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Jones CEL, Shabuz ZR, Bachmann M, Burke A, Brainard J, Cullum R, Saunders M, Dalton AM, Enwo OO, Steel N. Association between emergency department attendances, sociodemographic factors and long-term health conditions in the population of Norfolk and Waveney, England: Cross sectional study. PLoS One 2024; 19:e0303270. [PMID: 38718063 PMCID: PMC11078347 DOI: 10.1371/journal.pone.0303270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Demand for urgent and emergency health care in England has grown over the last decade, for reasons that are not clear. Changes in population demographics may be a cause. This study investigated associations between individuals' characteristics (including socioeconomic deprivation and long term health conditions (LTC)) and the frequency of emergency department (ED) attendances, in the Norfolk and Waveney subregion of the East of England. METHODS The study population was people who were registered with 91 of 106 Norfolk and Waveney general practices during one year from 1 April 2022 to 31 March 2023. Linked primary and secondary care and geographical data included each individual's sociodemographic characteristics, and number of ED attendances during the same year and, for some individuals, LTCs and number of general practice (GP) appointments. Associations between these factors and ED attendances were estimated using Poisson regression models. RESULTS 1,027,422 individuals were included of whom 57.4% had GP data on the presence or absence of LTC, and 43.1% had both LTC and general practitioner appointment data. In the total population ED attendances were more frequent in individuals aged under five years, (adjusted Incidence Rate Ratio (IRR) 1.25, 95% confidence interval 1.23 to 1.28) compared to 15-35 years); living in more socioeconomically deprived areas (IRR 0.61 (0.60 to 0.63)) for least deprived compared to most deprived,and living closer to the nearest ED. Among individuals with LTC data, each additional LTC was also associated with increased ED attendances (IRR 1.16 (1.15 to 1.16)). Among individuals with LTC and GP appointment data, each additional GP appointment was also associated with increased ED attendances (IRR 1.03 (1.026 to 1.027)). CONCLUSIONS In the Norfolk and Waveney population, ED attendance rates were higher for young children and individuals living in more deprived areas and closer to EDs. In individuals with LTC and GP appointment data, both factors were also associated with higher ED attendance.
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Affiliation(s)
| | | | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Amanda Burke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Julii Brainard
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Rachel Cullum
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Mike Saunders
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Alice M. Dalton
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Oby O. Enwo
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Nick Steel
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Petersen I, Kemp CG, Rao D, Wagenaar BH, Bachmann M, Sherr K, Kathree T, Luvuno Z, Van Rensburg A, Gigaba SG, Mthethwa L, Grant M, Selohilwe O, Hongo N, Faris G, Ras CJ, Fairall L, Bucibo S, Bhana A. Strengthening integrated depression services within routine primary health care using the RE-AIM framework in South Africa. PLOS Glob Public Health 2023; 3:e0002604. [PMID: 37956110 PMCID: PMC10642780 DOI: 10.1371/journal.pgph.0002604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/21/2023] [Indexed: 11/15/2023]
Abstract
Integration of mental health into routine primary health care (PHC) services in low-and middle-income countries is globally accepted to improve health outcomes of other conditions and narrow the mental health treatment gap. Yet implementation remains a challenge. The aim of this study was to identify implementation strategies that improve implementation outcomes of an evidence-based depression care collaborative implementation model integrated with routine PHC clinic services in South Africa. An iterative, quasi-experimental, observational implementation research design, incorporating the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, was applied to evaluate implementation outcomes of a strengthened package of implementation strategies (stage two) compared with an initial evaluation of the model (stage one). The first stage package was implemented and evaluated in 10 PHC clinics and the second stage strengthened package in 19 PHC clinics (inclusive of the initial 10 clinics) in one resource-scarce district in the province of KwaZulu-Natal, South Africa. Diagnosed service users were more likely to be referred for counselling treatment in the second stage compared with stage one (OR 23.15, SE = 18.03, z = 4.04, 95%CI [5.03-106.49], p < .001). Training in and use of a validated, mandated mental health screening tool, including on-site educational outreach and technical support visits, was an important promoter of nurse-level diagnosis rates (OR 3.75, 95% CI [1.19, 11.80], p = 0.02). Nurses who perceived the integrated care model as acceptable were also more likely to successfully diagnose patients (OR 2.57, 95% CI [1.03-6.40], p = 0.043). Consistent availability of a clinic counsellor was associated with a greater probability of referral (OR 5.9, 95%CI [1.29-27.75], p = 0.022). Treatment uptake among referred service users remained a concern across both stages, with inconsistent co-located counselling services associated with poor uptake. The importance of implementation research for strengthening implementation strategies along the cascade of care for integrating depression care within routine PHC services is highlighted.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Institute for Global Health, University College London, London, United Kingdom
| | - Christopher G. Kemp
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Bradley H. Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Zamasomi Luvuno
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - André Van Rensburg
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - Londiwe Mthethwa
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Merridy Grant
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Curtin University, Perth, Australia
| | - One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Nikiwe Hongo
- Mental Health Directorate, KwaZulu-Natal Department of Health, Pietermaritzburg, South Africa
| | - Gillian Faris
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Christy-Joy Ras
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Sanah Bucibo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- SA Medical Research Council, Health Systems Research Unit, Durban, South Africa
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Shayo EH, Murdoch J, Kiwale Z, Bachmann M, Bakari M, Mbata D, Masauni S, Kivuyo S, Mfinanga S, Jaffar S, Van Hout MC. Management of chronic conditions in resource limited settings: multi stakeholders' perception and experiences with receiving and providing integrated HIV, diabetes and hypertension services in Tanzania. BMC Health Serv Res 2023; 23:1120. [PMID: 37858150 PMCID: PMC10585858 DOI: 10.1186/s12913-023-10123-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND The rising prevalence of non-communicable diseases (NCDs) alongside the continuing high burden of HIV poses a serious challenge to middle- and low-income countries' healthcare systems. Pilot studies of integrated models of service delivery for HIV, hypertension and diabetes have demonstrated that they are feasible and acceptable among patients and care providers. This study assessed multi-stakeholders' perspectives of the delivery and receipt of integrated care in Tanzania. METHODS A qualitative process evaluation was conducted in Dar es Salaam region of Tanzania where the integrated service delivery model was implemented from July to November 2021. In-depth interviews were held with seven key informants at the national, regional and district levels, eight healthcare providers, two researchers working at the integrated clinic and forty patients benefiting from integrated services at a large hospital. Three focus group discussions were held with community leaders and residents of the hospital's catchment area, and clinic level observations were conducted. Thematic analysis was conducted followed by the use of Bronfenbrenner's ecological model to identify factors pertinent to sustaining and scaling up of the integrated model. RESULTS Participants of the study at all levels were aware of the increased prevalence of NCDs specifically for hypertension and diabetes and were concerned about the trend of increasing co-morbid conditions among people living with HIV (PLHIV). The integrated service delivery model was positively perceived by stakeholders because of its multiple benefits for both patients and the healthcare system. These include stigma and discrimination reduction, improved quality of care, efficient use of limited resources, cost and time saving, reduced duplication of services and fostering of early detection for undiagnosed conditions. The organisation of the clinic was critical in increased satisfaction. Several challenges were observed, which included costs for NCD services relative to free care for HIV and inconsistent availability of NCD medications. CONCLUSION Stakeholders reported numerous benefits of the integrated service delivery model that are fundamental in improving the health of many Tanzanians living with NCDs and HIV. These benefits highlight the need for policy and decision-makers to sustain and expand the integrated service delivery model as a solution to many challenges facing the health system especially at the primary care level.
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Affiliation(s)
| | | | - Zenais Kiwale
- National Institute for Medical Research, Dar-Es-Salaam, Tanzania
| | | | - Mtumwa Bakari
- National Institute for Medical Research, Dar-Es-Salaam, Tanzania
| | - Doris Mbata
- National Institute for Medical Research, Dar-Es-Salaam, Tanzania
| | - Salma Masauni
- National Institute for Medical Research, Dar-Es-Salaam, Tanzania
| | - Sokoine Kivuyo
- National Institute for Medical Research, Dar-Es-Salaam, Tanzania
| | - Sayoki Mfinanga
- National Institute for Medical Research, Dar-Es-Salaam, Tanzania
- Kings College London, London, England, UK
- Department of Statistics and Epidemiology, Muhimbili University of Health and Allied Sciences, Dar-Es-Salaam, Tanzania
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Kivuyo S, Birungi J, Okebe J, Wang D, Ramaiya K, Ainan S, Tumuhairwe F, Ouma S, Namakoola I, Garrib A, van Widenfelt E, Mutungi G, Jaoude GA, Batura N, Musinguzi J, Ssali MN, Etukoit BM, Mugisha K, Shimwela M, Ubuguyu OS, Makubi A, Jeffery C, Watiti S, Skordis J, Cuevas L, Sewankambo NK, Gill G, Katahoire A, Smith PG, Bachmann M, Lazarus JV, Mfinanga S, Nyirenda MJ, Jaffar S. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial. Lancet 2023; 402:1241-1250. [PMID: 37805215 DOI: 10.1016/s0140-6736(23)01573-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania. METHODS In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688. FINDINGS Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted). INTERPRETATION In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. FUNDING European Union Horizon 2020 and Global Alliance for Chronic Diseases.
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Affiliation(s)
- Sokoine Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda; Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kaushik Ramaiya
- Tanzania NCDs Alliance, Dar es Salaam, Tanzania; Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Samafilan Ainan
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Faith Tumuhairwe
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Simple Ouma
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Anupam Garrib
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | | | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | | | | | - Kenneth Mugisha
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | | | | | | | - Caroline Jeffery
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Stephen Watiti
- The National Forum of People Living with HIV Networks in Uganda, Kampala, Uganda
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Luis Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Geoff Gill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Sayoki Mfinanga
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Institute for Global Health, University College London, London, UK
| | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Kathree T, Bachmann M, Bhana A, Grant M, Mntambo N, Gigaba S, Kemp CG, Rao D, Petersen I. Management of Depression in Chronic Care Patients Using a Task-Sharing Approach in a Real-World Primary Health Care Setting in South Africa: Outcomes of a Cohort Study. Community Ment Health J 2023; 59:1261-1274. [PMID: 36964282 PMCID: PMC10447595 DOI: 10.1007/s10597-023-01108-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/27/2023] [Indexed: 03/26/2023]
Abstract
Depressive symptoms are common in South African primary care patients with chronic medical conditions, but are usually unrecognised and untreated. This study evaluated an integrated, task-sharing collaborative approach to management of depression comorbid with chronic diseases in primary health care (PHC) patients in a real-world setting. Existing HIV clinic counsellors provided a manualised depression counselling intervention with stepped-up referral pathways to PHC doctors for initiation of anti-depressant medication and/ or referral to specialist mental health services. Using a comparative group cohort design, adult PHC patients in 10 PHC facilities were screened with the Patient Health Questionnaire-9 with those scoring above the validated cut-off enrolled. PHC nurses independently assessed, diagnosed and referred patients. Referral for treatment was independently associated with substantial improvements in depression symptoms three months later. The study confirms the viability of task-shared stepped-up collaborative care for depression treatment using co-located counselling in underserved real-world PHC settings.
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Affiliation(s)
- Tasneem Kathree
- School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Arvin Bhana
- School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- Health Systems Research Unit, South African Medical Research Council, 491 Peter Mokaba Ridge Road, Overport, Durban, South Africa
| | - Merridy Grant
- School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Ntokozo Mntambo
- School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - Sithabisile Gigaba
- School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
| | - C. G. Kemp
- Department of international health, Johns Hopkins University, Baltimore, MD USA
| | - Deepa Rao
- Department of Global Health, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, United States of America
| | - Inge Petersen
- School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
- School of Applied Human Sciences, University of KwaZulu-Natal, Howard College, Mazisi Kunene Road, Durban, 4001 South Africa
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Peschke JC, Bergmann R, Mehnert M, Gonzalez Soto KE, Loureiro LR, Mitwasi N, Kegler A, Altmann H, Wobus M, Máthé D, Szigeti K, Feldmann A, Bornhäuser M, Bachmann M, Fasslrinner F, Arndt C. FLT3-directed UniCAR T-cell therapy of acute myeloid leukaemia. Br J Haematol 2023; 202:1137-1150. [PMID: 37460273 DOI: 10.1111/bjh.18971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 09/12/2023]
Abstract
Adaptor chimeric antigen receptor (CAR) T-cell therapy offers solutions for improved safety and antigen escape, which represent main obstacles for the clinical translation of CAR T-cell therapy in myeloid malignancies. The adaptor CAR T-cell platform 'UniCAR' is currently under early clinical investigation. Recently, the first proof of concept of a well-tolerated, rapidly switchable, CD123-directed UniCAR T-cell product treating patients with acute myeloid leukaemia (AML) was reported. Relapsed and refractory AML is prone to high plasticity under therapy pressure targeting one single tumour antigen. Thus, targeting of multiple tumour antigens seems to be required to achieve durable anti-tumour responses, underlining the need to further design alternative AML-specific target modules (TM) for the UniCAR platform. We here present the preclinical development of a novel FMS-like tyrosine kinase 3 (FLT3)-directed UniCAR T-cell therapy, which is highly effective for in vitro killing of both AML cell lines and primary AML samples. Furthermore, we show in vivo functionality in a murine xenograft model. PET analyses further demonstrate a short serum half-life of FLT3 TMs, which will enable a rapid on/off switch of UniCAR T cells. Overall, the presented preclinical data encourage the further development and clinical translation of FLT3-specific UniCAR T cells for the therapy of AML.
