High Personal Risk Research Articles

Prolonged laparoscopic surgery is associated with an increased risk of vertebral disc prolapse

The benefits of laparoscopic surgery to the patient are well recognised, however it is more physically demanding on the surgeon. A survey was sent to members of the British Society of Gynaecological Endoscopy to ascertain musculoskeletal symptoms and vertebral disc prolapse thought to occur as a result of undertaking laparoscopic surgery. A total of 19 (15%) participants were diagnosed with a vertebral disc prolapse, for which one-third needed definitive treatment. There was a statistically significant association with length of practice and numbers of hours worked per week, with the risk of disc prolapse. There was a multitude of other musculoskeletal symptoms reported. These findings suggest that gynaecological laparoscopic surgery carries a high personal health risk to the surgeon, which is likely to increase as the capability and superiority of laparoscopic techniques develop. There is an urgent need to explore further the ergonomic impact of laparoscopic work to enable improvements to be made.

Socio-economic inequality and HIV in South Africa

BackgroundThe linkage between the socio-economic inequality and HIV outcomes was analysed using data from a population-based household survey that employed multistage-stratified sampling. The goal is to help refocus attention on how HIV is linked to inequalities.MethodsA socio-economic index (SEI) score, derived using Multiple Correspondence Analysis of measures of ownership of durable assets, was used to generate three SEI groups: Low (poorest), Middle, and Upper (no so poor). Distribution of HIV outcomes (i.e. HIV prevalence, access to HIV/AIDS information, level of stigma towards HIV/AIDS, perceived HIV risk and sexual behaviour) across the SEI groups, and other background characteristics was assessed using weighted data. Univariate and multivariate logistic regression was used to assess the covariates of the HIV outcomes across the socio-economic groups. The study sample include 14,384 adults 15 years and older.ResultsMore women (57.5%) than men (42.3%) were found in the poor SEI [P<0.001]. HIV prevalence was highest among the poor (20.8%) followed by those in the middle (15.9%) and those in the upper SEI (4.6%) [P<0.001]. It was also highest among women compared to men (19.7% versus 11.4% respectively) and among black Africans (20.2%) compared to other races [P<0.001]. Individuals in the upper SEI reported higher frequency of HIV testing (59.3%) compared to the low SEI (47.7%) [P< 0.001]. Only 20.5% of those in poor SEI had “good access to HIV/AIDS information” compared to 79.5% in the upper SEI (P<0.001). A higher percentage of the poor had a stigmatizing attitude towards HIV/AIDS (45.6%) compared to those in the upper SEI (34.8%) [P< 0.001]. There was a high personal HIV risk perception among the poor (40.0%) and it declined significantly to 10.9% in the upper SEI.ConclusionsOur findings underline the disproportionate burden of HIV disease and HIV fear among the poor and vulnerable in South Africa. The poor are further disadvantaged by lack of access to HIV information and HIV/AIDS services such as testing for HIV infection. There is a compelling urgency for the national HIV/AIDS response to maximizing program focus for the poor particularly women.

The Effects of Expectation Disconfirmation on Appraisal, Affect, and Behavioral Intentions

People's risk perceptions can have powerful effects on their outcomes, yet little is known about how people respond to risk information that disconfirms a prior expectation. We experimentally examined the affective, cognitive, and behavioral consequences of expectation disconfirmation in the context of risk perceptions. Participants were randomly assigned and then prompted toward either a high or low personal risk estimate regarding a fictitious health threat. All participants then received the same risk feedback, which presented either a negative disconfirmation experience (i.e., worse than expected) in the high-risk estimate condition or a positive disconfirmation experience (i.e., better than expected) in the low-risk estimate condition. Participants who experienced the negative disconfirmation reported stronger intentions to prevent the threat in the future compared to participants who experienced the positive disconfirmation. This effect was mediated by both disappointment about the risk feedback and perceptions of the severity of the threat. These findings have implications for risk communication, suggesting that the provision of objective risk information may improve or diminish the likelihood of behavior change depending on people's initial expectations and their emotional and cognitive reactions to the information.

