Participatory approach to design social accountability interventions to improve maternal health services:a case study from the Democratic Republic of the Congo

Background:Social accountability(SA)comprises a set of mechanisms aiming to,on the one hand,enable users to raise their concerns about the health services provided to them(voice),and to hold health providers(HPs)accountable for actions and decisions related to the health service provision.On the other hand,they aim to facilitate HPs to take into account users’needs and expectations in providing care.This article describes the development of a SA intervention that aims to improve health services responsiveness in two health zones in the Democratic Republic of the Congo.Methods:Beneficiaries including men,women,community health workers(CHWs),representatives of the health sector and local authorities were purposively selected and involved in an advisory process using the Dialogue Model in the two health zones:(1)Eight focus group discussions(FGDs)were organized separately during consultation aimed at sharing and discussing results from the situation analysis,and collecting suggestions for improvement,(2)Representatives of participants in previous FGDs were involved in dialogue meetings for prioritizing and integrating suggestions from FGDs,and(3)the integrated suggestions were discussed by research partners and set as intervention components.All the processes were audio-taped,transcribed and analysed using inductive content analysis.Results:Overall there were 121 participants involved in the process,51 were female.They provided 48 suggestions.Their suggestions were integrated into six intervention components during dialogue meetings:(1)use CHWs and a health committee for collecting and transmitting community concerns about health services,(2)build the capacity of the community in terms of knowledge and information,(3)involve community leaders through dialogue meetings,(4)improve the attitude of HPs towards voice and the management of voice at health facility level,(5)involve the health service supervisors in community participation and;(6)use other existing interventions.These components were then articulated into three intervention components during programming to:create a formal voice system,introduce dialogue meetings improving enforceability and answerability,and enhance the health providers’responsiveness.Conclusions:The use of the Dialogue Model,a participatory process,allowed beneficiaries to be involved with other community stakeholders having different perspectives and types of knowledge in an advisory process and to articulate their suggestions on a combination of SA intervention components,specific for the two health zones contexts.

The association of diet quality and physical activity with cardiovascular disease and mortality in 85,545 older Australians:A longitudinal study

Background:A quality diet and an active lifestyle are both important cornerstones of cardiovascular disease(CVD)prevention.However,despite their interlinked effects on metabolic health,the 2 behaviors are rarely considered jointly,particularly within the context of CVD prevention.We examined the independent,interactive,and joint associations of diet and physical activity with CVD hospitalization,CVD mortality,and all-cause mortality.Methods:CVD-free Australian participants aged 4574 years(n=85,545)reported physical activity,diet,sociodemographic,and lifestyle characteristics at baseline(20062009)and follow-up(20122015),and data were linked to hospitalization and death registries(03/31/2019 for CVD hospitalization and all-cause mortality and 12/08/2017 for CVD mortality).Diet quality was categorized as low,medium,and high based on meeting dietary recommendations.Physical activity was operationalized as(a)total moderate-to-vigorous physical activity(MVPA)as per guidelines,and(b)the composition of MVPA as the ratio of vigorous-intensity physical activity(VPA)to total MVPA.We used a left-truncated cause-specific Cox proportional hazards model using time-varying covariates.Results:During a median of 10.7 years of follow-up,6576 participants were admitted to the hospital for CVD and 6581 died from all causes(876 from CVD during 9.3 years).A high-quality diet was associated with a 17%lower risk of all-cause mortality than a low-quality diet,and the highest MVPA category(compared with the lowest)was associated with a 44%and 48%lower risk of CVD and all-cause mortality,respectively.Multiplicative interactions between diet and physical activity were non-significant.For all outcomes,the lowest risk combinations involved a high-quality diet and the highest MVPA categories.Accounting for total MVPA,some VPA was associated with further risk reduction of CVD hospitalization and all-cause mortality.Conclusion:For CVD prevention and longevity,one should adhere to both a healthy diet and an active lifestyle and incorporate some VPA when possible.

From London buses to activity trackers:A reflection of 70 years of physical activity research

In 1953,Morris et al.^(1)published their ground-breaking findings among London bus drivers and conductors,linking physical activity to a major chronic disease for the first time.This seminal paper marked the birth of a new field—physical activity epidemiology.^(1)Since then,the field has flourished,evidenced by mounting scientific publications.^(2)Our knowledge about the role of physical activity in disease prevention has expanded from coronary heart disease in Morris et al.’s^(1)initial study to dozens of additional diseases and conditions,such as diabetes,cancers,and dementia.^(3)More than 7 decades and thousands of publications later,we critically reflect on several aspects of the progress in physical activity epidemiology.