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Affiliation(s)
- J C Peschke
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Mildred Scheel Early Career Center, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- National Center for Tumor Diseases Dresden (NCT/UCC): German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Partner Site, Dresden, Germany
| | - R Bergmann
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - M Mehnert
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Mildred Scheel Early Career Center, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - K E Gonzalez Soto
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - L R Loureiro
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - N Mitwasi
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - A Kegler
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - H Altmann
- National Center for Tumor Diseases Dresden (NCT/UCC): German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Partner Site, Dresden, Germany
- Medical Clinic and Polyclinic I, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - M Wobus
- Medical Clinic and Polyclinic I, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - D Máthé
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
- Hungarian Centre of Excellence for Molecular Medicine, In Vivo Imaging Advanced Core Facility, Szeged, Hungary
| | - K Szigeti
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - A Feldmann
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- National Center for Tumor Diseases Dresden (NCT/UCC): German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Partner Site, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - M Bornhäuser
- National Center for Tumor Diseases Dresden (NCT/UCC): German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Partner Site, Dresden, Germany
- Medical Clinic and Polyclinic I, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- School of Cancer and Pharmaceutical Science, King's College, London, UK
| | - M Bachmann
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- National Center for Tumor Diseases Dresden (NCT/UCC): German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Partner Site, Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - F Fasslrinner
- Mildred Scheel Early Career Center, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- Medical Clinic and Polyclinic I, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - C Arndt
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Mildred Scheel Early Career Center, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
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7
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Song F, Bachmann M, Howe A. Factors associated with the consultation of GPs among adults aged ≥16 years: an analysis of data from the Health Survey for England 2019. BJGP Open 2023; 7:BJGPO.2022.0177. [PMID: 37217212 PMCID: PMC10646211 DOI: 10.3399/bjgpo.2022.0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/06/2023] [Accepted: 03/14/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Understanding the factors associated with demands for general practice care is crucial for policy decision makers to appropriately allocate healthcare resources. AIM To investigate factors associated with the frequency of GP consultations. DESIGN & SETTING Data on 8086 adults aged ≥16 years was obtained from cross-sectional Health Survey for England (HSE) 2019. METHOD The primary outcome was the frequency of consultations of a GP in the last 12 months. Multivariable ordered logistic regression analysis was used to evaluate associations between GP consultations and a range of sociodemographic and health-related factors. RESULTS Frequency of GP consultations for all reasons was higher among females (odds ratio [OR] 1.81, 95% confidence interval [CI] = 1.64 to 2.01), those aged ≥75 years (OR 1.48, 95% CI = 1.15 to 1.92), ethnic minority populations (Black: OR 1.42, 95% CI = 1.09 to 1.84; Asian: OR 1.53, 95% CI = 1.25 to 1.87), lowest household income (OR 1.53, 95% CI = 1.29 to 1.83), adults with long-lasting illnesses (OR 3.78, 95% CI = 3.38 to 4.22), former smokers (OR 1.17, 95% CI = 1.04 to 1.22), being overweight (OR 1.14, 95% CI = 1.01 to 1.29), and being obese (OR 1.32, 95% CI = 1.16 to 1.50). Predictors of consultations for physical health problems were similar to predictors of consultations for any health problems. However, younger age was associated with more consultations for mental health problems, or a combination of mental and physical health problems. CONCLUSION The higher frequency of consultation of GPs is associated with female sex, older age, ethnic minority populations, being socioeconomically disadvantaged, existence of lasting illnesses, smoking, being overweight, and being obese. Older age is associated with increased consultations for physical health problems, but associated with reduced consultations for mental health or a combination of mental and physical health problems.
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Affiliation(s)
- Fujian Song
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Max Bachmann
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Amanda Howe
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
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8
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Sithole N, Castle A, Nxumalo S, Mazibuko L, Manyaapelo T, Abrahams-Gessel S, Dlamini S, Gareta D, Orne-Gliemann J, Baisley K, Bachmann M, Magula N, Gaziano TA, Siedner MJ. Protocol: Implementation evaluation of a combination intervention for sustainable blood pressure control in rural KwaZulu-Natal, South Africa (IMPACT BP): A three-arm, unblinded, parallel group individually randomized clinical trial. Contemp Clin Trials 2023; 131:107258. [PMID: 37308076 PMCID: PMC10527603 DOI: 10.1016/j.cct.2023.107258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hypertension is the primary risk factor for stroke and heart disease, which are leading causes of death in South Africa. Despite the availability of treatments, there is an implementation gap in how best to deliver hypertension care in this resource-limited region. METHODS We describe a three-arm parallel group individually randomized control trial to evaluate the effectiveness and implementation of a technology-supported, community-based intervention to improve blood pressure control among people with hypertension in rural KwaZulu-Natal. The study will compare three strategies: 1) standard of care (SOC arm) clinic-based management, 2) home-based blood pressure management supported by community blood pressure monitors (CBPM arm) and a mobile health application to record blood pressure readings and enable clinic-based nurses to remotely manage care, and 3) an identical strategy to the CBPM arm, except that participants will use a cellular blood pressure cuff, which automatically transmits completed readings over cellular networks directly to clinic-based nurses (eCBPM+ arm). The primary effectiveness outcome is change in blood pressure from enrollment to 6 months. The secondary effectiveness outcome is the proportion of participants with blood pressure control at 6 months. Acceptability, fidelity, sustainability, and cost-effectiveness of the interventions will also be assessed. CONCLUSIONS In this protocol, we report the development of interventions in partnership with the South Africa Department of Health, a description of the technology-enhanced interventions, and details of the study design so that our intervention and evaluation can inform similar efforts in rural, resource-limited settings. PROTOCOL Version 3 November 9th, 2022. CLINICALTRIALS gov Trial Registration: NCT05492955 SAHPRA Trial Number: N20211201. SANCTR Number: DOH-27-112,022-4895.
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Affiliation(s)
- Nsika Sithole
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
| | - Alison Castle
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | | | | | | | | | | | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Joanna Orne-Gliemann
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Nombulelo Magula
- Division of Internal Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Thomas A Gaziano
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Division of Internal Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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9
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Van Hout MC, Zalwango F, Akugizibwe M, Chaka MN, Birungi J, Okebe J, Jaffar S, Bachmann M, Murdoch J. Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial. BMC Health Serv Res 2023; 23:570. [PMID: 37268916 DOI: 10.1186/s12913-023-09534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/10/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up 'one-stop' integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. METHODS The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner's ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). RESULTS Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. CONCLUSIONS Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. TRIAL REGISTRATION NUMBER ISRCTN43896688.
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Affiliation(s)
| | - Flavia Zalwango
- MRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTM, Entebbe, Uganda
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Curran R, Murdoch J, van Rensburg AJ, Bachmann M, Awotiwon A, Ras CJ, Petersen I, Prince M, Moultrie H, Nzuza M, Fairall L. A health systems intervention to strengthen the integration of tuberculosis and COVID-19 detection: Outcomes of a quasi-experimental study in a high burden tuberculosis district in KwaZulu Natal, South Africa. Trop Med Int Health 2023; 28:324-334. [PMID: 36751975 DOI: 10.1111/tmi.13860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVES The adverse effects of the COVID-19 pandemic on tuberculosis (TB) detection have been well documented. Despite shared symptoms, guidance for integrated screening for TBand COVID-19 are limited, and opportunities for health systems strengthening curtailed by lockdowns. We partnered with a high TB burden district in KwaZulu-Natal, South Africa, to co-develop an integrated approach to assessing COVID-19 and TB, delivered using online learning and quality improvement, and evaluated its performance on TB testing and detection. METHODS We conducted a mixed methods study incorporating a quasi-experimental design and process evaluation in 10 intervention and 18 control clinics. Nurses in all 28 clinics were all provided access to a four-session online course to integrate TB and COVID-19 screening and testing, which was augmented with some webinar and in-person support at the 10 intervention clinics. We estimated the effects of exposure to this additional support using interrupted time series Poisson regression mixed models. Process evaluation data comprised interviews before and after the intervention. Thematic coding was employed to provide explanations for effects of the intervention. RESULTS Clinic-level support at intervention clinics was associated with a markedly higher uptake (177 nurses from 10 intervention clinics vs. 19 from 18 control clinics). Lack of familiarity with online learning, and a preference for group learning hindered the transition from face-to-face to online learning. Even so, any exposure to training was initially associated with higher rates of GeneXpert testing (adjusted incidence ratio [IRR] 1.11, 95% confidence interval 1.07-1.15) and higher positive TB diagnosis (IRR 1.38, 1.11-1.71). CONCLUSIONS These results add to the knowledge base regarding the effectiveness of interventions to strengthen TB case detection during the COVID-19 pandemic. The findings support the feasibility of a shift to online learning approaches in low-resource settings with appropriate support and suggest that even low-intensity interventions are capable of activating nurses to integrate existing disease control priorities during pandemic conditions.
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Affiliation(s)
- Robyn Curran
- Knowledge Translation Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jamie Murdoch
- School of Life Course and Population Sciences, Department of Social Science and Health, King's College, London, UK
| | - André J van Rensburg
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu Natal, Durban, South Africa
| | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK
| | - Ajibola Awotiwon
- Knowledge Translation Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Christy-Joy Ras
- Knowledge Translation Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu Natal, Durban, South Africa
| | - Martin Prince
- King's Global Health Institute, Department of Population Science, King's College, London, UK
| | - Harry Moultrie
- Centre for Tuberculosis, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Sandringham, South Africa.,School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mercury Nzuza
- Department of Health, Amajuba Health District, Newcastle, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, Department of Medicine, University of Cape Town, Cape Town, South Africa.,King's Global Health Institute, Department of Population Science, King's College, London, UK
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11
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Akugizibwe M, Zalwango F, Namulundu CM, Namakoola I, Birungi J, Okebe J, Bachmann M, Jamie M, Jaffar S, Van Hout MC. "After all, we are all sick": multi-stakeholder understanding of stigma associated with integrated management of HIV, diabetes and hypertension at selected government clinics in Uganda. BMC Health Serv Res 2023; 23:20. [PMID: 36624438 PMCID: PMC9827009 DOI: 10.1186/s12913-022-08959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/12/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Integrated care is increasingly used to manage chronic conditions. In Uganda, the integration of HIV, diabetes and hypertension care has been piloted, to leverage the advantages of well facilitated and established HIV health care provision structures. This qualitative study aimed to explore HIV stigma dynamics whilst investigating multi-stakeholder perceptions and experiences of providing and receiving integrated management of HIV, diabetes and hypertension at selected government clinics in Central Uganda. METHODS: We adopted a qualitative-observational design. Participants were purposively selected. In-depth interviews were conducted with patients and with health care providers, clinical researchers, policy makers, and representatives from international nongovernmental organizations (NGOs). Focus group discussions were conducted with community members and leaders. Clinical procedures in the integrated care clinic were observed. Data were managed using Nvivo 12 and analyzed thematically. RESULTS Triangulated findings revealed diverse multi-stakeholder perceptions around HIV related stigma. Integrated care reduced the frequency with which patients with combinations of HIV, diabetes, hypertension visited health facilities, reduced the associated treatment costs, increased interpersonal relationships among patients and healthcare providers, and increased the capacity of health care providers to manage multiple chronic conditions. Integration reduced stigma through creating opportunities for health education, which allayed patient fears and increased their resolve to enroll for and adhere to treatment. Patients also had an opportunity to offer and receive psycho-social support and coupled with the support they received from healthcare worker. This strengthened patient-patient and provider-patient relationships, which are building blocks of service integration and of HIV stigma reduction. Although the model significantly reduced stigma, it did not eradicate service level challenges and societal discrimination among HIV patients. CONCLUSION The study reveals that, in a low resource setting like Uganda, integration of HIV, diabetes and hypertension care can improve patient experiences of care for multiple chronic conditions, and that integrated clinics may reduce HIV related stigma.
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Affiliation(s)
| | | | | | - Ivan Namakoola
- MRC/UVRI and LSHTM, Uganda Research Unit, Entebbe, Uganda
| | | | - Joseph Okebe
- Liverpool School of Tropical Medicine, Liverpool, UK, England
| | | | | | - Shabbar Jaffar
- Liverpool School of Tropical Medicine, Liverpool, UK, England
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12
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Seward N, Hanlon C, Abdella A, Abrahams Z, Alem A, Araya R, Bachmann M, Bekele A, Bogale B, Brima N, Chibanda D, Curran R, Davies J, Beyene A, Fairall L, Farrant L, Frissa S, Gallagher J, Gao W, Gwyther L, Harding R, Kartha MR, Leather A, Lund C, Marx M, Nkhoma K, Murdoch J, Petersen I, Petrus R, van Rensburg A, Sandall J, Sevdalis N, Sheenan A, Tadesse A, Thornicroft G, Verhey R, Willott C, Prince M. HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies. Glob Health Action 2022; 15:1987044. [PMID: 35037844 PMCID: PMC8765245 DOI: 10.1080/16549716.2021.1987044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 09/25/2021] [Indexed: 12/03/2022] Open
Abstract
To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.
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Affiliation(s)
- Nadine Seward
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Charlotte Hanlon
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmed Abdella
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zulfa Abrahams
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Atalay Alem
- Department of Psychiatry, WHO Collaborating Centre for Mental Health Research and Capacity-, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ricardo Araya
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Max Bachmann
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Alemayehu Bekele
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Birke Bogale
- Faculty of Dentistry, Oral & Craniofacial Sciences, Centre for Host Microbiome Interactions, King’s College London, London, UK
- Department of Dentistry, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nataliya Brima
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Dixon Chibanda
- University of Zimbabwe, Harare, Zimbabwe
- Psychology Department, School of Applied Human Science College of Humanities, University of KwaZulu Natal, London, UK
| | - Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Justine Davies
- Centre for Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Andualem Beyene
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute and Department of Medicine, University of Cape Town, Cape Town, South Africa
- King’s Global Health Institute, King’s College London, London, UK
| | - Lindsay Farrant
- Division of Family Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Souci Frissa
- King’s Global Health Institute, King’s College London, London, UK
| | - Jennifer Gallagher
- Faculty of Dentistry, Oral & Craniofacial Sciences, Centre for Host Microbiome Interactions, King’s College London, London, UK
| | - Wei Gao
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | - Liz Gwyther
- Division of Family Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | | | - Andrew Leather
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Crick Lund
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Maggie Marx
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Kennedy Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK
| | - Jamie Murdoch
- Department of Population Health Science, Kings College London, London, UK
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Berea, Durban, South Africa
| | - Ruwayda Petrus
- Psychology Department, School of Applied Human Science College of Humanities, University of KwaZulu Natal, Berea, Durban, South Africa
| | - André van Rensburg
- Centre for Rural Health, University of KwaZulu-Natal, Berea, Durban, South Africa
| | - Jane Sandall
- Department of Women and Children’s Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Andrew Sheenan
- Department of Women and Children’s Health, School of Life Course Science, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Amezene Tadesse
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Graham Thornicroft
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Chris Willott
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Martin Prince
- King’s Global Health Institute, King’s College London, London, UK
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Van Hout MCA, Zalwango F, Akugizibwe M, Namulundu Chaka M, Bigland C, Birungi J, Jaffar S, Bachmann M, Murdoch J. Women living with HIV, diabetes and/or hypertension multi-morbidity in Uganda: a qualitative exploration of experiences accessing an integrated care service. JICA 2022. [DOI: 10.1108/jica-06-2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
PurposeWomen experience a triple burden of ill-health spanning non-communicable diseases (NCDs), reproductive and maternal health conditions and human immunodeficiency virus (HIV) in sub-Saharan Africa. Whilst there is research on integrated service experiences of women living with HIV (WLHIV) and cancer, little is known regarding those of WLHIV, diabetes and/or hypertension when accessing integrated care. Our research responds to this gap.Design/methodology/approachThe INTE-AFRICA project conducted a pragmatic parallel arm cluster randomised trial to scale up and evaluate “one-stop” integrated care clinics for HIV-infection, diabetes and hypertension at selected primary care centres in Uganda. A qualitative process evaluation explored and documented patient experiences of integrated care for HIV, diabetes and/or hypertension. In-depth interviews were conducted using a phenomenological approach with six WLHIV with diabetes and/or hypertension accessing a “one stop” clinic. Thematic analysis of narratives revealed five themes: lay health knowledge and alternative medicine, community stigma, experiences of integrated care, navigating personal challenges and health service constraints.FindingsWLHIV described patient pathways navigating HIV and diabetes/hypertension, with caregiving responsibilities, poverty, travel time and cost and personal ill health impacting on their ability to adhere to multi-morbid integrated treatment. Health service barriers to optimal integrated care included unreliable drug supply for diabetes/hypertension and HIV linked stigma. Comprehensive integrated care is recommended to further consider gender sensitive aspects of care.Originality/valueThis study whilst small scale, provides a unique insight into the lived experience of WLHIV navigating care for HIV and diabetes and/or hypertension, and how a “one stop” integrated care clinic can support them (and their children) in their treatment journeys.
