Determinants of delay in timely treatment seeking for diarrheal diseases among mothers with under-five children in central Ethiopia: A case control study

Background

Delays in seeking timely appropriate care contributes to a large number of deaths from diarrhea in children. This study aimed to identify determinants of delays in seeking timely treatment by mothers/caregivers of under-five children with diarrheal diseases.

Methods

We used an unmatched case-control study from February—March 2017 among 316 children: 158 cases and 158 controls. Cases were mothers/caregivers with under-five children who had signs/symptoms of diarrhea and sought treatment after 24 hours onset of symptom. Controls sought treatment within 24 hours. Field workers collected data using a pre-tested standardized questionnaire. Multivariate logistic regression was conducted to identify determinants of delay in timely diarrhea treatment seeking. Statistical significance was declared by using a p-value<0.05 and 95% of confidence interval (CI) for an adjusted-odds ratio (AOR).

Results

The determinants of delay in timely treatment seeking of mothers/caregivers of under-five children with diarrheal diseases were children <24months (AOR = 1.9,95%CI:1.1–3.4); fail to attend school (AOR = 2.4, 95%CI:1.2–4.6); being female children (AOR = 1.7,95%CI:1.05–2.9); preferring government health facility for the treatment of children with diarrheal diseases (AOR = 2.9, 95%CI, 1.3–6.7); lack of past history taking children to health facility and lack of counseling (AOR = 4.8, 95%CI:2.0–12.1); being in the15-25 years age (AOR = 1.7, 95%CI:1.1–3.0) and taking children to a health facility as a first response to diarrhea (AOR = 0.1, 95%CI:0.01–0.8).

Conclusions

Age of the child, maternal age, and disease related determinants were determinants for seeking timely treatment to diarrheal diseases. Providing skilled based health education and counseling to mothers/caregivers on seeking timely treatment and taking children with diarrheal diseases to a health facility as a first response to diarrhea is a paramount intervention to reduce morbidity and mortality of children.

Abstract P3-09-05: Getting the most out of the 21-gene recurrence score assay: Increasing actionable results with a combined pathologic-genomic model

Introduction: The 21-gene recurrence score (RS) assay categorizes hormone receptor positive, node negative breast cancers (BC) into 3 risk groups for recurrence. We previously showed that the AAMC Model, using only standard pathology data, accurately does the same. This study compares the recurrence rate of the AAMC Model's risk groups to RS-based risk groups. A 2-step approach then is used, in which the AAMC model is applied first, and the RS assay is used only for AAMC intermediate risk cases. AAMC intermediate cases were reclassified by RS into low or high risk groups.

Methods: From a prospective registry of newly diagnosed BC, we selected invasive, hormone receptor positive, HER2 negative, lymph node negative cases from 2005 to 2015 tested with RS assay. Five-year Kaplan-Meier distant recurrence rates were calculated for each risk category.

Results: 1268 cases were included. Five-year recurrence rates were similar between the AAMC Model's low risk group and RS&lt;18 low risk group, as well as between the AAMC Model's high risk group and the RS&gt;30 high risk group. Applying the RS assay to the 715 cases in the AAMC Model's intermediate group resulted in re-classifying 417 (58%) as low risk and 41 (6%) as high risk. Using RS alone, 33% of cases were intermediate risk (n=424), whereas in the 2-step approach 20% were intermediate risk (n=257). For the 2-step approach, the 5-year distant recurrence rate was 3.3% for the low risk group (n=740) and 24.4% for the high risk group (n=271).

Conclusions: Five-year recurrence rates in the AAMC Model's low and high risk groups were similar to those in RS-based risk groups. The 2-step approach, with RS used only for AAMC intermediate cases, resulted in larger low and high risk groups with equivalent prognostic accuracy, compared to use of the RS assay alone. The 2-step approach reliably identifies a large number of patients unlikely to benefit from 21 gene assay and provides substantial cost savings.

Kaplan-Meier Calculated 5-year Distant Recurrences Rates for 4 Models: 1268 Patients Oncotype DXTAILORxAAMC Model2 Step Model with OncotypeDX for AAMC IntermediatesLow RiskRS &lt; 18 (n=703)RS &lt; 11 (n=250)Grade 1 and PR ≥ 1% (n=323)AAMC Low or AAMC intermediate/RS &lt;18 (n=740) 3.4% (95% CI 1.6 – 5.1%, nf=17)4.0% (95% CI 0.8 – 7.2%, nf=8)2.7% (95% CI 0.0 – 5.4%, nf=5)3.3% (95% CI 1.4 – 5.2%, nf=16)Intermediate RiskRS 18 - 30 (n=424)RS 11 - 25 (n=787)Not meeting AAMC definition for low or high risk (n=715)AAMC Intermediate and RS 18-30 (n=257) 15.2% (95% CI 10.3 – 20.1%, nf=38)7.3% (95% CI 4.7 – 9.9%, nf=35)8.4% (95% CI 5.4 – 11.3%, nf=36)12.0% (95% CI 5.8 – 18.1%, nf=15)High RiskRS &gt; 30 (n=141)RS &gt; 25 (n=231)Grade 3 or ER &lt; 20% (n=230)AAMC High or AAMC intermediate/RS &gt; 30 (n=271) 23.0% (95% CI 14.7 – 31.3%, nf=27)22.9% (95% CI 15.9 – 29.9%, nf=39)22.8% (95% CI 16.1 – 29.5%, nf=41)24.4% (95% CI 18.0 – 30.7%, nf=51)RS= Recurrence Score, nf=number of recurrences, CI = confidence interval.

