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This study aimed to understand gender and ethnicity differences in HIV-related stigma experienced by 1026 HIV-positive individuals living in Ontario, Canada that were enrolled in the OHTN Cohort Study. Total and subscale HIV-related stigma scores were measured using the revised HIV-related Stigma Scale. Correlates of total stigma scores were assessed in univariate and multivariate linear regression. Women had significantly higher total and subscale stigma scores than men (total, median = 56.0 vs. 48.0, p<0.0001). Among men and women, Black individuals had the highest, Aboriginal and Asian/Latin-American/Unspecified people intermediate, and White individuals the lowest total stigma scores. The gender-ethnicity interaction term was significant in multivariate analysis: Black women and Asian/Latin-American/Unspecified men reported the highest HIV-related stigma scores. Gender and ethnicity differences in HIV-related stigma were identified in our cohort. Findings suggest differing approaches may be required to address HIV-related stigma based on gender and ethnicity; and such strategies should challenge racist and sexist stereotypes.

ObjectivesAssess the feasibility of a mobile health (mHealth)-supported home-delivered physical activity (PA) intervention (MOTIVATE-T2D) in people with recently diagnosed type 2 diabetes (T2D).DesignFeasibility multicentre, parallel group, randomised controlled trial (RCT).SettingParticipants were recruited from England and Canada using a decentralised design.ParticipantsAdults (40–75 years) recently diagnosed with T2D (5–24 months).InterventionsParticipants were randomised 1:1 to intervention (MOTIVATE-T2D) or active control groups. Participants codesigned 6month- home-delivered, personalised, progressive PA programmes supported by virtual behavioural counselling. MOTIVATE-T2D used biofeedback from wearable technologies to support the programme. The active control group received the same intervention without wearables.OutcomesThe primary outcomes were recruitment rate, retention and adherence to purposeful exercise. Clinical data on effectiveness were collected as exploratory outcomes at baseline, 6 and 12 months, with HbA1c and systolic blood pressure (BP) proposed as primary outcomes for a future full RCT.Resultsn=135 eligible participants expressed an interest in the trial, resulting in 125 participants randomised (age 55±9 years, 48% female, 81% white), a recruitment rate of 93%. Retention at 12 months was 82%. MOTIVATE-T2D participants were more likely to start (OR 10.4, CI 3.4 to 32.1) and maintain purposeful exercise at 6 (OR 7.1, CI 3.2 to 15.7) and 12 months (OR 2.9, CI 1.2 to 7.4). Exploratory clinical outcomes showed a potential effect in favour of MOTIVATE-T2D, including proposed primary outcomes HbA1c and systolic BP (between-group mean differences: HbA1c: 6 months: −5% change from baseline, CI −10 to 2: 12 months: −2% change from baseline, CI −8 to −4; systolic BP: 6 months: −1 mm Hg, CI −5 to 3: 12 months: −4 mm Hg, CI −8 to 1).ConclusionsOur findings support the feasibility of delivering the MOTIVATE-T2D mHealth-supported PA intervention for people with recently diagnosed T2D and progression to a full RCT to examine its clinical and cost-effectiveness.Trial registration numberISRCTN: 14335124; ClinicalTrials.gov: NCT0465353.

OBJECTIVE:-- To examine whether hyperglycemia at the time of presentation was associated with outcomes in patients admitted to non-intensive care settings with community-acquired pneumonia (CAP). RESEARCH DESIGN AND METHODS-- Prospective cohort study of consecutive patients admitted to six hospitals between 15 November 2000 and 14 November 2002. RESULTS:-- Of the 2,471 patients in this study (median age 75 years), 279 (11%) had serum glucose at presentation >11 mmol/l: 178 of the 401 patients (44%) with a prior diagnosis of diabetes and 101 of the 2,070 patients (5%) without a history of diabetes. Of patients hospitalized with CAP, 9% died and 23% suffered an in-hospital complication. Compared with those with values 11 mmol/l had an increased risk of death (13 vs. 9%, P = 0.03) and in-hospital complications (29 vs. 22%, P = 0.01). Compared with those patients with admission glucose 11 mmol/l. Even after adjustment for factors in the Pneumonia Severity Index, hyperglycemia on admission remained significantly associated with subsequent adverse outcomes: for each 1-mmol/l increase, risk of in-hospital complications increased 3% (0.2-6%). CONCLUSIONS:-- Hyperglycemia on admission is independently associated with adverse outcomes in patients with CAP, with the increased risks evident at lower glucose levels than previously reported.

