When Equality Is Not Equity: The Ethics of Access to Trauma Care: A Surgical Perspective.

OBJECTIVE: The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program. BACKGROUND: Traumatic injury is a leading cause of death and disability in the United States. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city, leading to a fallacy of distributive justice. METHODS: A descriptive analysis of community partners, trauma program leadership, trauma surgeons, and the violence intervention program director was performed. RESULTS: The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country, with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes ( P <0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018, developing both community-based and medical-legal partnerships. CONCLUSIONS: The persistent efforts of the community and key stakeholders led to a system change that improved trauma care for the South Side of Chicago.

The socio-economic and cultural impacts of the Pan Borneo Highway on Indigenous and local communities in Sabah, Malaysian Borneo.

Road and highway development can provide multiple benefits to society, but without careful planning, this development can result in negative social and environmental impacts. The 1,200 km Pan Borneo Highway project (PBH) in Sabah, Malaysian Borneo, is constructing new highways and up-grading 2-lane roads to 4-lane highways. We assessed the potential impact of the PBH on communities using three width scenarios of 50m, 75m and 100m for planned highway alignments, and identified potentially impacted dwellings and community lands. We estimated that 65-93 villages will be impacted, and that 1,712-7,093 dwellings and 3,420-6,695 ha of community lands (e.g. paddy, oil palm smallholdings and rubber) may be lost to the PBH. Due to land tenure technicalities, many affected households may not get compensation for the loss of their homes and lands. The PBH will disproportionally impact Sabah's Indigenous Peoples, with the Kadazandusun most affected. For this study to be constructive, we provide a low impact alternative alignment for a part of the PBH; discuss the socio-economic and cultural impacts of the PBH, and offer some perspectives on current planning procedures in Sabah to support more sustainable and equitable development.

Survival costs of reproduction are mediated by parasite infection in wild Soay sheep.

A trade-off between current and future fitness potentially explains variation in life-history strategies. A proposed mechanism behind this is parasite-mediated reproductive costs: individuals that allocate more resources to reproduction have fewer to allocate to defence against parasites, reducing future fitness. We examined how reproduction influenced faecal egg counts (FEC) of strongyle nematodes using data collected between 1989 and 2008 from a wild population of Soay sheep in the St. Kilda archipelago, Scotland (741 individuals). Increased reproduction was associated with increased FEC during the lambing season: females that gave birth, and particularly those that weaned a lamb, had higher FEC than females that failed to reproduce. Structural equation modelling revealed future reproductive costs: a positive effect of reproduction on spring FEC and a negative effect on summer body weight were negatively associated with overwinter survival. Overall, we provide evidence that parasite resistance and body weight are important mediators of survival costs of reproduction.

The S-curve discontinuity theory predicts the path towards a "well" society and increased longevity.

The logistic function or logistic growth curve is an "S" shape (sigmoid curve) that has been applied to numerous fields, including geology, physics, biology, mathematics, chemistry, economics, sociology, oncology, and statistics. The S-curve initiates with exponential growth, followed by slowing of growth as saturation occurs, and completion of growth at maturity. The S-curve follows the law of natural growth with a limiting factor, whether it be a competition for resources, investigation and demand for new products, or an economic bubble. The concept of the S-curve has been utilized in medicine to describe the advancements in the 20th century based on the diagnosis and treatment of disease (the "illness" curve [first S-curve]) and predict the future focused on disease prevention and health promotion (the "wellness" curve [second S-curve]). Herein, we propose a third S-curve that we are labeling the "longevity" curve.

The Association of Race, Socioeconomic Status, and Insurance on Trauma Mortality.

