HIV and mental health among young people in low-resource contexts in Southeast Asia: A qualitative investigation.

Young people aged 15-24 years comprise one-fourth of incident HIV infections in Southeast Asia. Given the high prevalence and impact of mental health issues among young people, we explored intersections of HIV and mental health, with a focus on adolescent and young key populations (AYKP) in Indonesia, the Philippines, Thailand, and Vietnam. Sixteen focus group discussions (4/country) with young people (n = 132; 16-24 years) and 41 key informant interviews with multisectoral HIV experts explored young people's lived experiences and unmet needs, existing programmes, and strategic directions for local and regional HIV responses. Cross-cutting challenges emerged in healthcare, family, school, and peer domains amid fragmented and under-resourced HIV and mental health services in socio-politically fraught environments. We identified strategic opportunities and initiatives in development and integration of youth-friendly HIV and mental health services; programmes to promote parent-adolescent communication about sex and HIV; and teacher training and resources to advance HIV and mental health awareness, serve as first-responders, and provide community referrals. Youth-led peer education programmes and LGBT-networks were central to the HIV response-promoting HIV prevention, sexual health, and mental health awareness for young people, and resilience and socioeconomic empowerment of peer educators themselves-thereby transforming sociocultural and political contexts of vulnerability.

Identifying the climatic drivers of honey bee disease in England and Wales.

Honey bee colony health has received considerable attention in recent years, with many studies highlighting multifactorial issues contributing to colony losses. Disease and weather are consistently highlighted as primary drivers of colony loss, yet little is understood about how they interact. Here, we combined disease records from government honey bee health inspections with meteorological data from the CEDA to identify how weather impacts EFB, AFB, CBP, varroosis, chalkbrood and sacbrood. Using R-INLA, we determined how different meteorological variables influenced disease prevalence and disease risk. Temperature caused an increase in the risk of both varroosis and sacbrood, but overall, the weather had a varying effect on the six honey bee diseases. The risk of disease was also spatially varied and was impacted by the meteorological variables. These results are an important step in identifying the impacts of climate change on honey bees and honey bee diseases.

Key recommendations to strengthen public-private partnership for adolescent health in resource constrained settings: Formative qualitative inquiry in Mongolia, Myanmar and the Philippines.

BACKGROUND: Public health services can be inaccessible for adolescents. The private sector provides many services, but often in parallel to the public sector. This study aimed to understand current private sector engagement in adolescent health service delivery and develop recommendations to strengthen partnerships. METHODS: The study focussed on Mongolia, Myanmar and the Philippines. An initial participatory workshop in each country was followed by semi-structured key-informant interviews (32 in total) with public and private sector actors and adolescents to explore: perceptions of the public and private sectors, strengths and challenges, existing models of partnership, and insights for successful public-private partnership (PPP). Interview transcripts were analysed thematically, with findings and recommendations verified through a second workshop in Mongolia and the Philippines. FINDINGS: The private sector already plays a significant role in adolescent health care, and stakeholders reported a genuine willingness for partnership. Strengthened PPP was identified as necessary to improve service accessibility and quality for adolescents, unburden the public sector and introduce new technologies, with advantages for the private sector including improved access to training and resources, and an enhanced public image. Recommendations for strengthened PPP included the need to establish the foundations for partnership, clearly define roles and co-ordinate stakeholders, ensure capacity and sustainability, and monitor and evaluate efforts. INTERPRETATION: This is the first comprehensive study of public-private partnership for adolescent health in the Asia Pacific region. It identifies stakeholders are willing for stronger partnerships and the benefits this partnership will bring. We define eight key recommendations to enable this partnership across sectors.

Recolonization by Slugs: Vertical and Horizontal Dispersal by the Field Slug, Deroceras reticulatum.

Following treatment with molluscicides or other controls, slugs can recolonize a site very quickly, but the proportion of the colonizing slugs moving from adjacent areas (horizontal dispersal) and the proportion from within the soil (vertical dispersal) has not previously been established. At a grassland site, barriers were used to exclude and trap slugs in order to estimate horizontal and vertical movement over a period of 32 months. For the first 15 months vertical movement made a significant contribution to the slugs recolonizing a grassland area. The ecological mechanisms occurring and the implications for the control of slugs are discussed.

Alarmingly High HIV Prevalence Among Adolescent and Young Men Who have Sex with Men (MSM) in Urban Indonesia.

