Mitigation policies, community mobility, and COVID-19 case counts in Australia, Japan, Hong Kong, and Singapore.

OBJECTIVES: The objective of the study was to characterize the timing and trends of select mitigation policies, changes in community mobility, and coronavirus disease 2019 (COVID-19) epidemiology in Australia, Japan, Hong Kong, and Singapore. STUDY DESIGN: Prospective abstraction of publicly available mitigation policies obtained from media reports and government websites. METHODS: Data analyzed include seven kinds of mitigation policies (mass gathering restrictions, international travel restrictions, passenger screening, traveler isolation/quarantine, school closures, business closures, and domestic movement restrictions) implemented between January 1 and April 26, 2020, changes in selected measures of community mobility assessed by Google Community Mobility Reports data, and COVID-19 epidemiology in Australia, Japan, Hong Kong, and Singapore. RESULTS: During the study period, community mobility decreased in Australia, Japan, and Singapore; there was little change in Hong Kong. The largest declines in mobility were seen in places that enforced mitigation policies. Across settings, transit-associated mobility declined the most and workplace-associated mobility the least. Singapore experienced an increase in cases despite the presence of stay-at-home orders, as migrant workers living in dormitories faced challenges to safely quarantine. CONCLUSIONS: Public policies may have different impacts on mobility and transmission of severe acute respiratory coronavirus-2 transmission. When enacting mitigation policies, decision makers should consider the possible impact of enforcement measures, the influence on transmission of factors other than movement restrictions, and the differential impact of mitigation policies on subpopulations.

PERPETRATION OF VIOLENCE BY FEMALE SEX WORKERS IN PAPUA NEW GUINEA: 'WE WILL CRUSH THEIR BONES'.

There is a small but important body of literature on female sex workers' (FSWs) violence towards others, but little of that focused on low- and middle-income countries. Drawn from a larger biobehavioural study of FSWs in three cities in Papua New Guinea, we analyse the interviews from 19 FSWs who reported having perpetrated physical violence towards four major groups: (1) ex-husbands; (2) clients; (3) other sex workers and (4) other people (mainly women). Our study demonstrates that FSWs' use of violence arises from a complex set of social, material and gendered circumstances and cannot be addressed in isolation from other aspects of their lives.

A diagnostic evaluation of a molecular assay used for testing and treating anorectal chlamydia and gonorrhoea infections at the point-of-care in Papua New Guinea.

OBJECTIVES: Papua New Guinea has among the highest prevalences of sexually transmissible infections (STIs) globally with no services able to accurately test for anorectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections. Here we prospectively evaluated the diagnostic performance of a molecular CT/NG assay used at the point-of-care (POC) with the aim of enhancing anorectal STI screening and same-day treatment. METHODS: Men who have sex with men, transgender women and female sex workers taking part in Papua New Guinea's first large-scale biobehavioural study were enrolled and asked to provide a self-collected anorectal swab for POC GeneXpert CT/NG testing. Same-day treatment was offered if positive. A convenience sample of 396 unique and randomly selected samples were transported to Australia for comparison using the Cobas 4800 CT/NG test (Roche Molecular Diagnostics, Pleasanton, CA, USA). RESULTS: A total of 326 samples provided valid results by Cobas whereas 70 samples provided invalid results suggesting inhibition. The positive, negative and overall percentage agreements of GeneXpert CT/NG for the detection of C. trachomatis were 96.7% (95% CI 92.3%-98.9%), 95.5% (95% CI 91.3%-98.0%) and 96.0% (95% CI 93.3%-97.8%), and for N. gonorrhoeae were 93.0% (95% CI 86.1%-97.1%), 100.0% (95% CI 98.3%-100.0%) and 97.8% (95% CI 95.6%-99.1%), respectively. CONCLUSIONS: The overall rate of agreement between the GeneXpert and Cobas CT/NG assays was high with 96.0% for C. trachomatis and 97.8% for N. gonorrhoeae. Results from this study data suggest that the GeneXpert CT/NG assay is suitable for testing self-collected anorectal specimens at the POC and that same-day treatment was feasible.

Functional gastrointestinal disorders are associated with the joint hypermobility syndrome in secondary care: a case-control study.