BACKGROUND: Although race, socioeconomic status, and insurance individually are associated with trauma mortality, their complex interactions remain ill defined. METHODS: This retrospective cross-sectional study from a single Level I center in a racially diverse community was linked by socioeconomic status, insurance, and race from 2000 to 2009 for trauma patients aged 18-64 years with an injury severity score more than 9. The outcome measure was inpatient mortality. Multiple logistic regression analyses were performed to investigate confounding variables known to predict trauma mortality. RESULTS: A total of 4,007 patients met inclusion criteria. Individually, race, socioeconomic status, and insurance were associated with increased mortality rate; however, in multivariate analysis, only insurance remained statistically significant and varied by insurance type with age. Odds of death were higher for Medicare (odds ratio [OR] = 3.63, p = .006) and other insurance (OR = 3.02, p = .007) than for Private Insurance. However, when grouped into ages 18-40 years versus 41-64 years, the insurance influences changed with Uninsured and Other insurance (driven by Tricare) predicting mortality in the younger age group, while Medicare remained predictive in the older age group. CONCLUSIONS: Insurance type, not race or socioeconomic status, is associated with trauma mortality and varies with age. Both Uninsured and Tricare insurance were associated with mortality in younger age trauma patients, whereas Medicare was associated with mortality in older age trauma patients. The lethality of the Tricare group warrants further investigation.

Metal Contamination in Low-Cost Jewelry and Toys in Cambodia.

BACKGROUND: The existence of lead-contaminated consumer products is a global issue. Toys and low-cost jewelry may contain toxic metals and Cambodia is known to have consumer products with toxic metals. OBJECTIVES: It is important to inform Cambodians about sources of toxic metals so that they can reduce their exposure risk, particularly for children. METHODS: Student volunteers purchased, or brought from home, low-cost jewelry and toys to either the University of Health Science or a Don Bosco Institute in Phnom Penh, Cambodia, where they were analyzed using X-ray fluorescence (XRF). The initial analysis was performed in 2011. A subset of the 2011 samples was re-analyzed in 2015 using new preparation techniques and a new x-ray fluorescence (XRF) unit. DISCUSSION: The analysis of low-cost jewelry in Phnom Penh in 2015 indicated that lead in jewelry clasps is a more serious health concern than was first perceived in 2011. Mercury, nickel, cadmium and copper were also found in toys, and occasionally these toys had been produced by well-known companies. Sources of jewelry production of samples in the present study are unknown. Lead in clasps in low-cost jewelry appeared to be the greatest risk to children in our sampling. CONCLUSION: One-third of toys and low-cost jewelry exceeded the United States and European Union guidelines for heavy metals. XRF analysis allows for rapid screening of lead and other toxic metals and could be used to reduce the sales of low-cost jewelry and toys containing toxic metals.

Leaded Paint in Cambodia-Pilot-scale Assessment.

BACKGROUND: Lead is a heavy metal that is well known to pose a threat to human health. Although the sale and use of lead paint has been banned in much of the developed world, lead is still commonly used in enamel paints in the developing world, including Cambodia. As Cambodia's economy grows, this may increase the purchase and use of lead-based paints, thus potentially exposing more of the population to the toxic effects of lead. OBJECTIVE: This study was performed to evaluate the concentration of lead in enamel paints in Cambodia using a method that is quick, effective, and cost-efficient. METHODS: A handheld X-ray fluorescence analyzer was used to evaluate 21 samples of enamel paint, including 8 replicates that were randomly purchased from three shops in Phnom Penh, Cambodia to evaluate the level of metals. All of the paint samples in the current study were manufactured in Thailand. DISCUSSION: Ninety percent of the enamel paints sampled in Cambodia exceeded the voluntary standard of 100 µg/g lead of the producing country, Thailand. The mean and median levels for lead were 11,833 µg/g, and 4,961 µg/g, respectively. CONCLUSION: Based on our pilot-scale assessment, high levels of lead appear to be common in enamel paints in Cambodia, and a fuller assessment of the situation is warranted. Import and production of such toxic products should be avoided and appropriate labeling and public warnings should be provided.

Assessment of the effects of oil sands naphthenic acids on the growth and morphology of Chlamydomonas reinhardtii using microscopic and spectromicroscopic techniques.

