Safety and Efficacy of N-SORB®, a Proprietary KD120 MEC Metabolically Activated Enzyme Formulation: A Randomized, Double-Blind, Placebo-Controlled Study.

Background: Enzymes are crucial for all aspects of metabolic function. Digestive enzymes from natural sources have been credited with beneficial effects in the digestion and absorption of food. N-SORB is a novel KD120 multienzyme complex (MEC) of metabolically activated enzymes composed of proteases, amylases, lipases, alpha-galactosidase, and glucoamylase from natural sources. These enzymes are encapsulated in a SK713 SLP (non-GMO soy lecithin phospholipid) absorption technology (Prodosome®). Objective: This randomized, double-blind placebo-controlled investigation assessed the safety and efficacy of N-SORB KD120 MEC in healthy male and female volunteers on various parameters of the blood, immunity, body composition, physical health, and quality of life following a 90-day intervention. Methods: Forty-six male and female (mean age: 25.8 ± 12.1 years) healthy volunteers were randomly assigned to receive either N-SORB (1 mL, twice daily) or placebo for 90 consecutive days. Complete blood count, as well as blood glucose, liver enzymes, and lipid profile were assessed pre- and post-intervention. Serum cytokine levels were determined by using a Bio-Plex Pro Human Cytokine 8-plex assay and enzyme linked immunosorbent assay (ELISA). Whole body composition analysis was performed by dual-energy x-ray absorptiometry (DEXA) to determine body fat mass, lean mass, and android and gynoid fat. Body weight, blood pressure, and physical health were assessed. Changes in quality of life were examined using the World Health Organization Quality of Life-abbreviated version and sleep quality was assessed using the 24-item Pittsburgh Sleep Quality Index (PSQI) questionnaire. Adverse events were monitored before, during, and after completion of the study. Results: Of the 46 subjects enrolled, a total of 40 subjects successfully completed the study. Compared to placebo, changes in blood cell counts including hematocrit, hemoglobin, mean corpuscular volume, platelets, and lymphocytes provide evidence of some improvement. Quality of life (QOL) parameters showed a small but significant improvement in the N-SORB group. A significant increase was observed in aspartate aminotransferase level in the placebo group at the end of 90 days of treatment; however, no increase was observed in the N-SORB group. No significant changes in blood urea nitrogen, serum creatinine, alkaline phosphatase, alanine aminotransferase, and lipid profile were observed between the placebo and treatment groups before and following intervention. No adverse effects were reported. Conclusions: This randomized, double blind, placebo-controlled clinical study demonstrates that short-term intervention with N-SORB improves the QOL and PSQI in healthy volunteers and did not significantly alter cardiometabolic parameters, lipid profile, or body composition.

Furostanolic saponins from Trigonella foenum-graecum alleviate diet-induced glucose intolerance and hepatic fat accumulation.

SCOPE: The objective of this study was to evaluate the effect of fenugreek furostanolic saponins (Fenfuro(TM) ) either alone or in combination with chlorogenic acid (GCB-70(TM) ) on insulin resistance in mice. METHODS AND RESULTS: Male C57BL/6J mice were subjected to a normal or high-fat diet (HFD) and were randomly assigned to receive Fenfuro(TM) , GCB-70(TM) , or their combination for 24 wk. Metabolic parameters, glucose tolerance, serum triglycerides, cardiac function, and hepatic insulin signaling were evaluated using indirect open-circuit calorimetry, intraperitoneal glucose tolerance test, oil red O staining, echocardiography, and Western blotting, respectively. Intraperitoneal glucose tolerance test revealed glucose intolerance in the mice receiving HFD, which was attenuated by Fenfuro(TM) . Serum triglyceride that was elevated following an HFD was reconciled by both Fenfuro(TM) and the combination. HFD compromised myocardial contractile function, which was unaffected by the treatment. Insulin-stimulated phosphorylation of Protein kinase B (AKT) in the liver was attenuated in mice receiving HFD, which was partially rescued by GCB-70(TM) . Neither treatment altered metabolic parameters or energy expenditure. CONCLUSION: Collectively, our data suggest that fenugreek furostanolic saponins and green coffee bean extract may have potential benefits in treating insulin resistance and related conditions.

