Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges.

BACKGROUND: Data on the social determinants of health can help primary care practices target improvement efforts, yet relevant data are rarely available. Our family practice located in Toronto, Ontario routinely collects patient-level sociodemographic data via a pilot-tested survey developed by a multi-organizational steering committee. We sought to use these data to assess the relationship between the social determinants and colorectal, cervical and breast cancer screening, and to describe the opportunities and challenges of using data on social determinants from a self-administered patient survey. METHODS: Patients of the family practice eligible for at least one of the three cancer screening types, based on age and screening guidelines as of June 30, 2015 and who had answered at least one question on a socio-demographic survey were included in the study. We linked self-reported data from the sociodemographic survey conducted in the waiting room with patients' electronic medical record data and cancer screening records. We created an individual-level income variable (low-income cut-off) that defined a poverty threshold and took household size into account. The sociodemographic characteristics of patients who were overdue for screening were compared to those who were up-to-date for screening for each cancer type using chi-squared tests. RESULTS: We analysed data for 5766 patients for whom we had survey data. Survey participants had significantly higher screening rates (72.9, 78.7, 74.4% for colorectal, cervical and breast cancer screening respectively) than the 13, 036 patients for whom we did not have survey data (59.2, 65.3, 58.9% respectively). Foreign-born patients were significantly more likely to be up-to-date on colorectal screening than their Canadian-born peers but showed no significant differences in breast or cervical cancer screening. We found a significant association between the low-income cut-off variable and cancer screening; neighbourhood income quintile was not significantly associated with cancer screening. Housing status was also significantly associated with colorectal, cervical and breast cancer screening. There was a large amount of missing data for the low-income cut-off variable, approximately 25% across the three cohorts. CONCLUSION: While we were able to show that neighbourhood income might under-estimate income-related disparities in screening, individual-level income was also the most challenging variable to collect. Future work in this area should target the income disparity in cancer screening and simultaneously explore how best to collect measures of poverty.

Guideline for opioid therapy and chronic noncancer pain

Guideline for opioid therapy and chronic noncancer pain: the objective is to inform the prescribing of opioids for adults with chronic noncancer pain.

Quantification of index tapping regularity after stroke with tri-axial accelerometry.

OBJECTIVE: Quantifying intrinsic components of movement may help to better understand the nature of motor deficits after stroke. Here we quantify the ability of stroke patients to finger tap in rhythm with auditory cues given at physiological rate. METHODS: Using tri-axial accelerometry, we measured tapping regularity (Regularity Index) during auditory-cued index-to-thumb tapping at 1.25 Hz in 20 prospectively selected right-handed chronic stroke patients (mean age 61 yrs) and 20 right-handed healthy subjects (7 young and 13 age matched; mean age 24 and 58 yrs, respectively). With the aim to validate our method, two measures of clinical deficit, the European Stroke Scale (ESS) and the maximum number of index-thumb taps in 15s (IT-Max) were recorded on the same day. RESULTS: There was no effect of age or hand used on the Regularity Index in the control subjects. In patients, the Regularity Index of their affected hand was significantly worse compared to their unaffected hand and to age-matched controls (p<0.05 and p<0.01, respectively). The Regularity Index significantly correlated with the ESS and IT-Max in the clinically expected direction (p=0.025 and 0.001, respectively). CONCLUSION: These data indicate that our method has validity to quantify finger-tapping regularity. After stroke, there is a deficit in the ability to keep pace with auditory cues that correlates, but does not equate, with other indices of motor function. Quantifying tapping regularity may provide novel insights into the mechanisms underlying recovery of finger dexterity after stroke.

Use of overlapping peptide mixtures as antigens for cytokine flow cytometry.

Intracellular cytokine staining and flow cytometry can be used to measure T-cell responses to defined antigens. Although CD8+ T-cell responses to soluble proteins are inefficiently detected by this approach, peptides can be used as antigens. Using overlapping peptides spanning an entire protein sequence, CD8+ T-cell responses can be detected to multiple epitopes, regardless of HLA type. In this study, overlapping peptide mixes of various lengths were compared and 15 amino acid peptides with 11 amino acid overlaps were found to stimulate both CD4+ and CD8+ T-cell responses. Such peptide mixes stimulated CD4+ T-cell responses equivalent to those observed with whole recombinant protein, while simultaneously stimulating CD8+ T-cell responses much higher than those observed with whole protein. Although 8-12 amino acid peptides produced the highest level of CD8+ T-cell responses, 15 amino acid peptides were still very effective. Peptides that were 20 amino acids in length, however, did not stimulate strong CD8+ T-cell responses at the same peptide dose. The cytokine responses to individual epitopes added up approximately to the response to the entire mix, demonstrating that large mixes can detect responses in a quantitative fashion. Unlike whole protein antigens, peptide mixes were effective at stimulating responses in both cryopreserved PBMC and blood stored for 24 h at room temperature. Thus, overlapping 15 amino acid peptide mixes may facilitate the analysis of antigen-specific CD4+ and CD8+ T-cell responses by cytokine flow cytometry, using clinical specimens that include shipped blood or cryopreserved PBMC.