Naphthenic acid fraction components (NAFCs) are thought to be a primary agent of toxicity in oil sands process waters (OSPWs) produced by industrial activity in Canada's Athabasca oil sands. They are a complex, poorly characterized mixture of compounds whose mechanisms of toxicity are not well understood. In this work, it was discovered that the unicellular green algae Chlamydomonas reinhardtii are much more tolerant of NAFCs than predicted based on comparison to Chlamydomonas spp. isolated from the OSPW tailings ponds, with exponential growth occurring at 100 mg L(-1) NAFC. Two cell wall mutants of C. reinhardtii exhibited greater tolerance to NAFC exposure. NAFC exposure induced changes in growth form and morphology were most pronounced in wild-type cells. Confocal scanning laser microscopy and Fourier-transform infrared spectromicroscopy indicated changes in cell wall surface proteins and their confirmation after exposure to NAFCs. Such alterations of cell wall proteins are consistent with the effects of surfactants on green algae, and indicate a possible role for classic naphthenic acids in the NAFC mixture to cause surfactant-mediated toxicity. The much greater tolerance to NAFCs under laboratory conditions indicates the likelihood that NAFCs do not act alone as agents of toxicity in algae such as C. reinhardtii, rather they seem to act in combination with other environmental factors to potentiate toxicity.

Cost-effectiveness analyses for mirtazapine and sertraline in dementia: randomised controlled trial.

BACKGROUND: Depression is a common and costly comorbidity in dementia. There are very few data on the cost-effectiveness of antidepressants for depression in dementia and their effects on carer outcomes. AIMS: To evaluate the cost-effectiveness of sertraline and mirtazapine compared with placebo for depression in dementia. METHOD: A pragmatic, multicentre, randomised placebo-controlled trial with a parallel cost-effectiveness analysis (trial registration: ISRCTN88882979 and EudraCT 2006-000105-38). The primary cost-effectiveness analysis compared differences in treatment costs for patients receiving sertraline, mirtazapine or placebo with differences in effectiveness measured by the primary outcome, total Cornell Scale for Depression in Dementia (CSDD) score, over two time periods: 0-13 weeks and 0-39 weeks. The secondary evaluation was a cost-utility analysis using quality-adjusted life years (QALYs) computed from the Euro-Qual (EQ-5D) and societal weights over those same periods. RESULTS: There were 339 participants randomised and 326 with costs data (111 placebo, 107 sertraline, 108 mirtazapine). For the primary outcome, decrease in depression, mirtazapine and sertraline were not cost-effective compared with placebo. However, examining secondary outcomes, the time spent by unpaid carers caring for participants in the mirtazapine group was almost half that for patients receiving placebo (6.74 v. 12.27 hours per week) or sertraline (6.74 v. 12.32 hours per week). Informal care costs over 39 weeks were £1510 and £1522 less for the mirtazapine group compared with placebo and sertraline respectively. CONCLUSIONS: In terms of reducing depression, mirtazapine and sertraline were not cost-effective for treating depression in dementia. However, mirtazapine does appear likely to have been cost-effective if costing includes the impact on unpaid carers and with quality of life included in the outcome. Unpaid (family) carer costs were lower with mirtazapine than sertraline or placebo. This may have been mediated via the putative ability of mirtazapine to ameliorate sleep disturbances and anxiety. Given the priority and the potential value of supporting family carers of people with dementia, further research is warranted to investigate the potential of mirtazapine to help with behavioural and psychological symptoms in dementia and in supporting carers.

Worsening severity of vitamin D deficiency is associated with increased length of stay, surgical intensive care unit cost, and mortality rate in surgical intensive care unit patients.

