Collaborative Research on Puerperal Infections in Bangladesh

Bangladesh is considered as a high-risk country for emerging infectious diseases because of its high population density, poverty, and unhygienic conditions. Although control efforts have primarily been focused on major infectious diseases such as diarrheal diseases, tuberculosis, malaria, and HIV infection, the prevalence and impact of many local or minor infectious diseases are still unclarified in this country. In this review, we present our recent experience and outcomes of collaborative research on puerperal infection (PI), which is a poorly defined infectious disease in Bangladesh. PI is the most common complication during the perinatal period in developing countries. We investigated the incidence of individual species of aerobic bacteria causing PIs and their drug resistance, and the genetic traits of isolates during the two-year period (2010-2012). The common species of isolates from patients with PIs were Escherichia coli, Enterococcus faecalis, Staphylococcus haemolyticus, Proteus mirabilis, Staphylococcus aureus, and Klebsiella pneumoniae. A remarkable finding was the high rates of resistance to cephalosporins among Gram-negative bacteria harboring extended-spectrum beta-lactamase genes, which were associated with carbapenem resistance in a few isolates. This study defined the importance of control of antimicrobial resistance in Bangladesh, and provided suggestions for the future direction of collaborative research on infectious diseases in Bangladesh.

A Home-Based Type 2 Diabetes Self-Management Intervention in Rural Guatemala

INTRODUCTION

Diabetes self-management education (DSME) is a fundamental element of type 2 diabetes care. Although 75% of adults with diabetes worldwide live in low-income and middle-income countries (LMICs), limited DSME research has been conducted in LMICs. The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala.

METHODS

We conducted a prospective study of a DSME intervention using a quasi-experimental, single-group pretest-posttest design. We enrolled 90 participants in the intervention, which consisted of 6 home visits (May 2014-July 2016) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan populations. Primary outcomes were changes in mean hemoglobin A1c (HbA1c) and mean systolic and diastolic blood pressure at baseline and at 12 months. Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion.

RESULTS

HbA1c decreased significantly from baseline to 12 months (absolute mean change, -1.5%; 95% confidence interval [CI], -1.9% to -1.0%; P < .001). Systolic blood pressure also improved significantly at 12 months (-6.2 mm Hg; 95% CI, -10.1 to -2.2 mm Hg; P = .002); changes in diastolic blood pressure were not significant (-1.6 mm Hg; 95% CI, -3.9 to -0.7 mm Hg; P = .17). We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion.

CONCLUSION

DSME interventions can be successfully delivered in a setting with an underresourced health system, high poverty rate, and unique cultural characteristics like Mayan Guatemala. Our findings point to the need for more DSME research in resource-limited settings globally.

Differential expression profiles of long non-coding RNAs as potential biomarkers for the early diagnosis of acute myocardial infarction

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality worldwide. The early diagnosis of AMI is crucial for deciding the course of treatment and saving lives. Long non-coding RNAs (lncRNAs) are recently discovered ncRNA class and their dysregulated expression has been implicated in cardiovascular diseases. In this study, we analyzed lncRNA expression pattern by using two microarray datasets of AMI and healthy samples from the Gene Expression Omnibus (GEO) database and tried to identify novel AMI-related lncRNAs and investigate the predictive roles of lncRNAs in the early diagnosis of AMI. From the discovery cohort, 11 differentially expressed lncRNAs were identified as candidate biomarkers that were validated in the discovery cohort, internal cohort and an independent cohort, respectively. Hierarchical clustering analysis suggested that the expression pattern of these 11 candidate lncRNA biomarkers was closely associated with disease status of samples. Then a lncRNA risk classifier was developed by integrating expression value of 11 differentially expressed lncRNAs using support vector machine (SVM) algorithm. The results of leaving one out cross-validation (LOOCV) suggested that the lncRNA risk classifier has a good discrimination between AMI patients and healthy samples with the area under ROC curve (AUC) of 0.955, 0.92 and 0.701 in three cohorts, respectively. Functional enrichment analysis suggested that these 11 candidate lncRNA biomarkers might be involved in inflammation- and immune-related biological processes. Our study indicates the potential roles in the early diagnosis of AMI and will improve our understanding of the molecular mechanism of the occurrence and recurrence of AMI.

Personalised Interventions-A Precision Approach for the Next Generation of Dietary Intervention Studies

Diet is a key modifiable risk factor for non-communicable diseases. However, we currently are not benefitting from the full potential of its protective effects. This is due to a number of reasons, including high individual variability in response to certain diets. It is now well acknowledged that in order to gain the full benefit of dietary regimes it is essential to take into account individual responses. With this in mind, the present review examines the concept of precision nutrition and the performance of n-of-1 studies, and discusses the development of certain approaches that will be critical for development of the concepts.

Cardio-Metabolic Benefits of Plant-Based Diets

Cardio-metabolic disease, namely ischemic heart disease, stroke, obesity, and type 2 diabetes, represent substantial health and economic burdens. Almost one half of cardio-metabolic deaths in the U.S. might be prevented through proper nutrition. Plant-based (vegetarian and vegan) diets are an effective strategy for improving nutrient intake. At the same time, they are associated with decreased all-cause mortality and decreased risk of obesity, type 2 diabetes, and coronary heart disease. Evidence suggests that plant-based diets may reduce the risk of coronary heart disease events by an estimated 40% and the risk of cerebral vascular disease events by 29%. These diets also reduce the risk of developing metabolic syndrome and type 2 diabetes by about one half. Properly planned vegetarian diets are healthful, effective for weight and glycemic control, and provide metabolic and cardiovascular benefits, including reversing atherosclerosis and decreasing blood lipids and blood pressure. The use of plant-based diets as a means of prevention and treatment of cardio-metabolic disease should be promoted through dietary guidelines and recommendations.