Qualitative motivators and barriers to pandemic vs. seasonal influenza vaccination among healthcare workers: a content analysis.

INTRODUCTION: Influenza is a major concern across healthcare environments. Annual vaccination of healthcare workers (HCW) remains a key mode of influenza prevention in healthcare settings. Yet influenza vaccine coverage among HCWs continues to be below recommended targets, in pandemic and non-pandemic settings. Thus, the primary objective of this analysis is to identify motivators and barriers to pandemic (panINFLU) and seasonal influenza vaccination (sINFLU) through the qualitative analysis of HCW provided reasons driving HCW's personal vaccination decisions. METHODS: Data were collected from a multi-professional sample of HCWs via a cross-sectional survey study, conducted at a tertiary-care hospital in Ontario, Canada. HCW provided and ranked qualitative reasons for personal (1) panINFLU (pH1N1) and (2) sINFLU (2008/2009 season) vaccine uptake and avoidance were used to identify key vaccination motivators and barriers through content analysis methodology. RESULTS: Most HCW vaccination motivators and barriers were found to be similar for panINFLU and sINFLU vaccines. Personal motivators had the greatest impact on vaccination (panINFLU 29.9% and sINFLU 33.9%). Other motivators included preventing influenza in loved ones, patients, and community, and awareness of HCW role in influenza transmission. In contrast, concerns of vaccine safety and limited HCW knowledge of influenza vaccines (panINFLU 46.2% and sINFLU 37.3%). HCW vaccination during the pandemic was motivated by panINFLU related fear, epidemiology, and workplace pro-vaccination policies. HCW perceptions of accelerated panINFLU vaccine development and vaccine safety compromises, negative views of external sources (i.e. media, pharmaceutical companies, and regulatory agencies) and pandemic management strategies were barriers specific to panINFLU vaccine. CONCLUSIONS: HCW panINFLU and sINFLU vaccine coverage can increase if future vaccination programs (1) highlight personal vaccination benefits (2) emphasize the impact HCW non-vaccination on family members, patients and community, (3) address HCW vaccine related knowledge gaps, and (4) implement pro-vaccination workplace policies consistent with those in place at the study site during pH1N1.

Predicting influenza vaccination uptake among health care workers: what are the key motivators?

BACKGROUND: Health care worker (HCW) vaccination was critical to protecting HCW during the H1N1 pandemic. However, vaccine uptake rates fell below recommended targets. This study examined motivators and barriers influencing HCW pH1N1 vaccination to identify modifiable factors that can improve influenza vaccine uptake. METHODS: A cross-sectional survey was conducted at a large Canadian tertiary care hospital. HCW (N = 3,275) completed measures of demographics, vaccination history, influenza risk factors, and attitudes toward pH1N1 vaccination. Self-reported vaccination was verified with staff vaccination records. Of the total sample, 2,862 (87.4%) HCW received the pH1N1 vaccine. Multiple logistic regression analyses were used to predict HCW vaccination. RESULTS: HCW attitudes toward vaccination significantly predicted vaccination, even after adjusting for demographics, vaccine history, and influenza risk factors. This model correctly predicted 95% (confidence interval [CI]: 0.93-0.96) of HCW vaccination. Key modifiable factors driving HCW vaccination include (1) desire to protect family members and patients, (2) belief that vaccination is important even if one is healthy, (3) confidence in vaccine safety, and (4) supervisor and physician encouragement. CONCLUSION: This research identified fundamental reasons why HCW get vaccinated and provides direction for future influenza vaccination programs. To enhance vaccine uptake, it is important to target HCW attitudes in influenza vaccine campaigns and create a culture of vaccine promotion in the workplace, including strong messaging from supervisors and physicians.

