Hiding from the sun - Vitamin D deficiency in refugees

Copyright © 2007 Royal Australian College of General Practitioners Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners.BACKGROUND It has been well established that women who wear a veil for cultural reasons and dark skinned migrants from Africa have an increased prevalence of vitamin D deficiency. Many refugee patients also come from countries where their skin is covered or they are indoors for most of the day. OBJECTIVE This article explores the risk, diagnosis and management of vitamin D deficiency in the Australian refugee population. DISCUSSION In 2004–2005, 75% of the 7000 refugees settling in Australia were from African countries and 20% were from the Middle East. Refugees may be exposed to less sunlight in Australia than in their country of origin because of an indoor lifestyle or an increased latitude. Refugee health centres confirm that vitamin D deficiency is present in 40–80% of refugee patients. Importantly, this is often asymptomatic. General practitioners are encouraged to test for vitamin D deficiency in refugees, especially as part of the initial health assessment.Jill Benson; Sue Skul

What factors hinder the decision-making process for women with cancer and contemplating fertility preservation treatment?

Background: Although fertility preservation (FP) treatment options have increased, the existing evidence suggests that many women with cancer do not feel well supported in making these decisions, but find them stressful and complex and fail to take up fertility care at this crucial time. Whilst existing reviews have all made important contributions to our understanding of the FP decision-making process, none of them examine solely and specifically these processes for women of reproductive age with a diagnosis of any cancer, leaving a gap in the knowledge base. Given the expectation that care is patient-centred, our review aims to address this gap which may be of help to those managing patients struggling to make difficult decisions in the often brief period before potentially sterilising cancer treatment is started. Objective and rationale: Underpinning this narrative review was the question “What factors hinder the decision-making process for women with any cancer and contemplating FP treatment?” Our objectives were to i) assess and summarise this existing literature, ii) identify the factors that hinder this decision-making process, iii) explore to what extent these factors may differ for women choosing different methods of FP, and iv) make recommendations for service delivery and future research. Search methods: A systematic search of the medical and social science literature from the 1st January 2005 up to the end of January 2016 was carried out using three electronic databases (Web of Science (PubMed), Ovid SP Medline and CINAHL via Ebsco). Included in the review were quantitative, qualitative and mixed-method studies. Reference lists of relevant papers were also hand searched. From the 983 papers identified, 46 papers were included. Quality assessment was undertaken using the Mixed Methods Appraisal Tool and thematic analysis was used to analyse the data. Outcomes: From the analysis, six key themes with 15 sub-themes emerged: 1) fertility information provision (lack of information, timing of the information, patient-provider communication); 2) fear concerning the perceived risks associated with pursuing FP (delaying cancer treatment, aggravating a hormone positive cancer, consequences of a future pregnancy); 3) non-referral from oncology (personal situation, having a hormone positive cancer, not a priority, transition between service issues); 4) the dilemma (in survival mode, whether to prioritise one treatment over another); 5) personal situation (parity, relationship status); and 6) costs (financial concerns). Wider implications: This review has found that a wide range of internal and external factors impact the FP decision-making process. Key external issues related to current service delivery such as the provision and timing of FP information, and lack of referral from oncology to the fertility clinic. However, internal issues such as women’s fears concerning the perceived risks associated with pursuing FP also hindered decision-making but these ‘risks’ were typically overestimated and non-evidence based. These findings suggest that the implementation of a range of decision support interventions may be of benefit within the clinical care pathway of FP and cancer. Women would benefit from the provision of more evidence-based FP information, ideally received at cancer diagnosis, in advance of seeing a fertility specialist, for example through the implementation of patient decision aids. Health care professionals in both oncology and fertility services may also benefit from the implementation of training programs and educational tools targeted at improving the communication skills needed to improve collaborative decision-making and deliver care that is patient-centred. Exploration of the current barriers, both intellectual and practical, that prevent some patients from accepting FP will help care providers to do better for their patients in the future. Finally, the extent to which a poor prognosis and moral, ethical and religious beliefs influence the FP decision-making process also warrant further research

Repeat pneumococcal polysaccharide vaccine in Indigenous Australian adults is associated with decreased immune responsiveness.

