Cryptosporidiosis in low-resource healthcare settings : Near-patient diagnostics, risk factors, and parasite shedding dynamics in young Ethiopian children

Bakgrunn: Tarmparasitten Cryptosporidium er en ledende årsak til diaré og dødsfall hos småbarn i lavinntektsland. Målretta behandling trengs, men forutsetter presise diagnostiske tester som er egna for ressursfattige helseinstitusjoner. Forebygging bør rettes mot etablerte risikofaktorer. Varighet av parasittutskilling er ikke godt kjent. Formål: Å evaluere diagnostisk presisjon for to pasientnære tester for kryptosporidiose, risikofaktorer for sykdom, og dynamikk i parasittutskilling over tid, hos småbarn i Etiopia. Metoder: Fra desember 2016 til juli 2018 rekrutterte CRYPTO-POC-studien totalt 1384 barn under 5 år med diaré, fra et sjukehus og et helsesenter, og 946 kontroller uten diaré. Diagnostikkstudien inkluderte 912 barn med diaré og 706 kontroller. LED-AP-mikroskopi og en papirstrimmelhurtigtest, utført av lokale helsearbeidere, blei sammenligna med et panel av tre referansetester. Risikofaktorer hos barn under 2 år blei undersøkt i en kasus-kasus-kontroll-studie som omfatta 59 barn med kryptosporidiose, 432 barn med diaré av andre årsaker, og 725 kontrollbarn uten diaré. En 60-dagers oppfølgingsstudie samla gjentatte avføringsprøver fra 53 barn med kryptosporidiose, støtta av Cryptosporidium genotyping. Resultater: LED-AP og hurtigtesten hadde sensitivitet på hhv. 88 og 89%, og positiv og negativ prediktiv verdi på hhv. 88% og 99%. Spesifisitet var 99% for begge tester. LED-AP var rimeligere (0.7 USD per test). Operasjonelle utfordringer blei kartlagt. De viktigste risikofaktorer var sosioøkonomiske forhold knytta til foreldre, bruk av vann fra vannposter, og akutt underernæring. Parasittutskilling strakk seg ut i tid, med median varighet på 31 dager, men kvantitativ utskilling avtok med 10x per uke i de første fire uker etter symptomdebut. Konklusjon: LED-AP-metoden er en pålitelig test for kryptosporidiose som kan tas inn i eksisterende laboratorieinfrastruktur. Hurtigtesten er et godt alternativ. Forebyggende tiltak bør inkludere opplæring og støtte til barnas foreldre og ernæringsstøtte til barn med moderat og alvorlig underernæring. Medikamentelle intervensjonsstudier bør inkludere parasittutskilling over tid som et sekundært endepunkt.Background: Cryptosporidium is a leading cause of diarrhoea and death in children younger than two years of age in low-and-middle income countries. Targeted treatment is needed but requires accurate and setting-appropriate diagnostic tests. Prevention should target known risk factors. Duration of parasite shedding is not well known. Objectives: To evaluate the diagnostic accuracy of two near-patient tests for cryptosporidiosis, risk factors for disease, and parasite shedding patterns, in young children in Ethiopia. Methods: From Dec 2016 to Jul 2018 the CRYPTO-POC study enrolled 1384 children under 5 years with diarrhoea, from a hospital and a health center, and 946 controls without diarrhoea. A diagnostic accuracy study in 912 cases and 706 controls compared results from LED-AP microscopy and a test strip, performed by local healthcare workers, against a panel of three reference tests. Risk factors in children under 2 years were examined in a case-case-control analysis of 59 cases with cryptosporidiosis, 432 diarrhoea cases without cryptosporidiosis, and 725 non-diarrhoea controls. A 60-day follow-up study was conducted in 53 cryptosporidiosis cases, supported by Cryptosporidium genotyping. Results: The sensitivities of LED-AP and the test strip were 88% and 89%, and positive and negative predictive values 88% and 99%, respectively. Specificity was 99% for both tests. LED-AP was cheaper at 0.7 USD per test. Important operational issues were identified. Caregiver-related socioeconomic factors, public-tap water use, previous healthcare attendance, and acute malnutrition were important risk factors for cryptosporidiosis. Prolonged parasite shedding was common, with a median duration of 31 days, although with a 10-fold drop in quantity per week for the first four weeks. Conclusions and consequences: LED-AP is an accurate test for cryptosporidiosis that can be integrated with existing laboratory infrastructure, near the point of care. The test strip is a good alternative. Nutritional management of moderate acute malnutrition, focused caregiver education and closer follow-up of children who present for health care can be explored as preventive interventions. Parasite shedding duration can be considered as a secondary treatment outcome in cryptosporidiosis intervention trials.Doktorgradsavhandlin