BACKGROUND: The overlap of unexplained gastrointestinal (GI) and somatic symptoms is well established in patients with functional gastrointestinal disorders (FGID). Joint hypermobility syndrome (JHS) is a non-inflammatory connective tissue disorder associated with GI and somatic symptoms. We aimed to determine whether there is an association between diagnosis of JHS and FGID and the impact of this association on comorbidities and quality of life (QOL). METHODS: Prospective case-control study in secondary care GI clinics over 2 years. JHS was assessed by the first author prior to consultation in 641 consecutive new patients. Diagnosis of FGID (cases, n = 336) or organic disorders (controls, n = 305) was established blind to JHS status. JHS prevalence was compared in cases (FGID patients) and controls (organic disorders patients). Extra-intestinal comorbidity and QOL were compared in FGID patients with and without JHS. KEY RESULTS: JHS prevalence was higher in FGID compared to organic GI disorders (39.0% vs 27.5%, ORadj: 1.51, CI: 1.07-2.12, p = 0.02), and particularly associated with functional gastroduodenal disorders (44.1%, ORadj: 2.08, CI: 1.25-3.46, p = 0.005), specifically postprandial distress syndrome (51%, ORadj: 1.99, CI: 1.06-3.76, p = 0.03). FGID patients with JHS had increased chronic pain (23.2% vs 11.9%, p = 0.01), fibromyalgia (10.5% vs 3.1%, p = 0.01), somatization scores (13 vs 10, p < 0.001), urinary autonomic scores (30.5 vs 20.7, p = 0.03), and worse pain-related QOL scores (45.0 vs 63.5, p = 0.004). CONCLUSIONS & INFERENCES: JHS is significantly associated with FGID, and this subgroup of patients have increased comorbidity and decreased QOL. Further research is required to understand the pathophysiological basis of this association.

Polymorphisms in ALOX12, but not ALOX15, are significantly associated with BMD in postmenopausal women.

The murine arachidonate 15-lipoxygenase gene (Alox15) has recently been identified as a negative regulator of peak bone mineral density (BMD). The human ALOX15 gene shares significant sequence homology with the murine Alox15 gene; however, the human arachidonate 12-lipoxygenase gene (ALOX12) is functionally more similar to the mouse gene. Multiple single-nucleotide polymorphisms (SNPs) in the human ALOX15 and ALOX12 genes have previously been reported to be significantly associated with BMD in humans. On the basis of these data, we carried out our own investigation of the human ALOX15 and ALOX12 genes and their relationship with hip and spine BMD parameters. The study population consisted of 779 postmenopausal women with a mean (+/- standard deviation) age of 62.5 +/- 5.9 years at BMD measurement and was recruited from a single large general practice in Chingford, northeast London. Three SNPs from ALOX15 and five from ALOX12 were analyzed. None of the SNPs that we analyzed in ALOX15 were significantly associated with any of the BMD parameters or fracture data. However, we found that three SNPs from ALOX12, all previously associated with spine BMD in women, were significantly associated with spine and various hip BMD parameters in our cohort (P = 0.029-0.049). In conclusion, we found no association between polymorphism in ALOX15 and BMD phenotypes but were able to replicate previous findings that genetic variation in ALOX12 seems to play a role in determining bone structure in Caucasian women.

Regression to the mean using the disease activity score in eligibility and response criteria for prescribing TNF-alpha inhibitors in adults with rheumatoid arthritis.

