Statins are associated with decreased mortality risk after status epilepticus.

BACKGROUND AND PURPOSE: Statins display anti-inflammatory and anti-epileptogenic properties in animal models, and may reduce the epilepsy risk in elderly humans; however, a possible modulating role on outcome in patients with status epilepticus (SE) has not been assessed. METHODS: This cohort study was based on a prospective registry including all consecutive adults with incident SE treated in our center between April 2006 and September 2012. SE outcome was categorized at hospital discharge into 'return to baseline', 'new disability' and 'mortality'. The role of potential predictors, including statins treatment on admission, was evaluated using a multinomial logistic regression model. RESULTS: Amongst 427 patients identified, information on statins was available in 413 (97%). Mean age was 60.9 (±17.8) years; 201 (49%) were women; 211 (51%) had a potentially fatal SE etiology; and 191 (46%) experienced generalized-convulsive or non-convulsive SE in coma. Statins (simvastatin, atorvastatin or pravastatin) were prescribed prior to admission in 76 (18%) subjects, mostly elderly. Whilst 208 (50.4%) patients returned to baseline, 58 (14%) died. After adjustment for established SE outcome predictors (age, etiology, SE severity score), statins correlated significantly with lower mortality (relative risk ratio 0.38, P = 0.046). CONCLUSION: This study suggests for the first time that exposure to statins before an SE episode is related to its outcome, involving a possible anti-epileptogenic role. Other studies are needed to confirm this intriguing finding.

Medication incidents in primary care medicine: protocol of a study by the Swiss Federal Sentinel Reporting System.

BACKGROUND/RATIONALE: Patient safety is a major concern in healthcare systems worldwide. Although most safety research has been conducted in the inpatient setting, evidence indicates that medical errors and adverse events are a threat to patients in the primary care setting as well. Since information about the frequency and outcomes of safety incidents in primary care is required, the goals of this study are to describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. Label="METHODS AND ANALYSIS" ="METHODS"/> <AbstractText STUDY DESIGN AND SETTING: We will conduct a prospective surveillance study to identify cases of medication incidents among primary care patients in Switzerland over the course of the year 2015. PARTICIPANTS: Patients undergoing drug treatment by 167 general practitioners or paediatricians reporting to the Swiss Federal Sentinel Reporting System. INCLUSION CRITERIA: Any erroneous event, as defined by the physician, related to the medication process and interfering with normal treatment course. EXCLUSION CRITERIA: Lack of treatment effect, adverse drug reactions or drug-drug or drug-disease interactions without detectable treatment error. PRIMARY OUTCOME: Medication incidents. RISK FACTORS: Age, gender, polymedication, morbidity, care dependency, hospitalisation. STATISTICAL ANALYSIS: Descriptive statistics to assess type, frequency, seasonal and regional distribution of medication incidents and logistic regression to assess their association with potential risk factors. Estimated sample size: 500 medication incidents. LIMITATIONS: We will take into account under-reporting and selective reporting among others as potential sources of bias or imprecision when interpreting the results. ETHICS AND DISSEMINATION: No formal request was necessary because of fully anonymised data. The results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT0229537.

Serum 25-hydroxyvitamin D level and kidney function decline in a Swiss general adult population.

Molecular evidence suggests that levels of vitamin D are associated with kidney function loss. Still, population-based studies are limited and few have considered the potential confounding effect of baseline kidney function. This study evaluated the association of serum 25-hydroxyvitamin D with change in eGFR, rapid eGFR decline, and incidence of CKD and albuminuria. Baseline (2003-2006) and 5.5-year follow-up data from a Swiss adult general population were used to evaluate the association of serum 25-hydroxyvitamin D with change in eGFR, rapid eGFR decline (annual loss >3 ml/min per 1.73 m(2)), and incidence of CKD and albuminuria. Serum 25-hydroxyvitamin D was measured at baseline using liquid chromatography-tandem mass spectrometry. eGFR and albuminuria were collected at baseline and follow-up. Multivariate linear and logistic regression models were used considering potential confounding factors. Among the 4280 people included in the analysis, the mean±SD annual eGFR change was -0.57±1.78 ml/min per 1.73 m(2), and 287 (6.7%) participants presented rapid eGFR decline. Before adjustment for baseline eGFR, baseline 25-hydroxyvitamin D level was associated with both mean annual eGFR change and risk of rapid eGFR decline, independently of baseline albuminuria. Once adjusted for baseline eGFR, associations were no longer significant. For every 10 ng/ml higher baseline 25-hydroxyvitamin D, the adjusted mean annual eGFR change was -0.005 ml/min per 1.73 m(2) (95% confidence interval, -0.063 to 0.053; P=0.87) and the risk of rapid eGFR decline was null (odds ratio, 0.93; 95% confidence interval, 0.79 to 1.08; P=0.33). Baseline 25-hydroxyvitamin D level was not associated with incidence of CKD or albuminuria. The association of 25-hydroxyvitamin D with eGFR decline is confounded by baseline eGFR. Sufficient 25-hydroxyvitamin D levels do not seem to protect from eGFR decline independently from baseline eGFR.

