Background: Road traffic injuries (RTIs) are the eighth leading cause of death worldwide, with an estimated 90% of RTIs occurring in low- and middle-income countries (LMICs) like Brazil. There has been minimal research in evaluation of delays in transport of RTI patients to trauma centers in LMICs. The objective of this study is to determine specific causes of delays in prehospital transport of road traffic injury patients to designated trauma centers in Maringá, Brazil. Methods: A qualitative method was used based on the Consolidated Criteria for Reporting Qualitative Research (COREQ) approach. Eleven health care providers employed at prehospital or hospital settings were interviewed with questions specific to delays in care for RTI patients. A thematic analysis was conducted. Results: Responses to primary causes of delay in treatment to RTI patients fell into the following categories: 1) lack of public education, 2) traffic, 3) insufficient personnel/ambulances, 4) bureaucracy, and 5) poor location of stations. Suggestions for improvement in delays fell into the categories of 1) need for centralized station/avoid traffic, 2) improving public education, 3) Increase personnel, 4) increase ambulances, 5) proper extrication/rapid treatment. Conclusion: Our study found varied responses between hospital and SAMU providers regarding specific causes of delay for RTI patients; SAMU providers cited primarily traffic, bureaucracy, and poor location as primary factors while hospital employees focused more on public health aspects. These results mirror prehospital system challenges in other developing countries, but also provide solutions for improvement with better infrastructure and public health campaigns.
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Christopher A Cleveland;
Kayla B Garrett;
Erin K Box;
Alec T Thompson;
Ellen K Haynes;
Deborah L Elder;
Robert L Richards;
Ania A Majewska;
Sarah Anne J Guagliardo;
Ryan E Wiegand;
John A Bryan, II;
Fernando Torres-Velez;
Karmen Unterwegner;
Mario Romero;
Hubert Zirimwabagabo;
Metinou Sidouin;
Philip Tchindebet Oaukou;
Mbang Mahammat Ada;
Bongo Nare Richard Ngandolo;
Charles Mackenzie;
Timothy G Geary;
Adam J Weiss;
Michael J Yabsley
Dracunculus medinensis (Guinea worm [GW]), a zoonotic nematode targeted for eradication, has been managed using interventions aimed at humans; however, increases in domestic dog GW infections highlight the need for novel approaches. We conducted two clinical trials evaluating the efficacy of subcutaneously injected flubendazole (FBZ) as a treatment of GW infection. The first trial was conducted administering FBZ to experimentally infected ferrets; the second trial involved administering FBZ or a placebo to domestic dogs in the Republic of Tchad (Chad). We found contrasting results between the two trials. When adult gravid female GW were recovered from ferrets treated with FBZ, larvae presented in poor condition, with low to no motility, and an inability to infect copepods. Histopathology results indicated a disruption to morulae development within uteri of worms from treated animals. Results from the trial in Chadian dogs failed to indicate significant treatment of or prevention against GW infection. However, the difference in treatment intervals (1 month for ferrets and 6 months for dogs) or the timing of treatment (ferrets were treated later in the GW life-cycle than dogs) could explain different responses to the subcutaneous FBZ injections. Both trials provided valuable data guiding the use of FBZ in future trials (such as decreasing treatment intervals or increasing the dose of FBZ in dogs to increase exposure), and highlighted important lessons learned during the implementation of a field-based, double-blinded randomized control trial in Chadian dogs.
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Jesmin Pervin;
Allisyn Moran;
Monjur Rahman;
Abdur Razzaque;
Lynn Sibley;
Peter K. Streatfield;
Laura J. Reichenbach;
Marge Koblinsky;
Daniel Hruschka;
Anisur Rahman
Background: Antenatal Care (ANC) during pregnancy can play an important role in the uptake of evidence-based services vital to the health of women and their infants. Studies report positive effects of ANC on use of facility-based delivery and perinatal mortality. However, most existing studies are limited to cross-sectional surveys with long recall periods, and generally do not include population-based samples.
Methods: This study was conducted within the Health and Demographic Surveillance System (HDSS) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Matlab, Bangladesh. The HDSS area is divided into an icddr,b service area (SA) where women and children receive care from icddr,b health facilities, and a government SA where people receive care from government facilities. In 2007, a new Maternal, Neonatal, and Child Health (MNCH) program was initiated in the icddr,b SA that strengthened the ongoing maternal and child health services including ANC. We estimated the association of ANC with facility delivery and perinatal mortality using prospectively collected data from 2005 to 2009. Using a before-after study design, we also determined the role of ANC services on reduction of perinatal mortality between the periods before (2005 - 2006) and after (2008-2009) implementation of the MNCH program.
