Perioperative mortality: Analysis of 3 years of operative data across 7 general surgical projects of Médecins Sans Frontières in Democratic Republic of Congo, Central African Republic, and South Sudan.

BACKGROUND: The African continent has the greatest burden of surgical disability-adjusted life years, yet the least is known about operative care here. This analysis describes the surgical patients admitted to 7 hospitals supported by the Médécins Sans Frontières (MSF) over 3 years in 3 conflict-affected countries-Eastern Democratic Republic of Congo, Central African Republic, and South Sudan. METHODS: A standardized operative data collection tool was used for routine collection of operative inpatient data between 2011 and 2013 at 7 MSF surgical facilities. Surgical records of 14,482 patients were analyzed to describe surgical epidemiology, major procedures, and perioperative mortality. The perioperative mortality rate (POMR) was calculated within 2 days of admission (POMR2) and within 30 days from admission (POMR30). The POMR is used as a marker of quality of operative care. RESULTS: Caesarean delivery was the most common major procedure performed and had a POMR30 of 5.28 per 1,000 admissions. The overall inpatient mortality was 19.67 per 1,000 admissions. Children had greater POMR than adults for the same procedure types (47.97 vs 15.89 deaths per 1,000 admissions, P < .001); 85.1% of all major procedures were emergency procedures and between 3 and 30% of admissions were related to violence. After adjustment, perioperative death was associated with emergency surgery, violence, and age younger than 15 years. CONCLUSION: POMRs varied by age group and type of major procedure performed. Collecting surgical data is achievable and can inform future planning and support for national surgical programs. More information is needed on operative outcomes in adults and children in low-resource settings to improve quality and access to care

Alcohol-specific activity in hospitals in England

Alcohol-related harm is placing increasing demands on the NHS. At a time when unprecedented efficiencies need to be made by the NHS and local authorities, preventative action must be taken seriously. This analysis explores trends in alcohol-specific activity in hospitals due to alcohol poisoning and alcohol-related inpatient admissions by looking at six years of hospital activity data in England. The analysis also explores the use of hospital services before and after a diagnosis of alcohol-related liver disease and highlights opportunities for preventative action to reduce future alcohol-related harm in England

‘They treat us like machines’: migrant workers’ conceptual framework of labour exploitation for health research and policy

Background: The exploitation of migrant workers ranks high on global political agendas including the Sustainable Development Goals. Research on exploited workers, using assessment tools where exploitation is defined by professional experts, indicates serious health concerns and needs. Yet, migrant workers are rarely asked about their understanding of a phenomenon they may experience. Our study aimed to conceptualise ‘labour exploitation’ from the perspective of migrant workers employed in manual low-skilled jobs. Methods: Twenty-seven Latin Americans working in London (UK) participated in Group Concept Mapping; a participatory mixed-method where qualitative data are collected to define a concept’s content and then analysed using quantitative methods to generate a structured conceptual framework. Participants generated statements describing the concept content during brainstorming sessions, and structured them during sorting-rating exercises. Multi-Dimensional Scaling and Cluster Analysis were performed, generating a conceptual framework that clarified the dimensions, subdimensions and constituent statements of the concept of labour exploitation from migrant workers’ perspectives. Results: Three key dimensions were identified: ‘poor employment conditions and lack of protection’, covering contractual arrangements and employment relations; ‘disposability and abuse of power’ (or ‘dehumanisation’) covering mechanisms or means which make migrant workers feel disposable and abused; and ‘health and safety and psychosocial hazards’ encompassing issues from physical and psychosocial hazards to a lack of health and social protection. ‘Dehumanisation’ has not been included in mainstream tools assessing exploitation, despite its importance for study participants who also described harsh situations at work including sexual, physical and verbal abuse. Conclusion: Our study provides a conceptual framework of labour exploitation that gives voice to migrant workers and can be operationalised into a measure of migrant labour exploitation. It also calls for the dimension ‘dehumanisation’ and structural forms of coercion to be integrated into mainstream conceptualisations, and their workplace hazards to be urgently addressed

The value of theory in programmes to implement clinical guidelines: Insights from a retrospective mixed-methods evaluation of a programme to increase adherence to national guidelines for chronic disease in primary care.