Citation Format: Mylander C, Rosman M, Gage M, Fujii T, Le Du F, Raghavendra A, Sinha A, Espinosa Fernandez JR, James A, Ueno N, Tafra L, Jackson R. Getting the most out of the 21-gene recurrence score assay: Increasing actionable results with a combined pathologic-genomic model [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-09-05.

The Role of Health Extension Workers in Linking Pregnant Women With Health Facilities for Delivery in Rural and Pastoralist Areas of Ethiopia

Background

Women's preference to give birth at home is deeply embedded in Ethiopian culture. Many women only go to health facilities if they have complications during birth. Health Extension Workers (HEWs) have been deployed to improve the utilization of maternal health services by bridging the gap between communities and health facilities. This study examined the barriers and facilitators for HEWs as they refer women to mid-level health facilities for birth.

Methods

A qualitative study was conducted in three regions: Afar Region, Southern Nations Nationalities and People's Region and Tigray Region between March to December 2014. Interviews and focus group discussions were conducted with 45 HEWs, 14 women extension workers (employed by Afar Pastoralist Development Association, Afar Region) and 11 other health workers from health centers, hospitals or health offices. Data analysis was done based on collating the data and identifying key themes.

Results

Barriers to health facilities included distance, lack of transportation, sociocultural factors and disrespectful care. Facilitators for facility-based deliveries included liaising with Health Development Army (HDA) leaders to refer women before their expected due date or if labour starts at home; the introduction of ambulance services; and, provision of health services that are culturally more acceptable for women.

Conclusion

HEWs can effectively refer more women to give birth in health facilities when the HDA is well established, when health staff provide respectful care, and when ambulance is available at any time.

The effect of the A-frame on forelimb kinematics in experienced and inexperienced agility dogs

Limited research has evaluated the kinematics of agility dogs over different equipment despite the growing popularity of recreational and competitive agility. A-frames are associated with a higher risk of injury; these risks could be related to how dogs approach the equipment. We hypothesised that forelimb (FL) and spinal kinematics would differ throughout the different phases of negotiating the A-frame: incline, apex, decline, and between experienced and inexperienced agility dogs. Eight agility dogs of mixed breed and age, all trained on the A-frame participated in the study. Participants were divided into two groups: inexperienced dogs (ID: <4 years training; n=4) and experienced dogs (ED: >4years training; n=4), and undertook 3 runs over the A-frame. Reflective markers were placed on each dog’s carpus (Ca), radiohumeral (RH) and scapulohumerus (SH) joints, Atlas, C3 and L3. Video footage was transferred to Dartfish™ to enable FL joint angles to be calculated for the approach (last stride), incline (FL contact), apex (FL over), decline (FL touchdown and FL departure). The range of movement (ROM) for spinal markers was also calculated. Wilcoxon signed rank analyses, with Bonferroni correction applied (P<0.02), indicated if kinematics differed for ED and ID between the phases. Similar kinematic patterns were observed through all phases for C3 and L3, however a greater ROM was found for ED: C3 and ID: L3. For Atlas, ED stayed in flexion for all phases whilst ID movement varied: approach-incline extension, incline-apex: flexion, apex to decline extension followed by flexion. No significant differences in FL joint angles existed (P>0.02). No significant differences in kinematic measures were seen between ED and ID dogs in any phase of the A-frame. ED demonstrate consistent movement patterns; ID vary their head and neck position more, and exaggerate their apex jump. Rounding the A-frame apex could encourage a less-extreme technique in ID.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Diagnostic accuracy of individual antenatal tools for prediction of small-for-gestational age at birth

OBJECTIVE

To determine the accuracy of fetal and newborn growth charts for the prediction of small-for-gestational age (SGA) at birth (birth weight < 10^th centile).

METHODS

This was a prospective cohort study performed within a UK specialist fetal growth clinic. A total of 105 consecutive pregnant women referred for a suspected SGA fetus were included. All pregnancies were managed according to a standard protocol using estimated fetal weight (EFW) plotted on customized Gestation Related Optimal Weight (GROW) charts. The last antenatal estimates of EFW (according to charts of GROW, Hadlock et al. and Mikolajczyk et al.), abdominal circumference (AC) (according to charts of Hadlock et al., INTERGROWTH-21^st Project and Chitty et al.) or change in AC over time (calculated according to Pregnancy Outcome Prediction (POP) study) were compared against four birth-weight charts (GROW, INTERGROWTH-21^st , Mikolajczyk et al. and World Health Organization (WHO)). The ability of each antenatal test to predict adverse perinatal outcome (APO) was assessed.

