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Turner L, Ball J, Meredith P, Kitson-Reynolds E, Griffiths P. The association between midwifery staffing and reported harmful incidents: a cross-sectional analysis of routinely collected data. BMC Health Serv Res 2024; 24:391. [PMID: 38549131 PMCID: PMC10976845 DOI: 10.1186/s12913-024-10812-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/01/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Independent inquiries have identified that appropriate staffing in maternity units is key to enabling quality care and minimising harm, but optimal staffing levels can be difficult to achieve when there is a shortage of midwives. The services provided and how they are staffed (total staffing, skill-mix and deployment) have been changing, and the effects of workforce changes on care quality and outcomes have not been assessed. This study aims to explore the association between daily midwifery staffing levels and the rate of reported harmful incidents affecting mothers and babies. METHODS We conducted a cross-sectional analysis of daily reports of clinical incidents in maternity inpatient areas matched with inpatient staffing levels for three maternity services in England, using data from April 2015 to February 2020. Incidents resulting in harm to mothers or babies was the primary outcome measure. Staffing levels were calculated from daily staffing rosters, quantified in Hours Per Patient Day (HPPD) for midwives and maternity assistants. Understaffing was defined as staffing below the mean for the service. A negative binomial hierarchical model was used to assess the relationship between exposure to low staffing and reported incidents involving harm. RESULTS The sample covered 106,904 maternal admissions over 46 months. The rate of harmful incidents in each of the three services ranged from 2.1 to 3.0 per 100 admissions across the study period. Understaffing by registered midwives was associated with an 11% increase in harmful incidents (adjusted IRR 1.110, 95% CI 1.002,1.229). Understaffing by maternity assistants was not associated with an increase in harmful incidents (adjusted IRR 0.919, 95% 0.813,1.039). Analysis of specific types of incidents showed no statistically significant associations, but most of the point estimates were in the direction of increased incidents when services were understaffed. CONCLUSION When there is understaffing by registered midwives, more harmful incidents are reported but understaffing by maternity assistants is not associated with higher risk of harms. Adequate registered midwife staffing levels are crucial for maintaining safety. Changes in the profile of maternity service workforces need to be carefully scrutinised to prevent mothers and babies being put at risk of avoidable harm.
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Affiliation(s)
| | - Jane Ball
- University of Southampton, Southampton, UK
| | | | | | - Peter Griffiths
- University of Southampton, Southampton, UK
- National Institute for Health Research Applied Research Centre (Wessex), Southampton, UK
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Ross P, Hodgson CL, Ilic D, Watterson J, Gowland E, Collins K, Powers T, Udy A, Pilcher D. The Impact of Nursing Skill-mix on Adverse Events in Intensive Care: A Single Centre Cohort Study. Contemp Nurse 2023:1-13. [PMID: 37096967 DOI: 10.1080/10376178.2023.2207687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
BACKGROUND The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed. OBJECTIVE To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE. DESIGN & SETTING We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient. RESULTS A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003). CONCLUSION An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.