Associations between fruit and vegetable consumption and psychological distress: results from a population-based study.

BACKGROUND: Several studies observed associations of various aspects of diet with mental health, but little is known about the relationship between following the 5-a-day recommendation for fruit and vegetables consumption and mental health. Thus, we examined the associations of the Swiss daily recommended fruit and vegetable intake with psychological distress. METHODS: Data from 20,220 individuals aged 15+ years from the 2012 Swiss Health Survey were analyzed. The recommended portions of fruit and vegetables per day were defined as 5-a-day (at least 2 portions of fruit and 3 of vegetables). The outcome was perceived psychological distress over the previous 4 weeks (measured by the 5-item mental health index [MHI-5]). High distress (MHI-5 score ≤ 52), moderate distress (MHI-5 > 52 and ≤ 72) and low distress (MHI-5 > 72 and ≤ 100) were differentiated and multinomial logistic regression analyses adjusted for known confounding factors were performed. RESULTS: The 5-a-day recommendation was met by 11.6 % of the participants with low distress, 9.3 % of those with moderate distress, and 6.2 % of those with high distress. Consumers fulfilling the 5-a-day recommendation had lower odds of being highly or moderately distressed than individuals consuming less fruit and vegetables (moderate vs. low distress: OR = 0.82, 95 % confidence interval [CI] 0.69-0.97; high vs. low distress: OR = 0.55, 95 % CI 0.41-0.75). CONCLUSIONS: Daily intake of 5 servings of fruit and vegetable was associated with lower psychological distress. Longitudinal studies are needed to further determine the causal nature of this relationship.

Prediction of multiple infections after severe burn trauma: a prospective cohort study.

OBJECTIVE: To develop predictive models for early triage of burn patients based on hypersusceptibility to repeated infections. BACKGROUND: Infection remains a major cause of mortality and morbidity after severe trauma, demanding new strategies to combat infections. Models for infection prediction are lacking. METHODS: Secondary analysis of 459 burn patients (≥16 years old) with 20% or more total body surface area burns recruited from 6 US burn centers. We compared blood transcriptomes with a 180-hour cutoff on the injury-to-transcriptome interval of 47 patients (≤1 infection episode) to those of 66 hypersusceptible patients [multiple (≥2) infection episodes (MIE)]. We used LASSO regression to select biomarkers and multivariate logistic regression to built models, accuracy of which were assessed by area under receiver operating characteristic curve (AUROC) and cross-validation. RESULTS: Three predictive models were developed using covariates of (1) clinical characteristics; (2) expression profiles of 14 genomic probes; (3) combining (1) and (2). The genomic and clinical models were highly predictive of MIE status [AUROCGenomic = 0.946 (95% CI: 0.906-0.986); AUROCClinical = 0.864 (CI: 0.794-0.933); AUROCGenomic/AUROCClinical P = 0.044]. Combined model has an increased AUROCCombined of 0.967 (CI: 0.940-0.993) compared with the individual models (AUROCCombined/AUROCClinical P = 0.0069). Hypersusceptible patients show early alterations in immune-related signaling pathways, epigenetic modulation, and chromatin remodeling. CONCLUSIONS: Early triage of burn patients more susceptible to infections can be made using clinical characteristics and/or genomic signatures. Genomic signature suggests new insights into the pathophysiology of hypersusceptibility to infection may lead to novel potential therapeutic or prophylactic targets.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study.

