Upper Versus Lower Gastrointestinal Delivery for Transplantation of Fecal Microbiota in Recurrent or Refractory Clostridium difficile Infection: A Collaborative Analysis of Individual Patient Data From 14 Studies.

GOALS: The aim of this study was to compare upper gastrointestinal (UGI) versus lower gastrointestinal (LGI) delivery routes of fecal microbiota transplantation (FMT) for refractory or recurrent/relapsing Clostridium difficile infection (CDI). BACKGROUND: FMT has been proven to be a safe and highly effective therapeutic option for CDI. Delivery, however, could be via the UGI or LGI routes, and it is unclear as to which route provides better clinical outcome. STUDY: A systematic search for studies that reported the use of FMT for CDI treatment was conducted. Individual patient data that included demographic (age and sex) and clinical (route of FMT delivery, CDI outcome after FMT, and follow-up time) information were obtained. Kaplan-Meier cumulative hazard curves and Cox proportional hazard models were used to assess clinical failure after FMT by the route of delivery. RESULTS: Data from 305 patients treated with FMT (208 via LGI route and 97 via UGI route) for CDI were analyzed. At 30 and 90 days, the risk of clinical failure was 5.6% and 17.9% in the UGI group compared with 4.9% and 8.5% in the LGI delivery route group, respectively. A time-varying analysis suggested a 3-fold increase in hazard of clinical failure for UGI delivery (hazard ratio, 3.43; 95% confidence interval, 1.32-8.93) in the period after 30 days. CONCLUSIONS: FMT delivered via the LGI seems to be the most effective route for the prevention of recurrence/relapse of CDI. A randomized controlled trial is necessary to confirm whether FMT delivered via the LGI is indeed superior to that delivered via the UGI route.

Animals may act as social buffers: Skin conductance arousal in children with autism spectrum disorder in a social context.

Children with autism spectrum disorder (ASD) experience high rates of social stress and anxious arousal. Preliminary evidence suggests that companion animals can act as buffers against the adverse effects of social stress in adults. We measured continuous physiological arousal in children with ASD and typically developing (TD) children in a social context during four conditions: (a) a baseline of reading silently, (b) a scripted classroom activity involving reading aloud, (c) free play with peers and toys, and (d) free play with peers and animals (guinea pigs). Our results confirmed heightened arousal among children with ASD compared to TD children in all conditions, except when the animals were present. Children with ASD showed a 43% decrease in skin conductance responses during free play with peers in the presence of animals, compared to toys. Thus, animals may act as social buffers for children with ASD, conferring unique anxiolytic effects.

A history of comorbid depression and anxiety predicts new onset of heart disease.

The objective of the current study was to examine whether a history of comorbid depression and anxiety predicted new onset of heart disease. Data from 6 surveys, spanning 15 years, of the Australian Longitudinal Study on Women's Health, a large prospective cohort study were used, including health status, lifestyle, and sociodemographic measures. Participants of the 1946-1951 cohort who did not self-report heart disease at surveys 1 (1996) and 2 (1998) were included in the study (n = 11,828). After adjusting for health status, lifestyle and sociodemographic factors, a history of comorbid depression and anxiety (odds ratio (OR) = 1.78; 95 % confidence interval (CI) = 1.41-2.24) was associated with new onset of heart disease. A history of comorbid depression and anxiety is an important predictor of new onset of heart disease in mid-aged women. Due to the possible detrimental consequences of heart disease, psychological factors as well as established predictors should be considered when assessing a person's risk for heart disease.

Effects of Animal-Assisted Activities with Guinea Pigs in the Primary School Classroom.

This study investigated the effects of a classroom-based animal-assisted activities (AAA) program with guinea pigs on the social functioning of primary school children. We hypothesized that participants in the experimental condition (n = 64), compared with a waitlist control group (n = 64), would demonstrate improvements in social functioning following the program. Parents and teachers used the Social Skills Rating System (SSRS) to evaluate the social skills and problem behaviors of 128 participating children (age range = 4.8 to 12.7 years) before and after an 8-week period. Teachers also rated academic competence at both time points. Children who participated in the AAA program demonstrated significantly greater improvements in social functioning than their control group peers, as defined by greater increases in social skills (teacher SSRS) and decreases in problem behaviors (parent and teacher SSRS). There were no significant differences between the groups in academic competence. AAA participants demonstrated significant increases in social skills and decreases in problem behaviors from pre- to post-program on the teacher version of the SSRS. Control group participants did not show significant changes on these measures. These findings suggest that an AAA program with guinea pigs may be a feasible addition to the primary school classroom in order to improve social functioning. Further component analysis will be necessary to determine whether the animal is the active ingredient in AAA programs of this nature.

