A comparison of outcomes among hospital survivors with and without severe comorbidity admitted to the intensive care unit.

Little is known about the experiences of patients with severe comorbidity discharged from Intensive Care Units (ICUs). This project aimed to determine the effects of an ICU stay for patients with severe comorbidity by comparing 1) quality of life (QOL), 2) the symptom profile of hospital survivors and 3) health service use after hospital discharge for patients admitted to ICU with and without severe comorbidity. A case-control study was used. Patients with severe comorbidity were matched to a contemporaneous cohort of ICU patients by age and severity of illness. Assessment tools were the Medical Outcome Study 36-item short-form and European Organisation for Research and Treatment of Cancer QLQ-C15-PAL questionnaires for QOL and the Symptom Assessment Scale for symptom distress. A proportional odds assumption was performed using an ordinal regression model. The difference in QOL outcome was the dependent variable for each pair. Health service use after discharge from ICU was monitored with patient diaries. Patients aged 18+ years admitted to an ICU in a metropolitan teaching hospital between 2011 and 2012 were included. We recruited 30 cases and 30 controls. QOL improved over the six months after hospital discharge for patients with and without severe comorbidity (P <0.01) within the groups but there was no difference found between the groups (P >0.3). There was no difference in symptoms or health service use between patients with and without severe comorbidity. ICU admission for people with severe comorbidity can be appropriate to stabilise the patient's condition and is likely to be followed by some overall improvement over the six months after hospital discharge.

Maintaining a way of life for São Miguel Island (the Azores archipelago, Portugal): an assessment of coastal processes and protection.

Traditional hard engineering structures and recently emerging soft engineering alternatives have been employed to protect vulnerable coastlines. Despite negative publicity, they have ensured community survival where socio-economic benefits outweigh adverse impacts. This is especially true for Small Islands (SI) where increasing sea levels and storm intensities threaten already limited land availability. This paper presents coastal vulnerability in São Miguel Island (the Azores SI archipelago) and considers SI issues with regard to coastal land loss. Regional wave statistics using 1998 to 2011 wind record showed: periods ranging from 7 to 13s (circa 83%); wave heights between 1 and 3m (circa 60%); and increasing trends in westerly (p=0.473), easterly (p=0.632) and southeasterly (p=0.932) waves. Sea level analyses between 1978 and 2007 indicated a statistically significant rising trend (2.5 ± 0.4 mm yr(-1); p=0.000), while between 1996 and 2007 it was 3.3 ± 1.5 mm yr(-1) (p=0.025), agreeing with other global sea level studies. Based on 2001 and 2008 population data and using zonal statistics, circa 60% of the Island's population was found to reside within 1 km of the sea and the percentage of total population was linearly correlated with distance from the shoreline (r(2)=99%). Three case studies show hard coastal engineering solutions preserved Azorean coastal lifestyle and had little or no observed negative impacts on their environs. Although hard engineering is likely to remain a valuable and feasible coastal protection option, an inventory of São Miguel's population distribution, surf breaks, bathymetry and coastal erosion rates showed the potential of using multifunctional artificial reefs as a soft engineering solution. These offshore submerged breakwaters offer coastal protection while providing additional benefits such as surfing amenity and beach widening. Consequently, findings of this work can inform other SI communities.

Meeting the food and nutrition needs of the poor: the role of fish and the opportunities and challenges emerging from the rise of aquaculture.

People who are food and nutrition insecure largely reside in Asia and Sub-Saharan Africa and for many, fish represents a rich source of protein, micronutrients and essential fatty acids. The contribution of fish to household food and nutrition security depends upon availability, access and cultural and personal preferences. Access is largely determined by location, seasonality and price but at the individual level it also depends upon a person's physiological and health status and how fish is prepared, cooked and shared among household members. The sustained and rapid expansion of aquaculture over the past 30 years has resulted in >40% of all fish now consumed being derived from farming. While aquaculture produce increasingly features in the diets of many Asians, it is much less apparent among those living in Sub-Saharan Africa. Here, per capita fish consumption has grown little and despite the apparently strong markets and adequate biophysical conditions, aquaculture has yet to develop. The contribution of aquaculture to food and nutrition security is not only just an issue of where aquaculture occurs but also of what is being produced and how and whether the produce is as accessible as that from capture fisheries. The range of fish species produced by an increasingly globalized aquaculture industry differs from that derived from capture fisheries. Farmed fishes are also different in terms of their nutrient content, a result of the species being grown and of rearing methods. Farmed fish price affects access by poor consumers while the size at which fish is harvested influences both access and use. This paper explores these issues with particular reference to Asia and Africa and the technical and policy innovations needed to ensure that fish farming is able to fulfil its potential to meet the global population's food and nutrition needs.