BACKGROUND: Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. METHODS: A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used. RESULTS: We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2). CONCLUSIONS: Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.

Image guided critical screw placement precision in the cervical spine : important or incidental? : results of a series of 91 consecutive cases using OVEM

Study design: A retrospective study of image guided cervical implant placement precision. Objective: To describe a simple and precise classification of cervical critical screw placement. Summary of Background Data: "Critical" screw placement is defined as implant insertion into a bone corridor which is surrounded circumferentially by neurovascular structures. While the use of image guidance has improved accuracy, there is currently no classification which provides sufficient precision to assess the navigation success of critical cervical screw placement. Methods: Based on postoperative clinical evaluation and CT imaging, the orthogonal view evaluation method (OVEM) is used to classify screw accuracy into grade I (no cortical breach), grade la (screw thread cortical breach), grade II (internal diameter cortical breach) and grade III (major cortical breach causing neural or vascular injury). Grades II and III are considered to be navigation failures, after accounting for bone corridor / screw mismatch (minimal diameter of targeted bone corridor being smaller than an outer screw diameter). Results: A total of 276 screws from 91 patients were classified into grade I (64.9%), grade la (18.1%), and grade II (17.0%). No grade III screw was observed. The overall rate of navigation failure was 13%. Multiple logistic regression indicated that navigational failure was significantly associated with the level of instrumentation and the navigation system used. Navigational failure was rare (1.6%) when the margin around the screw in the bone corridor was larger than 1.5 mm. Conclusions: OVEM evaluation appears to be a useful tool to assess the precision of critical screw placement in the cervical spine. The OVEM validity and reliability need to be addressed. Further correlation with clinical outcomes will be addressed in future studies.

Prevalence of overweight and obesity in children from urban and rural Niagara

Purpose: The influence of environment in the development of overweight and obesity is an ongoing concern. This investigation examined the influence of urbanization on the rates of childhood overweight and obesity. Method: 2167 (1090M, 1077F) grade four children from 75 schools in Ontario's Niagara Region were sampled. A sophisticated algorithm overlaying electoral boundaries, population densities, and the knowledge of community members was used to classify schools into one of three location categories: urban {N= 1588), urban fringe {N= 379), and rural (A^= 234). Each subject was measured for: height, weight, and aerobic performance (Leger). Physical activity was evaluated with the self-report Participation Questionnaire (free-time and organized sport activities), and teacher's evaluations of student activity. Overweight (overweight and obesity combined) was measured both as a continuous (BMI) and categorical variable (BMI category), to evaluate the prevalence by location. A multivariate analysis was used to test for a suppression effect. Results: BMI and BMI category did not differ significantly by location or gender, and no evidence of a gender interaction existed. According to both a linear and logistic regression, physical activity or fitness levels did not suppress the influence of location on BMI and BMI category. Age, gender, free-time activity, organized sports, fitness level, and number of siblings, were all found to significantly influence overweight. Conclusions: It is plausible that the prevalence of overweight does not differ in urban and rural children from the Niagara Region. Further investigation is recommended, examining subjects by individual location of residence, in multiple regions throughout Ontario.