Occupational physical activity, all-cause, cardiovascular disease, and cancer mortality in 349,248 adults: Prospective and longitudinal analyses of the MJ Cohort

Background:Evidence on the health benefits of occupational physical activity(OPA)is inconclusive.We examined the associations of baseline OPA and OPA changes with all-cause,cardiovascular disease(CVD),and cancer mortality and survival times.Methods:This study included prospective and longitudinal data from the MJ Cohort,comprising adults over 18 years recruited in 1998-2016,349,248 adults(177,314 women)with baseline OPA,of whom 105,715(52,503 women)had 2 OPA measures at 6.3±4.2 years(mean±SD)apart.Exposures were baseline OPA,OPA changes,and baseline leisure-time physical activity.Results:Over a mean mortality follow-up of 16.2±5.5 years for men and 16.4±5.4 years for women,11,696 deaths(2033 of CVD and 4631 of cancer causes)in men and 8980 deaths(1475 of CVD and 3689 of cancer causes)in women occurred.Combined moderately heavy/heavy baseline OPA was beneficially associated with all-cause mortality in men(multivariable-adjusted hazard ratio(HR)=0.93,95%confidence interval(95%CI):0.89-0.98 compared to light OPA)and women(HR=0.86,95%CI:0.79-0.93).Over a mean mortality follow-up of 12.5±4.6 years for men and 12.6±4.6 years for women,OPA decreases in men were detrimentally associated(HR=1.16,95%CI:1.01-1.33)with all-cause mortality,while OPA increases in women were beneficially(HR=0.83,95%CI:0.70-0.97)associated with the same outcome.Baseline or changes in OPA showed no associations with CVD or cancer mortality.Conclusion:Higher baseline OPA was beneficially associated with all-cause mortality risk in both men and women.Our longitudinal OPA analyses partly confirmed the prospective findings,with some discordance between sex groups.

Sensorineural Hearing Loss in Multidrug-Resistant Tuberculosis Patients in Kinshasa (Democratic Republic of Congo): Prospective Cohort Study of Therapeutic Regimen with Aminoglycoside versus Bedaquiline

Context: Multidrug-resistant tuberculosis (MDR-TB) remains a major public health problem in developing countries such as the Democratic Republic of Congo (DRC), which continues to face the emergence of MDR-TB cases. Because of the ototoxic effects of AGs, the World Health Organization (WHO) has recommended the introduction of the bedaquiline regimen. However, very few data are available regarding the susceptibility of bedaquiline to induce hearing loss, hence the present study set out to compare the AG-based regimen and the bedaquiline-based regimen in the occurrence of hearing loss in MDR-TB patients. Methods: This is a prospective multicenter cohort study that included 335 MDR-TB patients, performed in Kinshasa (DRC) during the period from January 2020 to January 2021. Sociodemographic, clinical, biological and audiometric data were analyzed using Stata 17. Repeated-measures analysis of variance was used to compare changes in the degree of hearing loss over time between the two groups of patients on AG and bedaquiline regimens. The double-difference method was estimated using regression with fixed-effects. A p value < 0.05 was considered the threshold for statistical significance. Results: The degree of hearing loss was similar between the two groups at the first month [AGs (28 dB) vs BDQ (30 dB);p = 0.298]. At six months, the mean degree of hearing loss was significantly greater in the aminoglycoside regimen group [AGs (60.5 dB) vs BDQ (44 dB);p < 0.001]. The double difference was significant, with a greater increase in hearing loss in the AGs group (diff-in-diff 18.3;p < 0.001). After adjustment for age and serum albumin, the group receiving the AG-based regimen had a 2-point greater worsening than those with bedaquiline at the sixth month (diff-in-diff 19.8;p Conclusion: Hearing loss is frequent with both treatment regimens, but more marked with the Aminoglycoside-based regimen. Thus, bedaquiline should also benefit for audiometric monitoring in future MDR-TB patients.

