Indole clubbed 2,4-thiazolidinedione linked 1,2,3-triazole as a potent antimalarial and antibacterial agent against drug-resistant strain and molecular modeling studies

In the face of escalating challenges of microbial resistance strains, this study describes the design and synthesis of 5-({1-[(1H-1,2,3-triazol-4-yl)methyl]-1H-indol-3-yl}methylene)thiazolidine-2,4-dione derivatives, which have demonstrated significant antimicrobial properties. Compared with the minimum inhibitory concentrations (MIC) values of ciprofloxacin on the respective strains, compounds 5a, 5d, 5g, 5l, and 5m exhibited potent antibacterial activity with MIC values ranging from 16 to 25 µM. Almost all the synthesized compounds showed lower MIC compared to standards against vancomycin-resistant enterococcus and methicillin-resistant Staphylococcus aureus strains. Additionally, the majority of the synthesized compounds demonstrated remarkable antifungal activity, against Candida albicans and Aspergillus niger, as compared to nystatin, griseofulvin, and fluconazole. Furthermore, the majority of compounds exhibited notable inhibitory effects against the Plasmodium falciparum strain, having IC50 values ranging from 1.31 to 2.79 μM as compared to standard quinine (2.71 μM). Cytotoxicity evaluation of compounds 5a-q on SHSY-5Y cells at up to 100 μg/mL showed no adverse effects. Comparison with control groups highlights their noncytotoxic characteristics. Molecular docking confirmed compound binding to target active sites, with stable protein-ligand complexes displaying drug-like molecules. Molecular dynamics simulations revealed dynamic stability and interactions. Rigorous tests and molecular modeling unveil the effectiveness of the compounds against drug-resistant microbes, providing hope for new antimicrobial compounds with potential safety.

Impact of laws prohibiting domestic violence on wasting in early childhood

Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue.

Abortion Legal Reform and Neonatal Mortality in Mozambique

INTRODUCTION

Abortion law reforms have been hypothesized to influence reproductive, maternal, and neonatal health services and health outcomes, as well as social inequalities in health. In 2014, Mozambique legalized abortion in specific circumstances. However, due to challenges implementing the law, there is concern that it may have negatively influenced neonatal outcomes.

METHODS

Using a difference-in-differences design, we used birth history data collected via the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) between 2004 and 2018 to assemble a panel of 476 939 live births across 17 countries including Mozambique. We estimated the effect of the abortion reform on neonatal mortality by comparing Mozambique to a series of control countries that did not change their abortion policies. We also conducted stratified analyses to examine heterogeneity in effect estimates by household wealth, educational attainment, and rural/urban residence.

RESULTS

The reform was associated with an additional 5.6 (95% CI = 1.3, 9.9) neonatal deaths per 1,000 live birth. There was evidence of a differential effect of the reform, with a negative effect of the reform on neonatal outcomes for socially disadvantaged women, including those with no schooling, in poorer households, and living in rural areas.

DISCUSSION

Given the delay in implementation, our analyses suggest that abortion reform in Mozambique was associated with an initial increase in neonatal mortality particularly among socially disadvantaged women. This may be due to the delay in effective implementation, including the dissemination of clear guidelines and expansion of safe abortion services. Longer-term follow-up is needed to assess the impact of the reform after 2018, when services were expanded. Abortion legal reform without adequate implementation and enforcement is unlikely to be sufficient to improve abortion access and health outcomes.

Is the impact of paid maternity leave policy on the prevalence of childhood diarrhoea mediated by breastfeeding duration? A causal mediation analysis using quasi-experimental evidence from 38 low-income and middle-income countries

OBJECTIVES

Quasi-experimental evidence suggests that extending the duration of legislated paid maternity leave is associated with lower prevalence of childhood diarrhoea in low-income and middle-income countries (LMICs). This could be due to a variety of mechanisms. This study examines whether this effect is mediated by changes in breastfeeding duration.

DESIGN AND SETTING

Difference-in-difference approach and causal mediation analysis were used to perform secondary statistical analysis of cross-sectional data from Demographic and Health Surveys (DHSs) in 38 LMICs.

PARTICIPANTS

We merged longitudinal data on national maternity leave policies with information on childhood diarrhoea related to 639 153 live births between 1996 and 2014 in 38 LMICs that participated in the DHS at least twice between 1995 and 2015.

PRIMARY OUTCOME MEASURE

Our outcome was whether the child had bloody stools in the 2 weeks prior to the interview. This measure was used as an indicator of severe diarrhoea because the frequency of loose stools in breastfed infants can be difficult to distinguish from pathological diarrhoea based on survey data.

RESULTS

A 1-month increase in the legislated duration of paid maternity leave was associated with a 34% (risk ratio 0.66, 95% CI 0.47 to 0.91) reduction in the prevalence of bloody diarrhoea. Breast feeding for at least 6 months and 12 months mediated 10.6% and 7.4% of this effect, respectively.

CONCLUSION

Extending the duration of paid maternity leave appears to lower diarrhoea prevalence in children under 5 years of age in LMICs. This effect is slightly mediated by changes in breastfeeding duration.

The intergenerational effect of tuition-free lower-secondary education on children's nutritional outcomes in Africa

One in five child deaths under age 5 are a result of severe wasting. Malnutrition at early ages is linked to lifelong consequences, such as reduced cognitive skills, reduced earnings in adulthood and chronic health conditions. Countries worldwide have committed to addressing child undernutrition, and ending hunger is foundational to the Millennium Development Goals. In this paper, we study the intergenerational effect of providing free tuition in secondary school on future children's nutrition. We combined a novel longitudinal dataset that captures educational policies for 40 African countries from 1990 to 2019 with the Demographic and Health Survey (DHS). We identified three countries that introduced free secondary education several years after implementing free primary education. Exploiting this variation in timing we estimate the additional impact of providing free secondary education over free primary education. Using a difference-in-difference approach, we find that introducing free secondary education significantly reduced wasting. Cohorts exposed to free secondary had an 18% relative decrease in wasting. The impact on cohorts exposed only to free primary was smaller and not statistically significant. Expanding free secondary education has long-term, intergenerational benefits and is an effective path to reducing malnutrition. Results are robust to different specifications.

Patterns of antibiotic use for acute respiratory infections in under-three-year-old children in India: A cross-sectional study

Background

Despite its mostly viral etiology, antibiotics are frequently used to treat acute respiratory infections (ARIs) in children. India is one of the largest global consumers of antibiotics and has one of the highest rates of resistance to antimicrobial treatments. However, the epidemiology of antibiotic treatment among young children in India is poorly understood.

Methods

Using nationally representative household survey data from the Indian National Family Health Surveys (NFHS) conducted between 2015 and 2016 and 2019 and 2021, we estimated the prevalence of antibiotic use among 17 472 children under the age of three who reported ARI symptoms within two weeks before their mothers were interviewed. To assess the factors associated with antibiotic use for the treatment of ARI symptoms, we used multivariable logistic regression models that included sociodemographic, child-related, household, and health care related characteristics, with results reported on the prevalence difference (PD) scale.

Results

We estimated that 18.7% (95% CI = 17.8-19.6) of under-three-year-old (U3) children who exhibited ARI symptoms in the two weeks prior to the survey were given antibiotics as a treatment. The highest prevalence was observed in the southern and northern geographic zones of India. Furthermore, multivariable regression models indicated that children with greater access to health services were more likely to receive antibiotics for ARI treatment, regardless of the type of health care facility (public, private or pharmacy/unregulated). Additionally, the prevalence of antibiotic consumption was higher among children from families with religious affiliations other than Muslim and Hindu backgrounds (i.e. Christian, Sikh, Buddhist/neo-Buddhist, Jain, Jewish, Parsi, no religion and other) (PD = 11.7 (95% CI = 6.3-16.7)) compared to Hindu families and among mothers with a secondary or higher education (PD = 5.8 (95% CI = 1.7-9.9)) compared to mothers lacking formal education.