Indonesia's HIV epidemic is concentrated among key populations. While prevalence among men who have sex with men (MSM) is high, transmission among young MSM (15-24-years-old) remains poorly understood. We conducted a respondent driven sampling survey of 211 young MSM in urban Bandung, Indonesia in 2018-2019 to estimate HIV prevalence and associated risk factors. Thirty percent of young MSM were HIV antibody positive. This is nearly 100-fold greater than Indonesia's population prevalence and sevenfold higher than average estimates for young MSM across Asia and the Pacific Region. Individual risk factors associated with HIV infection were being 20-24 years old, having a steady partner and preferring the receptive position during sex. Issues of stigma, discrimination and social exclusion were common. Few young MSM who were open with friends and family members about their sexual identity. Among those that were, close to half reported experiencing feelings of aversion from these groups. Wider structural factors that reduce social tolerance, restrict the rights of young MSM and compel concealment of sexual identity are likely to fuel high-risk behaviors and limit access to essential testing care and support services including pre-exposure prophylaxis which is not yet widely available. Urgent health, social, legal and political actions are required to respond to these factors and reduce the disproportionate contribution of young MSM to Indonesia's HIV epidemic.

Geo-epidemiology and environmental co-variate mapping of primary biliary cholangitis and primary sclerosing cholangitis.

BACKGROUND & AIMS: Autoimmune liver disease (AILD) is thought to result from a complex interplay between genetics and the environment. Studies to date have focussed on primary biliary cholangitis (PBC) and demonstrated higher disease prevalence in more urban, polluted, and socially deprived areas. This study utilises a large cohort of patients with PBC and primary sclerosing cholangitis (PSC) to investigate potential environmental contributors to disease and to explore whether the geo-epidemiology of PBC and PSC are disease-specific or pertain to cholestatic AILD in general. METHODS: All adult patients with PBC and PSC in a tightly defined geographical area within the UK were identified. Point- and area-based analyses and structural equation modelling (SEM) were used to investigate for disease clustering and examine for relationships between prevalence, distribution of environmental contaminants, and socio-economic status. RESULTS: We identified 2,150 patients with PBC and 472 with PSC. Significant spatial clustering was seen for each disease. A high prevalence of PBC was found in urban, post-industrial areas with a strong coal-mining heritage and increased environmental cadmium levels, whereas a high PSC prevalence was found in rural areas and inversely associated with social deprivation. CONCLUSIONS: This study demonstrates spatial clustering of PBC and PSC and adds to our understanding of potential environmental co-variates for both diseases. Disease clustering, within the same geographical area but over different scales, is confirmed for each disease with distinct risk profiles identified and associations with separate putative environmental factors and socio-economic status. This suggests that different triggers and alternative pathways determine phenotypic expression of autoimmunity in the affected population. Co-variate analysis points towards the existence of specific disease triggers. LAY SUMMARY: This study looked for potential environmental triggers in patients with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) living in the north-east of England and north Cumbria. We found that PBC was more common in urban areas with a history of coal mining and high levels of cadmium whereas PSC was more common in rural areas with lower levels of social deprivation.

Effects of Primary Biliary Cholangitis on Quality of Life and Health Care Costs in the United Kingdom.

BACKGROUND & AIMS: There have been few high-quality studies of the costs, preference-based health-related quality of life (HRQoL) and cost effectiveness of treatments for primary biliary cholangitis (PBC). We aimed to estimate the marginal effects of PBC complications and symptoms, accounting for treatment, on HRQoL and the annual cost of health care in the United Kingdom (UK). These are essential components for evaluation of cost effectiveness and this information will aid in evaluation of new treatments. METHODS: Questionnaires were mailed to 4583 participants in the UK-PBC research cohort and data were collected on HRQoL and use of the National Health Service (NHS) in the UK from 2015 through 2016. HRQoL was measured using the EQ-5D-5L instrument. The annual cost of resource use was calculated using unit costs obtained from NHS sources. We performed econometric analyses to determine the effects of treatment, symptoms, complications, liver transplantation status, and patient characteristics on HRQoL and annual costs. RESULTS: In an analysis of data from 2240 participants (over 10% of all UK PBC patients), we found that PBC symptoms have a considerable effect on HRQoL. Ursodeoxycholic acid therapy was associated with significantly higher HRQoL regardless of response status. Having had a liver transplant and ascites were also independently associated with reduced HRQoL. Having had a liver transplant (US$4294) and esophageal varices (US$3401) were the factors with the two greatest mean annual costs to the NHS. Symptoms were not independently associated with cost but were associated with reduction in HRQoL for patients, indicating the lack of effective treatments for PBC symptoms. CONCLUSIONS: In an analysis of data from 2240 participants in the UK PBC, we found that HRQoL and cost estimates provide greater insight into the relative importance of PBC-related symptoms and complications. These findings provide estimates for health technology assessments of new treatments for PBC.