Acceptability of Telemedicine and Other Cancer Genetic Counseling Models of Service Delivery in Geographically Remote Settings

This work examined acceptability of cancer genetic counseling models of service delivery among Maine residents at risk for hereditary cancer susceptibility disorders. Pre-counseling, participants ranked characteristics reflecting models of care from most to least important including: mode-of-communication (in-person versus telegenetics), provider level of training (genetic specialty versus some training/experience), delivery format (one-on-one versus group counseling), and location (local versus tertiary service requiring travel). Associations between models of care characteristic rankings and patient characteristics, including rural residence, perceived cancer risk, and perceived risk for a hereditary cancer risk susceptibility disorder were examined. A total of 149/300 (49.7% response rate) individuals from 11/16 Maine counties responded; 30.8% were from rural counties; 92.2% indicated that an important/the most important model of care characteristic is provider professional qualifications. Among other characteristics, 65.1% ranked one-on-one counseling as important/the most important. In-person and local counseling were ranked the two least important characteristics (51.8% and 52.1% important/the most important, respectively). Responses did not vary by patient characteristics with the exception of greater acceptance of group counseling among those at perceived high personal cancer risk. Cancer telegenetic services hold promise for access to expert providers in a one-on-one format for rurally remote clients.

Abstract P4-14-11: Risk reducing mastectomy for women with high personal breast cancer risk

Abstract Introduction: For high-risk familial history of breast cancer, risk reducing mastectomy (RRM) is now regarded as one of the management options. The aim of this study is to analyse the outcome of women undergoing RRM from 1994 to 2010 during which surgical techniques evolved and were refined. Methods: A cohort of women undergoing RRM was followed from this single centre. Surgical and further details about demographics, comorbidities, and follow-up were retrieved form medical records. Analysis was carried out using the IBM®-SPSS®-Statistics-19system. Results: Of 154 women 139 had bilateral RRM and 15 had unilateral surgery after earlier contralateral breast cancer. Median age at operation was 39.4 years (22–63years). 54 (45.5%) women were BRCA1/2 gene mutation carriers. Most women had nipple sacrificing (86) skin-sparing mastectomy with immediate reconstruction. 132 (85.7%) had submuscular expander/implant reconstruction, whilst 9 had either LD flap reconstruction or TRAM flap reconstruction. 31 (20.1%) women had some complication including haematoma requiring evacuation, minor skin/nipple necrosis, but implant loss was rare (2). 52 (33.8%) women had revisional surgeries in 5 years post RRM of whom 29 had one unanticipated secondary operation. Complications were more common in the early years of the cohort. On histology, 3 women were identified with lobular carcinoma in-situ and one was associated with 1mm of microinvasion. 4 had ductal carcinoma in-situ and 2 of them were BRCA carriers. Two (1.2%) primary breast cancers were subsequently identified during a mean follow-up period of 9.82 years (2–18 years) but this was substantially less than prediction modelling. Both were BRCA gene mutation carriers - one had nipple sparing RRM and the other did not. Conclusions: In asymptomatic high-risk women, RRM is safe and efficacious in reducing medium term future breast cancer incidence. Surgery carries the risk of complications and cosmetic revisions can be anticipated. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-11.

THE PREVALENCE OF CONDOM USE AMONG UNIVERSITY STUDENTS IN ZIMBABWE: IMPLICATIONS FOR PLANNING AND POLICY

Young people, especially university students, are at high risk of HIV infections because of little or no parental or administrative prohibitions in campus environments. The aim of this study was to ascertain the level of condom use among university students in Zimbabwe; that is, condom use at last sex and consistent condom use among both regular and casual partners. The study draws on self-completed questionnaires administered to university students. The results reveal that, while 78.3% of sexually active respondents had used condoms in penetrative sexual encounters before, only 56.2% had used condoms at their last sexual encounter. As expected, consistent condom use was lower in regular sexual partnerships than it was in casual partnerships (30.6% versus 54.6%). Condom use at first sex and high personal HIV risk perception were found to be the most important factors in explaining condom use at last sex and consistent condom use with casual partners. Condom use intentions were high, as 75% of respondents indicated that they would use condoms at their next sexual encounters. Whilst this is commendable, use rates should ideally be higher still. Campus HIV/AIDS programmers should endeavour to ensure that condoms are available at all times in order to help translate these intentions into actual condom use. In addition, promotional programmes should encourage those who have not yet initiated sexual intercourse to use condoms at their first sex and also to improve personal HIV risk perceptions in order to trigger initiation of protective sexual behaviours.

18. Risk reducing mastectomy for women with high personal breast cancer risk

Introduction: For high-risk familial history of breast cancer, risk reducing mastectomy (RRM) is now regarded as one of the management options. The aim of this study is to analyse the outcome of women undergoing RRM from 1994 to 2010 during which surgical techniques were evolved and refined.

P5-20-03: Personalizing Supportive Care: A Clinical Prediction Model for Neutropenic Complications in Patients with Early-Stage Breast Cancer (ESBC) Receiving Intermediate Risk Chemotherapy.

