When is a randomised controlled trial health equity relevant? Development and validation of a conceptual framework.

BACKGROUND: Randomised controlled trials can provide evidence relevant to assessing the equity impact of an intervention, but such information is often poorly reported. We describe a conceptual framework to identify health equity-relevant randomised trials with the aim of improving the design and reporting of such trials. METHODS: An interdisciplinary and international research team engaged in an iterative consensus building process to develop and refine the conceptual framework via face-to-face meetings, teleconferences and email correspondence, including findings from a validation exercise whereby two independent reviewers used the emerging framework to classify a sample of randomised trials. RESULTS: A randomised trial can usefully be classified as 'health equity relevant' if it assesses the effects of an intervention on the health or its determinants of either individuals or a population who experience ill health due to disadvantage defined across one or more social determinants of health. Health equity-relevant randomised trials can either exclusively focus on a single population or collect data potentially useful for assessing differential effects of the intervention across multiple populations experiencing different levels or types of social disadvantage. Trials that are not classified as 'health equity relevant' may nevertheless provide information that is indirectly relevant to assessing equity impact, including information about individual level variation unrelated to social disadvantage and potentially useful in secondary modelling studies. CONCLUSION: The conceptual framework may be used to design and report randomised trials. The framework could also be used for other study designs to contribute to the evidence base for improved health equity.

Respiratory health status is impaired in UK HIV-positive adults with virologically suppressed HIV infection.

OBJECTIVES: We sought to evaluate whether people living with HIV (PLWH) using effective antiretroviral therapy (ART) have worse respiratory health status than similar HIV-negative individuals. METHODS: We recruited 197 HIV-positive and 93 HIV-negative adults from HIV and sexual health clinics. They completed a questionnaire regarding risk factors for respiratory illness. Respiratory health status was assessed using the St George's Respiratory Questionnaire (SGRQ) and the Medical Research Council (MRC) breathlessness scale. Subjects underwent spirometry without bronchodilation. RESULTS: PLWH had worse respiratory health status: the median SGRQ Total score was 12 [interquartile range (IQR) 6-25] in HIV-positive subjects vs. 6 (IQR 2-14) in HIV-negative subjects (P < 0.001); breathlessness was common in the HIV-positive group, where 47% compared with 24% had an MRC breathlessness score ≥ 2 (P = 0.001). Eighteen (11%) HIV-positive and seven (9%) HIV-negative participants had airflow obstruction. In multivariable analyses (adjusted for age, gender, smoking, body mass index and depression), HIV infection remained associated with higher SGRQ and MRC scores, with an adjusted fold-change in SGRQ Total score of 1.54 [95% confidence interval (CI) 1.14-2.09; P = 0.005] and adjusted odds ratio of having an MRC score of ≥ 2 of 2.45 (95% CI 1.15-5.20; P = 0.02). Similar findings were obtained when analyses were repeated including only HIV-positive participants with a viral load < 40 HIV-1 RNA copies/mL. CONCLUSIONS: Despite effective ART, impaired respiratory health appears more common in HIV-positive adults, and has a significant impact on health-related quality of life.

Age, time living with diagnosed HIV infection, and self-rated health.