RESULTS

Birth weight < 10^th centile was assigned in 62 (59%) neonates using the GROW chart, 57 (54%) using the Mikolajczyk et al. chart, 55 (52%) using the INTERGROWTH-21^st chart and 51 (49%) using the WHO chart. AC-Hadlock had the best negative likelihood ratio (range, 0.3-0.4) and sensitivity (range, 74%-82%) for predicting SGA as defined by all four postnatal birth-weight charts. AC-INTERGROWTH-21^st had the best positive likelihood ratio (range, 5.9-10.9) and specificity (94%-96%). For prediction of APO, AC-Hadlock and EFW-GROW had the best sensitivities (57% and 52%, respectively), whereas AC-POP had the best positive likelihood ratio (2.2) and specificity (88%). Antenatal prediction of APO increased to a sensitivity of 61% when AC-POP and EFW-GROW were combined; however, specificity was only 56%.

CONCLUSIONS

We have identified wide variation in the diagnostic accuracy of various antenatal tools for the prediction of both SGA and APO, dependent on the choice of chart. Suboptimal diagnostic accuracy of commonly used antenatal tests may lead to increasing medicalization without prevention of APO. Researchers should focus their attention on a combination of fetal biometry and biomarkers for better prediction of SGA and prevention of APO. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Factors that hinder or enable maternal health strategies to reduce delays in rural and pastoralist areas in Ethiopia

OBJECTIVES

To document factors that hinder or enable strategies to reduce the first and second delays of the Three Delays in rural and pastoralist areas in Ethiopia.

METHODS

A key informant study was conducted with 44 Health Extension Workers in Afar Region, Kafa Zone (Southern Nation, Nationalities and Peoples' Region), and Adwa Woreda (Tigray Region). Health Extension Workers were trained to interview women and ask for stories about their recent experiences of birth. We interviewed the Health Extension Workers about their experiences referring women for Skilled Birth Attendance and Emergency Obstetric and Newborn Care. Data were analysed using thematic analysis.

RESULTS

Themes related to reducing the first delay, such as the tradition of home birth, decision-making, distance and unavailability of transport, did not differ between the three locations. Themes related to reducing the second delay differed substantially. Health Extension Workers in Adwa Woreda were more likely to call ambulances due to support from the Health Development Army and a functioning referral system. In Kafa Zone, some Health Extension Workers were discouraged from calling ambulances as they were used for other purposes. In Afar Region, few Health Extension Workers were called to assist women as most women give birth at home with Traditional Birth Attendants unless they need to travel to health facilities for Emergency Obstetric and Newborn Care.

CONCLUSIONS

Initiatives to reduce delays can improve access to maternal health services, especially when Health Extension Workers are supported by the Health Development Army and a functioning referral system, but district (woreda) health offices should ensure that ambulances are used as intended.

Constructing diagnostic likelihood: clinical decisions using subjective versus statistical probability

BACKGROUND

Although physicians are highly trained in the application of evidence-based medicine, and are assumed to make rational decisions, there is evidence that their decision making is prone to biases. One of the biases that has been shown to affect accuracy of judgements is that of representativeness and base-rate neglect, where the saliency of a person's features leads to overestimation of their likelihood of belonging to a group. This results in the substitution of 'subjective' probability for statistical probability.

METHODS

This study examines clinicians' propensity to make estimations of subjective probability when presented with clinical information that is considered typical of a medical condition. The strength of the representativeness bias is tested by presenting choices in textual and graphic form. Understanding of statistical probability is also tested by omitting all clinical information.

RESULTS

For the questions that included clinical information, 46.7% and 45.5% of clinicians made judgements of statistical probability, respectively. Where the question omitted clinical information, 79.9% of clinicians made a judgement consistent with statistical probability. There was a statistically significant difference in responses to the questions with and without representativeness information (χ2 (1, n=254)=54.45, p<0.0001).

CONCLUSIONS

Physicians are strongly influenced by a representativeness bias, leading to base-rate neglect, even though they understand the application of statistical probability. One of the causes for this representativeness bias may be the way clinical medicine is taught where stereotypic presentations are emphasised in diagnostic decision making.

Robust anti-obesity and metabolic effects of a dual GLP-1/glucagon receptor peptide agonist in rodents and non-human primates

AIMS

To characterize the pharmacology of MEDI0382, a peptide dual agonist of glucagon-like peptide-1 (GLP-1) and glucagon receptors.