Evaluation of cytotoxic T-lymphocyte responses in human and nonhuman primate subjects infected with human immunodeficiency virus type 1 or simian/human immunodeficiency virus.

Cytotoxic T-lymphocyte (CTL) responses have been implicated as playing an important role in control of human immunodeficiency virus (HIV) infection. However, it is technically difficult to demonstrate CTL responses consistently in nonhuman primate and human subjects using traditional cytotoxicity assay methods. In this study, we systematically evaluated culture conditions that may affect the proliferation and expansion of CTL effector cells and presented a sensitive method for detection of cytotoxicity responses with bulk CTL cultures. We confirmed the sensitivity and specificity of this method by demonstration of vigorous CTL responses in a simian-HIV (SHIV)-infected rhesus macaque. The expansion of epitope-specific CTL effector cells was also measured quantitatively by CTL epitope-major histocompatibility complex tetramer complex staining. In addition, two new T-cell determinants in the SIV gag region are identified. Last, we showed the utility of this method for studying CTL responses in chimpanzee and human subjects.

When obesity is desirable: a longitudinal study of the Miami HIV-1-infected drug abusers (MIDAS) cohort.

Despite widespread nutrient deficiencies, a substantial proportion of the MIDAS cohort exhibits obesity, which has been linked to immune dysregulation in other clinical settings. Herein, the effects of obesity on immune function, disease progression, and mortality were evaluated longitudinally in 125 HIV-1-seropositive drug users, with comparison measures in 148 HIV-1-seronegative controls. Data were collected at a community clinic from 1992 to 1996, before administration of highly active antiretroviral therapy. Results indicated that overweight/obesity, defined as body mass index (BMI; kg/m2) > or =27, was evident in 18% of the HIV-1-seropositive patients and 29% of the seronegative patients. At baseline, no significant immunologic differences were observed among lean, nonobese, and obese groups. Over an 18-month period, 60.5% of the nonobese HIV-1-seropositive patients exhibited a 25% decline in CD4 cell count, compared with 18% of the obese patients (p<.004). During the follow-up period, 38% of the lean and 13% of the nonobese study subjects died of HIV-1-related causes. Measurements of BMI were inversely associated with progression to death, independent of CD4 count <200 cells/mm3 (p<.02). These data suggest that mild-to-moderate obesity in HIV-1-infected chronic drug users does not impair immune function and is associated with better HIV-1-related survival.

Gustatory sweating syndrome of the submandibular gland.

Gustatory sweating syndrome involving the submandibular gland is rare. We present a case of a patient who experienced this syndrome 5 years after undergoing submandibular gland resection. Our patient was satisfied simply with an explanation of the disorder and reassurance. But in cases where further intervention is sought, medical and surgical options are available and should be individualized for the patient.

A comparison of root growth dynamics of silver maple and flowering dogwood in compacted soil at differing soil water contents.

