Systematic review and meta-analyses investigating whether risk stratification explains lower rates of coronary angiography among women with Non-ST-Segment Elevation Acute Coronary Syndrome

BACKGROUND: Guidelines recommend that all non-ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised that the widely reported gender disparity in the use of angiography might be the result of women more frequently being stratified into the lower-risk category.

OBJECTIVES: The aim of the study was to review studies reporting risk stratification of NSTEACS patients by gender, compare risk profiles, and assess impact on use of coronary angiography.

METHODS: PubMed, Scopus, and EMBASE databases were searched on June 17, 2014, using MeSH terms/subheadings and/or key words with no further limits. The search revealed 1230 articles, of which 25 met our objective.

RESULTS: Among the 28 risk-stratified populations described in the 25 articles, women were more likely to be stratified as high-risk in 13 studies; men were more likely to be stratified as high-risk in 3 studies. After meta-analyses, women had a 23% higher odds of being stratified as high-risk than did men (P = .001). Lower-risk patients were more likely to receive an angiogram in 15 study populations.

CONCLUSIONS: Contrary to our hypothesis, this review showed that women with NSTEACS are more likely than men to be considered high-risk when stratified using a range of risk assessment methods. Lower rates of angiography in women form part of a broader treatment-risk paradox, which may involve gender bias in the selection of patients for invasive therapy.

The mediating role of dietary factors and leisure time physical activity on socioeconomic inequalities in body mass index among Australian adults

BACKGROUND: The relationship between socioeconomic position and obesity has been clearly established, however, the extent to which specific behavioural factors mediate this relationship is less clear. This study aimed to ascertain the contribution of specific dietary elements and leisure-time physical activity (LTPA) to variations in obesity with education in the baseline (1990-1994) Melbourne Collaborative Cohort Study (MCCS).

METHODS: 18, 489 women and 12, 141 men were included in this cross-sectional analysis. A series of linear regression models were used in accordance with the products of coefficients method to examine the mediating role of alcohol, soft drink (regular and diet), snacks (healthy and sweet), savoury items (healthy and unhealthy), meeting fruit and vegetable guidelines and LTPA on the relationship between education and body mass index (BMI).

RESULTS: Compared to those with lowest educational attainment, those with the highest educational attainment had a 1 kg/m2 lower BMI. Among men and women, 27% and 48%, respectively, of this disparity was attributable to differences in LTPA and diet. Unhealthy savoury item consumption and LTPA contributed most to the mediated effects for men and women. Alcohol and diet soft drink were additionally important mediators for women.

CONCLUSIONS: Diet and LTPA are potentially modifiable behavioural risk factors for the development of obesity that contribute substantially to inequalities in BMI. Our findings highlight the importance of specific behaviours which may be useful to the implementation of effective, targeted public policy to reduce socioeconomic inequalities in obesity.

Hydrogen bonding interactions in poly(ε-caprolactone-dimethyl siloxane-ε-caprolactone)/poly(hydroxyether of bisphenol A) triblock copolymer/homopolymer blends and the effect on crystallization, microphase separation and self-assembly

This study investigated the self-assembled microphase separated morphologies that are obtained in bulk, by the complexation of a semicrystalline poly(ε-caprolactone-dimethyl siloxane-ε-caprolactone) (PCL-PDMS-PCL) triblock copolymer and a homopolymer, poly(hydroxyether of bisphenol A) (PH) in tetrahydrofuran (THF). In these blends, microphase separation takes place due to the disparity in intermolecular interactions; specifically, the homopolymer interacts with PCL blocks through hydrogen bonding interactions. The crystallization, microphase separation and crystalline structures of a triblock copolymer/homopolymer blends were investigated. The phase behavior of the complexes was investigated using small-angle X-ray scattering and transmission electron microscopy. At low PH concentrations, PCL interacts relatively weakly with PH, whereas in complexes containing more than 50 wt% PH, the PCL block interacts significantly with PH, leading to the formation of composition-dependent nanostructures. SAXS and TEM results indicate that the lamellar morphology of neat PCL-PDMS-PCL triblock copolymer changes into disordered structures at 40-60 wt% PH. Spherical microdomains were obtained in the order of 40-50 nm in complexes with 80 wt% PH. At this concentration, the complexes show a completely homogenous phase of PH/PCL, with phase-separated spherical PDMS domains. The formation of these nanostructures and changes in morphology depends on the strength of hydrogen bonding between PH/PCL blocks and also the phase separated PDMS blocks.