MATERIALS AND METHODS

MEDI0382 was evaluated in vitro for its ability to stimulate cAMP accumulation in cell lines expressing transfected recombinant or endogenous GLP-1 or glucagon receptors, to potentiate glucose-stimulated insulin secretion (GSIS) in pancreatic β-cell lines and stimulate hepatic glucose output (HGO) by primary hepatocytes. The ability of MEDI0382 to reduce body weight and improve energy balance (i.e. food intake and energy expenditure), as well as control blood glucose, was evaluated in mouse models of obesity and healthy cynomolgus monkeys following single and repeated daily subcutaneous administration for up to 2 months.

RESULTS

MEDI0382 potently activated rodent, cynomolgus and human GLP-1 and glucagon receptors and exhibited a fivefold bias for activation of GLP-1 receptor versus the glucagon receptor. MEDI0382 produced superior weight loss and comparable glucose lowering to the GLP-1 peptide analogue liraglutide when administered daily at comparable doses in DIO mice. The additional fat mass reduction elicited by MEDI0382 probably results from a glucagon receptor-mediated increase in energy expenditure, whereas food intake suppression results from activation of the GLP-1 receptor. Notably, the significant weight loss elicited by MEDI0382 in DIO mice was recapitulated in cynomolgus monkeys.

CONCLUSIONS

Repeated administration of MEDI0382 elicits profound weight loss in DIO mice and non-human primates, produces robust glucose control and reduces hepatic fat content and fasting insulin and glucose levels. The balance of activities at the GLP-1 and glucagon receptors is considered to be optimal for achieving weight and glucose control in overweight or obese Type 2 diabetic patients.

Learning disability and advocacy: obstacles to client empowerment

Citizen advocacy, with its aim to empower, has the potential to transform the lives of people with learning disabilities, but an inevitable consequence of client empowerment is professional disempowerment. Professional workers are unlikely to relinquish power, control and influence without some resistance. As this paper seeks to show there are a number of ways for statutory agencies to neutralize the effect of citizen advocacy. If this challenge is to be met then a number of radical changes need to be made in the way advocacy programmes operate: the volunteering principle should be abandoned; full-time advocates should be appointed; generic rather than specialist advocacy services should be established; and, in order to protect the operational independence of advocacy programmes, funding should come from central and not local government sources. If the kind of fundamental changes, proposed in this paper, are not introduced then the credibility of advocacy services will be irretrievably damaged with the result that people with learning disabilities will continue to remain disadvantaged. If people with learning disabilities are to be empowered they need strong, independent, informed and expert representation.

Novel psychoactive substances: An investigation of temporal trends in social media and electronic health records

BACKGROUND

Public health monitoring is commonly undertaken in social media but has never been combined with data analysis from electronic health records. This study aimed to investigate the relationship between the emergence of novel psychoactive substances (NPS) in social media and their appearance in a large mental health database.

METHODS

Insufficient numbers of mentions of other NPS in case records meant that the study focused on mephedrone. Data were extracted on the number of mephedrone (i) references in the clinical record at the South London and Maudsley NHS Trust, London, UK, (ii) mentions in Twitter, (iii) related searches in Google and (iv) visits in Wikipedia. The characteristics of current mephedrone users in the clinical record were also established.

RESULTS

Increased activity related to mephedrone searches in Google and visits in Wikipedia preceded a peak in mephedrone-related references in the clinical record followed by a spike in the other 3 data sources in early 2010, when mephedrone was assigned a 'class B' status. Features of current mephedrone users widely matched those from community studies.

CONCLUSIONS

Combined analysis of information from social media and data from mental health records may assist public health and clinical surveillance for certain substance-related events of interest. There exists potential for early warning systems for health-care practitioners.

Health Extension Workers' and Mothers' Attitudes to Maternal Health Service Utilization and Acceptance in Adwa Woreda, Tigray Region, Ethiopia

BACKGROUND

The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs' and mother's attitudes to maternal health services in Adwa Woreda, Tigray Region.

METHODS

In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women's social status and mobility; and women's perceptions of skilled birth attendant's care. All data were analyzed thematically.

FINDINGS

There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women's Development Groups (WDGs), and referral by ambulance to health facilities either before a woman's Expected Due Date (EDD) or if labour started at home.

CONCLUSION

With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women's groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.

Delays to diagnosis and treatment in patients presenting to mental health services with bipolar disorder

Introduction

There are often substantial delays before diagnosis and initiation of treatment in people bipolar disorder. Increased delays are a source of considerable morbidity among affected individuals.

Aims

To investigate the factors associated with delays to diagnosis and treatment in people with bipolar disorder.

Methods

Retrospective cohort study using electronic health record data from the South London and Maudsley NHS Foundation Trust (SLaM) from 1364 adults diagnosed with bipolar disorder. The following predictor variables were analysed in a multivariable Cox regression analysis on diagnostic delay and treatment delay from first presentation to SLaM: age, gender, ethnicity, compulsory admission to hospital under the UK Mental Health Act, marital status and other diagnoses prior to bipolar disorder.

