Inverse Association Between Gluteofemoral Obesity and Risk of Barrett's Esophagus in a Pooled Analysis

BACKGROUND & AIMS: Gluteofemoral obesity (determined by measurement of subcutaneous fat in hip and thigh regions) could reduce risks of cardiovascular and diabetic disorders associated with abdominal obesity. We evaluated whether gluteofemoral obesity also reduces risk of Barrett's esophagus (BE), a premalignant lesion associated with abdominal obesity.

METHODS: We collected data from non-Hispanic white participants in 8 studies in the Barrett's and Esophageal Adenocarcinoma Consortium. We compared measures of hip circumference (as a proxy for gluteofemoral obesity) from cases of BE (n=1559) separately with 2 control groups: 2557 population-based controls and 2064 individuals with gastroesophageal reflux disease (GERD controls). Study-specific odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using individual participant data and multivariable logistic regression and combined using random effects meta-analysis.

RESULTS: We found an inverse relationship between hip circumference and BE (OR per 5 cm increase, 0.88; 95% CI, 0.81-0.96), compared with population-based controls in a multivariable model that included waist circumference. This association was not observed in models that did not include waist circumference. Similar results were observed in analyses stratified by frequency of GERD symptoms. The inverse association with hip circumference was only statistically significant among men (vs population-based controls: OR, 0.85; 95% CI, 0.76-0.96 for men; OR, 0.93; 95% CI, 0.74-1.16 for women). For men, within each category of waist circumference, a larger hip circumference was associated with decreased risk of BE. Increasing waist circumference was associated with increased risk of BE in the mutually adjusted population-based and GERD control models.

CONCLUSIONS: Although abdominal obesity is associated with increased risk of BE, there is an inverse association between gluteofemoral obesity and BE, particularly among men.

Staff training in autism: The one-eyed wo/man….

Having well-trained staff is key to ensuring good quality autism services, especially since people affected with autism generally tend to have higher support needs than other populations in terms of daily living as well as their mental and physical health. Poorly-trained staff can have detrimental effects on service provision and staff morale and can lead to staff burn-out as well as increased service user anxiety and stress. This paper reports on a survey with health, social care, and education staff who work within the statutory autism services sector in the UK that explored their knowledge and training with regards to autism. Interview data obtained from staff and service users offer qualitative illustrations of survey findings. Overall, the findings expose an acute lack of autism specific training that has detrimental impacts. At best this training was based on brief and very basic awareness raising rather than on in-depth understanding of issues related to autism or skills for evidence-based practice. Service users were concerned with the effects that lack of staff training had on the services they received. The paper concludes with a discussion of policy routes to achieving quality staff training based on international best practice. The focus is on improving the quality of life and mental health for services users and staff as well as making potentially significant cost-savings for governments.

A Strategy for Maternity Care in Northern Ireland 2012-2018

DHSSPS has carried out a review of policy on maternity service provision in Northern Ireland. The review focused on the best available evidence for the care and treatment of mothers-to-be; quality, safety and service sustainability; wider workforce issues; and professional roles and responsibilities. As a result, a draft strategy was developed, which was the subject of a public consultation from 28 September 2011 to 23 January 2012. Following an analysis of the responses to the consultation, the final strategy, A Strategy for Maternity Care in Northern Ireland 2012-2018, was published on 2 July 2012. The Strategy is outcomes focused. The six outcomes are:- give every baby and family the best start in life; effective communication and high-quality maternity care; healthier women at the start of pregnancy (preconception care); effective, locally accessible, antenatal care and a positive experience for prospective parents; safe labour and birth (intrapartum) care with improved experiences for mothers and babies; and appropriate advice, and support for parents and baby after birth The strategy aims to provide women and their partners, HSC staff, commissioners and policy makers with a clear pathway for maternity care in Northern Ireland from pre conceptual care through to postnatal care. Within the document, twenty two objectives have been identified which link to the six outcomes identified above. The HSC Board and Public Health Agency will co-lead on implementation. An action plan will be developed to take account of the outcomes and objectives listed in the document. The Department will receive an annual report on progress towards implementation.