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Mitwasi N, Hassan H, Arndt C, Loureiro L, Neuber C, Kegler A, Kubeil M, Toussaint M, Deuther-Conrad W, Bachmann M, Feldmann A. 45P The RevCAR T cell platform: A switchable and combinatorial therapeutic strategy for glioblastoma. Immuno-Oncology and Technology 2022. [DOI: 10.1016/j.iotech.2022.100150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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15
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Sellami S, Bachmann M, Brembilla N, Drukala J, Wehrle-Haller B, Boehncke W, Shutova M. 362 The role for epidermal αV integrin complexes in the pathogenesis of psoriatic inflammation. J Invest Dermatol 2022. [DOI: 10.1016/j.jid.2022.09.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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16
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Moncrieff J, Jakobsen JC, Bachmann M. Later is not necessarily better: limitations of survival analysis in studies of long-term drug treatment of psychiatric conditions. BMJ Evid Based Med 2022; 27:246-250. [PMID: 34556539 PMCID: PMC9340015 DOI: 10.1136/bmjebm-2021-111743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 12/04/2022]
Abstract
Survival analysis is routinely used to assess differences between groups in relapse prevention and treatment discontinuation studies involving people with long-term psychiatric conditions. The actual outcome in survival analysis is 'time to event', yet, in the mental health field, there has been little consideration of whether a temporary delay to relapse is clinically relevant in a condition that can last for decades. Moreover, in psychiatric drug trials, a pattern of elevated early relapses following randomisation to placebo or no treatment is common. This may be the result of the withdrawal of previous treatment leading to physiological withdrawal effects, which may be mistaken for relapse, or genuine relapse precipitated by the process of withdrawal. Such withdrawal effects typically produce converging survival curves eventually. They inevitably lead to differences in time to relapse, even when there is little or no difference in the cumulative risk of relapse at final follow-up. Therefore, statistical tests based on survival analyses can be misleading because they obscure these withdrawal effects. We illustrate these difficulties in a trial of antipsychotic reduction versus maintenance, and a trial of prophylactic esketamine in people with treatment-resistant depression. Both illustrate withdrawal-related effects that underline the importance of long-term follow-up and question the use of tests based on time to event. Further discussion of the most relevant outcome and appropriate approach to analysis, and research on patient and carer preferences is important to inform the design of future trials and interpretation of existing ones.
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Affiliation(s)
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Parretti HM, Belderson P, Eborall H, Naughton F, Loke Y, Steel N, Bachmann M, Hardeman W. "I have travelled along on my own"-Experiences of seeking help for serious non-COVID health problems during the COVID-19 pandemic: A qualitative study. Br J Health Psychol 2022; 28:116-135. [PMID: 35880686 PMCID: PMC9349934 DOI: 10.1111/bjhp.12615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/17/2022] [Accepted: 07/03/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVES During COVID-19 the UK general population has been given strong messages to stay at home. Concurrently unprecedented changes occurred in healthcare access with moves to remote/triage systems. Data have shown that the number of people accessing healthcare services decreased and there are significant concerns that the pandemic has negatively affected help-seeking for serious conditions, with potentially increased morbidity and mortality. An understanding of help-seeking is urgently needed to inform public campaigns. We aimed to develop an in-depth, theory-based understanding of how, when and why people sought help for potentially serious symptoms (e.g., related to major cardiovascular events or cancer diagnoses) during the pandemic, and what influenced their decisions. DESIGN Qualitative semi-structured interviews. METHODS We interviewed 25 adults recruited through a targeted social media campaign. Interviews were conducted via telephone or online platform. Our topic guide was informed by the Model of Pathways to Treatment and the Capability-Opportunity-Motivation-Behaviour model. RESULTS The analysis identified four main themes: Delay in recognition, Holding on to concerns, Weighing it up and Long-term impacts. Multiple societal and environmental factors influenced participants' help-seeking and motivation, capability and opportunity to seek help, with long-term impacts on well-being and future help-seeking. CONCLUSIONS There is a need for clear guidance about pathways to raise concerns about symptoms and gain advice while usual healthcare contacts are paused or stopped. Recommendations for future interventions to support help-seeking during pandemics include clearer messaging, co-produced with end-users, on when, where and how to seek help.
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Affiliation(s)
| | - Pippa Belderson
- Norwich Medical SchoolUniversity of East AngliaNorwichUK,School of Health SciencesUniversity of East AngliaNorwichUK
| | | | - Felix Naughton
- School of Health SciencesUniversity of East AngliaNorwichUK
| | - Yoon Loke
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Nick Steel
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Max Bachmann
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Wendy Hardeman
- School of Health SciencesUniversity of East AngliaNorwichUK
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Morillo D, Mena-Bucheli S, Ochoa A, Chico ME, Rodas C, Maldonado A, Arteaga K, Alchundia J, Solorzano K, Rodriguez A, Figueiredo C, Ardura-Garcia C, Bachmann M, Perkin MR, Chis Ster I, Cruz A, Romero NC, Cooper P. Prospective study of factors associated with asthma attack recurrence (ATTACK) in children from three Ecuadorian cities during COVID-19: a study protocol. BMJ Open 2022; 12:e056295. [PMID: 35710244 PMCID: PMC9207574 DOI: 10.1136/bmjopen-2021-056295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Asthma is a growing health problem in children in marginalised urban settings in low-income and middle-income countries. Asthma attacks are an important cause of emergency care attendance and long-term morbidity. We designed a prospective study, the Asthma Attacks study, to identify factors associated with recurrence of asthma attacks (or exacerbations) among children and adolescents attending emergency care in three Ecuadorian cities. METHODS AND ANALYSIS Prospective cohort study designed to identify risk factors associated with recurrence of asthma attacks in 450 children and adolescents aged 5-17 years attending emergency care in public hospitals in three Ecuadorian cities (Quito, Cuenca and Portoviejo). The primary outcome will be rate of asthma attack recurrence during up to 12 months of follow-up. Data are being collected at baseline and during follow-up by questionnaire: sociodemographic data, asthma history and management (baseline only); recurrence of asthma symptoms and attacks (monthly); economic costs of asthma to family; Asthma Control Test; Pediatric Asthma Quality of life Questionnaire; and Newcastle Asthma Knowledge Questionnaire (baseline only). In addition, the following are being measured at baseline and during follow-up: lung function and reversibility by spirometry before and after salbutamol; fractional exhaled nitric oxide (FeNO); and presence of IgG antibodies to SARS-CoV-2 in blood. Recruitment started in 2019 but because of severe disruption to emergency services caused by the COVID-19 pandemic, eligibility criteria were modified to include asthmatic children with uncontrolled symptoms and registered with collaborating hospitals. Data will be analysed using logistic regression and survival analyses. ETHICS AND DISSEMINATION Ethical approval was obtained from the Hospital General Docente de Calderon (CEISH-HGDC 2019-001) and Ecuadorian Ministry of Public Health (MSP-CGDES-2021-0041-O N° 096-2021). The study results will be disseminated through presentations at conferences and to key stakeholder groups including policy-makers, postgraduate theses, peer-review publications and a study website. Participants gave informed consent to participate in the study before taking part.
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Affiliation(s)
- Diana Morillo
- Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
| | | | - Angélica Ochoa
- Department of Biosciences, Universidad de Cuenca, Cuenca, Ecuador
| | - Martha E Chico
- Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
| | - Claudia Rodas
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador
| | - Augusto Maldonado
- School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
- Emergency Department, Hospital General Docente Calderón, Quito, Ecuador
| | - Karen Arteaga
- Emergency Department, Hospital Verdi Cevallos Balda, Portoviejo, Ecuador
| | - Jessica Alchundia
- Pediatric Pneumology, Hospital de Especialidades Portoviejo, Portoviejo, Ecuador
| | - Karla Solorzano
- Pediatric Pneumology, Hospital de Especialidades Portoviejo, Portoviejo, Ecuador
| | | | - Camila Figueiredo
- Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | | | - Max Bachmann
- Norwich Medical School, University of East Anglia, University of East Anglia, Norwich, UK
| | | | - Irina Chis Ster
- Institute of Infection and Immunity, St. George's University of London, London, UK
- Institute of Infection and Immunity, St. George's University of London, London, UK
| | - Alvaro Cruz
- Núcleo de Excelência em Asma, Universidade Federal da Bahia, Salvador, Brazil
| | - Natalia Cristina Romero
- School of Medicine, Universidad Internacional del Ecuador, Quito, Ecuador
- GRAAL, Grups de Recerca d'America i Africa Llatines, Cerdanyola del Valles, Barcelona, Spain
| | - Philip Cooper
- Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
- Institute of Infection and Immunity, St. George's University of London, London, UK
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Bachmann M, Okon P, Blunk C, Kuhnitzsch C, Martens S, Steinhöfel O, Zeyner A. Ensiling and thermic treatment effects on nutrient content, protein solubility, and in vitro fermentation of partial crop faba beans. Anim Feed Sci Technol 2022. [DOI: 10.1016/j.anifeedsci.2022.115349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Louwagie G, Kanaan M, Morojele NK, Van Zyl A, Moriarty AS, Li J, Siddiqi K, Turner A, Mdege ND, Omole OB, Tumbo J, Bachmann M, Parrott S, Ayo-Yusuf OA. Effect of a brief motivational interview and text message intervention targeting tobacco smoking, alcohol use and medication adherence to improve tuberculosis treatment outcomes in adult patients with tuberculosis: a multicentre, randomised controlled trial of the ProLife programme in South Africa. BMJ Open 2022; 12:e056496. [PMID: 35165113 PMCID: PMC8845202 DOI: 10.1136/bmjopen-2021-056496] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate the effectiveness of a complex behavioural intervention, ProLife, on tuberculosis (TB) treatment success, medication adherence, alcohol use and tobacco smoking. DESIGN Multicentre, individual, randomised controlled trial where participants were assigned (1:1) to the ProLife intervention or usual care. SETTING 27 primary care clinics in South Africa. PARTICIPANTS 574 adults starting treatment for drug-sensitive pulmonary TB who smoked tobacco or reported harmful/hazardous alcohol use. INTERVENTIONS The intervention, delivered by lay health workers (LHWs), consisted of three brief motivational interviewing (MI) sessions, augmented with short message service (SMS) messages, targeting medication adherence, alcohol use and tobacco smoking. OUTCOME MEASURES The primary outcome was successful versus unsuccessful TB treatment at 6-9 months, from TB records. Secondary outcomes were biochemically confirmed sustained smoking cessation, reduction in the Alcohol Use Disorder Identification Test (AUDIT) score, improved TB and antiretroviral therapy (ART) adherence and ART initiation, each measured at 3 and 6 months by questionnaires; and cure rates in patients who had bacteriology-confirmed TB at baseline, from TB records. RESULTS Between 15 November 2018 and 31 August 2019, 574 participants were randomised to receive either the intervention (n=283) or usual care (n=291). TB treatment success rates did not differ significantly between intervention (67.8%) and control (70.1%; OR 0.9, 95% CI 0.64% to 1.27%). There was no evidence of an effect at 3 and 6 months, respectively, on continuous smoking abstinence (OR 0.65, 95% CI 0.37 to 1.14; OR 0.76, 95% CI 0.35 to 1.63), TB medication adherence (OR 1.22, 95% CI 0.52 to 2.87; OR 0.89, 95% CI 0.26 to 3.07), taking ART (OR 0.79, 95% CI 0.38 to 1.65; OR 2.05, 95% CI 0.80 to 5.27) or AUDIT scores (mean score difference 0.55, 95% CI -1.01 to 2.11; -0.04, 95% CI -2.0 to 1.91) and adjusting for baseline values. Cure rates were not significantly higher (OR 1.16, 95% CI 0.83 to 1.63). CONCLUSIONS Simultaneous targeting of multiple health risk behaviours with MI and SMS using LHWs may not be an effective approach to improve TB outcomes. TRIAL REGISTRATION NUMBER ISRCTN62728852.
