Beyond MPOWER: a systematic review of population-level factors that affect European tobacco smoking rates.

BACKGROUND: Population-level factors within and beyond the scope of the World Health Organization's (WHO) MPOWER policy package have significant impacts on smoking rates. However, no synthesis of the existing evidence exists. This systematic review identifies population-level factors that influence cigarette smoking rates in European countries. METHODS: We searched the ProQuest database collection for original, peer-reviewed quantitative evaluations that investigated the effects of population-level exposures on smoking rates in European countries. Of the 3122 studies screened, 62 were ultimately included in the review. A standardized data extraction form was used to identify key characteristics of each study including publication year, years evaluated, countries studied, population characteristics, study design, data sources, analytic methods, exposure studied, relevant covariates and effects on tobacco smoking outcomes. RESULTS: One hundred and fifty-five population-level exposures were extracted from the 62 studies included in the review, 99 of which were related to WHO MPOWER measures. An additional 56 exposures fell into eight policy realms: economic crises, education policy, macro-economic factors, non-MPOWER tobacco regulations, population welfare, public policy, sales to minors and unemployment rates. About one-half of the MPOWER exposures affected smoking rates (55/99) and did so in an overwhelmingly positive way (55/55). Over three-quarters of the non-MPOWER exposures were associated with statistically significant changes in smoking outcomes (43/56), with about two-thirds of these exposures leading to a decrease in smoking (29/43). CONCLUSIONS: Population-level factors that fall outside of the WHO's MPOWER measures are an understudied research area. The impacts of these factors on tobacco control should be considered by policymakers.

Classifying European cigarette consumption trajectories from 1970 to 2015.

OBJECTIVES: To systematically code and classify longitudinal cigarette consumption trajectories in European countries since 1970. DESIGN: Blinded duplicate qualitative coding of periods of year-over-year relative increase, plateau, and decrease of national per capita cigarette consumption and categorisation of historical cigarette consumption trajectories based on longitudinal patterns emerging from the data. SETTING: 41 countries or former countries in the European region for which data are available between 1970 and 2015. RESULTS: Regional trends in longitudinal consumption patterns identify stable or decreasing consumption throughout Northern, Western and Southern European countries, while Eastern and Southeastern European countries experienced much greater instability. The 11 emergent classes of historical cigarette consumption trajectories were also regionally clustered, including a distinctive inverted U or sine wave pattern repeatedly emerging from former Soviet and Southeastern European countries. CONCLUSIONS: The open-access data produced by this study can be used to conduct comparative international evaluations of tobacco control policies by separating impacts likely attributable to gradual long-term trends from those more likely attributable to acute short-term events. The complex, regionally clustered historical trajectories of cigarette consumption in Europe suggest that the enduring normative frame of a gently sloping downward curve in cigarette consumption can offer a false sense of security among policymakers and can distract from plausible causal mechanisms among researchers. These multilevel and multisectoral causal mechanisms point to the need for a greater understanding of the political economy of regional and global determinants of cigarette consumption.

Hierarchical assembly of pH-responsive surfactant-cyclodextrin complexes.

In this work, the inclusion complexes of alkyl ethoxy carboxylates with α-cyclodextrin (αCD) and ß-cyclodextrin (ßCD) were investigated. The thermodynamics of the complexation process was probed by isothermal titration calorimetry (ITC) and volumetry as a function of the degree of ionization of the surfactant. The complexation process was shown to be an enthalpically driven pH-independent process. For both types of cyclodextrins, the complexes were found to spontaneously self-assemble into highly-ordered supramolecular aggregates probed by small-angle neutron scattering and electron and optical microscopy. Herein, we report the formation of thin platelets for nonionized surfactant systems and equally spaced multilayered hollow cylinders for ionized systems in a hierarchical self-assembly process. In addition, the analysis allowed unveiling the effect of the number of ethylene oxides in the surfactants and the CD cavity size on the morphology of the aggregates. Finally, this study also highlights the importance of examining the tuning parameters' influence on the short and long-range interactions involved in the control of the assembly process.

The COVID-19 Inventory: Measuring anxiety related to illness pandemic across college males and females.

