Meal-derived glucagon responses are related to lower hepatic phosphate concentrations in obesity and type 2 diabetes

Aim. - Type 2 diabetes (T2D) alters glucagon, glucagon-like peptide (GLP)-1, glucose-dependent insulinotropic polypeptide (GIP) and hepatic energy metabolism, yet the possible relationships remain unclear.Methods. - In this observational study, lean insulin-sensitive control subjects (BMI: 23.2 +/- 1.5 kg/m(2)), age-matched insulin-resistant obese subjects (BMI: 34.3 +/- 1.7 kg/m(2)) and similarly obese elderly T2D patients (BMI: 32.0 +/- 2.4 kg/m(2)) underwent mixed-meal tolerance tests (MMTTs), and assessment of hepatic gamma ATP, inorganic phosphate (P-i) and lipids using P-31/H-1 magnetic resonance spectroscopy. Meal-induced secretion of glucagon and incretins was calculated from incremental areas under the concentration-time curves (iAUCs). Peripheral and adipose tissue insulin sensitivity were assessed from time courses of circulating glucose, insulin and free fatty acids.Results. - MMTT-derived peripheral insulin sensitivity was lowest in T2D patients (P &lt;0.001), while glucagon concentrations were comparable across all three groups. At 260 min, GLP-1 was lower in T2D patients than in controls, whereas GIP was lowest in obese individuals. Fasting glucagon concentrations correlated positively with fasting (r = 0.60) and postprandial hepatocellular lipid levels (160 min: r= 0.51, 240 min: r = 0.59), and negatively with adipose tissue insulin sensitivity (r = -0.73). Higher meal-induced glucagon release (iAUC(0)(-260) (min)) correlated with lower fasting (r = -0.62) and postprandial P(i )levels (160 min: r = -0.43, 240 min: r = -0.42; all P &lt;0.05). Higher meal-induced release of GIP (iAUC(0-260) (min)) correlated positively with fasting (r = 0.54) and postprandial serum triglyceride concentrations (iAUC(0-260 min, )r = 0.54; all P &lt;0.01).Conclusion. - Correlations between fasting glucagon and hepatic lipids and between meal-induced glucagon and hepatic P-i suggest a role for glucagon in hepatic energy metabolism. (C) 2018 Elsevier Masson SAS. All rights reserved.</p

Clinical Frailty Scale (CFS) reliably stratifies octogenarians in German ICUs: a multicentre prospective cohort study

Background: In intensive care units (ICU) octogenarians become a routine patients group with aggravated therapeutic and diagnostic decision-making. Due to increased mortality and a reduced quality of life in this high-risk population, medical decision-making a fortiori requires an optimum of risk stratification. Recently, the VIP-1 trial prospectively observed that the clinical frailty scale (CFS) performed well in ICU patients in overall-survival and short-term outcome prediction. However, it is known that healthcare systems differ in the 21 countries contributing to the VIP-1 trial. Hence, our main focus was to investigate whether the CFS is usable for risk stratification in octogenarians admitted to diversified and high tech German ICUs. Methods: This multicentre prospective cohort study analyses very old patients admitted to 20 German ICUs as a sub-analysis of the VIP-1 trial. Three hundred and eight patients of 80 years of age or older admitted consecutively to participating ICUs. CFS, cause of admission, APACHE II, SAPS II and SOFA scores, use of ICU resources and ICU- and 30-day mortality were recorded. Multivariate logistic regression analysis was used to identify factors associated with 30-day mortality. Results: Patients had a median age of 84 [IQR 82–87] years and a mean CFS of 4.75 (± 1.6 standard-deviation) points. More than half of the patients (53.6%) were classified as frail (CFS ≥ 5). ICU-mortality was 17.3% and 30-day mortality was 31.2%. The cause of admission (planned vs. unplanned), (OR 5.74) and the CFS (OR 1.44 per point increase) were independent predictors of 30-day survival. Conclusions: The CFS is an easy determinable valuable tool for prediction of 30-day ICU survival in octogenarians, thus, it may facilitate decision-making for intensive care givers in Germany. Trial registration: The VIP-1 study was retrospectively registered on ClinicalTrials.gov (ID: NCT03134807 ) on May 1, 2017

Champion and audit and feedback strategy fidelity and their relationship to depression intervention fidelity: A mixed method study