BACKGROUND: Vitamin D deficiency is the most common nutritional deficiency in the United States. It is seldom measured or recognized, and rarely is treated, particularly in critically ill patients. The purpose of this study was to investigate the prevalence and impact of vitamin D deficiency in surgical intensive care unit patients. We hypothesized that severe vitamin D deficiency increases the length of stay, mortality rate, and cost in critically ill patients admitted to surgical intensive care units. METHODS: We performed a prospective observational study of vitamin D status on 258 consecutive patients admitted to the Surgical Intensive Care Unit at Grady Memorial Hospital between August 2009 and January 2010. Vitamin D levels (25 [OH]2 vitamin-D3) were measured by high-pressure liquid chromatography and tandem mass spectrometry. Vitamin D deficiency was defined as follows: severe deficiency was categorized as less than 13 ng/mL; moderate deficiency was categorized as 14 to 26 ng/mL; mild deficiency was categorized as 27 to 39 ng/mL; and normal levels were categorized as greater than 40 ng/mL. RESULTS: Of the 258 patients evaluated, 70.2% (181) were men, and 29.8% (77) were women; 57.6% (148) were African American and 32.4% (109) were Caucasian. A total of 138 (53.5%) patients had severe vitamin D deficiency, 96 (37.2%) had moderate deficiency, 18 (7.0%) had mild deficiency, and 3 (1.2%) of the patients had normal vitamin D levels. The mean length of stay in the Surgical Intensive Care Unit for the severe vitamin D-deficient group was 13.33 ± 19.5 days versus 7.29 ± 15.3 days and 5.17 ± 6.5 days for the moderate and mild vitamin D-deficient groups, respectively, which was clinically significant (P = .002). The mean treatment cost during the patient stay in the surgical intensive care unit was $51,413.33 ± $75,123.00 for the severe vitamin D-deficient group, $28,123.65 ± $59,752.00 for the moderate group, and $20,414.11 ± $25,714.30 for the mild vitamin D-deficient group, which also was clinically significant (P = .027). More importantly, the mortality rate for the severe vitamin D-deficient group was 17 (12.3%) versus 11 (11.5%) in the moderate group (P = .125). Because no deaths occurred in the mildly or normal vitamin D-deficient groups, we compared the mortality rate between severe/moderate and mild/normal vitamin D groups (P = .047). CONCLUSIONS: In univariate analysis, severe and moderate vitamin D deficiency was related inversely to the length of stay in the surgical intensive care unit (r = .194; P = .001), related inversely to surgical intensive care unit treatment cost (r = .194; P = .001) and mortality (r = .125; P = .023), compared with the mild vitamin D-deficient group, after adjusting for age, sex, race, and comorbidities (myocardial infarctions, acute renal failure, and pneumonia); the length of stay, surgical intensive care unit cost, and mortality remained significantly associated with vitamin D deficiency.

Beliefs about medications predict adherence to antidepressants in older adults.

BACKGROUND: Adherence to treatment is a complex and poorly understood phenomenon. This study investigates the relationship between older depressed patients' adherence to antidepressants and their beliefs about and knowledge of the medication. METHODS: Assessment was undertaken of 108 outpatients over the age of 55 years diagnosed with depressive disorder and treated for at least four weeks with antidepressants. Adherence was assessed using two self-report measures: the Medication Adherence Rating Scale (MARS) and a Global Adherence Measure (GAM). Potential predictors of adherence investigated included sociodemographic, medication and illness variables. In addition, 33 carers were interviewed regarding general medication beliefs. RESULTS: 56% of patients reported 80% or higher adherence on the GAM. Sociodemographic variables were not associated with adherence on the MARS. Specific beliefs about medicines, such as "my health depends on antidepressants" (necessity) and being less worried about becoming dependant on antidepressants (concern) were highly correlated with adherence. General beliefs about medicines causing harm or being overprescribed, experiencing medication side-effects and severity of depression also correlated with poor adherence. Linear regression with the MARS as the dependent variable explained 44.3% of the variance and showed adherence to be higher in subjects with healthy specific beliefs who received more information about antidepressants and worse with depression severity and autonomic side-effects. CONCLUSIONS: Our findings strongly support a role for specific beliefs about medicines in adherence. Challenging patients' beliefs, providing information about treatment and discussing side-effects could improve adherence. Poor response to treatment and medication side-effects can indicate poor adherence and should be considered before switching medications.

Alcohol-related brain damage: a 21st-century management conundrum.

Alcohol-related brain damage has a growing impact on service provision. Despite the benefit of therapeutic interventions and a relatively good prognosis in the context of service provision, few services exist. Both national and local initiatives are required in order to provide psychosocial rehabilitation for this marginalised group of patients.

Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial.