Understanding Suicide and Help-seeking in Urban and Rural Areas in Northern Ireland

Funded by HSC R&D Division, Public Health Agency Why did we start? Most people who complete suicide are in contact with their family doctors or other services in the months prior to death. A better understanding of the nature of these contacts and the various pathways experienced by suicidal people should reveal the gaps and barriers to effective service provision. We also need better information about the difficulties experienced by family carers, both prior to the death and afterwards. Of particular interest to policy makers in Northern Ireland was a concern that people from rural areas may be at increasing risk of suicide. We were commissioned by the Health and Social Care R&D Division of the Northern Ireland Public Health Agency to address the gaps in our understanding of suicide in NI. What did we do? We undertook a mixed methods study in which we examined the records of 403 people who took their own lives over a two-year period between March 2007 and February 2009. We linked these data to GP records and then examined help-seeking pathways of people and their contacts with services. We did in-depth face-to-face interviews with 72 bereaved relatives and friends who discussed their understanding of the events and circumstances surrounding the death, the experience of seeking help for the family member, the personal impact of the suicide, and use of support services. Additionally, we interviewed 19 General Practitioners about their experiences of managing people who died by suicide.            

Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial

BACKGROUND: Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion. METHODS: A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114). RESULTS: There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use. CONCLUSIONS: Simplified follow-up after early medical abortion will not change women's opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women's postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods. TRIAL REGISTRATION: Clinicaltrials.gov NCT01827995.

Exploring the Experiences of Community-based Children's Nurses Providing Palliative Care

Aim: To explore the experiences of community children’s nurses (CCNs) and children’s palliative care nurses (CPCNs) who provide end-stage palliative care to children with cancer in the family home. Method: A qualitative approach was adopted. One-to-one interviews and facilitated case discussions were undertaken with 30 community nurses who had provided palliative care to a child or young person with cancer. A grounded theory approachwas used for data analysis. Findings: Because of the relative rarity of childhood cancer many CCNs and CPCNs engage infrequently in the palliative care of children or young people. This makes it difficult for them to develop and maintain knowledge and skills. There is a variation in the out-of-hours service provision available to families. Conclusion: Further funding is needed to develop teams of trained, experienced CCNs and CPCNs who can provide palliative care for children and young people 24 hours a day and 365 days a year. Keywords Community nursing, oncology, out-of-hours services, palliative care

Providing Palliative Care for the Child with Cancer: The Experience of GPs

Background Childhood cancers are rare and general practitioners (GPs) have limited experience in caring for these children and even less in providing their palliative care. Most families prefer that their child is cared for at home in the palliative phase of their illness, with professional support from those known to them (Chambers and Oakhill 1995, Vickers and Carlisle 2000, Craft and Killen 2007). A community based qualitative study examined the experiences of ten GPs following their involvement in the care of a child with cancer receiving palliative care within the family home. Methods Data collection was through 1:1 in-depth interviews and facilitated case discussion supported by field notes and grounded theory analysis (chronological comparative data analysis identifying generated themes). Social worlds theory was used as a framework to aid examination, and facilitate critical understanding, of the experiences of the GPs. Findings This presentation focuses on five of the findings relating to the experiences of the GP; the impact of minimal contact; lack of knowledge and experience, uncertain role, out of hours service provision and the emotional toll. Findings highlighted that GPs often have to re-establish their role at the child’s transition to palliative care. Factors hindering the GP in this process include a deficit of specialist knowledge and experience of paediatric palliative care and lack of role clarity. Conclusions/points of interest Strategies for enhancing the role of the Macmillan team in supporting GPs have been identified by this study, such as enhanced collaborative working. Findings have also provided further confirmation of the substantial variation in out of hours medical palliative care provision; with evidence that some GPs work beyond their remit in providing informal out of hours care. This presentation details the findings of one aspect (the experiences of GPs) of a wider study that explored the experiences of 54 community based health professionals (GPs, community nurses and allied health professionals) who had been involved in caring for a dying with cancer receiving palliative care at home (Neilson 2009).