BACKGROUND: Programmes have had limited success in improving guideline adherence for chronic disease. Use of theory is recommended but is often absent in programmes conducted in 'real-world' rather than research settings. MATERIALS AND METHODS: This mixed-methods study tested a retrospective theory-based approach to evaluate a 'real-world' programme in primary care to improve adherence to national guidelines for chronic obstructive pulmonary disease (COPD). Qualitative data, comprising analysis of documents generated throughout the programme (n>300), in-depth interviews with planners (clinicians, managers and improvement experts involved in devising, planning, and implementing the programme, n = 14) and providers (practice clinicians, n = 14) were used to construct programme theories, experiences of implementation and contextual factors influencing care. Quantitative analyses comprised controlled before-and-after analyses to test 'early' and evolved' programme theories with comparators grounded in each theory. 'Early' theory predicted the programme would reduce emergency hospital admissions (EHA). It was tested using national analysis of standardized borough-level EHA rates between programme and comparator boroughs. 'Evolved' theory predicted practices with higher programme participation would increase guideline adherence and reduce EHA and costs. It was tested using a difference-in-differences analysis with linked primary and secondary care data to compare changes in diagnosis, management, EHA and costs, over time and by programme participation. RESULTS: Contrary to programme planners' predictions in 'early' and 'evolved' programme theories, admissions did not change following the programme. However, consistent with 'evolved' theory, higher guideline adoption occurred in practices with greater programme participation. CONCLUSIONS: Retrospectively constructing theories based on the ideas of programme planners can enable evaluators to address some limitations encountered when evaluating programmes without a theoretical base. Prospectively articulating theory aided by existing models and mid-range implementation theories may strengthen guideline adoption efforts by prompting planners to scrutinise implementation methods. Benefits of deriving programme theory, with or without the aid of mid-range implementation theories, however, may be limited when the evidence underpinning guidelines is flawed

Monitoring and Evaluating Psychosocial Intervention Outcomes in Humanitarian Aid.

Existing tools for evaluating psychosocial interventions (un-validated self-reporting questionnaires) are not ideal for use in non-Western conflict settings. We implement a generic method of treatment evaluation, using client and counsellor feedback, in 18 projects in non-Western humanitarian settings. We discuss our findings from the perspective of validity and suggestions for future research. A retrospective analysis is executed using data gathered from psychosocial projects. Clients (n = 7,058) complete two (complaints and functioning) rating scales each session and counsellors rate the client's status at exit. The client-completed pre- and post-intervention rating scales show substantial changes. Counsellor evaluation of the clients' status shows a similar trend in improvement. All three multivariable models for each separate scale have similar associations between the scales and the investigated variables despite different cultural settings. The validity is good. Limitations are: ratings give only a general impression and clinical risk factors are not measured. Potential ceiling effects may influence change of scales. The intra and inter-rater reliability of the counsellors' rating is not assessed. The focus on client and counsellor perspectives to evaluate treatment outcome seems a strong alternative for evaluation instruments frequently used in psychosocial programming. The session client rated scales helps client and counsellor to set mutual treatment objectives and reduce drop-out risk. Further research should test the scales against a cross-cultural valid gold standard to obtain insight into their clinical relevance

Prevalence of anxiety, depression and post-traumatic stress disorder in the Kashmir Valley.

BACKGROUND: Following the partition of India in 1947, the Kashmir Valley has been subject to continual political insecurity and ongoing conflict, the region remains highly militarised. We conducted a representative cross-sectional population-based survey of adults to estimate the prevalence and predictors of anxiety, depression and post-traumatic stress disorder (PTSD) in the 10 districts of the Kashmir Valley. METHODS: Between October and December 2015, we interviewed 5519 out of 5600 invited participants, ≥18 years of age, randomly sampled using a probability proportional to size cluster sampling design. We estimated the prevalence of a probable psychological disorder using the Hopkins Symptom Checklist (HSCL-25) and the Harvard Trauma Questionnaire (HTQ-16). Both screening instruments had been culturally adapted and translated. Data were weighted to account for the sampling design and multivariate logistic regression analysis was conducted to identify risk factors for developing symptoms of psychological distress. FINDINGS: The estimated prevalence of mental distress in adults in the Kashmir Valley was 45% (95% CI 42.6 to 47.0). We identified 41% (95% CI 39.2 to 43.4) of adults with probable depression, 26% (95% CI 23.8 to 27.5) with probable anxiety and 19% (95% CI 17.5 to 21.2) with probable PTSD. The three disorders were associated with the following characteristics: being female, over 55 years of age, having had no formal education, living in a rural area and being widowed/divorced or separated. A dose-response association was found between the number of traumatic events experienced or witnessed and all three mental disorders. INTERPRETATION: The implementation of mental health awareness programmes, interventions aimed at high risk groups and addressing trauma-related symptoms from all causes are needed in the Kashmir Valley

Evaluation of HIV testing algorithms in Ethiopia: the role of the tie-breaker algorithm and weakly reacting test lines in contributing to a high rate of false positive HIV diagnoses.