BACKGROUND: Depression is common in dementia but the evidence base for appropriate drug treatment is sparse and equivocal. We aimed to assess efficacy and safety of two of the most commonly prescribed drugs, sertraline and mirtazapine, compared with placebo. METHODS: We undertook the parallel-group, double-blind, placebo-controlled, Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) trial in participants from old-age psychiatry services in nine centres in England. Participants were eligible if they had probable or possible Alzheimer's disease, depression (lasting ≥4 weeks), and a Cornell scale for depression in dementia (CSDD) score of 8 or more. Participants were ineligible if they were clinically critical (eg, suicide risk), contraindicated to study drugs, on antidepressants, in another trial, or had no carer. The clinical trials unit at King's College London (UK) randomly allocated participants with a computer-generated block randomisation sequence, stratified by centre, with varying block sizes, in a 1:1:1 ratio to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks (outcomes to 39 weeks were also assessed), assessed with a mixed linear-regression model adjusted for baseline CSDD, time, and treatment centre. This study is registered, number ISRCTN88882979 and EudraCT 2006-000105-38. FINDINGS: Decreases in depression scores at 13 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (mean difference 1·17, 95% CI -0·23 to 2·58; p=0·10) or mirtazapine (0·01, -1·37 to 1·38; p=0·99), or between participants in the mirtazapine and sertraline groups (1·16, -0·25 to 2·57; p=0·11); these findings persisted to 39 weeks. Fewer controls had adverse reactions (29 of 111 [26%]) than did participants in the sertraline group (46 of 107, 43%; p=0·010) or mirtazapine group (44 of 108, 41%; p=0·031), and fewer serious adverse events rated as severe (p=0·003). Five patients in every group died by week 39. INTERPRETATION: Because of the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants, with usual care, for first-line treatment of depression in Alzheimer's disease should be reconsidered. FUNDING: UK National Institute of Health Research HTA Programme.

Can the protein costs of bacterial resistance be offset by altered feeding behaviour?

1. Mounting an immune response is likely to be costly in terms of energy and nutrients, and so it is predicted that dietary intake should change in response to infection to offset these costs. The present study focuses on the interactions between a specialist grass-feeding caterpillar species, the African armyworm Spodoptera exempta, and an opportunist bacterium, Bacillus subtilis. 2. The main aims of the study were (i) to establish the macronutrient costs to the insect host of surviving a systemic bacterial infection, (ii) to determine the relative importance of dietary protein and carbohydrate to immune system functions, and (iii) to determine whether there is an adaptive change in the host's normal feeding behaviour in response to bacterial challenge, such that the nutritional costs of resisting infection are offset. 3. We show that the survival of bacterially infected larvae increased with increasing dietary protein-to-carbohydrate (P:C) ratio, suggesting a protein cost associated with bacterial resistance. As dietary protein levels increased, there was an increase in antibacterial activity, phenoloxidase (PO) activity and protein levels in the haemolymph, providing a potential source for this protein cost. However, there was also evidence for a physiological trade-off between antibacterial activity and phenoloxidase activity, as larvae whose antibacterial activity levels were elevated in response to immune activation had reduced PO activity. 4. When given a choice between two diets varying in their P:C ratios, larvae injected with a sub-lethal dose of bacteria increased their protein intake relative to control larvae whilst maintaining similar carbohydrate intake levels. These results are consistent with the notion that S. exempta larvae alter their feeding behaviour in response to bacterial infection in a manner that is likely to enhance the levels of protein available for producing the immune system components and other factors required to resist bacterial infections ('self-medication').

The race gap in support group participation by breast cancer survivors: real or artifact?

Addressing methodological weaknesses of previous research, this study assesses whether African American women are, in fact, less likely to participate in breast cancer support groups than are White women. Of the breast cancer survivors, 958 (26% African Americans, 73% Caucasian) completed interviews concerning demographic characteristics, other support networks, effects of illness on home and spiritual life, and support group participation. Contrary to previous research, no race difference was found in support group participation. This research suggests more effort needs to be paid to sampling techniques and other methodological factors to adequately reflect the experiences and needs of breast cancer survivors, specifically African American women.

Parasites as a viability cost of sexual selection in natural populations of mammals.

Sexual selection in mammals has resulted in the evolution of sexual size dimorphism (SSD), with males usually being the larger sex. Comparative analyses indicate that the evolution of SSD is associated with the evolution of male-biased mortality, suggesting a possible causal link between the two. Here, we use a comparative approach to investigate the possible role of parasites in generating this relation. We show that there is a robust association between male-biased parasitism and the degree of sexual selection, as measured by mating system (monogamous or polygynous) and by the degree of SSD. There is also a positive correlation, across taxa, between male-biased mortality and male-biased parasitism. These results are consistent with the hypothesis that parasites contribute to the observed association between SSD and male-biased mortality.