Multiple disparities in adult mortality in relation to social and health care perspective: results from different data sources

BACKGROUND

Disparity in adult mortality (AM) with reference to social dynamics and health care has not been sufficiently examined. This study aimed to identify the gap in the understanding of AM in relation to religion, political stability, economic level, and universal health coverage (UHC).

METHODS

A cross-national study was performed with different sources of data, using the administrative record linkage theory. Data was created from the 2013 World Bank data catalogue by region, The Economist (Political instability index 2013), Stuckler David et al. (Universal health coverage, 2010), and religious categories of all UN country members. Descriptive statistics, a t-test, an ANOVA followed by a post hoc test, and a linear regression were used where applicable.

RESULT

The average AM rate for males and females was 0.20 ± 0.10 and 0.14 ± 0.10, respectively. There was high disparity of AM between countries with and without UHC and between groups with low and high income. UHC and political stability would significantly reduce AMR by >0.41 in both sexes and high economic status would reduce male AMR by 0.44, and female AMR by 0.70.

CONCLUSIONS

It can be concluded that effective health care; UHC and political stability significantly reduce AM.

Perceived stress and smoking across 41 countries: A global perspective across Europe, Africa, Asia and the Americas

Within recent years, there has been a seismic shift in smoking rates from high-income to low- and middle-income countries (LMICs). Evidence indicates that perceived stress may comprise a barrier for smoking cessation, but little is known about the association of perceived stress and smoking in LMICs. We conducted a cross-sectional, community-based study comprising 217,561 people [mean age 38.5 (SD = 16.1) years, 49.4% males]. A perceived stress score [range 2 (lowest-stress) 10 (highest-stress)] was computed from the Perceived Stress Scale. Multivariable logistic regression analyses were conducted. In the overall sample, a one-unit increase in perceived-stress resulted in a 5% increased odds of smoking (OR = 1.05; 95%CI = 1.03–1.06). Increased stress was associated with smoking in Africa (OR = 1.06; 95%CI = 1.04–1.09), Americas (OR = 1.03; 95%CI = 1.01–1.05), and Asia (OR = 1.06; 95%CI = 1.04–1.08), but not Europe (OR = 0.99; 95%CI = 0.95–1.02). Increasing levels of perceived stress were significantly associated with heavy smoking (≥30 cigarettes per day) among daily smokers (OR = 1.08; 95%CI = 1.02–1.15). A country-wide meta-analysis showed that perceived stress is associated with daily smoking in most countries. Prospective studies are warranted to confirm/refute this relationship, which may have meaningful public health implications.

Household survey of HIV incidence in Rwanda: a national observational cohort study

BACKGROUND

In Rwanda, HIV prevalence among adults aged 15-49 years has been stable at 3% since 2005. The aim of this study was to characterise HIV incidence across Rwanda.

METHODS

We did a nationally representative, prospective HIV incidence survey for the period of 2013-14, which used two-stage sampling. We randomly selected 492 villages in the first sampling stage and 14 households per village in the second stage. Participants completed a questionnaire and 14 140 people were tested for HIV. 13 728 participants were HIV negative, and were enrolled in the incidence cohort. Participants were retested and surveyed again after 12 months. Weights were calculated as the inverse of the probability to select the villages and the households.

FINDINGS

The study period was from Nov 5, 2013, to Nov 15, 2014. Among 14 222 respondents from 6792 households, 14 140 were tested for HIV and 13 728 were HIV negative. Of 12 593 people who participated in the endpoint data collection activities, 5965 (47·4%) were men and the mean age was 30 years (SD 10·8). 11 237 (89·2%) participants lived in rural areas, 4826 (38·3%) were single, and 7140 (56·7%) were married or cohabitating. During the year, 35 participants had seroconversion, including 13 men and 22 women, resulting in an overall incidence of 0·27 per 100 person-years (95% CI 0·18-0·35). Incidence was 0·21 per 100 person-years (0·10-0·32) in men and 0·32 per 100 person-years (0·19-0·45) in women. Our findings suggested multiple breakouts, with multiple seroconversions occurring in three villages and two households. Incidence was higher in adults aged 36-45 years (0·37 per 100 person-years, 0·12-0·62; adjusted hazard ratio [aHR] 4·49, 95% CI 1·30-14·70) relative to those aged 16-25, higher in western province (0·57 per 100 person-years, 0·31-0·87; aHR 5·90, 1·33-25·28) relative to the northern province, and higher in urban areas (0·65 per 100 person-years, 0·23-1·07; aHR 3·10, 1·28-6·99) than in rural areas.

INTERPRETATION

The incidence of HIV in Rwanda was higher than that previously estimated from models, with outbreaks seeming to contribute to the ongoing epidemic. Characterisation of incident infections can help the national HIV programmes to plan for preventive interventions tailored to the most at risk populations.

FUNDING

Global Fund to Fight HIV, Tuberculosis and Malaria, WHO Rwanda, UNAIDS Rwanda, and the Government of Rwanda.

Pediatric HIV care and treatment services in Tanzania: implications for survival

BACKGROUND

Improving child survival for HIV-infected children remains an important health agenda. We present progress regarding care and treatment services to HIV infected children in Tanzania.

METHODS

The National AIDS Control Programme Care and Treatment (CTC 2) database was used to obtain information of all children aged 0-14yearsenrolled in the HIV Care and Treatment Program between January 2011 and December 2014. We assessed eligibility for ART, time from enrolment to ART initiation, nutritional status, and mortality using Kaplan-Meier methods.