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Affiliation(s)
- Goedele Louwagie
- Research, Postgraduate Studies and Innovation, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Mona Kanaan
- Department of Health Sciences, University of York, York, UK
| | - Neo Keitumetse Morojele
- Department of Psychology, University of Johannesburg, Auckland Park, South Africa
- Alcohol, Tobacco and Other Drug Research Unit, Medical Research Council of South Africa, Pretoria, South Africa
| | - Andre Van Zyl
- Research, Postgraduate Studies and Innovation, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Andrew Stephen Moriarty
- Department of Health Sciences and the Hull York Medical School, University of York, York, UK
| | - Jinshuo Li
- Department of Health Sciences, University of York, York, UK
| | - Kamran Siddiqi
- Department of Health Sciences and the Hull York Medical School, University of York, York, UK
| | - Astrid Turner
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | | | - Olufemi Babatunde Omole
- Department of Family Medicine, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - John Tumbo
- Department of Family Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Olalekan A Ayo-Yusuf
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
- Africa Centre for Tobacco Industry Monitoring and Policy Research, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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McCombe G, Murtagh S, Lazarus JV, Van Hout MC, Bachmann M, Jaffar S, Garrib A, Ramaiya K, Sewankambo NK, Mfinanga S, Cullen W. Integrating diabetes, hypertension and HIV care in sub-Saharan Africa: a Delphi consensus study on international best practice. BMC Health Serv Res 2021; 21:1235. [PMID: 34781929 PMCID: PMC8591882 DOI: 10.1186/s12913-021-07073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background Although HIV continues to have a high prevalence among adults in sub-Saharan Africa (SSA), the burden of noncommunicable diseases (NCD) such as diabetes and hypertension is increasing rapidly. There is an urgent need to expand the capacity of healthcare systems in SSA to provide NCD services and scale up existing chronic care management pathways. The aim of this study was to identify key components, outcomes, and best practice in integrated service provision for the prevention, identification and treatment of HIV, hypertension and diabetes. Methods An international, multi stakeholder e-Delphi consensus study was conducted over two successive rounds. In Round 1, 24 participants were asked to score 27 statements, under the headings ‘Service Provision’ and ‘Benefits of Integration’, by importance. In Round 2, the 16 participants who completed Round 1 were shown the distribution of scores from other participants along with the score that they attributed to an outcome and were asked to reflect on the score they gave, based on the scores of the other participants and then to rescore if they wished to. Nine participants completed Round 2. Results Based on the Round 1 ranking, 19 of the 27 outcomes met the 70% threshold for consensus. Four additional outcomes suggested by participants in Round 1 were added to Round 2, and upon review by participants, 22 of the 31 outcomes met the consensus threshold. The five items participants scored from 7 to 9 in both rounds as essential for effective integrated healthcare delivery of health services for chronic conditions were improved data collection and surveillance of NCDs among people living with HIV to inform integrated NCD/HIV programme management, strengthened drug procurement systems, availability of equipment and access to relevant blood tests, health education for all chronic conditions, and enhanced continuity of care for patients with multimorbidity. Conclusions This study highlights the outcomes which may form key components of future complex interventions to define a model of integrated healthcare delivery for diabetes, hypertension and HIV in sub-Saharan Africa.
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Affiliation(s)
| | | | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | | | | | - Anupam Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Sayoki Mfinanga
- National Institute for Medical Research, Dar es Salaam, Tanzania
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Mfinanga SG, Nyirenda MJ, Mutungi G, Mghamba J, Maongezi S, Musinguzi J, Okebe J, Kivuyo S, Birungi J, van Widenfelt E, Van Hout MC, Bachmann M, Garrib A, Bukenya D, Cullen W, Lazarus JV, Niessen LW, Katahoire A, Shayo EH, Namakoola I, Ramaiya K, Wang D, Cuevas LE, Etukoit BM, Lutale J, Meshack S, Mugisha K, Gill G, Sewankambo N, Smith PG, Jaffar S. Integrating HIV, diabetes and hypertension services in Africa: study protocol for a cluster randomised trial in Tanzania and Uganda. BMJ Open 2021; 11:e047979. [PMID: 34645657 PMCID: PMC8515479 DOI: 10.1136/bmjopen-2020-047979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION HIV programmes in sub-Saharan Africa are well funded but programmes for diabetes and hypertension are weak with only a small proportion of patients in regular care. Healthcare provision is organised from stand-alone clinics. In this cluster randomised trial, we are evaluating a concept of integrated care for people with HIV infection, diabetes or hypertension from a single point of care. METHODS AND ANALYSIS 32 primary care health facilities in Dar es Salaam and Kampala regions were randomised to either integrated or standard vertical care. In the integrated care arm, services are organised from a single clinic where patients with either HIV infection, diabetes or hypertension are managed by the same clinical and counselling teams. They use the same pharmacy and laboratory and have the same style of patient records. Standard care involves separate pathways, that is, separate clinics, waiting and counselling areas, a separate pharmacy and separate medical records. The trial has two primary endpoints: retention in care of people with hypertension or diabetes and plasma viral load suppression. Recruitment is expected to take 6 months and follow-up is for 12 months. With 100 participants enrolled in each facility with diabetes or hypertension, the trial will provide 90% power to detect an absolute difference in retention of 15% between the study arms (at the 5% two-sided significance level). If 100 participants with HIV infection are also enrolled in each facility, we will have 90% power to show non-inferiority in virological suppression to a delta=10% margin (ie, that the upper limit of the one-sided 95% CI of the difference between the two arms will not exceed 10%). To allow for lost to follow-up, the trial will enrol over 220 persons per facility. This is the only trial of its kind evaluating the concept of a single integrated clinic for chronic conditions in Africa. ETHICS AND DISSEMINATION The protocol has been approved by ethics committee of The AIDS Support Organisation, National Institute of Medical Research and the Liverpool School of Tropical Medicine. Dissemination of findings will be done through journal publications and meetings involving study participants, healthcare providers and other stakeholders. TRIAL REGISTRATION NUMBER ISRCTN43896688.
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Affiliation(s)
- Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Janneth Mghamba
- Directors office, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Sarah Maongezi
- Non-Communicable Diseases Control Programme, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Joshua Musinguzi
- AIDS Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Joseph Okebe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sokoine Kivuyo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | | | | | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Anupam Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Walter Cullen
- School of Medicine, University College Dublin School of Medicine, Dublin, Ireland
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth Henry Shayo
- Policy Analysis and Advocacy, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - L E Cuevas
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Janet Lutale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Geoff Gill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
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Shiri T, Birungi J, Garrib AV, Kivuyo SL, Namakoola I, Mghamba J, Musinguzi J, Kimaro G, Mutungi G, Nyirenda MJ, Okebe J, Ramaiya K, Bachmann M, Sewankambo NK, Mfinanga S, Jaffar S, Niessen LW. Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings - an empirical socio-economic cohort study in Tanzania and Uganda. BMC Med 2021; 19:230. [PMID: 34503496 PMCID: PMC8431904 DOI: 10.1186/s12916-021-02094-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Integration of health services might be an efficient strategy for managing multiple chronic conditions in sub-Saharan Africa, considering the scope of treatments and synergies in service delivery. Proven to promote compliance, integration may lead to increased economies-of-scale. However, evidence on the socio-economic consequences of integration for providers and patients is lacking. We assessed the clinical resource use, staff time, relative service efficiency and overall societal costs associated with integrating HIV, diabetes and hypertension services in single one-stop clinics where persons with one or more of these conditions were managed. METHODS 2273 participants living with HIV infection, diabetes, or hypertension or combinations of these conditions were enrolled in 10 primary health facilities in Tanzania and Uganda and followed-up for up to 12 months. We collected data on resources used from all participants and on out-of-pocket costs in a sub-sample of 1531 participants, while a facility-level costing study was conducted at each facility. Health worker time per participant was assessed in a time-motion morbidity-stratified study among 228 participants. The mean health service cost per month and out-of-pocket costs per participant visit were calculated in 2020 US$ prices. Nested bootstrapping from these samples accounted for uncertainties. A data envelopment approach was used to benchmark the efficiency of the integrated services. Last, we estimated the budgetary consequences of integration, based on prevalence-based projections until 2025, for both country populations. RESULTS Their average retention after 1 year service follow-up was 1911/2273 (84.1%). Five hundred and eighty-two of 2273 (25.6%) participants had two or all three chronic conditions and 1691/2273 (74.4%) had a single condition. During the study, 84/2239 (3.8%) participants acquired a second or third condition. The mean service costs per month of managing two conditions in a single participant were $39.11 (95% CI 33.99, 44.33), $32.18 (95% CI 30.35, 34.07) and $22.65 (95% CI 21.86, 23.43) for the combinations of HIV and diabetes and of HIV and hypertension, diabetes and hypertension, respectively. These costs were 34.4% (95% CI 17.9%, 41.9%) lower as compared to managing any two conditions separately in two different participants. The cost of managing an individual with all three conditions was 48.8% (95% CI 42.1%, 55.3%) lower as compared to managing these conditions separately. Out-of-pocket healthcare expenditure per participant per visit was $7.33 (95% CI 3.70, 15.86). This constituted 23.4% (95% CI 9.9, 54.3) of the total monthly service expenditure per patient and 11.7% (95% CI 7.3, 22.1) of their individual total household income. The integrated clinics' mean efficiency benchmark score was 0.86 (range 0.30-1.00) suggesting undercapacity that could serve more participants without compromising quality of care. The estimated budgetary consequences of managing multi-morbidity in these types of integrated clinics is likely to increase by 21.5% (range 19.2-23.4%) in the next 5 years, including substantial savings of 21.6% on the provision of integrated care for vulnerable patients with multi-morbidities. CONCLUSION Integration of HIV services with diabetes and hypertension control reduces both health service and household costs, substantially. It is likely an efficient and equitable way to address the increasing burden of financially vulnerable households among Africa's ageing populations. Additional economic evidence is needed from longer-term larger-scale implementation studies to compare extended integrated care packages directly simultaneously with evidence on sustained clinical outcomes.
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Affiliation(s)
- Tinevimbo Shiri
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Anupam V Garrib
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Sokoine L Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Janneth Mghamba
- Directors Office, Ministry of Health, Community Development, Gender, Elderly and Children, Kampala, Uganda
| | - Joshua Musinguzi
- Directors Office, Ministry of Health, Community Development, Gender, Elderly and Children, Kampala, Uganda
| | - Godfather Kimaro
- School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Moffat J Nyirenda
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Joseph Okebe
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Kaushik Ramaiya
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - M Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Sayoki Mfinanga
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
- National Institutes for Medical Research, Dar es Salaam, Tanzania
- School of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shabbar Jaffar
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Louis W Niessen
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Petersen I, Kemp CG, Rao D, Wagenaar BH, Sherr K, Grant M, Bachmann M, Barnabas RV, Mntambo N, Gigaba S, Van Rensburg A, Luvuno Z, Amarreh I, Fairall L, Hongo NN, Bhana A. Implementation and Scale-Up of Integrated Depression Care in South Africa: An Observational Implementation Research Protocol. Psychiatr Serv 2021; 72:1065-1075. [PMID: 33691487 PMCID: PMC8410621 DOI: 10.1176/appi.ps.202000014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND People with chronic general medical conditions who have comorbid depression experience poorer health outcomes. This problem has received scant attention in low- and middle-income countries. The aim of the ongoing study reported here is to refine and promote the scale-up of an evidence-based task-sharing collaborative care model, the Mental Health Integration (MhINT) program, to treat patients with comorbid depression and chronic disease in primary health care settings in South Africa. METHODS Adopting a learning-health-systems approach, this study uses an onsite, iterative observational implementation science design. Stage 1 comprises assessment of the original MhINT model under real-world conditions in an urban subdistrict in KwaZulu-Natal, South Africa, to inform refinement of the model and its implementation strategies. Stage 2 comprises assessment of the refined model across urban, semiurban, and rural contexts. In both stages, population-level effects are assessed by using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework with various sources of data, including secondary data collection and a patient cohort study (N=550). The Consolidated Framework for Implementation Research is used to understand contextual determinants of implementation success involving quantitative and qualitative interviews (stage 1, N=78; stage 2, N=282). RESULTS The study results will help refine intervention components and implementation strategies to enable scale-up of the MhINT model for depression in South Africa. NEXT STEPS Next steps include strengthening ongoing engagements with policy makers and managers, providing technical support for implementation, and building the capacity of policy makers and managers in implementation science to promote wider dissemination and sustainment of the intervention.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Christopher G Kemp
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Deepa Rao
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Bradley H Wagenaar
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Kenneth Sherr
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Merridy Grant
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Max Bachmann
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Ruanne V Barnabas
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Ntokozo Mntambo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Sithabisile Gigaba
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - André Van Rensburg
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Zamasomi Luvuno
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Ishmael Amarreh
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Lara Fairall
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Nikiwe N Hongo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa (Petersen, Grant, Gigaba, Van Rensburg, Luvuno, Bhana); Department of Global Health (Kemp, Rao, Wagenaar, Sherr, Barnabas), Department of Psychiatry and Behavioral Sciences (Rao), Department of Epidemiology (Wagenaar), University of Washington, Seattle; Norwich Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom (Bachmann); School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa (Mntambo, Gigaba); Center for Global Mental Health Research, National Institute of Mental Health, Bethesda, Maryland (Amarreh); Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa, and King's Global Health Institute, King's College London, London (Fairall); Mental Health and Substance Abuse Directorate, KwaZulu-Natal Department of Health, Natalia, Pietermaritzburg, South Africa (Hongo); Health Systems Research Unit, South African Medical Research Council, Durban, South Africa (Bhana)
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Sampson M, Clark A, Bachmann M, Garner N, Irvine L, Howe A, Greaves C, Auckland S, Smith J, Turner J, Rea D, Rayman G, Dhatariya K, John WG, Barton G, Usher R, Ferns C, Pascale M. Effects of the Norfolk diabetes prevention lifestyle intervention (NDPS) on glycaemic control in screen-detected type 2 diabetes: a randomised controlled trial. BMC Med 2021; 19:183. [PMID: 34407811 PMCID: PMC8375190 DOI: 10.1186/s12916-021-02053-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/06/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The purpose of this trial was to test if the Norfolk Diabetes Prevention Study (NDPS) lifestyle intervention, recently shown to reduce the incidence of type 2 diabetes in high-risk groups, also improved glycaemic control in people with newly diagnosed screen-detected type 2 diabetes. METHODS We screened 12,778 participants at high risk of type 2 diabetes using a fasting plasma glucose and glycosylated haemoglobin (HbA1c). People with screen-detected type 2 diabetes were randomised in a parallel, three-arm, controlled trial with up to 46 months of follow-up, with a control arm (CON), a group-based lifestyle intervention of 6 core and up to 15 maintenance sessions (INT), or the same intervention with additional support from volunteers with type 2 diabetes trained to co-deliver the lifestyle intervention (INT-DPM). The pre-specified primary end point was mean HbA1c compared between groups at 12 months. RESULTS We randomised 432 participants (CON 149; INT 142; INT-DPM 141) with a mean (SD) age of 63.5 (10.0) years, body mass index (BMI) of 32.4 (6.4) kg/m2, and HbA1c of 52.5 (10.2) mmol/mol. The primary outcome of mean HbA1c at 12 months (CON 48.5 (9.1) mmol/mol, INT 46.5 (8.1) mmol/mol, and INT-DPM 45.6 (6.0) mmol/mol) was significantly lower in the INT-DPM arm compared to CON (adjusted difference -2.57 mmol/mol; 95% CI -4.5, -0.6; p = 0.007) but not significantly different between the INT-DPM and INT arms (-0.55 mmol/mol; 95% CI -2.46, 1.35; p = 0.57), or INT vs CON arms (-2.14 mmol/mol; 95% CI -4.33, 0.05; p = 0.07). Subgroup analyses showed the intervention had greater effect in participants < 65 years old (difference in mean HbA1c compared to CON -4.76 mmol/mol; 95% CI -7.75, -1.78 mmol/mol) than in older participants (-0.46 mmol/mol; 95% CI -2.67, 1.75; interaction p = 0.02). This effect was most significant in the INT-DPM arm (-6.01 mmol/mol; 95% CI -9.56, -2.46 age < 65 years old and -0.22 mmol/mol; 95% CI -2.7, 2.25; aged > 65 years old; p = 0.007). The use of oral hypoglycaemic medication was associated with a significantly lower mean HbA1c but only within the INT-DPM arm compared to CON (-7.0 mmol/mol; 95% CI -11.5, -2.5; p = 0.003). CONCLUSION The NDPS lifestyle intervention significantly improved glycaemic control after 12 months in people with screen-detected type 2 diabetes when supported by trained peer mentors with type 2 diabetes, particularly those receiving oral hypoglycaemics and those under 65 years old. The effect size was modest, however, and not sustained at 24 months. TRIAL REGISTRATION ISRCTN34805606 . Retrospectively registered 14.4.16.