Results

The median diagnostic delay was 62 days (interquartile range: 17–243) and median treatment delay was 31 days (4–122). Compulsory hospital admission was associated with a significant reduction in both diagnostic delay (hazard ratio 2.58, 95% CI 2.18–3.06) and treatment delay (4.40, 3.63–5.62). Prior diagnoses of other psychiatric disorders were associated with increased diagnostic delay, particularly alcohol (0.48, 0.33–0.41) and substance misuse disorders (0.44, 0.31–0.61). Prior diagnosis of schizophrenia and psychotic depression were associated with reduced treatment delay.

Conclusions

Some individuals experience a significant delay in diagnosis and treatment of bipolar disorder, particularly those with alcohol/substance misuse disorders. These findings highlight a need to better identify the symptoms of bipolar disorder and offer appropriate treatment sooner in order to facilitate improved clinical outcomes. This may include the development of specialist early intervention services.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Geothermal Gases--Community Experiences, Perceptions, and Exposures in Northern California

Lake County, California, is in a high geothermal-activity area. Over the past 30 years, the city of Clearlake has reported health effects and building evacuations related to geothermal venting. Previous investigations in Clearlake revealed hydrogen sulfide at levels known to cause health effects and methane at levels that can cause explosion risks. The authors conducted an investigation in multiple cities and towns in Lake County to understand better the risk of geothermal venting to the community. They conducted household surveys and outdoor air sampling of hydrogen sulfide and methane and found community members were aware of geothermal venting and some expressed concerns. The authors did not, however, find hydrogen sulfide above the California Environmental Protection Agency air quality standard of 30 parts per billion over one hour or methane above explosive thresholds. The authors recommend improving risk communication, continuing to monitor geothermal gas effects on the community, and using community reports and complaints to monitor and document geothermal venting incidents.

Barriers and facilitators to accessing skilled birth attendants in Afar region, Ethiopia

OBJECTIVE

to explore barriers and facilitators that enable women to access skilled birth attendance in Afar Region, Ethiopia.

DESIGN

researchers used a Key Informant Research approach (KIR), whereby Health Extension Workers participated in an intensive training workshop and conducted interviews with Afar women in their communities. Data was also collected from health-care workers through questionnaires, interviews and focus groups.

PARTICIPANTS

fourteen health extension workers were key informants and interviewers; 33 women and eight other health-care workers with a range of experience in caring for Afar childbearing women provided data as individuals and in focus groups.

FINDINGS

participants identified friendly service, female skilled birth attendants (SBA) and the introduction of the ambulance service as facilitators to SBA. There are many barriers to accessing SBA, including women׳s low status and restricted opportunities for decision making, lack of confidence in health-care facilities, long distances, cost, domestic workload, and traditional practices which include a preference for birthing at home with a traditional birth attendant.

KEY CONCLUSIONS

many Afar men and women expressed a lack of confidence in the services provided at health-care facilities which impacts on skilled birth attendance utilisation.

IMPLICATIONS FOR PRACTICE

ambulance services that are free of charge to women are effective as a means to transfer women to a hospital for emergency care if required and expansion of ambulance services would be a powerful facilitator to increasing institutional birth. Skilled birth attendants working in institutions need to ensure their practice is culturally, physically and emotionally safe if more Afar women are to accept their midwifery care. Adequate equipping and staffing of institutions providing emergency obstetric and newborn care will assist in improving community perceptions of these services. Most importantly, mutual respect and collaboration between traditional birth attendants (Afar women׳s preferred caregiver), health extension workers and skilled birth attendants will help ensure timely consultation and referral and reduce delay for women if they require emergency maternity care.

Whole-genome sequencing in hierarchy with pulsed-field gel electrophoresis: the utility of this approach to establish possible sources of MRSA cross-transmission

BACKGROUND

In order to study the micro-epidemiology of meticillin-resistant Staphylococcus aureus (MRSA) effectively, the molecular typing method used must be able to distinguish between different MRSA strains. Pulsed-field gel electrophoresis (PFGE) can detect small genetic differences but is limited in its potential to distinguish isolates within a major lineage. Whole-genome sequencing (WGS) provides sufficient resolution to support or exclude links between otherwise indistinguishable isolates, but lacks the practical utility of conventional typing methods.

AIM

To explore the utility of WGS in a hierarchical approach with PFGE to help establish possible sources of MRSA cross-transmission in the intensive care setting.

METHODS

Possible transmission routes from donor to recipient via the hands of staff, the air or environmental surfaces were identified. Focused molecular typing used PFGE to explore these transmission hypotheses. WGS was applied when an acquisition event involved a common PFGE pulsotype.

