Case 2 : Saving the Rural Ontario Maternity Services – Can We Do It?

Inaya, manager of the ‘low-risk’ project at Provincial Council for Maternal and Child Health (PCMCH), had to come up with an integrative solution for the issues encompassing maternity care in Ontario. The low-risk project aims “to design and develop effective low risk maternal and newborn strategy for Ontario (2015-2018) to ensure that all women have an equitable choice of delivery options, and access to the right level of care at the right time, no matter where they live in the province”. In response to external and internal challenges facing Ontario’s hospitals, the province has seen the closure of rural maternity programs over the last few years. The women in communities that are unable to sustain local services must travel to access distant services, and depending on the distance to the nearest referral center, may be away from their homes and communities during the critical pregnancy period and child birth. The separation of pregnant women from their families and communities can cause negative outcomes. The health and economic impacts of the inability to access local maternal programs are well documented. Different stakeholders have indicated the importance of alternative, sustainable models of interprofessional collaboration of midwifery, primary and specialty care, and the efficient allocation of human health resources (PCMCH, 2015). To create the framework of the model, PCMCH formed a leadership team and expert panel consisting of different care providers. Inaya had to identify barriers and potential solutions by engaging different care providers and exploring the challenges from their perspectives. The findings would be used to work with relevant partners, such as associations of different health care professionals, to develop potential solutions for the Ministry. The goal of the case is to provide readers with the opportunity to apply the concept of collaboration and also explore the barriers to achieving inter-professional collaboration from the key stakeholders’ perspectives

A shader based adaptation of selected sixteenth century maps

This research develops a technique focused on shading and texturing, with an emphasis on line work and color, to emulate the unique qualities of copperplate line-engraving from 16th century cartography. A visual analysis of selected maps determines the defining characteristics adapted for three-dimensional computer generated environments. The resulting work is presented in a short time-based animation

Attentional Biases to Foods: The Effects of Caloric Content and Cognitive Restraint

The goal of the present study was to determine whether female restrained and unrestrained eaters demonstrated differential levels of attentional bias to high calorie foods when they were presented as distractors in a flanker task. This task consisted of four blocks of 68 trials in which three food pictures were briefly presented simultaneously on a computer screen. On each trial a high or low calorie target food was presented in the center of a pair of high or low calorie food flanker pictures and participants’ reaction times to answer a basic question about whether they would consume the target food for breakfast were recorded. In Experiment 1, in which all participants were fed a snack prior to engaging in the flanker task, there was no evidence that restrained (n = 29) or unrestrained (n = 37) eaters had an attentional bias. However, in Experiment 2, when participants completed the flanker task while hungry, restrained eaters (n = 27) experienced response conflict only when low calorie targets were flanked by high calorie distractors, whereas unrestrained eaters (n = 46) were distracted by high calorie flankers regardless of the caloric content of the target cue. The results from this implicit task indicate that flankers interfere with hungry participants’ responses to varying degrees depending on their cognitive restraint. Whether attentional bias to food cues subsequently affects food choices and eating behavior is a topic for further investigation

Multi-hazard groundwater risks to water supply from shallow depths: challenges to achieving the sustainable development goals in Bangladesh

Background: Groundwater currently provides 98% of all drinking-water supply in Bangladesh. Groundwater is found throughout Bangladesh but its quality (i.e. arsenic and salinity contamination) and quantity (i.e., water-storage depletion) vary across hydrological environments, posing unique challenges to certain geographical areas and population groups. Yet, no national-scale, multi-parameter groundwater hazard maps currently exist enabling water resources managers and policy makers to identify vulnerable areas to public health. Methods: We develop, for the first time, groundwater multi-hazard maps at the national scale of Bangladesh combining information on arsenic, salinity and water storage. We apply geospatial techniques in ‘R’ programming language and ArcGIS environment, linking hydrological indicators for water quality and quantity to construct risk maps. A range of socio-economic variables including access to drinking and irrigation water supplies and social vulnerability (i.e., poverty) are overlaid on these risk maps to estimate exposures. Results: Our multi-parameter groundwater hazard maps show that a considerable proportion of land area (5% to 24% under extremely-high to high risks) in Bangladesh is currently under combined risk of arsenic and salinity contamination, and groundwater-storage depletion. As small as 6.5 million (2.2 million poor) to 24.4 million (8.6 million poor) people are exposed to a combined risk of high arsenic, salinity and groundwater-storage depletion. Conclusions: Our groundwater hazard maps reveal areas and exposure of population groups to water risks posed by arsenic and salinity contamination and depletion of water storage. These geospatial hazard maps can potentially guide policymakers in prioritizing mitigation and adaptation measures in order to achieve the United Nation’s Sustainable Development Goals across the water, agriculture and public health sectors in Bangladesh