Reliability and Validity Assessment of the Observation of Human-Animal Interaction for Research (OHAIRE) Behavior Coding Tool.

The Observation of Human-Animal Interaction for Research (OHAIRE) is a coding tool developed to capture the behavior of children when interacting with social partners and animals in naturalistic settings. The OHAIRE behavioral categories of focus are emotional displays, social communication behaviors toward adults and peers, behaviors directed toward animals or experimental control objects, and interfering behaviors. To date, the OHAIRE has been used by 14 coders to code 2,732 min of video across four studies with a total of 201 participants ages 5 to 18 years (M = 10.1, SD = 2.5). Studies involved animal-assisted intervention with three species (i.e., dogs, horses, and guinea pigs) and three populations (i.e., autism spectrum disorder, attention-deficit hyperactivity disorder, and typically developing children) in a school, a therapeutic horseback riding program, a group therapy program, and the hospital setting. We explored the psychometric properties of the OHAIRE through analyses of its inter-rater reliability, intra-rater reliability, convergent and divergent validity, and internal structure, using data from these four human-animal interaction studies. The average inter-rater reliability was excellent (kappa = 0.81), with good reliability in most of the behavioral categories coded. Intra-rater reliability was consistently excellent (0.87 ≤ kappa ≤0.96). Internal structure analyses with Cronbach's alpha supported the exploratory use of subscales to measure social communication behaviors toward peers (α = 0.638) and adults (α = 0.605), and interactions experimental control objects (α = 0.589), and the use of a subscale to measure interactions with animals (α = 0.773). Correlation analyses with multiple questionnaires showed a convergence between positive emotional display and social behaviors as assessed by the OHAIRE and social skills as assessed by the Social Skills Rating System (SSRS) and the Social Communication Questionnaires (SCQ). Little concordance was found between the OHAIRE and the Social Responsiveness Scale (SRS) or the Aberrant Behavior Checklist-Community (ABC). The OHAIRE shows promise for wider use in the field of Human-Animal Interaction, with a need for generalization across more settings and ages.

25-Hydroxyvitamin D Concentrations and Clostridium difficile Infection: A Meta-Analysis.

BACKGROUND: Well-known risk factors for Clostridium difficile infection (CDI) are exposure to antibiotics and gastric acid suppressants. Recent studies have provided some evidence of an association between hypovitaminosis D and the risk of CDI. Therefore, this meta-analysis aimed to pool all the existing evidence to investigate the association between 25-hydroxyvitamin D (25[OH]D) and CDI. METHODS: A systematic search was conducted in 3 databases (PubMed, Embase, and Web of Sciences) for epidemiological studies that examined the association between mean 25(OH)D concentrations and CDI as well as between 25(OH)D status and CDI severity or recurrence. 25(OH)D status was defined as "lower" or "higher" at a threshold concentration of <20 or ≥20 ng/mL, respectively. Pooled effect sizes were computed using the inverse variance heterogeneity model of meta-analysis. RESULTS: Eight publications (n = 4479 patients) were included in the meta-analysis. The mean concentration of 25(OH)D in patients with CDI was 3.54 ng/mL (95% confidence interval [CI], 0.39-6.89 ng/mL) lower than in patients without CDI. Patients with lower 25(OH)D status had a higher odds (odds ratio [OR], 1.61; 95% CI, 1.02-2.53) of developing severe CDI compared with those with a higher 25(OH)D status. No significant association was found between 25(OH)D status and CDI recurrence. CONCLUSION: The results of this meta-analysis suggest that lower mean concentrations of 25(OH)D were associated with CDI. A lower 25(OH)D status increased the odds of severe CDI but not of CDI recurrence.

Risk of cardiovascular disease in HIV-positive Queensland men receiving combined antiretroviral therapy.

UNLABELLED: Background Cardiovascular disease (CVD) is a major cause of death among HIV-positive individuals receiving combination antiretroviral therapy (cART). The risk of CVD is estimated using a variety of risk calculations, however, currently there is no specific CVD risk calculator endorsed for Australians receiving cART. METHODS: A retrospective study of 210 Queensland men older than 35 years with cART-treated HIV was conducted to estimate the prevalence of CVD and the risk of a cardiovascular event occurring within 5 years. The weighted Cohen's kappa coefficient was used to estimate the agreement between the Australian Absolute CVD Risk Calculator and the Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) 5-year Estimated CVD Risk Equation. RESULTS: The prevalence of CVD was 31.9%. Hypertensive disease was the most prevalent CVD (25.2%). Queensland men with cART-treated HIV were at moderate risk (5%) of a cardiovascular event in the next 5 years. There was a substantial agreement (κ=0.63) between the Australian Absolute CVD Risk Calculator and the D:A:D 5-year Estimated CVD Risk Equation. CONCLUSIONS: Queensland men with cART-treated HIV are experiencing high prevalence of CVD and are at moderate risk of a CVD event in the next 5 years. Primary care guidelines should emphasise CVD prevention as a keystone for the treatment of people living with HIV.