Consuming sex: the association between modern goods, lifestyles and sexual behaviour among youth in Madagascar.

BACKGROUND: Ethnographic evidence suggests that transactional sex is sometimes motivated by youth's interest in the consumption of modern goods as much as it is in basic survival. There are very few quantitative studies that examine the association between young people's interests in the consumption of modern goods and their sexual behaviour. We examined this association in two regions and four residence zones of Madagascar: urban, peri-urban and rural Antananarivo, and urban Antsiranana. We expected risky sexual behaviour would be associated with interests in consuming modern goods or lifestyles; urban residence; and socio-cultural characteristics. METHODS: We administered a population-based survey to 2, 255 youth ages 15-24 in all four residence zones. Focus group discussions guided the survey instrument which assessed socio-demographic and economic characteristics, consumption of modern goods, preferred activities and sexual behaviour. Our outcomes measures included: multiple sexual partners in the last year (for men and women); and ever practicing transactional sex (for women). RESULTS: Overall, 7.3% of women and 30.7% of men reported having had multiple partners in the last year; and 5.9% of women reported ever practicing transactional sex. Bivariate results suggested that for both men and women having multiple partners was associated with perceptions concerning the importance of fashion and a series of activities associated with modern lifestyles. A subset of lifestyle characteristics remained significant in multivariate models. For transactional sex bivariate results suggested perceptions around fashion, nightclub attendance, and getting to know a foreigner were key determinants; and all remained significant in multivariate analysis. We found peri-urban residence more associated with transactional sex than urban residence; and ethnic origin was the strongest predictor of both outcomes for women. CONCLUSIONS: While we found indication of an association between sexual behaviour and interest in modern goods, or modern lifestyles, such processes did not single-handedly explain risky sexual behaviour among youth; these behaviours were also shaped by culture and conditions of economic uncertainty. These determinants must all be accounted for when developing interventions to reduce risky transactional sex and vulnerability to HIV.

Hepatitis C virus: the role of molecular mimicry in response to interferon treatment.

Chronic hepatitis C virus (HCV) infection is one of the major causes of chronic liver disease worldwide. In order for HCV to persist, the virus must escape immune recognition or inhibit the host immune response. The NS5A protein contains the interferon sensitivity-determining region (ISDR) and is able to repress dsRNA-dependent protein kinase (PKR) thus influencing the response to interferon (IFN) therapy. Patients who respond to IFN therapy have stronger antibody reactivity against the NS5A compared to IFN non-responders. Therefore, given the possible role for the ISDR in IFN resistance and differential antibody reactivity, it is possible that variation in ISDR may be involved in viral immune escape and development of persistent HCV infection employing aspects of host mimicry. In this study, pre-treatment samples obtained from HCV infected patients were used to investigate the effect of different NS5A ISDR variants on the IFN antiviral response and their involvement in immune evasion. The NS5A was identified as a homologue of the variable region of immunoglobulins (Ig). The IFN resistant genotypes had higher levels of similarity to Ig compared to IFN sensitive genotypes. Expression of NS5A-6003 (HCV genotype 1b) and NS5A-6074 (HCV genotype 2a) was able to rescue vesicular stomatitis virus (VSV) from IFN inhibition and restore luciferase activity. A correlation between Ig-like NS5A structure and also antibody response with the outcome of IFN treatment was observed.

Factors influencing pandemic influenza vaccination of healthcare workers--a systematic review.