Conclusions

Our findings provide an important baseline for monitoring the use of antibiotics for the treatment of acute respiratory infections, and for designing interventions to mitigate potential misuse among young children in India.

Network pharmacology analysis of Plumbago zeylanica to identify the therapeutic targets and molecular mechanisms involved in ameliorating hemorrhoids

Plumbago zeylanica is an important plant used in the Ayurvedic system of medicine for the treatment of hemorrhoids or piles. Despite its clinical uses, its molecular mechanism, for ameliorating hemorrhoids is not yet explored. Hence, the present study evaluated the plausible molecular mechanisms of P. zeylanica in the treatment of hemorrhoids using network pharmacology and other in silico analysis. Network pharmacology was carried out by protein, GO, and KEGG enrichment analysis. Further ADME/T, molecular docking and dynamics studies of the resultant bioactive compounds of P. zeylanica with the regulated proteins were evaluated. Results of the network pharmacology analysis revealed that the key pathways and plausible molecular mechanisms involved in the treatment effects of P. zeylanica on hemorrhoids are cell migration, proliferation, motility, and apoptosis which are synchronized by cancer, focal adhesion, and by signalling relaxin, Rap1, and calcium pathways which indicates the involvement of angiogenesis and vasodilation which are the characteristic features of hemorrhoids. Further, the molecular docking and dynamics studies revealed that the bio active ingredients of P. zeylanica strongly bind with the key target proteins in the ambiance of hemorrhoids. Hence, the study revealed the mechanism of P. zeylanica in ameliorating hemorrhoids.Communicated by Ramaswamy H. Sarma.

Targeted Degradation of Structured RNAs via Ribonuclease-Targeting Chimeras (RiboTacs)

INTRODUCTION

RNA structural motifs can serve as recognition sites for proteins or regulatory elements. Notably, these specific RNA shapes are directly related to many diseases. Targeting specific RNA motifs using small molecules is an emerging domain of study within the area of drug discovery. Targeted degradation strategies are a relatively modern technology in drug discovery, with important clinical and therapeutic outcomes. These approaches involve using small molecules to selectively degrade specific biomacromolecules associated with a disease."Ribonuclease-Targeting Chimeras" (RiboTaCs) represent a promising type of targeted degradation strategy because of their ability to selectively degrade structured RNA targets.

AREAS COVERED

In this review, the authors present the evolution of RiboTaCs, their underlying mechanism, and their in-vitro validation. The authors summarize several disease-associated RNAs that have been previously targeted for degradation using the RiboTaC strategy and discuss how their degradation led to alleviating disease-associated phenotypes in-vitro and in-vivo.

EXPERT OPINION

There are several future obstacles that still need to be overcome for RiboTaC technology to fully realize its potential. Despite these challenges, the authors are optimistic about its prospects, which have the potential to fundamentally transform the treatment of a wide range of diseases.

Impact evaluation of the TAMANI project to improve maternal and child health in Tanzania

BACKGROUND

The Tabora Maternal and Newborn Health Initiative project was a multicomponent intervention to improve maternal and newborn health in the Tabora region of Tanzania. Components included training healthcare providers and community health workers, infrastructure upgrades, and improvements to health management. This study aimed to examine the impact of trainings on four key outcomes: skilled birth attendance, antenatal care, respectful maternity care and patient-provider communication.

METHODS

Trainings were delivered sequentially at four time points between 2018 and 2019 in eight districts (two districts at a time). Cross-sectional surveys were administered to a random sample of households in all districts at baseline and after each training wave. Due to practical necessities, the original stepped wedge cluster randomised design of the evaluation was altered mid-programme. Therefore, a difference-in-differences for multiple groups in multiple periods was adopted to compare outcomes in treated districts to not yet treated districts. Risk differences were estimated for the overall average treatment effect on the treated and group/time dynamic effects.

RESULTS

Respondents reported 3895 deliveries over the course of the study. The intervention was associated with a 12.9 percentage point increase in skilled birth attendance (95% CI 0.4 to 25.4), which began to increase 4 months after the end of training in each district. There was little evidence of impact on antenatal care visits, respectful treatment during delivery and patient-provider communication.

CONCLUSION

Interventions to train local healthcare workers in basic and comprehensive emergency obstetric and newborn care increased skilled birth attendance but had limited impact on other pregnancy-related outcomes.

Network pharmacology and molecular modelling study of Enhydra fluctuans for the prediction of the molecular mechanisms involved in the amelioration of nephrolithiasis

In view of the ethno medicinal use of Enhydra fluctuans for the treatment of kidney stones; the present study aimed to elucidate the molecular mechanisms involved in the amelioration of nephrolithiasis through a network pharmacology approach. The phytoconstituents were queried in DIGEP-Pred to identify the regulated proteins. The modulated proteins were then enriched in the STRING to predict the protein-protein interactions and the probably regulated pathways were traced in the Kyoto Encyclopedia of Genes and Genomes. Further, the network was constructed using Cytoscape ver 3.5.1. Results showed that β-carotene was found to be regulating maximum targets i.e. 26. In addition, 63 proteins were triggered by the components in which the vitamin D receptor was targeted by the maximum phytoconstituents i.e. 16. The enrichment analysis identified the regulation of 67 pathways in which fluid shear stress and atherosclerosis-associated pathways (KEGG entry hsa05418) regulated ten genes. Further, protein kinase C-α was traced in 23 different pathways. In addition, the majority of the regulated genes were identified from the extracellular space via the modulation of 43 genes. Also, nuclear receptor activity had the maximum molecular function via the regulation of 7 genes. Likewise, the response to organic substance was predicted to trigger the top genes i.e. 43. In contrast, Stigmasterol, Baicalein-7-o-glucoside, and Kauran-16-ol were found to have a high affinity to bind with the VDR receptor confirmed by the molecular modelling and the dynamics. Hence, the study elucidated the probable molecular mechanisms of E. fluctuans in managing nephrolithiasis and identified the lead molecules, their targets, and possible pathways.Communicated by Ramaswamy H. Sarma.

The Abundant Phytocannabinoids in Rheumatoid Arthritis: Therapeutic Targets and Molecular Processes Identified Using Integrated Bioinformatics and Network Pharmacology

The endocannabinoid system consists of several phytocannabinoids, cannabinoid receptors, and enzymes that aid in numerous steps necessary to manifest any pharmacological activity. It is well known that the endocannabinoid system inhibits the pathogenesis of the inflammatory and autoimmune disease rheumatoid arthritis (RA). To the best of our knowledge, no research has been done that explains the network-pharmacology-based anti-rheumatic processes by focusing on the endocannabinoid system. Therefore, the purpose of this study is to further our understanding of the signaling pathways, associated proteins, and genes underlying RA based on the abundant natural endocannabinoids. The knowledge on how the phytocannabinoids in Cannabis sativa affect the endocannabinoid system was gathered from the literature. SwissTarget prediction and BindingDB databases were used to anticipate the targets for the phytocannabinoids. The genes related to RA were retrieved from the DisGeNET and GeneCards databases. Protein–protein interactions (high confidence > 0.7) were carried out with the aid of the string web server and displayed using Cytoscape. The Kyoto Encyclopedia of Genes and Genomes (KEGG) metabolic pathway analysis was used to perform enrichment analyses on the endocannabinoid–RA common targets. ShinyGO 0.76 was used to predict the biological processes listed in the Gene Ontology (GO) classification system. The binding affinity between the ligand and the receptors was precisely understood using molecular docking, induced-fit docking, and a molecular dynamics simulation. The network pharmacology analyses predicted that processes like response to oxygen-containing compounds and peptodyl-amino acid modification are related to the potential mechanisms of treatment for RA. These biological actions are coordinated by cancer, neuroactive ligand–receptor interaction, lipids and atherosclerosis, the calcium signaling pathway, and the Rap1 signaling pathway. According to the results of molecular docking, in the context of RA, phytocannabinoids may bind to important target proteins such PIK3CA, AKT1, MAPK9, PRKCD, BRAF, IGF1R, and NOS3. This entire study predicted the phytocannabinoids’ systemic biological characteristics. Future experimental research is needed, however, to confirm the results so far.

