Cost-effectiveness of a Community-based Hypertension Improvement Project (ComHIP) in Ghana: results from a modelling study

OBJECTIVE

To undertake a cost-effectiveness analysis of a Community-based Hypertension Improvement Project (ComHIP) compared with standard hypertension care in Ghana.

DESIGN

Cost-effectiveness analysis using a Markov model.

SETTING

Lower Manya Krobo, Eastern Region, Ghana.

INTERVENTION

We evaluated ComHIP, an intervention with multiple components, including: community-based education on cardiovascular disease (CVD) risk factors and healthy lifestyles; community-based screening and monitoring of blood pressure by licensed chemical sellers and CVD nurses; community-based diagnosis, treatment, counselling, follow-up and referral of hypertension patients by CVD nurses; telemedicine consultation by CVD nurses and referral of patients with severe hypertension and/or organ damage to a physician; information and communication technologies messages for healthy lifestyles, treatment adherence support and treatment refill reminders for hypertension patients; Commcare, a cloud-based health records system linked to short-message service (SMS)/voice messaging for treatment adherence, reminders and health messaging. ComHIP was evaluated under two scale-up scenarios: (1) ComHIP as currently implemented with support from international partners and (2) ComHIP under full local implementation.

MAIN OUTCOME MEASURES

Incremental cost per disability-adjusted life-year (DALY) averted from a societal perspective over a time horizon of 10 years.

RESULTS

ComHIP is unlikely to be a cost-effective intervention, with current ComHIP implementation and ComHIP under full local implementation costing on average US$12 189 and US$6530 per DALY averted, respectively. Results were robust to uncertainty analyses around model parameters.

CONCLUSIONS

High overhead costs and high patient costs in ComHIP suggest that the societal costs of ensuring appropriate hypertension care are high and may not produce sufficient impact to achieve cost-effective implementation. However, these results are limited by the evidence quality of the effectiveness estimates, which comes from observational data rather than from randomised controlled study design.

Using community pharmacies to expand access to screening for noncommunicable diseases in suburban Ghana-A facility-based survey on client needs and acceptability

BACKGROUND

Many of the 28 million deaths from noncommunicable diseases (NCDs) in low- and middle-income countries each year could be prevented through early detection and intervention. The introduction of screening for NCDs in community pharmacies (CPs) in Ghana could enhance access to early detection.

METHODS

We surveyed clients in three districts in suburban Ghana to assess perceived need for screening, willingness to be screened in CPs, and willingness to receive NCD health promotion information through text messages (NCD m-Health). We performed regression analysis to identify predictors of NCD m-Health acceptability.

RESULTS

We interviewed 330 clients in six CPs, 134 (42.3%) of whom were females. The median age was 34 years (interquartile range, 27-43). Fifty-four (16.4%) had no formal education. Although most respondents knew obesity (74.9%), smoking (81.9%), and excessive dietary salt (91.7%) were risk factors for NCDs, only 27.0% knew family history carried similar risk. Most respondents, 61.6% and 70.6%, respectively, had not had their weight and blood pressure (BP) checked for more than 12 months. These included about a third of respondents who were known hypertensives. Similarly, 71.3% of 80 participants with a family history of hypertension had not had their BPs checked. Screening for NCDs in CPs and the sending of NCD m-Health messages was deemed acceptable to 98.5% and 83.1% of the participants, respectively. Formal education beyond junior high school (Grade 9) was the strongest independent predictor of NCD m-Health acceptance (OR = 4.77; 95% CI, 1.72-13.18; P value < 0.01). One hundred and twenty-five (39.4%) participants indicated they would consider unsolicited NCD m-Health messages an invasion of their privacy.

CONCLUSION

An urgent need exists to promote access to NCD screening in these communities. Its introduction into CPs is acceptable to nearly all the clients surveyed. The introduction of NCD m-Health as an accompaniment requires consideration for the privacy of clients.