Many bottomland tree species are tolerant of compacted soil and perform well in urban environments; however, the mechanism underlying this tolerance is unknown. Increased soil water content has been shown to alleviate some of the effects of soil compaction on plant growth, presumably because increasing soil water reduces soil strength. We hypothesized that tree species tolerant of very wet soils would have opportunities for root growth in compacted soil when high soil water contents reduced soil strength, whereas species intolerant of bottomland conditions would not. We tested this hypothesis on flowering dogwood (Cornus florida L.), a mesic species intolerant of inundation, and silver maple (Acer saccharinum L.), a bottomland species. Seedlings of both species were grown in pots for 21 and 30 days, respectively, in a growth chamber in native loam soil maintained at various combinations of soil strength and soil water tension. Downward root growth rate decreased in response to increasing soil strength in both species. At low soil strength (0.6 MPa), downward root growth rate of dogwood seedlings slowed when soil was either excessively wet or dry, whereas root growth rate of silver maple seedlings increased linearly with soil water content. In moderately compacted soil (1.5 g cm(-3) bulk density), silver maple seedlings had greater root growth rate, root length per plant, and ratio of root length to root dry weight in wet soil (0.006 MPa soil water tension) than in moist and dry soils (0.026 and 0.06 MPa, respectively), even though mean oxygen diffusion rate (ODR) was only 0.28 &mgr;g cm(-2) (SE = 0.05). No such effect was detected in highly compacted soil (1.7 g cm(-3) bulk density) in either species. Mean ODR showed a weak positive correlation with soil water tension (r = 0.40, P = 0.07), but was unrelated to soil strength. We conclude that silver maple roots can grow in moderately compacted soil when high soil water content decreases soil strength, whereas dogwood is unable to take advantage of this opportunity.

Drug use and syphilis. Co-factors for HIV transmission among commercial sex workers in Guyana.

A cross-sectional survey was conducted among 124 street- and brothel-based female commercial sex workers (CSWs) in Georgetown in January and February 1997 to determine the seroprevalence of human immunodeficiency virus (HIV) infection and describe the sexual practices and drug use patterns. Their median age was 30 years (range 17 to 52 years). 119 (88%) reported regular alcohol consumption while looking for clients, 27 (22%) said they smoked cocaine and 51 (42%) reported use of marijuana. Street-based CSWs were significantly more likely to report marijuana use (p = 0.033). 72% reported that they never used condoms with regular sex partners and 35% reported that they never used condoms with clients. Brothel-based women were significantly more likely to report consistent condom use with their clients (p = 0.05). 46% (54/118) tested HIV positive and 28% (33/118) had a positive serological test for syphilis. Factors that were significantly associated with HIV infection included a positive serological test for syphilis (OR = 7.56; 95% CI = 2.7-21.97; p < 0.01) and a history of having received treatment for syphilis (OR = 2.93; 95% CI = 1.12-7.8). Weak associations were also found between HIV infection and a history of cocaine use (OR = 2.57; 95% CI = 0.95-7.11; p = 0.039); having more than four clients per night (OR = 5.14; 95% CI = 1.65-16.74; p = 0.04); and a history of receiving treatment for salpingitis (OR = 2.31; 95% CI = .93-5.75; p = 0.0035). No statistically significant association was found between HIV infection and marijuana use nor any sociodemographic variables (age, place of work, and duration of sex work). There is an urgent need for a community based behavioural intervention programme targetting this high risk population.

Drug use and syphilis. Co-factors for HIV transmission among commercial sex workers in Guyana

A cross-sectional survey was conducted among 124 street- and brothel-based female commercial sex workers (CSWs) in Georgetown in January and February 1997 to determine the seroprevalence of human immunodeficiency virus (HIV) infection and describe the sexual practices and drug use patterns. Their median age was 30 years (range 17 to 52 years). 119 (88) reported regular alcohol consumption while looking for clients, 27 (22) said they smoked cocaine and 51 (42) reported use of marijuana. Street-based CSWs were significantly more likely to report marijuana use (p = 0.033). 72reported that they never used condoms with regular sex partners and 35reported that they never used condoms with clients. Brothel-based women were significantly more likely to report consistent condom use with their clients (p = 0.05). 46(54/118) tested HIV positive and 28(33/118) had a positive serological test for syphilis. Factors that were significantly associated with HIV infection included a positive serological test for syphilis (OR = 7.56; 95CI = 2.7-21.97; p < 0.01) and a history of having received treatment for syphilis (OR = 2.93; 95CI = 1.12-7.8). Weak associations were also found between HIV infection and a history of cocaine use (OR = 2.57; 95CI = 0.95-7.11; p = 0.039); having more than four clients per night (OR = 5.14; 95CI = 1.65-16.74; p = 0.04); and a history of receiving treatment for salpingitis (OR = 2.31; 95CI = .93-5.75; p = 0.0035). No statistically significant association was found between HIV infection and marijuana use nor any sociodemographic variables (age, place of work, and duration of sex work). There is an urgent need for a community based behavioural intervention programme targetting this high risk population.

The developmental implications of prenatal and/or postnatal crack cocaine exposure in preschool children: a preliminary report.