Inhibitory activity of Enhydra fluctuans Lour. on calcium oxalate crystallisation through in silico and in vitro studies

The decoction of the whole plant of Enhydra fluctuans is used ethno medicinally by various tribes for the treatment of kidney stones and urinary problems. However, no scientific studies were carried out to delineate its influence on urinary stone formation and crystallisation. Hence, the present study is proposed to investigate the effect of the aqueous extract of Enhydra fluctuans extract on in vitro crystallisation of calcium oxalate. The present study also evaluated. in silico studies of the metabolites with the target proteins present in the renal calcium oxalate stone matrix. The plant material was subjected to decoction to obtain an aqueous extract. The effect of the extract on calcium oxalate crystallization was evaluated by in vitro nucleation and aggregation assays. Further, the metabolites present in E. fluctuans were mined from the existing literature and their number was found to be 35. The selected 35 metabolites of E. fluctuans were subjected to molecular docking with the 5 proteins which are known to be responsible for calcium oxalate crystal growth. Results of in vitro studies indicated that the extract (50, 100, and 200 μg/mL) and standard drug cystone (1,000 μg/mL) exhibited an inhibitory role in the nucleation process where the percentage inhibitions were 52.69, 43.47, 21.98, and 31.67 μg/mL respectively. The results of molecular docking studies revealed that 2 out of 35 metabolites i.e. Baicalein-7-O-diglucoside and 4',5,6,7-Tetrahydroxy-8-methoxy isoflavone-7-O-beta-D- galactopyranosyl-(1→3)-O-beta-D-xylopyranosyl-(1→4)- O-alpha-L-rhamnopyranoside showed modulatory effects on the four renal stone matrix-associated protein (Human CTP: Phosphoethanolamine Cytidylyltransferase (Protein Data Bank ID: 3ELB), UDP glucose: glycoprotein glucosyltransferase 2 (Gene: UGGT2) (AlphaFold) and RIMS-binding protein 3A (Gene: RIMBP3) (AlphaFold), and Ras GTPase activating-like protein (PDB: 3FAY) based on their docking scores which indicates that they may inhibit the crystallization process. Findings from this study show that Enhydra fluctuans may be effective in the prevention of the crystallization of calcium oxalate. However, further, in vivo studies as well as molecular studies are needed to be conducted to confirm and strengthen its anti-urolithiatic activity and to elucidate the possible mechanism of action involved therein.

1251 FRAILTY PREVALENCE AND RISK OF SARCOPENIA IN OLDER HEART FAILURE (HF) INPATIENTS

Introduction

Both frailty and HF are common in the elderly population. Elderly HF patients have an increased risk of frailty and elderly frail patients are at a higher risk of developing HF. Frailty is an independent predictor of mortality in cardiovascular disease. Sarcopenia (defined as decreased muscle mass and muscle strength and/or performance) is also prevalent in HF patients and may progress to cardiac cachexia. HF may induce sarcopenia and sarcopenia may contribute to the poor prognosis of HF.

Aims

Methods

A cross-sectional, retrospective analysis of consecutive patients, 60 years and over, admitted with HF to a UK hospital. Data was manually extracted from anonymized electronic records. The Rockwood Clinical Frailty Scale (CFS) was used for assessment for frailty and the SARC-F tool was used for screening for sarcopenia. Patients with medical history of HF but did not present with decompensated HF were excluded. Also, patients with incomplete data were excluded. The IBM SPSS 28 statistical package was used for statistical analysis. Descriptive statistics and risk estimates were calculated.

Results

163 patients were analysed; 82 males and 81 females. The mean age was 81.4 years (SD 9.69). 71.5 % of patients were frail while 28.5 % were non-frail. The risk of sarcopenia was 10.9 times greater in the frail than in the non-frail patients (OR = 10.9; 95% C.I 4.85 – 24.67). There was a lower risk of sarcopenia in male patients than in the female patients (OR =0.45; 95% C.I 0.22 – 0.94).

Conclusions

Frailty is prevalent in older heart failure inpatients. It significantly increases the risk of sarcopenia in these patients. Women are at higher risk of sarcopenia than men. More research is needed into frailty and sarcopenia in.

1242 CO-MORBIDITY, FRAILTY AND EJECTION FRACTION IN OLDER HEART FAILURE INPATIENTS

Introduction

Co-morbidities and frailty are common in older heart failure patients. The aim of this study is to explore the relationship between co-morbidity, frailty and ejection fraction (EF) in older heart failure inpatients

Methods

A cross-sectional, observational, retrospective analysis of consecutive patients aged 60 years and over who were admitted with heart failure in a UK hospital. Patients with incomplete data were excluded. The Carlson’s comorbidity index (CCI) was used to compute comorbidity and the Rockwood Clinical Frailty Scale (CFS) was used to measure frailty. The EF was calculated as the midpoint of the ranges measured by echocardiography. IBM SPSS 28 software was used for statistical analysis. Descriptive statistics were used to measure baseline characteristics and Pearson’s correlation coefficient and linear regression were used to calculate correlation.

Results and discussion

101 patients were analysed; 48 males and 53 females. Mean age was 81.2 years(SD 9.98). Mean CCI was 6.97(SD 1.63) and mean CFS was 5.09(SD 1.14). There was statistically significant positive correlation between CCI and CFS (r= 0.232; p= .01). There was statistically significant inverse correlation between CCI and EF (r= -.277; p=. 005). When taking into account the level of frailty the correlation between CCI and EF was much stronger in non-frail than in frail patients (r= -.612; p=. 035 and r= -.216; p= .047 respectively). There was no correlation between CFS and EF (r= .095; p=.26). This was not surprising as HFpEF is the most common type of HF in the elderly. HFpEF patients are more likely to have more comorbidities and to be more frail compared to HFrEF patients.

Conclusion

There was a positive correlation between multi-morbidity and frailty in older inpatients admitted with heart failure. There was statistically significant inverse correlation between CCI and ejection fraction but there was no correlation between frailty and ejection.

A Causal Mediation Analysis for Investigating the Effect of a Randomized Cash-Transfer Program in Nicaragua

Mediation analysis can be applied to data from randomized trials of health and social interventions to draw causal inference concerning their mechanisms. We used data from a cluster-randomized trial in Nicaragua, fielded between 2000 and 2002, to investigate whether the impact of providing access to a conditional cash-transfer program on child nutritional outcomes was mediated by child health check-ups and household dietary diversity. In a sample of 443 children 6-35 months old, we estimated the controlled direct (CDE) effect of random assignment on measured height-for-age z scores had we intervened so that all children received a health check-up and had the same level of household dietary diversity, using inverse-probability weighted marginal structural models to account for mediator-outcome confounding. Sensitivity analyses corrected the CDE for potential nondifferential error in the measurement of dietary diversity. Treatment assignment increased height-for-age z score by 0.37 (95% CI: 0.05, 0.69) standard deviations. The CDE was 0.20 (95% CI: -0.17, 0.57) standard deviations, suggesting nearly one-half of the program's impact on child nutrition would be eliminated had we intervened on these factors, although estimates were relatively imprecise. This study provides an illustration of how causal mediation analysis can be applied to examine the mechanisms of multifaceted interventions.

The Impact of Cannabis Decriminalization and Legalization on Road Safety Outcomes: A Systematic Review

INTRODUCTION

There is substantial debate concerning the impact of cannabis decriminalization and legalization on road safety outcomes.

METHODS

Seven databases were systematically searched: Embase, MEDLINE, and PsycINFO through Ovid as well as Web of Science Core Collection, SafetyLit, Criminal Justice Database (ProQuest), and Transport Research International Documentation (from inception to June 16, 2021). Eligible primary studies examined group-level cannabis decriminalization or legalization and a road safety outcome in any population.

