Institutional capacity for health systems research in East and Central African schools of public health: experiences with a capacity assessment tool

BACKGROUND: Despite significant investments in health systems research (HSR) capacity development, there is a dearth of information regarding how to assess HSR capacity. An alliance of schools of public health (SPHs) in East and Central Africa developed a tool for the self-assessment of HSR capacity with the aim of producing institutional capacity development plans. METHODS: Between June and November 2011, seven SPHs across the Democratic Republic of Congo, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda implemented this co-created tool. The objectives of the institutional assessments were to assess existing capacities for HSR and to develop capacity development plans to address prioritized gaps. A mixed-method approach was employed consisting of document analysis, self-assessment questionnaires, in-depth interviews, and institutional dialogues aimed at capturing individual perceptions of institutional leadership, collective HSR skills, knowledge translation, and faculty incentives to engage in HSR. Implementation strategies for the capacity assessment varied across the SPHs. This paper reports findings from semi-structured interviews with focal persons from each SPH, to reflect on the process used at each SPH to execute the institutional assessments as well as the perceived strengths and weaknesses of the assessment process. Results The assessment tool was robust enough to be utilized in its entirety across all seven SPHs resulting in a thorough HSR capacity assessment and a capacity development plan for each SPH. Successful implementation of the capacity assessment exercises depended on four factors: (i) support from senior leadership and collaborators, (ii) a common understanding of HSR, (iii) adequate human and financial resources for the exercise, and (iv) availability of data. Methods of extracting information from the results of the assessments, however, were tailored to the unique objectives of each SPH. Conclusions This institutional HSR capacity assessment tool and the process for its utilization may be valuable for any SPH. The self-assessments, as well as interviews with external stakeholders, provided diverse sources of input and galvanized interest around HSR at multiple levels.DFI

Ontologías en disputa: Diálogos entre la antropología y la arqueología para la problematización de paisajes regionals