Background: Globally, mental health disorders rank as the greatest cause of disability. Low and middle-income countries (LMICs) hold a disproportionate share of the mental health burden, especially as it pertains to depression. Depression is highly prevalent among those with non-communicable diseases (NCDs), creating a barrier to successful treatment. While some treatments have proven efficacy in LMIC settings, wide dissemination is challenged by multiple factors, leading researchers to call for implementation strategies to overcome barriers to care provision. However, implementation strategies are often not well defined or documented, challenging the interpretation of study results and the uptake and replication of strategies in practice settings. Assessing implementation strategy fidelity (ISF), or the extent to which a strategy was implemented as designed, overcomes these challenges. This study assessed fidelity of two implementation strategies (a ‘basic’ champion strategy and an ‘enhanced’ champion ​+ ​audit and feedback strategy) to improve the integration of a depression intervention, measurement based care (MBC), at 10 NCD clinics in Malawi. The primary goal of this study was to assess the relationship between the implementation strategies and MBC fidelity using a mixed methods approach. Methods: We developed a theory-informed mixed methods fidelity assessment that first combined an implementation strategy specification technique with a fidelity framework. We then created corresponding fidelity indicators to strategy components. Clinical process data and one-on-one in-depth interviews with 45 staff members at 6 clinics were utilized as data sources. Our final analysis used descriptive statistics, reflexive-thematic analysis (RTA), data merging, and triangulation to examine the relationship between ISF and MBC intervention fidelity. Results: Our mixed methods analysis revealed how ISF may moderate the relationship between the strategies and MBC fidelity. Leadership engagement and implementation climate were critical for clinics to overcome implementation barriers and preserve implementation strategy and MBC fidelity. Descriptive statistics determined champion strategy fidelity to range from 61 to 93% across the 10 clinics. Fidelity to the audit and feedback strategy ranged from 82 to 91% across the 5 clinics assigned to that condition. MBC fidelity ranged from 54 to 95% across all clinics. Although correlations between ISF and MBC fidelity were not statistically significant due to the sample of 10 clinics, associations were in the expected direction and of moderate effect size. A coefficient for shared depression screening among clinicians had greater face validity compared to depression screening coverage and functioned as a proximal indicator of implementation strategy success. Conclusion: Fidelity to the basic and enhanced strategies varied by site and were influenced by leadership engagement and implementation climate. Champion strategies may benefit from the addition of leadership strategies to help address implementation barriers outside the purview of champions. ISF may moderate the relationship between strategies and implementation outcomes

Willingness to act upon beliefs about 'treatment as prevention' among Australian gay and bisexual men

HIV 'treatment as prevention' (TasP) is highly effective in reducing HIV transmission in serodiscordant couples. There has been little examination of gay and bisexual men's attitudes towards TasP, particularly regarding men's willingness to act on beliefs about TasP. We conducted an online cross-sectional survey of Australian men in late 2012 to investigate knowledge and beliefs about new developments in HIV prevention. Amongst 839 men (mean age 39.5 years), men tended to disagree that TasP was sufficiently effective to justify reduced condom use, although HIV-positive men had more favourable attitudes. Only a minority of men were aware of any evidence for TasP; and one-quarter incorrectly believed that evidence for the effectiveness of TasP already existed for the homosexual population. One-fifth (20.5%) of men reported that they would be willing to have condomless anal intercourse with an opposite-status sexual partner when the HIV-positive partner was taking HIV treatments. Factors independently associated with such willingness were: HIV-positive serostatus, reporting any serodiscordant or serononconcordant condomless anal intercourse with a regular male partner in the previous six months, reporting any condomless anal intercourse with a casual male partner in the previous six months, and having greater beliefs in the effectiveness of TasP. This indicated that the men most willing to rely on TasP to prevent transmission were already engaging in higher risk practices. Biomedical HIV prevention represents a rapidly changing environment with new research as well as community and policy responses emerging at a fast pace. For men with serodiscordant sexual partners to successfully apply TasP to reducing transmission risk, more support and education is needed to enable better utilisation of TasP in specific relational and sexual contexts

Developing a mHealth intervention to promote uptake of HIV testing among African communities in the UK: a qualitative study