Current estimates of the prevalence of opioid withdrawal in newborns from the 2012 Better Outcomes Registry and Network Ontario reveal that more than 4 births per 1000 display recognizable symptoms of neonatal abstinence syndrome (NAS). With a growing consensus surrounding aspects of newborn opioid withdrawal care, clinicians might agree that all infants exposed to maternal opioids require supportive observation and care to ensure appropriate adaptation and growth in the newborn period and, likewise, that there exists a smaller percentage of newborns who require additional pharmacotherapy. However, due to the dearth of comparative studies of NAS tools, there remains a lack of evidence to support the use of a specific NAS method of scoring or treatment. Two types of NAS treatment protocols currently in use include a symptom-only versus weight-based protocols. Our Neonatal Intensive Care Unit (NICU) has used both models. A formal structured NAS tool and weight-based morphine delivery system began in our NICU in 1999. We audited all newborns with known exposure to maternal opioids in our NICU from the years 2000 to 2014. The Finnegan scoring tool was used throughout all years of the chart audit. Modifications made to the Finnegan scoring tool from the MOTHER study were adapted for use in our NICU at the same time as adopting the Johns Hopkins model of symptom-only based morphine delivery in 2006. The objective of this comparative study using a retrospective chart audit is to compare length of stay (LOS) and total accumulative morphine dose across these two morphine delivery protocols. Our audit revealed that there were a significantly higher proportion of newborns in the symptom-only model that received morphine and, perhaps accordingly, also had a significantly higher LOS compared to those in the weight-based model. Comparing only those infants who did receive morphine, the comparative total accumulative dose of morphine and LOS were not significantly different between the weight-based and symptom-only morphine delivery models.

Background Although some studies show higher antiretroviral concentrations in women compared to men, data are limited. We conducted a cross-sectional study of HIV-positive women to determine if protease inhibitor (PI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) C min and C max values were significantly different than historical general population (predominantly male) averages and to evaluate correlates of higher concentrations. Methods HIV-positive women with virologic suppression (viral load < 50copies/mL) on their first antiretroviral regimen were enrolled. Timed blood samples for C min and C max were drawn weekly for 3 weeks. The ratio of each individual’s median C min and C max to the published population mean values for their PI or NNRTI was calculated and assessed using Wilcoxon sign-rank. Intra- and inter-patient variability of antiretroviral drug levels was assessed using coefficient of variation and intra-class correlation. Linear regression was used to identify correlates of the square root-transformed C min and C max ratios. Results Data from 82 women were analyzed. Their median age was 41 years (IQR=36-48) and duration of antiretrovirals was 20 months (IQR=9-45). Median antiretroviral C min and C max ratios were 1.21 (IQR=0.72-1.89, p=0.003) (highest ratios for nevirapine and lopinavir) and 0.82 (IQR=0.59-1.14, p=0.004), respectively. Nevirapine and efavirenz showed the least and unboosted atazanavir showed the most intra- and inter-patient variability. Higher CD4+ count correlated with higher C min . No significant correlates for C max were found. Conclusions Compared to historical control data, C min in the women enrolled was significantly higher whereas C max was significantly lower. Antiretroviral C min ratios were highly variable within and between participants. There were no clinically relevant correlates of drug concentrations. Trial registration NCT00433979

Some low-acuity emergency department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study assessed the frequency and determinants of patients' efforts to access alternative care before ED presentation. Patients aged 17 years and older were randomly selected from 2 urban ED sites in Edmonton. Survey data were collected on use and characteristics of alternative care before the ED visit. Information was also collected on patient demographics and factors influencing their perception of whether the ED was the best care option. Of the 1,389 patients approached, 905 (65%) completed the survey and data from 894 participants were analyzed. Sixty-one percent reported that they sought alternative care before visiting the ED. Eighty-nine of the patients who attempted alternative access before the ED visit felt that the ED was their best care option. Results of the multivariate logistic regression analysis showed that injury presentation, living arrangements, smoking status and whether or not patients had a family practitioner were predictors for seeking alternative care before visiting the ED. Most ambulatory patients attempt to look for other sources of care before presenting to the ED. Despite this attempted access to alternative care, while patients wait for ED care, they perceive that the ED is their best care option at that point in time.

Background. The Canadian Women's HIV Study (CWHS) enrolled human immunodeficiency virus (HIV)-positive and high-risk HIV-negative women in a longitudinal cohort. This analysis considered the effects of HIV and highly active antiretroviral therapy (HAART) on HPV persistence and cervical squamous intraepithelial lesions (SILs). Methods. Longitudinal cytopathologic and HPV DNA results were analyzed using multistate models. States of cervical SIL were defined as absent, present, and treatment; HPV states were defined as negative or positive. Demographic variables and markers of sexual activity were considered predictors. Results were calculated on the basis of transition probabilities and reported as hazard ratios (HRs). Results. The CWHS followed 750 HIV-positive and 323 HIV-negative women during 1993-2002. A total of 467 and 456 women were included in the longitudinal cervical cytopathologic and HPV DNA analyses, respectively. HIV-positive women had increased prevalence (46.6% vs 28.7%; P<.0001), increased acquisition (HR, 2.3; P= .03), and decreased clearance (HR, 0.4; P <.001) of oncogenic HPV as compared to HIV-negative women. Oncogenic HPV infection predicted progression of cervical dysplasia from normal to abnormal SIL (HR, 2.8; P = .002). Among HIVpositive participants, HAART increased the likelihood of regression (from present to absent) of cervical SIL (HR, 3.3; P = .02) and increased the clearance of oncogenic HPV types other than HPV-16 or HPV-18 (HR, 2.2; P = .01). Conclusions. This analysis demonstrated beneficial effects of HAART on cervical SIL in HIV-positive women.