Novel approach to trigger nanostructures in thermosets using competitive Hydrogen-Bonding-Induced Phase Separation (CHIPS)

A new route to prepare nanostructured thermosets by the utilization of intermolecular hydrogen-bonding interactions is demonstrated here. In this study, competitive hydrogen-bonding-induced microphase separation (CHIPS) in epoxy resin (ER) containing an amphiphilic block copolymer poly(ε-caprolactone)-block-poly(2-vinylpyridine) (PCL-b-P2VP) is investigated for the first time. The phase separation takes place due to the disparity in the hydrogen-bonding interactions in ER/P2VP and ER/PCL pairs leading to the formation of ordered nanostructures in the ER/block copolymer blends. SAXS and TEM results indicate that the hexagonally packed cylindrical morphology of neat PCL-b-P2VP block copolymer remains but becomes a core-shell structure at 10 wt % addition of ER, and changes to regular lamellae structures at 20-50 wt % then to disordered lamellae with 60 wt % ER. Wormlike structures are obtained in the blends with 70 wt % ER, followed by a completely homogeneous phase of ER/P2VP and ER/PCL. The formation of nanostructures and changes in morphologies depend on the relative strength of hydrogen-bonding interactions between each component block copolymer and the homopolymer. This versatile method to develop nanostructured thermosets, involving competitive hydrogen-bonding interactions, could be used for the fabrication of hierarchical and functional materials.

Gender difference in the use of coronary interventions for patients with acute coronary syndrome: experience from a major metropolitan hospital in Melbourne, Australia

BACKGROUND: Literature suggests an ongoing gender disparity in the use of coronary angiography and subsequent interventions among patients with acute coronary syndrome (ACS). OBJECTIVES: The study aimed to examine gender differences in the use of coronary interventions amongst patients with acute coronary syndrome (ACS) admitted to a major metropolitan hospital in Melbourne during the period 2009-2012. METHODS: We undertook a retrospective analysis of a hospital database of 2096 ACS patients. ACS included unstable angina (UA), ST-segment-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). RESULTS: The mean age of the patients was 64.3 years and 624 (30%) were women. Half of them were diagnosed as NSTEMI, 23% as STEMI and 25% as UA. Compared to men, women were older at admission, less likely to be diagnosed with STEMI and less likely to smoke. No gender difference was observed for severe co-morbidities or use of coronary angiography. Women diagnosed with STEMI were 39% less likely to receive an angioplasty stent (adjusted odds ratio 0.61, 95% confidence intervals 0.39-0.96) and 66% less likely to receive grafts (adjusted OR 0.34, 95% CIs 0.13-0.93). Women diagnosed with NSTEMI were 44% less likely to receive grafts (adjusted OR 0.56, 95% CIs 0.37-0.83). Younger women aged 35-49 years were less likely to receive an angioplasty stent, and older women >50 years were less likely to receive grafts. CONCLUSIONS: Adherence to guideline based treatment will help to ensure knowledge translation from guideline to practice. Further research investigating symptom presentation, use of non-invasive tests and medical management of ACS by gender may further explain gender difference for coronary interventions.

The comparative cost of food and beverages at remote Indigenous communities, Northern Territory, Australia

OBJECTIVE: To determine the average price difference between foods and beverages in remote Indigenous community stores and capital city supermarkets and explore differences across products.

METHODS: A cross-sectional survey compared prices derived from point-of-sale data in 20 remote Northern Territory stores with supermarkets in capital cities of the Northern Territory and South Australia for groceries commonly purchased in remote stores. Average price differences for products, supply categories and food groups were examined.

RESULTS: The 443 products examined represented 63% of food and beverage expenditure in remote stores. Remote products were, on average, 60% and 68% more expensive than advertised prices for Darwin and Adelaide supermarkets, respectively. The average price difference for fresh products was half that of packaged groceries for Darwin supermarkets and more than 50% for food groups that contributed most to purchasing.

CONCLUSIONS: Strategies employed by manufacturers and supermarkets, such as promotional pricing, and supermarkets' generic products lead to lower prices. These opportunities are not equally available to remote customers and are a major driver of price disparity.

IMPLICATIONS: Food affordability for already disadvantaged residents of remote communities could be improved by policies targeted at manufacturers, wholesalers and/or major supermarket chains.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting

BACKGROUND: Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.

METHODS: Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.

RESULTS: Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.