Exploring the relationship between ethnicity and hypertension in Canada

Background: Previous work examining differences in hypertension across ethnic groups employ race as the principal variable. While differences in hypertension have been identified across racial groups, there is great variation between ethnic groups amongst racial groupings that could mask differences in hypertension and cardiovascular disease (CVD) risk. In light of Canada's ethnic diversity, research aimed at identifying specific groups that are at a health disadvantage is essential for understanding the health of the overall population. In addition, this research would be beneficial for creating programs and policies aimed at reducing or eliminating these disparities. Since CVD is the leading cause of mortality in Canada and hypertension is one of the most significant and modifiable risk factors for CVD, it is important to move past crude classifications based on race and examine ethnic group differences. The purpose of this study is to examine the relationship between ethnicity and hypertension in Canada, while employing more narrow classifications for ethnicity than previous studies. In addition, because ethnicity has been shown to be representative of an individual's social experience, this study also aims to investigate whether this relationship can be explained by one or all of the following variable: socioeconomic status, physical activity, body mass index, smoking status, daily alcohol consumption or acculturation. Methods. This study used the 2004 Canadian Community Health Survey, cycle 2.1 to compare 29 different ethnic groups in Canada on whether they had high blood pressure that had been diagnosed by a health professional. Associations were examined using logistic regression. Subsequent logistic regression analyses included socioeconomic status, physical activity, body mass index, smoking status, daily alcohol consumption and acculturation to test for the effect of each of these variables on the relationship between ethnicity and hypertension. Results. Ukrainians, Chinese, Portuguese, South Asians, Aboriginals, Blacks, Filipinos and South East Asians were found to have significantly higher odds of having high blood pressure than Canadians (OR's = 1.50, 1.56, 2.72, 1.38, 1.36, 1.66, 2.21 & 2.24 respectively, p<.001). In addition, the only significant mediating effects were between SES and Aboriginals as well as obesity and Aboriginals. None of the other independent variables accounted for >10% of the risk experienced by the ethnic groups that were significantly associated with hypertension. Interpretation: The odds of having high blood pressure in Canada varies considerably across ethnic groups within racial groups indicating previous research is not specific enough to inform policy and program development. Because this study was not able to explain this relationship using the sociodemographic and lifestyle factors mentioned above, future research should be done to determine what places certain ethnic groups at a greater risk in order to tailor interventions aimed at reducing high blood pressure that are suited to the specific needs of each cultural group.

The impact of tobacco control policies on university students' smoking in Ontario

Objective. Despite steady declines in the prevalence of tobacco use among Canadians, young adult tobacco use has remained stubbornly high over the past two decades (CTUMS, 2005a). Currently in Ontario, young adults have the highest proportion of smokers of all age cohorts at 26%. A growing body of evidence shows that smoking restrictions and other tobacco control policies can reduce tobacco use and consumption among adults and deter initiation among youth; whether young adult university students' smoking participation is influenced by community smoking restrictions, campus tobacco control policies or both remains an empirical question. The purpose of this study is to examine the relationship among current smoking status of students on university campuses across Ontario and various tobacco control policies, 3including clean air bylaws of students' home towns, clean air by-laws of the community where the university is situated, and campus policies. Methods. Two data sets were used. The 200512006 Tobacco Use in a Representative Sample of Post-Secondary Students data set provides information about the tobacco use of 10,600 students from 23 universities and colleges across Ontario. Data screening for this study reduced the sample to 5,114 17-to-24 year old undergraduate students from nine universities. The second data set is researcher-generated and includes information about strength and duration of, and students' exposure to home town, local and campus tobacco control policies. Municipal by-laws (of students' home towns and university towns) were categorized as weak, moderate or strong based on criteria set out in the Ontario Municipal By-law Report; campus policies were categorized in a roughly parallel fashion. Durations of municipal and campus policies were calculated; and length of students' exposure to the policies was estimated (all in months). Multinomial logistic regression analyses were used to examine the relationship between students' current smoking status (daily, less-than-daily, never-smokers) and the following policy measures: strength of, duration of, and students' exposure to campus policy; strength of, duration of, and students' exposure to the by-law in the university town; and, strength of, duration of, and students' exposure to the by-law in the home town they grew up in. Sociodemographic variables were controlled for. Results. Among the Ontario university students surveyed, 7.0% currently use tobacco daily and 15.4% use tobacco less-than-daily. The proportions of students experiencing strong tobacco control policies in their home town, the community in which their university is located and at their current university were 33.9%,64.1 %, and 31.3% respectively. However, 13.7% of students attended a university that had a weak campus policy. Multinomial logistic regressions suggested current smoking status was associated with university town by-law strength, home town by-law strength and the strength of the campus tobacco control policy. In the fmal model, after controlling for sociodemographic factors, a strong by-law in the university town and a strong by-law in students' home town were associated with reduced odds of being both a less-than-daily (OR = 0.64, 95%CI: 0.48-0.86; OR = 0.80, 95%CI: 0.66-0.95) and daily smoker (OR = 0.59, 95%CI: 0.39-0.89; OR = 0.76, 95%CI: 0.58-0.99), while a weak campus tobacco control policy was associated with higher odds of being a daily smoker (OR = 2.08, 95%CI: 1.31-3.30) (but unrelated to less-than-daily smoking). Longer exposure to the municipal by-law (OR = 0.93; 95%CI: 0.90-0.96) was also related to smoking status. Conclusions. Students' smoking prevalence was associated with the strength of the restrictions in university, and with campus-specific tobacco control policies. Lessthan- daily smoking was not as strongly associated with policy measures as daily smoking was. University campuses may wish to adopt more progressive campus policies and support clean air restrictions in the broader community. More research is needed to determine the direction of influence between tobacco control policies and students' smoking.