Gland ducts and multilayered epithelium in mucosal biopsies from gastroesophageal-junction region are useful in characterizing esophageal location

SUMMARY. There is controversy as to whether oxynto-cardiac mucosa (OCM), cardiac mucosa (CM) and intestinal metaplasia (IM) found in the gastroesophageal-junction region line the anatomic stomach, esophagus or both. A total of 785 retroflex biopsies taken at the endoscopic gastroesophageal junction in 244 patients were evaluated for the presence of gland ducts and multilayered epithelium which are two recognized markers of esophageal mucosa. Oxyntic mucosa was found in 287 biopsies, OCM in 283, CM in 158, IM in 30 and squamous epithelium in 53 (some biopsies had more than one epithelial type). Esophageal gland ducts and multilayered epithelium were absent in all biopsies with oxyntic mucosa. Sixty-four (13.6%) of 471 biopsies with OCM, CM and IM contained esophageal gland ducts, and 68 of 471 (14.4%) contained multilayered epithelium. Ninety-eight of 471 (20.8%) biopsies contained either gland ducts or multilayered epithelium. This study shows that 20.8% of biopsies at the gastroesophageal junction with OCM, CM and IM can be definitively characterized as lining the anatomic esophagus by the finding of gland ducts and multilayered epithelium. The absence of these markers in oxyntic mucosa confirms this epithelium as gastric. The presence of gland ducts and multilayered epithelium can be used by pathologists to objectively ascribe an esophageal or gastric location to a biopsy from the gastroesophageal junction.

Distribution and significance of epithelial types in columnar-lined esophagus

An abnormal columnar-lined esophagus (CLE) is characterized by the presence of cardiac mucosa (CM) oxynto-cardiac mucosa (OCM), and intestinal metaplastic epithelium (IM) between gastric oxyntic mucosa and esophageal squamous epithelium. Thirty-two patients with CLE measuring 2-16 cm long had 5-37 biopsies per patient that showed CM, OCM, or IM for a total of 424 biopsies. Detailed mapping of the distribution of epithelial types within the CLE showed a distinct zonation of epithelial types; CM was present throughout the CLE, whereas OCM and IM tended to occur in the distal and proximal part of the CLE, respectively. All 32 patients (64 of 68 biopsies) showed IM at the most proximal level, compared with 22 of 32 patients (40 of 102 biopsies) in the most distal level biopsies. The density of goblet cells was highest in the most proximal level. The differences in prevalence and density of goblet cells between most proximal and most distal level biopsies were highly significant. These data suggest that for a given number of biopsies within the CLE, the likelihood of finding IM is greatest when the biopsies are concentrated in the most proximal area of the CLE. We suggest that glandular transformation of squamous epithelium results in CM. which evolves into OCM and IM by development of specialized parietal cells and goblet cells, respectively. The severity and nature of reflux cause these epithelial transformations in a constant and predictable manner. Recognition of these changes permits the development of morphologic definitions of reflux disease and the characterization of the sequence of epithelial changes that represent the reflux-adenocarcinoma sequence.

Carditis: a manifestation of gastroesophageal reflux disease

This series consists of 141 patients in whom cardiac mucosa (CM) was present in biopsy samples from the gastroesophageal junctional region. Inflammation of CM, irrespective of its exact anatomic location, was defined as carditis and classified as acute or chronic based on the number of inflammatory cells present. In all cases, CM showed significant chronic inflammation. One hundred and eleven (79%) of the 141 patients with carditis showed no evidence of gastritis in biopsy samples from the gastric antrum and body. Helicobacter pylori was present in 20 of 141 (14%) patients; of these, 17 had evidence of a pangastritis, with 15 of these patients also showing H. pylori in CM. Patients with severe chronic inflammation in CM had a significantly higher acid exposure of the lower esophagus as quantitated by a 24-hour pH test than those with mild chronic inflammation in CM. Acute inflammation was uncommon in CM; it was present in only 26 of 141 (18.4%) patients. There was no significant difference in acid exposure of the lower esophagus between patients with and without acute inflammation in CM. The presence of acute inflammation in CM was significantly associated with distal gastritis and H. pylori infection. Men with carditis had quantitatively higher acid exposure of the lower esophagus than did women with this disorder. This difference was greatest in men with severe inflammation in CM who had no evidence of distal gastritis. These findings provide evidence that chronic inflammation in CM is strongly associated with acid reflux and that H. pylori is not a significant etiologic factor in carditis. They also show that in patients with CM in whom H. pylori gastritis develops, the infection frequently spreads to involve CM, resulting in acute inflammation with neutrophils that is superimposed on the chronic inflammation already present.

