Serb forces committed widespread abuses of human rights against ethnic Albanians.

The evolution of child health programmes in developing countries: from targeting diseases to targeting people.

Mortality rates among children and the absolute number of children dying annually in developing countries have declined considerably over the past few decades. However, the gains made have not been distributed evenly: childhood mortality remains higher among poorer people and the gap between rich and poor has grown. Several poor countries, and some poorer regions within countries, have experienced a levelling off of or even an increase in childhood mortality over the past few years. Until now, two types of programmes--short-term, disease-specific initiatives and more general programmes of primary health care--have contributed to the decline in mortality. Both types of programme can contribute substantially to the strengthening of health systems and in enabling households and communities to improve their health care. In order for them to do so, and in order to complete the unfinished agenda of improving child health globally, new strategies are needed. On the one hand, greater emphasis should be placed on promoting those household behaviours that are not dependent on the performance of health systems. On the other hand, more attention should be paid to interventions that affect health at other stages of the life cycle while efforts that have been made to develop interventions that can be used during childhood continue.

Public health and complex emergencies: new issues, new conditions.

Public health practice in complex emergencies has become increasingly sophisticated and well informed over the course of the past quarter century. Humanitarian relief organizations have learned many lessons in the areas of food, water and sanitation, shelter, and primary health. However, closer scrutiny from the media and funding agencies, together with changing conditions and an increasingly insecure environment, will require that changes be made. First and foremost, nongovernmental organizations must recognize that an increasing proportion of morbidity and mortality is the consequence of widespread human rights abuses. These organizations should become more familiar with international human rights and humanitarian law, and their personnel should receive clear guidance as to how to recognize and report violations. At the same time, nongovernmental organizations will have to work more closely with military forces that have a very different organizational culture. In addition, as emergencies become more complex, nongovernmental organizations should do more to attract and retain seasoned professionals. Finally, advances in both technical and operational areas will occur only through carefully designed and implemented research.

Cost-effectiveness of oral cholera vaccine in a stable refugee population at risk for epidemic cholera and in a population with endemic cholera.

Recent large epidemics of cholera with high incidence and associated mortality among refugees have raised the question of whether oral cholera vaccines should be considered as an additional preventive measure in high-risk populations. The potential impact of oral cholera vaccines on populations prone to seasonal endemic cholera has also been questioned. This article reviews the potential cost-effectiveness of B-subunit, killed whole-cell (BS-WC) oral cholera vaccine in a stable refugee population and in a population with endemic cholera. In the population at risk for endemic cholera, mass vaccination with BS-WC vaccine is the least cost-effective intervention compared with the provision of safe drinking-water and sanitation or with treatment of the disease. In a refugee population at risk for epidemic disease, the cost-effectiveness of vaccination is similar to that of providing safe drinking-water and sanitation alone, though less cost-effective than treatment alone or treatment combined with the provision of water and sanitation. The implications of these data for public health decision-makers and programme managers are discussed. There is a need for better information on the feasibility and costs of administering oral cholera vaccine in refugee populations and populations with endemic cholera.

PIP: The recent development of safe, reasonably effective oral cholera vaccines has made it possible to consider their use in situations where the risk of epidemic cholera is high. This article reviews the potential cost-effectiveness of the B-subunit killed whole-cell (BS-WC) oral cholera vaccine in both a stable refugee population and a population with endemic cholera. Baseline epidemiologic assumptions were applied to the standard populations to generate the expected morbidity and mortality levels for cholera and simple diarrhea; then, the net costs per case and per death averted by various interventions were calculated. In the population at risk for endemic cholera, the net costs per disability-adjusted life year (DALY) averted are considerably higher since incidence and access to health care are lower. In this population, mass vaccination with BS-WC vaccine is the least cost-effective intervention compared with the provision of safe drinking water and sanitation or with treatment of the disease. In the refugee population, the net costs per DALY averted are much lower since attack rates are higher and access to health care facilities is assumed to be 100%. In this population, the cost-effectiveness for vaccination is similar to that of providing safe drinking water and sanitation alone and less cost-effective than treatment alone or treatment combined with the provision of water and sanitation. Ultimately, the relative cost-effectiveness of an oral cholera vaccine will depend not only on its safety, effectiveness, and duration of protection against the El Tor biotype, but also on the feasibility of administering it to high-risk populations.

Nasogastric tube feeding and medication administration: a survey of nursing practices.

Using a 62-item, investigator-developed mailed questionnaire, this descriptive study of 350 randomly selected staff nurses sought to identify variations in practices in the care of patients with nasogastric tubes (NGT). Reported here are the results from the 35 questionnaire items related to NGT feedings and medication administration. Wide variations were found in the amount of gastric residual considered "excessive," as well as in whether the entire residual was returned to the stomach. A large percentage of the nurses relied on physicians' orders for gavage feeding rate, giving additional water, and using the liquid form of a medication. Data indicate that published nursing research is not consistently used in practice, which represents a theory-practice gap. In addition, a theory-practice deficit in several areas related to NGT feedings points to the need for further research.