BACKGROUND: Due to close proximity in dormitories, classes, and social activities, college students have been identified as a vulnerable population throughout the COVID-19 pandemic of 2020. OBJECTIVES: This study tested properties of a new COVID-19 Inventory (C-19-I). It was expected that the measure would show acceptable validity and reliability, females would report greater COVID-19 anxiety than males, and the addition of gender would improve a regression model of COVID-19 anxiety. METHOD: Participants were 201 college undergraduates who completed multiple self-report measures and two snack selection tasks. RESULTS: The C-19-I showed a multifactor solution and acceptable psychometric properties. Females scored higher than males and were more likely than males to select a healthy snack after responding to questions about illness and contamination. CONCLUSIONS: This study validates a new measure of COVID-19 anxiety and contributes to a deeper understanding of how college adults respond to pandemic illness.

Is Malaria an Important Cause of Death among Adults?

A long-held assumption has been that nearly all malaria deaths in high-transmission areas are of children younger than 5 years and pregnant women. Most global malaria mortality estimates incorporate this assumption in their calculations. In 2010, the Indian Million Death Study, which assigns cause of death by verbal autopsy (VA), challenged the reigning perception, producing a U-shaped mortality age curve, with rates rising after age 45 years in areas of India with substantial malaria transmission. Similar patterns are seen in Africa in the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) network, also relying on VA. Whether these results are accurate or are misidentified deaths can be resolved by improving the evidence for assigning causes for adult acute infectious deaths in high malaria transmission areas. The options for doing so include improving the accuracy of VA and adding postmortem biological evidence, steps we believe should be initiated without delay.

Validating mental health assessment in Kenya using an innovative gold standard.

With the growing burden of mental health disorders worldwide, alongside efforts to expand availability of evidence-based interventions, strategies are needed to ensure accurate identification of individuals suffering from mental disorders. Efforts to locally validate mental health assessments are of particular value, yet gold-standard clinical validation is costly, time-intensive, and reliant on available professionals. This study aimed to validate assessment items for mental distress in Kenya, using an innovative gold standard and a combination of culturally adapted and locally developed items. The mixed-method study drew on surveys and semi-structured interviews, conducted by lay interviewers, with 48 caregivers. Interviews were used to designate mental health "cases" or "non-cases" based on emotional health problems, identified through a collaborative clinical rating process with local input. Individual mental health survey items were evaluated for their ability to discriminate between cases and non-cases. Discriminant survey items included 23 items adapted from existing mental health assessment tools, as well as 6 new items developed for the specific cultural context. When items were combined into a scale, results showed good psychometric properties. The use of clinically rated semi-structured interviews provides a promising alternative gold standard that can help address the challenges of conducting diagnostic clinical validation in low-resource settings.

National Burden Estimates of healthy life lost in India, 2017: an analysis using direct mortality data and indirect disability data.

BACKGROUND: Many countries, including India, seek locally constructed disease burden estimates comprising mortality and loss of health to aid priority setting for the prevention and treatment of diseases. We created the National Burden Estimates (NBE) to provide transparent and understandable disease burdens at the national and subnational levels, and to identify gaps in knowledge. METHODS: To calculate the NBE for India, we combined 2017 UN death totals with national and subnational mortality rates for 2010-17 and causes of death from 211 166 verbal autopsy interviews in the Indian Million Death Study for 2010-14. We calculated years of life lost (YLLs) and years lived with disability (YLDs) for 2017 using published YLD-YLL ratios from WHO Global Health Estimates. We grouped causes of death into 45 groups, including ill-defined deaths, and summed YLLs and YLDs to calculate disability-adjusted life-years (DALYs) for these causes in eight age groups covering rural and urban areas and 21 major states of India. FINDINGS: In 2017, there were about 9·7 million deaths and 486 million DALYs in India. About three quarters of deaths and DALYs occurred in rural areas. More than a third of national DALYs arose from communicable, maternal, perinatal, and nutritional disorders. DALY rates in rural areas were at least twice those of urban areas for perinatal and nutritional conditions, chronic respiratory diseases, diarrhoea, and fever of unknown origin. DALY rates for ischaemic heart disease were greater in urban areas. Injuries caused 11·4% of DALYs nationally. The top 15 conditions that accounted for the most DALYs were mostly those causing mortality (ischaemic heart disease, perinatal conditions, chronic respiratory diseases, diarrhoea, respiratory infections, cancer, stroke, road traffic accidents, tuberculosis, and liver and alcohol-related conditions), with disability mostly due to a few conditions (nutritional deficiencies, neuropsychiatric conditions, vision and other sensory loss, musculoskeletal disorders, and genitourinary diseases). Every condition that was common in one part of India was uncommon elsewhere, suggesting state-specific priorities for disease control. INTERPRETATION: The NBE method quantifies disease burden using transparent, intuitive, and reproducible methods. It provides a simple, locally operable tool to aid policy makers in priority setting in India and other low-income and middle-income countries. The NBE underlines the need for many more countries to collect nationally representative cause of death data, paired with focused surveys of disability. FUNDING: Ministry of Health and Family Welfare, Government of India.