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Affiliation(s)
- Paul Ross
- Clinical Nurse Specialist, Alfred Intensive Care Unit, 55 Commercial Road, Melbourne, 3181, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Victoria, Australia. Tel: +61 3 9903 4840
| | - Carol L Hodgson
- Head of the Division of Clinical Trials and Cohort Studies, Deputy Director of the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Victoria, Australia. Tel: +61 399030598,
| | - Dragan Ilic
- Director, Teaching & Learning, Head, Medical Education Research & Quality (MERQ), School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Victoria, Australia. Tel: +61 3 9903 4840,
| | - Jason Watterson
- Clinical Nurse Manager, Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC 3199, Australia
- School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Victoria, Australia. Tel: +61 3 9903 4840,
| | - Emily Gowland
- Manager, Alfred Intensive Care Unit, 55 Commercial Road, Melbourne, 3181, Victoria, Australia. Tel: +61 3 9903 4840, E-mail:
| | - Kathleen Collins
- ICU Registries Manager, Alfred Intensive Care Unit, 55 Commercial Road, Melbourne, 3181, Victoria, Australia. Tel: 61 402 455 343, E-mail:
| | - Tim Powers
- Statistician, Data Science and AI Platform, 15 Innovation Way, Monash University, Clayton Campus, Victoria 3800, Tel: 61 425 873 733,
| | - Andrew Udy
- Deputy Director, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Victoria, Australia
- Head of ICU Research, The Alfred, 55 Commercial Road, Prahran VIC 3004, Victoria, Australia, Tel: +61 438755568,
| | - David Pilcher
- Chairman, Australian and New Zealand Intensive Care Society Centre for Outcome and Resources Evaluation, Camberwell, VIC 3124
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University
- Intensivist, Department of Intensive Care, Alfred Health, Commercial Road, Prahran VIC 3004, Tel: +61 447 264 253,
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Johansen LT, Braut GS, Acharya G, Andresen JF, Øian P. Adverse events reporting by obstetric units in Norway as part of their quality assurance and patient safety work: an analysis of practice. BMC Health Serv Res 2021; 21:931. [PMID: 34493278 PMCID: PMC8424984 DOI: 10.1186/s12913-021-06956-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Norwegian Board of Health Supervision aims to contribute to the improvement of quality and patient safety in the healthcare services. Planned audits were performed to investigate how 12 selected Norwegian obstetric units reported and analyzed adverse events as the part of their quality assurance and patient safety work. METHODS Serious adverse events coded as birth asphyxia, shoulder dystocia and severe postpartum hemorrhage that occurred during 2014 (the most recent year for which the quality assured data were available) were obtained from the Medical Birth Registry of Norway. The obstetric units were asked to submit medical records, internal adverse events reports, and their internal guidelines outlining which events should be reported to the quality assurance system. We identified the adverse events at each obstetric unit that were reported internally and/or to the central authorities. Two obstetricians carried out an evaluation of each event reported. RESULTS Five hundred fifty-three serious adverse events were registered among 17,323 births that took place at the selected units. Twenty-one events were excluded because of incorrect coding or missing information. Eight events were registered in more than one category, and these were distributed to the category directly related to injury or adverse outcome. Nine of twelve (75 %) obstetric units had written guidelines describing which events should be reported. The obstetric units reported 49 of 524 (9.3 %) serious adverse events in their internal quality assurance system and 39 (7.4 %) to central authorities. Of the very serious adverse events, 29 of 149 (19.4 %) were reported. Twenty-three of 49 (47 %) reports did not contain relevant assessments or proposals for improving quality and patient safety. CONCLUSIONS This study showed that adverse event reporting and analyses by Norwegian obstetric units, as a part of quality assurance and patient safety work, are suboptimal. The reporting culture and compliance with guidelines need to be improved substantially for better safety in patient care, risk mitigation and clinical quality assurance.
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Affiliation(s)
- Lars T Johansen
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway.
| | - Geir Sverre Braut
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway.,Stavanger University Hospital, Stavanger, Norway.,Western Norway University of Applied Sciences, Sogndal, Norway
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.,Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institute and Center for Fetal Medicine, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Fredrik Andresen
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway
| | - Pål Øian
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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Kamath P, Kamath A, Ullal SD. Liver injury associated with drug intake during pregnancy. World J Hepatol 2021; 13:747-762. [PMID: 34367496 PMCID: PMC8326163 DOI: 10.4254/wjh.v13.i7.747] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/14/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.