RESULTS

A total of 65 reports of 64 observational studies were eligible, including 39 that applied a quasi-experimental design. Studies examined recreational cannabis legalization (n=50), medical cannabis legalization (n=22), and cannabis decriminalization (n=5). All studies except 1 used data from the U.S. or Canada. Studies found mixed impacts of legalization on attitudes, beliefs, and self-reported driving under the influence. Medical legalization, recreational legalization, and decriminalization were associated with increases in positive cannabis tests among drivers. Few studies examined impacts on alcohol or other drug use, although findings suggested a decrease in positive alcohol tests among drivers associated with medical legalization. Medical legalization was associated with reductions in fatal motor-vehicle collisions, whereas recreational legalization was conversely associated with increases in fatal collisions.

DISCUSSION

Increased cannabis positivity may reflect changes in cannabis use; however, it does not in itself indicate increased impaired driving. Subgroups impacted by medical and recreational legalization, respectively, likely explain opposing findings for fatal collisions. More research is needed concerning cannabis decriminalization; the impacts of decriminalization and legalization on nonfatal injuries, alcohol and other drugs; and the mechanisms by which legalization impacts road safety outcomes.

Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

BACKGROUND

Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality.

METHODS AND FINDINGS

We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = -4.8, 10.7], 6.5 (95% CI = -0.6, 13.6), and 5.8 (95% CI = -1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = -1.3, 2.6), 0.8 (95% CI = -1.7, 3.4), and 1.3 (95% CI = -2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas.

CONCLUSIONS

In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

970 FRAILTY IS INVERSELY CORRELATED WITH SERUM ALBUMIN IN ACUTE HIP FRACTURE

Introduction

Frailty and sarcopenia have been shown to significantly increase the risk of falls, traumatic hip fractures and all-cause mortality in the elderly. The assessment of frailty using a validated clinical frailty scale such as that proposed by Rockwood et al., therefore, continues to remain an important step in determining post-operative prognosis in patients undergoing hip fracture surgery. The purpose of this study was to examine the relationship between frailty and serum albumin—an independent biochemical predictor of survival in hip fracture patients (1).

Method

This retrospective cross-sectional study analysed 190 patients, aged above 60 years, admitted to Queen’s Hospital Burton (QHB) between the 1st January and 28th December 2019 with a newly diagnosed hip fracture. Pre-operative serum albumin levels (g/L) and Rockwood clinical frailty scores (rCFS) were recorded from electronic medical records (EMR). Using the SPSS 27 statistical package, Pearson’s correlation co-efficient and linear regression analysis were carried out using these variables.

Results

A total of 190 patients were included in the study (57 male, 133 female). Mean patient age was 82.2 ± 8.47 years. More than 50% of patients had a Rockwood CFS ≥5. Mean serum albumin (g/L) was 37.3 ± 6.56. A statistically significant inverse correlation was demonstrated between pre-operative serum albumin levels and Rockwood CFS (r = −0.243, p < 0.001).

Conclusion

This study showed how serum albumin, a negative acute phase reactant and marker of chronic malnutrition, is inversely associated with frailty in hip fracture patients and the important role of Rockwood CFS and pre-operative serum albumin levels in the prognostication of hip fractures in the elderly. References 1) Bohl D, Shen M, Hannon C, Fillingham Y, Darrith B, Della Valle C. Serum Albumin Predicts Survival and Postoperative Course Following Surgery for Geriatric Hip Fracture. Journal of Bone and Joint Surgery. 2017;99(24):2110–2,118.

975 RELATIONSHIP BETWEEN HAND GRIP STRENGTH (HGS) AND 10 YEAR PROBABILITY OF MAJOR OSTEOPOROTIC FRACTURES IN OLDER

Introduction

HGS has been shown to be associated with adverse outcomes in a wide range of conditions. It has also been found to be associated with bone mineral density and is inversely associated with risk of osteoporotic fractures. The aim of this study was to determine the association between HGS and 10 year probability of sustaining a major osteoporotic fractures in older inpatient and to evaluate the effect of gender on this association.

Method

This was a cross-sectional, observational analysis of older patients admitted into hospital between September and November 2021. HGS was measured in these patients using the JAMAR hydraulic hand held dynamometer. The Southampton protocol was used. The FRAX UK tool (without BMD) was used to calculate 10 year probability of major osteoporotic fractures. Patients were included if they were 60 years and above. Younger patients were excluded as were stroke patients. Patients with incomplete data were excluded from analysis. The SPSS 27 package was used for statistical analysis. Baseline characteristics were calculated using descriptive statistics. Pearson’s correlation coefficient and linear regression were used to calculate correlation.

Results

104 patients were analysed—41 males and 63 females. Mean age was 83 years (SD 8.2). Grip strength was inversely correlated with FRAX UK in predicting 10 year probability of major osteoporotic fractures in all patients, male patients and female patients (r = −0.452; p < 0.001, r = −0.351; p = 0.02 and r = −0.271; p = 0.03 respectively).

Conclusion

Grip strength is negatively associated with increased probability of major osteoporotic fractures in older inpatients. Reference(s) Ma Y, Fu L, Jia L, et al. Muscle strength rather than muscle mass is associated with osteoporosis in older Chinese adults. J Formos Med Assoc. 2018;117(2):101–108. doi:10.1016/j.jfma.2017.03.004

974 ASSOCIATION BETWEEN NOTTINGHAM HIP FRACTURE SCORE AND FRAILTY IN ELDERLY ACUTE HIP FRACTURE PATIENTS

Introduction

Nottingham Hip Fracture Score (NHFS) is a well validated risk stratification tool that has been shown to predict 30 day mortality in elderly patients with acute hip fractures. A lot of older patients that sustain hip fractures are frail. The Rockwood Clinical Frailty Scale (CFS) has been validated as a tool to screen for frailty in acutely ill patients and has been shown to predict outcomes in acutely ill elderly patients. The aim of this study was to determine if there is any correlation between the NHFS and CFS in elderly patients with acute hip fractures and to evaluate the effect of gender on this correlation.

Method

A retrospective, cross-sectional analysis was carried out on patients admitted with acute hip fractures between January and December 2019 in a single centre trauma and orthopaedic unit. Data was extracted from anonymized electronic patient records. Patients were included if they were 60 years and above; those less than 60 were excluded. Patients with missing data were excluded from analysis. NHFS and CFS were calculated in these patients. SPSS 27 IBM software was used for statistical analysis. Baseline characteristics were calculated using descriptive statistics and spearman’s correlation co-efficient and linear regression were used to determine correlation.

Results

A total of 268 patients were analysed—65 males and 202 females. Mean age was 83 years (SD 8.5). There was statistically significant positive correlation between NHFS and CFS in all patients, male patients and female patients (r = 0.589; p < 0.001, r = 0.603; p < 0.001, and r = 0.599; p < 0.001 respectively).

Conclusion

NHFS is positively correlated with CFS in elderly acute hip fracture patients. Reference(s) Doherty W.J, Stubbs T.A et al. Prediction of Postoperative Outcomes Following Hip Fracture Surgery: Independent Validation and Recalibration of the Nottingham Hip Fracture Score. Journal of the American Medical Directors Association;22(3):663–669.e2.

Paid Maternity Leave in Vietnam: Awareness, Perceptions, Gaps, and Uptake Among Formally Employed Pregnant Women and Mothers of Infants

Objectives

To examine the uptake of Vietnam's paid maternity leave policy in terms of entitlements and awareness, perceptions, and gaps in implementation through the lens of formally employed female workers.

Methods

In this mixed methods study, we interviewed 494 formally employed female workers, among whom 107 were pregnant and 387 were mothers of infants and conducted in-depth interviews with a subset of these women (n = 39).