Abstract Background: Neutropenic complications including severe and febrile neutropenia (FN) represent major dose-limiting toxicities of cancer chemotherapy. A general risk model for neutropenic complications across major solid tumors has been developed and validated (Lyman et al. Cancer 2011). Current guidelines recommend consideration of primary prophylaxis with a colony-stimulating factor (CSF) in patients at &amp;gt;20% risk of FN. The decision for primary CSF prophylaxis in patients on intermediate risk chemotherapy (10-20%) is based on physician assessment of individual patient risk factors for FN. This study assesses the ability of this general FN risk model to identify ESBC patients on intermediate risk chemotherapy who are at a personal high risk for developing a neutropenic complication. Methods: A prospective cohort study accrued 4458 consenting patients starting a new chemotherapy regimen at 115 randomly selected community oncology practices throughout the United States from 2002–2006. The risk of severe or febrile neutropenia (SNFN) in cycle 1 and across 4 cycles was estimated [±95% CI] utilizing logistic regression analysis and adjusting for key clinical factors including among others: age, prior chemotherapy, abnormal hepatic or renal function, low pretreatment white blood count, immunosuppressive medications, CSF prophylaxis, and planned relative dose intensity as well as major chemotherapeutic agents. The cumulative risk of FN across 4 cycles was also estimated by the product limit method of Kaplan and Meier. Results: Among 1224 patients with ESBC, 822 received intermediate risk chemotherapy based on National Comprehensive Cancer Network guidelines. Among these patients, cycle 1 SNFN occurred in 37%, at least one episode of FN over 4 cycles of chemotherapy in 17%, with 15% receiving primary CSF prophylaxis. The predicted risk of cycle 1 SNFN ranged from 1%-79%, with mean (median) risk of 33.8% (39.0%). Model performance was good with a c-statistic of 0.73 [0.69−0.76]. Based on this general FN risk model, cycle 1 SNFN occurred in 47% of predicted high risk ESBC patients [42 — 52%] compared to 13% [8-17%] of low risk patients. One or more FN events over 4 cycles occurred in 20% [17-24%] of predicted high risk versus 10% [6-14%] in low risk patients. The cumulative risk of FN by Kaplan-Meier estimation was 23% in high risk and 10% in low risk patients. Model sensitivity and specificity for FN were 83% and 33%, respectively. The majority of SNFN (76%) and FN (58%) events among high risk patients occurred in cycle 1. 50% of high risk patients who did not receive primary CSF prophylaxis went on to receive CSF during subsequent cycles. Conclusions: Based on good test performance characteristics, this clinical FN prediction model also identifies ESBC patients receiving intermediate risk chemotherapy at high personal risk for FN (FN &amp;gt;20%) over the first 4 cycles of chemotherapy. Half of predicted high risk patients without primary CSF prophylaxis will be given CSF in subsequent cycles after the occurrence of a neutropenic complication. This also confirms previous clinical trial findings that the majority of febrile neutropenic events occur in the first cycle. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-20-03.

H1N1 Preventive Health Behaviors in a University Setting

Background: When H1N1 emerged in 2009, institutions of higher education were immediately faced with questions about how best to protect their community from the virus, yet limited information existed to help predict student preventive behaviors. Methods: The authors surveyed students at a large urban university in November 2009 to better understand how students perceived their susceptibility to and the severity of H1N1, which preventive behaviors they engaged in, and if policies impacted their preventive health decisions. Results: Preventive health behavior messaging had a mixed impact on students. Students made simple behavior changes to protect themselves from H1N1, especially if they perceived a high personal risk of contracting H1N1. Although policies were instituted to enable students to avoid classes when ill, almost no student self-isolated for the entire duration of their illness. Conclusions: These findings can help inform future decision making in a university setting to best influence preventive health behaviors.

Heterogeneity in Values of Morbidity Risks from Drinking Water

This paper reports the stated preference values for reducing the morbidity risks from drinking water estimated using a nationally representative U.S. sample of 3,585 households. Based on the average annual gastrointestinal (GI) illness risk in the U.S. from drinking water of about 5 illnesses per 100 population, eliminating the GI risk has a median annual value per household of $219. The considerable heterogeneity in the values arises largely from differences in attitudes towards risk and price sensitivity. Using interval regressions, we find that valuations are greater for those who perceive a high personal risk, consume a large quantity of tap water, or are environmentalists. The paper explores several methodological issues pertaining to the iterative choice format involving a choice between two policies characterized by their cost and GI risk. The analysis adjusts for starting point effects by basing valuations on the tradeoffs that are estimated to prevail at the “equitable tradeoff rate,” which is the starting cost-water quality tradeoff rate that produces a 50–50 split in the initial policy choice between policies with greater tradeoff rates and policies with lower tradeoff rates. The heterogeneity in valuations is also explored by examining quantile regression results and the determinants of the unbounded valuation amounts at the low and high extremes.