SU-E-T-221: Evaluation of Technology Using Probabilistic Decision Models.

PURPOSE: Medical physicists are often asked to evaluate or choose appropriatetechnology for clinical applications. These are multidimensionalproblems that also suffer from different degrees of uncertainty in thevariables. Probabilistic decision models are a robust andmathematically correct means of handling these issues. The principlesof constructing such models are presented along with practicalexamples in the areas of IGRT, IMRT and proton therapy. METHODS: Influence diagrams are used to model the variables and theiruncertainties and include action and reward variables. Influencediagrams are directed acyclic graphs that use Bayesian probabilitycalculus to propagate probabilities and to update prior probabilitiesin the presence of evidence. An influence diagram was used to modelthe question of whether brain tumors are better treated with x-rayIMRT or proton therapy, with or without CT-guided localization. Datafor the conditional probabilities of the model were obtained from theliterature and included models of TCP, NTCP and induction of secondmalignancies, as well as data on the probability density functions forinterfraction patient motion. Dosimetric data were obtained using theCMS treatment planning system. RESULTS: Several different tumor types and sites were studied. The critical variables in the model were identified andstudied using analyses of evidence, parameters and value ofinformation. The impact of imaging was significant, regardless of theradiation type. The models used in determining some of theconditional probabilities parameters also played an important role inranking alternatives. CONCLUSIONS: Although such choices are difficult, physicists mustproceed with the best data at hand. Without a rigorous framework onwhich to build a model of the process, decisions are likely to be based onunstated assumptions and incorrect inference. The example ofcomparing irradiation modalities for brain tumors shows the power ofinfluence diagrams in this critical context.

Informed consent in the context of pharmacogenomic research: ethical considerations.

Although the scientific research surrounding pharmacogenomics (PGx) has been relatively plentiful, the ethical research concerning this discipline has developed rather conservatively. Following investigation of the ethical, legal and social issues (ELSI) of PGx research, as well as consulting with key stakeholders, we identified six outstanding ethical issues raised by the informed consent process in PGx research: (1) scope of consent; (2) consent to 'add-on' studies; (3) protection of personal information; (4) commercialization; (5) data sharing; and (6) potential risks stemming from population-based research. In discussing these six areas as well as offering specific considerations, this article offers a solid base from which future practical guidelines for informed consent in PGx research can be constructed. As such, this effort works toward filling the ELSI gap and provides ethical support to the numerous PGx projects undertaken by researchers every year.

A Markov decision process approach to temporal modulation of dose fractions in radiation therapy planning.

The current state of the art in cancer treatment by radiation optimizes beam intensity spatially such that tumors receive high dose radiation whereas damage to nearby healthy tissues is minimized. It is common practice to deliver the radiation over several weeks, where the daily dose is a small constant fraction of the total planned. Such a 'fractionation schedule' is based on traditional models of radiobiological response where normal tissue cells possess the ability to repair sublethal damage done by radiation. This capability is significantly less prominent in tumors. Recent advances in quantitative functional imaging and biological markers are providing new opportunities to measure patient response to radiation over the treatment course. This opens the door for designing fractionation schedules that take into account the patient's cumulative response to radiation up to a particular treatment day in determining the fraction on that day. We propose a novel approach that, for the first time, mathematically explores the benefits of such fractionation schemes. This is achieved by building a stylistic Markov decision process (MDP) model, which incorporates some key features of the problem through intuitive choices of state and action spaces, as well as transition probability and reward functions. The structure of optimal policies for this MDP model is explored through several simple numerical examples.