OBJECTIVES: An increasing proportion of people living with HIV are older adults, who may require specialized care. Adverse physical and psychological effects of HIV infection may be greatest among older people or those who have lived longer with HIV. METHODS: The ASTRA study is a cross-sectional questionnaire study of 3258 HIV-diagnosed adults (2248 men who have sex with men, 373 heterosexual men and 637 women) recruited from UK clinics in 2011-2012. Associations of age group with physical symptom distress (significant distress for at least one of 26 symptoms), depression and anxiety symptoms (scores ≥ 10 on PHQ-9 and GAD-7, respectively), and health-related functional problems (problems on at least one of three domains of the Euroqol 5D-3L)) were assessed, adjusting for time with diagnosed HIV infection, gender/sexual orientation and ethnicity. RESULTS: The age distribution of participants was: < 30 years, 5%; 30-39 years, 23%; 40-49 years, 43%; 50-59 years, 22%; and ≥ 60 years, 7%. Overall prevalences were: physical symptom distress, 56%; depression symptoms, 27%; anxiety symptoms, 22%; functional problems, 38%. No trend was found in the prevalence of physical symptom distress with age [adjusted odds ratio (OR) for trend across age groups, 0.96; 95% confidence interval (CI) 0.89, 1.04; P = 0.36]. The prevalence of depression and anxiety symptoms decreased with age [adjusted OR 0.86 (95% CI 0.79, 0.94; P = 0.001) and adjusted OR 0.85 (95% CI 0.77, 0.94; P = 0.001), respectively], while that of functional problems increased (adjusted OR 1.28; 95% CI 1.17, 1.39; P < 0.001). In contrast, a longer time with diagnosed HIV infection was strongly and independently associated with a higher prevalence of symptom distress, depression symptoms, anxiety symptoms, and functional problems (P < 0.001 for trends, adjusted analysis). CONCLUSIONS: Among people living with HIV, although health-related functional problems were more common with older age, physical symptom distress was not, and mental health was more favourable. These results suggest that a longer time with diagnosed HIV infection, rather than age, is the dominating factor contributing to psychological morbidity and lower quality of life.

Protocol for the development of a CONSORT-equity guideline to improve reporting of health equity in randomized trials.

BACKGROUND: Health equity concerns the absence of avoidable and unfair differences in health. Randomized controlled trials (RCTs) can provide evidence about the impact of an intervention on health equity for specific disadvantaged populations or in general populations; this is important for equity-focused decision-making. Previous work has identified a lack of adequate reporting guidelines for assessing health equity in RCTs. The objective of this study is to develop guidelines to improve the reporting of health equity considerations in RCTs, as an extension of the Consolidated Standards of Reporting Trials (CONSORT). METHODS/DESIGN: A six-phase study using integrated knowledge translation governed by a study executive and advisory board will assemble empirical evidence to inform the CONSORT-equity extension. To create the guideline, the following steps are proposed: (1) develop a conceptual framework for identifying "equity-relevant trials," (2) assess empirical evidence regarding reporting of equity-relevant trials, (3) consult with global methods and content experts on how to improve reporting of health equity in RCTs, (4) collect broad feedback and prioritize items needed to improve reporting of health equity in RCTs, (5) establish consensus on the CONSORT-equity extension: the guideline for equity-relevant trials, and (6) broadly disseminate and implement the CONSORT-equity extension. DISCUSSION: This work will be relevant to a broad range of RCTs addressing questions of effectiveness for strategies to improve practice and policy in the areas of social determinants of health, clinical care, health systems, public health, and international development, where health and/or access to health care is a primary outcome. The outcomes include a reporting guideline (CONSORT-equity extension) for equity-relevant RCTs and a knowledge translation strategy to broadly encourage its uptake and use by journal editors, authors, and funding agencies.

Body condition score at calving affects systemic and hepatic transcriptome indicators of inflammation and nutrient metabolism in grazing dairy cows.