Determinants of the Sensorineural Hearing Loss in Patients with Multidrug-Resistant Tuberculosis in Kinshasa (Democratic Republic of the Congo): A Prospective Cohort Study

Background: The onset of the hearing loss is a major challenge during the treatment of multidrug-resistant tuberculosis (MDR-TB). Aminoglycoside-based regimens, to a lesser extent based on bedaquiline, induce ototoxic sensorineural hearing loss. Research on risk factors is essential to enable high-risk individuals to benefit from preventive measures in settings with limited resources. Objective: This study aimed to assess the determinants of the hearing loss in patients with MDR-TB. Methods: This prospective multicenter cohort study included 337 patients with MDR-TB. It was performed in Kinshasa (Democratic Republic of the Congo) between January 2020 and January 2021. Sociodemographic, clinical, biological, therapeutic, and audiometric data were exported and analyzed using Stata 17 and MedCalc. The fixed-effect linear regression panel model was used to assess the degree of the hearing loss over time according to the following covariates: therapeutic regimen (aminoglycosides, bedaquiline, or alternate), stage of chronic kidney disease (CKD), age at inclusion, body mass index, serum albumin level, HIV status, alcohol intake, hypertension, and hemoglobin level. The Hausman test was used to select between fixed- and random-effect estimators. The threshold for statistical significance was set at p Result: A total of 236 patients (70%) received an aminoglycoside-based regimen, 61 (18%) received a bedaquiline-based regimen, and 40 (12%) received aminoglycosides relayed by bedaquiline. The frequency of the hearing loss increased from 62% to 96.3% within six months for all therapeutic regimens. The Hearing loss worsened, with moderate (72.4%) and profound (16%) deafness being predominant. An Exposure to the treatment for more than one month (β coeff: 27.695, Se: 0.793, p β coeff: 6.102, Se: 1.779, p β coeff: 5.610, Se: 1.682, p = 0.001), and an eGFR β coeff: 6.730, Se: 2.70, p = 0.013) were the independent risk factors associated with the hearing loss in patients with MDR-TB. Conclusions: The Hearing loss was more prevalent and worsened during the treatment of the patients with MDR-TB. An Exposure for more than one month, AG-based regimens, advanced age, hypoalbuminemia, and CKD have emerged as the main determinants of the worsening of the hearing loss.

Prognostic factors associated with hospital survival in comatose survivors of cardiac arrest

AIM: To identify patient, cardiac arrest and management factors associated with hospital survival in comatose survivors of cardiac arrest.METHODS: A retrospective, single centre study of comatose patients admitted to our intensive care unit(ICU) following cardiac arrest during the twenty year period between 1993 and 2012. This study was deemed by the Human Research Ethics Committee(HREC) of Monash Health to be a quality assurance exercise, and thus did not require submission to the Monash Health HREC(Research Project Application, No. 13290Q). The study population included all patients admitted to ourICU between 1993 and 2012, with a discharge diagnosis including "cardiac arrest". Patients were excluded if they did not have a cardiac arrest prior to ICU admission(i.e.,if their primary arrest was during their admission to ICU),or were not comatose on arrival to ICU. Our primary outcome measure was survival to hospital discharge.Secondary outcome measures were ICU and hospita length of stay(LOS), and factors associated with surviva to hospital discharge.RESULTS: Five hundred and eighty-two comatose patients were admitted to our ICU following cardiac arrest, with 35% surviving to hospital discharge. The median ICU and hospital LOS was 3 and 5 d respectively.There was no survival difference between in-hospital and out-of-hospital cardiac arrests. Males made up 62% of our cardiac arrest population, were more likely to have a shockable rhythm(56% vs 37%, P < 0.001), and were more likely to survive to hospital discharge(40%vs 28%, P = 0.006). On univariate analysis, therapeutic hypothermia, regardless of method used(e.g., rapid infusion of ice cold fluids, topical ice, "Arctic Sun", passive rewarming, "Bair Hugger") and location initiated(e.g.,pre-hospital, emergency department, intensive care) was associated with increased survival. There was however no difference in survival associated with target temperature,time at target temperature, location of initial cooling,method of initiating cooling, method of maintaining cooling or method of rewarming. Patients that survived were more likely to have a shockable rhythm(P < 0.001),shorter time to return of spontaneous circulation(P <0.001), receive therapeutic hypothermia(P = 0.03), be of male gender(P = 0.006) and have a lower APACHEⅡ score(P < 0.001). After multivariate analysis, only a shockable initial rhythm(OR = 6.4, 95%CI: 3.95-10.4;P < 0.01) and a shorter time to return of spontaneous circulation(OR = 0.95, 95%CI: 0.93-0.97; P < 0.01) was found to be independently associated with survival to hospital discharge.CONCLUSION: In comatose survivors of cardiac arrest, shockable rhythm and shorter time to return of spontaneous circulation were independently associated with increased survival to hospital discharge.

