Selection of confounding variables should not be based on observed associations with exposure

In observational studies, selection of confounding variables for adjustment is often based on observed baseline incomparability. The aim of this study was to evaluate this selection strategy. We used clinical data on the effects of inhaled long-acting beta-agonist (LABA) use on the risk of mortality among patients with obstructive pulmonary disease to illustrate the impact of selection of confounding variables for adjustment based on baseline comparisons. Among 2,394 asthma and COPD patients included in the analyses, the LABA ever-users were considerably older than never-users, but cardiovascular co-morbidity was equally prevalent (19.9% vs. 19.9%). Adjustment for cardiovascular co-morbidity status did not affect the crude risk ratio (RR) for mortality: crude RR 1.19 (95% CI 0.93–1.51) versus RR 1.19 (95% CI 0.94–1.50) after adjustment for cardiovascular co-morbidity. However, after adjustment for age (RR 0.95, 95% CI 0.76–1.19), additional adjustment for cardiovascular co-morbidity status did affect the association between LABA use and mortality (RR 1.01, 95% CI 0.80–1.26). Confounding variables should not be discarded based on balanced distributions among exposure groups, because residual confounding due to the omission of confounding variables from the adjustment model can be relevant

Risk of Cardiovascular Events and Death—Does Insurance Matter?

BACKGROUND: Many Americans lack health insurance. Despite good evidence that lack of insurance compromises access to care, few prospective studies examine its relationship to health outcomes. OBJECTIVE: To determine the relationship between insurance and cardiovascular outcomes and the relationship between insurance and selected process measures. DESIGN AND PARTICIPANTS: We used data from 15,792 participants in the Atherosclerosis Risk in Communities Study, a prospective cohort study. Participants were enrolled in 1987–1989 and returned for follow-up visits every 3 years, for a total of 4 visits. MAIN OUTCOME MEASURES: We estimated the hazard of myocardial infarction, stroke, and death associated with insurance status using Cox proportional hazard modeling. We used generalized estimating equations to examine the association between insurance status and risk of (1) reporting no routine physical examinations, (2) being unaware of a personal cardiovascular risk condition, and (3) inadequate control of cardiovascular risk conditions. RESULTS: Persons without insurance had higher rates of stroke (adjusted hazard ratio, 95% CI 1.22–2.22) and death (adjusted hazard ratio 1.26, 95% CI 1.03–1.53), but not myocardial infarction, than those who were insured. The uninsured were less likely to report routine physical examinations (adjusted risk ratio 1.13, 95% CI 1.08–1.18); more likely to be unaware of hypertension (adjusted risk ratio 1.12, 95% CI 1.00–1.25) and hyperlipidemia (adjusted risk ratio 1.11, 95% CI 1.03–1.19); and more likely to have poor blood pressure control (adjusted risk ratio 1.23, 95% CI 1.08–1.39). CONCLUSIONS: Lack of health insurance is associated with increased rates of stroke and death and with less awareness and control of cardiovascular risk conditions. Health insurance may improve cardiovascular risk factor awareness, control and outcomes

Linkage to HIV Care and Antiretroviral Therapy in Cape Town, South Africa

BACKGROUND: Antiretroviral therapy (ART) has been scaled-up rapidly in Africa. Programme reports typically focus on loss to follow-up and mortality among patients receiving ART. However, little is known about linkage and retention in care of individuals prior to starting ART. METHODOLOGY: Data on adult residents from a periurban community in Cape Town were collected at a primary care clinic and hospital. HIV testing registers, CD4 count results provided by the National Health Laboratory System and ART registers were linked. A random sample (n = 885) was drawn from adults testing HIV positive through antenatal care, sexual transmitted disease and voluntary testing and counseling services between January 2004 and March 2009. All adults (n = 103) testing HIV positive through TB services during the same time period were also included in the study. Linkage to HIV care was defined as attending for a CD4 count measurement within 6 months of HIV diagnosis. Linkage to ART care was defined as initiating ART within 6 months of HIV diagnosis in individuals with a CD4 count ≤200 cells/µl taken within 6 months of HIV diagnosis. FINDINGS: Only 62.6% of individuals attended for a CD4 count measurement within 6 months of testing HIV positive. Individuals testing through sexually transmitted infection services had the best (84.1%) and individuals testing on their own initiative (53.5%) the worst linkage to HIV care. One third of individuals with timely CD4 counts were eligible for ART and 66.7% of those were successfully linked to ART care. Linkage to ART care was highest among antenatal care clients. Among individuals not yet eligible for ART only 46.3% had a repeat CD4 count. Linkage to HIV care improved in patients tested in more recent calendar period. CONCLUSION: Linkage to HIV and ART care was low in this poor peri-urban community despite free services available within close proximity. More efforts are needed to link VCT scale-up to subsequent care

The Nevados de Payachata volcanic region (18°S/69°W, N. Chile)