RESULTS

A total of 29,531 (14,304 boys and 15,227 girls) ART-naive children aged 0-14 years were enrolled during the period, approximately 6700 to 8000 children per year. The male to female ratio was 48:50. At enrolment 72% were eligible for ART, 2-3% of children were positive for TB, and 2-4% were severely malnourished. Between 2011 and 2014, 2368 (8%) died, 9243 (31%) were Lost to Follow-up and 17,920 (61%) were on care or ART. The probability of death was 31% (95% CI 26-35), 43% (40-47), 52% (49-55) and 61% (58-64) by 1,2, 5 and 10 years of age, respectively. The hazard of death was greatest at very young ages (<2 years old), and decreased sharply by 4 years old. Children who were on ART had around 10-15% higher survival over time.

CONCLUSIONS

Significant progress has been made regarding provision of paediatric HIV care and treatment in Tanzania. On average 7000 children are enrolled annually, and that approximately two thirds of children diagnosed under the age of 2 years were initiated on ART within a month. Provision of ART as soon as the child is diagnosed is the biggest factor in improving survival. However we noted that i) most children had advanced disease at the time of enrolment ii) approximately two-thirds of children were missing a baseline CD4 measurement and only 35% of children had either a CD4 count or percentage recorded, indicating limited access to CD4 testing services, and iii) 31% were lost to follow-up (LTFU). These challenges need to be addressed to improve early detection, enrolment and retention of HIV-infected children into care and improve documentation of services offered.

Unintentional Child and Adolescent Drowning Mortality from 2000 to 2013 in 21 Countries: Analysis of the WHO Mortality Database

Limited research considers change over time for drowning mortality among individuals under 20 years of age, or the sub-cause (method) of those drownings. We assessed changes in under-20 drowning mortality from 2000 to 2013 among 21 countries. Age-standardized drowning mortality data were obtained through the World Health Organization (WHO) Mortality Database. Twenty of the 21 included countries experienced a reduction in under-20 drowning mortality rate between 2000 and 2013, with decreases ranging from −80 to −13%. Detailed analysis by drowning method presented large variations in the cause of drowning across countries. Data were missing due to unspecified methods in some countries but, when known, drowning in natural bodies of water was the primary cause of child and adolescent drowning in Poland (56–92%), Cuba (53–81%), Venezuela (43–56%), and Japan (39–60%), while drowning in swimming pools and bathtubs was common in the United States (26–37%) and Japan (28–39%), respectively. We recommend efforts to raise the quality of drowning death reporting systems and discuss prevention strategies that may reduce child and adolescent drowning risk, both in individual countries and globally.

Animal-related factors associated with moderate-to-severe diarrhea in children younger than five years in western Kenya: A matched case-control study

BACKGROUND

Diarrheal disease remains among the leading causes of global mortality in children younger than 5 years. Exposure to domestic animals may be a risk factor for diarrheal disease. The objectives of this study were to identify animal-related exposures associated with cases of moderate-to-severe diarrhea (MSD) in children in rural western Kenya, and to identify the major zoonotic enteric pathogens present in domestic animals residing in the homesteads of case and control children.

METHODOLOGY/PRINCIPAL FINDINGS

We characterized animal-related exposures in a subset of case and control children (n = 73 pairs matched on age, sex and location) with reported animal presence at home enrolled in the Global Enteric Multicenter Study in western Kenya, and analysed these for an association with MSD. We identified potentially zoonotic enteric pathogens in pooled fecal specimens collected from domestic animals resident at children's homesteads. Variables that were associated with decreased risk of MSD were washing hands after animal contact (matched odds ratio [MOR] = 0.2; 95% CI 0.08-0.7), and presence of adult sheep that were not confined in a pen overnight (MOR = 0.1; 0.02-0.5). Variables that were associated with increased risk of MSD were increasing number of sheep owned (MOR = 1.2; 1.0-1.5), frequent observation of fresh rodent excreta (feces/urine) outside the house (MOR = 7.5; 1.5-37.2), and participation of the child in providing water to chickens (MOR = 3.8; 1.2-12.2). Of 691 pooled specimens collected from 2,174 domestic animals, 159 pools (23%) tested positive for one or more potentially zoonotic enteric pathogens (Campylobacter jejuni, C. coli, non-typhoidal Salmonella, diarrheagenic E. coli, Giardia, Cryptosporidium, or rotavirus). We did not find any association between the presence of particular pathogens in household animals, and MSD in children.

CONCLUSIONS AND SIGNIFICANCE

Public health agencies should continue to promote frequent hand washing, including after animal contact, to reduce the risk of MSD. Future studies should address specific causal relations of MSD with sheep and chicken husbandry practices, and with the presence of rodents.

Clinical and laboratory predictors of death in African children with features of severe malaria: a systematic review and meta-analysis

BACKGROUND

The criteria for defining severe malaria have evolved over the last 20 years. We aimed to assess the strength of association of death with features currently characterizing severe malaria through a systematic review and meta-analysis.

METHOD

Electronic databases (Medline, Embase, Cochrane Database of Systematic Reviews, Thomson Reuters Web of Knowledge) were searched to identify publications including African children with severe malaria. PRISMA guidelines were followed. Selection was based on design (epidemiological, clinical and treatment studies), setting (Africa), participants (children < 15 years old with severe malaria), outcome (survival/death rate), and prognostic indicators (clinical and laboratory features). Quality assessment was performed following the criteria of the 2011 Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Odds ratios (ORs) were calculated for each study and prognostic indicator, and, when a test was assessed in at least two studies, pooled estimates of ORs were computed using fixed- or random-effects meta-analysis.