INTRODUCTION: Maintaining the health and availability of Health care workers (HCW) is an essential component of pandemic preparedness. A key to protecting HCW during the H1N1 pandemic was influenza vaccination. Numerous researchers have reported on factors influencing H1N1 vaccination behaviour in various HCW groups. This systematic review aims to inform future influenza vaccine interventions and pandemic planning processes via the examination of literature in HCW H1N1 vaccination, in order to identify factors that are (1) unique to pandemic influenza vaccination and (2) similar to seasonal influenza vaccination research. METHODS: We conducted a comprehensive review of literature (MEDLINE, PubMed, EMBASE, PsycINFO, CINHAL, AMED, Cochrane Library, ProQuest, and grey literature sources) published between January 2005 and December 2011 to identify studies relevant to HCW pH1N1 vaccine uptake/refusal. RESULTS: 20 publications sampling HCW from different geographic regions are included in this review. H1N1 vaccine coverage was found to be variable (9-92%) across HCW populations, and self-reported vaccine status was the most frequently utilized predictor of pandemic vaccination. HCW were likely to accept the H1N1 vaccine if they perceived, (1) the H1N1 vaccine to be safe, (2) H1N1 vaccination to be effective in preventing infection to self and others (i.e. loved ones, co-workers and patients), and (3) H1N1 was a serious and severe infection. Positive cues to action, such as the access of scientific literature, trust in public health communications and messaging, and encouragement from loved ones, physicians and co-workers were also found to influence HCW H1N1 uptake. Previous seasonal influenza vaccination was found to be an important socio-demographic predictor of vaccine uptake. Factors unique to HCW pandemic vaccine behaviour are (1) lack of time and vaccine access related barriers to vaccination, (2) perceptions of novel and rapid pandemic vaccine formulation, and (3) the strong role of mass media on vaccine uptake. CONCLUSIONS: Many of the factors that influenced HCW pandemic vaccination decisions have previously been reported in seasonal influenza vaccination literature, but some factors were unique to pandemic vaccination. Future influenza vaccine campaigns should emphasize the benefits of vaccination and highlight positive cues to vaccination, while addressing barriers to vaccine uptake in order to improve vaccine coverage among HCW populations. Since pandemic vaccination factors tend be similar among different HCW groups, successful pandemic vaccination strategies may be effective across numerous HCW populations in pandemic scenarios.

Pharmacotherapy of obesity - benefit, bias and hyperbole.

Overweight and obesity, if sustained, are serious medical problems reaching an epidemic proportion. It is estimated that over 55% of the adult population is affected by overweight and obesity. Both overweight and obesity put these individuals at a high risk for the development of insulin resistance, hypertension, dyslipidemia, type 2 diabetes and coronary heart disease. A weight loss of between 5% and 10% of the initial body weight has been shown to greatly reduce these health risks associated with overweight and obesity. Typically, the first-line clinical strategy for weight loss is a combination of supervised diet, exercise and behavior modification. Although life style modification can exert beneficial effects in overweighed and obese individuals, it is difficult to achieve and maintain weight losses solely by life style change. Anti-obesity drugs may be used in obese patients (BMI of 30 or greater), or overweight patients with established comorbidities (BMI > 27), where dietary and lifestyle modifications are unsuccessful in achieving a 10% weight reduction following at least three months of the supervised care. Current anti-obesity drug therapy is geared towards reducing energy/food intake via actions on either gastrointestinal system or the central control of appetite and feeding. A thorough understanding of the molecular pathways involved in weight gain and appetite suppression should help for a better drug design and development. This mini review will focus on the molecular mechanisms and currently available pharmacotherapeutic interventions in overweight and obesity.

Smoking and binge drinking among Canadian survivors of childhood and adolescent cancers: a comparative, population-based study.