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Affiliation(s)
- Priyanka Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Ashwin Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Sheetal D Ullal
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
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Flenady V, Kettle I, Laporte J, Birthisel D, Hardiman L, Matsika A, Whelan N, Lehner C, Payton D, Utz M, Wojcieszek AM, Lawford H, Walsh T, Ellwood D. Making every birth count: Outcomes of a perinatal mortality audit program. Aust N Z J Obstet Gynaecol 2021; 61:540-547. [PMID: 33792893 DOI: 10.1111/ajo.13325] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stillbirth rates have shown little improvement for two decades in Australia. Perinatal mortality audit is key to prevention, but the literature suggests that implementation is suboptimal. AIM To determine the proportion of perinatal deaths which are associated with contributing factors relating to care in Queensland, Australia. MATERIALS AND METHODS Retrospective audit of perinatal deaths ≥ 34 weeks gestation by the Health Department in Queensland was undertaken. Cases and demographic information were obtained from the Queensland Perinatal Data Collection. A multidisciplinary panel used the Perinatal Society of Australia and New Zealand (PSANZ) perinatal mortality audit guidelines to classify the cause of death and to identify contributing factors. Contributing factors were classified as 'insignificant', 'possible', or 'significant'. RESULTS From 1 January to 31 December 2018, 65 deaths (56 stillbirths and nine neonatal deaths) were eligible and audited. Most deaths were classified as unexplained (51.8% of stillbirths). Contributing factors were identified in 46 (71%) deaths: six insignificant (all stillbirths), 20 possibly related to outcome (17 stillbirths), and 20 significantly (16 stillbirths). Areas for practice improvements mainly related to the care for women with risk factors for stillbirth, especially antenatal care. The PSANZ guidelines were applied and enabled a systematic approach. CONCLUSIONS A high proportion of late gestation perinatal deaths are associated with contributing factors relating to care. Improving antenatal care for women with risk factors for stillbirth is a priority. Perinatal mortality audit is a valuable step in stillbirth prevention and the PSANZ guidelines allow a systematic approach to aid implementation and reporting.
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Affiliation(s)
- Vicki Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia
| | - Imogen Kettle
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Johanna Laporte
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Deborah Birthisel
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Leah Hardiman
- Maternity Choices Australia, Brisbane, Queensland, Australia
| | | | - Nikki Whelan
- Wesley Medical Research Ltd, Brisbane, Queensland, Australia
| | - Christoph Lehner
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Diane Payton
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Miles Utz
- Statistical Services Branch, Queensland Health, Brisbane, Queensland, Australia
| | - Aleena M Wojcieszek
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia
| | - Harriet Lawford
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia
| | - Teresa Walsh
- New Life Midwifery, Ipswich, Queensland, Australia
| | - David Ellwood
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia.,Griffith University and Gold Coast University Hospital, Gold Coast, Queensland, Australia
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6
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Kapito E, Chirwa E, Maluwa A, Kachimanga C, Openshaw M, Rankin S, Rose S, Muller A, Baltzell K. Underreporting of maternal and neonatal complications: A comparison of information in maternity registers and client charts at a rural community hospital in Malawi. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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German translation and validation of the Reporting of Clinical Adverse Events Scale (RoCAES-D). BMC Health Serv Res 2020; 20:689. [PMID: 32711515 PMCID: PMC7382079 DOI: 10.1186/s12913-020-05546-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/15/2020] [Indexed: 11/11/2022] Open
Abstract
Background Reporting of adverse events is an important aspect of patient safety management in hospitals, which may help to prevent future adverse events. Yet, only a small proportion of such events is actually reported in German hospitals. Therefore, it is crucial to evaluate attitudes of clinical staff towards reporting of adverse events. The aim of this study was to translate the Reporting of Clinical Adverse Events Scale (RoCAES) developed by Wilson, Bekker and Fylan (2008) and validate it in a sample of German-speaking health professionals. Methods The questionnaire covers five factors (perceived blame, perceived criteria for identifying events that should be reported, perceptions of colleagues’ expectations, perceived benefits of reporting, and perceived clarity of reporting procedures) and was translated into German language according to translation guidelines. Within a cross-sectional study in a sample of 120 health professionals in German hospitals, internal consistency (omega) and construct validity (confirmatory factor analysis) of the German scale RoCAES-D was assessed. Results The reliability was high (omega = 0.87) and the factor analysis showed a poor model fit (RMSEA: 0.074, χ2/df: 1.663, TLI: 0.690). Resulting from lower model fit of the original model (RMSEA: 0.082, χ2/df: 1.804, TLI: 0.606), one item was deleted due to low factor loadings and a low R2 (0.001), and two items were reallocated from the factor ‘perceived benefits’ to ‘perceived blame’. Conclusion The successful translation and initial validation of the RoCAES-D might be a good starting point for further research. A cultural adaptation of the scale needs to be done to initiate a large-scale usage of the questionnaire.