RESULTS

A total of 601 articles were identified and screened and 30 publications were retained. Features with the highest pooled ORs were renal failure (5.96, 95% CI 2.93-12.11), coma score (4.83, 95% CI 3.11-7.5), hypoglycemia (4.59, 95% CI 2.68-7.89), shock (4.31, 95% CI 2.15-8.64), and deep breathing (3.8, 95% CI 3.29-4.39). Only half of the criteria had an OR > 2. Features with the lowest pooled ORs were impaired consciousness (0.58, 95% CI 0.25-1.37), severe anemia (0.76, 95% CI 0.5- 1.13), and prostration (1.12, 95% CI 0.45-2.82).

CONCLUSION

The findings of this meta-analysis show that the strength of association between the criteria defining severe malaria and death is quite variable for each clinical and/or laboratory feature (OR ranging from 0.58 to 5.96). This ranking allowed the identification of features weakly associated with death, such as impaired consciousness and prostration, which could assist to improve case definition, and thus optimize antimalarial treatment.

High magnitude of under nutrition among HIV infected adults who have not started ART in Tanzania--a call to include nutrition care and treatment in the test and treat model

Background

Undernutrition among people living with HIV (PLWHIV) can be ameliorated if nutrition specific and sensitive interventions are integrated into their HIV care and treatment centers (CTC). Integrated care is lacking despite expansion of antiretroviral therapy (ART) coverage, representing a substantial missed opportunity. This research aims to examine nutritional status and associated risk factors among HIV-positive adults prior to ART initiation in Tanzania in order to characterize existing gaps and inform early integration of nutrition care into CTC.

Methods

We analyzed data from 3993 pre-ART adults living with HIV enrolled in CTCs within the Trial of Vitamin (TOV3) and progression of HIV/AIDS study in Dar es salaam, Tanzania. The primary outcome for this analysis was undernutrition, measured as body mass index (BMI) below 18.5 kg/m². We conducted descriptive analyses of baseline characteristics and utilized multiple logistic regression to determine independent factors associated with pre-ART undernutrition.

Results

Undernutrition was prevalent in about 27.7% of pre-ART adults, with a significantly higher magnitude among males compared to females (30% vs. 26.6%, p < 0.025). Severe undernutrition (BMI < 16.0 kg/m²) was prevalent in one in four persons, with a trend toward higher magnitudes among females (26.2% vs. 21.1% p = 0.123). Undernutrition was also more prevalent among younger adults (p < 0.001), those with lower wealth quintiles (p = 0.003), and those with advanced HIV clinical stage (p < 0.001). Pre-ART adults presented with poor feeding practices, hallmarked by low dietary diversity scores and infrequent consumption of proteins, vegetables, and fruits. After adjusting for confounders and important co-variates, pre-ART undernutrition was associated with younger age, low wealth indices, advanced clinical stage, and low dietary diversity.

Conclusions

One in every four pre-ART PLWHIV presented with undernutrition in Dar es salaam, Tanzania. Risk factors for undernourishment included younger age, lower household income, advanced HIV clinical stage, and lower dietary diversity score. Knowledge of the prevalence and prevailing risk factors for undernutrition among pre-ART PLWHIV should guide targeted, early integration of nutrition interventions into routine HIV care and treatment in high-prevalence, low-income settings such as Tanzania.

Presence of Concomitant Systemic Cancer is Not Associated with Worse Functional Long-Term Outcome in Patients with Intracerebral Hemorrhage

BACKGROUND

Data on clinical characteristics and outcome of patients with intracerebral hemorrhage (ICH) and concomitant systemic cancer disease are very limited.

METHODS

Nine hundred and seventy three consecutive primary ICH patients were analyzed using our prospective institutional registry over a period of 9 years (2006-2014). We compared clinical and radiological parameters as well as outcome - scored using the modified Rankin Scale (mRS) and analyzed in a dichotomized fashion as favorable outcome (mRS = 0-3) and unfavorable outcome (mRS = 4-6) - of ICH patients with and without cancer. Relevant imbalances in baseline clinical and radiological characteristics were adjusted using propensity score (PS) matching.

RESULTS

Prevalence of systemic cancer among patients with ICH was 8.5% (83/973). ICH patients with cancer were older (77 [70-82] vs. 72 [63-80] years; p = 0.002), had more often prior renal dysfunction (19/83 [22.9%] vs.107/890 [12.0%]; p = 0.005), and smaller hemorrhage volumes (10.1 [4.8-24.3] vs. 15.3 [5.4-42.9] mL; p = 0.017). After PS-matching there were no significant differences neither in mortality nor in functional outcome both at 3 months (mortality: 33/81 [40.7%] vs. 55/158 [34.8%]; p = 0.368; mRS = 0-3: 28/81 [34.6%] vs. 52/158 [32.9%]; p = 0.797) and 12 months (mortality: 39/78 [50.0%] vs. 70/150 [46.7%]; p = 0.633; mRS = 0-3: 25/78 [32.1%] vs. 53/150 [35.3%]; p = 0.620) among patients with and without concomitant systemic cancer. ICH volume tended to be highest in patients with hematooncologic malignancy and smallest in urothelial cancer.

CONCLUSIONS

Patients with ICH and concomitant systemic cancer on average are older; however, they show smaller ICH volumes compared to patients without cancer. Yet, mortality and functional outcome is not different in ICH patients with and without cancer. Thus, the clinical history or the de novo diagnosis of concomitant malignancies in ICH patients should not lead to unjustified treatment restrictions.