Effect of Source Activity and Source Volume on Intrinsic Uniformity of SPECT Gamma Camera

Purpose: The quality control of the gamma camera is obligatory for the proper diagnosis of the patients. The most intensive and sensitive routine quality control of gamma camera is intrinsic uniformity. The main objective of this research work is to determine the best parameters for daily quality control testing of intrinsic uniformity for dual head Single Photon Emission Computed Tomography (SPECT) gamma camera.Method: The integral and differential intrinsic uniformity test for both Useful Field Of View (UFOV) and Central Field Of View (CFOV) was done by placing a point source of 99mTc in front of the detectors with removed collimators to measure the effect of source activity and source volume on intrinsic uniformity.Result: The result shows that the best intrinsic uniformity image is obtained at activity volume in the range of 0.2 – 0.7 ml in 3 ml syringe with source activity between 70 – 200 MBq since place of point source on the central axis of the detector at a distance from its face equal to five times the diameter of the useful field of view as defined by the lead mask.Conclusion: Finally we can conclude that, the lower the intrinsic uniformity the better the imaging and diagnosis

Salt tolerance QTLs of an endemic rice landrace, \u3ci\u3eHorkuch\u3c/i\u3e at seedling and reproductive stages

Salinity has a significant negative impact on production of rice. To cope with the increased soil salinity due to climate change, we need to develop salt tolerant rice varieties that can maintain their high yield. Rice landraces indigenous to coastal Bangladesh can be a great resource to study the genetic basis of salt adaptation. In this study, we implemented a QTL analysis framework with a reciprocal mapping population developed from a salt tolerant landrace Horkuch and a high yielding rice variety IR29. Our aim was to detect genetic loci that contributes to the salt adaptive responses of the two different developmental stages of rice which are very sensitive to salinity stress. We identified 14 QTLs for 9 traits and found that most are unique to specific developmental stages. In addition, we detected a significant effect of the cytoplasmic genome on the QTL model for some traits such as leaf total potassium and filled grain weight. This underscores the importance of considering cytoplasm-nuclear interaction for breeding programs. Finally, we identified QTLs co-localization for multiple traits that highlights the possible constraint of multiple QTL selection for breeding programs due to different contributions of a donor allele for different traits

Introducing pulse oximetry for outpatient management of childhood pneumonia::An implementation research adopting a district implementation model in selected rural facilities in Bangladesh

BACKGROUND: Pulse oximetry has potential for identifying hypoxaemic pneumonia and substantially reducing under-five deaths in low- and middle-income countries (LMICs) setting. However, there are few examples of introducing pulse oximetry in resource-constrained paediatric outpatient settings, such as Integrated Management of Childhood Illness (IMCI) services. METHODS: The National IMCI-programme of Bangladesh designed and developed a district implementation model for introducing pulse oximetry in routine IMCI services through stakeholder engagement and demonstrated the model in Kushtia district adopting a health system strengthening approach. Between December 2020 and June 2021, two rounds of assessment were conducted based on WHO's implementation research framework and outcome variables, involving 22 IMCI service-providers and 1680 children presenting with cough/difficulty-in-breathing in 12 health facilities. The data collection procedures included structured-observations, re-assessments, interviews, and data-extraction by trained study personnel. FINDINGS: We observed that IMCI service-providers conducted pulse oximetry assessments on all eligible children in routine outpatient settings, of which 99% of assessments were successful; 85% (95% CI 83,87) in one attempt, and 69% (95% CI 67,71) within one minute. The adherence to standard operating procedure related to pulse oximetry was 92% (95% CI 91,93), and agreement regarding identifying hypoxaemia was 97% (95% CI 96,98). The median performance-time was 36 seconds (IQR 20,75), which was longer among younger children (2-11 months: 44s, IQR 22,78; 12-59 months: 30s, IQR 18,53, p < 0.01) and among those classified as pneumonia/severe-pneumonia than as no-pneumonia (41s, IQR 22,70; 32s, IQR 20,62, p < 0.01). We observed improvements in almost all indicators in round-2. IMCI service-providers and caregivers showed positive attitudes towards using this novel technology for assessing their children. INTERPRETATION: This implementation research study suggested the adoption, feasibility, fidelity, appropriateness, acceptability, and sustainability of pulse oximetry introduction in routine IMCI services in resource-poor settings. The learning may inform the evidence-based scale-up of pulse oximetry linked with an oxygen delivery system in Bangladesh and other LMICs. FUNDING: This research was funded by the UK National Institute for Health Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (Harmony Outcomes): a double-blind, randomised placebo-controlled trial

Background: Glucagon-like peptide 1 receptor agonists differ in chemical structure, duration of action, and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. We aimed to determine the safety and efficacy of albiglutide in preventing cardiovascular death, myocardial infarction, or stroke. Methods: We did a double-blind, randomised, placebo-controlled trial in 610 sites across 28 countries. We randomly assigned patients aged 40 years and older with type 2 diabetes and cardiovascular disease (at a 1:1 ratio) to groups that either received a subcutaneous injection of albiglutide (30–50 mg, based on glycaemic response and tolerability) or of a matched volume of placebo once a week, in addition to their standard care. Investigators used an interactive voice or web response system to obtain treatment assignment, and patients and all study investigators were masked to their treatment allocation. We hypothesised that albiglutide would be non-inferior to placebo for the primary outcome of the first occurrence of cardiovascular death, myocardial infarction, or stroke, which was assessed in the intention-to-treat population. If non-inferiority was confirmed by an upper limit of the 95% CI for a hazard ratio of less than 1·30, closed testing for superiority was prespecified. This study is registered with ClinicalTrials.gov, number NCT02465515. Findings: Patients were screened between July 1, 2015, and Nov 24, 2016. 10 793 patients were screened and 9463 participants were enrolled and randomly assigned to groups: 4731 patients were assigned to receive albiglutide and 4732 patients to receive placebo. On Nov 8, 2017, it was determined that 611 primary endpoints and a median follow-up of at least 1·5 years had accrued, and participants returned for a final visit and discontinuation from study treatment; the last patient visit was on March 12, 2018. These 9463 patients, the intention-to-treat population, were evaluated for a median duration of 1·6 years and were assessed for the primary outcome. The primary composite outcome occurred in 338 (7%) of 4731 patients at an incidence rate of 4·6 events per 100 person-years in the albiglutide group and in 428 (9%) of 4732 patients at an incidence rate of 5·9 events per 100 person-years in the placebo group (hazard ratio 0·78, 95% CI 0·68–0·90), which indicated that albiglutide was superior to placebo (p&lt;0·0001 for non-inferiority; p=0·0006 for superiority). The incidence of acute pancreatitis (ten patients in the albiglutide group and seven patients in the placebo group), pancreatic cancer (six patients in the albiglutide group and five patients in the placebo group), medullary thyroid carcinoma (zero patients in both groups), and other serious adverse events did not differ between the two groups. There were three (&lt;1%) deaths in the placebo group that were assessed by investigators, who were masked to study drug assignment, to be treatment-related and two (&lt;1%) deaths in the albiglutide group. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. Evidence-based glucagon-like peptide 1 receptor agonists should therefore be considered as part of a comprehensive strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. Funding: GlaxoSmithKline