BACKGROUND: In Ethiopia a tiebreaker algorithm using 3 rapid diagnostic tests (RDTs) in series is used to diagnose HIV. Discordant results between the first 2 RDTs are resolved by a third 'tiebreaker' RDT. Médecins Sans Frontières uses an alternate serial algorithm of 2 RDTs followed by a confirmation test for all double positive RDT results. The primary objective was to compare the performance of the tiebreaker algorithm with a serial algorithm, and to evaluate the addition of a confirmation test to both algorithms. A secondary objective looked at the positive predictive value (PPV) of weakly reactive test lines. METHODS: The study was conducted in two HIV testing sites in Ethiopia. Study participants were recruited sequentially until 200 positive samples were reached. Each sample was re-tested in the laboratory on the 3 RDTs and on a simple to use confirmation test, the Orgenics Immunocomb Combfirm® (OIC). The gold standard test was the Western Blot, with indeterminate results resolved by PCR testing. RESULTS: 2620 subjects were included with a HIV prevalence of 7.7%. Each of the 3 RDTs had an individual specificity of at least 99%. The serial algorithm with 2 RDTs had a single false positive result (1 out of 204) to give a PPV of 99.5% (95% CI 97.3%-100%). The tiebreaker algorithm resulted in 16 false positive results (PPV 92.7%, 95% CI: 88.4%-95.8%). Adding the OIC confirmation test to either algorithm eliminated the false positives. All the false positives had at least one weakly reactive test line in the algorithm. The PPV of weakly reacting RDTs was significantly lower than those with strongly positive test lines. CONCLUSION: The risk of false positive HIV diagnosis in a tiebreaker algorithm is significant. We recommend abandoning the tie-breaker algorithm in favour of WHO recommended serial or parallel algorithms, interpreting weakly reactive test lines as indeterminate results requiring further testing except in the setting of blood transfusion, and most importantly, adding a confirmation test to the RDT algorithm. It is now time to focus research efforts on how best to translate this knowledge into practice at the field level. TRIAL REGISTRATION: Clinical Trial registration #: NCT01716299

Accounting for False Positive HIV Tests: Is Visceral Leishmaniasis Responsible?

BACKGROUND: Co-infection with HIV and visceral leishmaniasis is an important consideration in treatment of either disease in endemic areas. Diagnosis of HIV in resource-limited settings relies on rapid diagnostic tests used together in an algorithm. A limitation of the HIV diagnostic algorithm is that it is vulnerable to falsely positive reactions due to cross reactivity. It has been postulated that visceral leishmaniasis (VL) infection can increase this risk of false positive HIV results. This cross sectional study compared the risk of false positive HIV results in VL patients with non-VL individuals. METHODOLOGY/PRINCIPAL FINDINGS: Participants were recruited from 2 sites in Ethiopia. The Ethiopian algorithm of a tiebreaker using 3 rapid diagnostic tests (RDTs) was used to test for HIV. The gold standard test was the Western Blot, with indeterminate results resolved by PCR testing. Every RDT screen positive individual was included for testing with the gold standard along with 10% of all negatives. The final analysis included 89 VL and 405 non-VL patients. HIV prevalence was found to be 12.8% (47/ 367) in the VL group compared to 7.9% (200/2526) in the non-VL group. The RDT algorithm in the VL group yielded 47 positives, 4 false positives, and 38 negatives. The same algorithm for those without VL had 200 positives, 14 false positives, and 191 negatives. Specificity and positive predictive value for the group with VL was less than the non-VL group; however, the difference was not found to be significant (p = 0.52 and p = 0.76, respectively). CONCLUSION: The test algorithm yielded a high number of HIV false positive results. However, we were unable to demonstrate a significant difference between groups with and without VL disease. This suggests that the presence of endemic visceral leishmaniasis alone cannot account for the high number of false positive HIV results in our study

Risk factors for diagnosed noma in northwest Nigeria: A case-control study, 2017

Background Noma (cancrum oris), a neglected tropical disease, rapidly disintegrates the hard and soft tissue of the face and leads to severe disfiguration and high mortality. The disease is poorly understood. We aimed to estimate risk factors for diagnosed noma to better guide existing prevention and treatment strategies using a case-control study design. Methods Cases were patients admitted between May 2015 and June 2016, who were under 15 years of age at reported onset of the disease. Controls were individuals matched to cases by village, age and sex. Caretakers answered the questionnaires. Risk factors for diagnosed noma were estimated by calculating unadjusted and adjusted odds ratios (ORs) and respective 95% confidence intervals (CI) using conditional logistic regression. Findings We included 74 cases and 222 controls (both median age 5 (IQR 3, 15)). Five cases (6.5%) and 36 (16.2%) controls had a vaccination card (p = 0.03). Vaccination coverage for polio and measles was below 7% in both groups. The two main reported water sources were a bore hole in the village (cases n = 27, 35.1%; controls n = 63, 28.4%; p = 0.08), and a well in the compound (cases n = 24, 31.2%; controls n = 102, 45.9%; p = 0.08). The adjusted analysis identified potential risk and protective factors for diagnosed noma which need further exploration. These include the potential risk factor of the child being fed pap every day (OR 9.8; CI 1.5, 62.7); and potential protective factors including the mother being the primary caretaker (OR 0.08; CI 0.01, 0.5); the caretaker being married (OR 0.006; CI 0.0006, 0.5) and colostrum being given to the baby (OR 0.4; CI 0.09, 2.09). Interpretation This study suggests that social conditions and infant feeding practices are potentially associated with being a diagnosed noma case in northwest Nigeria; these findings warrant further investigation into these factors