Loyality. Content, premises &varieties

Erfaringsbasert master 90 poengDenne master oppgaven er skrevet i forbindelse med et studie i offentlig ledelse og styring ved Høgskolen i Hedmark campus Rena. Interessen for tema lojalitet er en følge av egen erfaring, studiet og temaets aktualitet. Jeg valgte å se på hva ansatte legger i begrepet lojalitet, hva som skaper og påvirker lojalitet og mot hvem de ansatte faktisk er lojale. Metoden som ble brukt var casebasert gruppeintervju og kvalitativ metode. Gjennom et teoretisk fundament, disse intervjuene og påfølgende analysearbeid har jeg fått frem mange interessante funn. Funn viktig for organisasjoner og deres ledere, nå og i fremtiden. Jeg fant ut at lojaliteten var mangfoldig og innholdsrik. Lojalitet var både dynamisk og foranderlig, samtidig som det kan være noe fast og konkret. Til hvem man var lojal kunne være kontekstuelt betinget, og noe som ble koblet ut og inn avhengig av både situasjon og person. Stor endringsfrekvens og stadig økende krav til de ansatte var typiske faktorer som utfordret og hemmet lojaliteten. Informasjon, medbestemmelse, god ledelse og involvering var faktorer som påvirket lojaliteten i positiv retning, og som også da var med å skape lojalitet. Sist, men ikke minst, var lojalitet noe som måtte fortjenes. Gjensidig tillit og lojalitet var noen av de viktigste premissene for lojalitetThis Master’s thesis was written in conjunction with a Master’s Degree in public administration at the Høgskolen i Hedmark (College of Hedmark) campus Rena. The interest for the theme loyalty comes from personal experience, the Master’s Degree and the theme’s relevance. I chose to focus on how employees define loyalty, what creates and influences loyalty and to whom employees are actually loyal. Methods used were case-based group interviews and qualitative methods. Through fundamental theory, these interviews and subsequent analytical work, I have made several interesting discoveries. Discoveries that is important for organizations and their leaders, today and in the future. I discovered that loyalty was both dynamic and changeable, but at the same time it could be something concrete. To whom an employee was loyal depended on context, and loyalty changed depending on both the situation and the individual. Continuous changes and increasingly high demands on the employees were typical factors that challenged and restricted loyalty. Information, joint decision-making, good leadership and involvement were factors that positively influenced loyalty, and also helped create loyalty. Finally, loyalty was something that had to be earned. Mutual trust and loyalty was one of the most important premises for loyalt

Weight gain during treatment course of allogenic hematopoietic stem cell transplantation in patients with hematological malignancies affects treatment outcome