OBJECTIVES: When patients with rheumatoid arthritis (RA) are selected to start TNF-alpha inhibitors on the basis of high disease activity scores (DAS), some of the fall in DAS will be due to regression to the mean (RTM). We have assessed the extent to which such RTM explains DAS improvements on TNF-alpha inhibitors in routine clinical practice. METHODS: We retrospectively evaluated DAS28 scores that had been recorded as part of routine assessment for two RA cohorts. (i) Thirty-five patients receiving TNF-alpha inhibitors who had been assessed when starting TNF-alpha inhibitors, 9-21 months prior and 1.5-6 months post-treatment. (ii) One hundred and seventy-seven clinic patients assessed twice, a year apart in the years immediately before the introduction of TNF-alpha inhibitors. RESULTS: In patients receiving TNF-alpha inhibitors, mean DAS fell 1.8 (95% confidence interval [CI] 1.3, 2.3) from baseline but only 0.9 (95% CI 0.4, 1.4) from the previous routine assessment. Twenty-four (69%) patients showed a fall in DAS of >1.2 from baseline but only 17 (49%) from the previous assessment. Regression analysis of results from the pre-biological era estimated that as much as 0.6 of the 1.8 apparent DAS response to TNF-alpha inhibitors might be accounted for by RTM. CONCLUSIONS: Assessing change in DAS from commencement of biological therapy may overestimate response, due to the impact of RTM and fluctuation in disease. Adequacy of response might be better assessed by serial assessments and a wider range of patient-centred outcomes.

Touch-screen computer systems in the rheumatology clinic offer a reliable and user-friendly means of collecting quality-of-life and outcome data from patients with rheumatoid arthritis.

OBJECTIVES: To investigate the feasibility of collecting rheumatoid arthritis (RA) patient self-administered outcome data using touch-screen computers in a routine out-patient clinic. METHODS: Forty patients with RA completed the touch-screen and paper Rheumatoid Arthritis Quality of Life Questionnaire (RAQol) in the clinic and rated ease of use and preference. Forty-five others completed the Stanford Health Assessment Questionnaire (HAQ) and visual analogue scales (VASs) for pain, fatigue and global arthritis activity on touch screen and paper and a joint assessment on touch screen. They rated ease of use and willingness to complete the assessment again. Joints were independently assessed, and completion times and technical problems recorded. RESULTS: No technical problems were encountered. The touch-screen RAQol took no longer to complete, was preferred by 64% (33% had no preference) and was rated significantly higher for ease of use (two-tailed P=0.003, n=40) even by computer naïve patients (two-tailed P=0.031, n=24). Intraclass correlation coefficients between methods were high for RAQol (0.986) and tender joint counts (0.918), and as high for the pain, fatigue and global activity (0.855, 0.741, 0.881) as for test-retest of the paper versions (0.865, 0.746, 0.863). Ninety-eight per cent rated the touch screen very/quite easy for HAQ and VAS, and 90% for joint assessment. Ninety-six per cent stated a willingness to complete the touch-screen assessment in clinic again. CONCLUSIONS: Touch-screen questionnaires in the clinic can produce comparable results to paper, eliminate the need for data entry and afford immediate access to results. It is an acceptable, and in many cases a preferable, option to paper, regardless of age and previous experience of computers.

A simple extension to the Rheumatoid Arthritis Quality of Life Questionnaire (RAQol) to explore individual patient concerns and monitor group outcome in clinical practice.

OBJECTIVES: To find out if the RAQol, if extended by a qualifying question on the level of concern associated with each item, can function both as a group outcome measure and as a useful tool to identify the concerns of individual patients. METHODS: Thirty-seven rheumatoid arthritis (RA) patients completed the questionnaire before and after starting a biological therapy. One hundred and forty-five others receiving routine care completed it at baseline, weeks 12 and 13 with EuroQol VAS and questions on global arthritis impact and any other concerns. Reproducibility was assessed in all 59 participants whose condition remained stable between weeks 12 and 13. RESULTS: The RAQol score was highly reproducible (intraclass correlation coefficient 0.986, n=59), reflected global RA impact (P = 0.000, n=140), negatively correlated with EuroQol VAS (Spearman coefficient=-0.639, two-tailed significance=0.000, n=142), responsive to biological therapy (two-tailed P= 0.000) and to increased global RA impact over 12 weeks (two-tailed P=0.012, n=37), and had high internal consistency (Cronbach's alpha=0.94, n=143). The number of issues of great concern and their percentage contribution to the RAQol score were related to global arthritis impact (P=0.000 for both) and reduced by a biological therapy (two-tailed P=0.000 and 0.001 respectively). The mean kappa for consistency in identifying each item as a concern was 0.801 (range 0.633-0.921). CONCLUSIONS: Use of the 'extended' RAQol in clinical practice could provide a valid and sensitive score for monitoring group outcome and a comprehensive and consistent list of an individual's main issues of concern to assist assessment of needs in routine clinical practice.