BACKGROUND: Indigenous adults residing in the Northern Territory of Australia experience elevated rates of invasive pneumococcal disease despite the routine use of 23-valent pneumococcal polysaccharide vaccine (23vPPV). We hypothesised that the limited protection from 23vPPV may be due to hyporesponsiveness as a result of vaccine failure from repeated vaccination. To explore this possibility, we evaluated the immune response to a first and second dose of 23vPPV in Indigenous adults and a first dose of 23vPPV in non-Indigenous adults. METHODS: Serotype-specific IgG was measured by ELISA for all 23 vaccine serotypes at baseline and at one month post-vaccination. Individuals were considered to have an adequate immune response if paired sera demonstrated either: a four-fold rise in antibody concentration; a two-fold rise if the post vaccination antibody was >1.3μg/ml but 4.0μg/ml for at least half of the serotypes tested (12/23). Our per-protocol analysis included the comparison of outcomes for three groups: Indigenous adults receiving a second 23vPPV dose (N=20) and Indigenous (N=60) and non-Indigenous adults (N=25) receiving their first 23vPPV dose. RESULTS: All non-Indigenous adults receiving a first dose of 23vPPV mounted an adequate immune response (25/25). There was no significant difference in the proportion of individuals with an adequate response using our definition (primary endpoint), with 88% of Indigenous adults mounted an adequate response following first dose 23vPPV (53/60) compared to 70% having an adequate response following a second dose of 23vPPV (14/20; p=0.05). The risk difference between Indigenous participants receiving first dose compared to non-Indigenous participants receiving first dose was significant when comparing a response threshold of at least 70% (-27%, 95% CI: -43% to -11%; p=0.01) and 90% (-38%, 95% CI: -60% to -16%; p=0.006) of serotypes with a positive response. CONCLUSION: Indigenous participants demonstrated a poorer response to a first dose 23vPPV compared to their non-Indigenous counterparts, with lower IgG following a second 23vPPV dose. These findings highlight the critical need to evaluate the efficacy of future pneumococcal vaccine programs in the Australian Indigenous populations that recommend repeated doses of 23vPPV

Observational study of the development and evaluation of a fertility preservation patient decision aid for teenage and adult women diagnosed with cancer: The Cancer, Fertility and Me research protocol

Introduction: Women diagnosed with cancer and facing potentially sterilising cancer treatment have to make time-pressured decisions regarding fertility preservation with specialist fertility services whilst undergoing treatment of their cancer with oncology services. Oncologists identify a need for resources enabling them to support women’s fertility preservation decisions more effectively; women report wanting more specialist information to make these decisions. The overall aim of the ‘Cancer, Fertility and Me’ study is to develop and evaluate a new evidence-based patient decision aid (ptDA) for women with any cancer considering fertility preservation to address this unmet need. Methods and analysis: This is a prospective mixed-method observational study including women of reproductive age (16 years +) with a new diagnosis of any cancer across two regional cancer and fertility centres in Yorkshire, UK. The research involves three stages. In Stage 1 the aim is to develop the ptDA using a systematic method of evidence synthesis and multidisciplinary expert review of current clinical practice and patient information. In Stage 2, the aim is to assess the face validity of the ptDA. Feedback on its content and format will be ascertained using both questionnaires and interviews with patients, user groups and key stakeholders. Finally, in Stage 3 the acceptability of using this resource when integrated into usual cancer care pathways at the point of cancer diagnosis and treatment planning will be evaluated. This will involve a quantitative and qualitative evaluation of the ptDA in clinical practice. Measures chosen include using count data of the ptDAs administered in clinics and accessed online, decisional and patient-reported outcome measures and qualitative feedback. Quantitative data will be analysed using descriptive statistics, paired sample t tests and confidence intervals; interviews will be analysed using thematic analysis. Ethics and dissemination: Research Ethics Committee approval (Ref: 16/EM/0122) and Health Research Authority approval (Ref: 194751) has been granted. Findings will be published in open access peer-reviewed journals, presented at conferences for academic and health professional audiences, with feedback to health professionals and program managers. The Cancer, Fertility and Me ptDA will be disseminated via a diverse range of open-access media, study and charity websites, professional organisations and academic sources. External endorsement will be sought from the International Patient Decision Aid Standards (IPDAS) Collaboration inventory of ptDAs and other relevant professional organisations e.g. the British Fertility Society. Trial registration number: NCT02753296 (www.clinicaltrials.gov); pre-results