Transmission of West Nile virus in the Niagara Region among a population at risk for exposure

Background. West Nile Virus (WNV), a mosquito-borne flavivirus, is one of an increasing number of infectious diseases that have been emerging or re-emerging in the last two decades. Since the arrival ofWNV to Canada to present date, the Niagara Region has only reported 30 clinical cases, a small number compared to the hundreds reported in other regions of similar conditions. Moreover, the last reported human case in Niagara was in 2006. As it has been demonstrated that the majority of WNV infections are asymptomatic, the question remains whether the lack of clinical cases in Niagara truly reflects the lack of transmission to humans or if infections are still occurring but are mostly asymptomatic. Objectives. The general objective of this study was to establish whether or not active WNV transmission could be detected in a human population residing in Niagara for the 2007 transmission season. To fullfil this objective, a cross-sectional seroprevalence study was designed to investigate for the presence of anti-WNV antibodies in a sample of Mexican migrant agricultural workers employed in farms registered with the Seasonal Agricultural Workers Program (SAWP). Due to the Mexican origin of the study participants, three specific research objectives were proposed: a) determine the seroprevalence ofanti-WNV antibodies as well as anti-Dengue virus antibodies (a closely related virus prevalent in Mexico and likely to confound WNV serology); b) analyze risk factors associated with WNV and Dengue virus seropositivity; and c) assess the awareness of study participants about WNV infection as well as their understanding of the mode of transmission and clinical importance of the infection. Methodology: After obtaining ethics clearance from Brock University, farms were visited and workers invited to participate. Due to time constraints, only a small number of farms were enrolled with a resulting convenience and non-randomized study sample. Workers' demographic and epidemiological data were collected using a standardized questionnaire and blood samples were drawn to determine serum anti-WNV and anti- Dengue antibodies with a commercial ELISA. All positive samples were sent to the National Microbiology Laboratory in Winnipeg, Manitoba for confirmation with the Plaque Reduction Neutralization Test (PRNT). Data was analyzed with Stata 10.0. Antibody determinations were reported as seroprevalence proportions for both WNV and Dengue. Logistic regression was used to analyze risk factors that may be associated with seropositivity and awareness was reported as a proportion of the number of individuals possessing awareness over the total number of participants. Results and Discussion. In total 92 participants working in 5 farms completed the study. Using the commercial ELISA, seropositivity was as follows: 2.2% for WNV IgM, 20.7% for WNV IgG, and 17.1 % for Dengue IgG. Possible cross-reactivity was demonstrated in 15/20 (75.0%) samples that were positive for both WNV IgG and Dengue IgG. Confirmatory testing with the PRNT demonstrated that none of the WNV ELISA positive samples had antibodies to WNV but 13 samples tested positive for anti-Dengue antibodies (14.1 % Dengue sereoprevalence). The findings showed that the ELISA performance was very poor for assessing anti-WNV antibodies in individuals previously exposed to Dengue virus. However, the ELISA had better sensitivity and specificity for assessing anti-Dengue antibodies. Whereas statistical analysis could not be done for WNV seropositivity, as all samples were PRNT negative, logistic regression demonstrated several risk factors for Dengue exposure_ The first year coming to Canada appeared to be significantly associated with increased exposure to Dengue while lower socio-economic housing and the presence of a water basin in the yard in Mexico appeared to be significantly associated with a decreased exposure to Dengue_ These seemingly contradictory results illustrate that in mobile populations such as migrant workers, risk factors for exposure to Dengue are not easily identified and more research is needed. Assessing the awareness of WNV and its clinical importance showed that only 23% of participants had some knowledge of WNV, of which 76% knew that the infection was mosquito-borne and 47% recognized fever as a symptom. The identified lack of understanding and awareness was not surprising since WNV is not a visible disease in Mexico. Since WNV persists in an enzootic cycle in Niagara and the occurrence of future outbreaks is unpredictable, the agricultural workers remain at risk for transmission. Therefore it important they receive sufficient health education regarding WNV before leaving Mexico and during their stay in Canada. Conclusions. Human transmission of WNV could not be proven among the study participants even when due to their occupation they are at high risk for mosquito bites. The limitations of the study sample do not permit generalizable conclusions, however, the study findings are consistent with the absence of clinical cases in the Niagara Region, so it is likely that human transmission is indeed neglible or absent. As evidenced by our WNV serology results, PRNT must be utilized as a confirmatory test since false positivity occurs frequently. This is especially true when previous exposure to Dengue virus is likely.