The WHO global reference list of 100 core health indicators: the example of Sierra Leone

The global reference list of 100 core health indicators is a standard set of indicators published by the World Health Organization in 2015. We reviewed core health indicators in the public domain and in-country for Sierra Leone, the African continent and globally. Review objectives included assessing available sources, accessibility and feasibility of obtaining data and informing efforts to monitor program progress. Our search strategy was guided by feasibility considerations targeting mainly national household surveys in Sierra Leone and topic-specific and health statistics reports published annually by WHO. We also included national, regional and worldwide health indicator estimates published with open access in the literature and compared them with cumulative annual indicators from the weekly national epidemiological bulletin distributed by the Sierra Leone Ministry of Health and Sanitation. We obtained 70 indicators for Sierra Leone from Internet sources and 2 (maternal mortality and malaria incidence) from the national bulletin. Of the 70 indicators, 14 (20%) were modified versions of WHO indicators and provided uncertainty intervals. Maternal mortality showed considerable differences between 2 international sources for 2015 and the most recent national bulletin. We were able to obtain the majority of core indicators for Sierra Leone. Some indicators were similar but not identical, uncertainty intervals were limited and estimates differed for the same year between sources. Current efforts to improve health and mortality surveillance in Sierra Leone will improve availability and quality of reporting in the future. A centralized core indicator reporting website should be considered.

Health insurance for patients with HIV/AIDS in Vietnam: coverage and barriers

Background

Health insurance (HI) plays an important role in ensuring the financial equity by the risk pooling mechanism and reducing the economic burden of healthcare for HIV/AIDS patients. However, there is a lack of evidence to clearly understand HI coverage in regard to people living with HIV (PLWH). We conducted this study to explore the coverage and barriers of HI among PLWH in Vietnam.

Methods

A cross- sectional study was conducted in multi-sites including 3 hospitals and 5 outpatient clinics in Hanoi and Nam Dinh in 2013. A convenience sampling approach was used to recruit the participants. A structured questionnaire was used to examine current status of using HI, lacking information about HI, feeling difficulties in accessing, using and paying HI. Multivariate logistic regression was conducted to examine factors associated with HI use and barriers.

Results

Among 1133 HIV/AIDS patients, the coverage of HI was 46.0%. About 36.4% lacked information about HI, 21.0% felt difficulty in accessing HI. Meanwhile, the proportions of patients feeling difficulty in using HI and paying HI were 19.9 and 18.6%, respectively. Multivariate regression found that lacking information about HI and feeling difficulty in accessing HI were main barriers of having HI among PLWH.

Conclusion

This study found a high proportion of PLWH was not covered by HI. Lacking information about HI and feeling difficulty in accessing HI were primary barriers that should be resolved via timely educational campaigns and consultations as well as supports from families in order to expand effectively the HI coverage.

Lifetime self-reported arthritis is associated with elevated levels of mental health burden: A multi-national cross sectional study across 46 low- and middle-income countries

Population-based studies investigating the relationship of arthritis with mental health outcomes are lacking, particularly among low- and middle-income countries (LMICs). We investigated the relationship between arthritis and mental health (depression spectrum, psychosis spectrum, anxiety, sleep disturbances and stress) across community-dwelling adults aged ≥18 years across 46 countries from the World Health Survey. Symptoms of psychosis and depression were established using questions from the Mental Health Composite International Diagnostic Interview. Severity of anxiety, sleep problems, and stress sensitivity over the preceding 30 days were self-reported. Self-report lifetime history of arthritis was collected, including presence or absence of symptoms suggestive of arthritis: pain, stiffness or swelling of joints over the preceding 12-months. Multivariable logistic regression analyses were undertaken. Overall, 245,706 individuals were included. Having arthritis increased the odds of subclinical psychosis (OR = 1.85; 95%CI = 1.72–1.99) and psychosis (OR = 2.48; 95%CI = 2.05–3.01). People with arthritis were at increased odds of subsyndromal depression (OR = 1.92; 95%CI = 1.64–2.26), a brief depressive episode (OR = 2.14; 95%CI = 1.88–2.43) or depressive episode (OR = 2.43; 95%CI = 2.21–2.67). Arthritis was also associated with increased odds for anxiety (OR = 1.75; 95%CI = 1.63–1.88), sleep problems (OR = 2.23; 95%CI = 2.05–2.43) and perceived stress (OR = 1.43; 95%CI = 1.33–1.53). Results were similar for middle-income and low-income countries. Integrated interventions addressing arthritis and mental health comorbidities are warranted to tackle this considerable burden.

Obesity, Waist Circumference, Weight Change, and Risk of Incident Psoriasis: Prospective Data from the HUNT Study

Although psoriasis has been associated with obesity, there are few prospective studies with objective measures. We prospectively examined the effect of body mass index, waist circumference, waist-hip ratio, and 10-year weight change on the risk of developing psoriasis among 33,734 people in the population-based Nord-Trøndelag Health Study (i.e., HUNT), Norway. During follow-up, 369 incident psoriasis cases occurred. Relative risk (RR) of psoriasis was estimated by Cox regression. One standard deviation higher body mass index, waist circumference, and waist-hip ratio gave RRs of 1.22 (95% confidence interval [CI] = 1.11-1.34), 1.26 (95% CI = 1.15-1.39), and 1.18 (95% CI = 1.07-1.31), respectively. Compared with normal weight participants, obese people had an RR of 1.87 (95% CI = 1.38-2.52), whereas comparing the fourth with the first quartile of waist circumference gave an RR of 1.95 (95% CI = 1.46-2.61). One standard deviation higher weight change gave an RR of 1.20 (95% CI = 1.07-1.35), and people who increased their body weight by 10 kg or more had an RR of 1.72 (95% CI = 1.15-2.58) compared with being weight stable. In conclusion, obesity and high abdominal fat mass doubles the risk of psoriasis, and long-term weight gain substantially increases psoriasis risk. Preventing weight gain and promoting maintenance of a normal body weight could reduce incidence of psoriasis.

