Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study

Background: Integrated care for diabetes and associated conditions at primary level health facilities can make care available to a much larger population, especially in rural areas. Aim: This process evaluation was to understand how the authors' integrated care was implemented and experienced by the care providers and patients, and to inform modifications prior to province-wide scale-up. Design & setting: The mixed-method study was conducted as part of a cluster randomised trial on integrated diabetes care at 14 public health facilities. Method: The care practices were assessed by analysing the routine clinical records of 495 registered patients with diabetes. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data. Results: The intervention and the study were implemented as intended under routine conditions in rural health centres. Key service processes effectively delivered included: skill-based training; screening and diagnostic tests; treatment card records; and the additional case management as per desk guide, including monitoring progress in glucose and weight at follow-up consultations, and mobile phone calls to help adherence. However, social and cultural factors affected clients' ability to change lifestyles, especially for women. The intervention effect was limited by the short study follow-up of only 9 months. Conclusion: Integrated diabetes care was feasible, both for providers and patients, and potentially scalable at primary care facilities under routine conditions in Pakistan. Additional operational interventions are required for sustained drug supplies, supervision, in-service training, and to address the social challenges to healthy activity and eating, especially for women

Effectiveness of an integrated diabetes care package at primary healthcare facilities: a cluster randomised trial in Pakistan

Background: There were an estimated 7 million people living with diabetes in Pakistan in 2014, and this is predicted to reach 11.4 million by 2030. Aim: To assess if an integrated care package can achieve better control of diabetes. Design & setting: The pragmatic cluster randomised controlled trial (cRCT) was conducted from December 2014–June 2016 at 14 primary healthcare facilities in Sargodha district. Opportunistic screening, diagnostic testing, and patient recording processes were introduced in both the control 'testing, treating, and recording' (TTR) arm, and the intervention 'additional case management' (ACM) arm, which also included a clinical care guide and pictorial flipbook for lifestyle education, associated clinician training, and mobile phone follow-up. Method: Clinics were randomised on a 1:1 basis (sealed envelope lottery method) and 250 patients recruited in the ACM arm and 245 in the TTR-only arm (age ≥25 years and HbA1c >7%). The primary outcome was mean change in HbA1c (%) from baseline to 9-month follow-up. Patients and staff were not blinded. Results: The primary outcome was available for n = 238/250 (95.2%) participants in the ACM arm and n = 219/245 (89.4%) participants in the TTR-only arm (all clusters). Cluster level mean outcome was -2.26 pp (95% confidence intervals [CI] = -2.99 to -1.53) for the ACM arm, and -1.44 pp (95% CI = -2.34 to -0.54) for the TTR-only arm. Cluster level mean ACM–TTR difference (covariate-unadjusted) was -0.82 pp (95% CI = -1.86 to 0.21; P = 0.11). Conclusion: The ACM intervention in public healthcare facilities did not show a statistically significant effect on HbA1c reduction compared to the control (TTR-only) arm. Future evaluation should assess changes after a longer follow-up period, and minimal care enhancement in the comparator (control) arm

Delivering integrated hypertension care at private health facilities in urban Pakistan: a process evaluation

Background: In Pakistan about 18% of all adults are affected by hypertension, and only one in eight of the prevalent cases have their hypertension controlled. As in many other low-middle income countries, a public–private partnership approach is being considered for delivering non-communicable disease care in urban areas. Aim: This process evaluation was undertaken to understand how an integrated care intervention was experienced by the care providers and patients, and to inform modifications before possible scaling. Design & setting: The mixed-methods study was conducted as part of a cluster randomised trial on integrated hypertension care at 26 private clinics. Method: The care practices were assessed by analysing the clinical records of 1138 registered patients with hypertension. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data. Results: District-led objective selection and context-sensitive staff training helped to get the clinics engaged in partnership working. About one-third of patients with hypertension had associated diabetes or renal compromise. The prescription of drugs is influenced by multiple non-clinical considerations of providers and patients. Many doctors allowed the use of home-based remedies as supplements to the prescribed allopathic drugs. Female patients faced more challenges in managing lifestyle changes. The intervention improved adherence to follow-up visits, but patient attrition remained a challenge. Conclusion: The integrated hypertension care intervention at private clinics is feasible, and leads to improved diagnosis and treatment in low-income country urban setting. The authors recommend continued implementation research and informed scaling of hypertension care at private clinics

Dynamic analysis of closed die electromagnetic sheet metal forming to predict deformation and failure of AA6061-T6 alloy using a fully coupled finite element model.