FINDINGS

Thirty-eight of the 78 acquisition events could not be explored as clinical isolates were not available. PFGE excluded all potential donors from 26 of the remaining 40 acquisition events, but did identify a probable source in 14 new colonizations. Within the hypotheses tested, PFGE supported links between patients occupying the same bay, the same bed space, adjacent isolation rooms and different wards. When a patient source was not identified, PFGE implicated the ward environment and the hands of staff. However, WGS disproved three of these transmission pathways.

CONCLUSION

WGS can complement conventional typing methods by confirming or refuting possible MRSA transmission hypotheses. Epidemiological data are crucial in this process.

Is tibial tuberosity-trochlear groove distance an appropriate measure for the identification of knees with patellar instability?

PURPOSE

Tibial tuberosity-trochlear groove distance (TT-TG) has been regarded as a useful tool for establishing therapeutic choices for patellar instability. Recently, it has been shown that TT-TG negatively correlated with the quadriceps angle, suggesting that if used individually, neither provide a valid measure of instability. This study aimed to compare TT-TG distance between both knees in patients with unilateral instability to assess whether this measurement is a decisive element in the management decisions for patellar instability.

METHODS

Sixty-two patients (18 male and 44 female), reporting to a specialist patella clinic for recurrent unilateral patellar instability, were included in the study. Patients underwent bilateral long leg computed tomography scan to determine TT-TG distance in both knees. Tibial TT-TG in symptomatic and asymptomatic knees in the same individual was compared statistically.

RESULTS

Mean TT-TG distance in the symptomatic knee was 16.9 (±4.9) mm, compared to 15.6 (±5.6) mm in the asymptomatic knee. Tibial TT-TG was not significantly different between stable and unstable knees (n.s.).

CONCLUSIONS

The lack of difference in TT-TG distance between stable and unstable knees suggests that TT-TG distance alone may not be a decisive element in establishing therapeutic choices for patellar instability. It should, therefore, be interpreted with caution during clinical evaluations.

LEVEL OF EVIDENCE

II.

Epidemiology of vaginal prolapse in mixed-age ewes in New Zealand

AIMS

Identify environmental, animal, and management factors associated with risk of vaginal prolapse in ewes, to enable farmers and advisors to make pragmatic decisions based on empirical observations for control of the condition.

METHODS

Two longitudinal studies conducted over 2 years to identify factors associated with incidence of prolapse in (i) cohorts of 200 individually identified mixed-age (MA) ewes, and (ii) all MA ewes, on voluntarily participating sheep-breeding farms in Hawkes Bay (HB) and Southland regions of New Zealand.

RESULTS

The overall annual incidences of prolapse on 113 farms in 2000 and 88 in 2001 were 1.21 and 0.82 per 100 MA ewes, respectively, and 1.05 for both years combined. A total of 406 prolapses were recorded among 36,695 individually identified cohort ewes. Individual farm incidences for both years varied from 0-5.9 (mean=1.56, median=1.39) on Southland and 0-3.9 (mean=0.75, median=0.54) per 100 ewes on HB farms. The crude relative risk of a prolapse occurring in a MA ewe was 5.31 times higher for ewes carrying twins and 11.3 times higher for ewes carrying triplets, than single lambs. Flocks made up of predominantly pure or crossbred Perendale ewes appeared to be at lower risk than flocks with other breeds. Shearing in the 3 months leading up to mating appeared to be protective, as was shearing in the second half of pregnancy. The risk was higher on farms with moderate to steep terrain than on farms with flat terrain. The identified risk factors in the individually identified cohorts were: access to salt and feeding of swedes in the latter part of pregnancy, moderate to steep lambing paddocks, multiple lambs detected at scanning, and weight gain between start of mating and scanning. The condition recurred in 2001 in six (35%) of 17 study ewes that had prolapsed during 2000. Culling policies for female offspring of affected ewes did not influence incidence at the farm level; nor did feeding hay or grain in late pregnancy. Furthermore, there was no association between incidence and body condition scores measured prior to and after mating, at scanning, or at time of set stocking.

CLINICAL SIGNIFICANCE

Vaginal prolapse is an inevitable consequence of sheep reproduction and its incidence is expected to increase as reproductive rates increase. This study provides some firm leads as to the relative importance of risk factors and gives guidance for risk reduction, e.g. by identification and separate management of ewes carrying twins or triplets, using flat paddocks for lambing, and guarding against gain in weight between the start of mating and scanning.

The place of birth in Kafa Zone, Ethiopia

In this qualitative study, I used an ethnographic approach to provide an understanding about the place of birth in rural and semiurban Kafa Zone, Ethiopia. I interviewed women about birth at home and asked what would happen if there were serious problems and a woman was taken to a health facility. The development of health services aimed at reducing maternal mortality implies that the place of birth must change from home to health facility, but the distance from international policy to its implementation is vast and the pathway is not a direct, linear route.