Examining the potential application of childhood stature in assessing adolescent overweight and obesity

Background: Increasing Overweight and Obesity (OwOb) prevalence in pediatric populations is becoming a public health concern in many countries. The purpose of this study was to determine if childhood stature components, particularly the Leg Length Index (LLI = [height - sitting height]! height), were useful in assessing risk of OwOb in adolescence. Methods: Data was from a longitudinal study conducted in south Ontario since 2004. Approximately 2360 students had body composition measurements including sitting height and standing height at baseline. Among them, 1167 children (573 girls, 594 boys) who had weight and height measured at the 5 th year follow-up, were included in this analysis. OwOb was defined using age and sex specific BMI (kg!m 2 ) cut-off points corresponding to adults' BMI ~ 25. Results: Overall, 34% (n=298) of adolescents were considered as OwOb. The results from logistic regression analysis indicated that with 1 unit increase in LLI the odds of OwOb decreased 24% (Odds Ratio, [95% Confidence Interval], 0.76, [0.66-0.87]) after adjusted for age, sex and baseline waist circumference. Further adjusting for birth weight, birth order, breastfeeding, child's physical activity, maternal smoking, education, mother's age at birth and mother's BMI, did not change the relationship. Our results also indicated that mother's smoking status is associated with LLI. Discussion: Although LLI measured at childhood in this study is related to OwOb risk in adolescents, the underlying mechanism is unclear and further study is needed.

Predictors of primary health care utilization by former residents of institutions in Ontario

For years institutionalization has been the primary method of service delivery for persons with developmental disabilities (DD). However, in Ontario the last institution was closed on March 31, 2009 with former residents now residing in small, communitybased homes. This study investigated potential predictors of primary health care utilization by former residents. Several indirect measures were employed to gather information from 60 participants on their age, health status, adaptive functioning level, problem behaviour, mental health status and, total psychotropic medication use. A direct measure was used to gather primary health care utilization information, which served as the dependent variable. A stepwise linear regression failed to reveal significant predictors of health care utilization. The data were subsequently dichotomized and the outcomes of a logistic regression analysis indicated that mental health status, psychotropic medication use and, an interaction between mental health status and health status significantly predicted higher primary health care usage.

The relationship between body mass index and breast cancer recurrence/progression and breast cancer-specific death

The aim of this study was to describe the nonlinear association between body mass index (BMI) and breast cancer outcomes and to determine whether BMI improves prediction of outcomes. A cohort of906 breast cancer patients diagnosed at Henry Ford Health System, Detroit (1985-1990) were studied. The median follow-up was 10 years. Multivariate logistic regression was used to model breast cancer recurrence/progression and breast cancer-specific death. Restricted cubic splines were used to model nonlinear effects. Receiver operator characteristic areas under the curves (ROC AUC) were used to evaluate prediction. BMI was nonlinearly associated with recurrence/progression and death (p= 0.0230 and 0.0101). Probability of outcomes increased with increase or decrease ofBMI away from 25. BMI splines were suggestive of improved prediction of death. The ROC AUCs for nested models with and without BMI were 0.8424 and 0.8331 (p= 0.08). I f causally associated, modifying patients BMI towards 25 may improve outcomes.