Calving body condition score (BCS) is an important determinant of early-lactation dry matter intake, milk yield, and disease incidence. The current study investigated the metabolic and molecular changes induced by the change in BCS. A group of cows of mixed age and breed were managed from the second half of the previous lactation to achieve mean group BCS (10-point scale) that were high (HBCS, 5.5; n=20), medium (MBCS, 4.5; n=18), or low (LBCS, 3.5; n=19). Blood was sampled at wk -4, -3, -2, 1, 3, 5, and 6 relative to parturition to measure biomarkers of energy balance, inflammation, and liver function. Liver was biopsied on wk 1, 3, and 5 relative to parturition, and 10 cows per BCS group were used for transcript profiling via quantitative PCR. Cows in HBCS and MBCS produced more milk and had greater concentrations of nonesterified fatty acids and ß-hydroxybutyrate postpartum than LBCS. Peak concentrations of nonesterified fatty acids and ß-hydroxybutyrate and greater hepatic triacylglycerol concentrations were recorded in HBCS at wk 3. Consistent with blood biomarkers, HBCS and MBCS had greater expression of genes associated with fatty acid oxidation (CPT1A, ACOX1), ketogenesis (HMGCS2), and hepatokines (FGF21, ANGPTL4), whereas HBCS had the lowest expression of APOB (lipoprotein transport). Greater expression during early lactation of BBOX1 in MBCS and LBCS suggested greater de novo carnitine synthesis. The greater BCS was associated with lower expression of growth hormone/insulin-like growth factor-1 signaling axis genes (GHR1A, IGF1, and IGFALS) and greater expression of gluconeogenic genes. These likely contributed to the higher milk production and greater gluconeogenesis. Despite greater serum haptoglobin around calving, cows in HBCS and MBCS had greater blood albumin. Cows in MBCS, however, had a higher albumin:globulin ratio, probably indicating a less pronounced inflammatory status and better liver function. The marked decrease in expression of NFKB1, STAT3, HP, and SAA3 coupled with the increase in ALB on wk 3 in MBCS cows were consistent with blood measures. Overall, results suggest that the greater milk production of cows with higher calving BCS is associated with a proinflammatory response without negatively affecting expression of genes related to metabolism and the growth hormone/insulin-like growth factor-1 axis. Results highlight the sensitivity of indicators of metabolic health and inflammatory state to subtle changes in calving BCS and, collectively, indicate a suboptimal health status in cows calving at either BCS 3.5 or 5.5 relative to BCS 4.5.

Diagnosis and management of Enterococcus spp infections during rehabilitation of cold-stunned Kemp's ridley turtles (Lepidochelys kempii): 50 cases (2006-2012).

OBJECTIVE: To evaluate clinical data for cold-stunned Kemp's ridley turtles (Lepidochelys kempii) with Enterococcus spp infections during rehabilitation. DESIGN: Retrospective case series. ANIMALS: 50 stranded cold-stunned Kemp's ridley turtles hospitalized between 2006 and 2012. PROCEDURES: Medical records for turtles from which Enterococcus spp were isolated were reviewed retrospectively, and clinical data, including morphometric data, body temperature at admission, physical examination findings, antimicrobial medication history, history of medications administered IV, environmental data, day of diagnosis, clinical signs at diagnosis, microbiological testing results, sources of positive culture results, hematologic and plasma biochemical data, cytologic and histopathologic results, radiographic findings, antimicrobial treatments, time to first negative culture result, treatment duration, results of subsequent cultures, and case outcome, were collated and analyzed. RESULTS: Enterococcus spp were isolated from bacteriologic cultures of blood, bone, joint, and respiratory tract samples and a skin lesion, with supporting evidence of infection provided by histopathologic, cytologic, and radiographic data. Positive culture results were associated with clinical problems such as lethargy, anorexia, and lameness. Most (34/43 [79%]) turtles for which an antemortem diagnosis was made survived with treatment and were released into the wild. CONCLUSIONS AND CLINICAL RELEVANCE: Cold-stunned Kemp's ridley turtles may be affected by serious Enterococcus spp infections during rehabilitation. Recognition and treatment of these infections are important for successful rehabilitation.

Calving body condition score affects indicators of health in grazing dairy cows.