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Affiliation(s)
- Michael Sampson
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK.
- Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nikki Garner
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Lisa Irvine
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Amanda Howe
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Colin Greaves
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Sara Auckland
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Jane Smith
- University of Exeter Medical School, College of Medicine & Health, University of Exeter, Exeter, UK
| | - Jeremy Turner
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Dave Rea
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Gerry Rayman
- Department of Diabetes and Endocrinology, Ipswich General Hospital NHS Trust, Ipswich, UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - W Garry John
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department Clinical Biochemistry, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Garry Barton
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Rebecca Usher
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Clare Ferns
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Melanie Pascale
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, UK
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Murdoch J, Curran R, van Rensburg AJ, Awotiwon A, Dube A, Bachmann M, Petersen I, Fairall L. Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study. Infect Dis Poverty 2021; 10:67. [PMID: 33971979 PMCID: PMC8108019 DOI: 10.1186/s40249-021-00840-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite progress towards End TB Strategy targets for reducing tuberculosis (TB) incidence and deaths by 2035, South Africa remains among the top ten high-burden tuberculosis countries globally. A large challenge lies in how policies to improve detection, diagnosis and treatment completion interact with social and structural drivers of TB. Detailed understanding and theoretical development of the contextual determinants of problems in TB care is required for developing effective interventions. This article reports findings from the pre-implementation phase of a study of TB care in South Africa, contributing to HeAlth System StrEngThening in Sub-Saharan Africa (ASSET)-a five-year research programme developing and evaluating health system strengthening interventions in sub-Saharan Africa. The study aimed to develop hypothetical propositions regarding contextual determinants of problems in TB care to inform intervention development to reduce TB deaths and incidence whilst ensuring the delivery of quality integrated, person-centred care. METHODS Theory-building case study design using the Context and Implementation of Complex Interventions (CICI) framework to identify contextual determinants of problems in TB care. Between February and November 2019, we used mixed methods in six public-sector primary healthcare facilities and one public-sector hospital serving impoverished urban and rural communities in the Amajuba District of KwaZulu-Natal Province, South Africa. Qualitative data included stakeholder interviews, observations and documentary analysis. Quantitative data included routine data on sputum testing and TB deaths. Data were inductively analysed and mapped onto the seven CICI contextual domains. RESULTS Delayed diagnosis was caused by interactions between fragmented healthcare provision; limited resources; verticalised care; poor TB screening, sputum collection and record-keeping. One nurse responsible for TB care, with limited integration of TB with other conditions, and policy focused on treatment adherence contributed to staff stress and limited consideration of patients' psychosocial needs. Patients were lost to follow up due to discontinuity of information, poverty, employment restrictions and limited support for treatment side-effects. Infection control measures appeared to be compromised by efforts to integrate care. CONCLUSIONS Delayed diagnosis, limited psychosocial support for patients and staff, patients lost to follow-up and inadequate infection control are caused by an interaction between multiple interacting contextual determinants. TB policy needs to resolve tensions between treating TB as epidemic and individually-experienced social problem, supporting interventions which strengthen case detection, infection control and treatment, and also promote person-centred support for healthcare professionals and patients.
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Affiliation(s)
- Jamie Murdoch
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK.
| | - Robyn Curran
- University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town, Mowbray, 7700, South Africa
| | | | - Ajibola Awotiwon
- University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town, Mowbray, 7700, South Africa
| | - Audry Dube
- University of Cape Town Lung Institute, Knowledge Translation Unit, University of Cape Town, Mowbray, 7700, South Africa
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Inge Petersen
- Centre for Rural Health, University of KwaZulu Natal, Durban, South Africa
| | - Lara Fairall
- King's Global Health Institute, King's College London, London, SE1 9NH, UK
- Knowledge Translation Unit, Department of Medicine, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
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27
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Petersen I, Fairall L, Zani B, Bhana A, Lombard C, Folb N, Selohilwe O, Georgeu-Pepper D, Petrus R, Mntambo N, Kathree T, Bachmann M, Levitt N, Thornicroft G, Lund C. Erratum to "Effectiveness of a task-sharing collaborative care model for identification and management of depressive symptoms in patients with hypertension attending public sector primary care clinics in South Africa: Pragmatic parallel cluster randomised controlled trial". [JAD 282C (2021) 112-121]. J Affect Disord 2021; 286:370. [PMID: 33714560 DOI: 10.1016/j.jad.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Inge Petersen
- Centre for Rural Health and School of Applied Human Sciences, University of KwaZulu- Natal, South Africa. Howard College, Mazisi Kunene Avenue, Durban, 4001, South Africa.
| | - Lara Fairall
- Global King's Health Institute, Kings College London, United Kingdom; Knowledge Translation Unit, University of Cape Town, South Africa.
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, South Africa.
| | - Arvin Bhana
- Centre for Rural Health and School of Applied Human Sciences, University of KwaZulu- Natal, South Africa. Howard College, Mazisi Kunene Avenue, Durban, 4001, South Africa; Health Systems Research Unit, South African Medical Research Council, South Africa.
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, South Africa; Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, South Africa.
| | - Naomi Folb
- Knowledge Translation Unit, University of Cape Town, South Africa.
| | - One Selohilwe
- Centre for Rural Health and School of Applied Human Sciences, University of KwaZulu- Natal, South Africa. Howard College, Mazisi Kunene Avenue, Durban, 4001, South Africa.
| | | | - Ruwayda Petrus
- School of Applied Human Sciences, University of KwaZulu-Natal, South Africa.
| | - Ntokozo Mntambo
- School of Applied Human Sciences, University of KwaZulu-Natal, South Africa.
| | - Tasneem Kathree
- Centre for Rural Health and School of Applied Human Sciences, University of KwaZulu- Natal, South Africa. Howard College, Mazisi Kunene Avenue, Durban, 4001, South Africa.
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, United Kingdom.
| | - Naomi Levitt
- Division of Endocrinology, University of Cape Town, South Africa.
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.
| | - Crick Lund
- Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom; Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa.
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McIntosh A, Bachmann M, Siedner MJ, Gareta D, Seeley J, Herbst K. Effect of COVID-19 lockdown on hospital admissions and mortality in rural KwaZulu-Natal, South Africa: interrupted time series analysis. BMJ Open 2021; 11:e047961. [PMID: 33737445 PMCID: PMC7977076 DOI: 10.1136/bmjopen-2020-047961] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/30/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To assess the effect of lockdown during the 2020 COVID-19 pandemic on daily all-cause admissions, and by age and diagnosis subgroups, and the odds of all-cause mortality in a hospital in rural KwaZulu-Natal (KZN). DESIGN Observational cohort. SETTING Referral hospital for 17 primary care clinics in uMkhanyakude District. PARTICIPANTS Data collected by the Africa Health Research Institute on all admissions from 1 January to 20 October: 5848 patients contributed to 6173 admissions. EXPOSURE Five levels of national lockdown in South Africa from 27 March 2020, with restrictions decreasing from levels 5 to 1, respectively. OUTCOME MEASURES Changes and trends in daily all-cause admissions and risk of in-hospital mortality before and at each stage of lockdown, estimated by Poisson and logistic interrupted time series regression, with stratification for age, sex and diagnosis. RESULTS Daily admissions decreased during level 5 lockdown for infants (incidence rate ratio (IRR) compared with prelockdown 0.63, 95% CI 0.44 to 0.90), children aged 1-5 years old (IRR 0.43, 95% CI 028 to 0.65) and respiratory diagnoses (IRR 0.57, 95% CI 0.36 to 0.90). From level 4 to level 3, total admissions increased (IRR 1.17, 95% CI 1.06 to 1.28), as well as for men >19 years (IRR 1.50, 95% CI 1.17 to 1.92) and respiratory diagnoses (IRR 4.26, 95% CI 2.36 to 7.70). Among patients admitted to hospital, the odds of death decreased during level 5 compared with prelockdown (adjusted OR 0.48, 95% CI 0.28 to 0.83) and then increased in later stages. CONCLUSIONS Level 5 lockdown is likely to have prevented the most vulnerable population, children under 5 years and those more severely ill from accessing hospital care in rural KZN, as reflected by the drop in admissions and odds of mortality. Subsequent increases in admissions and in odds of death in the hospital could be due to improved and delayed access to hospital as restrictions were eased.
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Affiliation(s)
- Amy McIntosh
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Max Bachmann
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- DSI-MRC South African Population Research Infrastructure Network, Durban, South Africa
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29
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Sampson M, Clark A, Bachmann M, Garner N, Irvine L, Howe A, Greaves C, Auckland S, Smith J, Turner J, Rea D, Rayman G, Dhatariya K, John WG, Barton G, Usher R, Ferns C, Pascale M. Lifestyle Intervention With or Without Lay Volunteers to Prevent Type 2 Diabetes in People With Impaired Fasting Glucose and/or Nondiabetic Hyperglycemia: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:168-178. [PMID: 33136119 PMCID: PMC7607494 DOI: 10.1001/jamainternmed.2020.5938] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Nearly half of the older adult population has diabetes or a high-risk intermediate glycemic category, but we still lack trial evidence for effective type 2 diabetes prevention interventions in most of the current high-risk glycemic categories. OBJECTIVE To determine whether a group-based lifestyle intervention (with or without trained volunteers with type 2 diabetes) reduced the risk of progression to type 2 diabetes in populations with a high-risk glycemic category. DESIGN, SETTING, AND PARTICIPANTS The Norfolk Diabetes Prevention Study was a parallel, 3-arm, group-based, randomized clinical trial conducted with up to 46 months of follow-up from August 2011 to January 2019 at 135 primary care practices and 8 intervention sites in the East of England. We identified 141 973 people at increased risk of type 2 diabetes, screened 12 778 (9.0%), and randomized those with a high-risk glycemic category, which was either an elevated fasting plasma glucose level alone (≥110 and <126 mg/dL [to convert to millimoles per liter, multiply by 0.0555]) or an elevated glycated hemoglobin level (≥6.0% to <6.5%; nondiabetic hyperglycemia) with an elevated fasting plasma glucose level (≥100 to <110 mg/dL). INTERVENTIONS A control arm receiving usual care (CON), a theory-based lifestyle intervention arm of 6 core and up to 15 maintenance sessions (INT), or the same intervention with support from diabetes prevention mentors, trained volunteers with type 2 diabetes (INT-DPM). MAIN OUTCOMES AND MEASURES Type 2 diabetes incidence between arms. RESULTS In this study, 1028 participants were randomized (INT, 424 [41.2%] [166 women (39.2%)]; INT-DPM, 426 [41.4%] [147 women (34.5%)]; CON, 178 [17.3%] [70 women (%39.3)]) between January 1, 2011, and February 24, 2017. The mean (SD) age was 65.3 (10.0) years, mean (SD) body mass index 31.2 (5) (calculated as weight in kilograms divided by height in meters squared), and mean (SD) follow-up 24.7 (13.4) months. A total of 156 participants progressed to type 2 diabetes, which comprised 39 of 171 receiving CON (22.8%), 55 of 403 receiving INT (13.7%), and 62 of 414 receiving INT-DPM (15.0%). There was no significant difference between the intervention arms in the primary outcome (odds ratio [OR], 1.14; 95% CI, 0.77-1.7; P = .51), but each intervention arm had significantly lower odds of type 2 diabetes (INT: OR, 0.54; 95% CI, 0.34-0.85; P = .01; INT-DPM: OR, 0.61; 95% CI, 0.39-0.96; P = .033; combined: OR, 0.57; 95% CI, 0.38-0.87; P = .01). The effect size was similar in all glycemic, age, and social deprivation groups, and intervention costs per participant were low at $153 (£122). CONCLUSIONS AND RELEVANCE The Norfolk Diabetes Prevention lifestyle intervention reduced the risk of type 2 diabetes in current high-risk glycemic categories. Enhancing the intervention with DPM did not further reduce diabetes risk. These translatable results are relevant for current diabetes prevention efforts. TRIAL REGISTRATION ISRCTN Registry Identifier: ISRCTN34805606.