Histology of the gastroesophageal junction: an autopsy study

Current diagnostic criteria for reflux disease and Barrett's esophagus are based on the belief that the gastroesophageal junction normally contains 2 cm of cardiac mucosa composed of mucous glands devoid of parietal cells. This autopsy study disproves this belief. Even when the entire circumference of the gastroesophageal junction is examined, pure cardiac mucosa was completely absent in 56% of patients. All patients had oxyntocardiac mucosa, in which glands contained a mixture of mucous and parietal cells. Cardiac and oxyntocardiac mucosae were present only in part of the circumference of the junction in 50% of patients. The measured maximum length of cardiac plus oxyntocardiac mucosa was less than 0.5 cm in 76% of patients. There was a tendency for the presence and extent of cardiac mucosa to increase with age. Cardiac mucosa at the junction is therefore frequently absent, has considerable individual variation, is very small in extent when present, is commonly absent from some part of the circumference of the junction, and increases in prevalence and length with age. These characteristics of cardiac mucosa make it highly unlikely that it is a normal structure. We develop the hypothesis that cardiac mucosa represents an early histologic manifestation of gastroesophageal reflux.

Necrotizing fasciitis following laparoscopic surgery. Case report and review of the literature

Necrotizing fasciitis is a rare and potentially fatal infection characterized by rapid and progressive involvement of the fascia and subcutaneous tissues. Early diagnosis, aggressive initial debridement followed by planned redebridements in conjunction with nutritional support and antibiotics remain the mainstay of therapy. We present a case of necrotizing fasciitis of the abdominal wall following a laparoscopically assisted vaginal hysterectomy. Literature is reviewed and discussed with reference to this catastrophic infection in the age of laparoscopic surgery.

Controlling the Magnification Factor of Self-Organizing Feature Maps

The magnification exponents μ occurring in adaptive map formation algorithms like Kohonen's self-organizing feature map deviate for the information theoretically optimal value μ = 1 as well as from the values that optimize, e.g., the mean square distortion error (μ = 1/3 for one-dimensional maps). At the same time, models for categorical perception such as the "perceptual magnet" effect, which are based on topographic maps, require negative magnification exponents μ < 0. We present an extension of the self-organizing feature map algorithm, which utilizes adaptive local learning step sizes to actually control the magnification properties of the map. By change of a single parameter, maps with optimal information transfer, with various minimal reconstruction errors, or with an inverted magnification can be generated. Analytic results on this new algorithm are complemented by numerical simulations.

Effects of lead and cadmium on adrenal and thyroid functions in rats

Seventy sexually mature male rats were injected with lead (50 and 250 mcg), cadmium, (50 and 250 mcg) and a mixture of lead (25 mcg) and cadmium (25 mcg) for 70 days. TSR results show that 250 mcg cadmium had a stimulating effect but 1/10 of the dose of cadmium plus 25 mcg lead had the opposite effect. Plasma thyroid hormones indicated that 50 mcg lead had a stimulating effect on T4 but cadmium and a mixture of lead and cadmium had a suppressing effect on both T4 and T3. Plasma corticosterone and adrenal cortical histology showed increased adrenal function in animals treated with 50 mcg lead, 50 mcg and 250 mcg cadmium and a mixture of lead and cadmium. The data indicated that cadmium had more deleterious effects on thyroid and adrenal function than lead.

Effects of cadium on growth, sexual development, and metabolism in female rats

Female rats were exposed to cadmium by multiple intramuscular injections of 250 mug CaCl2 for 54 days. Activity and haircoat were affected, sores on the sites of injection and persistent diestrus were observed in the treated rats. Morphological examination of organs revealed a smaller weight and size in reproductive organs and pituitary, but enlargement of liver, spleen, and kidney. The ratic enzymatic demethylation activity.

Environmental interaction of lead and cadmium on reproduction and metabolism of male rats

To study the environmental interaction of lead and cadmium on reproduction and metabolism 70 male sprague Dawley rats were divided equally into 7 goups. Goups 1 and 2 served as controls, 3 and 4 were injected daily with 50 and 250 ug of lead respectively, 5 and 6 with 50 and 250 ug of cadmium respectively and group 7 with 25 ug of both lead and cadmium. After 70 days of injections rats were sacrificed. In group 6 cadmium injection caused enlargement of adrenal, liver, kidney and spleen but retarded growth, reduction in size of prostate, testes, epididymis and hepatic enzyme activity. Groups 4 and6 had the highest and most significant mineral concentration in blood and liver. Testes histology of group 7 showed an absence of spermatogenesis in some seminiferous tubules indicating that low levels of lead and cadmium together have a more synergetic damaging effect on rat testes than higher levels of lead or cadmium alone. This study suggests that blood mineral levels should be used with other more sensitive clinical tests to assess the toxicity picture in humans.