Subduction-related volcanism in the Nevados de Payachata region of the Central Andes at 18°S comprises two temporally and geochemically distinct phases. An older period of magmatism is represented by glaciated stratocones and ignimbrite sheets of late Miocene age. The Pleistocene to Recent phase (≤0.3 Ma) includes the twin stratovolcanoes Volcan Pomerape and Volcan Parinacota (the Nevados de Payachata volcanic group) and two small centers to the west (i. e., Caquena and Vilacollo). Both stratovolcanoes consist of an older dome-and-flow series capped by an andesitic cone. The younger cone, i. e., V. Parinacota, suffered a postglacial cone collapse producing a widespread debris-avalanche deposit. Subsequently, the cone reformed during a brief, second volcanic episode. A number of small, relatively mafic, satellitic cinder cones and associated flows were produced during the most recent activity at V. Parinacota. At the older cone, i. e., V. Pomerape, an early dome sequence with an overlying isolated mafic spatter cone and the cone-forming andesitic-dacitic phase (mostly flows) have been recognized. The two Nevados de Payachata stratovolcanoes display continuous major- and trace-element trends from high-K 2 O basaltic andesites through rhyolites (53%–76% SiO 2 ) that are well defined and distinct from those of the older volcanic centers. Petrography, chemical composition, and eruptive styles at V. Parinacota differ between pre- and post-debris-avalanche lavas. Precollapse flows have abundant amphibole (at SiO 2 > 59 wt%) and lower Mg numbers than postcollapse lavas, which are generally less silicic and more restricted in composition. Compositional variations indicate that the magmas of the Nevados de Payachata volcanic group evolved through a combination of fractional crystallization, crustal assimilation, and intratrend magma mixing. Isotope compositions exhibit only minor variations. Pb-isotope ratios are relatively low ( 206 Pb/ 204 Pb = 17.95–18.20 and 208 Pb/ 204 Pb = 38.2–38.5); 87 Sr/ 86 Sr ratios range 0.70612–0.70707, 143 Nd/ 144 Nd ratios range 0.51238–0.51230, and γ 18 O SMOW values range from + 6.8% o to + 7.6% o SMOW. A comparison with other Central Volcanic Zone centers shows that the Nevados de Payachata magmas are unusually rich in Ba (up to 1800 ppm) and Sr (up to 1700 ppm) and thus represent an unusual chemical signature in the Andean arc. These chemical and isotope variations suggest a complex petrogenetic evolution involving at least three distinct components. Primary mantle-derived melts, which are similar to those generated by subduction processes throughout the Andean arc, are modified by deep crustal interactions to produce magmas that are parental to those erupted at the surface. These magmas subsequently evolve at shallower levels through assimilation-crystallization processes involving upper crust and intratrend magma mixing which in both cases were restricted to end members of low isotopic contrast.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47805/1/445_2005_Article_BF01073587.pd

Effects of laterally wedged insoles on symptoms and disease progression in medial knee osteoarthritis: a protocol for a randomised, double-blind, placebo controlled trial

<p>Abstract</p> <p>Background</p> <p>Whilst laterally wedged insoles, worn inside the shoes, are advocated as a simple, inexpensive, non-toxic self-administered intervention for knee osteoarthritis (OA), there is currently limited evidence to support their use. The aim of this randomised, double-blind controlled trial is to determine whether laterally wedges insoles lead to greater improvements in knee pain, physical function and health-related quality of life, and slower structural disease progression as well as being more cost-effective, than control flat insoles in people with medial knee OA.</p> <p>Methods/Design</p> <p>Two hundred participants with painful radiographic medial knee OA and varus malalignment will be recruited from the community and randomly allocated to lateral wedge or control insole groups using concealed allocation. Participants will be blinded as to which insole is considered therapeutic. Blinded follow up assessment will be conducted at 12 months after randomisation. The outcome measures are valid and reliable measures recommended for OA clinical trials. Questionnaires will assess changes in pain, physical function and health-related quality-of-life. Magnetic resonance imaging will measure changes in tibial cartilage volume. To evaluate cost-effectiveness, participants will record the use of all health-related treatments in a log-book returned to the assessor on a monthly basis. To test the effect of the intervention using an intention-to-treat analysis, linear regression modelling will be applied adjusting for baseline outcome values and other demographic characteristics.</p> <p>Discussion</p> <p>Results from this trial will contribute to the evidence regarding the effectiveness of laterally wedged insoles for the management of medial knee OA.</p> <p>Trial registration</p> <p>ACTR12605000503628; NCT00415259.</p

The mammals of Angola

Scientific investigations on the mammals of Angola started over 150 years ago, but information remains scarce and scattered, with only one recent published account. Here we provide a synthesis of the mammals of Angola based on a thorough survey of primary and grey literature, as well as recent unpublished records. We present a short history of mammal research, and provide brief information on each species known to occur in the country. Particular attention is given to endemic and near endemic species. We also provide a zoogeographic outline and information on the conservation of Angolan mammals. We found confirmed records for 291 native species, most of which from the orders Rodentia (85), Chiroptera (73), Carnivora (39), and Cetartiodactyla (33). There is a large number of endemic and near endemic species, most of which are rodents or bats. The large diversity of species is favoured by the wide range of habitats with contrasting environmental conditions, while endemism tends to be associated with unique physiographic settings such as the Angolan Escarpment. The mammal fauna of Angola includes 2 Critically Endangered, 2 Endangered, 11 Vulnerable, and 14 Near-Threatened species at the global scale. There are also 12 data deficient species, most of which are endemics or near endemics to the countryinfo:eu-repo/semantics/publishedVersio