Results

Of the 494 women interviewed, 268 (54.3%) were working in blue-collar jobs and more than 90% were contributing to the public social insurance fund. Among the 387 mothers on paid maternity leave, 51 (13.2%) did not receive cash entitlements during their leave. Among the 182 mothers with infants aged 6–11 months, 30 (16.5%) returned to work before accruing 180 days of maternity leave. Of 121 women who had returned to work, 26 (21.5%) did not receive a one-hour paid break every day to express breastmilk, relax or breastfeed, and 46 (38.0%) worked the same or more hours per day than before maternity leave. Although most women perceived maternity leave as beneficial for the child's health (92.5%), mother's health (91.5%), family (86.2%), and society (90.7%), fewer women perceived it as beneficial for their income (59.5%), career (46.4%), and employers (30.4%). Not all formally employed women were aware of their maternity protection rights: women were more likely to mention the six-month paid maternity leave (78.7%) and one-hour nursing break (62.3%) than the other nine entitlements (2.0–35.0%). In-depth interviews with pregnant women and mothers of infants supported findings from the quantitative survey.

Conclusions

Although Vietnam's maternity protection policy helps protect the rights of women and children, our study identified implementation gaps that limit its effectiveness. In order to ensure that all women and their families can fully benefit from maternity protection, there is a need to increase awareness of the full set of maternity entitlements, strengthen enforcement of existing policies, and expand entitlements to the informal sector.

Funding Sources

Bill & Melinda Gates Foundation (Grant Number OPP50838) and Irish Aid.

E-learning in formal education under forced conditions using SDT and TAM

This study aims to understand the students’ attitude towards e-learning under the forced environment of the COVID-19 pandemic. This study gives a fresh insight into e-learning, considering the lack of comprehensive research on the influencing variables that impact the user acceptance of e-learning by learners in the Indian Universities during COVID-19 pandemic. The rational model has been constituted based on the Technological Acceptance Model (TAM) and Self-Determination Theory (SDT) to study the effective influence of Autonomy, Relatedness & Competency on the construct of TAM. The result showed significant relations of the self-determination variables with perceived ease of use & perceived usefulness, which further helps us establish a relationship between intrinsic & extrinsic factors of SDT framework with attitude and satisfaction level of Indian University students towards e-learning. This study will assist in bridging the gap between the understanding of organizations and actual factors impacting students’ learning process during the pandemic of COVID-19.

Altered electrochemical properties of iron oxide nanoparticles by carbon enhance molecular biocompatibility through discrepant atomic interaction

Recent advancement in nanotechnology seeks exploration of new techniques for improvement in the molecular, chemical, and biological properties of nanoparticles. In this study, carbon modification of octahedral-shaped magnetic nanoparticles (MNPs) was done using two-step chemical processes with sucrose as a carbon source for improvement in their electrochemical application and higher molecular biocompatibility. X-ray diffraction analysis and electron microscopy confirmed the alteration in single-phase octahedral morphology and carbon attachment in Fe3O4 structure. The magnetization saturation and BET surface area for Fe3O4, Fe3O4/C, and α-Fe2O3/C were measured as 90, 86, and 27 emu/g and 16, 56, and 89 m2/g with an average pore size less than 7 nm. Cyclic voltammogram and galvanostatic charge/discharge studies showed the highest specific capacitance of carbon-modified Fe3O4 and α-Fe2O3 as 213 F/g and 192 F/g. The in vivo biological effect of altered physicochemical properties of Fe3O4 and α-Fe2O3 was assessed at the cellular and molecular level with embryonic zebrafish. Mechanistic in vivo toxicity analysis showed a reduction in oxidative stress in carbon-modified α-Fe2O3 exposed zebrafish embryos compared to Fe3O4 due to despaired influential atomic interaction with sod1 protein along with significant less morphological abnormalities and apoptosis. The study provided insight into improving the characteristic of MNPs for electrochemical application and higher biological biocompatibility.

Impact of abortion law reforms on women's health services and outcomes: a systematic review protocol

BACKGROUND

A country's abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women's access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women's health services and outcomes in LMICs.

METHODS

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women's health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

DISCUSSION

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women's health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126927.

Impact of abortion law reforms on health services and health outcomes in low- and middle-income countries: a systematic review

While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, expanding the grounds on which abortion can be performed legally. However, the implications of these reforms on women's access to and use of health services, as well as their health outcomes, are uncertain. This systematic review aimed to evaluate and synthesize empirical research evidence concerning the effects of abortion law reforms on women's health services and health outcomes in LMICs. We searched Medline, Embase, CINAHL and Web of Science databases, as well as grey literature and reference lists of included studies. We included pre-post and quasi-experimental studies that aimed to estimate the causal effect of a change in abortion law on at least one of four outcomes: (1) use of and access to abortion services, (2) fertility rates, (3) maternal and/or neonatal morbidity and mortality and (4) contraceptive use. We assessed the quality of studies using the quasi-experimental study design series checklist and synthesized evidence through a narrative description. Of the 2796 records identified by our search, we included 13 studies in the review, which covered reforms occurring in Uruguay, Ethiopia, Mexico, Nepal, Chile, Romania, India and Ghana. Studies employed pre-post, interrupted time series, difference-in-differences and synthetic control designs. Legislative reforms from highly restrictive to relatively liberal were associated with reductions in fertility, particularly among women from 20 to 34 years of age, as well as lower maternal mortality. Evidence regarding the impact of abortion reforms on other outcomes, as well as whether effects vary by socioeconomic status, is limited. Further research is required to strengthen the evidence base for informing abortion legislation in LMICs. This review explicitly points to the need for rigorous quasi-experimental studies with sensitivity analyses to assess underlying assumptions. The systematic review was registered in PROSPERO database CRD42019126927.

537 AGE, FRAILTY AND COMORBIDITY IN COVID-19 INPATIENTS 65 AND OLDER

Introduction

Higher incidence of COVID-19 and poorer outcomes have been shown to be associated with age, frailty and comorbidity. Older people have more risk of severe COVID 19; hospitalization, ITU admission, ventilation and mortality.

Aim

To assess the correlation between age, frailty and comorbidity in COVID-19 inpatients 65 years and older.

Methods

A retrospective, cross-sectional analysis was carried out on COVID 19 inpatients 65 and older in a UK district general hospital. Patients with no microbiological evidence of COVID-19 and patients with incomplete data were excluded from the study. Demographic data, frailty score and comorbidity index were extracted from the electronic records of patients. SPSS 27 statistical software was used to perform descriptive analysis and linear regression coefficient.

Results

357 COVID-19 patients 65 and over were assessed; 207 males and 150 females. Mean age was 81.9 +/− 9.31. Frailty scores were measured using the Rockwood Clinical Frailty Scale (CFS) and comorbidity was calculated using the Charlson Comorbidity Index (CCI). There was positive correlation between age and Clinical Frailty Scale (r=. 436; p<. 001), between age and Charlson Comorbidity Index (r=. 448; p<. 001, and between frailty and comorbidity (r=. 429; p<. 001).

Conclusion

In COVID-19 inpatients 65 and older, there was positive correlation between age and Clinical Frailty Scale, between age and Charlson Comorbidity Index and between frailty and comorbidity. More studies are needed to explore the interaction between age, frailty and comorbidity and COVID 19 morbidity and mortality.

152 The Relationship Between 25(OH) Vitamin D and Bone Mineral Density (BMD) in Patients 65 Years and Older with Prior Fragility Fractures

Introduction

25(OH) vitamin D [25(OH) D] levels are known to influence skeletal health as well as muscle function. Some studies suggest a positive association between 25(OH) D levels and BMD at various skeletal sites in men but not in women. These findings were mostly observed in younger (less than 50 year old) cohorts. Evidence for this association in older patients with prior fragility fractures is lacking. Aim: To assess the correlation of 25(OH) D levels with T-scores at the neck of femur, hip and spine in patients 65 years and older with prior fragility fractures and the effect of gender on the correlation.

Methods

A retrospective, cross-sectional analysis of patients 65 and older with previous fragility fractures in patients attending a fracture prevention service. Data was extracted from the electronic records. SPSS 26 statistical software was used for statistical analysis. Pearson correlation coefficient was used to calculate correlation and regression coefficient for gender.