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)Background aims: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective treatment for patients with hematological malignancies; however, allo-HSCT does not come without the cost of treatmentrelated morbidity and mortality. Early detection of risk factors could be helpful in identifying patients who could benefit from early interventions. Many patients gain weight during the allo-HSCT treatment, although little is known about the impact of weight gain. Methods: Weight gain in 146 consecutively enrolled adult patients undergoing allo-HSCT was explored. Results: In total, 141 patients (97%) gained weight along the course of allo-HSCT. Median weight increase was 4.8 kg (range 0.016.1 kg), with median increase in body weight 6.5% (range 0.0%30.8%). Maximum weight increase was observed at day +7 (range day 8, +44). Weight gain was associated with increased incidence of acute graft-versus-host disease. Patients with weight gain >10% had a significantly greater 5-year mortality compared with those with lower weight gain (P = 0.031, rank sum test). Conclusions: Weight gain is a simple variable with the ability to provide prognostic information for patients undergoing allo-HSCT.publishedVersio

Sikkerhet på hurtigbåter : En oppfølgende intervjuundersøkelse

-Denne rapporten oppsummerer en intervjuundersøkelse som ble gjennomført som en oppfølging av en spørreskjemaundersøkelse (Fenstad et al., 2012). Det ble i alt intervjuet 28 blant mannskaper og administrativt ansatte om sikkerhet i hurtigbåtnæringen. Informantene vurderer at sikkerhet har blitt et viktigere tema i hurtigbåtnæringen de senere årene. Det er utarbeidet kvalitets- og sikkerhetsstyringssystemer i tråd med ISM- koden. Bruken av systemene støter imidlertid an mot «sjømannskulturen», som vektlegger erfaringsbaserte arbeidsmåter og hvor «papirarbeid» omtales i negative ordelag. Mannskapene ombord anser at bemanningen om bord er for knapp dersom de oppstår nødsituasjoner. Dette settes i sammenheng med konkurransesituasjonen som rederiene er i, særlig gjennom anbudsregimet. Man ønsker at Sjøfartsdirektoratet benytter seg mer av kompetansen som ligger i næringen. Vi foreslår noen tema for et arbeidsseminar for rederier og Sjøfartsdirektoratet avslutningsvis i rapporten.

Cryptosporidium Infections in Africa—How Important Is Zoonotic Transmission? A Review of the Evidence

Cryptosporidium, a protozoan parasite in the phylum Apicomplexa, is the etiological agent of cryptosporidiosis, an intestinal infection characterized by profuse watery diarrhea. Over 30 species of Cryptosporidium are recognized, some host specific whereas others infect a broader host range. Cryptosporidium hominis and Cryptosporidium parvum are the species most commonly associated with human infection; C. hominis is largely associated only with human infections, but C. parvum is also associated with infection in animals, especially young ruminants. In some regions, cryptosporidiosis is a serious veterinary problem, particularly for calves, and lambs. Many outbreaks of human cryptosporidiosis have been associated with zoonotic transmission following contact with infected animals. In Africa, where cryptosporidiosis is a major contributor to pediatric morbidity and mortality, evidence suggests transmission is principally anthroponotic. Given the frequent close contact between humans and animals in Africa, the apparent predominance of human-to-human transmission is both interesting and puzzling. In this article, after a brief “text book” introduction to the parasite, we consider in separate sections the different aspects of relevance to Cryptosporidium transmission in African countries, describing different aspects of the various species and subtypes in human and animal infections, considering livestock management practices in different African countries, and looking for any characteristic “hot spots” where zoonotic transmission has apparently occurred. Studies where transmission networks have been investigated are particularly relevant. Finally, in a separate section, we try to gather these different strands of evidence together in order to assess the reasons behind the apparent predominance of anthroponotic transmission in Africa. Reviewing the available evidence provides an opportunity to re-think transmission pathways, not only in Africa but also elsewhere, and also to pose questions. Does the predominance of human-to-human transmission in Africa reflect a relative absence of zoonotic C. parvum in African livestock? Are Africans less susceptible to zoonotic Cryptosporidium infection, perhaps resulting from early immunostimulation by C. hominis or due to inherent genetic traits? Is the African environment—in all its variety—simply more detrimental to oocyst survival? Will the so-called hypertransmissible subtypes, currently relatively rare in Africa, be introduced from Europe or elsewhere, and, if so, will they fade out or establish and spread? Our intention with this manuscript is not only to summarize and consolidate diverse data, thereby providing an overview of data gaps, but also to provide food for thought regarding transmission of a parasite that continues to have a considerable impact on both human and animal health.publishedVersio