Not All Slugs Are the Same: Variation in Growth and Development of the Slug Deroceras reticulatum.

Models to forecast slug populations make assumptions about growth and mortality in response to environmental factors. To refine these models, the growth trajectories and survival of Deroceras reticulatum, a worldwide pest, hatching in spring and autumn were compared at three rearing temperatures (ambient, 12 °C and 15 °C). Deroceras reticulatum reared under identical conditions showed great variation in growth and strong bimodality in growth rates. At all rearing temperatures, growth was influenced by hatching season; in all cases, fast growers dominated in autumn and slow growers dominated in spring. Survival was influenced by hatching season: autumn-born slugs survived better at ambient temperatures, but spring-born slugs had better survival at 15 °C. Deroceras reticulatum may be partitioned into "slow growers" and "fast growers". Fast growers responded to warmer conditions, growing to large sizes. Slow growers, in contrast, gained weight at comparable rates to ambient reared slugs, regardless of the elevated constant temperatures. The peaks of slug activity in autumn and spring are possibly not distinct generations as some slugs may mature early/late and slip into the alternative cohort. Rather, the observed autumn and spring peaks in slug numbers may be a response of a mixed-age population to the favourable environmental conditions at that time.

Chronic bee paralysis as a serious emerging threat to honey bees.

Chronic bee paralysis is a well-defined viral disease of honey bees with a global distribution that until recently caused rare but severe symptomatology including colony loss. Anecdotal evidence indicates a recent increase in virus incidence in several countries, but no mention of concomitant disease. We use government honey bee health inspection records from England and Wales to test whether chronic bee paralysis is an emerging infectious disease and investigate the spatiotemporal patterns of disease. The number of chronic bee paralysis cases increased exponentially between 2007 and 2017, demonstrating chronic bee paralysis as an emergent disease. Disease is highly clustered spatially within most years, suggesting local spread, but not between years, suggesting disease burnt out with periodic reintroduction. Apiary and county level risk factors are confirmed to include scale of beekeeping operation and the history of honey bee imports. Our findings offer epidemiological insight into this damaging emerging disease.

High Risk Behaviors for HIV and STIs Among Men Who Have Sex with Men Aged 15-19 Years - Guangzhou City and Tianjin Municipality, China, 2018.

WHAT IS ALREADY KNOWN ON THIS TOPIC?: There has been a steady increase of new reported HIV infections in individuals aged 15-24 years, primarily from self-reported men who have sex with men (MSM). WHAT IS ADDED BY THIS REPORT?: MSM aged 15-19 years practiced behaviors that put them at high risk for HIV and other sexually transmitted infections (STIs). Systems to address their unique risks and vulnerabilities in both school settings and in high impact HIV interventions may be inadequate. WHAT ARE THE IMPLICATIONS FOR PUBLIC HEALTH PRACTICE?: Special needs of MSM aged 15-19 years must be met by starting sex education in junior high school and sensitizing health workers in and out of school settings on quality counselling, testing, and referral. Piloting approaches that address age of consent issues are also suggested.

How to Observe Users' Movements in Virtual Environments: Viewpoint Control in a Power Wheelchair Simulator.