Results

151 patients were included; 26 males and 126 females. Mean age was 76.2 and 74.1 years respectively. In the males there was good positive, statistically significant correlation between the 25(OH) D and T-scores at the neck of femur (r = 0.415; p < 0.05) and hip (r = 0.413; p < 0.05), but correlation with T-score of the spine was not statistically significant (r = 0.349; p = 0.103). In the females there was no statistically significant correlation between 25(OH) D and T-scores at the neck of femur, hip or spine (r = 0.163; p = 0.077), (r = 0.096; p = 0.299) and (r = 0.114; p = 0.217) respectively.

Conclusion

In males, 65 years and older, with prior fragility fracture, there is a positive significant correlation between 25(OH) D and BMD at the neck of femur and hip whereas there is no significant correlation in females.

93 Does Spinal Bone Mineral Density Predict An Absolute 10 Year Probability of Sustaining A Major Osteoporotic Fracture

Introduction

Spine and hip bone mineral density (BMD) have previously been shown to predict the risk of sustaining future fractures. Although these have been shown in population studies, there is a paucity of trials looking at the relationship between BMD and 10 year probability of major osteoporotic fractures (Using FRAX UK without BMD) in patients with previous fragility fractures.

Aims

To evaluate the correlation between spinal T-score and an absolute 10 year probability of sustaining a major osteoporotic fracture (using FRAX without BMD) in patients with prior fragility fractures.

Methods

A retrospective cross-sectional analysis of 202 patients (29 males and 173 females) with prior fragility fractures attending a fracture prevention clinic between January and August 2019 was performed. Patients with pathological and high impact traumatic fractures were excluded. The BMD at the spine was determined using the lowest T-score of the vertebrae from L1 to L4. Using the FRAX (UK) without BMD, the absolute 10 year probability of sustaining a major osteoporotic fracture was calculated for each patient. Statistical analysis was performed using SPSS 26 software.

Results

The mean T-score at the spine was −1.15 (SD +/− 1.90) for all patients, −0.68 (SD +/− 0.45) for males and − 1.23 (SD +/− 0.14) for females. The mean FRAX score without BMD for major osteoporotic fracture was 18.5% (SD +/− 8.84) for all patients, 11.41% (SD +/−0.62) and 19.7% (SD +/−0.68) for males and females respectively. Pearson correlation coefficient showed a statistically significant, slightly negative correlation between spinal T- score and the FRAX (UK) without BMD (r = −0.157; p < 0.05). Correlation was not statistically significant when males (r = 0.109; p = 0.59) and females (r = 0.148; p = 0.053) were considered independently.

Conclusion

In patients with prior fragility fracture spinal BMD has a statistically significant negative correlation with an absolute 10 year probability of sustaining a major osteoporotic fracture.

153 Age and the Extent of Chest Radiographic Findings in Hospitalized Patients with COVID 19

Introduction

Since the emergence of COVID 19 in December 2019, its clinical and radiological features are still being discovered and their prognostic implications evaluated. Chest X-ray (CXR) typically shows patchy or diffuse asymmetric airspace opacities. Regardless of the different classifications of radiological findings that have been used, it is becoming clear that multi-lobar changes in the lungs are associated with poorer outcomes than single lobar involvement or minimal/no radiological abnormalities.

Aim: To assess the correlation of age with the extent of CXR findings in hospitalized COVID 19 patients.

Methods

A retrospective, cross-sectional analysis was carried out on inpatients with RT-PCR confirmed COVID 19. Chest X-ray findings were classified as minimal/no radiological changes, single lobar opacification and multi-lobar changes (involving 2 or more lobes and/or ARDS changes). SPSS 26 software was used for statistical analysis. Spearman’s correlation and linear regression were used to assess correlation.

Results

211 patients were included in the analysis; 124 males and 87 females. Mean age of the patients was 72.4 years; SD +/−16.15. There was significant positive correlation between age and degree and extent of radiological changes in all patients (r = 0.367; p < 0.01). This correlation persisted even when broken down by gender (r = 0.448; p < 0.01) for males and (r = 0.322; p < 0.01) for females. Discussion: Older age has been repeatedly reported as a risk factor for poor prognosis in COVID 19. The main findings of COVID-19 on CXR are those of atypical or organizing pneumonia. Older people tend to have more extensive involvement of the lungs. There could be many explanations for the CXR correlation with age including the diminished cardiovascular reserve with ageing, the accumulation of comorbidities and decreased or abnormal immune response.

Conclusion

Age significantly correlate with the extent of chest radiographic findings in inpatients with COVID 19.

Real-Time Emotion Classification Using EEG Data Stream in E-Learning Contexts

In face-to-face and online learning, emotions and emotional intelligence have an influence and play an essential role. Learners’ emotions are crucial for e-learning system because they promote or restrain the learning. Many researchers have investigated the impacts of emotions in enhancing and maximizing e-learning outcomes. Several machine learning and deep learning approaches have also been proposed to achieve this goal. All such approaches are suitable for an offline mode, where the data for emotion classification are stored and can be accessed infinitely. However, these offline mode approaches are inappropriate for real-time emotion classification when the data are coming in a continuous stream and data can be seen to the model at once only. We also need real-time responses according to the emotional state. For this, we propose a real-time emotion classification system (RECS)-based Logistic Regression (LR) trained in an online fashion using the Stochastic Gradient Descent (SGD) algorithm. The proposed RECS is capable of classifying emotions in real-time by training the model in an online fashion using an EEG signal stream. To validate the performance of RECS, we have used the DEAP data set, which is the most widely used benchmark data set for emotion classification. The results show that the proposed approach can effectively classify emotions in real-time from the EEG data stream, which achieved a better accuracy and F1-score than other offline and online approaches. The developed real-time emotion classification system is analyzed in an e-learning context scenario.

Social inequalities, debt, and health in the United States

Background

Household financial debt has more than tripled since the 1980s in the United States. The experience of indebtedness is socially structured and there is mounting evidence that debt is linked to decrements in health. However, it is unclear whether debt contributes to social disparities in health.

Objective

We examined whether household debt, measured by debt in excess of income and wealth, mediated education-based social inequalities in health, including cardiovascular risk factors (hypertension) and chronic conditions (diabetes, coronary heart disease, and psychiatric problems).

Method

We used longitudinal data from a sample of over 10,500 adults aged 18 years and older surveyed biennially between 1999 and 2015 as part of the Panel Study of Income Dynamics (PSID). We estimated the total effect of education on our health outcomes. To assess mediation by levels of household debt, we then estimated the controlled direct effect of education through pathways not mediated by levels of household debt, after accounting for lagged time-varying confounders and loss to follow-up using marginal structural models.

Results

Compared to respondents with at least a high school education, respondents with less than a high school education reported higher household debts in excess of income and wealth; they also reported a higher incidence of hypertension [risk ratio (RR) = 1.25, 95%CI = 1.13, 1.39), coronary heart disease (RR = 1.42, 95%CI: 1.25, 1.62), diabetes (RR = 1.50, 95%CI: 1.34, 1.68), and psychiatric problems (RR = 1.39, 95%CI: 1.24, 1.56). Compared to the total effects, the controlled direct effects of education on health were attenuated, particularly for death or first onset of hypertension and coronary heart disease, after fixing levels of household debt-to-income and debt-to-wealth.

Conclusion

Our results provide early evidence that household debt in excess of wealth partly mediates education-based inequalities in hypertension and coronary heart disease in the United States, with less consistent evidence for other chronic conditions.

Effectiveness of trauma centre verification: a systematic review and meta-analysis

Background

There is a growing trend toward verification of trauma centres, but its impact remains unclear. This systematic review aimed to synthesize available evidence on the effectiveness of trauma centre verification.

Methods

We conducted a systematic search of the CINAHL, Embase, HealthStar, MEDLINE and ProQuest databases, as well as the websites of key injury organizations for grey literature, from inception to June 2019, without language restrictions. Our population consisted of injured patients treated at trauma centres. The intervention was trauma centre verification. Comparison groups comprised nonverified trauma centres, or the same centre before it was first verified or re-verified. The primary outcome was in-hospital mortality; secondary outcomes included adverse events, resource use and processes of care. We computed pooled summary estimates using random-effects meta-analysis.