Measuring nasal bacterial load and its association with otitis media

BACKGROUND: Nasal colonisation with otitis media (OM) pathogens, particularly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, is a precursor to the onset of OM. Many children experience asymptomatic nasal carriage of these pathogens whereas others will progress to otitis media with effusion (OME) or suppurative OM. We observed a disparity in the prevalence of suppurative OM between Aboriginal children living in remote communities and non-Aboriginal children attending child-care centres; up to 60% and <1%, respectively. This could not be explained by the less dramatic difference in rates of carriage of respiratory bacterial pathogens (80% vs 50%, respectively). In this study, we measured nasal bacterial load to help explain the different propensity for suppurative OM in these two populations. METHODS: Quantitative measures (colony counts and real-time quantitative PCR) of the respiratory pathogens S. pneumoniae, H. influenzae and M. catarrhalis, and total bacterial load were analysed in nasal swabs from Aboriginal children from remote communities, and non-Aboriginal children attending urban child-care centres. RESULTS: In both populations nearly all swabs were positive for at least one of these respiratory pathogens. Using either quantification method, positive correlations between bacterial load and ear state (no OM, OME, or suppurative OM) were observed. This relationship held for single and combined bacterial respiratory pathogens, total bacterial load, and the proportion of respiratory pathogens to total bacterial load. Comparison of Aboriginal and non-Aboriginal children, all with a diagnosis of OME, demonstrated significantly higher loads of S. pneumoniae and M. catarrhalis in the Aboriginal group. The increased bacterial load despite similar clinical condition may predict persistence of middle ear effusions and progression to suppurative OM in the Aboriginal population. Our data also demonstrated the presence of PCR-detectable non-cultivable respiratory pathogens in 36% of nasal swabs. This may have implications for the pathogenesis of OM including persistence of infection despite aggressive therapies. CONCLUSION: Nasal bacterial load was significantly higher among Aboriginal children and may explain their increased risk of suppurative OM. It was also positively correlated with ear state. We believe that a reduction in bacterial load in high-risk populations may be required before dramatic reductions in OM can be achieved

The knowledge and expectations of parents about the role of antibiotic treatment in upper respiratory tract infection – a survey among parents attending the primary physician with their sick child

BACKGROUND: Upper respiratory tract infections (URTI) are common. The etiologic factor is usually viral, but many physicians prescribe antibiotics. We aimed to evaluate parents' expectations of and knowledge about the role of antibiotics in childhood URTI. METHODS: The study was conducted in thirteen primary care pediatric clinics. Parents of children aged 3 months to 6 years who attended with URTI symptoms were included when it was the first attendance in the current illness. Questionnaire about the current illness, reasons for attending and expectations from the visit, knowledge about URTI was filled before the visit. RESULTS: In 122 visits the average age was 2.8 ± 1.9 years. The main reasons for the visit were to avoid complications (81%) and to be examined (78%). Expected treatment was: cough suppressants (64%), anti-congestants (57%), paracetamol (56%), natural remedies (53%) and antibiotics (25%). In 28% the child had received antibiotics in past URTI. Only 37% thought that antibiotics would not help in URTI and 27% knew that URTI is a self-limited disease. 61% knew that URTI is a viral disease. Younger parental age and higher education were associated with lower expectations to receive antibiotics (p = 0.01, p < 0.005 respectively). While previous antibiotic treatment (p < 0.001), past perceived complications (p = 0.05) and the thought that antibiotics help in URTI (p < 0.001) were associated with a greater expectation for antibiotics. CONCLUSIONS: A quarter of the parents attending the physician with URTI are expecting to get antibiotics. Predictors were lower education, older parental age, receiving antibiotics in the past and the belief that antibiotics help in URTI