Pregnancy rates of beef cattle are not affected by Campylobacter fetus subsp. venerealis real-time PCR-positive breeding sires in New Zealand

AIMS

Campylobacter fetus subspecies venerealis (C. fetus venerealis) is the causal agent of bovine genital campylobacteriosis, a venereal disease that is asymptomatic in bulls but responsible for reproductive wastage in female cattle. In New Zealand, a commercial real-time PCR assay was introduced in 2007 to identify the DNA of this pathogen in preputial scrapings; however, concerns were raised about the specificity of the test following anecdotal reports of a high number of test-positive bulls with no apparent relationship to reproductive performance. The objective of this study, therefore, was to examine the association between real-time PCR assay results from beef breeding bulls and pregnancy rates in beef herds using these bulls.

METHODS

Veterinarians from four veterinary practices selected beef cattle herds with relatively high and low pregnancy rates between December 2008 and February 2009. Preputial scrapings were collected from bulls used for mating in those herds. Samples were tested using the real-time PCR assay under consideration. Bivariable and multivariable analyses were used to assess the relationship between pregnancy rates in each mob (15-month-old heifers, 27-month-old heifers and mixed-age cows) and the percentage of real-time PCR-positive bulls in each mob.

RESULTS

Sixty-four (28.8%) of 222 bulls tested positive, 130 (58.6%) tested negative, and 28 (12.6%) returned an inconclusive result to the real-time PCR assay. The percentage of bulls testing real-time PCR-positive in these mobs was not associated with pregnancy rates (p=0.757) after controlling for mob, average body condition score of cows, cow to bull ratio, length of the mating period, and farm.

CONCLUSION

Real-time PCR assay results were not associated with pregnancy rates, suggesting that the specificity of the real-time PCR assay was too low to be used to reliably detect C. fetus venerealis. This study adds to a growing body of evidence indicating that C. fetus venerealis strains are either absent from, or present at clinically insignificant levels of endemicity among, beef breeding herds in New Zealand.

CLINICAL SIGNIFICANCE

The real-time PCR assay that was assessed in this study should not be used for the detection of C. fetus venerealis in bulls or for investigations of low conception rates in cattle in New Zealand. During the course of this survey, sequencing analysis of an apparent C. fetus venerealis isolate from the intestines of a Friesian bull turned out to be Campylobacter hyointestinalis. As a consequence, this real-time PCR assay for C. fetus venerealis is no longer being offered by diagnostic laboratories in New Zealand.

Carbonated beverages consumption among New Zealand youth and associations with BMI and waist circumference

AIM

The primary aim of this study was to describe the carbonated beverage (soft drink) consumption patterns of New Zealand (NZ) youth and to investigate the influence that home availability of soft drinks had on their consumption. A secondary aim was to determine if there was an association between soft drink consumption and body mass index (BMI) or waist circumference.

METHODS

Data from Youth '07, a nationally representative survey of the health and well-being of NZ youth, including 8,697 NZ students aged 13 to 17 years, were analysed.

RESULTS

The relevant data was available for 8697 students of whom 4633 identified as NZ European. 1621 Māori, 1.098 Asian, 834 Pacific, and 504 Other. Twenty nine percent (29%) were categorised as high consumers of soft drinks (>4 times a week), 45.4% were moderate consumers (1-3 times a week), and 25.6% were low consumers (had not consumed soft drinks in the past week). Male gender, Pacific ethnicity, and high deprivation were all significantly associated with being in the high consumer group. Fifty eight percent (58%) of children who reported that soft drinks were 'usually' available at home were in the high consumption group, compared to 15.1% of children who reported that these drinks were never available at home. After adjusting for possible confounders, waist circumference was significantly associated with soft drink consumption (p<0.05), however, BMI was not. Mean soft drink consumption for boys was 3.5 times per week and was 2.0 for girls.

CONCLUSION

This study provides detailed information on soft drink consumption patterns of NZ youth and highlights factors associated with high consumption. Moderating the availability of soft drinks in the home is likely to significantly reduce their consumption among NZ youth.

Dietary intakes of Pacific ethnic groups and European people

OBJECTIVE

To compare dietary intakes, food servings, and cooking practices of Pacific ethnic groups with New Zealand Europeans.

METHODS

Daily nutrient intakes were calculated from a self-administered food frequency questionnaire from a cross-sectional health screening study. Participants were Pacific (n=954) and New Zealand European (n=1.745) people aged 35 to 74 years.

RESULTS

Total energy intakes in Samoan and Niuean men were higher than European men, while for women, total energy intakes were significantly higher in all Pacific ethnic groups compared to New Zealand European women. Pacific men and women had lower alcohol and calcium intakes compared to New Zealand Europeans, and Pacific men had higher protein and cholesterol intakes. Pacific adults reported eating more servings of fish, chicken and bread, fewer servings of cheese and breakfast cereal per month, and boiled their meat more often than European adults.

