A change in the study evaluation paradigm reveals that larynx preservation compromises survival in T4 laryngeal cancer patients

Background: Larynx preservation (LP) is recommended for up to low-volume T4 laryngeal cancer as an evidence-based treatment option that does not compromise survival. However, a reevaluation of the current literature raises questions regarding whether there is indeed reliable evidence to support larynx preservation for T4 tumor patients. Methods: In an observational cohort study of 810 laryngeal cancer patients, we evaluated the outcomes of all T4 tumor patients treated with primary chemo-radiotherapy (CRT) or primary radiotherapy alone (RT) compared with upfront total laryngectomy followed by adjuvant (chemo)radiotherapy (TL + a[C]RT). Additionally, we reevaluated the studies that form the evidence base for the recommendation of LP for patients with up to T4 tumors (Pfister et al., J Clin Oncol 24:3693–704, 2006). Results: The evaluation of all 288 stage III and IV patients together did not show a significant difference in overall survival (OS) between CRT-LP and TL + a(C)RT (hazard ratio (HR) 1.23; 95% confidence interval (CI): 0.82–1.86; p = 0.31) using a multivariate proportional hazard model. However, a subgroup analysis of T4 tumor patients alone (N = 107; 13.9%) revealed significantly worse OS after CRT compared with TL + a(C)RT (HR 2.0; 95% CI: 1.04–3.7; p = 0.0369). A reevaluation of the subgroup of T4 patients in the 5 LP studies that led to the ASCO clinical practice guidelines revealed that only 21–45 T4 patients had differential data on survival outcome. These data, however, showed a markedly worse outcome for T4 patients after LP. Conclusions: T4 laryngeal cancer patients who reject TL as a treatment option should be informed that their chance of organ preservation with primary conservative treatment is likely to result in a significantly worse outcome in terms of OS. Significant loss of survival in T4 patients after LP is also confirmed in recent literature

Intensity and Inhalation of Smoking in the Aetiology of Laryngeal Cancer

The carcinogenic effect of smoking on laryngeal cancer is well established; however, the risk pattern for detailed smoking characteristics is less clear. Thus, the aim of this analysis was to quantify the impact of different inhalation behaviours on the risk of laryngeal cancer. We conducted a population-based case control study in Germany, frequency-matched for sex and age, using a standardized questionnaire covering lifelong smoking details, including age at start, time since quitting, types of smoking products, duration, intensity and inhalation behaviour. We found higher risks for increasing duration and intensity of smoking. A clear dose-response relationship was found in all inhalation subgroups, i.e., not only for deep inhalers, but also for those puffing on a cigarette. Clearly reduced risks could be observed for quitting smoking. Changing inhalation habits might be considered as a first step to reducing the risk of developing laryngeal cancer. However, the best way to effectively reduce laryngeal cancer risk is to quit smoking

Training needs for research in health inequities among health and demographic researchers from eight African and Asian countries

Background: To support equity focussed public health policy in low and middle income countries, more evidence and analysis of the social determinants of health inequalities is needed. This requires specific know how among researchers. The INDEPTH Training and Research Centres of Excellence (INTREC) collaboration will develop and provide training on the social determinants of health approach for health researchers from the International Network for the Demographic Evaluation of Populations and Their Health in Low- and Middle-Income Countries (INDEPTH) in Africa and Asia. To identify learning needs among the potential target group, this qualitative study explored what INDEPTH researchers from Ghana, Tanzania, South Africa, Kenya, Indonesia, India, Vietnam, and Bangladesh feel that they want to learn to be able to conduct research on the causes of health inequalities in their country. Methods: Using an inductive method, online concept-mapping, participants were asked to generate statements in response to the question what background knowledge they would need to conduct research on the causes of health inequalities in their country, to sort those statements into thematic groups, and to rate them in terms of how important it would be for the INTREC program to offer instruction on each of the statements. Statistical techniques were used to structure statements into a thematic cluster map and average importance ratings of statements/clusters were calculated. Results: Of the 150 invited researchers, 82 participated in the study: 54 from Africa; 28 from Asia. Participants generated 59 statements and sorted them into 6 broader thematic clusters: “assessing health inequalities”; “research design and methods”; “research and policy”; “demography and health inequalities”; “social determinants of health” and “interventions”. African participants assigned the highest importance to further training on methods for assessing health inequalities. Asian participants assigned the highest importance to training on research and policy. Conclusion: The identified thematic clusters and statements provide a detailed understanding of what INDEPTH researchers want to learn in order to be able to conduct research on the social determinants of health inequalities. This offers a framework for developing capacity building programs in this emerging field of public health research

Exploring the role narrative free-text plays in discrepancies between physician coding and the InterVA regarding determination of malaria as cause of death, in a malaria holo-endemic region