BACKGROUND: Objectives of this study were to describe the prevalence of smoking and binge drinking among survivors of childhood and adolescent cancer compared to controls who had never had cancer, and to identify factors associated with these behaviors. PROCEDURE: Data came from a national, multi-centre, population-based study of survivors of childhood and adolescent cancer (n = 1,263) aged 16 to 37 years and an age and gender matched control group (n = 1,422). Logistic regression analyses were performed to determine the likelihood and predictors of current smoking and binge drinking. RESULTS: Survivors were less likely to be current smokers (OR(adj) = 0.65, 95% CI = 0.54-0.77) and binge drinkers (OR(adj) = 0.66, 95% CI = 0.55-0.78) than the controls. Still, a substantial proportion of survivors reported smoking (23%) and binge drinking (25%). Survivors' smoking and binge drinking did not vary substantially by the clinical factors assessed. Survivors who received therapy associated with cardiac and/or pulmonary toxicity were as likely to smoke as non-exposed survivors. For both the survivors and controls current smoking and binge drinking were associated with lower education and higher reported stress. Binge drinking was also associated with being male and life dissatisfaction in both groups. CONCLUSIONS: This study indicates a need to reduce smoking and binge drinking among survivors of childhood and adolescent cancer and to design interventions addressing the underlying reasons for adopting unhealthy behaviors despite their risk for late effects. We identified factors related to smoking and binge drinking among survivors: being male, lower educational attainment, life dissatisfaction and high stress, which should help inform intervention development.

Resuscitating patients with early severe sepsis: a Canadian multicentre observational study.

BACKGROUND: Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure. METHODS: A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure. RESULTS: Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 +/- 16.5 yr and 29.0 +/- 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval (CI)] for 2-4 L 1.67 (1.03-2.70) and > 4 L 2.34 (1.23-4.44) and a reduced risk of renal failure [OR, 95% CI for 2-4 L 0.48 (0.28-0.83) and > 4 L 0.45 (0.22-0.92)] in the first 24 hr of severe sepsis. Administration of colloid and crystalloid fluid as compared to crystalloid fluid alone was associated with a lower risk of renal failure [OR, 95% CI 0.45 (0.26 to 0.76)]. CONCLUSION: An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials.

Access to bathtub grab bars: evidence of a policy gap.

This paper examines access to bathtub grab bars in privately and publicly owned apartment buildings and explores the profile of seniors who have access to bathtub grab bars. Results indicate that bathtub grab bars were significantly more prevalent in apartments that were publicly owned (91.3%) as compared to privately owned (37.8%) (p < 0.05). Results of a logistic regression for participants residing in non-universal-access buildings indicated that seniors were more likely to have grab bars in their bathtubs if they were older, were in poor health, had had a fall in the previous year, or used a mobility aid. Among those who did not have bathtub grab bars, 33 per cent reported fear of falling while bathing, 20 per cent reported difficulty bathing, and 23 per cent were found to have impaired balance. Findings are discussed in light of policy implications for universal access to grab bars, with apartment buildings being a logical place to start.

Face-to-face interviewing in predonation screening: lack of effect on detected human immunodeficiency virus and hepatitis C virus infections.

BACKGROUND: Predonation screening has become more elaborate over the years, while human immunodeficiency virus (HIV)- and hepatitis C virus (HCV)-positive donations have declined. The impact of face-to-face interviewing and of the format of the Donor Health Assessment Questionnaire (DHAQ) have not been evaluated. STUDY DESIGN AND METHODS: Canadian Blood Services DHAQ records between 1990 and 2004 were examined, and changes in them were tracked. The proportion of first-time donors permanently deferred for HIV or HCV risk, and the HIV and HCV rates per 100,000 donations, were calculated annually. Time-series analysis was used to determine whether major predonation screening changes had any effect on the HIV or HCV rates or permanent deferrals. RESULTS: In 1992, receiving money or drugs for sex was added to the DHAQ; otherwise, the content of high-risk questions changed little between 1990 and 2004. In 1997, the method of administration of the DHAQ changed from donor-completed to face-to-face interviewing for high-risk questions. Permanent deferrals for HIV or HCV risk factors and HIV and HCV rates in first-time donors decreased over this period. The HIV rates were close to 0 before 1997, whereas HCV rates decreased steadily through 2004. There was no interruption in rates in 1997 when the method of administration changed. CONCLUSION: Face-to-face interviewing for high-risk questions had no effect on HIV or HCV rates in first-time donations over 15 years of observation (during the latter 8 of which face-to-face interviewing was in place), and it did not increase permanent deferrals for HIV or HCV risk factors.

