The joint effects of water and sanitation on diarrhoeal disease: a multicountry analysis of the Demographic and Health Surveys

ObjectivesTo assess whether the joint effects of water and sanitation infrastructure, are acting antagonistically (redundant services preventing the same cases of diarrhoeal disease), independently, or synergistically; and to assess how these effects vary by country and over time.MethodsWe used data from 217 Demographic and Health Surveys conducted in 74 countries between 1986 and 2013. We used modified Poisson regression to assess the impact of water and sanitation infrastructure on the prevalence of diarrhoea among children under 5.ResultsThe impact of water and sanitation varied across surveys, and adjusting for socio‐economic status drove these estimates towards the null. Sanitation had a greater effect than water infrastructure when all 217 surveys were pooled; however, the impact of sanitation diminished over time. Based on survey data from the past 10 years, we saw no evidence for benefits in improving drinking water or sanitation alone, but we estimated a 6% reduction of both combined (prevalence ratio = 0.94, 95% confidence limit 0.91–0.98).ConclusionsWater and sanitation interventions should be combined to maximise the number of cases of diarrhoeal disease prevented in children under 5. Further research should identify the sources of variability seen between countries and across time. These national surveys likely include substantial measurement error in the categorisation of water and sanitation, making it difficult to interpret the roles of other pathways.ObjectifsEvaluer les effets conjoints des infrastructures de l'eau et d'assainissement afin de voir si elles sont des services redondants prévenant les mêmes cas de maladies diarrhéiques, si elles agissent indépendamment ou en synergie et d’évaluer comment ces effets varient selon les pays et au fil du temps.MéthodesNous avons utilisé les données de 217 enquêtes démographiques et santé menées dans 90 pays entre 1986 et 2013. Nous avons utilisé la régression de Poisson modifiée pour évaluer l'impact des infrastructures de l'eau et d'assainissement sur la prévalence de la diarrhée chez les enfants de moins de cinq ans.RésultatsL'impact de l'eau et de l'assainissement variait dans toutes les enquêtes et l'ajustement pour le statut socioéconomique conduisait ces estimations vers le néant. L'assainissement avait un effet plus important que l'infrastructure de l'eau lorsque toutes les 217 enquêtes ont été poolées. Toutefois, l'impact de l'assainissement a diminué au fil du temps. Basé sur des données d'enquêtes des dix dernières années, nous n'avons vu aucune preuve pour les bénéfices de l'amélioration de l'eau potable ou de l'assainissement seuls, mais nous avons estimé une réduction de 6% pour la combinaison des deux (rapport de prévalence = 0,94; IC95%: 0,91 à 0,98).ConclusionsLes interventions sur l'eau et l'assainissement devraient être combinées pour maximiser le nombre de cas de maladies diarrhéiques prévenus chez les enfants de moins de cinq ans. Des recherches supplémentaires devraient identifier les sources de variabilité observées entre les pays et dans le temps. Ces enquêtes nationales comportent probablement une erreur importante de mesure dans la catégorisation de l'eau et de l'assainissement, ce qui rend difficile l'interprétation des rôles des autres voies.ObjetivosEvaluar el efecto conjunto del agua e infraestructura sanitaria, y determinar si son servicios redundantes que previenen los mismos casos de enfermedad diarreica, actúan de forma independiente o actúan de forma sinérgica; y evaluar como dichos efectos varían según el país y a lo largo del tiempo.MétodosHemos utilizado los datos de 217 Censos Demográficos y de Salud realizados en 90 países entre 1986 y 2013. Hemos realizado una regresión de Poisson modificada para evaluar el impacto del agua y de la infraestructura sanitaria sobre la prevalencia de la diarrea en niños menores de cinco años.ResultadosEl impacto del agua y del saneamiento variaba a lo largo de los censos, y el ajustar según el estatus socioeconómico llevaba los resultados a cero. El saneamiento tenía un mayor efecto que la infraestructura para el agua si se agrupaban los 217 censos; sin embargo, el impacto del saneamiento disminuía a lo largo del tiempo. Basado en los datos censales de los últimos diez años, no encontramos evidencia de los beneficios de la mejora del agua para consumo o del saneamiento por sí solos, pero hemos estimado una reducción del 6% de las dos intervenciones combinadas (tasa de prevalencia = 0.94, IC 95% 0.91‐0.98).ConclusionesLas intervenciones en el agua o el saneamiento deberían combinarse para maximizar el número de casos de enfermedad diarréica prevenidas en niños menores de cinco años. Estudios futuros deberían identificar las fuentes de variabilidad observada entre países y a lo largo del tiempo. Es posible que los censos nacionales incluyan un error sustancial en la medición de las categorías de agua y saneamiento, lo cual complica la determinación del papel de vías alternativas.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/110633/1/tmi12441.pd