Estudo numérico do impacto das emissões veiculares e fixas da cidade de Manaus nas concentrações de poluentes atmosféricos da região amazônica

The main aim of this study was to evaluate the impact of the urban pollution plume from the city of Manaus by emissions from mobile and stationary sources in the atmospheric pollutants concentrations of the Amazon region, by using The Weather Research and Forecasting with Chemistry (WRF-Chem) model. The air pollutants analyzed were CO, NOx, SO2, O3, PM2.5, PM10 and VOCs. The model simulations have been configured with a grid spacing of 3 km, with 190 x and 136 y grid points in horizontal spacing, centered in the city of Manaus during the period of 17 and 18 of March 2014. The anthropogenic emissions inventories have gathered from mobile sources that were estimated the emissions of light and heavy-duty vehicles classes. In addition, the stationary sources have considered the thermal power plants by the type of energy sources used in the region as well as the emissions from the refinery located in Manaus. Various scenarios have been defined with numerical experiments that considered only emissions by biogenic, mobile and stationary sources, and replacement fuel from thermal power plant, along with a future scenario consisting with twice as much anthropogenic emissions. A qualitative assessment of simulation with base scenario has also been carried out, which represents the conditions of the region in its current state, where several statistical methods were used in order to compare the results of air pollutants and meteorological fields with observed ground-based data located in various points in the study grid. The qualitative analysis showed that the model represents satisfactorily the variables analyzed from the point of view of the adopted parameters. Regarding the simulations, defined from the base scenarios, the numerical experiments indicate relevant results such as: it was found that the stationary sources scenario, where the thermal power plants are predominant, resulted in the highest concentrations, for all air pollutants evaluated, except for carbon monoxide when compared to the vehicle emissions scenario; The replacement of the energy matrix of current thermal power plants for natural gas have showed significant reductions in pollutants analyzed, for instance, 63% reductions of NOx in the contribution of average concentration in the study grid; A significant increase in the concentrations of chemical species was observed in a futuristic scenario, reaching up to a 81% increase in peak concentrations of SO2 in the study area. The spatial distributions of the scenarios have showed that the air pollution plume from Manaus is predominantly west and southwest, where it can reach hundreds of kilometers to areas dominated by original soil covering.

FluxEngine: A flexible processing system for calculating atmosphere-ocean carbon dioxide gas fluxes and climatologies

The air-sea flux of greenhouse gases (e.g. carbon dioxide, CO2) is a critical part of the climate system and a major factor in the biogeochemical development of the oceans. More accurate and higher resolution calculations of these gas fluxes are required if we are to fully understand and predict our future climate. Satellite Earth observation is able to provide large spatial scale datasets that can be used to study gas fluxes. However, the large storage requirements needed to host such data can restrict its use by the scientific community. Fortunately, the development of cloud-computing can provide a solution. Here we describe an open source air-sea CO2 flux processing toolbox called the ‘FluxEngine’, designed for use on a cloud-computing infrastructure. The toolbox allows users to easily generate global and regional air-sea CO2 flux data from model, in situ and Earth observation data, and its air-sea gas flux calculation is user configurable. Its current installation on the Nephalae cloud allows users to easily exploit more than 8 terabytes of climate-quality Earth observation data for the derivation of gas fluxes. The resultant NetCDF data output files contain >20 data layers containing the various stages of the flux calculation along with process indicator layers to aid interpretation of the data. This paper describes the toolbox design, the verification of the air-sea CO2 flux calculations, demonstrates the use of the tools for studying global and shelf-sea air-sea fluxes and describes future developments.