This research presents a fully coupled 3D numerical model to analyse the dynamics of high-speed electromagnetic forming process for aluminium alloy AA6061-T6. The effect of Lorentz force distribution, velocity and kinetic energy on deformation, the bounce back effect and failure of the sheet has been investigated. Experiments were performed for AA6061-T6 alloy using an 18.750 KJ electromagnetic forming machine for varying the sheet thickness (0.5 mm, 1.02 mm and 1.63 mm) compared with the simulation results. The results showed that increasing the sheet thickness increases the Lorentz force due to a higher induced current. The inertial forces were more pronounced in thicker sheets (1.63 mm) as compared to the thinner sheets (0.5 mm and 1.02 mm), resulting in a higher bounce back effect for the thicker sheet. The numerical model accurately predicted the sheet failure for the 0.5-mm sheet, as also observed from the experimentation. The sheet deformation from simulations was found to be in good agreement with the experimental results

Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation

Background: In Pakistan,the estimated prevalence of chronic obstructive pulmonary disease (COPD) and asthma are 2.1% and 4.3% respectively, and existing care is grossly lacking both in coverage and quality. An integrated approach is recommended for delivering COPD and asthma care at public health facilities. Aim: To understand how an integrated care package was experienced by care providers and patients, and to inform modifications prior to scaling up. Design & setting: The mixed-methods study was conducted as part of cluster randomised trials on integrated COPD and asthma care at 30 public health facilities. Method: The care practices were assessed by analysing the clinical records of n = 451 asthma and n = 313 COPD patients. Semi-structured interviews with service providers and patients were used to understand their care experiences. A framework approach was applied to analyse and interpret qualitative data. Results: Utilisation of public health facilities for chronic lung conditions was low, mainly because of the non-availability of inhalers. When diagnosed, around two-thirds (69%) of male and more than half (55%) of female patients had severe airway obstruction. The practice of prescribing inhalers differed between intervention and control arms. Patient non-adherence to follow-up visits remained a major treatment challenge (though attrition was lower and slower in the intervention arm). Around half of the male responders who smoked at baseline reported having quit smoking. Conclusion: The integrated care of chronic lung conditions at public health facilities is feasible and leads to improved diagnosis and treatment in a low-income country setting. The authors recommend scaling of the intervention with continued implementation research, especially on improving patient adherence to treatment

Enhanced hypertension care through private clinics in Pakistan: a cluster randomised trial

Background Hypertension in Pakistan affects 33% of people aged ≥45 years, and in urban areas around 70% of basic health care occurs in private facilities. Aim To assess whether enhanced care at urban private clinics resulted in better control of hypertension, cardiovascular disease (CVD) risk factors, and treatment adherence. Design & setting A two-arm cluster randomised controlled trial was conducted at 26 private clinics (in three districts of Punjab) between January 2015–September 2016. Both arms had enhanced screening and diagnosis of hypertension and related conditions, and patient recording processes. Intervention facilities also had a clinical care guide, additional drugs for hypertension, a patient lifestyle education flipchart, associated training, and mobile phone follow-up. Method Clinics were randomised in a 1:1 ratio (sealed envelope lottery method). A total of 574 intervention and 564 control patients in 13 clusters in each arm were recruited (male and female, aged ≥25 years, systolic blood pressure [SBP] >140 mmHg, and/or diastolic blood pressure [DBP] >90 mmHg). The primary outcome was change in SBP from baseline to 9-month follow-up. Staff and patients were not blinded, but outcome assessors were blinded. Results Nine-month primary outcomes were available for 522/574 (90.9%) intervention and 484/564 (85.8%) control participants (all clusters). The unadjusted cluster-level analysis results were as follows: mean intervention outcome was -25.2 mmHg (95% confidence intervals [CI] = -29.9 to -20.6); mean control outcome was -9.4 mmHg (95% CI = 21.2 to 2.2); and mean control–intervention difference was 15.8 (95% CI = 3.6 to 28.0; P = 0.01). Conclusion The findings and separate process evaluation support the scaling of an integrated CVD–hypertension care intervention in urban private clinics in areas lacking public primary care in Pakistan

Historical and future trends in emergency pituitary referrals: a machine learning analysis

Purpose: Acute pituitary referrals to neurosurgical services frequently necessitate emergency care. Yet, a detailed characterisation of pituitary emergency referral patterns, including how they may change prospectively is lacking. This study aims to evaluate historical and current pituitary referral patterns and utilise state-of-the-art machine learning tools to predict future service use. Methods: A data-driven analysis was performed using all available electronic neurosurgical referrals (2014–2021) to the busiest U.K. pituitary centre. Pituitary referrals were characterised and volumes were predicted using an auto-regressive moving average model with a preceding seasonal and trend decomposition using Loess step (STL-ARIMA), compared against a Convolutional Neural Network-Long Short-Term Memory (CNN-LSTM) algorithm, Prophet and two standard baseline forecasting models. Median absolute, and median percentage error scoring metrics with cross-validation were employed to evaluate algorithm performance. Results: 462 of 36,224 emergency referrals were included (referring centres = 48; mean patient age = 56.7 years, female:male = 0.49:0.51). Emergency medicine and endocrinology accounted for the majority of referrals (67%). The most common presentations were headache (47%) and visual field deficits (32%). Lesions mainly comprised tumours or haemorrhage (85%) and involved the pituitary gland or fossa (70%). The STL-ARIMA pipeline outperformed CNN-LSTM, Prophet and baseline algorithms across scoring metrics, with standard accuracy being achieved for yearly predictions. Referral volumes significantly increased from the start of data collection with future projected increases (p < 0.001) and did not significantly reduce during the COVID-19 pandemic. Conclusion: This work is the first to employ large-scale data and machine learning to describe and predict acute pituitary referral volumes, estimate future service demands, explore the impact of system stressors (e.g. COVID pandemic), and highlight areas for service improvement