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Affiliation(s)
- Michael Sampson
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England.,Norwich Medical School, University of East Anglia, Norwich, England
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Nikki Garner
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
| | - Lisa Irvine
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Amanda Howe
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Colin Greaves
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, England.,University of Exeter Medical School, College of Medicine & Health, University of Exeter, Exeter, England
| | - Sara Auckland
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
| | - Jane Smith
- Norwich Medical School, University of East Anglia, Norwich, England.,University of Exeter Medical School, College of Medicine & Health, University of Exeter, Exeter, England
| | - Jeremy Turner
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
| | - Dave Rea
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
| | - Gerry Rayman
- Department of Diabetes and Endocrinology, Ipswich General Hospital, Ipswich, England
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
| | - W Garry John
- Department Clinical Biochemistry, Norfolk and Norwich University Hospital NHS Trust, Norwich, England
| | - Garry Barton
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Rebecca Usher
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
| | - Clare Ferns
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
| | - Melanie Pascale
- Elsie Bertram Diabetes Centre, Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital National Health Service Trust, Norwich, England
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Abstract
The logistical and infectious peculiarities and requirements challenge the intensive care treatment teams aiming at a successful liberation of patients from long-term mechanical ventilation. Especially in the pandemic, it is therefore important to use all potentials for weaning and decannulation, respectively, in patients with prolonged weaning.Weaning centers represent units of intensive medical care with a particular specialization in prolonged weaning. They are an integral part of a continuous care concept for these patients. A systematic weaning concept in the pandemic includes structural, personnel, equipment, infectiological and hygienic issues. In addition to the S2k guideline "Prolonged weaning" this position paper hightlights a new classification in prolonged weaning and organizational structures required in the future for the challenging pandemic situation. Category A patients with high weaning potential require a structured respiratory weaning in specialized weaning units, so as to get the greatest possible chance to realize successful weaning. Patients in category B with low or currently nonexistent weaning potential should receive a weaning attempt after an intermediate phase of further stabilization in an out-of-hospital ventilator unit. Category C patients with no weaning potential require a permanent out-of-hospital care, alternatively finishing mechanical ventilation with palliative support.Finally, under perspective in the position paper the following conceivable networks and registers in the future are presented: 1. locally organized regional networks of certified weaning centers, 2. a central, nationwide register of weaning capacities accordingly the already existing DIVI register and 3. registration of patients in difficult or prolonged weaning.
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Affiliation(s)
- M Westhoff
- Klinik für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer, Zentrum für Pneumologie und Thoraxchirurgie, Hemer
- Universität Witten-Herdecke, Witten
| | - J Geiseler
- Medizinische Klinik IV: Klinik für Pneumologie, Beatmungs- und Schlafmedizin, Klinikum Vest GmbH, Paracelsus-Klinik, Marl
| | - B Schönhofer
- Pneumologische Praxis und pneumologischer Konsildienst im Klinikum Agnes Karll Laatzen, Klinikum Region Hannover, Laatzen, Germany
| | - M Pfeifer
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinik Regensburg, Regensburg
- Abteilung für Pneumologie, Fachklinik für Lungenerkrankungen Donaustauf, Donaustauf
- Krankenhaus Barmherzige Brüder, Klinik für Pneumologie und konservative Intensivmedizin, Regensburg
| | - D Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Akademisches Lehrkrankenhaus der Philipps-Universität Marburg, Schmallenberg
| | - M Bachmann
- Klinik für Intensiv- und Beatmungsmedizin, Asklepios-Klinik Harburg, Hamburg
| | - W Randerath
- Institut für Pneumologie an der Universität zu Köln, Köln
- Klinik für Pneumologie, Krankenhaus Bethanien, Solingen
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31
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Curran R, Murdoch J, Bachmann M, Bateman E, Cornick R, Picken S, Simelane ML, Fairall L. Addressing the quality of paediatric primary care: health worker and caregiver perspectives from a process evaluation of PACK child, a health systems intervention in South Africa. BMC Pediatr 2021; 21:58. [PMID: 33509149 PMCID: PMC7842050 DOI: 10.1186/s12887-021-02512-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background The WHO’s Integrated Management of Childhood Illness (IMCI) has resulted in progress in addressing infant and child mortality. However, unmet needs of children continue to present a burden upon primary healthcare services. The capacity of services and quality of care offered require greater support to address these needs by extending and integrating curative and preventive care for the child with a long-term health condition and the child older than 5, not prioritised in IMCI. In response to these needs, the PACK Child intervention was developed and piloted in October 2017–February 2019 in the Western Cape Province of South Africa. We report health worker and caregiver perspectives of the existing paediatric primary care context as well as the extent to which PACK Child functions to address perceived problems within the current local healthcare system. Methods This process evaluation involved 52 individual interviews with caregivers, 10 focus group discussions with health workers, 3 individual interviews with trainers, and 31 training observations. Interviews and focus groups explored participants’ experiences of paediatric primary care, perspectives of the PACK Child intervention, and tensions with implementation in each context. Inductive thematic analysis was used to analyse verbatim interview and discussion transcripts. Results Perspectives of caregivers and health workers suggest an institutionalised focus of paediatric primary care to treating children’s symptoms as acute episodic conditions. Health workers’ reports imply that this focus is perpetuated by interactions between contextual features such as, IMCI policy, documentation-driven consultations, overcrowded clinics and verticalised care. Whilst these contextual conditions constrained health workers’ ability to translate skills developed within PACK Child training into practice, the intervention initiated expanded care of children 0–13 years and those with long-term health conditions, enhanced professional competence, improved teamwork and referrals, streamlined triaging, and facilitated probing for psychosocial risk. Conclusion PACK Child appears to be catalysing paediatric primary care to address the broader needs of children, including long-term health conditions and the identification of psychosocial problems. However, to maximise this requires primary care to re-orientate from risk minimisation on the day of attendance towards a view of the child beyond the day of presentation at clinics. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02512-7.
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Affiliation(s)
- Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa.
| | - Jamie Murdoch
- School of Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Sandra Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Makhosazana Lungile Simelane
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Observatory, Cape Town, Western Cape, 7925, South Africa.,King's Global Health Institute, King's College London, London, SE1 9NH, UK
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Seuring T, Serneels P, Suhrcke M, Bachmann M. Diabetes, employment and behavioural risk factors in China: Marginal structural models versus fixed effects models. Econ Hum Biol 2020; 39:100925. [PMID: 33038852 DOI: 10.1016/j.ehb.2020.100925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/12/2020] [Accepted: 09/04/2020] [Indexed: 06/11/2023]
Abstract
We use longitudinal data from the China Health and Nutrition Survey, covering the years 1997-2011, to estimate the effect of a diabetes diagnosis on an economic outcome (employment probabilities) and behavioural risk factors (alcohol consumption, smoking cessation, body mass index (BMI), physical activity and hypertension) for men and women. We apply two complementary statistical techniques-marginal structural models (MSMs) and fixed effects (FE) models-to deal with confounding. Both methods suggest, despite their different underlying assumptions, similar patterns that indicate important differences between men and women. Employment probabilities decline substantially after the diagnosis for women (-12.4 (MSM) and -15.5 (FE) percentage points), but do not change significantly for men. In particular, the MSM estimates indicate an increase in hypertension (13 percentage points) and a decrease in physical activity for women, while men have small and statistically insignificant changes in these outcomes. For BMI, the MSM results indicate statistically significant changes for men (-.76), but not for women, while the FE estimates show similar reductions for men and women (-.80 and -.73 respectively). Men also reduce their alcohol consumption, but do not cease to smoke. For women these risk factors have a prevalence close to zero to begin with, though women seem to still reduce alcohol consumption somewhat. These results suggest important gender differences in the impact of diabetes in China. To narrow these inequities policies supporting women to reduce diabetes related risk factors are likely important.
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Affiliation(s)
- Till Seuring
- Luxembourg Institute of Socio-Economic Research, 11 Porte des Sciences, 4366 Esch-sur-Alzette/Belval, Luxembourg.
| | - Pieter Serneels
- School of International Development, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR47TJ, UK
| | - Marc Suhrcke
- Luxembourg Institute of Socio-Economic Research, 11 Porte des Sciences, 4366 Esch-sur-Alzette/Belval, Luxembourg; Centre for Health Economics, University of York, Heslington, York YO105DD, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR47TJ, UK
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33
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Cao S, Gan Y, Wang C, Bachmann M, Wei S, Gong J, Huang Y, Wang T, Li L, Lu K, Jiang H, Gong Y, Xu H, Shen X, Tian Q, Lv C, Song F, Yin X, Lu Z. Post-lockdown SARS-CoV-2 nucleic acid screening in nearly ten million residents of Wuhan, China. Nat Commun 2020; 11:5917. [PMID: 33219229 PMCID: PMC7679396 DOI: 10.1038/s41467-020-19802-w] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/27/2020] [Indexed: 12/13/2022] Open
Abstract
Stringent COVID-19 control measures were imposed in Wuhan between January 23 and April 8, 2020. Estimates of the prevalence of infection following the release of restrictions could inform post-lockdown pandemic management. Here, we describe a city-wide SARS-CoV-2 nucleic acid screening programme between May 14 and June 1, 2020 in Wuhan. All city residents aged six years or older were eligible and 9,899,828 (92.9%) participated. No new symptomatic cases and 300 asymptomatic cases (detection rate 0.303/10,000, 95% CI 0.270-0.339/10,000) were identified. There were no positive tests amongst 1,174 close contacts of asymptomatic cases. 107 of 34,424 previously recovered COVID-19 patients tested positive again (re-positive rate 0.31%, 95% CI 0.423-0.574%). The prevalence of SARS-CoV-2 infection in Wuhan was therefore very low five to eight weeks after the end of lockdown.
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Affiliation(s)
- Shiyi Cao
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yong Gan
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chao Wang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK
| | - Shanbo Wei
- Wuhan Municipal Health Commission, Wuhan, Hubei, China
| | - Jie Gong
- Wuhan Centre for Clinical Laboratory, Wuhan, Hubei, China
| | - Yuchai Huang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tiantian Wang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liqing Li
- Department of Management Science and Engineering, School of Economics and Management, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Kai Lu
- Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Heng Jiang
- Centre for Alcohol Policy Research, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Yanhong Gong
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hongbin Xu
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xin Shen
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qingfeng Tian
- School of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Chuanzhu Lv
- Department of Emergency, Hainan Clinical Research Centre for Acute and Critical Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China.
| | - Fujian Song
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK.
| | - Xiaoxv Yin
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Zuxun Lu
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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34
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Hoegen P, Lang C, Akbaba S, Häring P, Splinter M, Miltner A, Bachmann M, Stahl-Arnsberger C, Brechter T, Bernhardt D, Klüter S, Syed M, Weykamp F, König L, Debus J, Hörner-Rieber J. PO-1652: In silico trial of cone-beam-CT guided adaptive planning for radiotherapy of locally advanced NSCLC. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)01670-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Vdovenko D, Wijnen W, Zarak Crnkovic M, Blyszczuk P, Bachmann M, Costantino S, Paneni F, Camici G, Luescher T, Eriksson U. IL-23 promotes T-cell mediated cardiac inflammation but protects the heart from fibrosis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Cardiac inflammation varies widely and, in some cases, triggers autoimmune myocarditis and further inflammatory dilated cardiomyopathy (iDCM) and heart failure. In children, myocarditis leads to cardiomyopathy in almost half of affected individuals and up to 20% of sudden death cases in young adults have been reported to be due to myocarditis. IL-12 and IL-23 belong to the same family of cytokines known to mediate inflammatory conditions. Both regulate the differentiation of T cells: IL-12 promotes towards IFN-gamma-producing Th-1 cells, while IL-23 induces IL-17-producing Th-17 cells. Heart-reactive CD4+Th17 cells play a leading role in the development of myocarditis, however, literature reports excessiveness of IL-23 in Th17-derived IL-17 production. Therapeutic strategies blocking IL-23 were suggested as a promising approach, though the specific role of IL-23 in pathogenesis is unclear and the long-term perspectives stay elusive.
Purpose
We aim to explore the role IL-23 compared to IL-12 in the manifestation of cardiac autoimmune myocarditis.
Methodology
We use dendritic cell (DC) model of experimental autoimmune myocarditis in IL-12 and IL-23-deficient mice. Mice were injected with bone marrow-derived in vitro activated and loaded with cardiac-specific peptide DCs. This model mimics natural processes taking place during heart inflammation and provides a unique method to address the role of DCs-derived cytokines. Cardiac inflammation, as well as remodeling and heart function, were analysed at the acute and chronic stages of the disease.
Results
Surprisingly, all mice developed acute myocarditis, though wt receiving IL-23−/−bmDCs showed a twofold decrease in heart-infiltrating T cells and lower numbers of Th17 population. Further decrease of heart-infiltrating T cells appeared upon total systemic IL-23 deficiency. In comparison to IL-12, directly inducing differentiation of IFN-gamma–producing Th1, IL-23 cannot induce Th17 differentiation. None of the two cytokines affect proliferation, though, IL-23 activates T cell migratory potential and increases T cell migration by twofold. At the same time, deficiency of IL-23-production by bmDCs leads to lower migration of T cells. We also show an involvement of RhoA, and the other Rho GTPases, in the mechanism of migration as blocking revoke the IL-23 effect on T cells. Moreover, we further observed more fibrosis and worse heart functioning in IL-23−/−, but not IL-12−/− mice at the chronic stage what underlines the importance of IL-23-dependent T cell trafficking in the resolution of the acute stage of autoimmune myocarditis.
Conclusion
Our observations underline IL-23 as an important cytokine responsible for T cell trafficking and resolution of the inflammation in autoimmune myocarditis. Therapeutic approaches involving inflammatory cytokine targeting are a promising clinical perspective though IL-23 deficiency might lead to increased cardiac remodeling and iDCM progression.