Accuracy of Physicians in Diagnosing HIV and AIDS-Related Death in the Adult Population of Addis Ababa, Ethiopia

Background: The lack of cause of death information is the main challenge in monitoring the effectiveness of interventions aimed at reducing HIV and AIDS-related deaths in countries where the majority of deaths occur at home. Objective: To evaluate the accuracy of physician reviewers of verbal autopsies in diagnosing HIV and AIDS-related deaths in the adult population of Addis Ababa, the capital of Ethiopia. Methods: This study was done within the context of a burial surveillance system in Addis Ababa. Trained interviewers completed a standard verbal autopsy questionnaire and an independent panel of physicians reviewed the completed form to assign cause of death. Physicians' review was compared to a reference standard constructed based on prospectively collected HIV-serostatus and patients' hospital record. Sensitivity and specificity were calculated to validate the physicians' verbal autopsy diagnoses against reference standards. Results: Physicians accurately identified AIDS-related deaths with sensitivity and specificity of 0.88 (95% CI: 0.80 - 0.93) and 0.77 (95% CI: 0.64 - 0.87), respectively. Generally, there was high level of agreement (Cohen's Kappa Statistic (K > 0.6) between the first two physicians with some yearly variations. In 2008 and 2009 there was an almost perfect agreement (K > 0.80). Conclusion: This study demonstrated the agreement level between two independent physicians in diagnosing AIDS-related death is very high and thus using a single verbal autopsy coder is practical for programmatic purposes in countries where there is critical shortage of doctors.

Profile of abortion in Chile, with extremely restrictive law

Chile, together with El Salvador, Malta and Nicaragua has the most restrictive abortion laws. In these countries there is very little information on pregnancies that end in abortions. An analysis is made of official information regarding hospital discharges for abortion in Chile between 2001 and 2010, classified according to age and according to the WHO ICD 10. The Chilean Ministry of Health’s Statistics Office (DEIS) collected the data. In 334,485 hospital discharges for abortion, Ectopic Abortion (O00), the Hydatidiform Mole (O01) and Other Abnormal Products of Conception (O02) corresponded to 37.2% of hospital discharges. Spontaneous Abortion (O03) reached 15% and Non Specified Abortion (O06) reached 35.5% and most probably included complications of induced abortions. 77% of hospital discharges corresponded to women between 20 and 34 years of age. Adolescents correspond to 11% of hospital discharges. In the annual average of 33,500 hospital discharges, Other Abnormal Products of Conception (O02), Other Abortions (O05), and Non Specified Abortions (O05) contribute to 72.7% of hospital discharges. This is explained by incomplete diagnoses, by means of the omission of induced abortion as this would mean jail for the woman and legal red-tape for the health personnel involved. Maternal mortality has not fallen. Abortion Mortality and Fatality rates do not change. There is a discrepancy between the law and hospital discharge diagnoses for abortion. The antiabortion law remains unheeded and obeys an ideological bias that brings damage and abuse to Chilean women. The aim of this study is to gain better information from a country that does not allow abortion under any circumstance, and its usefulness to countries in similar situations, together with its negative consequences on woman’s health and rights.

Stair climbing,genetic predisposition,and the risk of incident type 2 diabetes:A large population-based prospective cohort study

Background:Cross-sectional evidence and small-scale trials suggest positive effects of stair climbing on cardiometabolic disease and glucose regulation.However,few studies have examined the long-term association between stair climbing and the incidence of type 2 diabetes(T2D).We aimed to prospectively evaluate the association of stair climbing with T2D and assess modifications by genetic predisposition to T2D.Methods:We included 451,699 adults(mean age=56.3±8.1 years,mean±SD;55.2%females)without T2D at baseline in the UK Biobank and followed up to March 31,2021.Stair climbing information was collected through the touchscreen questionnaire.Genetic risk score for T2D consisted of 424 single nucleotide polymorphisms.Results:During a median follow up of 12.1 years,14,896 T2D cases were documented.Compared with participants who reported no stair climbing,those who climbed stairs regularly had a lower risk of incident T2D(10-50 steps/day:hazard ratio(HR)=0.95,95%confidence interval(95%CI):0.89-1.00;60-100 steps/day:HR=0.92,95%CI:0.87-0.98;110-150 steps/day:HR=0.86,95%CI:0.80-0.91;>150 steps/day:HR=0.93,95%CI:0.87-0.99,p for trend=0.0007).We observed a significant interaction between stair climbing and genetic risk score on the subsequent T2D risk(p for interaction=0.0004),where the risk of T2D showed a downward trend in subjects with low genetic risk and those who reported stair climbing activity of 110-150 steps/day appeared to have the lowest overall T2D risk among those with intermediate to high genetic risk.Conclusion:A higher number of stairs climbed at home was associated with lower T2D incidence risk,especially among individuals with a low genetic predisposition to T2D.These findings highlight that stair climbing,as incidental physical activity,offers a simple and low-cost complement to public health interventions for T2D prevention.