Influence of cytokine gene polymorphisms on proinflammatory/anti-inflammatory cytokine imbalance in premature coronary artery disease

BACKGROUND: Genetic information has the potential to create a more personalised, prompt, early and accurate risk evaluation. The effect of these genetic variants on the serum biomarker levels (phenotype) needs to be studied to assess their potential causal role in the pathogenesis of premature coronary artery disease (PCAD). Objectives were to determine the genotypic distribution of interleukin (IL) 18, tumour necrosis factor-α (TNFA), IL6 and IL10 single nucleotide polymorphisms (SNPs) in Pakistani PCAD cases and disease free controls and to study the effect of these gene polymorphisms on the serum cytokine levels (IL18, TNFA, IL6 and IL10) and cytokine imbalance (IL18:IL10 and TNFA:IL10). MATERIAL AND METHODS: The case-control study was carried out in National University of Sciences and Technology, Islamabad in collaboration with the Cardiovascular Genetics Institute, University College London, UK. Subjects (n=340) with >70% stenosis in at least a single major coronary artery on angiography were taken as PCAD cases along with 310 angiographically verified controls. ELISA was performed for measuring the concentrations of serum IL18, TNFA, IL6 and IL10. Genotyping was done using TAQMAN assay. RESULTS: The risk allele frequencies (RAFs) of rs1800795 (IL6) and rs187238 (IL18) cytokine gene promoter SNPs were significantly higher in the PCAD cases as compared with the controls. Serum IL18 and IL10 levels were significantly greater in the IL18 rs187238 GG genotype patients while serum IL18 and IL6 levels were significantly higher in patients having the IL6 rs1800795 CC genotype. IL18 SNP rs1946519 significantly altered the IL18, TNFA, IL6, IL18/IL10 and TNFA/IL10 ratio levels followed by TNFA SNP rs1800629 which significantly altered the serum levels of IL18, IL18:IL-0 and TNFA:IL10 ratios. CONCLUSIONS: The association of the selected SNPs with differential serum cytokine levels especially the cytokine imbalance points towards their potential causal role in the immune inflammatory pathogenic pathway of PCAD

Involvement of Bruton's tyrosine kinase in FcepsilonRI-dependent mast cell degranulation and cytokine production.

We investigated the role of Bruton's tyrosine kinase (Btk) in FcepsilonRI-dependent activation of mouse mast cells, using xid and btk null mutant mice. Unlike B cell development, mast cell development is apparently normal in these btk mutant mice. However, mast cells derived from these mice exhibited significant abnormalities in FcepsilonRI-dependent function. xid mice primed with anti-dinitrophenyl monoclonal IgE antibody exhibited mildly diminished early-phase and severely blunted late-phase anaphylactic reactions in response to antigen challenge in vivo. Consistent with this finding, cultured mast cells derived from the bone marrow cells of xid or btk null mice exhibited mild impairments in degranulation, and more profound defects in the production of several cytokines, upon FcepsilonRI cross-linking. Moreover, the transcriptional activities of these cytokine genes were severely reduced in FcepsilonRI-stimulated btk mutant mast cells. The specificity of these effects of btk mutations was confirmed by the improvement in the ability of btk mutant mast cells to degranulate and to secrete cytokines after the retroviral transfer of wild-type btk cDNA, but not of vector or kinase-dead btk cDNA. Retroviral transfer of Emt (= Itk/Tsk), Btk's closest relative, also partially improved the ability of btk mutant mast cells to secrete mediators. Taken together, these results demonstrate an important role for Btk in the full expression of FcepsilonRI signal transduction in mast cells

Quality Of Antenatal Care In Rural Southern Tanzania: A Reality Check.

Counselling on the danger signs of unpredictable obstetric complications and the appropriate management of such complications are crucial in reducing maternal mortality. The objectives of this study were to identify gaps in the provision of ANC services and knowledge of danger signs as well as the quality of care women receive in case of complications. The study took place in the Rufiji District of Tanzania in 2008 and was conducted in seven health facilities. The study used (1) observations from 63 antenatal care (ANC) sessions evaluated with an ANC checklist, (2) self-assessments of 11 Health workers, (3) interviews with 28 pregnant women and (4) follow-up of 12 women hospitalized for pregnancy-related conditions.Blood pressure measurements and abdominal examinations were common during ANC visits while urine testing for albumin or sugar or haemoglobin levels was rare which was often explained as due to a lack of supplies. The reasons for measuring blood pressure or abdominal examinations were usually not explained to the women. Only 15/28 (54%) women were able to mention at least one obstetric danger sign requiring medical attention. The outcomes of ten complicated cases were five stillbirths and three maternal complications. There was a considerable delay in first contact with a health professional or the start of timely interventions including checking vital signs, using a partograph, and detailed record keeping. Linking danger signs to clinical and laboratory examination results during ANC with the appropriate follow up and avoiding delays in emergency obstetric care are crucial to the delivery of coordinated, effective care interventions