Socioeconomic Disparity in Global Burden of Cataract: An Analysis for 2013 With Time Trends Since 1990

PURPOSE

To assess socioeconomic disparity in global burden of cataract, by using disability-adjusted life years (DALYs).

DESIGN

International, comparative burden-of-disease study.

METHODS

Published data on national age-standardized DALY rates caused by cataract and human development index (HDI) between 1990 and 2013 were obtained. The association between age-standardized DALY rates and HDI in 2013 was analyzed. The health-related Gini coefficients and the concentration indexes were calculated to explore the trends in between-country inequality in cataract burden from 1990 to 2013.

RESULTS

Multiple comparison revealed that lower-HDI countries had higher age-standardized DALY rates caused by cataract. Age-standardized DALY rates were inversely associated with HDI (β = -0.522, P < .01). From 1990 to 2013, global age-standardized DALY rates showed a trend of decline, whereas the Gini coefficients increased from 0.409 to 0.439. The concentration indexes indicated that socioeconomic-associated inequality declined in the 1990s and subsequently increased since 2000, with values of -0.259 in 1990, -0.244 in 2000, and -0.273 in 2013.

CONCLUSIONS

Global health progress in cataract was accompanied by widening inequality, with cataract burden being more concentrated in countries with lower socioeconomic status. The findings highlight the need to provide more cataract services for developing countries, to combat global vision loss caused by cataract.

The cultural aspect: How to measure and interpret epidemiological data on alcohol-use disorders across cultures

AIMS

To examine the cultural impact on the diagnosis of alcohol-use disorders using European countries as examples.

DESIGN

Narrative review.

RESULTS

There are strong cultural norms guiding heavy drinking occasions and loss of control. These norms not only indicate what drinking behaviour is acceptable, but also whether certain behaviours can be reported or not. As modern diagnostic systems are based on lists of mostly behavioural criteria, where alcohol-use disorders are defined by a positive answer on at least one, two or three of these criteria, culture will inevitably co-determine how many people will get a diagnosis. This explains the multifold differences in incidence and prevalence of alcohol-use disorders, even between countries where the average drinking levels are similar. Thus, the incidence and prevalence of alcohol-use disorders as assessed by surveys or rigorous application of standardised instruments must be judged as measuring social norms as well as the intended mental disorder.

CONCLUSIONS

Current practice to measure alcohol-use disorders based on a list of culture-specific diagnostic criteria results in incomparability in the incidence, prevalence or disease burden between countries. For epidemiological purposes, a more grounded definition of diagnostic criteria seems necessary, which could probably be given by using heavy drinking over time.

Potential of small-molecule fungal metabolites in antiviral chemotherapy

Various viral diseases, such as acquired immunodeficiency syndrome, influenza, and hepatitis, have emerged as leading causes of human death worldwide. Scientific endeavor since invention of DNA-dependent RNA polymerase of pox virus in 1967 resulted in better understanding of virus replication and development of various novel therapeutic strategies. Despite considerable advancement in every facet of drug discovery process, development of commercially viable, safe, and effective drugs for these viruses still remains a big challenge. Decades of intense research yielded a handful of natural and synthetic therapeutic options. But emergence of new viruses and drug-resistant viral strains had made new drug development process a never-ending battle. Small-molecule fungal metabolites due to their vast diversity, stereochemical complexity, and preapproved biocompatibility always remain an attractive source for new drug discovery. Though, exploration of therapeutic importance of fungal metabolites has started early with discovery of penicillin, recent prediction asserted that only a small percentage (5-10%) of fungal species have been identified and much less have been scientifically investigated. Therefore, exploration of new fungal metabolites, their bioassay, and subsequent mechanistic study bears huge importance in new drug discovery endeavors. Though no fungal metabolites so far approved for antiviral treatment, many of these exhibited high potential against various viral diseases. This review comprehensively discussed about antiviral activities of fungal metabolites of diverse origin against some important viral diseases. This also highlighted the mechanistic details of inhibition of viral replication along with structure-activity relationship of some common and important classes of fungal metabolites.

Increasing HDL-C levels with medication: current perspectives

PURPOSE OF REVIEW

To date, observational studies have repeatedly demonstrated an inverse association between HDL cholesterol (HDL-C) levels and cardiovascular outcomes. Although the efficacy of established HDL-modifying treatment strategies have been examined in multiple large-scale phase III trials, findings from these experimental studies conflict with the hypothesis that HDL-C levels are atheroprotective. In this review, we describe the trial evidence to date, and attempt to place these results in the broader context of recent hypotheses for the association between HDL-C levels and clinical outcomes.

RECENT FINDINGS

Both translational and genetic studies are in line with the hypothesis that HDL-C levels do not hold causal importance for cardiovascular risk reduction. In addition to its possible role as a biomarker for other atherogenic lipoproteins, efforts should be made to elucidate HDLs' role in lipoprotein flux, which is increasingly being linked to surrogate outcomes of importance to cardiovascular epidemiology. In the future, it will be of great importance to link this measure of HDL functionality to clinical endpoints.

SUMMARY

Although trial evidence does not support an atheroprotective role of overall HDL-C plasma levels, HDL function/lipoprotein flux holds great promise for the development of novel therapeutic approaches.