The burden of non-adherence to cardiovascular medications among the aging population in Australia: a meta-analysis.

BACKGROUND: Non-adherence to cardiovascular medications is a problem worldwide, even in Australia, which has a socialized medical system, Medicare. OBJECTIVE: The aim of this systematic review was to evaluate the burden of non-adherence to cardiovascular medications and factors thereof in Australia. DATA SOURCES: Pubmed, Embase, CINAHL, PsycInfo, Cochrane Library databases were searched. ELIGIBILITY CRITERIA: Articles were included if they were in English, peer-reviewed and provided empirical data on adherence to cardiovascular medication for an Australian cohort. METHODS: A meta-analysis of prevalence of medication non-adherence using the double arcsine square root transformed proportion was undertaken. Studies were pooled in homogenous prevalence groups and factors that differed across groups were ascertained. RESULTS: Five studies, including eight datasets and 76,867 subjects were analyzed. Three more or less homogenous prevalence categories were discernable: low [19 %, 95 % confidence interval (CI) 15-24], moderate (26 %, 95 % CI 23-29) and high (43 %, 95 % CI 43-44; this was a single study) prevalence of non-adherence. There were minimal clear patterns across groups in relation to typical factors of non-adherence (patient, condition, healthcare system or socioeconomic factors). Measurements used for non-adherence were similar for six of the eight included datasets, suggesting this did not affect prevalence of non-adherence or inclusion in a prevalence group. CONCLUSIONS: Non-adherence to cardiovascular medications is a serious problem in the aging Australian setting with an overall prevalence of between 14 and 43 %. The lack of patterns in the typical factors of non-adherence suggests that another factor, such as patients' beliefs about their conditions and medications, may be playing a stronger role in their non-adherence than clinical or sociodemographic factors. This is an area for further research.

Comorbidities, Exposure to Medications, and the Risk of Community-Acquired Clostridium difficile Infection: a systematic review and meta-analysis.

BACKGROUND: Clostridium difficile infection (CDI) has been extensively described in healthcare settings; however, risk factors associated with community-acquired (CA) CDI remain uncertain. This study aimed to synthesize the current evidence for an association between commonly prescribed medications and comorbidities with CA-CDI. METHODS: A systematic search was conducted in 5 electronic databases for epidemiologic studies that examined the association between the presence of comorbidities and exposure to medications with the risk of CA-CDI. Pooled odds ratios were estimated using 3 meta-analytic methods. Subgroup analyses by location of studies and by life stages were conducted. RESULTS: Twelve publications (n=56,776 patients) met inclusion criteria. Antimicrobial (odds ratio, 6.18; 95% CI, 3.80-10.04) and corticosteroid (1.81; 1.15-2.84) exposure were associated with increased risk of CA-CDI. Among the comorbidities, inflammatory bowel disease (odds ratio, 3.72; 95% CI, 1.52-9.12), renal failure (2.64; 1.23-5.68), hematologic cancer (1.75; 1.02-5.68), and diabetes mellitus (1.15; 1.05-1.27) were associated with CA-CDI. By location, antimicrobial exposure was associated with a higher risk of CA-CDI in the United States, whereas proton-pump inhibitor exposure was associated with a higher risk in Europe. By life stages, the risk of CA-CDI associated with antimicrobial exposure greatly increased in adults older than 65 years. CONCLUSIONS: Antimicrobial exposure was the strongest risk factor associated with CA-CDI. Further studies are required to investigate the risk of CA-CDI associated with medications commonly prescribed in the community. Patients with diarrhea who have inflammatory bowel disease, renal failure, hematologic cancer, or diabetes are appropriate populations for interventional studies of screening.

Clostridium difficile infection seasonality: patterns across hemispheres and continents - a systematic review.