THE DEVELOPMENT OF A FERTILITY PRESERVATION DECISION AID TO SUPPORT TEENAGE AND ADULT WOMEN WITH CANCER

Introduction We describe the protocol for a recently funded three-year study (Yorkshire Cancer Research). Our aims are to develop a new evidence based fertility preservation (FP) decision aid (DA) and evaluate the impact of administering this resource at the point of cancer diagnosis/cancer treatment planning stage in oncology. While a few DAs exist to support the FP process, they are exclusively for breast cancer patients, and none have been developed for the UK female cancer population. Method A multi-centre prospective mixed-method observational study including teenage and adult women of reproductive age (16 years +) with a new diagnosis of any cancer attending cancer hospitals across two large Yorkshire cities. The study involves three stages: Stage 1 (Development of the DA), Stage 2 (Assessing the Learner Verification of the DA), Stage 3 (A quantitative and qualitative evaluation of the DA in routine clinical care). Results We are currently in Stage 1. NHS Research Ethics Committee approval has been granted. The content of the DA is being informed by a systematic literature review, an environmental scan of publically available literature, a previous three-year study carried out in Sheffield alongside clinical evidence from oncology and fertility guidelines and international patient decision aids standards. Discussion It is anticipated that our new DA will enable teenage and adult women to feel better supported and make more informed FP treatment decisions. It should also raise fertility awareness and improve the care of the women whilst they make FP choices and transition between oncology and fertility services

A Regional Initiative to Reduce Skin Infections amongst Aboriginal Children Living in Remote Communities of the Northern Territory, Australia

Skin infections are endemic in many in remote Australian Aboriginal communities and have been linked to very high rates of chronic heart and kidney disease in this population. We report the results of a regional collaboration that aimed to reduce skin infections amongst children aged less than 15 years in five remote communities. The program included annual mass scabies treatment days offered to all residents and routine screening/follow-up of children. Trained community workers helped conduct over 6000 skin assessments on 2329 children over a three year period. Of every 100 children seen at the commencement of the study, 47 were found to have skin sores and many had multiple sores. We demonstrate a reduction both in the number of children with skin sores and in the severity of those sores. On average, of every 100 children seen per month, there were 14 fewer children with skin sores and seven fewer children with multiple sores. Overall improvement in treatment uptake was a critical factor. We found no discernible impact against scabies. While the burden of skin infections remains unacceptably high, we believe the results presented here are a good news story for local action to address a serious public health problem

The clinical course of acute otitis media in high-risk Australian Aboriginal children: a longitudinal study

BACKGROUND: It is unclear why some children with acute otitis media (AOM) have poor outcomes. Our aim was to describe the clinical course of AOM and the associated bacterial nasopharyngeal colonisation in a high-risk population of Australian Aboriginal children. METHODS: We examined Aboriginal children younger than eight years who had a clinical diagnosis of AOM. Pneumatic otoscopy and video-otoscopy of the tympanic membrane (TM) and tympanometry was done every weekday if possible. We followed children for either two weeks (AOM without perforation), or three weeks (AOM with perforation), or for longer periods if the infection persisted. Nasopharyngeal swabs were taken at study entry and then weekly. RESULTS: We enrolled 31 children and conducted a total of 219 assessments. Most children had bulging of the TM or recent middle ear discharge at diagnosis. Persistent signs of suppurative OM (without ear pain) were present in most children 7 days (23/30, 77%), and 14 days (20/26, 77%) later. Episodes of AOM did not usually have a sudden onset or short duration. Six of the 14 children with fresh discharge in their ear canal had an intact or functionally intact TM. Perforation size generally remained very small (<2% of the TM). Healing followed by re-perforation was common. Ninety-three nasophyngeal swabs were taken. Most swabs cultured Streptococcus pneumoniae (82%), Haemophilus influenzae (71%), and Moraxella catarrhalis (95%); 63% of swabs cultured all three pathogens. CONCLUSION: In this high-risk population, AOM was generally painless and persistent. These infections were associated with persistent bacterial colonisation of the nasopharynx and any benefits of antibiotics were modest at best. Systematic follow up with careful examination and review of treatment are required and clinical resolution cannot be assumed