The supportive and palliative care needs of Australian families of children who die from cancer.

OBJECTIVE: To identify the perceptions of parents of children who died from cancer regarding the palliative and supportive care they received in hospital and in community settings. METHOD: Face-to-face or telephone questionnaires. Setting Tertiary paediatric oncology centres in Western Australia, New South Wales, Queensland and Victoria. PARTICIPANTS: 69 parents. RESULTS: Parents indicated the need for clear and honest information about their child's condition and prognosis throughout the trajectory of illness. Parents also required access to, and advice from, multidisciplinary health professionals when caring for their child at home. Parents preferred to care for their child at home wherever possible throughout the palliative care trajectory of their child's cancer and were well supported by immediate and extended family and friends. However, many families were affected emotionally and financially by the burden of caring for their child with incurable cancer. Families required financial and practical assistance with providing care from their child. Parents wanted and needed more practical resources and information to assist with the management of their child's nutrition and pain, as well as for the support of their other children. CONCLUSION: Care for children and their families should be coordinated by a multidisciplinary team in consultation with children and their families, and should be linked and integrated with the treating hospital in collaboration with community services.

Payment for antiretroviral drugs is associated with a higher rate of patients lost to follow-up than those offered free-of-charge therapy in Nairobi, Kenya.

This retrospective analysis of routine programme data from Mbagathi District Hospital, Nairobi, Kenya shows the difference in rates of loss to follow-up between a cohort that paid 500 shillings/month (approximately US$7) for antiretroviral drugs (ART) and one that received medication free of charge. A total of 435 individuals (mean age 31.5 years, 65% female) was followed-up for 146 person-years: 265 were in the 'payment' cohort and 170 in the 'free' cohort. The incidence rate for loss to follow-up per 100 person-years was 47.2 and 20.5, respectively (adjusted hazard ratio 2.27, 95% CI 1.21-4.24, P=0.01). Overall risk reduction attributed to offering ART free of charge was 56.6% (95% CI 20.0-76.5). Five patients diluted their ART regimen to one tablet (instead of two tablets) twice daily in order to reduce the monthly cost of medication by half. All these patients were from the payment cohort. Payment for ART is associated with a significantly higher rate of loss to follow-up, as some patients might be unable to sustain payment over time. In resource-limited settings, ART should be offered free of charge in order to promote treatment compliance and prevent the emergence of drug resistance.

Risk factors for suicide in China's youth: a case-control study.

BACKGROUND: Suicide is the most common cause of death among youth in China. METHOD: A case-control psychological autopsy study in 23 geographically representative disease surveillance points around China collected information from family members and close associates of 114 persons aged 15-24 years who died by suicide (cases) and 91 who died of other injuries (controls). RESULTS: Among the 114 suicides 61% were female, 88% lived in rural villages, 70% died by ingesting pesticides (most commonly stored in the home), 24% previously attempted suicide, and 45% met criteria of a mental illness at the time of death. Multivariate logistic regression identified several independent risk factors: severe life events within 2 days before death (OR 31.8, 95% CI 2.6-390.6), presence of any depressive symptoms within 2 weeks of death (OR 21.1, 95% CI 4.6-97.2), low quality of life in the month before death (OR 9.7, 95% CI 2.8-34.1), and acute stress at time of death (moderate: OR 3.1, 95% CI 0.8-11.9; high: OR 9.1, 95% CI 1.2-66.8). A significant interaction between mental illness at time of death and gender indicated that diagnosis was an important predictor of suicide in males (OR 14.0, 95% CI 2.6-76.5) but not in females (OR 0.3, 95% CI 0.0-3.6). Prior suicide attempt was related to suicide in the univariate analysis (OR 57.5) but could not be included in the multivariate model because no controls had made prior attempts. CONCLUSIONS: Suicide prevention efforts for youth in China must focus on restricting access to pesticides, early recognition and management of depressive symptoms and mental illnesses, improving resiliency, and enhancing quality of life.