Heterogeneity in Values of Morbidity Risks from Drinking Water

This paper reports the stated preference values for reducing the morbidity risks from drinking water estimated using a nationally representative U.S. sample of 3,585 households. Based on the average annual gastrointestinal (GI) illness risk in the U.S. from drinking water of about 5 illnesses per 100 population, eliminating the GI risk has a median annual value per household of $219. The considerable heterogeneity in the values arises largely from differences in attitudes towards risk and price sensitivity. Using interval regressions, we find that valuations are greater for those who perceive a high personal risk, consume a large quantity of tap water, or are environmentalists. The paper explores several methodological issues pertaining to the iterative choice format involving a choice between two policies characterized by their cost and GI risk. The analysis adjusts for starting point effects by basing valuations on the tradeoffs that are estimated to prevail at the “equitable tradeoff rate,” which is the starting cost-water quality tradeoff rate that produces a 50-50 split in the initial policy choice between policies with greater tradeoff rates and policies with lower tradeoff rates. The heterogeneity in valuations is also explored by examining quantile regression results and the determinants of the unbounded valuation amounts at the low and high extremes.

P2-173 Chronic diseases: studying and understanding outcome using routine data: chronic kidney disease (CKD), an example

Internationally, chronic disease represents a major healthcare challenge for the 21st century. Prognostic tools that streamline and target care have been developed for cardiovascular disease. This study illustrates how routine...

Testing two methods of presenting side effect risk information about common medicines

Abstract Focal points

Comparing Personal Risk, Melanoma Knowledge and Protective Behaviour in People With and Without Melanoma: A Postal Survey to Explore Educational Needs in Northeast Scotland

In Northeast Scotland, 132 people with melanoma and 139 people never affected by melanoma completed a questionnaire measuring risk, level of concern, protective behaviour and knowledge. In adjusted analysis, people with melanoma had significantly higher personal risk, level of concern, protective behaviour and melanoma knowledge scores than those never affected. These data suggest that people diagnosed with melanoma in Northeast Scotland are being educated about how to avoid a second primary. The results of the adjusted analysis also suggest that in Northeast Scotland, melanoma education should be targeted at older people, men and those of lower educational status. It is also likely that this questionnaire could be used in the healthy population of Northeast Scotland to detect those most likely to benefit from targeted education to help prevent melanoma, and to measure the effects of and quality of melanoma public education campaigns.

Making the Global City: Urban Citizenship at the Margins of Delhi

There is a growing scholarly interest in the spatialisation of class relations in post-industrial cities. Gentrified suburbs exclude the poor and re-work notions of public property and urban citizenship to the advantage of the rich. My study moves beyond the sanitised places of the inner city and shows how the cleaning mission affects life in the new spaces of deprivation. I analyse home making in a resettlement colony of Delhi. After being removed from the hubs of the labour market and with little state support, resettled slum dwellers struggle under harsh conditions for survival. Those who can afford this expensive venture embrace home ownership at high personal risks und by exploiting the channels of the informal economy, hoping that possessing a legal dwelling will root them more firmly in the city. In practice, the new status is an often uneasy fusion of a formal and informal status and thus remains essentially precarious in an environment that criminalises informality.

Attitudes to Living and Working in Pandemic Conditions among Emergency Prehospital Medical Care Personnel

Little is known about the risk perceptions and attitudes of healthcare personnel, especially of emergency prehospital medical care personnel, regarding the possibility of an outbreak or epidemic event. This study was designed to investigate pre-event knowledge and attitudes of a national sample of the emergency prehospital medical care providers in relation to a potential human influenza pandemic, and to determine predictors of these attitudes. Surveys were distributed to a random, cross-sectional sample of 20% of the Australian emergency prehospital medical care workforce (n = 2,929), stratified by the nine services operating in Australia, as well as by gender and location. The surveys included: (1) demographic information; (2) knowledge of influenza; and (3) attitudes and perceptions related to working during influenza pandemic conditions. Multiple logistic regression models were constructed to identify predictors of pandemic-related risk perceptions. Among the 725 Australian emergency prehospital medical care personnel who responded, 89% were very anxious about working during pandemic conditions, and 85% perceived a high personal risk associated with working in such conditions. In general, respondents demonstrated poor knowledge in relation to avian influenza, influenza generally, and infection transmission methods. Less than 5% of respondents perceived that they had adequate education/training about avian influenza. Logistic regression analyses indicate that, in managing the attitudes and risk perceptions of emergency prehospital medical care staff, particular attention should be directed toward the paid, male workforce (as opposed to volunteers), and on personnel whose relationship partners do not work in the health industry. These results highlight the potentially crucial role of education and training in pandemic preparedness. Organizations that provide emergency prehospital medical care must address this apparent lack of knowledge regarding infection transmission, and procedures for protection and decontamination. Careful management of the perceptions of emergency prehospital medical care personnel during a pandemic is likely to be critical in achieving an effective response to a widespread outbreak of infectious disease.