Symptomatic and asymptomatic secondary transmission of Cryptosporidium parvum following two related outbreaks in schoolchildren

Two related outbreaks (in 2009 and 2012) of cryptosporidiosis in Norwegian schoolchildren during a stay at a remote holiday farm provided us with a natural experiment to investigate possible secondary transmission of Cryptosporidium parvum IIa A19G1R1. After the children had returned home, clinical data and stool samples were obtained from their household contacts. Samples were investigated for the presence of Cryptosporidium oocysts by immunofluorescence antibody test. We found both asymptomatic and symptomatic infections, which are likely to have been secondary transmission. Laboratory-confirmed transmission rate was 17% [4/23, 95% confidence interval (CI) 7·0–37·1] in the 2009 outbreak, and 0% (95% CI 0–16·8) in the 2012 outbreak. Using a clinical definition, the probable secondary transmission rate in the 2012 outbreak was 8% (7/83, 95% CI 4·1–16·4). These findings highlight the importance of hygienic and public health measures during outbreaks or individual cases of cryptosporidiosis. We discuss our findings in light of previous studies reporting varying secondary transmission rates of Cryptosporidium spp

Prolonged and persistent diarrhoea is not restricted to children with acute malnutrition:An observational study in Ethiopia

Under embargo until: 2020-07-20Objectives: To assess the prevalence of prolonged and persistent diarrhoea, to estimate their co‐occurrence with acute malnutrition and association with demographic and clinical factors. Methods: Case–control study where cases were children under 5 years of age with diarrhoea and controls were children without diarrhoea, frequency‐matched weekly by age and district of residency. Controls for cases 0–11 months were recruited from vaccination rooms, and controls for cases 12–59 months were recruited by house visits using random locations in the catchment area of the study sites. Data were analysed by mixed model logistic regression. Results: We enrolled 1134 cases and 946 controls. Among the cases, 967 (85%) had acute diarrhoea (AD), 129 (11%) had ProD and 36 (3.2%) had PD. More cases had acute malnutrition at enrolment (17% vs. 4%, P < 0.0001) and more were born prematurely (5.7% vs. 1.8%, P < 0.0001) than controls. About 75% of ProPD cases did not have acute malnutrition. Cases with AD and ProPD had different symptomatology, even beyond illness duration. Conclusions: ProPD is common among children presenting with diarrhoea and is not confined to children with acute malnutrition. There is an urgent need for studies assessing causes of ProPD with and without acute malnutrition to develop treatment guidelines for these conditions.acceptedVersio

Surgery for degenerative cervical myelopathy in the elderly: a nationwide registry-based observational study with patient-reported outcomes

Background - The aim of this study was to investigate whether clinical outcomes in patients aged ≥ 70 undergoing decompressive surgery for degenerative cervical myelopathy (DCM) differ from those of younger patients (50–70 years) at 1 year. Methods - Data were obtained from the Norwegian Registry for Spine Surgery (NORspine). Among 651 patients included, 177 (27.2%) were ≥ 70 years old. The primary outcome was change in the Neck Disability Index (NDI). Secondary outcomes were changes in the European Myelopathy Score (EMS), quality of life (EuroQoL EQ-5D), numeric rating scales (NRS) for headache, neck pain, and arm pain, and complications. Results - Significant improvements in all patient-reported outcomes (PROMs) were detected for both age cohorts at 1 year. For the two age cohorts combined, there was a statistically significant improvement in the NDI score (mean 9.2, 95% CI 7.7 to 10.6, P  Conclusion - Surgery for DCM was associated with significant improvement across a wide range of PROMs for both younger and elderly patients. Surgery for DCM should not be denied based on age alone