Physical activity volume,frequency,and intensity:Associations with hypertension and obesity over 21 years in Australian women

Background:Optimal patterns of accrual of recommended levels of physical activity(PA)for prevention of hypertension and obesity are not known.The overall aim of this study was to investigate whether different patterns of accumulation of PA are differentially associated with hypertension and obesity in Australian women over 21 years.Specifically,we investigated whether,for the same weekly volume of PA,the number of sessions(frequency)and vigorousness of PA(intensity)were associated with a reduction in the occurrence of hypertension and obesity in women.Methods:Data from the 1973-1978 and 1946-1951 cohorts of the Australian Longitudinal Study on Women's Health were analyzed(n=20,588;12%-16%with a Bachelor's or higher degree).Self-reported PA,hypertension,height,and weight were collected using mail surveys every 3 years from 1998/2000 to 2019/2021.Generalized Estimating Equation models with a 3-year lag model were used to investigate the association of PA volume(metabolic equivalent min/week)(none;33-499;500-999;≥1000,weekly frequency(none;1-2 times;3-4times;5-7 times;≥8 times),and the proportion of vigorous PA to total volume of PA(none;0%;1%-33%;34%-66%;67%-100%)with odds of hypertension and obesity from 2000 to 2021.Results:The cumulative incidence of hypertension was 6%in the 1973-1978 and 23%in the 1946-1951 cohort;27%of women in the 1973-1978;and 15%in the 1946-1951 cohort developed obesity over the period.Overall,a higher volume of PA was associated with reduced odds of hypertension and obesity.When the volume of PA was considered,the odds of hypertension did not vary according to the frequency or intensity of PA.However,increased proportion of vigorous PA to the total volume of PA was associated with a small additional reduction in the risk of obe sity.Conclusion:PA volume appears to be more important than the pattern of accumulation for the prevention of hypertension and obesity.Incorporating more sessions,particularly of vigorous-intensity PA,may provide extra benefits for the prevention of obesity.

The health and economic benefits of the global programme to eliminate lymphatic filariasis (2000–2014)

Background:Lymphatic filariasis(LF),also known as elephantiasis,is a neglected tropical disease(NTD)targeted for elimination through a Global Programme to Eliminate LF(GPELF).Between 2000 and 2014,the GPELF has delivered 5.6 billion treatments to over 763 million people.Updating the estimated health and economic benefits of this significant achievement is important in justifying the resources and investment needed for eliminating LF.Method:We combined previously established models to estimate the number of clinical manifestations and disability-adjusted life years(DALYs)averted from three benefit cohorts(those protected from acquiring infection,those with subclinical morbidity prevented from progressing and those with clinical disease alleviated).The economic savings associated with this disease prevention was then analysed in the context of prevented medical expenses incurred by LF clinical patients,potential income loss through lost-labour,and prevented costs to the health system to care for affected individuals.The indirect cost estimates were calculated using the human capital approach.A combination of four wage sources was used to estimate the fair market value of time for an agricultural worker with LF infection(to ensure a conservative estimate,the lowest wage value was used).Results:We projected that due to the first 15 years of the GPELF 36 million clinical cases and 175(116–250)million DALYs will potentially be averted.It was estimated that due to this notable health impact,US$100.5 billion will potentially be saved over the lifetimes of the benefit cohorts.This total amount results from summing the medical expenses incurred by LF patients(US$3 billion),potential income loss(US$94 billion),and costs to the health system(US$3.5 billion)that were projected to be prevented.The results were subjected to sensitivity analysis and were most sensitive to the assumed percentage of work hours lost for those suffering from chronic disease(changing the total economic benefit between US$69.30–150.7 billion).Conclusions:Despite the limitations of any such analysis,this study identifies substantial health and economic benefits that have resulted from the first 15 years of the GPELF,and it highlights the value and importance of continued investment in the GPELF.