The objectives of this study were to determine the effect of calving body condition score (BCS) on cow health during the transition period in a pasture-based dairying system. Feed inputs were managed during the second half of the previous lactation so that BCS differed at drying off (BCS 5.0, 4.0, and 3.0 for high, medium, and low treatments, respectively: a 10-point scale); feed allowance was managed after cows were dried off, such that the BCS differences established during lactation remained at the subsequent calving (BCS 5.5, 4.5, and 3.5; n=20, 18, and 19, for high, medium, and low treatments, respectively). After calving, cows were allocated pasture and pasture silage to ensure grazing residuals >1,600 kg of DM/ha. Milk production was measured weekly; blood was sampled regularly pre- and postpartum to measure indicators of health, and udder and uterine health were evaluated during the 6 wk after calving. Milk weight, fat, protein, and lactose yields, and fat content increased with calving BCS during the first 6 wk of lactation. The effect of calving BCS on the metabolic profile was nonlinear. Before calving, cows in the low group had lower mean plasma ß-hydroxybutyrate and serum Mg concentrations and greater mean serum urea than cows in the medium and high BCS groups, which did not differ from each other. During the 6 wk after calving, cows in the low group had lower serum albumin and fructosamine concentrations than cows in the other 2 treatment groups, whereas cows in the low- and medium-BCS groups had proportionately more polymorphonucleated cells in their uterine secretions at 3 and 5 wk postpartum than high-BCS cows. In comparison, plasma ß-hydroxybutyrate and nonesterified fatty acid concentrations increased linearly in early lactation with calving BCS, consistent with a greater negative energy balance in these cows. Many of the parameters measured did not vary with BCS. The results highlight that calving BCS and, therefore, BCS through early lactation are not effective indicators of functional welfare, with the analyses presented indicating that both low and high BCS at calving will increase the risk of disease: cows in the low group were more prone to reproductive compromise and fatter cows had an increased risk of metabolic diseases. These results are important in defining the welfare consequences of cow BCS.

Cooking fuel type, household ventilation, and the risk of acute lower respiratory illness in urban Bangladeshi children: a longitudinal study.

UNLABELLED: Acute lower respiratory illnesses (ALRI) are the leading cause of death among children <5 years. Studies have found that biomass cooking fuels are an important risk factor for ALRI. However, few studies have evaluated the influence of natural household ventilation indicators on ALRI. The purpose of this study was to assess the association between cooking fuel, natural household ventilation, and ALRI. During October 17, 2004-September 30, 2005, children <5 years living in a low-income neighborhood of Dhaka, Bangladesh, were assessed weekly for ALRI and surveyed quarterly about biomass fuel use, electric fan ownership, and natural household ventilation (windows, ventilation grates, and presence of a gap between the wall and ceiling). Bivariate and multivariate analyses were performed using generalized estimating equations. Six thousand and seventy-nine children <5 years enrolled during the study period (99% participation) experienced 1291 ALRI. In the multivariate model, ≥2 windows [OR = 0.75, 95% CI = (0.58, 0.96)], ventilation grates [OR = 0.80, 95% CI = (0.65, 0.98)], and not owning an electric fan [OR = 1.50, 95% CI = (1.21, 1.88)] were associated with ALRI; gap presence and using biomass fuels were not associated with ALRI. Structural factors that might improve household air circulation and exchange were associated with decreased ALRI risk. Improved natural ventilation might reduce ALRI among children in low-income families. PRACTICAL IMPLICATIONS: The World Health Organization has stated that controlling pneumonia is a priority for achieving the fourth Millennium Development Goal, which calls for a two-third reduction in mortality of children <5 years old compared to the 1990 baseline. Our study represents an important finding of a modifiable risk factor that might decrease the burden of respiratory illness among children living in Bangladesh and other low-income settings similar to our study site. We found that the existence of at least two windows in the child's sleeping room was associated with a 25% decreased ALRI risk. Increasing available natural ventilation within the household in similar settings has the potential to reduce childhood mortality because of acute lower respiratory illnesses.

Rainfall, household crowding, and acute respiratory infections in the tropics.

SUMMARYAcute respiratory infections (ARI) are the leading cause of death worldwide in children aged <5 years, and understanding contributing factors to their seasonality is important for targeting and implementing prevention strategies. In tropical climates, ARI typically peak during the pre-rainy and rainy seasons. One hypothesis is that rainfall leads to more time spent indoors, thus increasing exposure to other people and in turn increasing the risk of ARI. A case-crossover study design in 718 Bangladeshi children aged <5 years was used to evaluate this hypothesis. During a 3-month period with variable rainfall, rainfall was associated with ARI [odds ratio (OR) 2·97, 95% confidence interval (CI) 1·87-4·70]; some evidence of an increased strength of association as household crowding increased was found (≥3 people/room, OR 3·31, 95% CI 2·03-5·38), but there was a lack of association in some of the most crowded households (≥5 to <6 people/room, OR 1·55, 95% CI 0·54-4·47). These findings suggest that rainfall may be increasing exposure to crowded conditions, thus leading to an increased risk of ARI, but that additional factors not captured by this analysis may also play a role.