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): The Swiss National Science Foundation
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Affiliation(s)
- D Vdovenko
- University of Zurich, Center for Molecular Cardiology, Zurich, Switzerland
| | - W.J Wijnen
- University of Zurich, Center for Molecular Cardiology, Zurich, Switzerland
| | - M Zarak Crnkovic
- University of Zurich, Center for Molecular Cardiology, Zurich, Switzerland
| | - P Blyszczuk
- University Hospital Zurich, Department of Rheumatology, Zurich, Switzerland
| | - M Bachmann
- GZO Zurich Regional Health Center, Department of Medicine, Wetzikon, Switzerland
| | - S Costantino
- University of Zurich, Center for Molecular Cardiology, Zurich, Switzerland
| | - F Paneni
- University of Zurich, Center for Molecular Cardiology, Zurich, Switzerland
| | - G.G Camici
- University of Zurich, Center for Molecular Cardiology, Zurich, Switzerland
| | - T.F Luescher
- University of Zurich, Center for Molecular Cardiology, Zurich, Switzerland
| | - U Eriksson
- GZO Zurich Regional Health Center, Department of Medicine, Wetzikon, Switzerland
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Zani B, Fairall L, Petersen I, Folb N, Bhana A, Thornicroft G, Hanass-Hancock J, Lund C, Bachmann M. Predictors of receiving a diagnosis, referral and treatment of depression in people on antiretroviral therapy in South African primary care: a secondary analysis of data from a randomised trial. Trop Med Int Health 2020; 25:1450-1466. [PMID: 32985080 PMCID: PMC7756779 DOI: 10.1111/tmi.13495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To describe the receipt of a diagnosis, referral and treatment for depression in people receiving antiretroviral therapy (ART), with depressive symptoms and attending primary care clinics in South Africa, and investigate factors associated with receiving these components of care. Methods This is a secondary analysis of data from a randomised controlled trial of an intervention intended to improve detection and treatment of depression in primary care patients receiving ART. In this analysis, we combined cross‐sectional and longitudinal data from the intervention and control arms. Using regression models and adjusting for intra‐cluster correlation of outcomes, we investigated associations between socioeconomic characteristics, depressive symptoms, stress, disability and stigma, and receipt of a diagnosis, referral and treatment for depression. Results Of 2002 participants enrolled, 18% reported a previous diagnosis of depression by a healthcare worker and 10% reported having received counselling from a specialist mental health worker. Diagnosis, referral and counselling during the follow‐up period were appropriately targeted, being independently more frequent in participants with higher enrolment scores for depressive symptoms, stress or disability. Participants with higher stigma scores at enrolment were independently less likely to receive counselling. Severe socio‐economic deprivation was common but was not associated with treatment. Conclusion While the receipt of a diagnosis, referral and treatment for depression were uncommon, they seemed to be appropriately targeted. Socio‐economic deprivation was not associated with treatment.
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Affiliation(s)
- B Zani
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - L Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa.,King's Global Health Institute, King's College London, London, UK.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - I Petersen
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - N Folb
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - A Bhana
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa.,Health Systems Research Unit, South African Medical Research Council, Durban, South Africa
| | - G Thornicroft
- Centre for Global Mental Health, King's College London, London, UK
| | - J Hanass-Hancock
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa.,School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - C Lund
- Centre for Global Mental Health, King's College London, London, UK.,Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - M Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
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Van Hout MC, Bachmann M, Lazarus JV, Shayo EH, Bukenya D, Picchio CA, Nyirenda M, Mfinanga SG, Birungi J, Okebe J, Jaffar S. Strengthening integration of chronic care in Africa: protocol for the qualitative process evaluation of integrated HIV, diabetes and hypertension care in a cluster randomised controlled trial in Tanzania and Uganda. BMJ Open 2020; 10:e039237. [PMID: 33033029 PMCID: PMC7542920 DOI: 10.1136/bmjopen-2020-039237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION In sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions. METHODS AND ANALYSIS This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors. ETHICS AND DISSEMINATION Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services. TRIAL REGISTRATION NUMBER ISRCTN43896688; Pre-results.
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Affiliation(s)
- Marie-Claire Van Hout
- Public Health Institute, Liverpool John Moores University, Liverpool, Merseyside, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Elizabeth Henry Shayo
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Dominic Bukenya
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Camila A Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Moffat Nyirenda
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Sayoki Godfrey Mfinanga
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Josephine Birungi
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
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Saraiva S, Bachmann M, Andrade M, Liria A. Bridging the mental health treatment gap: effects of a collaborative care intervention (matrix support) in the detection and treatment of mental disorders in a Brazilian city. Fam Med Community Health 2020; 8:fmch-2019-000263. [PMID: 32958519 PMCID: PMC7507894 DOI: 10.1136/fmch-2019-000263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective To analyse temporal trends in diagnosis and treatment of mental disorders in primary care following implementation of a collaborative care intervention (matrix support). Design Dynamic cohort design with retrospective time-series analysis. Structured secondary data on medical visits to general practitioners of all study clinics were extracted from the municipal electronic records database. Annual changes in the odds of mental disorders diagnoses and antidepressants prescriptions were estimated by multiple logistic regression at visit and patient-year levels with diagnoses or prescriptions as outcomes. Annual changes during two distinct stages of the intervention (stage 1 when it was restricted to mental health (2005–2009), and stage 2 when it was expanded to other areas (2010–2015)) were compared by adding year–period interaction terms to each model. Setting 49 primary care clinics in the city of Florianópolis, Brazil. Participants All adults attending primary care clinics of the study setting between 2005 and 2015. Results 3 131 983 visits representing 322 100 patients were analysed. At visit level, the odds of mental disorder diagnosis increased by 13% per year during stage 1 (OR 1.13, 95% CI 1.11 to 1.14, p<0.001) and decreased by 5% thereafter (OR 0.95, 95% CI 0.94 to 0.95, p<0.001). The odds of incident mental disorder diagnoses decreased by 1% per year during stage 1 (OR 0.99, 95% CI 0.98 to 1.00, p=0.012) and decreased by 7% per year during stage 2 (OR 0.93, 95% CI 0.92 to 0.93, p<0.001). The odds of antidepressant prescriptions in patients with a mental disorder diagnosis increased by 7% per year during stage 1 (OR 1.07, 95% CI 1.05 to 1.20, p<0.001); this was driven by selective serotonin reuptake inhibitor prescriptions which increased 14% per year during stage 1 (OR 1.14, 95% CI 1.12 to 1.18, p<0.001) and 9% during stage 2 (OR 1.09, 95% CI 1.08 to 1.10, p<0.001). The odds of incident antidepressant prescriptions did not increase during stage 1 (OR 1.00, 95% CI 0.97 to 1.02, p=0.665) and increased by 3% during stage 2 (OR 1.03, 95% CI 1.00 to 1.04, p<0.001). Changes per year were all significantly greater during stage 1 than stage 2 (p values for interaction terms <0.05), except for antidepressant prescriptions during visits (p=0.172). Conclusion The matrix support intervention may increase diagnosis and treatment of mental disorders when inter-professional collaboration is adequately supported. Competing demands to the primary care teams can subsequently reduce these effects. Future studies should assess clinical outcomes and identify active components and factors associated with successful implementation.
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Affiliation(s)
- Sonia Saraiva
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Matheus Andrade
- Secretaria Municipal de Saúde (Municipal Health Department), Florianópolis, Brazil
| | - Alberto Liria
- Departamento de Especialidades Médicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Alcalá de Henares, Spain
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Mukhtyar C, Steel L, Jones C, Bachmann M. THU0553 A HEALTH ECONOMIC ANALYSIS OF THE USE OF COLOUR DOPPLER ULTRASONOGRAPHY AS THE PRIMARY DIAGNOSTIC MODALITY IN PATIENTS WITH SUSPECTED GIANT CELL ARTERITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:EULAR has recommended ultrasonography (US) as first imaging modality for diagnosis of Giant Cell Arteritis (GCA)1. For patients with a high pre-test probability who have a negative scan, the recommendation is to use another diagnostic modality like temporal artery biopsy (TAB) to make a diagnosis1. We know that a fast-track pathway incorporating US, results in better clinical outcomes2; but there are little data on the health-economics of this approach. Since 2017, we have used ultrasonography as the primary diagnostic modality for suspected GCA. In patients with a high pre-test probability with a negative ultrasonography, we perform a temporal artery biopsy.Objectives:To compare the cost of investigating GCA using first-line US and second-line TAB the use of TAB only. To compare the cost per definite diagnosis of GCA.Methods:Number of cases from 2007-2009 and 2017-2019 were calculated by the number of TAB performed and number of referrals to hospital GCA clinic, respectively. Costs of the procedure were calculated as per the nationally agreed tariff by the United Kingdom National Health Service. For ease of comparison, we used the 2018/19 tariff (£1284/TAB; £51 for US)Results:In 2007-2009, 162 cases were referred to clinic and had a TAB, of which 86 were positive. No cases had US. The 2018/19 corrected cost was £208008; the cost per positive diagnosis was £2418.70 (Table 1).In 2017-2019, 419 patients were referred to the GCA clinic, 416 of whom had US for diagnosis. 3 individuals had a TAB as the first diagnostic modality and 66 others were referred for a TAB because of a high pre-test probability and negative US. The 2018/19 corrected cost of this pathway was £109812 and the cost per positive diagnosis was £773.32 (Table 1).Table 1.Numbers of cases investigated for suspected GCA by TAB or US and the costs corrected to 2018/19 UK NHS tariff.YearsNo of referralsNo of TABNo of USNo of patients with GCATotal costCost of making 1 positive diagnosis2007-09162162086£208008£2418.702017-1941969416142£109812£773.32If all cases in 2017-2019 had a TAB for suspected GCA, the 2018/19 corrected cost would have been £537996. The estimated 2018/19 corrected savings in our center was £142728/year. The estimated 2018/19 corrected savings per definite diagnosis of GCA has dropped by £1645.37 (Table 1).Conclusion:The EULAR recommendation of using first-line US for diagnosis of GCA followed by a TAB in cases with uncertain diagnosis after US, is highly cost-effective in the UK, resulting in cost savings of >£140K per year.References:[1]Dejaco C, et al. Ann Rheum Dis. 2018 May;77(5):636-643.[2]Diamantopoulos AP, et al. Rheumatology (Oxford). 2016 Jan;55(1):66-70.Disclosure of Interests:None declared
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Murdoch J, Curran R, Cornick R, Picken S, Bachmann M, Bateman E, Simelane ML, Fairall L. Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child). BMC Health Serv Res 2020; 20:479. [PMID: 32471431 PMCID: PMC7257217 DOI: 10.1186/s12913-020-05201-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/08/2020] [Indexed: 12/05/2022] Open
Abstract
Background Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children in South Africa. The PACK Child intervention, comprising clinical decision support tool (guide), training strategy and health systems strengthening components, was developed to expand on WHO’s Integrated Management of Childhood Illness programme, extending care of children under 5 years to those aged 0–13 years, those with chronic conditions needing regular follow-up, integration of curative and preventive measures and routine care of the well child. In 2017–2018, PACK Child was piloted in 10 primary healthcare facilities in the Western Cape Province. Here we report findings from an investigation into the contextual features of South African primary care that shaped how clinicians delivered the PACK Child intervention within clinical consultations. Methods Process evaluation using linguistic ethnographic methodology which provides analytical tools for investigating human behaviour, and the shifting meaning of talk and text within context. Methods included semi-structured interviews, focus groups, ethnographic observation, audio-recorded consultations and documentary analysis. Analysis focused on how mapped contextual features structured clinician-caregiver interactions. Results Primary healthcare facilities demonstrated an institutionalised orientation to minimising risk upheld by provincial documentation, providing curative episodic care to children presenting with acute symptoms, and preventive care including immunisations, feeding and growth monitoring, all in children 5 years or younger. Children with chronic illnesses such as asthma rarely receive routine care. These contextual features constrained the ability of clinicians to use the PACK Child guide to facilitate diagnosis of long-term conditions, elicit and manage psychosocial issues, and navigate use of the guide alongside provincial documentation. Conclusion Our findings provide evidence that PACK Child is catalysing a transition to an approach that strikes a balance between assessing and minimising risk on the day of acute presentation and a larger remit of care for children over time. However, optimising success of the intervention requires reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and deployment of clinical staff to better address acute illnesses and long-term health conditions of children of all ages, as well as complex psychosocial issues surrounding the child.
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Affiliation(s)
- Jamie Murdoch
- School of Health Sciences, University of East Anglia, Edith Cavell Building, Colney Lane, Norwich, NR4 7TJ, UK.
| | - Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Sandy Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Makhosazana Lungile Simelane
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Mowbray, 7700, South Africa.,Department of Medicine, University of Cape Town, Observatory, 7925, South Africa.,King's Global Health Institute, King's College London, London, SE1 9NH, UK
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Wiesner B, Bachmann M, Blum TG, Forchheim S, Geiseler J, Kassin A, Kretzschmar E, Weber-Carstens S, Westhoff M, Witzenrath M, Grohé C. [Responsibilities of Weaning Centers during the COVID-19 Pandemic Outbreak - Recommendations for the Assignment of ICU Capacities in COVID-19 Patients as shown by the Berlin-Brandenburg POST-SAVE-Model]. Pneumologie 2020; 74:358-365. [PMID: 32294763 PMCID: PMC7356087 DOI: 10.1055/a-1153-9710] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Die enorme Zunahme von Patienten mit schwerer respiratorischer Insuffizienz aufgrund der COVID19-Pandemie erfordert einen systematischen Ansatz zur Optimierung der Betreuung von beatmeten Patienten. Ein standardisierter Algorithmus namens „SAVE“ wurde in Berlin entwickelt, um Patienten mit COVID-19-Infektion, die eine invasive Beatmung benötigen, zu lenken. Um Bettenkapazitäten auf den Intensivstationen sicherzustellen, muss eine konstante Patientenentlassung gewährleistet sein. Ein strukturierter Entlassungsprozess der Patienten nach der Akutbehandlung ist dringend erforderlich. In einem nächsten Schritt haben wir einen Triage-Algorithmus entwickelt, um Patienten auf SAVE-Intensivstationen zu identifizieren, die das Potenzial haben, von der Beatmung entwöhnt zu werden und in dafür spezialisierte Einrichtungen zu verlegen. Dieser Prozess ist das POST-SAVE-Konzept. In der vorliegenden Arbeit werden die Algorithmen dargestellt, einschließlich der Verwendung einer standardisierten digitalen Datenbank, der Verwendung geschulter Lotsen zur Erleichterung der Kommunikation zwischen SAVE-Intensivstationen und Weaningeinheiten und der Etablierung eines prospektiven Datenregisters, um Patienten dauerhaft hinsichtlich ihres Weaningpotenzials reevaluieren zu können.