Association between ambient fine particulate matter and preterm birth or term low birth weight: An updated systematic review and meta-analysis

An increasing number of studies have been conducted to determine a possible linkage between maternal exposure to ambient fine particulate matter and effects on the developing human fetus that can lead to adverse birth outcomes, but, the present results are not consistent. A total of 23 studies published before July 2016 were collected and analyzed and the mean value of reported exposure to fine particulate matter (PM_2.5) ranged from 1.82 to 22.11 We found a significantly increased risk of preterm birth with interquartile range increase in PM_2.5 exposure throughout pregnancy (odds ratio (OR) = 1.03; 95% conditional independence (CI): 1.01-1.05). The pooled OR for the association between PM_2.5 exposure, per interquartile range increment, and term low birth weight throughout pregnancy was 1.03 (95% CI: 1.02-1.03). The pooled ORs for the association between PM_2.5 exposure per 10 increment, and term low birth weight and preterm birth were 1.05 (95% CI: 0.98-1.12) and 1.02 (95% CI: 0.93-1.12), respectively throughout pregnancy. There is a significant heterogeneity in most meta-analyses, except for pooled OR per interquartile range increase for term low birth weight throughout pregnancy. We here show that maternal exposure to fine particulate air pollution increases the risk of preterm birth and term low birth weight. However, the effect of exposure time needs to be further explored. In the future, prospective cohort studies and personal exposure measurements needs to be more widely utilized to better characterize the relationship between ambient fine particulate exposure and adverse birth outcomes.

A Genetic Model to Study Increased Hexosamine Biosynthetic Flux

Recently, we identified harvest moon (hmn), a fully penetrant and expressive recessive zebrafish mutant with hepatic steatosis. Larvae showed increased triacylglycerol in the absence of other obvious defects. When we attempted to raise these otherwise normal-appearing mutants to adulthood, we observed a developmental arrest and death in the early juvenile period. In this study, we report the positional cloning of the hmn locus and characterization of the defects caused by the mutation. Using bulk segregant analysis and fine mapping, we find that hmn mutants harbor a point mutation in an invariant residue within the sugar isomerase 1 domain of the gene encoding the rate-limiting enzyme of the hexosamine biosynthetic pathway (HBP) glutamine-fructose-6-phosphate transamidase (Gfpt1). The mutated protein shows increased abundance. The HBP generates β-N-acetyl-glucosamine (GlcNAc) as a spillover pathway from glucose. GlcNAc can be O-linked to seryl and threonyl residues of diverse cellular proteins (O-GlcNAc modification). Although some of these O-GlcNAc modifications serve an essential structural role, many others are dynamically generated on signaling molecules, including several impacting insulin signaling. We find that gfpt1 mutants show global increase in O-GlcNAc modification, and, surprisingly, lower fasting blood glucose in males. Taken together with our previously reported work, the gfpt1 mutant we isolated demonstrates that global increase in O-GlcNAc modification causes some severe insulin resistance phenotypes (hepatic steatosis and runting) but does not cause hyperglycemia. This animal model will provide a platform for dissecting how O-GlcNAc modification alters insulin responsiveness in multiple tissues.

Physician opinions concerning legal abortion in Bogotá, Colombia

Since the decriminalisation of abortion in 2006, women in Colombia have continued to seek clandestine abortions, endangering their health and contributing to maternal mortality and morbidity. The goal of this study was to explore physicians' opinions towards and knowledge about legal abortion in Bogotá, Colombia, and key barriers to the legal abortion access. We conducted 13 key informant interviews followed by a survey with a probability sample of 49 doctors working in public hospitals in Bogotá. Interview and survey data showed lack of technical experience in the provision of abortion and nuanced opinions towards its practice. Key informants described ignorance and lack of abortion training in medical schools as key barriers to provision. In the survey, 16/49 respondents had performed an abortion, 24/49 had referred a woman for an abortion and only 33/49 showed correct knowledge of the law.

Pneumonia

Neonatal pneumonia may occur in isolation or as one component of a larger infectious process. Bacteria, viruses, fungi, and parasites are all potential causes of neonatal pneumonia, and may be transmitted vertically from the mother or acquired from the postnatal environment. The patient's age at the time of disease onset may help narrow the differential diagnosis, as different pathogens are associated with congenital, early-onset, and late-onset pneumonia. Supportive care and rationally selected antimicrobial therapy are the mainstays of treatment for neonatal pneumonia. The challenges involved in microbiological testing of the lower airways may prevent definitive identification of a causative organism. In this case, secondary data must guide selection of empiric therapy, and the response to treatment must be closely monitored.

Setting performance-based financing in the health sector agenda: a case study in Cameroon

BACKGROUND

More than 30 countries in sub-Saharan Africa have introduced performance-based financing (PBF) in their healthcare systems. Yet, there has been little research on the process by which PBF was put on the national policy agenda in Africa. This study examines the policy process behind the introduction of PBF program in Cameroon.

METHODS

The research is an explanatory case study using the Kingdon multiple streams framework. We conducted a document review and 25 interviews with various types of actors involved in the policy process. We conducted thematic analysis using a hybrid deductive-inductive approach for data analysis.

RESULTS

By 2004, several reports and events had provided evidence on the state of the poor health outcomes and health financing in the country, thereby raising awareness of the situation. As a result, decision-makers identified the lack of a suitable health financing policy as an important issue that needed to be addressed. The change in the political discourse toward more accountability made room to test new mechanisms. A group of policy entrepreneurs from the World Bank, through numerous forms of influence (financial, ideational, network and knowledge-based) and building on several ongoing reforms, collaborated with senior government officials to place the PBF program on the agenda. The policy changes occurred as the result of two open policy windows (i.e. national and international), and in both instances, policy entrepreneurs were able to couple the policy streams to effect change.