Genetic associations between frozen shoulder and tennis elbow: a female twin study.

OBJECTIVES: To estimate the heritability of frozen shoulder (FS) and tennis elbow (TE) and to examine the two disorders for possible genetic or environmental associations. METHODS: Self-reporting questionnaire data on risk factors for, and a physician diagnosis of, FS or TE were obtained from 865 monozygotic (MZ) and 963 dizygotic (DZ) unselected female twin pairs aged between 20 and 76 yr registered with the St Thomas' UK Adult Twin Registry. The heritability of each disorder was estimated in a classic twin study. The association between FS and TE was then explored by log-linear modelling comparing MZ with DZ individuals and twin pairs for the presence of both disorders. RESULTS: The prevalence of FS and TE were 11.6 and 16.7%, respectively. A heritability of 42% was estimated for FS and 40% for TE after adjusting for age. There was no confounding by environmental risk factors. Log-linear modelling demonstrated FS and TE, independently, to be associated within members of a twin pair and confirmed a stronger association in MZ than DZ pairs. In addition the two disorders occurred together 2-3 times more frequently in individuals than would be expected by chance. However, there was no association between FS and TE across members of a twin pair, implying no evidence for a shared genetic component to the two disorders. CONCLUSIONS: Genetic factors are implicated in the aetiology of both frozen shoulder and tennis elbow but are independent of each other. The two disorders occur together 2-3 times more frequently than by chance in individuals. However, the association is most likely mediated by individual-specific environmental factors common to the two conditions and not by a common genetic susceptibility.

A simple questionnaire to detect hypermobility: an adjunct to the assessment of patients with diffuse musculoskeletal pain.

The aim of the study was to develop a simple and reproducible self-reporting questionnaire that identifies individuals with hypermobility. Two hundred and twelve consecutive hypermobile female new attendees to the hypermobility clinic at two London teaching hospitals and a random selection of 57 healthy volunteers completed a 10-part questionnaire. Questions were selected from clinical experience (RG), and assessed musculoskeletal symptoms and past and present physical agility. Of the 212 cases, 30 were hypermobile with no other underlying disorder and 182 fulfilled the 1998 Brighton criteria for benign joint hypermobility syndrome (BJHS). Odds ratios for the presence of hypermobility were calculated for each question. Six questions were found to be significant and the model of 'best fit' for sensitivity and specificity contained five of these. To demonstrate the reproducibility of the five-part questionnaire a second cohort of 170 hypermobile cases with BJHS and 50 controls was surveyed. Analysis demonstrated that a positive answer to any two questions in the five-part questionnaire gave the highest combined sensitivity and specificity for detecting hypermobility. The sensitivity and specificity was 84% and 89% respectively in the first cohort and reproduced with values of 84% and 80% in the second cohort. Overall the questionnaire correctly identified 84% of all cases and controls. This simple and reproducible questionnaire for detecting hypermobility could be of particular use as an adjunct in the clinical assessment of chronic, diffuse pain syndromes where hypermobility is often missed yet is potentially treatable.

Autoimmune thrombocytopenia in primary antiphospholipid syndrome and systemic lupus erythematosus: the response to splenectomy.

OBJECTIVE: To study the outcome of splenectomy in the management of thrombocytopenia. METHODS: Cases of systemic lupus erythematosus (SLE) or primary antiphospholipid syndrome (PAPS) complicated by severe thrombocytopenia were identified from a database of patients attending outpatients over the period 1978 to 1996. Clinical presentation, laboratory investigations, and response to medical treatment and/or splenectomy were documented. RESULTS: A total of 17 patients had severe thrombocytopenia; splenectomy was performed on 13: 9 with SLE, 3 with PAPS, and 1 with lupus-like disease (LLD). After splenectomy, six of nine patients with SLE and all three patients with PAPS gained complete remission of thrombocytopenia. There were no complications from splenectomy. The remaining four patients, three with SLE and one with PAPS, remained in a stable partial or full remission with oral medication and did not require splenectomy. CONCLUSION: This study re-emphasizes the place for splenectomy in SLE patients and supports its role in the management of thrombocytopenia in PAPS.