<p>Abstract</p> <p>Background</p> <p>In countries where tracking mortality and clinical cause of death are not routinely undertaken, gathering verbal autopsies (VA) is the principal method of estimating cause of death. The most common method for determining probable cause of death from the VA interview is Physician-Certified Verbal Autopsy (PCVA). A recent alternative method to interpret Verbal Autopsy (InterVA) is a computer model using a Bayesian approach to derive posterior probabilities for causes of death, given an <it>a priori </it>distribution at population level and a set of interview-based indicators. The model uses the same input information as PCVA, with the exception of narrative text information, which physicians can consult but which were not inputted into the model. Comparing the results of physician coding with the model, large differences could be due to difficulties in diagnosing malaria, especially in holo-endemic regions. Thus, the aim of the study was to explore whether physicians' access to electronically unavailable narrative text helps to explain the large discrepancy in malaria cause-specific mortality fractions (CSMFs) in physician coding versus the model.</p> <p>Methods</p> <p>Free-texts of electronically available records (N = 5,649) were summarised and incorporated into the InterVA version 3 (InterVA-3) for three sub-groups: (i) a 10%-representative subsample (N = 493) (ii) records diagnosed as malaria by physicians and not by the model (N = 1035), and (iii) records diagnosed by the model as malaria, but not by physicians (N = 332). CSMF results before and after free-text incorporation were compared.</p> <p>Results</p> <p>There were changes of between 5.5-10.2% between models before and after free-text incorporation. No impact on malaria CSMFs was seen in the representative sub-sample, but the proportion of malaria as cause of death increased in the physician sub-sample (2.7%) and saw a large decrease in the InterVA subsample (9.9%). Information on 13/106 indicators appeared at least once in the free-texts that had not been matched to any item in the structured, electronically available portion of the Nouna questionnaire.</p> <p>Discussion</p> <p>Free-texts are helpful in gathering information not adequately captured in VA questionnaires, though access to free-text does not explain differences in physician and model determination of malaria as cause of death.</p

Disaggregating Health Inequalities Within Rio de Janeiro, Brazil, 2002-2010, by Applying an Urban Health Inequality Index

An urban health index (UHI) was used to quantify health inequalities within Rio de Janeiro, Brazil, for the years 2002-2010. Eight main health indicators were generated at the ward level using mortality data. The indicators were combined to form the index. The distribution of the rank ordered UHI-values provides information on inequality among wards, using the ratio of the extremes and the gradient of the middle values. Over the decade the ratio of extremes in 2010 declined relative to 2002 (1.57 vs. 1.32) as did the slope of the middle values (0.23 vs. 0.16). A spatial division between the affluent south and the deprived north and east is still visible. The UHI correlated on an ecological ward-level with socioeconomic and urban environment indicators like square meter price of apartments (0.54, p \u3c 0.01), low education of mother (-0.61, p \u3c 0.01), low income (-0.62, p \u3c 0.01) and proportion of black ethnicity (-0.55, p \u3c 0.01). The results suggest that population health and equity have improved in Rio de Janeiro in the last decade though some familiar patterns of spatial inequality remain

Comparison of all-cause and malaria-specific mortality from two West African countries with different malaria transmission patterns

BACKGROUND: Malaria is a leading cause of death in children below five years of age in sub-Saharan Africa. All-cause and malaria-specific mortality rates for children under-five years old in a mesoendemic malaria area (The Gambia) were compared with those from a hyper/holoendemic area (Burkina Faso). METHODS: Information on observed person-years (PY), deaths and cause of death was extracted from online search, using key words: "Africa, The Gambia, Burkina Faso, malaria, Plasmodium falciparum, mortality, child survival, morbidity". Missing person-years were estimated and all-cause and malaria-specific mortality were calculated as rates per 1,000 PY. Studies were classified as longitudinal/clinical studies or surveys/censuses. Linear regression was used to investigate mortality trends. RESULTS: Overall, 39 and 18 longitudinal/clinical studies plus 10 and 15 surveys and censuses were identified for The Gambia and Burkina Faso respectively (1960-2004). Model-based estimates for under-five all-cause mortality rates show a decline from 1960 to 2000 in both countries (Burkina Faso: from 71.8 to 39.0), but more markedly in The Gambia (from 104.5 to 28.4). The weighted-average malaria-specific mortality rate per 1000 person-years for Burkina Faso (15.4, 95% CI: 13.0-18.3) was higher than that in The Gambia (9.5, 95% CI: 9.1-10.1). Malaria mortality rates did not decline over time in either country. CONCLUSION: Child mortality in both countries declined significantly in the period 1960 to 2004, possibly due to socio-economic development, improved health services and specific intervention projects. However, there was little decline in malaria mortality suggesting that there had been no major impact of malaria control programmes during this period. The difference in malaria mortality rates across countries points to significant differences in national disease control policies and/or disease transmission patterns

Public and Private Maternal Health Service Capacity and Patient Flows in Southern Tanzania: Using a Geographic Information System to Link Hospital and National Census data.