Joint effect among p53, CYP1A1, GSTM1 polymorphism combinations and smoking on prostate cancer risk： an exploratory genotype-environment interaction study

Aim： To assess the role of several genetic factors in combination with an environmental factor as modulators of prostate cancer risk. We focus on allele variants of low-penetrance genes associated with cell control, the detoxification processes and smoking. Methods： In a case-control study we compared people carrying p53cd72 Pro allele, CYP1A1 M1 allele and GSTM1 null genotypes with their prostate cancer risk. Results： The joint risk for smokers carrying Pro^＊ and MI^＊, Pro^＊ and GSTM1null or GSTM1 null and CYP1A1 MI^＊ variants was significantly higher （odds ratio [OR]： 13.13, 95% confidence interval [CI]： 2.41-71.36; OR： 3.97, 95% CI： 1.13-13.95 and OR： 6.87, 95% CI： 1.68-27.97, respectively） compared with that for the reference group, and for non-smokers was not significant. OR for combinations among p53cd72, GSTM1 and CYP1A1 M1 in smokers were positively and significantly associated with prostate cancer risk compared with non-smokers and compared with the putative lowest risk group （OR： 8.87, 95% CI： 1.25-62.71）. Conclusion： Our results suggest that a combination of p53cd72, CYP1A1, GSTM1 alleles and smoking plays a significant role in modified prostate cancer risk on the study population, which means that smokers carrying susceptible genotypes might have a significantly higher risk than those carrying non-susceptible genotypes.

Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

Purpose： Early diagnosis of traumatic brain injury （TBI） is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale （GCS） of 12 or less can predict the presence of TBl and the severity of associated injuries in blunt trauma patients. Methods： A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel＇s National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant. Results： There were 303,435 blunt trauma patients, 8731 （2.9%） of them with GCS of 3-12 that including 6351 （72%） patients with GCS of 3-8 and 2380 （28%） patient with GCS of 9--12. In these 8731 patients with GCS of 3-12, 5372 （61.5%） patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12,1256 （89%） patients with GCS 3-8, 148 （11%） patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TB1. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI. Conclusion： The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.

Knowledge, attitudes and practice survey on Zika virus infection among pregnant women in Brunei Darussalam

To assess the knowledge, attitudes, and practices(KAP) on Zika virus infection among pregnant women in Brunei Darussalam by a cross-sectional survey. Methods: Between February and June 2017, we recruited 234 pregnant women from all government healthcare centres at Brunei-Muara district, using a modified systematic sampling approach. A pre-tested and self-administered questionnaire was used and data analysis was conducted using descriptive statistics and multiple logistic regression analyses. Results: The study participants were mainly Malay(87.2%) and their mean age was 28.0 years. The median knowledge score was 13, out of a possible score of 28. Most participants(92.7%) knew that Zika virus was transmitted by mosquito bites whereas some(34.6%) knew that sexual transmission was also possible. Media(radio, television or newspapers) was the preferred source of updated information on Zika virus, followed by healthcare workers(44.0%), government announcements(43.2%), and social media(38.0%). Pregnant women who were 25 years old or older [Adj. OR=3.62(95% CI: 1.57, 9.51)], not Malays [Adj. OR=3.32(95% CI: 1.35, 8.55)], and had an average monthly household income of more than BND $3 000 [Adj. OR=4.06(95% CI: 1.81, 19.44)] were more likely to score higher for knowledge on Zika virus. The median prevention practice score was 23, out of a possible score of 36. Most participants reported wearing covering clothes(98.3%) and kept their living surroundings clean(99.6%). Most participants(88.0%) agreed that Zika is an important issue in their community. Conclusion: We found a lack of knowledge on Zika virus infection among pregnant women attending government maternal and child healthcare centres in Brunei Darussalam, in particular that Zika virus can be sexually transmitted. Such information could be well disseminated at the healthcare centre level. Health literacy studies should be conducted to understand the facilitators and barriers of KAP on Zika virus infection among pregnant women.

Prevalence and correlates of depressive symptoms in adult patients with pulmonary tuberculosis in the Southwest Region of Cameroon