Geospatial, racial, and educational variation in firearm mortality in the USA, Mexico, Brazil, and Colombia, 1990-2015: a comparative analysis of vital statistics data.

BACKGROUND: Firearm mortality is a leading, and largely avoidable, cause of death in the USA, Mexico, Brazil, and Colombia. We aimed to assess the changes over time and demographic determinants of firearm deaths in these four countries between 1990 and 2015. METHODS: In this comparative analysis of firearm mortality, we examined national vital statistics data from 1990-2015 from four publicly available data repositories in the USA, Mexico, Brazil, and Colombia. We extracted medically-certified deaths and underlying population denominators to calculate the age-specific and sex-specific firearm deaths and the risk of firearm mortality at the national and subnational level, by education for all four countries, and by race or ethnicity for the USA and Brazil. Analyses were stratified by intent (homicide, suicide, unintentional, or undetermined). We quantified avoidable mortality for each country using the lowest number of subnational age-specific and period-specific death rates. FINDINGS: Between 1990 and 2015, 106·3 million medically-certified deaths were recorded, including 2 472 000 firearm deaths, of which 851 000 occurred in the USA, 272 000 in Mexico, 855 000 in Brazil, and 494 000 in Colombia. Homicides accounted for most of the firearm deaths in Mexico (225 000 [82·7%]), Colombia (463 000 [93·8%]), and Brazil (766 000 [89·5%]). Suicide accounted for more than half of all firearm deaths in the USA (479 000 [56·3%]). In each country, firearm mortality was highest among men aged 15-34 years, accounting for up to half of the total risk of death in that age group. During the study period, firearm mortality risks increased in Mexico and Brazil but decreased in the USA and Colombia, with marked national and subnational geographical variation. Young men with low educational attainment were at increased risk of firearm homicide in all four countries, and in the USA and Brazil, black and brown men, respectively, were at the highest risk. The risk of firearm homicide was 14 times higher in black men in the USA aged 25-34 years with low educational attainment than comparably-educated white men (1·52% [99% CI 1·50-1·54] vs 0·11% [0·10-0·12]), and up to four times higher than in comparably-educated men in Brazil, Colombia, and Mexico. In the USA, the risk of firearm homicide was more than 30 times higher in black men with post-secondary education than comparably educated white men. If countries could achieve the same firearm mortality rates nationally as in their lowest-burden states, 1 777 800 firearm deaths at all ages and in both sexes could be avoided, including 1 028 000 deaths in men aged 15-34 years. INTERPRETATION: Firearm mortality in the USA, Mexico, Brazil, and Colombia is highest among young adult men, and is strongly associated with race and ethnicity, and low education levels. Reductions in firearm deaths would improve life expectancy, particularly for black men in the USA, and would reduce racial and educational disparities in mortality. FUNDING: Canadian Institutes of Health Research and the University of Toronto Connaught Global Challenge.

Medication therapy management programs: promises and pitfalls.