Water quality trading: credit stacking and ancillary benefits

Ecosystems can provide many services. Wetlands, for example, can help mitigate water pollution from point sources as well as non-point sources, serve as habitat for wildlife, sequester carbon and serve as a place for recreation. Studies have found that these services can have substantial value to society. The sale of ecosystem credits has been found to be a possible way to finance construction investments in wetlands and easements to farmers to take their land out of production. At the same time, selling one ecosystem service credit may not always be enough to justify the investment. Traditionally market participants have only been allowed to sell a single credit from one piece of land, but recently there have been discussions about the possibility of selling more than one credit from a piece of land because it potentially could lead to more efficient ecosystem service provision. Selling multiple credits is sometimes referred to as credit stacking. This paper is an empirical study of the potential for credit stacking applied to the services provided by wetlands in the Upper Mississippi River Basin, specifically nitrogen, phosphorus and wildlife credits. In the setting of our study where costs are discrete rather than continuous we found that wetlands are a cost-effective way to reduce the nitrogen loads from wastewater treatment plants and that stacking nitrogen, phosphorus and wildlife credits may improve social welfare while leading to a higher level of ecosystem services. However, for credit stacking to be welfare improving we found that there needs to be a substantial demand for the credit that covers the majority of the investment in wetlands, while the credit aggregator has a choice between what ecosystem projects to undertake. If the credit that covers the majority of investment is sold first and is the sole basis of the investment decision and the objective is to improve welfare, a sequential implementation of ecosystem credits is not recommended; it would not lead to an increase in the total amount of ecosystem services provided though it would increase profit for the credit producer.

Experiences of care and adjustment to change in caregivers of children with autoimmune encephalitis: an interpretative phenomenological analysis

Background: Autoimmune encephalitis (AE) occurs in response to an antibody-mediated central nervous system disease and can lead to significant neurodisability. Prior research on family adjustment has described a reciprocal relationship between caregiver functioning, distress and clinical outcome in parents and children with encephalitis. There has been no previous research exploring the experiences of caregivers with a child with AE. Aims: To explore the perspectives of parents and/or caregivers with a child diagnosed with AE regarding (i) their own adjustment from hospital admission to post-discharge, and (ii) their experiences of care and service provision. Methods: A purposive sampling approach was used. Five parents of children with AE participated in a semi-structured interview exploring their experiences of caring for their child and service provision during acute care and post-discharge. Interpretative Phenomenological Analysis (IPA) was used to analyse the transcripts. Main findings and conclusions: Four shared super-ordinate themes with related subthemes emerged: (a) uncertainty, (b) managing our recovery, (c) changes in my child, (d) experiences of service provision. Participants reported emotional distress, often underpinned by recurrent experiences of uncertainty, and ‘loss’ of the previous child, and mediated by coping strategies and social support. While an overall positive experience of inpatient services was reported, parents often perceived post-discharge services as lacking in co-ordination, communication and formal follow-up, resulting in unmet support needs. Implications and recommendations for services, practitioners and future research are discussed.

A house, not a home? Examining the use of the private rented sector to resolve homelessness in Scotland