OBJECTIVE: We describe a networked, two-user virtual reality (VR) power wheelchair (PWC) simulator system in which an actor (client) and an observer (clinician) meet. We then present a study with 15 observers (expert clinicians) evaluating the effect of three principal forms of viewpoint control (egocentric-egomotion, egocentric-tethered, and client-centric) on the observer's assessment of driving tasks in a virtual environment (VE). BACKGROUND: VR allows for the simulation and assessment of real-world tasks in a controlled, safe, and repeatable environment. Observing users' movement behavior in such a VE requires appropriate viewpoint control for the observer. The VR viewpoint user interface should allow an observer to make judgments equivalent or even superior to real-world situations. METHOD: A purpose-built VR PWC simulator was developed. In a series of PWC driving tasks, we measured the perceived ease of use and sense of presence of the observers and compared the virtual assessment with real-world "gold standard" scores, including confidence levels in judgments. RESULTS: Findings suggest that with more immersive techniques, such as egomotion and tethered egocentric viewpoints, judgments are both more accurate and more confident. The ability to walk and/or orbit around the view significantly affected the observers' sense of presence. CONCLUSION: Incorporating the observer into the VE, through egomotion, is an effective method for assessing users' behavior in VR with implications for the transferability of virtual experiences to the real world. APPLICATION: Our application domain serves as a representative example for tasks where the movement of users through a VE needs to be evaluated.

Evaluation of Personal Exposure to Surgical Smoke Generated from Electrocautery Instruments: A Pilot Study.

Hospital technician surgical smoke exposures during several types of electrocautery-based procedures were evaluated. Personal and area air sampling was performed for 106 individual analytes including ultrafine particulate matter (UFP), volatile organic compounds, polycyclic aromatic hydrocarbons, phenol, aldehydes, carbon monoxide, hydrogen sulfide, and hydrogen cyanide. Acetone, d-limonene, ethanol, ethyl acetate, and fluorene were measured in surgical suites at concentrations 1.1- to 3.7-fold higher than those observed in background. Benzene, α-pinene, methylene chloride, and n-hexane were measured in the absence of a detectable background concentration. All analytes were measured at concentrations that were <1% of the corresponding US federal and state 8-h permissible exposure limits (PELs), if PELs existed. Full-shift average UFP concentrations ranged from 773 to 2257 particles/cm3, approximately one order of magnitude higher than surgical suite background concentrations. A comparison of two breast reduction procedures suggested that the use of smoke evacuators reduced UFP exposure by 6-fold. We concluded that selection and evaluation of key hazards, particularly UFP, under a variety of experimental conditions would be beneficial to elucidate potential health effects and causes osf employee complaints. Recommendations for successful sampling campaigns in future surgical smoke occupational exposure studies are provided. We also recommend the continued use of engineering controls, local exhaust ventilation, and surgical N95 respirators to reduce personal exposures to UFP in surgical smoke.

Transmission routes of rare seasonal diseases: the case of norovirus infections.

Norovirus (NoV) is the most commonly recognized cause of acute gastroenteritis, with over a million cases globally per year. While usually self-limiting, NoV poses a substantial economic burden because it is highly contagious and there are multiple transmission routes. Infection occurs through inhalation of vomitus; faecal-oral spread; and food, water and environmental contamination. While the incidence of the disease is predictably seasonal, much less is known about the relative contribution of the various exposure pathways in causing disease. Additionally, asymptomatic excretion and viral shedding make forecasting disease burden difficult. We develop a novel stochastic dynamic network model to investigate the contributions of different transmission pathways in multiple coupled social networks representing schools, hospitals, care-homes and family households in a community setting. We analyse how the networks impact on transmission. We used ward-level demographic data from Northumberland, UK to create a simulation cohort. We compared the results with extant data on NoV cases from the IID2 study. Connectivity across the simulated cohort was high. Cases of NoV showed marked seasonality, peaking in early winter and declining through the summer. For the first time, we show that fomites and food appear to be the most important exposure routes in determining the population burden of disease. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'. This theme issue is linked with the earlier issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'.

Staphylococcal resistance profiles in deep infection following primary hip and knee arthroplasty: a study using the NJR dataset.

INTRODUCTION: This study aimed to (1) report the rates of resistance against a variety of antibiotics for pure Staphylococcal infections, and (2) examine the impact of ALBC use at primary surgery has on resistance patterns for patients undergoing first-time revision of primary hip and knee arthroplasty for indication of infection. MATERIALS AND METHODS: Data from the National Joint Registry database for England and Wales were linked to microbiology data held by Public Health England to identify a consecutive series of 258 primary hip and knee arthroplasties performed between April 2003 and January 2014 that went on to have a revision for Staphylococcal deep periprosthetic infection. Multivariate binary logistic regression was used to study predictors of microorganism resistance to a range of antimicrobials. RESULTS: After adjusting for patient and surgical factors, multivariate analysis showed the use of gentamicin-loaded bone cement at the primary surgery was associated with a significant increase in the risk of Staphylococcal gentamicin resistance (odds ratio 8.341, 95% CI 2.297-30.292, p = 0.001) and methicillin resistance (odds ratio 3.870, 95% CI 1.319-11.359, p = 0.014) at revision for infection. CONCLUSIONS: Clinicians must anticipate the possibility of antibiotic resistance to ALBC utilised at primary surgery.