Background:Tuberculosis(TB)remains a global health challenge and depression is a significant contributor to the global burden of disease.Current evidence suggests that there is an association between depressive symptoms and TB,lower adherence to treatment,and increased morbidity and mortality.However,there is paucity of data regarding these associations in Cameroon.This study aimed to determine the prevalence and correlates of depression in adult patients with pulmonary TB(PTB)in the Southwest Region of Cameroon.Methods:A hospital-based cross-sectional study involving 265 patients with PTB was conducted from 2nd January to 31st March 2015 in the Limbe Regional Hospital and the Kumba District Hospital.Depression was diagnosed using the standard nine-item Patient Health Questionnaire,and classified as none,mild or moderate.Logistic regressions were used to investigate correlates of depression in these patients.Results:Of the 265 patients(mean age 36.9±10 years)studied,136(51.3%)were female.The prevalence of depression was 61.1%(95%CI:55.1–66.8),with a significant proportion(36.6%)having mild depression.Multivariable logistic regression analysis showed that being female(aOR=3.0,95%CI(1.7–5.5),P<0.001),having a family history of mental illness(aOR=2.5,95%CI:1.3–5.4,P>0.05),being on retreatment for TB(aOR=11.2,95%CI:5.2–31.1,P<0.001),having discontinued treatment(aOR=8.2,95%CI:1.1–23.3,P<0.05)and having a HIV/TB co-infection(aOR=2.5,95%CI:1.2–6.5,P<0.001)were factors associated with having a higher chance of being depressed.Conclusion:Our study suggests that there is a high prevalence of depression among PTB patients,with more than one in two patients affected.Multidisciplinary care for TB patients involving mental health practitioners is highly encouraged,especially for high-risk groups.

Immunization coverage,knowledge,satisfaction,and associated factors of non-National Immunization Program vaccines among migrant and left-behind families in China:evidence from Zhejiang and Henan provinces

Background Migrant and left-behind families are vulnerable in health services utilization,but little is known about their disparities in immunization of non-National Immunization Program(NIP)vaccines.This study aims to evaluate the immunization coverage,knowledge,satisfaction,and associated factors of non-NIP vaccines among local and migrant families in the urban areas and non-left-behind and left-behind families in the rural areas of China.Methods A cross-sectional survey was conducted in urban areas of Zhejiang and rural areas of Henan in China.A total of 1648 caregivers of children aged 1-6 years were interviewed face-to-face by a pre-designed online questionnaire,and their families were grouped into four types:local urban,migrant,non-left-behind,and left-behind.Non-NIP vaccines includedHemophilus influenza b(Hib)vaccine,varicella vaccine,rotavirus vaccine,enterovirus 71 vaccine(EV71)and 13-valent pneumonia vaccine(PCV13).Log-binomial regression models were used to calculate prevalence ratios(PRs)and 95%confidence intervals(CIs)for the difference on immunization coverage of children,and knowledge and satisfaction of caregivers among families.The network models were conducted to explore the interplay of immunization coverage,knowledge,and satisfaction.Logistic regression models with odds ratios(ORs)and 95%CIs were used to estimate the associated factors of non-NIP vaccination.Results The immunization coverage of all non-NIP vaccines and knowledge of all items of local urban families was the highest,followed by migrant,non-left-behind and left-behind families.Compared with local urban children,thePRs(95%CIs)for getting all vaccinated were 0.65(0.52-0.81),0.29(0.22-0.37)and 0.14(0.09-0.21)among migrant children,non-left-behind children and left-behind children,respectively.The coverage-knowledge-satisfaction network model showed the core node was the satisfaction of vaccination schedule.Non-NIP vaccination was associated with characteristics of both children and caregivers,including age of children(>2 years-OR:1.69,95%CI:1.07-2.68 for local urban children;2.67,1.39-5.13 for migrant children;3.09,1.23-7.76 for non-left-behind children);and below caregivers’characteristics:family role(parents:0.37,0.14-0.99 for non-left-behind children),age(≤35 years:7.27,1.39-37.94 for non-left-behind children),sex(female:0.49,0.30-0.81 for local urban children;0.31,0.15-0.62 for non-left-behind children),physical health(more than average:1.58,1.07-2.35 for local urban children)and non-NIP vaccines knowledge(good:0.45,0.30-0.68 for local urban children;7.54,2.64-21.50 for left-behind children).Conclusions There were immunization disparities in non-NIP vaccines among migrant and left-behind families compared with their local counterparts.Non-NIP vaccination promotion strategies,including education on caregivers,and optimization of the immunization information system,should be delivered particularly among left-behind and migrant families.