The Wellcome Trust in Australasia: return on investment.

The Wellcome Trust is the world's largest medical research charity. Investment by the Trust in research in Australia and New Zealand has contributed very substantially to local research capacity through support of people, equipment and programmes. Further, the Trust's funding has -successfully leveraged additional investment from both government and charitable foundations. Current initiatives are focused on development of research partnerships between Australasia and our regional neighbours.

Gene therapy for hypertension: sense and antisense strategies.

Gene therapy for hypertension is needed for the next generation of antihypertensive drugs. Current drugs, although effective, have poor compliance, are expensive and short-lasting (hours or one day). Gene therapy offers a way to produce long-lasting antihypertensive effects (weeks, months or years). We are currently using two strategies: antisense oligodeoxynucleotides (AS-ODN), an dantisense DNA delivered in viral vectors, to inhibit genes associated with vasoconstrictive properties. It is not necessary to know all the genes involved in hypertension, since many years of experience with drugs show which genes need to be controlled. AS-ODNs are short, single-stranded DNA that can be injected in naked form or in liposomes. AS-ODNs, targeted to AT1 receptors (AT1R), angiotensinogen (AGT), angiotensin converting enzyme (ACE) and beta 1-adrenergic receptors effectively reduce hypertension in rat models (SHR, 2K-1C and cold-induced) hypertension. The effects can last up to one month when delivered with liposomes. No side effects or toxic effects have been detected and repeated injections can be given. For the vector, adeno-associated virus (AAV) is used with a construct to include a CMV promoter, antisense DNA to AGT or AT1R and a reporter gene. Results in SHR demonstrate reduction and slowing of hypertension development with a single dose administration. Left ventricular hypertrophy is also reduced by AAV-AS-AGT treatment. Double transgenic mice (human renin plus human AGT) with high angiotensin II (Ang II) causing high blood pressure, treated with AAV-AT1R-AS, show a normalisation of blood pressure for over 6 months with a single injection of vector. We conclude that ODNs will probably be developed first because they can be treated like drugs for the treatment of hypertension with long-term effects. Viral vector delivery needs more engineering to be certain of its safety but one day may be used for a very prolonged control of blood pressure.

Developing community capacity and improving health in African American communities.

Community-based programs have produced mixed results. Community capacity is thought to be a major determinant of program effectiveness. Thus, enhancing community capacity may increase the beneficial effects of existing programs and enhance future program effectiveness. This highlights the need to focus on understanding the components of capacity and the methods of enhancing capacity. Although we are just beginning to examine and understand key concepts, community capacity is probably influenced by both relatively nonmodifiable characteristics (such as demographic factors, institutional resources, and social structures) and relatively modifiable characteristics (such as knowledge, skills, and the ability and willingness of members and agencies to work collaboratively). In their relationships with community members and agencies, academicians and public health practitioners may help acquire categorical funding to enhance opportunities to build community capacity and their own capacity as well. The relationship between academicians/practitioners and community members/agencies probably is influenced by a host of characteristics which determine the degree to which capacity can be built. This paper discusses: the key components of capacity; the factors that influence building capacity through collaborations; a community health advisor (CHA) model which both builds on sociocultural aspects of African American culture and is consistent with methods for building community capacity; and how modifications to this model allow it to be compatible with categorically funded projects.

Examining the burdens of gendered racism: implications for pregnancy outcomes among college-educated African American women.

OBJECTIVES: As investigators increasingly identify racism as a risk factor for poor health outcomes (with implications for adverse birth outcomes), research efforts must explore individual experiences with and responses to racism. In this study, our aim was to determine how African American college-educated women experience racism that is linked to their identities and roles as African American women (gendered racism). METHODS: Four hundred seventy-four (474) African American women collaborated in an iterative research process that included focus groups, interviews, and the administration of a pilot stress instrument developed from the qualitative data. Analysis of the qualitative and quantitative data from the responses of a subsample of 167 college-educated women was conducted to determine how the women experienced racism as a stressor. RESULTS: The responses of the women and the results from correlational analysis revealed that a felt sense of obligations for protecting children from racism and the racism that African American women encountered in the workplace were significant stressors. Strong associations were found between pilot scale items where the women acknowledged concerns for their abilities to provide for their children's needs and to the women's specific experiences with racism in the workplace (r = 0.408, p < .001). CONCLUSIONS: We hypothesize that the stressors of gendered racism that precede and accompany pregnancy may be risk factors for adverse birth outcomes.