Background : Strategies to improve maternal health in low-income countries are increasingly embracing partnership approaches between public and private stakeholders in health. In Tanzania, such partnerships are a declared policy goal. However, implementation remains challenging as unfamiliarity between partners and insufficient recognition of private health providers prevail. This hinders cooperation and reflects the need to improve the evidence base of private sector contribution. Objective : To map and analyse the capacities of public and private hospitals to provide maternal health care in southern Tanzania and the population reached with these services. Design : A hospital questionnaire was applied in all 16 hospitals (public n=10; private faith-based n=6) in 12 districts of southern Tanzania. Areas of inquiry included selected maternal health service indicators (human resources, maternity/delivery beds), provider-fees for obstetric services and patient turnover (antenatal care, births). Spatial information was linked to the 2002 Population Census dataset and a geographic information system to map patient flows and socio-geographic characteristics of service recipients. Results : The contribution of faith-based organizations (FBOs) to hospital maternal health services is substantial. FBO hospitals are primarily located in rural areas and their patient composition places a higher emphasis on rural populations. Also, maternal health service capacity was more favourable in FBO hospitals. We approximated that 19.9% of deliveries in the study area were performed in hospitals and that the proportion of c-sections was 2.7%. Mapping of patient flows demonstrated that women often travelled far to seek hospital care and where catchment areas of public and FBO hospitals overlap. Conclusions : We conclude that the important contribution of FBOs to maternal health services and capacity as well as their emphasis on serving rural populations makes them promising partners in health programming. Inclusive partnerships could increase integration of FBOs into the public health care system and improve coordination and use of scarce resources

Hospitalizations during the last months of life of nursing home residents: a retrospective cohort study from Germany

BACKGROUND: To describe hospitalisations of nursing home (NH) residents in Germany during their last months of life. METHODS: Retrospective cohort study on 792 NH residents in the Rhine-Neckar region in South-West Germany, newly institutionalized in the year 2000, who died until the study end (December 2001). Baseline variables were derived from a standardized medical examination routinely conducted by the medical service of the health care insurance plans in Germany. Information on hospitalisations and deaths was extracted form records of the pertinent health insurance plans. RESULTS: NH residents who died after NH stay of more than 1 year spent 5.8% of their last year of life in hospitals. Relative time spent in hospitals increased from 5.2% twelve months before death (N = 139 persons) to 24.1% in their last week of life (N = 769 persons). No major differences could be observed concerning age, gender or duration of stay in NH. Overall, 229 persons (28.9%) died in hospital. Among these, the last hospital stay lasted less than 3 days for 76 persons (31.9%). Another 25 persons (3.2%) died within three days after hospital discharge. CONCLUSION: Our study indicates that proximity of death is the most important driver of health care utilization among NH residents. The relation of age or gender to health care expenditures seem to be weak once time to death is controlled for. Duration of NH stay does not markedly change rates of hospitalisation during the last months of life

Occupational socioeconomic risk associations for head and neck cancer in Europe and South America: individual participant data analysis of pooled case–control studies within the INHANCE Consortium

Background: The association between socioeconomic disadvantage (low education and/or income) and head and neck cancer is well established, with smoking and alcohol consumption explaining up to three-quarters of the risk. We aimed to investigate the nature of and explanations for head and neck cancer risk associated with occupational socioeconomic prestige (a perceptual measure of psychosocial status), occupational socioeconomic position and manual-work experience, and to assess the potential explanatory role of occupational exposures. Methods: Pooled analysis included 5818 patients with head and neck cancer (and 7326 control participants) from five studies in Europe and South America. Lifetime job histories were coded to: (1) occupational social prestige-Treiman's Standard International Occupational Prestige Scale (SIOPS); (2) occupational socioeconomic position-International Socio-Economic Index (ISEI); and (3) manual/non-manual jobs. Results: For the longest held job, adjusting for smoking, alcohol and nature of occupation, increased head and neck cancer risk estimates were observed for low SIOPS OR=1.88 (95% CI: 1.64 to 2.17), low ISEI OR=1.74 (95% CI: 1.51 to 1.99) and manual occupations OR=1.49 (95% CI: 1.35 to 1.64). Following mutual adjustment by socioeconomic exposures, risk associated with low SIOPS remained OR=1.59 (95% CI: 1.30 to 1.94). Conclusions: These findings indicate that low occupational socioeconomic prestige, position and manual work are associated with head and neck cancer, and such risks are only partly explained by smoking, alcohol and occupational exposures. Perceptual occupational psychosocial status (SIOPS) appears to be the strongest socioeconomic factor, relative to socioeconomic position and manual/non-manual work