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Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review. Women Birth 2020; 34:113-121. [PMID: 32111556 DOI: 10.1016/j.wombi.2020.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 01/26/2023]
Abstract
PROBLEM Continuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers' Advisory Council, few women in Australia have access to such models. BACKGROUND Extensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice. AIM This paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women. METHODS A scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis. FINDINGS Two narrative themes emerged: (1) Hospital accreditation: 'Here to stay' but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care. DISCUSSION Regulatory frameworks drive hospitals' priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible. CONCLUSIONS Structural changes to Australia's health accreditation system are needed to prioritise, and mandate, continuity of midwifery care.
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Pasha O, McClure EM, Saleem S, Tikmani SS, Lokangaka A, Tshefu A, Bose CL, Bauserman M, Mwenechanya M, Chomba E, Carlo WA, Garces AL, Figueroa L, Hambidge KM, Krebs NF, Goudar S, Kodkany BS, Dhaded S, Derman RJ, Patel A, Hibberd PL, Esamai F, Tenge C, Liechty EA, Moore JL, Wallace DD, Koso-Thomas M, Miodovnik M, Goldenberg RL. A prospective cause of death classification system for maternal deaths in low and middle-income countries: results from the Global Network Maternal Newborn Health Registry. BJOG 2018; 125:1137-1143. [PMID: 29094456 DOI: 10.1111/1471-0528.15011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the causes of maternal death in a population-based cohort in six low- and middle-income countries using a standardised, hierarchical, algorithmic cause of death (COD) methodology. DESIGN A population-based, prospective observational study. SETTING Seven sites in six low- to middle-income countries including the Democratic Republic of the Congo (DRC), Guatemala, India (two sites), Kenya, Pakistan and Zambia. POPULATION All deaths among pregnant women resident in the study sites from 2014 to December 2016. METHODS For women who died, we used a standardised questionnaire to collect clinical data regarding maternal conditions present during pregnancy and delivery. These data were analysed using a computer-based algorithm to assign cause of maternal death based on the International Classification of Disease-Maternal Mortality system (trauma, termination of pregnancy-related, eclampsia, haemorrhage, pregnancy-related infection and medical conditions). We also compared the COD results to healthcare-provider-assigned maternal COD. MAIN OUTCOME MEASURES Assigned causes of maternal mortality. RESULTS Among 158 205 women, there were 221 maternal deaths. The most common algorithm-assigned maternal COD were obstetric haemorrhage (38.6%), pregnancy-related infection (26.4%) and pre-eclampsia/eclampsia (18.2%). Agreement between algorithm-assigned COD and COD assigned by healthcare providers ranged from 75% for haemorrhage to 25% for medical causes coincident to pregnancy. CONCLUSIONS The major maternal COD in the Global Network sites were haemorrhage, pregnancy-related infection and pre-eclampsia/eclampsia. This system could allow public health programmes in low- and middle-income countries to generate transparent and comparable data for maternal COD across time or regions. TWEETABLE ABSTRACT An algorithmic system for determining maternal cause of death in low-resource settings is described.
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Affiliation(s)
- O Pasha
- Aga Khan University, Karachi, Pakistan.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - S Saleem
- Aga Khan University, Karachi, Pakistan
| | | | - A Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - A Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - C L Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - E Chomba
- University Teaching Hospital, Lusaka, Zambia
| | - W A Carlo
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - K M Hambidge
- University of Colorado, School of Medicine, Denver, CO, USA
| | - N F Krebs
- University of Colorado, School of Medicine, Denver, CO, USA
| | - S Goudar
- KLE University's JN Medical College, Belagavi, India
| | - B S Kodkany
- KLE University's JN Medical College, Belagavi, India
| | - S Dhaded
- KLE University's JN Medical College, Belagavi, India
| | - R J Derman
- Thomas Jefferson University, Philadelphia, PA, USA
| | - A Patel
- Lata Medical Research Foundation, Nagpur, India
| | | | | | - C Tenge
- Moi University, Eldoret, Kenya
| | | | | | | | | | | | - R L Goldenberg
- Columbia University School of Medicine, New York, NY, USA
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