Changes to homelessness legislation in post-devolution Scotland have resulted in an expansion of rights for homeless households seeking formal assistance from local authorities. These changes have led to Scotland’s homelessness arrangements being considered among the most progressive in Europe. In recent years, however, the Scottish Government has increasingly promoted homelessness prevention and Housing Options approaches as a means by which homelessness might be avoided or resolved without recourse to statutory rights. As part of that, they have promoted greater use of the private rented sector (PRS) as a key housing option, with the potential to meet the needs of homeless households. The arguments made to support use of the PRS have much in common with arguments for privatisation in other areas of social policy, notably greater choice for the individual promoting better welfare outcomes, and competition among providers encouraging improvements in quality of service provision. Critics have argued that such benefits may not be realised and that, on the contrary, privatisation may lead to exclusion or act to worsen households’ outcomes. This thesis considers the extent to which the PRS has been utilised in Scotland to accommodate homeless households, and the consequences of this for their welfare. The thesis uses a combination of quantitative and qualitative methods. To examine trends in the use of the PRS, it presents quantitative analysis of the data on the operation of the statutory system and Housing Options arrangements, and of data from a survey of local authority homelessness strategy officers. To examine the consequences of this for homeless households, the thesis uses qualitative research involving face-to-face interviews with 35 homeless households across three local authority areas. This research considers the extent to which households’ experiences of homelessness, housing need and the PRS reflect the arguments presented in the literature, and how settled accommodation has impacted on households’ ability to participate fully in society. The research found an increasing but still limited role for the PRS in resolving statutory homelessness in Scotland, with indications that the PRS is being increasingly used as part of the Housing Options approach and as a means of resolving homelessness outside the statutory system. The PRS is being utilised to varying degrees across different local authority areas, and a variety of methods are being used to do so. While local authorities saw clear advantages to making greater use of the sector, a number of significant barriers including affordability, available stock and landlord preferences - made this difficult in practice. Research with previously homeless households in the PRS similarly found broadly positive experiences and views of the sector, particularly with regard to enabling households to access good quality accommodation in desirable areas of their choosing, with many households highlighting improvements relating to social inclusion and participation. Nevertheless, concerns around the security of tenure offered by the sector, repairs, service standards and unequal power relations between landlord and tenant persisted. As such, homeless households frequently expressed their decision to enter the sector in terms of a trade-off between choice and security.

Policy Implications of Ageing Sexualities

This article aims to open up debate on the policy implications of ageing sexualities. The article begins by discussing the heteronormative perspective that frames current discourse on older people’s needs and citizenship. It then presents data from an empirical study to highlight the concerns that older lesbians and gay men have about housing, health and social service provision, work and job security, and relationship recognition. The article illustrates how the heterosexual assumption that informs policy making can limit the development of effective strategies for supporting older lesbians and gay men; and raises broader questions about policy making, social inclusion and citizenship.

An epidemiological surveillance network of lumbar disc surgery to help prevention of and compensation for low back pain

International audience

Modelação do risco de perda dentária por doença periodontal

O prognóstico da perda dentária é um dos principais problemas na prática clínica de medicina dentária. Um dos principais fatores prognósticos é a quantidade de suporte ósseo do dente, definido pela área da superfície radicular dentária intraóssea. A estimação desta grandeza tem sido realizada por diferentes metodologias de investigação com resultados heterogéneos. Neste trabalho utilizamos o método da planimetria com microtomografia para calcular a área da superfície radicular (ASR) de uma amostra de cinco dentes segundos pré-molares inferiores obtida da população portuguesa, com o objetivo final de criar um modelo estatístico para estimar a área de superfície radicular intraóssea a partir de indicadores clínicos da perda óssea. Por fim propomos um método para aplicar os resultados na prática. Os dados referentes à área da superfície radicular, comprimento total do dente (CT) e dimensão mésio-distal máxima da coroa (MDeq) serviram para estabelecer as relações estatísticas entre variáveis e definir uma distribuição normal multivariada. Por fim foi criada uma amostra de 37 observações simuladas a partir da distribuição normal multivariada definida e estatisticamente idênticas aos dados da amostra de cinco dentes. Foram ajustados cinco modelos lineares generalizados aos dados simulados. O modelo estatístico foi selecionado segundo os critérios de ajustamento, preditibilidade, potência estatística, acurácia dos parâmetros e da perda de informação, e validado pela análise gráfica de resíduos. Apoiados nos resultados propomos um método em três fases para estimação área de superfície radicular perdida/remanescente. Na primeira fase usamos o modelo estatístico para estimar a área de superfície radicular, na segunda estimamos a proporção (decis) de raiz intraóssea usando uma régua de Schei adaptada e na terceira multiplicamos o valor obtido na primeira fase por um coeficiente que representa a proporção de raiz perdida (ASRp) ou da raiz remanescente (ASRr) para o decil estimado na segunda fase. O ponto forte deste estudo foi a aplicação de metodologia estatística validada para operacionalizar dados clínicos na estimação de suporte ósseo perdido. Como pontos fracos consideramos a aplicação destes resultados apenas aos segundos pré-molares mandibulares e a falta de validação clínica.