Surviving a life‐threatening crisis: Taiwan’s nurse leaders’ reflections and difficulties fighting the SARS epidemic

This study explored Taiwan's nurse leaders' reflections and experiences of the difficulties they encountered and survival strategies they employed fighting the severe acute respiratory syndrome epidemic and the background context framing these phenomena. On several continents in 2002-2003, the highly infectious severe acute respiratory syndrome overwhelmed health care systems and health professionals who had to provide care in situations involving high personal risk and stress, some becoming infected and dying. Nurse leaders in Taiwan had to develop new strategies and support systems for nursing care. A two-step within-method qualitative triangulation research design. Focus group in-depth interviews held with 70 nurse leaders from four Northern Taiwan hospitals involved in the severe acute respiratory syndrome epidemic. Participants then completed an open ended questionnaire. Content analysis was undertaken with data and stages and themes generated. Data were then analysed using Hobfall's concepts of conservation of resources to further discuss participants' reactions and actions in the severe acute respiratory syndrome crisis. Participants worked under incredible stress to lead the profession through a period of crisis. Five stages arose in the participants' involvement against severe acute respiratory syndrome over 12 weeks: facing shock and chaos; searching for reliable sources to clarify myths; developing and adjusting nursing care; supporting nurses and their clients; and rewarding nurses. Nurse leaders become important executors of intervention in this health disaster, requiring emotional intelligence to manage their internal conflicts and interpersonal relationships effectively. They developed sociopolitical and analytical abilities and crucial requirements for planning and implementing strategies in areas where none previously existed. Building support systems was an important resource for managing conflicts between familial and professional roles. Relevance to clinical practice. Findings will assist nurse leaders to prepare themselves and the profession to better deal with disaster management in similar infectious outbreaks in the future.

Vaccination with Dukoral® against travelers’ diarrhea (ETEC) and cholera

There is currently only one vaccine available that provides protection against diarrhea caused by Vibrio cholerae and, to a lesser degree, enterotoxigenic Escherichia coli (ETEC). Adverse events of this oral whole-cell/recombinant B-subunit vaccine have been negligible. Protective efficacy against cholera is 85%, while protection against the heat-labile toxin of ETEC reaches 67%. There is still a need for data on protection of Western travelers against travelers’ diarrhea in general by Dukoral® vaccination. However, current studies show a protective effect of up to 43%. Although the vaccine is only licensed for vaccination against cholera in most Western countries, there is mounting evidence that the oral cholera vaccine is a valuable option to those traveling to high-risk endemic areas. Vaccination against cholera and ETEC should be recommended for at-risk travelers, in particular those with high exposure at their travel destination or high personal risks through fluid loss.

Ethical planning for an influenza pandemic

A U.K. Pandemic Influenza Contingency Plan was developed in 2006 but little research has since been carried out as to how ethically acceptable it will be to society. A survey containing two hypothetical scenarios was distributed to 1,018 hospital staff. The survey considered their attitudes to the professional and ethical responsibilities of healthcare workers, and to resource allocation on the intensive care unit (ICU). Of those distributed, 406 (40%) surveys were returned. During a pandemic, 320 (79%) healthcare professionals would continue to work and 339 (83%) felt it would be unprofessional for doctors to leave work. Only 218 (54%) chose the same patient for the last ICU bed. Most staff surveyed felt they should (professionally) and would (voluntarily) work during a pandemic despite high personal risk. A wide diversity of opinion existed regarding resource allocation of ICU beds. These ethical issues require open debate to ensure U.K. pandemic plans are ethically acceptable and practically applicable.

Best surgical prophylaxis - risk-reducing mastectomy for women at high personal risk of breast cancer

Best surgical prophylaxis - risk-reducing mastectomy for women at high personal risk of breast cancer