Predictive ability of sequential surveys in determining donor loss from increasingly stringent variant Creutzfeldt-Jakob disease deferral policies.

BACKGROUND: Predonation screening questions about travel increase the safety of the blood supply from diseases such as variant Creutzfeldt-Jakob disease (vCJD) and malaria. This study examines the ability of sequential surveys to predict actual travel deferrals and the operational validity of travel questions. STUDY DESIGN AND METHODS: To assess donor travel histories before implementing key deferral policies, two donor surveys were carried out at Canadian Blood Services collection sites in February 1999 (8026 donors) and March 2001 (13,623 donors). In-person interviews were carried out with 1530 donors to assess the operational validity of the short travel question. Time-series analysis was used to determine whether there was a change in deferrals when deferral policies were implemented. Predicted donor loss estimates based on survey results were compared with actual deferrals. RESULTS: Deferrals increased significantly (p < 0.05) when vCJD deferral policies were implemented in October 1999 and September 2001, but not in October 2000. Survey data accurately predicted deferrals 6 months after implementation from the initial policy (2.51% predicted vs. 2.51% actual), but there were fewer deferrals than predicted for the second (2.89% predicted vs. 2.26% actual, p < 0.01) and third deferral policies (3.10% predicted vs. 1.89% actual, p < 0.01). There was 96 percent agreement between donor responses to a short screening question and a detailed travel history. CONCLUSION: The initial survey accurately predicted the actual donor deferral rate, but the deferral rate was less than predicted for subsequent, more stringent donor deferral policies. Donors answered a short travel question suitable for donor screening similarly to a very detailed travel history.

The bedside investigation of pulmonary embolism diagnosis study: a double-blind randomized controlled trial comparing combinations of 3 bedside tests vs ventilation-perfusion scan for the initial investigation of suspected pulmonary embolism.

BACKGROUND: We sought to determine whether using combinations of 3 bedside tests (7-variable clinical model, non-enzyme-linked immunosorbent assay D-dimer test, and alveolar dead-space fraction) to exclude pulmonary embolism (PE) before diagnostic imaging was as safe as a standard strategy of starting with ventilation-perfusion (V/Q) scan. METHODS: In this double-blind, randomized, controlled equivalency trial, patients were randomized to initial bedside tests or to initial V/Q scan without bedside tests. Patients assigned to the bedside test group had a sham V/Q scan performed if at least 2 of 3 bedside test results were negative; otherwise, they underwent an actual V/Q scan. Further diagnostic management was determined by a blinded physician after V/Q scan. The primary outcome measure was recurrent venous thromboembolic events during 3 months among patients who were not taking anticoagulant agents after the initial investigations were completed. RESULTS: Four hundred fifty-eight consecutive adults with suspected PE were eligible for the study; 398 of 399 consenting and randomized patients completed the study. The follow-up venous thromboembolic event rate was 2.4% in the bedside test group vs 3.0% in the V/Q scan group (P = .76). Pulmonary embolism was excluded in 34% (67/199) of the bedside test group patients with at least 2 negative results on 3 bedside tests vs 18% (35/199) excluded using only the 7-variable clinical model and the D-dimer test. CONCLUSION: Excluding PE with at least 2 negative results on 3 bedside tests safely eliminates the need for diagnostic imaging in 34% of patients with suspected PE.

Income inequality and health in Ontario: a multilevel analysis.