Climate, human behaviour or environment: individual-based modelling of Campylobacter seasonality and strategies to reduce disease burden.

BACKGROUND: With over 800 million cases globally, campylobacteriosis is a major cause of food borne disease. In temperate climates incidence is highly seasonal but the underlying mechanisms are poorly understood, making human disease control difficult. We hypothesised that observed disease patterns reflect complex interactions between weather, patterns of human risk behaviour, immune status and level of food contamination. Only by understanding these can we find effective interventions. METHODS: We analysed trends in human Campylobacter cases in NE England from 2004 to 2009, investigating the associations between different risk factors and disease using time-series models. We then developed an individual-based (IB) model of risk behaviour, human immunological responses to infection and environmental contamination driven by weather and land use. We parameterised the IB model for NE England and compared outputs to observed numbers of reported cases each month in the population in 2004-2009. Finally, we used it to investigate different community level disease reduction strategies. RESULTS: Risk behaviours like countryside visits (t = 3.665, P < 0.001 and t = - 2.187, P = 0.029 for temperature and rainfall respectively), and consumption of barbecued food were strongly associated with weather, (t = 3.219, P = 0.002 and t = 2.015, P = 0.045 for weekly average temperature and average maximum temperature respectively) and also rain (t = 2.254, P = 0.02527). This suggests that the effect of weather was indirect, acting through changes in risk behaviour. The seasonal pattern of cases predicted by the IB model was significantly related to observed patterns (r = 0.72, P < 0.001) indicating that simulating risk behaviour could produce the observed seasonal patterns of cases. A vaccination strategy providing short-term immunity was more effective than educational interventions to modify human risk behaviour. Extending immunity to 1 year from 20 days reduced disease burden by an order of magnitude (from 2412-2414 to 203-309 cases per 50,000 person-years). CONCLUSIONS: This is the first interdisciplinary study to integrate environment, risk behaviour, socio-demographics and immunology to model Campylobacter infection, including pathways to mitigation. We conclude that vaccination is likely to be the best route for intervening against campylobacteriosis despite the technical problems associated with understanding both the underlying human immunology and genetic variation in the pathogen, and the likely cost of vaccine development.

Oropharyngeal Microbiota in Frail Older Patients Unaffected by Time in Hospital.

Respiratory tract infections are the commonest nosocomial infections, and occur predominantly in frailer, older patients with multiple comorbidities. The oropharyngeal microbiota is the major reservoir of infection. This study explored the relative contributions of time in hospital and patient demographics to the community structure of the oropharyngeal microbiota in older patients with lower limb fracture. We collected 167 throat swabs from 53 patients (mean age 83) over 14 days after hospitalization, and analyzed these using 16S rRNA gene sequencing. We calculated frailty/comorbidity indices, undertook dental examinations and collected data on respiratory tract infections. We analyzed microbial community composition using correspondence (CA) and canonical correspondence analysis. Ten patients were treated for respiratory tract infection. Microbial community structure was related to frailty, number of teeth and comorbidity on admission, with comorbidity exerting the largest effect. Time in hospital neither significantly changed alpha (t = -0.910, p = 0.365) nor beta diversity (CA1 t = 0.022, p = 0.982; CA2 t = -0.513, p = 0.609) of microbial communities in patient samples. Incidence of respiratory pathogens were not associated with time in hospital (t = -0.207, p = 0.837), nor with alpha diversity of the oral microbiota (t = -1.599, p = 0.113). Patient characteristics at admission, rather than time in hospital, influenced the community structure of the oral microbiota.

Mechanisms Affecting the Gut of Preterm Infants in Enteral Feeding Trials.