Hypertension Management Using Mobile Technology and Home Blood Pressure Monitoring: Results of a Randomized Trial in Two Low/Middle-Income Countries

Abstract Objective: Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries (LMICs). Mobile health technologies may improve noncommunicable disease outcomes, but LMICs lack resources to provide these services. We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure (BP) monitoring as a strategy for improving systolic BPs (SBPs) and other outcomes of hypertensive patients in two LMICs. Subjects and Methods: This was a randomized trial with a 6-week follow-up. Participants with high SBPs (≥140?mm Hg if nondiabetic and ≥130?mm Hg if diabetic) were enrolled from clinics in Honduras and Mexico. Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States, plus a home BP monitor. At baseline, control patients received BP results, hypertension information, and usual healthcare. The primary outcome, SBP, was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs. Secondary outcomes included perceived health status and medication-related problems. Results: Of the 200 patients recruited, 181 (90%) completed follow-up, and 117 of 181 had low literacy or high hypertension information needs. The median annual income was $2,900 USD, and average educational attainment was 6.5 years. At follow-up intervention patients' SBPs decreased 4.2?mm Hg relative to controls (95% confidence interval ?9.1, 0.7; p=0.09). In the subgroup with high information needs, intervention patients' average SBPs decreased 8.8?mm Hg (?14.2, ?3.4, p=0.002). Compared with controls, intervention patients at follow-up reported fewer depressive symptoms (p=0.004), fewer medication problems (p<0.0001), better general health (p<0.0001), and greater satisfaction with care (p≤0.004). Conclusions: Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs. A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98494/1/tmj%2E2011%2E0271.pd

Cancer and psychiatric diagnoses in the year preceding suicide

BACKGROUND: Patients with cancer are known to be at increased risk for suicide but little is known about the interaction between cancer and psychiatric diagnoses, another well-documented risk factor. METHODS: Electronic medical records from nine healthcare systems participating in the Mental Health Research Network were aggregated to form a retrospective case-control study, with ICD-9 codes used to identify diagnoses in the 1 year prior to death by suicide for cases (N = 3330) or matching index date for controls (N = 297,034). Conditional logistic regression was used to assess differences in cancer and psychiatric diagnoses between cases and controls, controlling for sex and age. RESULTS: Among patients without concurrent psychiatric diagnoses, cancer at disease sites with lower average 5-year survival rates were associated with significantly greater relative risk, while cancer disease sites with survival rates of \u3e70% conferred no increased risk. Patients with most psychiatric diagnoses were at higher risk, however, there was no additional risk conferred to these patients by a concurrent cancer diagnosis. CONCLUSION: We found no evidence of a synergistic effect between cancer and psychiatric diagnoses. However, cancer patients with a concurrent psychiatric illness remain at the highest relative risk for suicide, regardless of cancer disease site, due to strong independent associations between psychiatric diagnoses and suicide. For patients without a concurrent psychiatric illness, cancer disease sites associated with worse prognoses appeared to confer greater suicide risk

Demographic and Psychosocial Factors Associated with Suicide Mortality Among Childbearing-Aged Individuals: A Case-Control Study

Objective: Examine pregnancy-related, demographic, psychosocial and healthcare utilization factors associated with suicide mortality among childbearing-aged women. Methods: Data from nine health care systems in the Mental Health Research Network were included. A case-control study design was used in which 290 childbearing-age women who died by suicide (cases) from 2000-2015 were matched with 2,900 childbearing-age women from the same healthcare system and enrolled during the same time period who did not die by suicide. Conditional logistic regression was used to analyze associations between patient characteristics and suicide. Results: Women who died by suicide were more likely to have mental health or substance use disorders (aOR = 2.36, 95%CI: 1.46, 3.82) and to have visited the emergency department in the year prior to index date (aOR = 3.35, 95%CI: 2.39, 4.68). Pregnancy (aOR = 0.17, 95% CI: 0.04, 0.78) and delivery of a liveborn baby (aOR = 0.39, 95% CI: 0.16, 0.92) within a year before index date were associated with lower risk of suicide mortality. Women who experienced pregnancy loss were more likely to die by suicide (aOR = 1.41, 95% CI: 0.49, 4.06), but this was not statistically significant potentially due to small sample size (n = 6 cases; n = 21 control). Conclusions: Childbearing-aged women with mental health and/or substance use disorders, prior emergency department encounters may benefit from routine screening and monitoring for suicide risk. Future research should further examine the relationship between pregnancy loss and suicide mortality

Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care

BACKGROUND: Insights from behavioral economics, or how individuals\u27 decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., Nudge ) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers? METHODS: The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians\u27 use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning. DISCUSSION: The ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04844021 . Registered 14 April 2021

Cardiac biomarkers in pediatric cardiomyopathy: Study design and recruitment results from the Pediatric Cardiomyopathy Registry

Background: Cardiomyopathies are a rare cause of pediatric heart disease, but they are one of the leading causes of heart failure admissions, sudden death, and need for heart transplant in childhood. Reports from the Pediatric Cardiomyopathy Registry (PCMR) have shown that almost 40% of children presenting with symptomatic cardiomyopathy either die or undergo heart transplant within 2 years of presentation. Little is known regarding circulating biomarkers as predictors of outcome in pediatric cardiomyopathy. Study Design: The Cardiac Biomarkers in Pediatric Cardiomyopathy (PCM Biomarkers) study is a multi-center prospective study conducted by the PCMR investigators to identify serum biomarkers for predicting outcome in children with dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM). Patients less than 21 years of age with either DCM or HCM were eligible. Those with DCM were enrolled into cohorts based on time from cardiomyopathy diagnosis: categorized as new onset or chronic. Clinical endpoints included sudden death and progressive heart failure. Results: There were 288 children diagnosed at a mean age of 7.2±6.3 years who enrolled in the PCM Biomarkers Study at a median time from diagnosis to enrollment of 1.9 years. There were 80 children enrolled in the new onset DCM cohort, defined as diagnosis at or 12 months prior to enrollment. The median age at diagnosis for the new onset DCM was 1.7 years and median time from diagnosis to enrollment was 0.1 years. There were 141 children enrolled with either chronic DCM or chronic HCM, defined as children ≥2 years from diagnosis to enrollment. Among children with chronic cardiomyopathy, median age at diagnosis was 3.4 years and median time from diagnosis to enrollment was 4.8 years. Conclusion: The PCM Biomarkers study is evaluating the predictive value of serum biomarkers to aid in the prognosis and management of children with DCM and HCM. The results will provide valuable information where data are lacking in children. Clinical Trial Registration: NCT01873976 https://clinicaltrials.gov/ct2/show/NCT01873976?term=PCM+Biomarker&rank=

Lessons learned from the Pediatric Cardiomyopathy Registry (PCMR) Study Group

Cardiomyopathy is a rare disorder of the heart muscle, affecting 1.13 cases per 100,000 children, from birth to 18 years of age. Cardiomyopathy is the leading cause of heart transplantation in children over the age of 1. The Pediatric Cardiomyopathy Registry funded in 1994 by the National Heart, Lung, and Blood Institute was established to examine the epidemiology of the disease in children below 18 years of age. More than 3500 children across the United States and Canada have been enrolled in the Pediatric Cardiomyopathy Registry, which has followed-up these patients until death, heart transplantation, or loss to follow-up. The Pediatric Cardiomyopathy Registry has provided the most in-depth illustration of this disease regarding its aetiology, clinical course, associated risk factors, and patient outcomes. Data from the registry have helped in guiding the clinical management of cardiomyopathy in children under 18 years of age; however, questions still remain regarding the most clinically effective diagnostic and treatment approaches for these patients. Future directions of the registry include the use of next-generation whole-exome sequencing and cardiac biomarkers to identify aetiology-specific treatments and improve diagnostic strategies. This article provides a brief synopsis of the work carried out by the Pediatric Cardiomyopathy Registry since its inception, including the current knowledge on the aetiologies, outcomes, and treatments of cardiomyopathy in children

The Safety of Ingested Caffeine: A Comprehensive Review

International audienc