CONCLUSIONS: Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Can Peto's paradox be used as the null hypothesis to identify the role of evolution in natural resistance to cancer? A critical review

BACKGROUND: Carcinogenesis affects not only humans but almost all metazoan species. Understanding the rules driving the occurrence of cancers in the wild is currently expected to provide crucial insights into identifying how some species may have evolved efficient cancer resistance mechanisms. Recently the absence of correlation across species between cancer prevalence and body size (coined as Peto's paradox) has attracted a lot of attention. Indeed, the disparity between this null hypothesis, where every cell is assumed to have an identical probability to undergo malignant transformation, and empirical observations is particularly important to understand, due to the fact that it could facilitate the identification of animal species that are more resistant to carcinogenesis than expected. Moreover it would open up ways to identify the selective pressures that may be involved in cancer resistance. However, Peto's paradox relies on several questionable assumptions, complicating the interpretation of the divergence between expected and observed cancer incidences. DISCUSSIONS: Here we review and challenge the different hypotheses on which this paradox relies on with the aim of identifying how this null hypothesis could be better estimated in order to provide a standard protocol to study the deviation between theoretical/theoretically predicted and observed cancer incidence. We show that due to the disproportion and restricted nature of available data on animal cancers, applying Peto's hypotheses at species level could result in erroneous conclusions, and actually assume the existence of a paradox. Instead of using species level comparisons, we propose an organ level approach to be a more accurate test of Peto's assumptions. SUMMARY: The accuracy of Peto's paradox assumptions are rarely valid and/or quantifiable, suggesting the need to reconsider the use of Peto's paradox as a null hypothesis in identifying the influence of natural selection on cancer resistance mechanisms.

Addressing the physical health of people with serious mental illness : a potential solution for an enduring problem

People with serious mental illness face significant inequalities in physical health care. As a result, the risk of cardiometabolic disorders and premature mortality is far greater than that observed in the general population. Contributiung to this disparity, is the lack of routine physical health screening by mental health clinicians. One possible solution is the implimentation of a physical health nurse consultant, whose role is to monitor and coordinate the physical health care of people with serious mental illness. Current evidence supports the implimentation of such a role, and a failure to address the widening gaps in physical health care will only serve to increase the disparities faced by people with serious mental illness.

Variations développementales chez les poissons hybrides clonaux Chrosomus eos-neogaeus : transgressions phénotypiques en 3D

Le succès écologique des organismes dépend principalement de leur phénotype. Une composante important du phénotype est la morphologie fonctionnelle car elle influence la performance d’un organisme donné dans un milieu donné et donc reflète son écologie. Des disparités dans la morphologie fonctionnelle ou dans le développement entre espèces peuvent donc mener à des différences écologiques. Ce projet évalue le rôle des mécanismes de variation morphologique dans la production de différences écologiques entre espèces au sein des poissons hybrides du complexe Chrosomus eos-neogaeus. En utilisant la microtomodensitométrie à rayons X et la morphométrie géométrique 3D, la forme des éléments des mâchoires est décrite pour comparer la variation morphologique et les différences développementales entre les membres du complexe C. eos neogaeus. Les hybrides présentent autant de variation phénotypique que les espèces parentales et présentent des phénotypes nouveaux, dit transgressifs. Les hybrides présentent aussi des différences marquées avec les espèces parentales dans leur allométrie et dans leur intégration phénotypique. Finalement, ceux-ci semblent être plastiques et en mesure de modifier leur phénotype pour occuper plusieurs environnements. L’entièreté de ces résultats suggère que des changements dans le développement des hybrides entraînent une différenciation phénotypique et écologique avec les espèces parentales.

WATER RESOURCES, HEALTH, AND THE SUSTAINABILITY OF INTERVENTIONS TO ACHIEVE WATER AND SANITATION TARGETS OF THE MILLENNIUM DEVELOPMENT GOALS IN A CHANGING WORLD

This dissertation addresses sustainability of rapid provision of safe water and sanitation required to meet the Millennium Development Goals. Review of health-related literature and global statistics demonstrates engineers' role in achieving the MDGs. This review is followed by analyses relating to social, environmental, and health aspects of meeting MDG targets. Analysis of national indicators showed that inadequate investment, poor or nonexistent policies and governance are challenges to global sanitation coverage in addition to lack of financial resources and gender disparity. Although water availability was not found to be a challenge globally, geospatial analysis demonstrated that water availability is a potentially significant barrier for up to 46 million people living in urban areas and relying on already degraded water resources for environmental income. A daily water balance model incorporating the National Resources Conservation Services curve number method in Bolivian watersheds showed that local water stress is linked to climate change because of reduced recharge. Agricultural expansion in the region slightly exacerbates recharge reductions. Although runoff changes will range from -17% to 14%, recharge rates will decrease under all climate scenarios evaluated (-14% to -27%). Increasing sewer coverage may place stress on the readily accessible natural springs, but increased demand can be sustained if other sources of water supply are developed. This analysis provides a method for hydrological analysis in data scarce regions. Data required for the model were either obtained from publicly available data products or by conducting field work using low-cost methods feasible for local participants. Lastly, a methodology was developed to evaluate public health impacts of increased household water access resulting from domestic rainwater harvesting, incorporating knowledge of water requirements of sanitation and hygiene technologies. In 37 West African cities, domestic rainwater harvesting has the potential to reduce diarrheal disease burden by 9%, if implemented alone with 400 L storage. If implemented in conjunction with point of use treatment, this reduction could increase to 16%. The methodology will contribute to cost-effectiveness evaluations of interventions as well as evaluations of potential disease burden resulting from reduced water supply, such as reductions observed in the Bolivian communities.