Contribution of early glycemic status in the development of severe retinopathy of prematurity in a cohort of ELBW infants.

OBJECTIVE: The objective of this study is to investigate the relationship between glycemic status and severe retinopathy of prematurity (ROP). STUDY DESIGN: This is a retrospective cohort study of 114 infants <1000 g admitted to a level IV neonatal intensive care unit within 48 h of life. A cumulative, time-weighted glucose level (TWGL) derived from plotting glucose values over time was included in logistic regression analysis to identify predictors for severe ROP. RESULT: Infants had 26.6 ± 2 weeks gestational age and had a birth weight of 782 ± 136 g. TWGL during first 10 and 30 days of life were greater in the severe ROP group (P<0.01). Unlike single events of glucose levels ≥ 150 mg dl(-1), 10 days TWGL ≥ 100 mg dl(-1) (odds ratio (OR) 5.2, P<0.02) and 30 days TWGL ≥ 118 mg dl(-1) (OR 5.7, P<0.02) were predictors for severe ROP (univariate). Multivariate regression confirmed 30 days TWGL ≥ 118 mg dl(-1) (OR 9.4 to 10) and gram-positive sepsis (OR 4.1 to 5) as predictors for severe ROP (P<0.05). CONCLUSION: High overall glycemic status is associated with the development of severe ROP.

Effect of setting a maximum milking time, from peak lactation, on production, milking time and udder health.

AIM: To examine the effect of setting a maximum milking time, from peak lactation until drying-off, on production, duration of milking, and udder health of dairy cows. METHODS: Forty cows were assigned in twin-pairs to be either milked until cups were removed at a milk flow-rate threshold of 0.35 kg/minute (Control), or until cups were removed at a milk flow-rate threshold of 0.35 kg/minute, or maximum time, whichever came first (MaxT). The maximum time was set by determining the milking time of the 70th percentile cow when ranked from fastest to slowest, irrespective of yield. The milking routine was typical of that practised on dairy farms in New Zealand, and involved no pre-milking preparation. The study began at peak lactation (68 (SD 7) days in milk; DIM) and continued for 26 weeks. Duration of milking and milk yield were measured for each milking. Composition of milk was determined from weekly herd tests, and milk quality from fortnightly somatic cell counts (SCC). Completeness of milking and teat condition were assessed during the study. The bacterial status of quarter milk samples was determined at the beginning and end of the study, and all treated cases of clinical mastitis recorded. ANOVA was used to examine the effect of treatment group on variables of interest. RESULTS: Total milk, fat and protein yields during the study period did not differ between treatments. On average, 30.3% of the morning and 27.6% of the afternoon milkings of MaxT cows reached the maximum time at which cups were removed, and were therefore shortened. While the average milking time of the slowest-milking cow was longer for the Control compared with MaxT group in Weeks 1-18, the average milking time did not differ between treatments. There was no difference in overall SCC, and the incidence of clinical mastitis, or the percentage of infected quarters at drying-off, was similar for the MaxT and Control cows. CONCLUSION: The results show that setting a maximum milking time can reduce the milking time of slower-milking cows in a herd without compromising overall herd production and udder health. CLINICAL RELEVANCE: Although the numbers of cows in the study were small there was no evidence of a major increase in SCC, or subclinical or clinical mastitis when a maximum milking time was set for slower-milking cows.

Use of diagnostic decision support systems in medical education.

BACKGROUND: Diagnostic decision support systems are designed to assist physicians with making diagnoses. This article illustrates some of the issues that will be faced as diagnostic decision support systems become used in medical education. OBJECTIVES: The objectives of this article are to examine 1) the skills that are needed to properly use these programs as part of the students' clinical experiences; 2) the changes that will be necessary in our curricula once these programs are more extensively utilized, including the implications of using these systems as an educational resource or simulation tool, and 3) the research issues that arise when these systems become an established part of our educational programs. METHODS: This is a critical analysis of the literature on diagnostic decision support systems and medical education. RESULTS: To optimally use diagnostic decision support programs, students will need grounding in the basic knowledge and skills that have always been necessary to become a physician, such as the ability to accurately gather and interpret clinical information from the patient. In addition, students will need specific skills in 1) selecting appropriate system vocabulary and functions, and 2) applying the diagnostic system's suggestions to their particular patient. CONCLUSIONS: When computer-based decision support systems are incorporated in medical education, they will likely lead to changes in the traditional medical curriculum. Research will be needed on how use of these programs changes the students' knowledge, problem-solving and information-seeking skills.