Global dynamic spatiotemporal pattern of seasonal influenza since 2009 influenza pandemic

Background:Understanding the global spatiotemporal pattern of seasonal influenza is essential for influenza control and prevention.Available data on the updated global spatiotemporal pattern of seasonal influenza are scarce.This study aimed to assess the spatiotemporal pattern of seasonal influenza after the 2009 influenza pandemic.Methods:Weekly influenza surveillance data in 86 countries from 2010 to 2017 were obtained from FluNet.First,the proportion of influenza A in total influenza viruses(PA)was calculated.Second,weekly numbers of influenza positive virus(A and B)were divided by the total number of samples processed to get weekly positive rates of influenza A(RWA)and influenza B(RWB).Third,the average positive rates of influenza A(RA)and influenza B(RB)for each country were calculated by averaging RWA,and RWB of 52 weeks.A Kruskal-Wallis test was conducted to examine if the year-to-year change in PA in all countries were significant,and a universal kriging method with linear semivariogram model was used to extrapolate RA and RB in all countries.Results:PA ranged from 0.43 in Zambia to 0.98 in Belarus,and PA in countries with higher income was greater than those countries with lower income.The spatial patterns of high RB were the highest in sub-Saharan Africa,Asia-Pacific region and South America.RWA peaked in early weeks in temperate countries,and the peak of RWB occurred a bit later.There were some temperate countries with non-distinct influenza seasonality(e.g.,Mauritius and Maldives)and some tropical/subtropical countries with distinct influenza seasonality(e.g.,Chile and South Africa).Conclusions:Influenza seasonality is not predictable in some temperate countries,and it is distinct in Chile,Argentina and South Africa,implying that the optimal timing for influenza vaccination needs to be chosen with caution in these unpredictable countries.

Serum bicarbonate may independently predict acute kidney injury in critically ill patients:An observational study

AIM: To explore whether serum bicarbonate at admission to intensive care unit(ICU) predicted development of acute kidney injury(AKI).METHODS:We studied all patients admitted to our ICU over a 2 year period(February 2010 to 2012).The ICU has a case mix of medical and surgical patients excluding cardiac surgical,trauma and neurosurgical patients.We analysed 2035 consecutive patients admitted to ICU during the study period.Data were collected by two investigators independently and in duplicate using a standardised spread sheet to ensure accuracy.Ambiguous data were checked for accuracy where indicated.AKI was defined using the Kidney Disease Improving Global Outcomes criteria.Patients were divided into two groups;patients who developed AKI or those who did not,in order to compare the baseline characteristics,and laboratory and physiologic data of the two cohorts.Regression analysis was used to identify if serum bicarbonate on admission predicted the development of AKI.RESULTS:Of 2036 patients 152(7.5%)were excluded due to missing data.AKI developed in 43.1%of the patients.The AKI group,compared to the nonAKI group,was sicker based on their lower systolic,diastolic and mean arterial pressures and a higher acutephysiology and chronic health evaluation(APACHE)Ⅲand SAPSⅡscores.Moreover,patients who developed AKI had more co-morbidities and a higher proportion of patients who developed AKI required mechanical ventilation.The multi-regression analysis of independent variables showed that serum bicarbonate on admission(OR=0.821;95%CI:0.796-0.846;P<0.0001),APACHEⅢ(OR=1.011;95%CI:1.007-1.015;P<0.0001),age(OR=1.016;95%CI:1.008-1.024;P<0.0001)and presence of sepsis at ICU admission(OR=2.819;95%CI:2.122-23.744;P=0.004)were each significant independent predictors of AKI.The area under the ROC curve was 0.8(95%CI:0.78-0.83),thereby demonstrating that the predictive model has relatively good discriminating power for predicting AKI.CONCLUSION:Serum bicarbonate on admission may independently be used to make a diagnosis of AKI.

Heparin induced thrombocytopenia in critically ill: Diagnostic dilemmas and management conundrums

Thrombocytopenia is often noted in critically ill patients. While there are many reasons for thrombocytopenia, the use of heparin and its derivatives is increasingly noted to be associated with thrombocytopenia. Heparin induced thrombocytopenia syndrome(HITS) is a distinct entity that is characterised by the occurrence of thrombocytopenia in conjunction with thrombotic manifestations after exposure to unfractionated heparin or low molecular weight heparin. HITS is an immunologic disorder mediated by antibodies to heparin-platelet factor 4(PF4) complex. HITS is an uncommon cause of thrombocytopenia. Reported incidence of HITS in patients exposed to heparin varies from 0.2% to up to 5%. HITS is rare in ICU populations, with estimates varying from 0.39%-0.48%. It is a complex problem which may cause diagnostic dilemmas and management conundrum. The diagnosis of HITS centers around detection of antibodies against PF4-heparin complexes. Immunoassays performed by most pathology laboratories detect the presence of antibodies, but do not reveal whether the antibodies are pathological. Platelet activation assays demonstrate the presence of clinically relevant antibodies, but only a minority of laboratories conduct them. Several anticoagulants are used in management of HITS. In this review we discuss the incidence, pathogenesis, diagnosis and management of HITS.