OBJECTIVE: To examine the association of income inequality at the public health unit level with individual health status in Ontario. METHODS: Cross-sectional multilevel study carried out among subjects aged 25 years or older residing in 42 public health units in Ontario. Individual-level data drawn from 30,939 respondents in 1996-97 Ontario Health Survey. Median area income and income inequality (Gini coefficient) calculated from 1996 census. Self-rated health status (SRH) and Health Utilities Index (HUI-3) scores were used as main outcomes. RESULTS: Controlling for individual-level factors including income, respondents living in public health units in the highest tercile of income inequality had odds ratios of 1.20 (95% CI 1.04 - 1.38) for fair/poor self-rated health, and 1.11 (95% CI 1.01 - 1.22) for HUI score below the median, compared with people living in public health units in the lowest tercile. Controlling further for median area income had little effect on the association. CONCLUSION: Income inequality was significantly associated with individual self-reported health status at public health unit level in Ontario, independent of individual income.

The burden of chronic kidney disease in renal transplant recipients.

The National Kidney Foundation has developed guidelines for the diagnosis and classification of chronic kidney disease (CKD) but it is not known whether these are applicable to renal transplant recipients. This study determined the prevalence of CKD according to the stages defined in the guidelines, the complications related to CKD and whether the prevalence of complications was related to CKD stage in 459 renal transplant recipients. CKD was present in 412 patients (90%) and 60% were in CKD Stage 3 with a glomerular filtration rate (GFR) between 30 and 59 mL/min/1.73 m2. The prevalence of anemia increased from 0% in Stage 1 to 33% in Stage 5 (p<0.001). Hypertension was present in 86% and increased from 60% in Stage 1 to 100% in Stage 5 (p=0.02). The number of anti-hypertensives per patient increased from 0.7 in Stage 1 to 2.3 in Stage 5 (p<0.001). The number of CKD complications per patient increased from 1.1 in Stage 1 to 2.7 in Stage 5 (p<0.001). We conclude that CKD and the complications of CKD are highly prevalent in renal transplant recipients. The classification of renal transplant patients by CKD stage may help clinicians identify patients at increased risk and target appropriate therapy to improve outcomes.

Application of the 1998 Canadian cholesterol guidelines to a military population: health benefits and cost effectiveness of improved cholesterol management.

OBJECTIVE: To determine whether statins are underprescribed in the Canadian military. The cost effectiveness of statin therapy in patients identified by the 1998 Canadian cholesterol interim guidelines was also explored. METHODS: Charts of 1424 Canadian military personnel (age 45 or older) were reviewed at 11 Canadian bases. Risk factors and cholesterol values were used to identify drug therapy candidates. Cost effectiveness ratios and health benefits in terms of years of life saved for statin therapy were estimated for the candidates using a validated cardiovascular disease life expectancy model. RESULTS: Of the 1313 personnel not on lipid lowering medication, 172 were identified as drug therapy candidates. An average of 2.89 years of life saved was forecast for the identified personnel, at an average cost of less than 10,000 dollars per year of life saved. CONCLUSIONS: The health benefits of statin therapy in this population are substantial and the cost effectiveness is acceptable. Statin therapy warrants greater attention as a preventive strategy for coronary artery disease.

Restricted driver licensing for medical impairments: does it work?

BACKGROUND: Medical conditions may adversely affect driving ability. Many North American jurisdictions provide restricted driving licences that permit people with certain medical conditions to drive under limited conditions, but the effectiveness of such programs has not yet been determined. The objectives of this study were to evaluate the rates of crashes and traffic violations among drivers with a restricted licence, compared with the rates in the general driving population, and to compare the crash and traffic violation rates before and after driving restrictions were imposed. METHODS: We retrospectively analyzed a cohort of all licensed Saskatchewan drivers registered from Jan. 1, 1992, to Apr. 19, 1999. The cohort was divided into those with a restricted licence and those with an unrestricted general licence. We used multivariate Poisson regression to calculate incidence rate ratios (IRRs) for at-fault crashes and traffic violations, adjusting for age, sex and residence (urban v. rural). We used interventional time series analysis to compare rates of crashes and traffic violations before and after the imposition of driving restrictions. RESULTS: Of the 703,758 drivers in the study, 23,185 (3.3%) had a restricted licence. Restricted licence holders had a higher crash rate than drivers without restrictions (adjusted IRR 1.13, 95% confidence interval [CI] 1.11-1.17). However, this rate was lower than that among male drivers (adjusted IRR 2.01, 95% CI 1.99-2.02) and urban drivers (adjusted IRR 1.38, 95% CI 1.37-1.39). Drivers with restricted licences had a lower traffic violation rate than those without restrictions (adjusted IRR 0.93, 95% CI 0.91-0.95). At-fault crash rates decreased by 12.8% (95% CI 2.4%-23.2%) and adjusted traffic violation rates decreased by 10.0% (95% CI 4.4%-15.7%) after restrictions were imposed. During the study period, licence restrictions likely averted up to 816 crashes and 751 traffic violations. INTERPRETATION: Province-wide population data suggest that a restricted licensing program appears to provide a significant decrease in the rates of crashes and traffic violations.