BACKGROUND: Medication therapy management (MTM) is one form of a medication benefit program offered by public and private health providers and insurers. Although the term was first coined in 2003, MTM in its earlier forms has been used since the 1990s as a mechanism to improve health metrics for medically complex patients. Its role expanded with the passage of Medicare Part D, as a mandated component to help patients with multiple chronic conditions, high drug costs, and high utilization to improve the effectiveness and safety of their medication treatments.  OBJECTIVE: To review the evidence on MTM effectiveness in order to (a) provide information on its establishment and goals and (b) summarize research findings under 3 outcomes: economic, clinical, and humanistic.  METHODS: PubMed, a search engine service of the National Center for Biotechnology Information was utilized by trained research assistants to search for articles with the following key words: MTM, randomized controlled trials on MTM, evaluation of MTM, comprehensive medication review, medication action plan, special needs population, special needs plans, Medicaid, disease management, adherence, non-adherence, compliance, chronic conditions, disabling chronic conditions, and disability. Additional searches were conducted for key articles in references listed in the most recent review articles. The initial search identified nearly 300 articles. RESULTS: When evaluated, most studies found economic benefits, but the quality of research design and end point measures varied considerably across evaluations. Clinical outcomes encompassed a wide range of potential metrics, from service utilization, to individual patient and population outcomes, and quality of care. Quality measures such as provider-prescribing habits and medication adherence were frequently found to improve. As noted with the economic outcomes studies, overall rigor of study design was suboptimal, and often underpowered.  Few studies have focused on humanistic outcomes such as improved patient quality of life.  CONCLUSIONS: Evidence suggests that MTM services are a promising way to manage complex patients, but there are gaps in the literature largely because of the limited number of studies with strong designs. Stronger evaluation of MTM programs is warranted.

Quantitative analysis of membrane trafficking in regulation of Cdc42 polarity.

Vesicle delivery of Cdc42 has been proposed as an important mechanism for generating and maintaining Cdc42 polarity at the plasma membrane. This mechanism requires the density of Cdc42 on secretory vesicles to be equal to or higher than the plasma membrane polarity cap. Using a novel method to estimate Cdc42 levels on post-Golgi secretory vesicles in intact yeast cells, we: (1) determined that endocytosis plays an important role in Cdc42's association with secretory vesicles (2) found that a GFP-tag placed on the N-terminus of Cdc42 negatively impacts this vesicle association and (3) quantified the surface densities of Cdc42 on post-Golgi vesicles which revealed that the vesicle density of Cdc42 is three times more dilute than that at the polarity cap. This work suggests that the immediate consequence of secretory vesicle fusion with the plasma membrane polarity cap is to dilute the local Cdc42 surface density. This provides strong support for the model in which vesicle trafficking acts to negatively regulate Cdc42 polarity on the cell surface while also providing a means to recycle Cdc42 between the cell surface and internal membrane locations.

CTL induction of tumoricidal nitric oxide production by intratumoral macrophages is critical for tumor elimination.

To characterize mechanisms of CTL inhibition within an ocular tumor microenvironment, tumor-specific CTLs were transferred into mice with tumors developing within the anterior chamber of the eye or skin. Ocular tumors were resistant to CTL transfer therapy whereas skin tumors were sensitive. CTLs infiltrated ocular tumors at higher CTL/tumor ratios than in skin tumors and demonstrated comparable ex vivo effector function to CTLs within skin tumors indicating that ocular tumor progression was not due to decreased CTL accumulation or inhibited CTL function within the eye. CD11b(+)Gr-1(+)F4/80(-) cells predominated within ocular tumors, whereas skin tumors were primarily infiltrated by CD11b(+)Gr-1(-)F4/80(+) macrophages (Ms), suggesting that myeloid derived suppressor cells may contribute to ocular tumor growth. However, CD11b(+) myeloid cells isolated from either tumor site suppressed CTL activity in vitro via NO production. Paradoxically, the regression of skin tumors by CTL transfer therapy required NO production by intratumoral Ms indicating that NO-producing intratumoral myeloid cells did not suppress the effector phase of CTL. Upon CTL transfer, tumoricidal concentrations of NO were only produced by skin tumor-associated Ms though ocular tumor-associated Ms demonstrated comparable expression of inducible NO synthase protein suggesting that NO synthase enzymatic activity was compromised within the eye. Correspondingly, in vitro-activated Ms limited tumor growth when co-injected with tumor cells in the skin but not in the eye. In conclusion, the decreased capacity of Ms to produce NO within the ocular microenvironment limits CTL tumoricidal activity allowing ocular tumors to progress.