Results: Antenatal care visits were associated with increased facility-based delivery in the icddr,b and government SAs. In the icddr,b SA, the adjusted odds of perinatal mortality was about 2-times higher (odds ratio (OR) 1.91; 95% confidence intervals (CI): 1.50, 2.42) among women who received ≤1 ANC compared to women who received ≥3 ANC visits. No such association was observed in the government SA. Controlling for ANC visits substantially reduced the observed effect of the intervention on perinatal mortality (OR 0.64; 95% CI: 0.52, 0.78) to non-significance (OR 0.81; 95% CI: 0.65, 1.01), when comparing cohorts before and after the MNCH program initiation (Sobel test of mediation P < 0.001).
Conclusions: ANC visits are associated with increased uptake of facility-based delivery and improved perinatal survival in the icddr,b SA. Further testing of the icddr,b approach to simultaneously improving quality of ANC and facility delivery care is needed in the existing health system in Bangladesh and in other low-income countries to maximize health benefits to mothers and newborns.
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Sean van Diepen;
Saket Girotra;
Benjamin S. Abella;
Lance B. Becker;
Bentley J. Bobrow;
Paul S. Chan;
Carol Fahrenbruch;
Christopher B. Granger;
James G. Jollis;
Bryan McNally;
Lindsay White;
Demetris Yannopoulos;
Thomas D. Rea
BACKGROUND: The HeartRescue Project is a multistate public health initiative focused on establishing statewide out-of-hospital cardiac arrest (OHCA) systems of care to improve case capture and OHCA care in the community, by emergency medical services (EMS), and at hospital level. METHODS AND RESULTS: From 2011 to 2015 in the 5 original HeartRescue states, all adults with EMS-treated OHCA due to a presumed cardiac cause were included. In an adult population of 32.8 million, a total of 64 988 OHCAs-including 10 046 patients with a bystander-witnessed OHCA with a shockable rhythm-were treated by 330 EMS agencies. From 2011 to 2015, the case-capture rate for all-rhythm OHCA increased from an estimated 39.0% (n=6762) to 89.2% (n=16 103; P<0.001 for trend). Overall survival to hospital discharge was 11.4% for all rhythms and 34.0% in the subgroup with bystander-witnessed OHCA with a shockable rhythm. We observed modest temporal increases in bystander cardiopulmonary resuscitation (41.8-43.5%, P<0.001 for trend) and bystander automated external defibrillator application (3.2-5.6%, P<0.001 for trend) in the all-rhythm group, although there were no temporal changes in survival. There were marked all-rhythm survival differences across the 5 states (8.0-16.1%, P<0.001) and across participating EMS agencies (2.7-26.5%, P<0.001). CONCLUSIONS: In the initial 5 years, the HeartRescue Project developed a population-based OHCA registry and improved statewide case-capture rates and some processes of care, although there were no early temporal changes in survival. The observed survival variation across states and EMS systems presents a future challenge to elucidate the characteristics of high-performing systems with the goal of improving OHCA care and survival.
Introduction Rapid growth of the older adult population requires greater epidemiologic characterization of dementia. We developed national prevalence estimates of diagnosed dementia and subtypes in the highest risk United States (US) population. Methods We analyzed Centers for Medicare & Medicaid administrative enrollment and claims data for 100% of Medicare fee-for-service beneficiaries enrolled during 2011–2013 and age ≥68 years as of December 31, 2013 (n = 21.6 million). Results Over 3.1 million (14.4%) beneficiaries had a claim for a service and/or treatment for any dementia subtype. Dementia not otherwise specified was the most common diagnosis (present in 92.9%). The most common subtype was Alzheimer's (43.5%), followed by vascular (14.5%), Lewy body (5.4%), frontotemporal (1.0%), and alcohol induced (0.7%). The prevalence of other types of diagnosed dementia was 0.2%. Discussion This study is the first to document concurrent prevalence of primary dementia subtypes among this US population. The findings can assist in prioritizing dementia research, clinical services, and caregiving resources.