Factors influencing patients' length of stay.

This study was conducted to evaluate the ability of AN-DRG version 3.1 to predict variation in patients' length of stay in hospital (LOS) and identify other factors that can influence the LOS by using routinely collected hospital morbidity data. A total of 18 DRGs that comprised 4,589 episodes were analysed. Multiple regression was used to model length of stay as a function of a number of independent variables. Overall only 37.6% of variation in mean length of stay could be explained. DRGs predicted 30% of the total variation. Other factors such as age, payment classification, source of referral, specialty of doctor, and ethnic group also influenced patient length of stay. It was concluded that the limited explanation was a consequence of a lack of a better indicator of severity within DRGs.

The reliability of multiple regression and an alternative method for extracting task-specific exposure estimates from time-weighted average data.

The reliability of multiple regression analysis as a method for determining task-specific exposures from multi-task time-weighted average data was evaluated in comparison with the alternative P-screen method. The performances of the two methods were tested using simulated sample data that were calculated as averages over six tasks, where task-specific concentrations drawn randomly from lognormal distributions were weighted by randomly generated task time-weights. Data sets consisted of 20 or 100 simulated samples. The simulated data sets conformed to requirements inherent in the P-screen method that at least one task be absent from each sample and each task be absent from at least one sample. In thousands of Monte Carlo trials under various conditions, the two methods were found to perform equally well when dichotomous task measures (occurrence/ nonoccurrence) were used. Combining the two methods did not improve reliability appreciably, suggesting that the methods are effectively equivalent when dichotomous task measures are used. When task durations were used as the regressors or time-weights, multiple regression was found to be more reliable than P-screen. It is well recognized that incidental or fundamental collinearities between regressors may undermine multiple regression analyses. The P-screen-related restrictions on the task structure of data sets reduces the potential for problems arising from such collinearities. However, the use of multivariate analysis of multiple-task samples will always be an imperfect substitute for single-task sampling.

Developing community capacity and improving health in African American communities.

Community-based programs have produced mixed results. Community capacity is thought to be a major determinant of program effectiveness. Thus, enhancing community capacity may increase the beneficial effects of existing programs and enhance future program effectiveness. This highlights the need to focus on understanding the components of capacity and the methods of enhancing capacity. Although we are just beginning to examine and understand key concepts, community capacity is probably influenced by both relatively nonmodifiable characteristics (such as demographic factors, institutional resources, and social structures) and relatively modifiable characteristics (such as knowledge, skills, and the ability and willingness of members and agencies to work collaboratively). In their relationships with community members and agencies, academicians and public health practitioners may help acquire categorical funding to enhance opportunities to build community capacity and their own capacity as well. The relationship between academicians/practitioners and community members/agencies probably is influenced by a host of characteristics which determine the degree to which capacity can be built. This paper discusses: the key components of capacity; the factors that influence building capacity through collaborations; a community health advisor (CHA) model which both builds on sociocultural aspects of African American culture and is consistent with methods for building community capacity; and how modifications to this model allow it to be compatible with categorically funded projects.

A multi-project systems approach to developing community trust and building capacity.

Community characteristics are being recognized as important determinants for effective community-based programs. Community capacity to collaboratively identify issues, establish collective goals, and mobilize resources is built on experience with such interactions and trust among collaborators. Conceptual approaches and methods to develop community capacity rarely have been a focus of research programs, at least in part due to categorical funding, which often limits the scope and duration of interventions, thereby limiting capacity development. This approach uses multiple categorical funding sources to create sustained community programs involving multiple systems to increase capacity. Quasi-experimental evidence of increases in community capacity within two Alabama communities is presented.