Objetivo/contexto: Hacia finales del siglo XX, el dualismo ontológico con el que antropólogos y arqueólogos nos hemos formado teórica y metodológicamente ha sido cuestionado y puesto en debate. En este contexto, nuestro objetivo es exponer críticamente los trabajos que se están realizando y que contribuyen a problematizar los paisajes enredados de existencias, materialidades, saberes, sentidos o prejuicios pasados y presentes, y con ello a restablecer el diálogo entre la antropología social y la arqueología. Metodología: Exponemos el estado actual de la apertura ontológica en clave latinoamericana. Problematizamos la noción de paisaje como concepto que permite diálogos teórico-metodológicos entre la antropología y la arqueología, así como con otras disciplinas. También presentamos ejes de comunicación y diálogo entre los artículos que forman parte del presente dossier para finalizar con los desafíos por delante en cuanto a traspasar fronteras disciplinarias, temporales y espaciales. Conclusiones: En contextos de históricas relaciones de poder, de profundas crisis socio-ambientales, los principales desafíos de la apertura ontológica serían: 1) generar referentes teóricos permeables a diversas disciplinas y saberes; 2) consolidar metodologías que integren lo etnográfico con lo arqueológico; 3) alentar diálogos constructivos hacia y con otras disciplinas y saberes, y 4) propiciar la comprensión del entramado político actual y la generación de políticas públicas que permitan diversas formas de relacionamiento con el entorno. Originalidad: El restablecimiento de diálogos entre la arqueología y la antropología social desde las aperturas ontológicas tiene el potencial de discutir cómo en determinados contextos se concretan y/o disputan paisajes y modos hegemónicos de habitar en el mundo, así como se problematizan los usos políticos del pasado y las políticas de uso del espacio y el ambiente.Objective/context: Towards the end of the 20th century, the ontological dualism with which anthropologists and archaeologists have trained us theoretically and methodologically has been questioned and debated. In this context, our objective is to critically expose the works that are being carried out and that contribute to problematizing the landscapes entangled with past and present existences, materialities, knowledge, senses or prejudices, and, with it, to re-establish the dialogue between social anthropology and archaeology. Methodology: We expose the current state of the ontological opening in Latin American code. We problematize the notion of landscape as a concept that allows theoretical-methodological dialogues between anthropology and archaeology, as well as with other disciplines. We also present axes of communication and dialogue between the articles that are part of this dossier, to end with the challenges ahead in terms of crossing disciplinary, temporal and spatial borders. Conclusions: In contexts of historical power relations, of deep socio-environmental crises, the main challenges for an ontological opening would be: 1) to generate theoretical referents permeable to various disciplines and fields of knowledge; 2) to consolidate methodologies that integrate the ethnographic with the archaeological; 3) to encourage constructive dialogues towards and with other disciplines and fields of knowledge; and 4) to propitiate the understanding of the current political framework and the generation of public policies that allow for diverse forms of relation with the environment. Originality: The re-establishment of dialogues between archaeology and social anthropology from ontological openings has the potential to discuss how, in certain contexts, landscapes and hegemonic ways of living are concretized and/or disputed, as well as the political uses of the past and the policies of use of space and the environment.Objetivo/contexto: No final do século XX, o dualismo ontológico com o qual antropólogos e arqueólogos se formaram teórica e metodologicamente vem sendo questionado e colocado em debate. Nesse contexto, nosso objetivo é expor criticamente os trabalhos que estão sendo realizados e que contribuem para problematizar as paisagens permeadas de existências, materialidades, saberes, sentidos ou preconceitos passados e presentes, e, com isso, reestabelecer o diálogo entre a antropologia social e a arqueologia. Metodologia: Expomos o estado atual da abertura ontológica no âmbito latino-americano. Problematizamos a noção de paisagem como conceito que permite diálogos teórico-metodológicos entre a antropologia e a arqueologia, assim como outras disciplinas. Também apresentamos eixos de comunicação e diálogo entre os artigos que fazem parte do presente dossiê para finalizar com os desafios que temos adiante sobre ultrapassar fronteiras disciplinares, temporais e espaciais. Conclusões: Em contextos de históricas relações de poder, de profundas crises socioambientais, os principais desafios para uma abertura ontológica seriam: 1) gerar referentes teóricos permeáveis a diversas disciplinas e saberes; 2) consolidar metodologias que integrem o etnográfico com o arqueológico; 3) promover diálogos construtivos com outras disciplinas e saberes; e 4) propiciar a compreensão da estrutura política atual e a geração de políticas públicas que permitam as diversas formas de relacionamentos com o ambiente. Originalidade: O reestabelecimento de diálogos entre a arqueologia e a antropologia social a partir das aberturas ontológicas tem o potencial de discutir como, em determinados contextos, se concretizam e/ou disputam paisagens e modos hegemônicos de habitar, bem como se problematizam os usos políticos do passado e as políticas de uso do espaço e do ambiente.Fil: Saldi, Leticia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto Argentino de Nivología, Glaciología y Ciencias Ambientales. Provincia de Mendoza. Instituto Argentino de Nivología, Glaciología y Ciencias Ambientales. Universidad Nacional de Cuyo. Instituto Argentino de Nivología, Glaciología y Ciencias Ambientales; ArgentinaFil: Mafferra, Luis Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto Argentino de Nivología, Glaciología y Ciencias Ambientales. Provincia de Mendoza. Instituto Argentino de Nivología, Glaciología y Ciencias Ambientales. Universidad Nacional de Cuyo. Instituto Argentino de Nivología, Glaciología y Ciencias Ambientales; ArgentinaFil: Barrientos Salinas, J. Alejandro. Universidad Mayor de San Andrés; Bolivi

Etiology and epidemiology of end-stage renal disease in Dutch children 1987-2001.

Contains fulltext : 47449.pdf (publisher's version ) (Closed access)In this retrospective study 351 children (<16.0 years) with end-stage renal disease (ESRD) accepted for renal replacement therapy (RRT) in the four Dutch pediatric centers were analyzed for the period 1987-2001. The data were compared with a previous study performed in 1979-1986. Eighty patients were of non-Dutch origin. An annual ESRD incidence of 5.8 patients per million of the child population (p.m.c.p.) was calculated, without significant changes with time. The final prevalence in Dutch children under 15 years of ESRD was 38.7 p.m.c.p. The most frequent primary renal disease leading to ESRD was urethral valves, with a significant increase vs. the previous observation period (14% vs. 6%). The distribution of primary renal diseases was similar in patients of non-Dutch origin and in Dutch patients. Peritoneal dialysis was the most frequent dialysis procedure initially applied (62% vs. 26% in the earlier observation period). Thirteen percent of all first transplantations (n=278) were pre-emptive and 19% from living donors. Five-year graft survival after a living-donor and a cadaver graft was 80% and 73%, respectively. Overall patient survival after 10 years on RRT was 94%