CONCLUSION

The policy agenda of PBF in Cameroon underlined the importance of a perceived crisis in the policy reform process and the advantage of building a team to carry forward the policy process. It also highlighted the role of other sources of information alongside scientific evidence (eg.: workshop and study tour), as well as the role of previous policies and experiences, in shaping or influencing respectively the way issues are framed and reformers' actions and choices.

HIV incidence in the Estonian population in 2013 determined using the HIV-1 limiting antigen avidity assay

OBJECTIVES

Estonia has one the highest number of new HIV diagnoses in the European Union, mainly among injecting drug users and heterosexuals. Little is known of HIV incidence, which is crucial for limiting the epidemic. Using a recent HIV infection testing algorithm (RITA) assay, we aimed to estimate HIV incidence in 2013.

METHODS

All individuals aged ≥18 years newly-diagnosed with HIV in Estonia January- December 2013, except blood donors and those undergoing antenatal screening, were included. Demographic and clinical data were obtained from the Estonian Health Board and the Estonian HIV-positive patient database. Serum samples were tested for recent infection using the LAg-avidity EIA assay. HIV incidence was estimated based on previously published methods.

RESULTS

Of 69,115 tested subjects, 286 (0.41%) were newly-diagnosed with HIV with median age of 33 years (IQR: 28-42) and 65% male. Self-reported routes of HIV transmission were mostly heterosexual contact (n = 157, 53%) and injecting drug use (n = 62, 21%); 64 (22%) were with unknown risk group. Eighty two (36%) were assigned recent, resulting in estimated HIV incidence of 0.06%, corresponding to 642 new infections in 2013 among the non-screened population. Incidence was highest (1.48%) among people who inject drugs.

CONCLUSIONS

These high HIV incidence estimates in Estonia call for urgent action of renewed targeted public health promotion and HIV testing campaigns.

Objectively measured physical activity patterns, sedentary time and parent-reported screen-time across the day in four-year-old Swedish children

Background

Physical activity (PA) improves health outcomes accumulating evidence suggests that sedentary time (ST), especially parent-reported screen-time, is associated with negative health outcomes in children. The aim of the present study is to describe levels and patterns of PA and ST across the day and week and activity pattern differences between the sexes, across all weekdays and time spent in and outside the preschool in four-year old children.

Methods

In total 899 four-year old Swedish children who had both complete questionnaire data on screen-time behaviors and objective activity variables and at least 4 days, including one weekend day, with more than 10 h of GT3X+ Actigraph accelerometer wear time data were included in the study. Patterns of PA and ST across the day and week and differences between sexes, weekdays vs. weekend days and time in preschool vs. time spent outside preschool were assessed.

Results

Children engaged in 150 min (SD 73) and 102 min (SD 60) of screen-time on weekend days and weekdays, with 97% and 86% of children exceeding the 1 h guideline for screen-time on weekend days and weekdays, respectively. Accelerometer data showed that boys are more active and less sedentary compared with girls and both sexes were more active and less sedentary on weekdays compared with weekend days, while parent-reported data showed that boys engage in more screen-time compared with girls. Children accumulated 24.8 min (SD. 19) MVPA during preschool time and 26.6 min (SD. 16) outside preschool hours on weekdays, compared with 22.4 min (SD. 18) MVPA during preschool time and 25.3 min (SD. 22) outside preschool hours on weekend days.

Conclusions

Four-year old Swedish children display different activity patterns across the day on weekdays compared to weekend days, with preschool hours during weekdays being the most active segments and preschool hours during weekend days being the least active segments of the day.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4600-5) contains supplementary material, which is available to authorized users.

Sexually transmitted infections: challenges ahead

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

Assessing and Improving Childhood Nutrition and Growth Globally

Improving maternal and child nutrition is central to global development goals and reducing the noncommunicable disease burden. Although the process of becoming malnourished starts in utero, the consequences of poor nutrition extend across the life cycle and into future generations. The global nutrition targets for 2025 include reducing infant and young child growth faltering, halting the increase of overweight children, improving breastfeeding practices, and reducing maternal anemia. In this review, we address nutritional assessment, discuss nonnutritive factors that affect growth, and endorse the evidence-based interventions that should be scaled up to improve maternal and child nutrition.

Disparity in access and outcomes for emergency neonatal surgery: intestinal atresia in Kampala, Uganda

BACKGROUND/AIM

Intestinal atresia is one of the leading causes of neonatal intestinal obstruction (NIO). The purpose of this study was to analyze the presentation and outcome of IA and compare with those from both similar and high-income country settings.

PATIENTS AND METHODS

A retrospective review of prospectively collected data from patient charts and pediatric surgical database for 2012-2015 was performed. Epidemiological data and patient characteristics were analyzed and outcomes were compared with those reported in other LMICs and high-income countries (HICs). Unmet need was calculated along with economic valuation or economic burden of surgical disease.

RESULTS

Of 98 patients, 42.9% were male. 35 patients had duodenal atresia (DA), 60 had jejunio-ileal atresia (JIA), and 3 had colonic atresia. The mean age at presentation was 7.14 days for DA and 6.7 days for JIA. Average weight for DA and JIA was 2.2 and 2.12 kg, respectively. All patients with DA and colonic atresia underwent surgery, and 88.3% of patients with JIA had surgery. Overall mortality was 43% with the majority of deaths attributable to aspiration, anastomotic leak, and sepsis. 3304 DALYs were calculated as met compared to 25,577 DALYs' unmet.

CONCLUSION

Patients with IA in Uganda present late in the clinical course with high morbidity and mortality attributable to a combination of late presentation, poor nutrition status, surgical complications, and likely underreporting of associated anomalies rather than surgical morbidity alone.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.