Background: HIV-related mHealth interventions have demonstrable efficacy in supporting treatment adherence, although the evidence base for promoting HIV testing is inconclusive. Progress is constrained by a limited understanding of processes used to develop interventions and weak theoretical underpinnings. This paper describes a research project that informed the development of a theory-based mHealth intervention to promote HIV testing amongst city-dwelling African communities in the UK. Methods: A community-based participatory social marketing design was adopted. Six focus groups (48 participants in total) were undertaken and analysed using a thematic framework approach, guided by constructs from the Health Belief Model. Key themes were incorporated into a set of text messages, which were pre-tested and refined. Results: The focus groups identified a relatively low perception of HIV risk, especially amongst men, and a range of social and structural barriers to HIV testing. In terms of self-efficacy around HIV testing, respondents highlighted a need for communities and professionals to work together to build a context of trust through co-location in, and co-involvement of, local communities which would in turn enhance confidence in, and support for, HIV testing activities of health professionals. Findings suggested that messages should: avoid an exclusive focus on HIV, be tailored and personalised, come from a trusted source, allay fears and focus on support and health benefits. Conclusions: HIV remains a stigmatized and de-prioritized issue within African migrant communities in the UK, posing barriers to HIV testing initiatives. A community-based participatory social marketing design can be successfully used to develop a culturally appropriate text messaging HIV intervention. Key challenges involved turning community research recommendations into brief text messages of only 160 characters. The intervention needs to be evaluated in a randomized control trial. Future research should explore the application of the processes and methodologies described in this paper within other communities

Tailoring youth-friendly health services in Nigeria: a mixed-methods analysis of a designathon approach

BACKGROUND: Young people in low- and middle-income countries are often neglected in designing youth-friendly health services, especially HIV testing and preventive services. Designathons, which are time-bounded co-creation events where individuals gather in teams to develop solutions to a problem, could promote youth participation and ownership of health services. OBJECTIVE: The purpose of this study is to examine youth participation in a designathon to create youth-friendly health services in Nigeria. METHODS: Our designathon was based on crowdsourcing principles and informed by a human-centered design approach. The designathon included an open call for Nigerian youths between 14 and 24 years to share ideas on how to promote uptake of HIV self-testing services and a three-day sprint event that brought together diverse teams to develop strategies enhancing linkage to care. Teams pitched their solutions to a panel of five independent experts who scored ideas based on the desirability, feasibility, potential impact, and teamwork. We used descriptive statistics to summarize participants' demographics and conducted a content analysis to synthesize themes from youth proposals. RESULTS: Nine hundred seventy-six youth across Nigeria applied to join the designathon. Forty-eight youth in 13 teams participated in the designathon with a median age of 20 years (IQR: 17-22]. Boys and young men were 48.5% (446/919) of the total applicants, 62.5% (30/48) of the designathon participants, and 63.6% (7/11) of the finalists. Students, from all educational levels, represented 91.2% (841/922) of the total applicants, 88.4% (38/43) of the designathon participants, and 90.0% (9/10) of the finalists. About twenty-three percent (3/13) of the final proposals were top ranked. The three finalist approaches to optimize youth-friendly health services centered on decentralizing service delivery to young people through mobile health technologies, use of mobile tents, or peer support services. CONCLUSIONS: Our open call engaged diverse groups of Nigerian youth, including young women and students. Our data suggest that designathons may be useful for developing tailored youth-friendly health services. Further research is needed to understand the designathon process and the effectiveness of the finalist submissions

The eClinical Care Pathway Framework: A novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections.

Despite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England.Using the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway).Use of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation.The Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway's standardised method of collecting data on demographics and sexual behaviour, with potential for interoperability with surveillance systems, could be a powerful tool for public health and clinical management.UKCRC Translational Infection Research (TIR) Initiative supported by the Medical Research Council, eSTI2 Consortium (Grant Number G0901608)

Enhancing HIV Self-Testing Among Nigerian Youth: Feasibility and Preliminary Efficacy of the 4 Youth by Youth Study Using Crowdsourced Youth-Led Strategies.