Efficacy and safety of dapagliflozin in patients with inadequately controlled type 1 diabetes (DEPICT-1):24 week results from a multicentre, double-blind, phase 3, randomised controlled trial

Background Dapagliflozin is a sodium-glucose cotransporter-2 inhibitor approved for the treatment of type 2 diabetes. We aimed to assess the efficacy and safety of dapagliflozin as an add-on to adjustable insulin in patients with inadequately controlled type 1 diabetes. Methods DEPICT-1 was a double-blind, randomised, parallel-controlled, three-arm, phase 3, multicentre study done at 143 sites in 17 countries. Eligible patients were aged 18–75 years and had inadequately controlled type 1 diabetes (HbA1cbetween ≥7·7% and ≤11·0% [≥61·0 mmol/mol and ≤97·0 mmol/mol]) and had been prescribed insulin for at least 12 months before enrolment. After an 8 week lead-in period to optimise diabetes management, patients were randomly assigned (1:1:1) using an interactive voice response system to dapagliflozin 5 mg or 10 mg once daily, given orally, or matched placebo. Randomisation was stratified by current use of continuous glucose monitoring, method of insulin administration, and baseline HbA1c. The primary efficacy outcome was the change from baseline in HbA1cafter 24 weeks of treatment in the full analysis set, which consisted of all randomly assigned patients who received at least one dose of study drug. An additional 55 patients who were incorrectly and non-randomly allocated to only dapagliflozin treatment groups were included in the safety analysis set. This study was registered with ClinicalTrials.gov, number NCT02268214; data collection for the present analysis was completed on Jan 4, 2017, and a 28 week extension phase is ongoing. Findings Between Nov 11, 2014, and April 16, 2016, 833 patients were assigned to treatment groups and included in safety analyses (dapagliflozin 5 mg [n=277] vs dapagliflozin 10 mg [n=296] vs placebo [n=260]; 778 of these patients were randomly assigned and included in the full analysis set for efficacy analyses (259 vs 259 vs 260; difference due to randomisation error affecting 55 patients). Mean baseline HbA1cwas 8·53% (70 mmol/mol; SD 0·67% [7·3 mmol/mol]). At week 24, both doses of dapagliflozin significantly reduced HbA1ccompared with placebo (mean difference from baseline to week 24 for dapagliflozin 5 mg vs placebo was −0·42% [95% CI −0·56 to −0·28; p&lt;0·0001] and for dapagliflozin 10 mg vs placebo was −0·45% [−0·58 to −0·31; p&lt;0·0001]). Among patients in the dapagliflozin 5 mg (n=277), dapagliflozin 10 mg (n=296), and placebo (n=260) groups, the most common adverse events were nasopharyngitis (38 [14%] vs 36 [12%] vs 39 [15%]), urinary tract infection (19 [7%] vs 11 [4%] vs 13 [5%]), upper respiratory tract infection (15 [5%] vs 15 [5%] vs 11 [4%]), and headache (12 [4%] vs 17 [6%] vs 11 [4%]). Hypoglycaemia occurred in 220 (79%), 235 (79%), and 207 (80%) patients in the dapagliflozin 5 mg, dapagliflozin 10 mg, and placebo groups, respectively; severe hypoglycaemia occurred in 21 (8%), 19 (6%), and 19 (7%) patients, respectively. Adjudicated definite diabetic ketoacidosis occurred in four (1%) patients in the dapagliflozin 5 mg group, five (2%) in the dapagliflozin 10 mg group, and three (1%) in the placebo group. Interpretation Our results suggest that dapagliflozin is a promising adjunct treatment to insulin to improve glycaemic control in patients with inadequately controlled type 1 diabetes. Funding AstraZeneca and Bristol-Myers Squibb

Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI) : a phase 3, placebo-controlled, randomised trial

Background: Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. Methods: The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). Findings: Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8–3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74–0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, p interaction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78–1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75–1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48–2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36–3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74–1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75–0·95, p=0·005, in contrast to patients without PCI where it did not, p interaction=0·012. Benefit was present irrespective of time from most recent PCI. Interpretation: In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk