Adapting and implementing training, guidelines and treatment cards to improve primary care-based hypertension and diabetes management in a fragile context: results of a feasibility study in Sierra Leone

Background Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention. Methods A mixed-method approach was used for the assessment, including 51 semi-structured interviews, review of routine treatment cards (retrieved for newly registered hypertensive and diabetic patients from June 2018 to March 2019 followed up for three months) and mentoring data, and observation of training. Thematic analysis was used for qualitative data and descriptive trend analysis and t-test was used for quantitative data, wherever appropriate. Results A Technical Working Group, established at district and national level, helped to adapt and develop the context-specific desktop guidelines for clinical management and lifestyle interventions and associated training curriculum and modules for community health officers (CHOs). Following a four-day training of CHOs, focusing on communication skills, diagnosis and management of hypertension and diabetes, and thanks to a CHO-based mentorship strategy, there was observed improvement of NCD knowledge and care processes regarding diagnosis, treatment, lifestyle education and follow up. The intervention significantly improved the average diastolic blood pressure of hypertensive patients (n = 50) three months into treatment (98 mmHg at baseline vs. 86 mmHg in Month 3, P = 0.001). However, health systems barriers typical of fragile settings, such as cost of transport and medication for patients and lack of supply of medications and treatment equipment in facilities, hindered the optimal delivery of care for hypertensive and diabetic patients. Conclusion Our study suggests the potential feasibility of this approach to strengthening primary care delivery of NCDs in fragile contexts. However, the approach needs to be built into routine supervision and pre-service training to be sustained. Key barriers in the health system and at community level also need to be addressed

Effectiveness of interventions to support the early detection of skin cancer through skin self-examination: a systematic review and meta-analysis.

BACKGROUND: As skin cancer incidence rises, there is a need to evaluate early detection interventions by the public using skin self-examination (SSE); however, the literature focuses on primary prevention. No systematic reviews have evaluated the effectiveness of such SSE interventions. OBJECTIVES: To systematically examine, map, appraise and synthesize, qualitatively and quantitatively, studies evaluating the early detection of skin cancer, using SSE interventions. METHODS: This is a systematic review (narrative synthesis and meta-analysis) examining randomized controlled trials (RCTs) and quasiexperimental, observational and qualitative studies, published in English, using PRISMA and National Institute for Health and Care Excellence guidance. The MEDLINE, Embase and PsycINFO databases were searched through to April 2015 (updated in April 2018 using MEDLINE). Risk-of-bias assessment was conducted. RESULTS: Included studies (n = 18), totalling 6836 participants, were derived from 22 papers; these included 12 RCTs and five quasiexperiments and one complex-intervention development. More studies (n = 10) focused on targeting high-risk groups (surveillance) than those at no higher risk (screening) (n = 8). Ten (45%) study interventions were theoretically underpinned. All of the study outcomes were self-reported, behaviour related and nonclinical in nature. Meta-analysis demonstrated the impact of the intervention on the degree of SSE activity from five studies, especially in the short term (up to 4 months) (odds ratio 2·31, 95% confidence interval 1·90-2·82), but with small effect sizes. Risk-of-bias assessment indicated that 61% of the studies (n = 11) were of weak quality. CONCLUSIONS: Four RCTs and a quasiexperimental study indicate that some interventions can enhance SSE activity and so are more likely to aid early detection of skin cancer. However, the actual clinical impact remains unclear, and this is based on overall weak study (evidence) quality

Developing a socio-ecological model of dietary behaviour for people living with diabetes or high blood glucose levels in urban Nepal: A qualitative investigation

Instances of non-communicable diseases such as diabetes are on the rise globally leading to greater morbidity and mortality, with the greatest burden in low and middle income countries [LMIC]. A major contributing factor to diabetes is unhealthy dietary behaviour. We conducted 38 semi structured interviews with patients, health professionals, policy-makers and researchers in Kathmandu, Nepal, to better understand the determinants of dietary behaviour amongst patients with diabetes and high blood glucose levels. We created a social ecological model which is specific to socio-cultural context with our findings with the aim of informing culturally appropriate dietary behaviour interventions for improving dietary behaviour. Our findings show that the most influential determinants of dietary behaviour include cultural practices (gender roles relating to cooking), social support (from family and friends), the political and physical environment (political will, healthy food availability) and individuals’ motivations and capabilities. Using these most influential determinants, we suggest potentially effective dietary interventions that could be implemented by policy makers. Our findings emphasise the importance of considering socio-cultural context in developing interventions and challenges one-size-fits-all approaches which are often encouraged by global guidelines. We demonstrate how multifaceted and multi layered models of behavioural influence can be used to develop policy and practice with the aim of reducing mortality and morbidity from diabetes

Ammonium regeneration: Its contribution to phytoplankton nitrogen requirements in a eutrophic environment

Ammonium regeneration, nutrient uptake, bacterial activity and primary production were measured from March to August 1980 in Bedford Basin, Nova Scotia, Canada, a eutrophic environment. Rates of regeneration and nutrient uptake were determined using 15N isotope dilution and tracer methodology. Although primary production, nutrient uptake and ammonium regeneration were significantly intercorrelated, no relationship was detected between these parameters and heterotrophic activity. The average contribution of ammonium to total nitrogen (ammonium+nitrate) uptake was similar in the spring and in the summer (approximately 60%). On a seasonal average basis, 36% of the phytoplankton ammonium uptake could be supplied by rapid remineralization processes. In spite of the high average contribution of NH4 regeneration to phytoplankton ammonia uptake, there is indirect evidence suggesting that other NH4 sources may occasionally be important

Development and testing of new candidate psoriatic arthritis screening questionnaires combining optimal questions from existing tools

Objective: Several questionnaires have been developed to screen for psoriatic arthritis (PsA), but head-to-head studies have found limitations. This study aimed to develop new questionnaires encompassing the most discriminative questions from existing instruments.<p></p> Methods: Data from the CONTEST study, a head-to-head comparison of 3 existing questionnaires, were used to identify items with a Youden index score of ≥0.1. These were combined using 4 approaches: CONTEST (simple additions of questions), CONTESTw (weighting using logistic regression), CONTESTjt (addition of a joint manikin), and CONTESTtree (additional questions identified by classification and regression tree [CART] analysis). These candidate questionnaires were tested in independent data sets.<p></p> Results: Twelve individual questions with a Youden index score of ≥0.1 were identified, but 4 of these were excluded due to duplication and redundancy. Weighting for 2 of these questions was included in CONTESTw. Receiver operating characteristic (ROC) curve analysis showed that involvement in 6 joint areas on the manikin was predictive of PsA for inclusion in CONTESTjt. CART analysis identified a further 5 questions for inclusion in CONTESTtree. CONTESTtree was not significant on ROC curve analysis and discarded. The other 3 questionnaires were significant in all data sets, although CONTESTw was slightly inferior to the others in the validation data sets. Potential cut points for referral were also discussed.<p></p> Conclusion: Of 4 candidate questionnaires combining existing discriminatory items to identify PsA in people with psoriasis, 3 were found to be significant on ROC curve analysis. Testing in independent data sets identified 2 questionnaires (CONTEST and CONTESTjt) that should be pursued for further prospective testing

Marine diatoms grown in chemostats under silicate or ammonium limitation. III. Cellular chemical composition and morphology of Chaetoceros debilis, Skeletonema costatum , and Thalassiosira gravida

Three marine diatoms, Skeletonema costatum, Chaetoceros debilis , and Thalassiosira gravida were grown under no limitation and ammonium or silicate limitation or starvation. Changes in cell morphology were documented with photomicrographs of ammonium and silicate-limited and non-limited cells, and correlated with observed changes in chemical composition. Cultures grown under silicate starvation or limitation showed an increase in particulate carbon, nitrogen and phosporus and chlorophyll a per unit cell volume compared to non-limited cells; particulate silica per cell volume decreased. Si-starved cells were different from Si-limited cells in that the former contained more particulate carbon and silica per cell volume. The most sensitive indicator of silicate limitation or starvation was the ratio C:Si, being 3 to 5 times higher than the values for non-limited cells. The ratios Si:chlorophyll a and S:P were lower and N:Si was higher than non-limited cells by a factor of 2 to 3. The other ratios, C:N, C:P, C:chlorophyll a , N:chlorophyll a , P:chlorophyll a and N:P were considered not to be sensitive indicators of silicate limitation or starvation. Chlorophyll a , and particulate nitrogen per unit cell volume decreased under ammonium limitation and starvation. NH 4 -starved cells contained more chlorophyll a , carbon, nitrogen, silica, and phosphorus per cell volume than NH 4 -limited cells. N:Si was the most sensitive ratio to ammonium limitation or starvation, being 2 to 3 times lower than non-limited cells. Si:chlorophyll a , P:chlorophyll a and N:P were less sensitive, while the ratios C:N, C:chlorophyll a , N:chlorophyll a , C:Si, C:P and Si:P were the least sensitive. Limited cells had less of the limiting nutrient per unit cell volume than starved cells and more of the non-limiting nutrients (i.e., silica and phosphorus for NH 4 -limited cells). This suggests that nutrient-limited cells rather than nutrient-starved cells should be used along with non-limited cells to measure the full range of potential change in cellular chemical composition for one species under nutrient limitation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/46631/1/227_2004_Article_BF00392568.pd