Quantitative analysis and molecular fingerprinting of methicillin-resistant Staphylococcus aureus nasal colonization in different patient populations: a prospective, multicenter study.

OBJECTIVES: To better understand the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in different patient populations, to perform quantitative analysis of MRSA in nasal cultures, and to characterize strains using molecular fingerprinting. DESIGN: Prospective, multicenter study. SETTING: Eleven different inpatient and outpatient healthcare facilities. PARTICIPANTS: MRSA-positive inpatients identified in an active surveillance program; inpatients and outpatients receiving hemodialysis; inpatients and outpatients with human immunodeficiency virus (HIV) infection; patients requiring cardiac surgery; and elderly patients requiring long-term care. METHODS. Nasal swab samples were obtained from January 23, 2006, through July 27, 2007; MRSA strains were quantified and characterized by molecular fingerprinting. RESULTS: A total of 444 nares swab specimens yielded MRSA (geometric mean quantity, 794 CFU per swab; range, 3-15,000,000 CFU per swab). MRSA prevalence was 20% for elderly residents of long-term care facilities (25 of 125 residents), 16% for HIV-infected outpatients (78 of 494 outpatients), 15% for outpatients receiving hemodialysis (31 of 208 outpatients), 14% for inpatients receiving hemodialysis (86 of 623 inpatients), 3% for HIV-infected inpatients (5 of 161 inpatients), and 3% for inpatients requiring cardiac surgery (6 of 199 inpatients). The highest geometric mean quantity of MRSA was for inpatients requiring cardiac surgery (11,500 CFU per swab). An association was found between HIV infection and colonization with the USA300 or USA500 strain of MRSA (P < or = .001). The Brazilian clone was found for the first time in the United States. Pulsed-field gel electrophoresis patterns for 11 isolates were not compatible with known USA types or clones. CONCLUSION: Nasal swab specimens positive for MRSA had a geometric mean quantity of 794 CFU per swab, with great diversity in the quantity of MRSA at this anatomic site. Outpatient populations at high risk for MRSA carriage were elderly residents of long-term care facilities, HIV-infected outpatients, and outpatients receiving hemodialysis.

Neonatal respiratory failure due to a novel mutation in the surfactant protein C gene.

A full-term infant developed respiratory distress immediately after birth, requiring a prolonged course of extra-corporeal membrane oxygenation, followed by high-frequency ventilation. She was unable to wean off mechanical ventilation, required tracheostomy, and ultimately lung transplantation. A novel mutation in the surfactant C protein gene was identified as the cause of her lung disease.

Age, gender, and race/ethnic differences in total body and subregional bone density.

SUMMARY: Total body bone density of adults from National Health and Nutrition Examination Survey (NHANES) 1999-2004 differed as expected for some groups (men>women and blacks>whites) but not others (whites>Mexican Americans). Cross-sectional age patterns in bone mineral density (BMD) of older adults differed at skeletal sites that varied by degree of weight-bearing. INTRODUCTION: Total body dual-energy X-ray absorptiometry (DXA) data offer the opportunity to compare bone density of demographic groups across the entire skeleton. METHODS: The present study uses total body DXA data (Hologic QDR 4500A, Hologic, Bedford MA, USA) from the NHANES 1999-2004 to examine BMD of the total body and selected skeletal subregions in a wide age range of adult men and women from three race/ethnic groups. Total body, lumbar spine, pelvis, right leg, and left arm BMD and lean mass from 13,091 adults aged 20 years and older were used. The subregions were chosen to represent sites with different degrees of weight-bearing. RESULTS: Mean BMD varied in expected ways for some demographic characteristics (men>women and non-Hispanic blacks>non-Hispanic whites) but not others (non-Hispanic whites>Mexican Americans). Differences in age patterns in BMD also emerged for some characteristics (sex) but not others (race/ethnicity). Differences in cross-sectional age patterns in BMD and lean mass by degree of weight-bearing in older adults were observed for the pelvis, leg, and arm. CONCLUSION: This information may be useful for generating hypotheses about age, race, and sex differences in fracture risk in the population.