Previous studies examining the development of prenatally cocaine-exposed children through 3 years of age have found no significant differences between exposed and control groups. This study explored the developmental correlates of prenatal and/or postnatal crack cocaine exposure in children between 4 and 6 years of age. Three groups were studied: Group 1, 18 prenatally-exposed children whose mothers continue to use crack; Group II, 28 children without prenatal exposure whose mothers presently use crack; and Group III, 28 children whose mothers never used crack. Mothers were street-recruited and were comparable in race and socioeconomic status. The three groups of children did not differ on neurological gross motor and expressive language measures. However, prenatally exposed children performed significantly worse than others on receptive language and visual motor drawing tests. Prenatal crack exposure predicted poor visual motor performance even after control for intrauterine alcohol and marijuana exposure, age, birth weight, and duration of maternal crack use.

The relative bioavailability of paracetamol and codeine after oral administration of a combination of buclizine, paracetamol and codeine, with or without docusate, and of paracetamol alone in healthy volunteers.

A randomized, double-blind, crossover study was carried out in 10 healthy volunteers to investigate whether the inclusion of the wetting agent docusate sodium (10 mg) in a combined oral formulation ('Migraleve') with buclizine hydrochloride (6.25 mg), codeine phosphate (8 mg) and paracetamol (500 mg) had any effect on the bioavailability of the analgesics. On 3 occasions at weekly intervals, the subjects were given 2 tablets of the standard formulation, the combination without docusate or 500 mg paracetamol alone. Blood samples were taken before and at fixed times during the 4 hours after administration of each preparation for estimation of plasma concentrations of paracetamol, by gas-liquid chromatography, and of codeine, by radioimmunoassay. The results showed that there were no significant differences between the mean paracetamol concentrations achieved after administration of each of the 3 preparations at any of the time points. Peak paracetamol plasma concentrations were 11.25 +/- 1.74 micrograms/ml at 0.5 hours, 9.6 +/- 1.04 micrograms/ml at 0.75 hours, and 9.53 +/- 1.66 micrograms/ml at 0.5 hours, respectively, after the standard formulation, the combination without docusate, and paracetamol alone. Mean elimination half-lives for paracetamol were 2.83 +/- 0.51, 1.92 +/- 0.20 and 2.49 +/- 0.46 hours, respectively, and the differences were not significant. The difference between mean plasma concentrations of codeine after the two preparations including this analgesic bordered on significance at 3 hours and was significant at 4 hours, but the areas under the curve were not significantly different. Peak codeine plasma concentrations after the standard formulation were 42.1 +/- 9.4 ng/ml at 0.75 hours compared with 36.9 +/- 3.4 ng/ml at 1.5 hours after the combination without docusate.(ABSTRACT TRUNCATED AT 250 WORDS)

Ergotamine toxicity and serum concentrations of ergotamine in migraine patients.

Twenty-five migraine patients (9 males and 16 females) aged 22-71 who had used between 7 and 60 mg ergotamine tartrate per week for 1.5-30 y volunteered to participate in the study. Side-effects attributable to ergotamine were wide ranging and included daily headache and pain in the limbs. Wide variation in sensitivity to the drug was observed and side-effects were not always proportional to the dose of ergotamine. Random serum ergotamine concentrations were estimated in all patients and 10 of them volunteered to take a 2 mg oral challenge of ergotamine tartrate. Ergotamine was not detected in 44% of the random estimations even though all patients exhibited clinical signs of ergotamine tartrate overdose. The remaining 56% estimations all showed low drug concentrations. After the 2 mg oral challenge of ergotamine in the 10 patients, significantly higher concentrations, but still within therapeutic range, were detected in the sera when compared with mean concentrations achieved after the same oral dose of the drug in healthy, non-migrainous subjects.

Results of a quality control scheme for the assay of theophylline in serum.

Twenty-eight laboratories in the United Kingdom, Europe, and Australia participated in pilot study to assess interlaboratory variability in determining serum theophylline levels. Each laboratory received two samples of pooled serum containing theophylline each month and was asked to report their results and method to us. Data obtained over a period of 12 months were collated, enabling certain conclusions to be drawn. Five methods of analysis were used: high pressure liquid chromatography (HPLC), gas--liquid chromatography, EMIT, thin-layer chromatography, and ultraviolet spectroscopy (UV). All of these methods, with the exception of UV, were found to be satisfactory, with HPLC marginally superior. Several laboratories improved their assay techniques over the period of operation of the scheme, and all found the scheme helpful in assessing the performance of their methods.