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Affiliation(s)
| | - M Bachmann
- Asklepios Klinikum Harburg, Zentrum für Atemwegs- und Thoraxmedizin
| | - T-G Blum
- Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin
| | | | | | - A Kassin
- Evangelische Lungenklinik, Berlin
| | | | - S Weber-Carstens
- Charité-Universitätsmedizin Berlin, Klinik für Anästhesiologie m.S. operative Intensivmedizin
| | - M Westhoff
- Lungenklinik Hemer, Klinik für Pneumologie, Schlaf- und Beatmungsmedizin; Universität Witten-Herdecke
| | - M Witzenrath
- Charité-Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Infektiologie und Pneumologie
| | - C Grohé
- Evangelische Lungenklinik, Berlin
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Bachmann M, Kuhnitzsch C, Thierbach A, Michel S, Bochnia M, Greef J, Martens S, Steinhöfel O, Zeyner A. Effects of toasting temperature and duration on in vitro ruminal gas production kinetics and post-ruminal crude protein from field pea (Pisum sativum) legume grain silages. Livest Sci 2020. [DOI: 10.1016/j.livsci.2020.103944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Janse Van Rensburg A, Dube A, Curran R, Ambaw F, Murdoch J, Bachmann M, Petersen I, Fairall L. Comorbidities between tuberculosis and common mental disorders: a scoping review of epidemiological patterns and person-centred care interventions from low-to-middle income and BRICS countries. Infect Dis Poverty 2020; 9:4. [PMID: 31941551 PMCID: PMC6964032 DOI: 10.1186/s40249-019-0619-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 12/23/2019] [Indexed: 12/22/2022] Open
Abstract
Background There is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders. Person-centred care holds much promise to ameliorate these comorbidities in low-to-middle income countries (LMICs) and emerging economies. Towards this end, this paper aims to review 1) the nature and extent of tuberculosis and common mental disorder comorbidity and 2) person-centred tuberculosis care in low-to-middle income countries and emerging economies. Main text A scoping review of 100 articles was conducted of English-language studies published from 2000 to 2019 in peer-reviewed and grey literature, using established guidelines, for each of the study objectives. Four broad tuberculosis/mental disorder comorbidities were described in the literature, namely alcohol use and tuberculosis, depression and tuberculosis, anxiety and tuberculosis, and general mental health and tuberculosis. Rates of comorbidity varied widely across countries for depression, anxiety, alcohol use and general mental health. Alcohol use and tuberculosis were significantly related, especially in the context of poverty. The initial tuberculosis diagnostic episode had substantial socio-psychological effects on service users. While men tended to report higher rates of alcohol use and treatment default, women in general had worse mental health outcomes. Older age and a history of mental illness were also associated with pronounced tuberculosis and mental disorder comorbidity. Person-centred tuberculosis care interventions were almost absent, with only one study from Nepal identified. Conclusions There is an emerging body of evidence describing the nature and extent of tuberculosis and mental disorders comorbidity in low-to-middle income countries. Despite the potential of person-centred interventions, evidence is limited. This review highlights a pronounced need to address psychosocial comorbidities with tuberculosis in LMICs, where models of person-centred tuberculosis care in routine care platforms may yield promising outcomes.
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Affiliation(s)
- André Janse Van Rensburg
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal Howard College, Berea, Durban, South Africa.
| | - Audry Dube
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Mowbray, Cape Town, South Africa
| | - Robyn Curran
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Mowbray, Cape Town, South Africa
| | - Fentie Ambaw
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Jamie Murdoch
- University of East Anglia School of Health Sciences, Norwich Research Park, Norwich, Norfolk, UK
| | - Max Bachmann
- University of East Anglia School of Health Sciences, Norwich Research Park, Norwich, Norfolk, UK
| | - Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal Howard College, Berea, Durban, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, George Street, Mowbray, Cape Town, South Africa.,King's Global Health Institute, King's College London, Stamford Street, London, UK
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Bachmann M, Kuhnitzsch C, Martens S, Steinhöfel O, Zeyner A. Estimation of gas production and post-ruminal crude protein from native or ensiled Pisum sativum and Vicia faba grains. Journal of Applied Animal Research 2020. [DOI: 10.1080/09712119.2020.1733581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- M. Bachmann
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - C. Kuhnitzsch
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Saxon State Office for Environment, Agriculture and Geology, Köllitsch, Germany
| | - S.D. Martens
- Saxon State Office for Environment, Agriculture and Geology, Köllitsch, Germany
| | - O. Steinhöfel
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Saxon State Office for Environment, Agriculture and Geology, Köllitsch, Germany
| | - A. Zeyner
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Acar A, Niemeyer D, Groß-Fengels W, Bachmann M, Wiest G. [Nocardiosis as a Differential Diagnosis of Pulmonary Epitheloid Cell Granulomas]. Pneumologie 2019; 73:538-543. [PMID: 31533175 DOI: 10.1055/a-0980-9028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A 47-year-old man presented with fever, weight loss and pulmonary consolidations and cavitation in the x-ray of the thorax. The comprehensive diagnostics resulted pulmonary epitholoid cell granulomas, therefore an immunosuppressive therapy was applied on suspicion of sarcoidosis. Progressivly the pulmonary infiltration increased and cerebral and abdominal abscesses were determined with microbiological detection of Nocardia farcinica. Despite antibiotic therapy, the patient died in a septic shock with multiple organ failure.Nocardiosis is a rare granulomatous bacterial infectious disease. Risk factors include immunosuppression and structural lung diseases. Characteristic is an abscess formation that can occur in any organ, while pulmonary onset is common.The case demonstrates the importance of considering rare differential diagnoses in the detection of pulmonary epithelioid granulomas.
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Affiliation(s)
- A Acar
- Asklepios Klinikum Hamburg-Harburg, Klinik für Atemwegs-, Lungen- und Thoraxmedizin
| | - D Niemeyer
- Asklepios Klinikum Hamburg-Harburg, Klinik für Atemwegs-, Lungen- und Thoraxmedizin
| | - W Groß-Fengels
- Asklepios Klinikum Hamburg-Harburg, Abteilung für Radiologie und Nuklearmedizin
| | - M Bachmann
- Asklepios Klinikum Hamburg-Harburg, Klinik für Atemwegs-, Lungen- und Thoraxmedizin
| | - G Wiest
- Asklepios Klinikum Hamburg-Harburg, Klinik für Atemwegs-, Lungen- und Thoraxmedizin
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Sharman M, Bachmann M. Prevalence and health effects of communicable and non-communicable disease comorbidity in rural KwaZulu-Natal, South Africa. Trop Med Int Health 2019; 24:1198-1207. [PMID: 31389103 DOI: 10.1111/tmi.13297] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe changes in prevalence of hypertension, diabetes, HIV and tuberculosis, and prevalence of comorbidity, and to investigate associations between each condition, and combinations of conditions, with self-reported general health and hospital admission. METHODS This study used data from a longitudinal population-based HIV and health surveillance cohort, conducted by the Africa Health Research Institute in Umkhanyakude district of rural KwaZulu-Natal, South Africa. RESULTS Prevalence of hypertension, HIV and diabetes increased from 2009 to 2015, and prevalence of tuberculosis decreased. 81% of the 47 334 participants were female; hypertension and diabetes were the commonest conditions in people over age 50, whereas HIV was most common in those younger than 50 years. Comorbidity of communicable and non-communicable conditions was commonest in 40- to 60-year-olds. The adjusted odd ratios (OR) for better self-reported general health with multimorbidity were 0.53 (95% CI 0.51-0.56), 0.29 (95% CI 0.27-0.29), 0.25 (95% CI 0.21-0.37) and 0.21 (95% CI 0.12-0.37) for one, two, three and four conditions, respectively, vs. no conditions. Tuberculosis was most strongly and inversely associated with better general health (OR 0.34 (0.31-0.37) and most strongly associated with hospital admission (OR 3.26 (2.32-2.99)). CONCLUSION The high prevalence of communicable and non-communicable conditions in this rural South African population is giving rise to a burden of multimorbidity, as increased access to antiretroviral treatment has reduced mortality in people with HIV. Healthcare systems must adapt by working towards integrated primary care for HIV/AIDS and non-communicable diseases.
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Affiliation(s)
- Monica Sharman
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Max Bachmann
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK.,School of Nursing and Public Health, University of KwaZulu Natal, Durban, South Africa
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Glatter M, Borewicz K, van den Bogert B, Wensch-Dorendorf M, Bochnia M, Greef JM, Bachmann M, Smidt H, Breves G, Zeyner A. Modification of the equine gastrointestinal microbiota by Jerusalem artichoke meal supplementation. PLoS One 2019; 14:e0220553. [PMID: 31393892 PMCID: PMC6687111 DOI: 10.1371/journal.pone.0220553] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 07/18/2019] [Indexed: 01/21/2023] Open
Abstract
The objective of this study was to investigate the impact of natural prebiotic active compounds on the microbial composition in different regions of the equine gastrointestinal tract. Twelve adult horses (body weight [bwt] 534 ± 64.5 kg; age 14 ± 7.5 years) were randomly divided into two feeding groups. Six horses received a basal diet consisting of 1.5 kg hay/100 kg bwt x d-1 and oat grains equal to 1.19 g starch/kg bwt x d-1, supplemented with Jerusalem artichoke meal providing prebiotic fructooligosaccharides + inulin in a quantity of 0.15 g/kg bwt x d-1. The remaining horses received a placebo added to the basal diet. The horses were fed for 21 d and euthanized at the end of the feeding period. Digesta samples from different parts of the gastrointestinal tract were taken, DNA extracted and the V1-V2 region of the 16S rRNA gene amplified. Supplementation with the prebiotic increased the relative abundance of Lactobacillus (P < 0.05), with a concurrent reduction of the relative abundance of Streptococcus mainly in the stomach (P < 0.05). In the hindgut, the supplemental prebiotic also increased the relative abundance of Lactobacillus but further reduced the relative abundance of fibrolytic bacteria, specifically the unclassified members of the families Lachnospiraceae (P < 0.05) and Ruminococcaceae. The relative abundance of the genus Ruminococcus increased solely in the caecum and colon transversum. Overall, the addition of the prebiotic significantly increased the diversity in nearly all parts of the gastrointestinal tract (P < 0.05). The feeding of this natural prebiotic compound to horses had an impact on the microbial community in the entire gastrointestinal tract. Furthermore, the effect on the bacterial community in the foregut (especially the stomach) was more pronounced in comparison to the effect in the hindgut. Therefore, the impact on stomach health should be carefully considered.
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Affiliation(s)
- M. Glatter
- Institute of Agricultural and Nutritional Sciences, Group Animal Nutrition, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- * E-mail:
| | - K. Borewicz
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - B. van den Bogert
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - M. Wensch-Dorendorf
- Institute of Agricultural and Nutritional Sciences, Biometrics and Informatics in Agriculture Group, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - M. Bochnia
- Institute of Agricultural and Nutritional Sciences, Group Animal Nutrition, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - J. M. Greef
- Julius Kuehn Institute, Federal Research Center for Cultivated Plants, Crop and Soil Science, Braunschweig, Germany
| | - M. Bachmann
- Institute of Agricultural and Nutritional Sciences, Group Animal Nutrition, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - H. Smidt
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - G. Breves
- Institute for Physiology and Cell Biology, University of Veterinary Medicine, Foundation, Hannover, Germany
| | - A. Zeyner
- Institute of Agricultural and Nutritional Sciences, Group Animal Nutrition, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Zarschler K, Bachmann M, Ddungu J, De Cola L, Stephan S, Bergmann R, Singh G. Ultrasmall silicon nanoparticles as promising platform for targeted multimodal imaging. Nucl Med Biol 2019. [DOI: 10.1016/s0969-8051(19)30352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Striese F, Bergmann R, Weißflog S, Arndt C, Feldmann A, Steinbach J, Bachmann M, Pietzsch HJ. Development and characterization of a 177Lu-labeled anti-prostate stem cell antigen (PSCA) monoclonal antibody for metastatic prostate cancer. Nucl Med Biol 2019. [DOI: 10.1016/s0969-8051(19)30244-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tørnes M, McLernon D, Bachmann M, Musgrave S, Warburton EA, Potter JF, Myint PK. Does service heterogeneity have an impact on acute hospital length of stay in stroke? A UK-based multicentre prospective cohort study. BMJ Open 2019; 9:e024506. [PMID: 30948571 PMCID: PMC6500188 DOI: 10.1136/bmjopen-2018-024506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To determine whether stroke patients' acute hospital length of stay (AHLOS) varies between hospitals, over and above case mix differences and to investigate the hospital-level explanatory factors. DESIGN A multicentre prospective cohort study. SETTING Eight National Health Service acute hospital trusts within the Anglia Stroke & Heart Clinical Network in the East of England, UK. PARTICIPANTS The study sample was systematically selected to include all consecutive patients admitted within a month to any of the eight hospitals, diagnosed with stroke by an accredited stroke physician every third month between October 2009 and September 2011. PRIMARY AND SECONDARY OUTCOME MEASURES AHLOS was defined as the number of days between date of hospital admission and discharge or death, whichever came first. We used a multiple linear regression model to investigate the association between hospital (as a fixed-effect) and AHLOS, adjusting for several important patient covariates, such as age, sex, stroke type, modified Rankin Scale score (mRS), comorbidities and inpatient complications. Exploratory data analysis was used to examine the hospital-level characteristics which may contribute to variance between hospitals. These included hospital type, stroke monthly case volume, service provisions (ie, onsite rehabilitation) and staffing levels. RESULTS A total of 2233 stroke admissions (52% female, median age (IQR) 79 (70 to 86) years, 83% ischaemic stroke) were included. The overall median AHLOS (IQR) was 9 (4 to 21) days. After adjusting for patient covariates, AHLOS still differed significantly between hospitals (p<0.001). Furthermore, hospitals with the longest adjusted AHLOS's had predominantly smaller stroke volumes. CONCLUSIONS We have clearly demonstrated that AHLOS varies between different hospitals, and that the most important patient-level explanatory variables are discharge mRS, dementia and inpatient complications. We highlight the potential importance of stroke volume in influencing these differences but cannot discount the potential effect of unmeasured confounders.
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Affiliation(s)
- Michelle Tørnes
- Ageing Clinical and Experimental Research Group, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
| | - David McLernon
- Medical Statistics Team, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
| | - Max Bachmann
- Norwich Medical School, Univeristy of East Anglia, Norwich, UK
| | | | | | - John F Potter
- Norwich Medical School, Univeristy of East Anglia, Norwich, UK
- Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research Group, College of Life Sciences and Medicine, University of Aberdeen, Aberdeen, UK
- Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, UK
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