Risk factors for low bone mass in healthy 40-60 year old women: a systematic review of the literature.

UNLABELLED: Based on a systematic review of the literature, only low body weight and menopausal status can be considered with confidence, as important risk factors for low BMD in healthy 40-60 year old women. The use of body weight to identify high risk women may reduce unnecessary BMD testing in this age group. INTRODUCTION: BMD testing of perimenopausal women is increasing but may be unnecessary as fracture risk is low. Appropriate assessment among younger women requires identification of risk factors for low BMD specific to this population. METHODS: We conducted a systematic literature review of risk factors for low BMD in healthy women aged 40-60 years. Articles were retrieved from six databases and reviewed for eligibility and methodological quality. A grade for overall strength of evidence for each risk factor was assigned. RESULTS: There was good evidence that low body weight and post-menopausal status are risk factors for low BMD. There was good or fair evidence that alcohol and caffeine intake, and reproductive history are not risk factors. There was inconsistent or insufficient evidence for the effect of calcium intake, physical activity, smoking, age at menarche, history of amenorrhea, family history of OP, race and current age on BMD. CONCLUSIONS: Based on current evidence in Caucasians, we suggest that, in healthy women aged 40-60 years, only those with a low body weight (< 70 kg) be selected for BMD testing. Further research is necessary to determine optimal race-specific discriminatory weight cut-offs and to evaluate the risk factors for which there was inconclusive evidence.

Risk factors for low BMD in healthy men age 50 years or older: a systematic review.

SUMMARY: In this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50 years or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture. Data specific to men has clinical and policy implications. INTRODUCTION: Osteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for low bone mineral density (BMD) and bone loss in healthy men age 50 years or older. MATERIALS AND METHODS: A systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL, CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained reviewers assessed articles using a priori criteria. RESULTS: Of 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis, and height/height loss. CONCLUSION: In this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary practice.

Nausea and vomiting in HIV: a symptom review.

Nausea and vomiting are two of the most common symptoms experienced by those with HIV. While the causes are most commonly attributed to medication side effects, infectious causes, gastroparesis and psychosomatic, therapy aimed at controlling symptoms has not been well studied. Since nausea and vomiting have been identified as the most common cause of discontinuation of highly active antiretroviral therapy (HAART) therapy, and due to the extensive morbidity associated with these symptoms, we sought to review and discuss causes and management of these symptoms in HIV-infected patients and demonstrate the need for further research in this area. Such studies could include investigation into the prophylactic use of antiemetics with initiation or modification of HAART therapy to monitor patient compliance. In addition, anticipatory nausea and vomiting should be further studied, as it could prove to be quite prevalent, as in cancer patients.

Tetanus antibody protection among HIV-infected US-born patients and immigrants.

INTRODUCTION: Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the Third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% nonprotective anti-tetanus antibody (ATA) level. Less work has been conducted among other vulnerable populations such as human immunodeficiency virus (HIV)-infected patients. The objective of this study was to measure ATA levels among the HIV immigrant population compared with US-born HIV-infected patients. METHODS: A convenience sample of 158 HIV-infected individuals was recruited to determine the levels of ATA. A nonprotective level of ATA was defined as below 0.15 IU/ml. RESULTS: Among the HIV-infected patients, 72% (114/158) were born in the USA. A total of 17% (27/158) lacked protective levels of ATA. A total of 6.1% (7/114) of those born in the USA lacked protection, compared to 45% (20/44) born outside the USA (p < 0.0001). CONCLUSION: The results illustrate that the country of birth is an important predictor of ATA protection, even among HIV-infected patients.