Results

Of 5125 citations identified, 29, all conducted in the United States, satisfied our inclusion criteria. Mortality was the most frequently investigated outcome (n = 20), followed by processes of care (n = 12), resource use (n = 12) and adverse events (n = 7). The risk of bias was serious to critical in 22 studies. We observed an imprecise association between verification and decreased mortality (relative risk 0.74, 95% confidence interval 0.52 to 1.06) in severely injured patients.

Conclusion

Our review showed mixed and inconsistent associations between verification and processes of care or patient outcomes. The validity of the published literature is limited by the lack of robust controls, as well as any evidence from outside the US, which precludes extrapolation to other health care jurisdictions. Quasiexperimental studies are needed to assess the impact of trauma centre verification.

Systematic reviews registration

PROSPERO no. CRD42018107083

Trauma system accreditation and patient outcomes in British Columbia: an interrupted time series analysis

OBJECTIVE

We aim to assess the impact of several accreditation cycles of trauma centers on patient outcomes, specifically in-hospital mortality, complications and hospital length of stay.

DESIGN

Interrupted time series.

SETTING

British Columbia, Canada.

PARTICIPANTS

Trauma patients admitted to all level I and level II trauma centers between January 2008 and March 2018.

EXPOSURE

Accreditation.

MAIN OUTCOMES AND MEASURES

We first computed quarterly estimates of the proportions of in-hospital mortality, complications and survival to discharge standardized for change in patient case-mix using prognostic scores and the Aalen-Johansen estimator of the cumulative incidence function. Piecewise regressions were then used to estimate the change in levels and trends for patient outcomes following accreditation.

RESULTS

For in-hospital mortality and major complications, the impact of accreditation seems to be associated with short- and long-term reductions after the first cycle and only short-term reductions for subsequent cycles. However, the 95% confidence intervals for these estimates were wide, and we lacked the precision to consistently conclude that accreditation is beneficial.

CONCLUSIONS

Applying a quasi-experimental design to time series accounting for changes in patient case-mix, our results suggest that accreditation might reduce in-hospital mortality and major complications. However, there was uncertainty around the estimates of accreditation. Further studies looking at clinical processes of care and other outcomes such as patient or health staff satisfaction are needed.

Constraints on the K_{S}^{0}→μ^{+}μ^{-} Branching Fraction

A search for the decay K_{S}^{0}→μ^{+}μ^{-} is performed using proton-proton collision data, corresponding to an integrated luminosity of 5.6  fb^{-1} and collected with the LHCb experiment during 2016, 2017, and 2018 at a center-of-mass energy of 13 TeV. The observed signal yield is consistent with zero, yielding an upper limit of B(K_{S}^{0}→μ^{+}μ^{-})<2.2×10^{-10} at 90% C.L.. The limit reduces to B(K_{S}^{0}→μ^{+}μ^{-})<2.1×10^{-10} at 90% C.L. once combined with the result from data taken in 2011 and 2012.

Impact of trauma centre accreditation on mortality and complications in a Canadian trauma system: an interrupted time series analysis

BACKGROUND

Periodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design.

METHODS

We included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation.

RESULTS

There were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to -9.08 (95% CI -13.29 to -4.87) and -9.60 (95% CI -15.77 to -3.43) percentage point reductions in mortality and complications, respectively.

CONCLUSION

Accreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

Extremes in water availability and suicide: Evidence from a nationally representative sample of rural Indian adults

BACKGROUND

Extremes in water availability, either exceptionally wet or dry conditions, can damage crops and may detrimentally affect the livelihood and well-being of people engaged in agriculture. We estimated the effect of water availability on suicide in rural India, a context where the majority of households are dependent upon agriculture.

METHODS

We used data from a nationally representative sample of 8.5 million people who were monitored for causes of death from 2001 to 2013. Water availability was measured with high-resolution precipitation and temperature data (i.e., the Standardized Precipitation Evapotranspiration Index). We used a fixed effects approach that modeled changes in water availability within districts (n = 569) over time (n = 13 years) to estimate the impact on suicide deaths. We restricted our analysis to rural areas and to deaths occurring during the growing season (June-March) among adults aged 15 or older, and controlled for sex, age, region, and year. We used Poisson regression with standard errors clustered at the district level and total deaths as the offset.

RESULTS

There were 9456 suicides and 249,786 total deaths in our study population between 2001 and 2013. Compared to normal growing seasons, the percent of deaths due to suicide increased by 18.7% during extremely wet growing seasons (95% CI: 6.2, 31.2) and by 3.6% during extremely dry growing seasons (95% CI: -17.9, 25.0). We found that effects varied by age.

CONCLUSIONS

We found extremes is water availability associated with an increase in suicide. Abnormally wet growing conditions may play an important, yet overlooked, role in suicide among rural Indian adults.

Social and Behavior Change Communication Interventions Delivered Face-to-Face and by a Mobile Phone to Strengthen Vaccination Uptake and Improve Child Health in Rural India: Randomized Pilot Study

Background

In resource-poor settings, lack of awareness and low demand for services constitute important barriers to expanding the coverage of effective interventions. In India, childhood immunization is a priority health strategy with suboptimal uptake.

Objective

To assess study feasibility and key implementation outcomes for the Tika Vaani model, a new approach to educate and empower beneficiaries to improve immunization and child health.

Methods

A cluster-randomized pilot trial with a 1:1 allocation ratio was conducted in rural Uttar Pradesh, India, from January to September 2018. Villages were randomly assigned to either the intervention or control group. In each participating village, surveyors conducted a complete enumeration to identify eligible households and requested participation before randomization. Interventions were designed through formative research using a social marketing approach and delivered over 3 months using strategies adapted to disadvantaged populations: (1) mobile health (mHealth): entertaining educational audio capsules (edutainment) and voice immunization reminders via mobile phone and (2) face-to-face: community mobilization activities, including 3 small group meetings offered to each participant. The control group received usual services. The main outcomes were prespecified criteria for feasibility of the main study (recruitment, randomization, retention, contamination, and adoption). Secondary endpoints tested equity of coverage and changes in intermediate outcomes. Statistical methods included descriptive statistics to assess feasibility, penalized logistic regression and ordered logistic regression to assess coverage, and generalized estimating equation models to assess changes in intermediate outcomes.

Results

All villages consented to participate. Gaps in administrative data hampered recruitment; 14.0% (79/565) of recorded households were nonresident. Only 1.4% (8/565) of households did not consent. A total of 387 households (184 intervention and 203 control) with children aged 0 to 12 months in 26 villages (13 intervention and 13 control) were included and randomized. The end line survey occurred during the flood season; 17.6% (68/387) of the households were absent. Contamination was less than 1%. Participation in one or more interventions was 94.0% (173/184), 78.3% (144/184) for the face-to-face strategy, and 67.4% (124/184) for the mHealth strategy. Determinants including place of residence, mobile phone access, education, and female empowerment shaped intervention use; factors operated differently for face-to-face and mHealth strategies. For 11 of 13 intermediate outcomes, regression results showed significantly higher basic health knowledge among the intervention group, supporting hypothesized causal mechanisms.

Conclusions

A future trial of a new intervention model is feasible. The interventions could strengthen the delivery of immunization and universal primary health care. Social and behavior change communication via mobile phones proved viable and contributed to standardization and scalability. Face-to-face interactions remain necessary to achieve equity and reach, suggesting the need for ongoing health system strengthening to accompany the introduction of communication technologies.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 44840759; https://doi.org/10.1186/ISRCTN44840759

Can a new emergency response system reduce traffic fatalities? The case of the 911-emergency response system in the Dominican Republic

BACKGROUND

In May 2014, the Dominican Republic introduced the 911-emergency response system (ERS) in Santo Domingo. Before its introduction, more than 40 phone numbers were available to report emergencies. The objective of this work is to assess whether this new emergency response system was effective in reducing traffic fatalities.