CONCLUSIONS

Substantial differences in dietary habits and cooking practices exist between European and the different Pacific adult groups mainly related to the frequency of consumption of certain food/nutrient groups and greater serving sizes in Pacific compared to New Zealand European adults. Implications Strategies targeting serving sizes and frequency of consumption of specific food groups may help address the major ethnic disparities in nutrition-related health problems in New Zealand.

Kelston Beverages Pilot Study: Rationale, design and implementation of a community and school based intervention to reduce sugary drink consumption among children and youth

The Kelston Beverages Study was designed to increase awareness of the sugar content of sugary drinks, the poor health consequences that high intake of these drinks have, and inform on ways to reduce intake of students. The aims of this pilot study were to refine interventions and processes designed to raise awareness of the harms that sugar sweetened beverages (SSBs) have on health, and to reduce their consumption among the youth of a small West Auckland suburb. There were three arms to this interventional study, one in schools, another in community organisations (churches, sports clubs and community groups), and the final arm is in the local retail sector. The school arm was the most extensive component and initially involved a survey of children's knowledge and consumption of sugar sweetened beverages (SSBs) using a brief questionnaire. The study evaluated any SSB policies in schools and for schools that did not have policies, opportunities were scoped to develop and implement them; a canteen AUDIT focussed particularly on beverages was carried out; and finally a student partnered social marketing exercise was undertaken that comprised 2 competitions, one to design a poster, and another to write and perform a rap. Children were re-surveyed at the completion of the intervention (7 months later) to determine change in knowledge and self-reported consumption of SSBs. Both the community organisations and retail arms of this study focussed on raising awareness into the harmful effects of SSBs and establishing healthy beverage policy in the respective organisations. Promising results with regards to acceptability, feasibility, and recruitment as well as valuable learnings with regard to process support the development of a proposal to conduct a cluster randomised trial of the interventions successfully tested in this pilot study.

An 'end-game' for sugar sweetened beverages?

OBJECTIVE

The epidemic of unhealthy weight is now in its third decade. The multitude of initiatives designed to address this issue (globally) have predominantly been ineffective as the prevalence of unhealthy weight has continued to rise. Public health professionals have proposed an 'endgame' for tobacco smoking in New Zealand by 2025, which has received widespread support. Similarly, here, to control the prevalence of unhealthy weight, we consider whether a similar approach to tobacco is justified to restrict the intake of sweetened beverages.

APPROACH

This paper reviews the evidence relating sugar sweetened beverages to unhealthy weight and adverse health effects. Current initiatives aimed at reducing sugar sweetened beverage consumption both internationally and in New Zealand are reviewed.

FINDINGS

Epidemiological evidence consistently links sugar-sweetened drink intake with unhealthy weight and other risk factors for cardiovascular disease, such as diabetes, gout, and raised blood pressure. Food disappearance data suggests that sugar intake continues to increase in New Zealand, and that a subtle addiction to sugar may underlie this trend. A number of successful initiatives to reduce sugary drink intake are described. IMPLICATION/CONCLUSION: We argue that an 'endgame' to the consumption of sugar-sweetened beverages be supported as a means to address the issue of unhealthy weight at a population level. Finally, a preliminary draft endgame plan is presented for consideration, dialogue and debate.

Changes in human dendritic cell number and function in severe obesity may contribute to increased susceptibility to viral infection

Dendritic cells (DCs) are key immune sentinels linking the innate and adaptive immune systems. DCs recognise danger signals and initiate T-cell tolerance, memory and polarisation. They are critical cells in responding to a viral illness. Obese individuals have been shown to have an impaired response to vaccinations against virally mediated conditions and to have an increased susceptibility to multi-organ failure in response to viral illness. We investigated if DCs are altered in an obese cohort (mean body mass index 51.7±7.3 kg m(-2)), ultimately resulting in differential T-cell responses. Circulating DCs were found to be significantly decreased in the obese compared with the lean cohort (0.82% vs 2.53%). Following Toll-like receptor stimulation, compared with lean controls, DCs generated from the obese cohort upregulated significantly less CD83 (40% vs 17% mean fluorescence intensity), a molecule implicated in the elicitation of T-cell responses, particularly viral responses. Obese DCs produced twofold more of the immunosuppressive cytokine interleukin (IL)-10 than lean controls, and in turn stimulated fourfold more IL-4-production from allogenic naive T cells. We conclude that obesity negatively impacts the ability of DCs to mature and elicit appropriate T-cell responses to a general stimulus. This may contribute to the increased susceptibility to viral infection observed in severe obesity.

Hepatic artery embolisation for liver metastases from neuroendocrine disease

The 2013 Alpine Liver and Pancreatic Surgery meeting was held in Madonna di Campiglio, Italy. The meeting was organised by the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The following abstracts were selected for presentation at the meeting.

Selective internal radiation treatment for hepatic malignancy

The 2013 Alpine Liver and Pancreatic Surgery meeting was held in Madonna di Campiglio, Italy. The meeting was organised by the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The following abstracts were selected for presentation at the meeting.