Estimating the risk of mortality attributable to recent late HIV diagnosis following admission to the intensive care unit: A single-centre observational cohort study

OBJECTIVES: Despite improvements in survival of people with HIV admitted to the intensive care unit (ICU), late diagnosis continues to contribute to in-ICU mortality. We quantify the population attributable fraction (PAF) of in-ICU mortality for recent late diagnosis among people with HIV admitted to a London ICU. METHODS: Index ICU admissions among people with HIV were considered from 2000 to 2019. Recent late diagnosis was a CD4 T-cell count < 350 cells/μL and/or AIDS-defining illness at/within 6 months prior to ICU admission. Univariate comparisons were conducted using Wilcoxon rank-sum/Cochran-Armitage/χ2 /Fisher's exact tests. We used Poisson regression (robust standard errors) to estimate unadjusted/adjusted (age, sex, calendar year of ICU admission) risk ratios (RRs) and regression standardization to estimate the PAF. RESULTS: In all, 207 index admissions were included [median (interquartile range) age: 46 (38-53) years; 72% male]; 58 (28%) had a recent late diagnosis, all of whom had a CD4 count < 350 cells/μL, and 95% had advanced HIV (CD4 count < 200 cells/μL and/or AIDS at admission) as compared with 57% of those who did not have a recent late diagnosis (p < 0.001). In-ICU mortality was 27% (55/207); 38% versus 22% in those who did and did not have a recent late diagnosis, respectively (p = 0.02). Recent late diagnosis was independently associated with increased in-ICU mortality risk (adjusted RR = 1.75) (95% confidence interval: 1.05-2.91), with 17.08% (16.04-18.12%) of deaths being attributable to this. CONCLUSIONS: There is a need for improved public health efforts focused on HIV testing and reporting of late diagnosis to better understand potentially missed opportunities for earlier HIV diagnosis in healthcare services

Rigor and Ethics in the World of Big-team Qualitative Data: Experiences From Research in International Development

In the large international projects where many qualitative researchers work, generating qualitative Big Data, data sharing represents the status quo. This is rarely acknowledged, even though the ethical implications are considerable and span both process and product. I argue that big-team qualitative researchers can strengthen claims to rigor in analysis (the product) by drawing on a growing body of knowledge about how to do credible secondary analysis. Since this necessitates a full account of how the research and the analysis are done (the process), I consider the structural disincentives for providing these. Debates around credibility and rigor are not new to qualitative research in international development, but they intensify when new actors such as program evaluators and quantitative researchers use qualitative methods on a large scale. In this context, I look at the utility of guidelines used by these actors to ensure the quality of qualitative research. I ask whether these offer pragmatic suggestions to improve its quality, recognizing the common and hierarchized separation between the generation and interpretation of data, or conversely, whether they set impossible standards and fail to recognize the differences between and respective strengths of qualitative and quantitative research

Using evidence-informed logic models to bridge methods in educational evaluation

Designs combining different types of data are increasingly used in educational evaluation, to provide both evidence of impact and an explanation of the processes by which impacts are created. Logic models are visual representations of how an intervention leads via a set of steps from resources and inputs to outputs and then sets of outcomes. Their use has become widespread to underpin evaluations; and they have become of more interest in education as they have been promoted by policy makers and funders including the Education Endowment Foundation (EEF) in England. This paper addresses the question: how can logic models be used to frame and implement educational evaluations using combinations of methods? To do so, the paper draws on theory-based evaluation literature to identify a set of issues to be considered: the role of implementation logic; causal mechanisms; the context of interventions; and the importance of considering and addressing issues around complexity. Using detailed examples from two study designs for EEF evaluations, the paper presents an evidence-informed logic model approach to deal with these issues. The paper concludes by reflecting on the practical and theoretical implications of this approach, laying out a set of key issues to address in future evaluations for which a design framed by an evidence-informed logic model may be appropriate

Emergency management in health: key issues and challenges in the UK

Background Emergency planning in the UK has grown considerably in recent years, galvanised by the threat of terrorism. However, deficiencies in NHS emergency planning were identified and the evidence-base that underpins it is questionable. Inconsistencies in terminologies and concepts also exist. Different models of emergency management exist internationally but the optimal system is unknown. This study examines the evidence-base and evidence requirements for emergency planning in the UK health context. Methods The study involved semi-structured interviews with key stakeholders and opinion leaders. Purposive sampling was used to obtain a breadth of views from various agencies involved in emergency planning and response. Interviews were then analysed using a grounded approach using standard framework analysis techniques. Results We conducted 17 key informant interviews. Interviewees identified greater gaps in operational than technical aspects of emergency planning. Social and behavioural knowledge gaps were highlighted with regards to how individuals and organisations deal with risk and behave in emergencies. Evidence-based approaches to public engagement and for developing community resilience to disasters are lacking. Other gaps included how knowledge was developed and used. Conflicting views with regards to the optimal configuration and operation of the emergency management system were voiced. Conclusions Four thematic categories for future research emerged: (i) Knowledge-base for emergency management: Further exploration is needed of how knowledge is acquired, valued, disseminated, adopted and retained. (ii) Social and behavioural issues: Greater understanding of how individuals approach risk and behave in emergencies is required. (iii) Organisational issues in emergencies: Several conflicting organisational issues were identified; value of planning versus plans, flexible versus standardized procedures, top-down versus bottom-up engagement, generic versus specific planning, and reactive versus proactive approaches to emergencies. (iv) Emergency management system: More study is required of system-wide issues relating to system configuration and operation, public engagement, and how emergency planning is assessed

Selection acting on genomes

C. K. is supported by a grant of the Vienna Science and Technology Fund (WWTF—MA016-061). M. A. receives funding from the Swiss National Science Foundation (grant 31003A_176316).Populations evolve as mutations arise in individual organisms and, through hereditary transmission, may become “fixed” (shared by all individuals) in the population. Most mutations are lethal or have negative fitness consequences for the organism. Others have essentially no effect on organismal fitness and can become fixed through the neutral stochastic process known as random drift. However, mutations may also produce a selective advantage that boosts their chances of reaching fixation. Regions of genomes where new mutations are beneficial, rather than neutral or deleterious, tend to evolve more rapidly due to positive selection. Genes involved in immunity and defense are a well-known example; rapid evolution in these genes presumably occurs because new mutations help organisms to prevail in evolutionary “arms races” with pathogens. In recent years genome-wide scans for selection have enlarged our understanding of the genome evolution of various species. In this chapter, we will focus on methods to detect selection on the genome. In particular, we will discuss probabilistic models and how they have changed with the advent of new genome-wide data now available.Publisher PD

Moving from war to peace in the Zambia–Angola borderlands

This paper explores the changing relationship between the people of North-Western Zambia and the nearby border with Angola, focusing on the period as Angola has moved from war to peace. Drawing on research conducted between 1996 and 2010, the paper examines how people&#x2019;s interactions with the border have changed, focusing on their cross-border livelihoods, identities and mobility. With the end of the war and the rehabilitation of the formal border crossing, legal restrictions and practical obstacles to movement have relaxed; at the same time, the conventions &#x2013; based on informal, 'illicit&#x2019; understandings between local officials and inhabitants on both sides of the border &#x2013; that operated for many years have been undermined. Hence, there has simultaneously been both an 'opening&#x2019; and 'closing&#x2019; of the border. Moreover, the breaking of these conventions since the end of the war has reduced the size of the zone of informal exchange and hybridity, or borderlands

Re-launching migration systems

The concept of the migration system, first popularised in the 1970s, has remained a staple component of any review of migration theory. Since then, it has been cast somewhat adrift from its conceptual moorings; today in the literature migration systems are generally either conflated with migrant networks or elevated to the heights of macro-level abstraction which divorces them from any empirical basis. At the same time, by taking on board more sophisticated notions of agency, emergence, and social mechanisms, the broader concept of the social system has moved on from the rather discredited structural-functionalist marina where it was first launched. In recent years, having been rejected by many social theorists, the social system has been subject to major reconstruction prior to its re-launch as a respectable and valuable area of social enquiry. This paper argues that, for the most part, these developments in systems theory have been ignored by those applying the concept of systems to the analysis of migration. It addresses the question of how the concept of the migration system can be reformulated in the light of these theoretical advances and what implications this may have for our research and analysis