METHODS

Weekly numbers of traffic fatalities per population and per vehicle fleet from January 2013 to December 2015 were obtained from the Ministry of Health and the National Institute of Statistics. A hybrid time-series difference-in-difference analysis using multivariable negative binomial regression models were used to compare trends in rates of traffic fatalities in Santo Domingo to La Romana and Santiago, before and after the introduction of the 911-ERS.

RESULTS

Estimates from negative binomial models suggest that the introduction of the 911-ERS in Santo Domingo relative to Santiago-La Romana was associated with a 17% reduction in the Incidence Rate Ratio (IRR) of traffic fatalities per 1 000 000 population (IRR = 0.83, 95% confidence interval [CI]: 0.67; 1.03) and with a 20% reduction in the IRR of weekly traffic fatalities per 1 000 000 vehicle fleet (IRR = 0.80, 95% CI:0.67; 0.99).

DISCUSSION

Our findings suggest that transitioning from multiple to one unique emergency phone number should be considered more attentively. Furthermore, the case of the Dominican Republic calls for more theoretical and methodological research to understand how to assess these road safety policies more accurately. Since various studies suggest that 911-ERS mature in the long run, how these systems evolve over time and other related variables should be carefully considered.

Effect of vaccination on children’s learning achievements: findings from the India Human Development Survey

Background

Beyond the prevention of illness and death, vaccination may provide additional benefits such as improved educational outcomes. However, there is currently little evidence on this question. Our objective was to estimate the effect of childhood vaccination on learning achievements among primary school children in India.

Methods

We used cohort data from the India Human Development Survey. Vaccination status and confounders were measured among children who were at least 12 months old at baseline in 2004–2005. In 2011–2012, the same children completed basic reading, writing and math tests. We estimated the effect of full vaccination during childhood on learning achievements using inverse probability of treatment-weighted logistic regression models and results reported on the risk difference scale. The propensity score included 33 potential community-, household-, mother- and child-level confounders as well as state fixed effects.

Results

Among the 4877 children included in our analysis, 54% were fully vaccinated at baseline, and 54% could read by the age of 8–11 years. The estimated effect of full vaccination on learning achievements ranged from 4 to 6 percentage points, representing relative increases ranging from 6% to 12%. Bias analysis suggested that our observed effects could be explained by unmeasured confounding, but only in the case of strong associations with the treatment and outcome.

Conclusion

These results support the hypothesis that vaccination has lasting effects on children’s learning achievements. Further work is needed to confirm findings and elucidate the potential mechanisms linking vaccines to educational outcomes.

Association of vitamin D with fatty acids in pregnancy

Preeclampsia is a pregnancy complication, associated with an increased risk of maternal and neonatal morbidity and mortality. The etiology of preeclampsia is not yet fully understood, although the current literature indicates an up regulation of inflammatory mediators. Vitamin D is known to have anti-inflammatory properties and influence vascular function. Fatty acids are also known to regulate inflammation in pregnancy. This study was carried out to explore the association of maternal vitamin D and fatty acids in pregnancy. The present study includes 69 normotensive control (NC) and 50 women with preeclampsia (PE). Maternal and cord serum 25-hydroxyvitamin D [25(OH)D] levels were lower (p<0.01for both) in women with PE compared to NC women. Maternal plasma total polyunsaturated fatty acids (PUFA) levels were lower (p<0.05) while levels of total saturated fatty acids (SFA) and total monounsaturated fatty acids (MUFA) were higher (p<0.05 for both) in women with PE. Cord erythrocyte PUFA levels were higher (p<0.01) in PE women. Maternal 25(OH)D levels were negatively associated with maternal systolic and diastolic BP (p<0.01 for both). Maternal 25(OH)D levels were positively associated with maternal total PUFA (p<0.01) and negatively associated with maternal total SFA (p<0.05), total MUFA (p<0.01). This study for the first time demonstrates an association of maternal vitamin D with fatty acid levels in pregnancy. Our results suggest that vitamin D and fatty acids may work in concert to regulate fetal growth.

State or market? How to effectively decrease alcohol-related crash fatalities and injuries

Background

It is estimated that more than 270 000 people die yearly in alcohol-related crashes globally. To tackle this burden, government interventions, such as laws which restrict blood alcohol concentration (BAC) levels and increase penalties for drunk drivers, have been implemented. The introduction of private-sector measures, such as ridesharing, is regarded as alternatives to reduce drunk driving and related sequelae. However, it is unclear whether state and private efforts complement each other to reduce this public health challenge.

Methods

We conducted interrupted time-series analyses using weekly alcohol-related traffic fatalities and injuries per 1 000 000 population in three urban conglomerates (Santiago, Valparaíso and Concepción) in Chile for the period 2010–2017. We selected cities in which two state interventions—the ‘zero tolerance law’ (ZTL), which decreased BAC, and the ‘Emilia law’ (EL), which increased penalties for drunk drivers—were implemented to decrease alcohol-related crashes, and where Uber ridesharing was launched.

Results

In Santiago, the ZTL was associated with a 29.1% decrease (95% CI 1.2 to 70.2), the EL with a 41.0% decrease (95% CI 5.5 to 93.2) and Uber with a non-significant 28.0% decrease (95% CI −6.4 to 78.5) in the level of weekly alcohol-related traffic fatalities and injuries per 1 000 000 population series. In Concepción, the EL was associated with a 28.9% reduction (95% CI 4.3 to 62.7) in the level of the same outcome. In Valparaíso, the ZTL had a −0.01 decrease (95% CI −0.02 to −0.00) in the trend of weekly alcohol-related crashes per 1 000 000 population series.

Conclusion

In Chile, concomitant decreases of alcohol-related crashes were observed after two state interventions were implemented but not with the introduction of Uber. Relationships between public policy interventions, ridesharing and motor vehicle alcohol-related crashes differ between cities and over time, which might reflect differences in specific local characteristics.

Measurement of f_{s}/f_{u} Variation with Proton-Proton Collision Energy and B-Meson Kinematics

The ratio of the B_{s}^{0} and B^{+} fragmentation fractions f_{s} and f_{u} is studied with B_{s}^{0}→J/ψϕ and B^{+}→J/ψK^{+} decays using data collected by the LHCb experiment in proton-proton collisions at 7, 8, and 13 TeV center-of-mass energies. The analysis is performed in bins of B-meson momentum, longitudinal momentum, transverse momentum, pseudorapidity, and rapidity. The fragmentation-fraction ratio f_{s}/f_{u} is observed to depend on the B-meson transverse momentum with a significance of 6.0σ. This dependency is driven by the 13 TeV sample (8.7σ), while the results for the other collision energies are not significant when considered separately. Furthermore, the results show a 4.8σ evidence for an increase of f_{s}/f_{u} as a function of collision energy.

Isospin Amplitudes in Λ_{b}^{0}→J/ψΛ(Σ^{0}) and Ξ_{b}^{0}→J/ψΞ^{0}(Λ) Decays

Ratios of isospin amplitudes in hadron decays are a useful probe of the interplay between weak and strong interactions and allow searches for physics beyond the standard model. We present the first results on isospin amplitudes in b-baryon decays, using data corresponding to an integrated luminosity of 8.5  fb^{-1}, collected with the LHCb detector in pp collisions at center of mass energies of 7, 8, and 13 TeV. The isospin amplitude ratio |A_{1}(Λ_{b}^{0}→J/ψΣ^{0})/A_{0}(Λ_{b}^{0}→J/ψΛ)|, where the subscript on A indicates the final-state isospin, is measured to be less than 1/21.8 at 95% confidence level. The Cabibbo suppressed Ξ_{b}^{0}→J/ψΛ decay is observed for the first time, allowing for the measurement |A_{0}(Ξ_{b}^{0}→J/ψΛ)/A_{1/2}(Ξ_{b}^{0}→J/ψΞ^{0})|=0.37±0.06±0.02, where the uncertainties are statistical and systematic, respectively.