Renin-angiotensin system blockade and the risk of hyperkalemia in chronic hemodialysis patients.

BACKGROUND: Blockade of the renin-angiotensin system by angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers can cause hyperkalemia in patients with chronic renal insufficiency who are not on dialysis, but the risk of hyperkalemia in hemodialysis patients is unknown. SUBJECTS AND METHODS: We conducted a prospective study of 251 adult hemodialysis patients to determine if renin-angiotensin system blockade was associated with hyperkalemia, defined as a predialysis serum potassium concentration of 5.5 mmol/L or higher. Medication use was determined by chart review and patient interview. Predialysis serum potassium concentration was measured monthly. RESULTS: There were 367 episodes of hyperkalemia during 1877 person-months of follow-up. After adjustment for potential confounding variables and for clustering of episodes by patient, use of an ACE inhibitor or an angiotensin receptor blocker was associated with a significantly higher risk of hyperkalemia (odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.4 to 3.4). The increased risk of hyperkalemia with renin-angiotensin system blockade was seen in anuric dialysis patients (OR = 2.3; 95% CI: 1.3 to 4.2), as well as those with residual renal function (OR = 2.1; 95% CI: 1.0 to 4.1). CONCLUSION: The use of ACE inhibitors or angiotensin receptor blockers is independently associated with an increased risk of developing hyperkalemia in chronic hemodialysis patients. The serum potassium concentration should be closely monitored when these medications are prescribed for hemodialysis patients.

Risk factors for genital chlamydial infection.

OBJECTIVE: To discuss the occurrence of genital chlamydia in developed countries and review the literature assessing the potential risk factors for this sexually transmitted disease. DATA SOURCES: A MEDLINE search was performed for all English citations from 1985 to 2000 that contain the keywords "Chlamydia trachomatis", "chlamydial infections", "risk factors" and "sex behaviour". All relevant references cited in articles that were obtained from the search were also included. DATA EXTRACTION: ALL ARTICLES OBTAINED FROM THE ABOVE SOURCES WERE EXAMINED, AND WERE INCLUDED IN THE REVIEW IF THEY MET THE FOLLOWING CRITERIA: primary study examining sociodemographic or behavioural risk factors associated with genital chlamydial infection using multivariate analysis; study subjects 12 years of age and older; and study setting in a developed country. DATA SYNTHESIS AND CONCLUSIONS: Genital chlamydial infection has become the most commonly reported bacterial infection in North America over the past decade. Thirty-eight cross-sectional studies and six cohort studies were included in the present review. Most studies demonstrated that young men and women are at higher risk of being infected with chlamydia than older subjects. Chlamydia seems to be found in a diverse group of people, and unlike gonorrhea, is not concentrated in low income, minority core groups with high rates of partner change. However, a number of studies have shown that communities with well-established control programs are beginning to demonstrate this pattern. There is no clear evidence that chlamydia is associated with type of partners, contraceptive use, or age at first intercourse. Future research should follow this sexually transmitted disease as it evolves through the epidemiological stages to ensure that preventive and treatment services are reaching those people who are most likely to be infected.