Injustice Everywhere: Hemingway's Struggle with Race, Gender, and Aesthetics

The purpose of this study was to critically evaluate the aesthetic decisions and theoretical complexity of three of Ernest Hemingway’s most experimental texts: IN OUR TIME, TO HAVE AND HAVE NOT, and THE GARDEN OF EDEN, and to show that the usually maligned Hemingway was an author invested in the avant-garde and in analyzing and dissecting rigid societal rules, not championing them. Through critical analysis this study examined how Hemingway makes specific aesthetic decisions in order to more clearly examine the disparity between whites and both women and racial minorities in America. The problems that Hemingway makes clear through his art are meant to have a profound effect upon the reader and encourage re-evaluation of societal rules, their purpose, and their fairness to those who are not white, male, and typically in a position of power. The findings demonstrate that Hemingway’s entire oeuvre is open to re-interpretation on the basis of a progressive view of the author.

An Analysis of the Factors that Influence Regional Economic Development Cooperation

This dissertation is a comparative case study of regional cooperation in the field of economic development. In the 21st century global economy, proponents of regionalism have put forth fresh arguments for collective action. A regional approach to economic development activity presents a classic social dilemma: How can local officials collectively improve the economic prospects of a region, and remain autonomous to act in the best interest of the local community? This research examines the role of social capital in overcoming this social dilemma. Three (3) comparable Metropolitan Statistical Areas (MSAs) form the empirical basis of this research. The Houston MSA, the Atlanta MSA and the Miami MSA present distinct variations of regionalized economic development activity. This dissertation seeks to explain this disparity in the dependent variable. The hypothesis is that accrued social capital is crucial to obtaining economic development cooperative agreements. This qualitative research utilized secondary demographic and economic databases, survey instruments, interviews, field observations, and a review of legislative and administrative decisions to formulate a clear understanding of the factors influencing the current state of regional economic development cooperation within each region. The study concludes that the legislative and executive decisions of state government exert inordinate influence on the capacity of local officials to cooperate regionally for economic development purposes.

Blessed are the Peacemakers: Transnational Alliance, Protective Accompaniment and the Presbyterian Church of Colombia

The purpose of this thesis was to explore how Christian networks enable strategies of transnational alliance, whereby groups in different nations strive to strengthen one another’s leverage and credibility in order to resolve conflicts and elaborate new possibilities. This research does so by analyzing the case of the Presbyterian Church of Colombia (IPC). The project examines the historical development of the IPC from the initial missionary period of the 1850s until the present. Specifically, the purpose of the study was to consider how the historical struggle to articulate autonomy and equality vis-à-vis the U.S. Presbyterians (PCUSA) and paternalist models of ecclesial relations has affected recent political strategies pursued by the IPC. Despite the paternalism of the early missionary model, changing conceptions of social transformation during the 60s contributed to a shift in relations. Over time the IPC and PCUSA negotiated relationships in which groups both acknowledge a problematic history and insist upon an ethnic of partnership and respect. Today, PCUSA groups, in concert with the IPC, collaborate on a range of transnational political strategies aimed at strengthening the IPC’s leverage in local struggles for justice and peace. A review of this case suggests that long-established Christian networks may have an advantage over other civil society groups such as NGOs in facilitating strategies of transnational alliance. Although civil society organizations often have better access to important resources needed for international advocacy initiatives, Christian networks, such as the one established between the IPC and U.S. Presbyterian communities, rely on a history of negotiating power-disparity in order to elaborate relationships based on listening and partnership. Such findings prove important not only to how we conceptualize transnational alliance but also to the ways that we think about the history and future of Christian networks.

Greater Miami: Stories

GREATER MIAMI: STORIES is a collection of short stories about the disparity between the hoped-for expectations of life in America—as seen through the prism of South Florida—and the reality of a life lived on the margins. The characters, ranging in age from early adulthood to the elderly, attempt to navigate the perils of a new and unfamiliar existence—physical and/or psychological—while seeking to recoup the losses of home and country, love and language. The collection uses Miami as its setting due to the wide demographic range of its inhabitants, and the stories address themes of memory, love, sex, opportunity and privilege, the mayhem born of disinformation, and the anxiety of displacement. Each story in the collection describes a pivotal moment when the characters encounter a truth that had previously eluded them and then must deal with the repercussions of that knowledge.