BACKGROUND: Studies have demonstrated seasonal variability in rates of Clostridium difficile infection (CDI). Synthesising all available information on seasonality is a necessary step in identifying large-scale epidemiological patterns and elucidating underlying causes. METHODS: Three medical and life sciences publication databases were searched from inception to October 2014 for longitudinal epidemiological studies written in English, Spanish or Portuguese that reported the incidence of CDI. The monthly frequency of CDI were extracted, standardized and weighted according to the number of follow-up months. Cross correlation coefficients (XCORR) were calculated to examine the correlation and lag between the year-month frequencies of reported CDI across hemispheres and continents. RESULTS: The search identified 13, 5 and 2 studies from North America, Europe, and Oceania, respectively that met the inclusion criteria. CDI had a similar seasonal pattern in the Northern and Southern Hemisphere characterized by a peak in spring and lower frequencies of CDI in summer/autumn with a lag of 8 months (XCORR = 0.60) between hemispheres. There was no difference between the seasonal patterns across European and North American countries. CONCLUSION: CDI demonstrates a distinct seasonal pattern that is consistent across North America, Europe and Oceania. Further studies are required to identify the driving factors of the observed seasonality.

Effects of classroom animal-assisted activities on social functioning in children with autism spectrum disorder.

OBJECTIVE: The objective of this study was to implement and evaluate a classroom-based Animal-Assisted Activities (AAA) program on social functioning in children with autism spectrum disorder (ASD). DESIGN: This was a multisite, control-to-intervention design study. SETTINGS/LOCATION: The study was conducted in 41 classrooms in 15 schools in Brisbane, Australia. SUBJECTS: Sixty-four (64) 5- to 12-year-old children diagnosed with ASD comprised the study group. INTERVENTION: The AAA program consisted of 8 weeks of animal exposure in the school classroom in addition to 16 20-minute animal-interaction sessions. OUTCOME MEASURES: Teacher- and parent-reported child behavior and social functioning were assessed through standardized instruments at three time points: upon study entry (Time 1), after an 8-week waiting period during the week prior to the AAA program (Time 2), and during the week following the 8-week AAA program (Time 3). RESULTS: Significant improvements were identified in social functioning, including increases in social approach behaviors and social skills, and decreases in social withdrawal behaviors, from before to after the AAA program, but not during the waitlist period. Over half of parents also reported that participants demonstrated an increased interest in attending school during the program. CONCLUSIONS: Results demonstrate the feasibility and potential efficacy of a new classroom-based Animal-Assisted Activities model, which may provide a relatively simple and cost-effective means of helping educators and families to improve the social functioning of children with ASD.

A population-based spatio-temporal analysis of Clostridium difficile infection in Queensland, Australia over a 10-year period.

OBJECTIVES: To identify the spatio-temporal patterns and environmental factors associated with Clostridium difficile infection (CDI) in Queensland, Australia. METHODS: Data from patients tested for CDI were collected from 392 postcodes across Queensland between May 2003 and December 2012. A binomial logistic regression model, with CDI status as the outcome, was built in a Bayesian framework, incorporating fixed effects for sex, age, source of the sample (healthcare facility or community), elevation, rainfall, land surface temperature, seasons of the year, time in months and spatially unstructured random effects at the postcode level. RESULTS: C. difficile was identified in 13.1% of the samples, the proportion significantly increased over the study period from 5.9% in 2003 to 18.8% in 2012. CDI peaked in summer (14.6%) and was at its lowest in autumn (10.1%). Other factors significantly associated with CDI included female sex (OR: 1.08; 95%CI: 1.01-1.14), community source samples (OR: 1.12; 95%CI: 1.05-1.20), and higher rainfall (OR: 1.09; 95%CI: 1.02-1.17). There was no significant spatial variation in CDI after accounting for the fixed effects in the model. CONCLUSIONS: There was an increasing annual trend in CDI in Queensland from 2003 to 2012. Peaks of CDI were found in summer (December-February), which is at odds with the current epidemiological pattern described for northern hemisphere countries. Epidemiologically plausible explanations for this disparity require further investigation.

Co-morbidity, ageing and predicted mortality in antiretroviral treated Australian men: a quantitative analysis.