Large randomized controlled trials (RCTs) in preterm infants offer unique opportunities for mechanistic evaluation of the risk factors leading to serious diseases, as well as the actions of interventions designed to prevent them. Necrotizing enterocolitis (NEC) a serious inflammatory gut condition and late-onset sepsis (LOS) are common feeding and nutrition-related problems that may cause death or serious long-term morbidity and are key outcomes in two current UK National Institutes for Health Research (NIHR) trials. Speed of increasing milk feeds trial (SIFT) randomized preterm infants to different rates of increases in milk feeds with a primary outcome of survival without disability at 2 years corrected age. Enteral lactoferrin in neonates (ELFIN) randomizes infants to supplemental enteral lactoferrin or placebo with a primary outcome of LOS. This is a protocol for the mechanisms affecting the gut of preterm infants in enteral feeding trials (MAGPIE) study and is funded by the UK NIHR Efficacy and Mechanistic Evaluation programme. MAGPIE will recruit ~480 preterm infants who were enrolled in SIFT or ELFIN. Participation in MAGPIE does not change the main trial protocols and uses non-invasive sampling of stool and urine, along with any residual resected gut tissue if infants required surgery. Trial interventions may involve effects on gut microbes, metabolites (e.g., short-chain fatty acids), and aspects of host immune function. Current hypotheses suggest that NEC and/or LOS are due to a dysregulated immune system in the context of gut dysbiosis, but mechanisms have not been systematically studied within large RCTs. Microbiomic analysis will use next-generation sequencing, and metabolites will be assessed by mass spectrometry to detect volatile organic and other compounds produced by microbes or the host. We will explore differences between disease cases and controls, as well as exploring the actions of trial interventions. Impacts of this research are multiple: translation of knowledge of mechanisms promoting gut health may explain outcomes or suggest alternate strategies to improve health. Results may identify new non-invasive diagnostic or monitoring techniques, preventative or treatment strategies for NEC or LOS, or provide data useful for risk stratification in future studies. Mechanistic evaluation might be especially informative where there are not clear effects on the primary outcome (ISRCTN 12554594).

Inadequate pre-operative glycaemic control in patients with diabetes mellitus adversely influences functional recovery after total knee arthroplasty : Patients with impaired glycaemic control exhibit poorer functional outcomes at 1-year post-arthroplasty.

PURPOSE: Whilst inadequate glycaemic control is associated with an increase in perioperative complications following total knee arthroplasty, the impact of glycaemic control in this at-risk patient group remains ill-defined. Identification of at-risk patients would allow targeted pre-operative glycaemic control intervention. METHODS: One hundred consecutive patients with a diagnosis of diabetes mellitus and one hundred age, sex and BMI matched patients without diabetes undergoing total knee arthroplasty in a single institution were analysed between 2008 and 2013. Inadequate glycaemic control was defined as having an HbA1c of greater than 64 mmol/mol (8.0 % NGSP) measured within the 3 months before surgery. Patient demographics, diabetes management and complications of diabetes were recorded and used as explanatory variables to deliver a generalised linear model. This allows for relationships to be defined between change in patient-reported function (SF-36, WOMAC) and these explanatory variables. RESULTS: The patient group with concomitant diabetes exhibited smaller improvements in WOMAC and SF-36 physical component summary at 1 year after knee arthroplasty. This effect was most pronounced in the subset of patients with inadequate glycaemic control recorded in the early pre-operative period. CONCLUSION: Patients with diabetes, particularly those with inadequate glycaemic control, exhibit less improvement at 1 year following knee arthroplasty than patients without diabetes mellitus. Clinical focus on modulating this factor in this at-risk group is warranted. LEVEL OF EVIDENCE: III.

GP contact with patients after treatment for hip fracture: frequency and determinants.

BACKGROUND: Patients with hip fracture have complex medical issues, both at the time of admission and after discharge from hospital. We have observed a surge in patient-initiated and carer-initiated contacts with general physicians (GPs) for periods longer than those usually reported, in a series of patients sustaining fractures from July 2008 to September 2013. OBJECTIVES: To establish (1) the frequency of contact with GPs (primary outcome) and (2) the factors influencing the frequency of different modes of contact. METHODS: Ten GP practices in West Northumberland were asked to retrospectively identify patients sustaining hip fractures, and to provide data on the number of GP contacts (patient visits to GP, telephone consultations, GP visits to patient's home) up to 1 year before and 1 year after fracture. Generalised linear models (GLM) were constructed using number of postfracture GP contacts as response variable; age, gender, residential status, number of prefracture contacts and days to contact postfracture were covariates. RESULTS: Each patient recorded cumulative 8.4 GP contacts before and 10.79 contacts after fracture. There were significantly more telephone contacts with GPs and GP home visits, but significantly fewer patient visits to GP clinics. In the GLM analysis, patient age and number of prefracture GP contacts predicted all types of postfracture contacts, while gender was not. Patients discharged home visited their GPs five times more frequently than those discharged to institutional care. CONCLUSIONS: After hip fractures, telephone contacts and GP visits to patients' homes increase, but patient visits to GP clinics decrease, influenced by age and residential status.

Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation.

BACKGROUND: For people with localised prostate cancer, active treatments are effective but have significant side effects. Minimally invasive treatments that destroy (or ablate) either the entire gland or the part of the prostate with cancer may be as effective and cause less side effects at an acceptable cost. Such therapies include cryotherapy, high-intensity focused ultrasound (HIFU) and brachytherapy, among others. OBJECTIVES: This study aimed to determine the relative clinical effectiveness and cost-effectiveness of ablative therapies compared with radical prostatectomy (RP), external beam radiotherapy (EBRT) and active surveillance (AS) for primary treatment of localised prostate cancer, and compared with RP for salvage treatment of localised prostate cancer which has recurred after initial treatment with EBRT. DATA SOURCES: MEDLINE (1946 to March week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (29 March 2013), EMBASE (1974 to week 13, 2013), Bioscience Information Service (BIOSIS) (1956 to 1 April 2013), Science Citation Index (1970 to 1 April 2013), Cochrane Central Register of Controlled Trials (CENTRAL) (issue 3, 2013), Cochrane Database of Systematic Reviews (CDSR) (issue 3, 2013), Database of Abstracts of Reviews of Effects (DARE) (inception to March 2013) and Health Technology Assessment (HTA) (inception to March 2013) databases were searched. Costs were obtained from NHS sources. REVIEW METHODS: Evidence was drawn from randomised controlled trials (RCTs) and non-RCTs, and from case series for the ablative procedures only, in people with localised prostate cancer. For primary therapy, the ablative therapies were cryotherapy, HIFU, brachytherapy and other ablative therapies. The comparators were AS, RP and EBRT. For salvage therapy, the ablative therapies were cryotherapy and HIFU. The comparator was RP. Outcomes were cancer related, adverse effects (functional and procedural) and quality of life. Two reviewers extracted data and carried out quality assessment. Meta-analysis used a Bayesian indirect mixed-treatment comparison. Data were incorporated into an individual simulation Markov model to estimate cost-effectiveness. RESULTS: The searches identified 121 studies for inclusion in the review of patients undergoing primary treatment and nine studies for the review of salvage treatment. Cryotherapy [3995 patients; 14 case series, 1 RCT and 4 non-randomised comparative studies (NRCSs)], HIFU (4000 patients; 20 case series, 1 NRCS) and brachytherapy (26,129 patients; 2 RCTs, 38 NRCSs) studies provided limited data for meta-analyses. All studies were considered at high risk of bias. There was no robust evidence that mortality (4-year survival 93% for cryotherapy, 99% for HIFU, 91% for EBRT) or other cancer-specific outcomes differed between treatments. For functional and quality-of-life outcomes, the paucity of data prevented any definitive conclusions from being made, although data on incontinence rates and erectile dysfunction for all ablative procedures were generally numerically lower than for non-ablative procedures. The safety profiles were comparable with existing treatments. Studies reporting the use of focal cryotherapy suggested that incontinence rates may be better than for whole-gland treatment. Data on AS, salvage treatment and other ablative therapies were too limited. The cost-effectiveness analysis confirmed the uncertainty from the clinical review and that there is no technology which appears superior, on the basis of current evidence, in terms of average cost-effectiveness. The probabilistic sensitivity analyses suggest that a number of ablative techniques are worthy of further research. LIMITATIONS: The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction. CONCLUSIONS: The findings indicate that there is insufficient evidence to form any clear recommendations on the use of ablative therapies in order to influence current clinical practice. Research efforts in the use of ablative therapies in the management of prostate cancer should now be concentrated on the performance of RCTs and the generation of standardised outcomes. STUDY REGISTRATION: This study is registered as PROSPERO CRD42012002461. FUNDING: The National Institute for Health Research Health Technology Assessment programme.