Although HIV self-testing (HIVST) has expanded in many regions, a few HIVST services have been tailored for and organized by youth. Innovative HIVST models are needed to differentiate testing services and generate local demand for HIVST among youth. The current pilot study aimed at examining the feasibility and efficacy of crowdsourced youth-led strategies to enhance HIVST as well as sexually transmitted infection (STI) testing. Teams of youth iteratively developed HIVST interventions using crowdsourcing approaches and apprenticeship training. Five interventions were selected and then evaluated among youth (ages 14-24) from September 2019 to March 2020. Given the similar outcomes and approaches, we present cumulative data from the completed interventions. We assessed HIVST uptake (self-report), STI uptake (facility reports for gonorrhea, syphilis, hepatitis B, and chlamydia testing), and quality of youth participation. Mixed-effect logistic regression models estimated intervention effects at baseline and 6 months. Of the 388 youths enrolled, 25.3% were aged 14-19, 58.0% were male, and 54.1% had completed secondary education. We observed a significant increase in HIVST from 3 months compared with 6 months (20% vs. 90%; p < 0.001). Among those who received an HIVST at 3 months, 324 out of 388 were re-tested at 6 months. We also observed significant increases in testing for all four STIs: syphilis (5-48%), gonorrhea (5-43%), chlamydia (1-45%), and hepatitis B testing (14-55%) from baseline to the 6-month follow-up. Youth participation in the intervention was robust. Youth-led HIVST intervention approaches were feasible and resulted in increased HIV/STI test uptake. Further research on the effectiveness of these HIVST services is needed

Youth engagement in HIV prevention intervention research in sub-Saharan Africa: a scoping review.

INTRODUCTION: Youth engagement in HIV research is generally recognized as essential, but often neglected or minimally implemented in practice. Engagement is a process of working collaboratively with diverse groups of people to address common issues. We conducted a scoping review of youth HIV prevention interventions in sub-Saharan Africa to identify and categorize forms and levels of youth engagement across the lifespan of intervention research. METHODS: We followed Arksey and O'Malley's framework for organizing a scoping review. We searched seven databases for related articles on identified intervention studies through May 28th 2020. Included studies focused on youth (10 to 24 years old) HIV prevention interventions in sub-Saharan Africa. Two reviewers independently examined citations and full manuscripts for inclusion. Data were extracted on study characteristics, location, description of youth engagement and extent of engagement. Youth engagement approaches were categorized based on Hart's ladder as substantial engagement (strong youth decision-making power), moderate engagement (shared decision making with adults), minimal engagement (no youth decision-making power) or no engagement. RESULTS: We identified 3149 citations and included 112 studies reporting on 74 unique HIV interventions. Twenty-two interventions were in low-income countries, 49 in middle-income countries, and three were in both. Overall, only nine interventions (12%) had substantial or moderate youth engagement, two-thirds (48, 65%) had minimal youth engagement and 17 interventions (23%) had no youth engagement. We also identified specific engagement strategies (e.g. youth-led research, crowdsourcing) that were feasible in multiple settings and resulted in substantial engagement. CONCLUSIONS: We found limited youth engagement in youth HIV prevention intervention studies in sub-Saharan Africa. However, several activities resulted in substantial youth engagement and could be relevant in many low-and-middle-income-country (LMIC) settings

Understanding the barriers to successful adoption and use of a mobile health information system in a community health center in São Paulo, Brazil: a cohort study

BACKGROUND: Mobile technology to support community health has surged in popularity, yet few studies have systematically examined usability of mobile platforms for this setting. METHODS: We conducted a mixed-methods study of 14 community healthcare workers at a public healthcare clinic in São Paulo, Brazil. We held focus groups with community healthcare workers to elicit their ideas about a mobile health application and used this input to build a prototype app. A pre-use test survey was administered to all participants, who subsequently use-tested the app on three different devices (iPhone, iPad mini, iPad Air). Usability was assessed by objectively scored data entry errors and through a post-use focus group held to gather open-ended feedback on end-user satisfaction. RESULTS: All of the participants were women, ranging from 18–64 years old. A large percentage (85.7%) of participants had at least a high school education. Internet (92.8%), computer (85.7%) and cell phone (71.4%) use rates were high. Data entry error rates were also high, particularly in free text fields, ranging from 92.3 to 100%. Error rates were comparable across device type. In a post-use focus group, participants reported that they found the app easy to use and felt that its design was consistent with their vision. The participants raised several concerns, including that they did not find filling out the forms in the app to be a useful task. They also were concerned about an app potentially creating more work for them and personal security issues related to carrying a mobile device in low-income areas. CONCLUSION: In a cohort of formally educated community healthcare workers with high levels of personal computer and cell phone use, we identified no technological barriers to adapting their existing work to a mobile device based system. Transferring current data entry work into a mobile platform, however, uncovered underlying dissatisfaction with some data entry tasks. This dissatisfaction may be a more significant barrier than the data entry errors our testing revealed. Our results highlight the fact that without a deep understanding of local process to optimize usability, technology-based solutions in health may fail. Developing such an understanding must be a central component in the design of any mHealth solution in global health