BACKGROUND: Life expectancy has increased in HIV-positive individuals receiving combination antiretroviral therapy (cART); however, they still experience increased mortality due to ageing-associated comorbidities compared with HIV-negative individuals. METHODS: A retrospective study of 314 Queensland HIV-infected males on cART was conducted. The negative impact of ageing was assessed by estimating the probability of 5-year mortality; comparisons were made between an HIV-specific predictive tool (VACS index) and the Australian Bureau of Statistics (ABS) life-tables to examine potential differences attributed to HIV. The negative impact of ageing was also assessed by the prevalence of comorbidities. Associations between comorbidity and estimates of predicted mortality by regression analysis were assessed. RESULTS: The mean predicted 5-year mortality rate was 6% using the VACS index compared with 2.1% using the ABS life-table (p<0.001). The proportion of patients at predicted high risk of mortality (>9%) using the VACS index or ABS life-table were 17% and 1.8% respectively. Comorbidities were also more prevalent in this cohort compared with rates of comorbidities in age-matched Australian men from the general population. Metabolic disease (38.2%) was the most prevalent comorbidity followed by renal (33.1%) and cardiovascular disease (23.9%). Multivariate analysis demonstrated that patients with a history of cardiovascular disease had a higher predicted risk of mortality (OR=1.69;95%CI:1.17-2.45) whereas ex-smokers had a lower predicted risk of mortality (OR=0.61;95%CI:0.41-0.92). CONCLUSIONS: Using the VACS Index there is an increased predicted risk of mortality in cART-treated HIV infected Australian men compared with age-matched men using the ABS data. This increased predicted mortality risk is associated with cardiovascular disease and the number of comorbidities per subject; which suggests that the VACS Index may discriminate between high and low predicted mortality risks in this population. However, until the VACS Index is validated in Australia this data may suggest the VACS Index overestimates predicted mortality risk in this country.

Social behaviors increase in children with autism in the presence of animals compared to toys.

BACKGROUND: Previous research has demonstrated the capacity of animal presence to stimulate social interaction among humans. The purpose of this study was to examine the interactions of children with autism spectrum disorder (ASD) with an adult and their typically-developing peers in the presence of animals (two guinea pigs) compared to toys. METHODS: Ninety-nine children from 15 classrooms in 4 schools met the inclusion criteria and participated in groups of three (1 child with ASD and 2 typically-developing peers). Each group was video-recorded during three 10-minute, free-play sessions with toys and three 10-minute, free-play sessions with two guinea pigs. Two blinded observers coded the behavior of children with ASD and their peers. To account for the nested study design, data were analyzed using hierarchical generalized linear modeling. RESULTS: Participants with ASD demonstrated more social approach behaviors (including talking, looking at faces, and making tactile contact) and received more social approaches from their peers in the presence of animals compared to toys. They also displayed more prosocial behaviors and positive affect (i.e., smiling and laughing) as well as less self-focused behaviors and negative affect (i.e., frowning, crying, and whining) in the presence of animals compared to toys. CONCLUSIONS: These results suggest that the presence of an animal can significantly increase positive social behaviors among children with ASD.

The effect of having a partner on activities of daily living in men and women aged 82-87 years.

BACKGROUND: Physical functioning is an important determinant of mortality and morbidity in older adults and there may be differences by gender and marital status. This study compared disability, measured by the ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), between older men and women who are either partnered or not partnered. METHODS: Participants included 5497 women and 1072 men aged 82-87 years from cross sectional surveys conducted in 2008 (the Health in Men Study and the Australian Longitudinal Study on Women's Health). Ordinal logistic regression was used to examine the relationship between disability and gender by marital status, adjusting for self-reported chronic conditions. RESULTS: Women reported a higher prevalence of most chronic conditions than men. Unpartnered men had significantly higher odds of reporting difficulty in dressing the lower body and doing heavy housework, and significantly lower odds of reporting difficulty managing money and preparing meals than partnered men. Unpartnered and partnered women had significantly lower odds of reporting difficulty in dressing the lower body, walking inside the house, using the toilet, preparing meals, taking medications, using the telephone and performing leisure activities than partnered men. However, unpartnered and partnered women had significantly higher odds of reporting difficulty with eating, shopping, and doing light or heavy housework than did partnered men. CONCLUSIONS: Differences between partnered and unpartnered older men and women in difficulty with ADLs and IADLs were identified, with women reporting less difficulty overall, regardless of partner status.

Urban-rural comparisons of outcomes for informal carers of elderly people in the community: a systematic review.

As the age of the general population increases, the number of elderly people who need care is increasing. It has been suggested that rural carers may be disadvantaged compared to urban carers, but it is not clear what affect geographic location has on carers. This paper presents a systematic review of the literature on urban-rural comparisons on various outcomes for informal carers who provide care for elderly people in the community. Of 150 articles that were reviewed, eight articles were included with three themes in the outcomes for carers: service use, health promotion behaviors and psychological health (such as carer stress, burden or depressive symptoms). Overall, there were few consistent or statistically significant differences between urban and rural carers. Many of the differences observed were explained by other factors, such as carer or care recipient characteristics. The literature search was limited to papers in the English language, involving quantitative methods and published in peer-reviewed journals. There were not enough studies found to examine other outcomes or to pool data across studies. There is too little evidence comparing urban and rural carers to inform clinicians and policy makers. More good-quality research is urgently needed.