Method matters: systematic effects of testing procedure on visual working memory sensitivity.

Visual working memory (WM) is traditionally considered a robust form of visual representation that survives changes in object motion, observer's position, and other visual transients. This article presents data that are inconsistent with the traditional view. We show that memory sensitivity is dramatically influenced by small variations in the testing procedure, supporting the idea that representations in visual WM are susceptible to interference from testing. In the study, participants were shown an array of colors to remember. After a short retention interval, memory for one of the items was tested with either a same-different task or a 2-alternative-forced-choice (2AFC) task. Memory sensitivity was much lower in the 2AFC task than in the same-different task. This difference was found regardless of encoding similarity or of whether visual WM required a fine or coarse memory resolution. The 2AFC disadvantage was reduced when participants were informed shortly before testing which item would be probed. The 2AFC disadvantage diminished in perceptual tasks and was not found in tasks probing visual long-term memory. These results support memory models that acknowledge the labile nature of visual WM and have implications for the format of visual WM and its assessment.

Socioeconomic position, stress, and cortisol in relation to waist circumference in African American and white women.

OBJECTIVE: Abdominal fat deposition has been shown to be related to hypertension, dyslipidemia and diabetes. Studies have shown a correlation between cortisol (a stress hormone) and abdominal fat deposition. Low socioeconomic position (SEP) has also been shown to be related to abdominal fat deposition. It is hypothesized that chronic stress associated with low SEP leads to high cortisol levels which in turn lead to abdominal fat deposition. Previous research in this area has included mainly European subjects. The purpose of this study was to examine the evidence for the SEP-chronic stress-cortisol-abdominal fat hypothesis in a sample of African American and White American women. DESIGN: Data from the Regional Assessment Health Surveillance Study (RAHSS), a survey and physical examination of a representative sample of African American and White adults residing in six counties in Georgia, were utilized. The study population included 111 African American and 119 White women. Abdominal fat deposition was measured by waist circumference (inches). Education and income were the measures of SEP. Other exposures examined included serum cortisol, self-reported daily stress level, cigarette smoking, marital status, and number of children. Associations were examined using multiple linear regression models adjusted for age and body mass index (BMI). RESULTS: Among White women, less-educated women had a waist circumference 2.22 inches larger (P < .05) than more highly educated women. Among African American women, separated or divorced women (+2.29 in, P < .05) and widowed women (+3.13 in, P < .01) had larger waist circumferences than married women. No other factors were significantly associated with waist circumference. CONCLUSIONS: The SEP-chronic stress abdominal fat accumulation hypothesis was only partially supported by the data. Different stressors and pathways may be important in producing abdominal fat accumulation in African American and White women.

The "delay effect" of donning a gown during cardiopulmonary resuscitation in a simulation model.

OBJECTIVE: We sought to determine whether the use of currently issued gowns delays initiation of chest compressions and ventilations during cardiopulmonary resuscitation and whether simple gown modifications can reduce this delay. METHODS: Firefighter defibrillation instructors were allocated into pairs and videotaped while performing standardized cardiac arrest scenarios. Three scenarios were compared: "no gown," "standard gown" and "modified gown." Key time intervals were extracted from videotaped data. RESULTS: Ninety-five scenarios were analyzed. Mean time interval to chest compression was 39 seconds (95% confidence interval [CI] 34-43) for "no gown" scenarios, 71 seconds (95% CI 66-77) for "standard gown" scenarios and 59 seconds (95% CI 54-63) for "modified gown" scenarios (p < 0.001). Time to first ventilation was 146 seconds (95% CI 134-158), 238 seconds (95% CI 224-253) and 210 seconds (95% CI 198-223) in the 3 groups, respectively (p < 0.001). Post hoc testing showed that the time differences between all groups were statistically significant. CONCLUSION: Standard gowns protect front-line care providers but cause significant delays to chest compressions and ventilations, potentially increasing patient morbidity and mortality. Minor gown modifications, including pre-tied neck straps and longer waist ties that tie in front, allow for easier use and shorter delays to time-critical interventions. Future research is required to reduce care delays while maintaining adequate protection of emergency medical service providers from infectious disease.