Social networks are believed to affect health-related behaviors and health. Data to examine the links between social relationships and health in low- and middle-income country settings are limited. We provide guidance for introducing an instrument to collect social network data as part of epidemiological surveys, drawing on experience in urban India. We describe development and fielding of an instrument to collect social network information relevant to health behaviors among adults participating in a large, population-based study of non-communicable diseases in Delhi, India. We discuss basic characteristics of social networks relevant to health including network size, health behaviors of network partners (i.e., network exposures), network homogeneity, network diversity, strength of ties, and multiplexity. Data on these characteristics can be collected using a short instrument of 11 items asked about up to 5 network members and 3 items about the network generally, administered in approximately 20 minutes. We found high willingness to respond to questions about social networks (97% response). Respondents identified an average of 3.8 network members, most often relatives (80% of network ties), particularly blood relationships. Ninety-one percent of respondents reported that their primary contacts for discussing health concerns were relatives. Among all listed ties, 91% of most frequent snack partners and 64% of exercise partners in the last two weeks were relatives. These results demonstrate that family relationships are the crux of social networks in some settings, including among adults in urban India. Collecting basic information about social networks can be feasibly and effectively done within ongoing epidemiological studies.
Background: Total body iron (TBI) that is calculated from ferritin and soluble transferrin receptor (sTfR) allows for the evaluation of the full range of iron status from deficiency to excess. However, both ferritin and sTfR are affected by inflammation and malaria, which may require a statistical adjustment. TBI has been used to assess iron status in the United States, but its use worldwide and in settings with inflammation has been limited.Objective: We examine whether inflammation-adjusted ferritin and sTfR concentrations affect TBI values and the prevalence of low TBI ( < 0 mg/kg) in preschool children (PSC) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y).Design: Cross-sectional data for PSC (8 surveys; n = 8413) and WRA (4 surveys; n = 4258) from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and combined. TBI and the prevalence of low TBI were compared following 3 adjustment approaches for ferritin and sTfR: 1) the exclusion of individuals with inflammation (C-reactive protein concentration > 5 mg/L or α-1-acid glycoprotein concentration > 1 g/L), 2) the application of arithmetic correction factors, and 3) the use of regression correction.Results: Regardless of the method that was used to adjust ferritin and sTfR for inflammation, the adjusted mean TBI decreased in both PSC and WRA compared with unadjusted values. Subsequently, inflammation-adjusted TBI increased the prevalence of low TBI by a median of 4-14 percentage points (pps) in PSC and 1-3 pps in WRA compared with unadjusted TBI. The regression approach resulted in a greater median increase than was achieved with the exclusion or correction-factor approaches, and accounting for malaria in addition to inflammation did not have an added effect on the prevalence estimates.Conclusion: The prevalence of low TBI is underestimated if it is not adjusted by inflammation, particularly in children living in areas with a high prevalence of inflammation.
Purpose: We evaluate the bidirectional association between urological symptoms (urinary incontinence, lower urinary tract symptoms and nocturia) and sleep related variables. Materials and Methods: Data were obtained from a prospective cohort study of 1,610 men and 2,535 women who completed baseline (2002 to 2005) and followup (2006 to 2010) phases of the BACH (Boston Area Community Health) Survey, a population based random sample survey. Sleep restriction (5 hours or less per night), restless sleep, sleep medication use and urological symptoms were assessed by self-report. Urinary incontinence was defined as weekly leakage or moderate/severe leakage, lower urinary tract symptoms (overall, obstructive, irritative) were defined by the AUA-SI (American Urological Association symptom index) and nocturia was defined as urinary frequency 2 or more times per night. Results: At the 5-year followup 10.0%, 8.5% and 16.0% of subjects newly reported lower urinary tract symptoms, urinary incontinence and nocturia, respectively, and 24.2%, 13.3% and 11.6% newly reported poor sleep quality, sleep restriction and use of sleep medication, respectively. Controlling for confounders, the odds of urological symptoms developing were consistently increased for subjects who reported poor sleep quality and sleep restriction at baseline, but only baseline nocturia was positively associated with incident sleep related problems at followup. Body mass index, a potential mediator, reduced selected associations between sleep and incident urinary incontinence and irritative symptoms, but C-reactive protein did not. Conclusions: These data suggest that self-reported sleep related problems and urological symptoms are linked bidirectionally, and that body mass index may be a factor in the relationship between sleep and the development of urological symptoms.
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Douglas Roblin;
Joshua Barzilay;
Dennis Tolsma;
Brandi Robinson;
Laura Schild;
Lee Cromwell;
Hayley Braun;
Rebecca Nash;
Joseph Gerth;
Enid Hunkeler;
Virginia P. Quinn;
Vin Tangpricha;
Michael Goodman
Purpose: We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system. Methods: A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews. Results: Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014. Conclusions: The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.