Our objective was to determine whether the addition of a broad-scope nurse practitioner (NP) would improve emergency department (ED) wait times, ED lengths of stay (LOS) and left-without-treatment (LWOT) rates. We hypothesized that the addition of a broad-scope NP during weekday ED shifts would result in shorter patient wait times, reduced LOS and fewer patients leaving the ED without treatment. This prospective observational study was conducted in a busy urban free-standing community ED. Intervention shifts, with NP coverage, were compared with control shifts (similar shifts with emergency physicians [EPs] working independently). Primary outcomes included patient wait times, ED LOS and LWOT rates. Patient demographics, triage category, the provider seen, the time to provider and ED LOS were captured using an electronic database. The addition of an NP was associated with a 12% increase in patient volume per shift and a 7-minute reduction in mean wait times for low-acuity patients. However, overall patient wait times and ED LOS did not differ between intervention and control shifts. During intervention shifts, EPs saw a smaller proportion of low-acuity patients and there was a trend toward a lower proportion of LWOT patients (11.9% v. 13.7%, p = 0.10). Adding a broad-scope NP to the ED staff may lower the proportion of patients who leave without treatment, reduce the proportion of low-acuity patients seen by EPs and expedite throughput for a subgroup of less urgent patients. However, it did not reduce overall wait times or ED LOS in this setting.

Abstract Background Human papillomavirus (HPV) vaccination is safe and efficacious in women without human immunodeficiency virus (HIV). Although good immunogenicity has been observed in women living with HIV (WLWH), efficacy data in this population are needed. Methods We enrolled 420 females aged ≥9 years (range, 9–65) living with HIV. Participants were to receive 3 doses of qHPV vaccine (0/2/6 months). The main endpoint was vaccine failure (ie, incident persistent qHPV infection, cervical intraepithelial neoplasia of grade 2 or higher [CIN2+], or genital warts). We compared these rates to published rates in vaccinated and unvaccinated women without HIV as well as unvaccinated WLWH. Results Among 279 eligible women, median follow-up was 2 years. In the intention-to-treat population, the incidence rate (IR) of persistent qHPV (HPV6/11/16/18) was 2.3 per 100 person-years (/100PY) (95% confidence interval [CI], 1.1–4.1), and IR of genital warts was 2.3/100PY (95% CI, 1.2–4.1). In the per-protocol efficacy population, IR of persistent qHPV was 1.0/100PY (95% CI, 0.3–2.6) and of genital warts was 1.0/100PY (95% CI, 0.3–2.5). No cases of CIN2+ occurred. Reported rates of qHPV-related infection and disease within vaccinated women without HIV, unvaccinated women without HIV, and vaccinated WLWH: 0.1 (95% CI, 0.02–0.03), 1.5 (95% CI, 1.1–2.0), and 1.2 (95% CI, 0.2–3.4) /100PY, respectively. The rate of persistent qHPV among vaccinated WLWH was lower than among unvaccinated WLWH (2.3 vs 6.0/100PY). Conclusions Vaccinated WLWH may be at higher risk for vaccine failure than vaccinated women without HIV. However, overall rates of vaccine failure were low, and rates of persistent qHPV were lower than in unvaccinated WLWH. Vaccinated women living with Human Immunodeficiency Virus (HIV) may be at higher risk for vaccine failure than vaccinated women without HIV. However, overall vaccine failure rates were low and rates of persistent vaccine-type HPV were lower than in unvaccinated women living with HIV.

This randomized trial included almost 1500 women with breast cancer and positive axillary nodes and compared treatment with doxorubicin and cyclophosphamide combined with either fluorouracil or docetaxel. The rates of disease-free and overall survival were significantly higher among women in the docetaxel group. This trial compared treatment with doxorubicin and cyclophosphamide combined with either fluorouracil or docetaxel. The rates of disease-free and overall survival were significantly higher among women in the docetaxel group. Adjuvant chemotherapy for breast cancer has undergone a major change over the past two decades. Chemotherapy with a regimen that includes an anthracycline or a combination of cyclophosphamide, methotrexate, and fluorouracil significantly decreases the risks of disease recurrence and death among women with early-stage breast cancer. 1 The overview analysis of the Early Breast Cancer Trialists' Collaborative Group demonstrated that, as compared with standard treatment with cyclophosphamide, methotrexate, and fluorouracil, regimens that contained doxorubicin or epirubicin reduced the annual risk of recurrence of breast cancer by 12 percent and the annual risk of death by 11 percent. Rates of disease-free and . . .