Aspects of spatial and habitat ecology of multiple Anopheles species (Diptera: Culicidae): malaria vectors in the highlands and foothills of Ecuador

The resurgence of malaria in highland regions of Africa, Oceania and recently in South America underlines the importance of the study of the ecology of highland mosquito vectors of malaria. Since the incidence of malaria is limited by the distribution of its vectors, the purpose of this PhD thesis was to examine aspects of the ecology of Anopheles mosquitoes in the Andes of Ecuador, South America. A historical literature and archival data review (Chapter 2) indicated that Anopheles pseudopunctipennis transmitted malaria in highland valleys of Ecuador prior to 1950, although it was eliminated through habitat removal and the use of chemical insecticides. Other anopheline species were previously limited to low-altitude regions, except in a few unconfirmed cases. A thorough larval collection effort (n=438 attempted collection sites) in all road-accessible parts of Ecuador except for the lowland Amazon basin was undertaken between 2008 - 2010 (Chapter 3). Larvae were identified morphologically and using molecular techniques (mitochondrial COl gene), and distribution maps indicated that all five species collected (Anopheles albimanus, An. pseudopunctipennis, Anopheles punctimacula, Anopheles oswaldoi s.l. and Anopheles eiseni) were more widespread throughout highland regions than previously recorded during the 1940s, with higher maximum altitudes for all except An. pseudopunctipennis (1541 m, 1930 m, 1906 m, 1233 m and 1873 m, respectively). During larval collections, to characterize species-specific larval habitat, a variety of abiotic and biotic habitat parameters were measured and compared between species-present and species-absent sites using chi-square tests and stepwise binary logistic regression analyses (Chapter 4). An. albimanus was significantly associated with permanent pools with sand substrates and An. pseudopunctipennis with gravel and boulder substrates. Both species were significantly associated with floating cyanobacterial mats and warmer temperatures, which may limit their presence in cooler highland regions. Anopheles punctimacula was collected more often than expected from algae-free, shaded pools with higher-than-average calculated dissolved oxygen. Anopheles oswaldoi s.l., the species occurring on the Amazonian side of the Andes, was associated with permanent, anthropogenic habitats such as roadside ditches and ponds. To address the hypothesis that human land use change is responsible for the emergence of multiple highland Anopheles species by creating larval habitat, common land uses in the western Andes were surveyed for standing water and potential larval habitat suitability (Chapter 5). Rivers and road edges provided large amounts of potentially suitable anopheline habitat in the western Andes, while cattle pasture also created potentially suitable habitat in irrigation canals and watering ponds. Other common land uses surveyed (banana farms, sugarcane plantations, mixed tree plantations, and empty lots) were usually established on steep slopes and had very little standing water present. Using distribution and larval habitat data, a GIS-based larval habitat distribution model for the common western species was constructed in ArcGIS v.l 0 (ESRI 2010) using derived data layers from field measurements and other sources (Chapter 6). The additive model predicted 76.4 - 97.9% of the field-observed collection localities of An. albimanus, An. pseudopunctipennis and An. punctimacula, although it could not accurately distinguish between species-absent and speciespresent sites due to its coarse scale. The model predicted distributional expansion and/or shift of one or more anopheline species into the following highland valleys with climate warming: Mira/Chota, Imbabura province, Tumbaco, Pichincha province, Pallatanga and Sibambe, Chimborazo province, and Yungilla, Azuay province. These valleys may serve as targeted sites of future monitoring to prevent highland epidemics of malaria. The human perceptions of malaria and mosquitoes in relation to land management practices were assessed through an interview-based survey (n=262) in both highlands and lowlands, of male and female land owners and managers of five property types (Chapter 7). Although respondents had a strong understanding of where the disease occurs in their own country and of the basic relationship among standing water, mosquitoes and malaria, about half of respondents in potential risk areas denied the current possibility of malaria infection on their own property. As well, about half of respondents with potential anopheline larval habitat did not report its presence, likely due to a highly specific definition of suitable mosquito habitat. Most respondents who are considered at risk of malaria currently use at least one type of mosquito bite prevention, most commonly bed nets. In conclusion, this interdisciplinary thesis examines the occurrence of Anopheles species in the lowland transition area and highlands in Ecuador, from a historic, geographic, ecological and sociological perspective.