Is there a safe limit of delay for emergency caesarean section in Ghana? Results of analysis of early perinatal outcome

Objective: To determine the limits of delaying caesarean section in a busy obstetric unit in a developing country setting that is not associated with neonatal survival.Methods: Retrospective cohort study of emergency cesarean sections. Indications were sub-divided into imminent threat and no imminent threat to fetal wellbeing. The primary outcomes was a composite measure of adverse perinatal outcome including stillbirth, 5-minute Apgar score < 7 and neonatal intensive care unit admission. Effect of decision-to-delivery interval on perinatal outcomes was evaluated using Kaplan-Meier survival analysis.Results: 495 women met inclusion criteria (142 ‘imminent threat’ group, 353 ‘no imminent threat’ group). The median decision-to-delivery interval was significantly shorter in the ‘imminent threat’ group (2.25 [95% CI 1.38 - 5.83] versus 3.42 [95% CI 1.83 - 5.85] hours, p <0.001). Only 1.7% and 12.7% sections were performed within 30 minutes and 1 hour, respectively. Risk of the composite outcome was significantly higher in the ‘imminent threat group (46.5% versus 31.2%, RR=1.49 [95% CI 1.18 – 1.89],  p=0.001). A 95% probability of ‘live intact’ survival occurred at 1hr and 2hrs respectively, for the imminent threat and the no imminent threat groupsConclusion: Increasing decision-to-delivery interval is associated with higher risk of adverse perinatal outcomes, but a 95% live intact survival can be achieved if the delivery occurs within 2 hours.Key words: Limits of delay, caesarean section, Ghana, perinatal outcom

Incidence, causes and correlates of maternal near‐miss morbidity: a multi‐centre cross‐sectional study

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/1/bjo15578-sup-0009-ICMJES9.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/2/bjo15578-sup-0008-ICMJES8.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/3/bjo15578-sup-0002-ICMJES2.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/4/bjo15578-sup-0003-ICMJES3.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/5/bjo15578_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/6/bjo15578-sup-0004-ICMJES4.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/7/bjo15578-sup-0005-ICMJES5.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/8/bjo15578.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/9/bjo15578-sup-0007-ICMJES7.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/10/bjo15578-sup-0006-ICMJES6.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149236/11/bjo15578-sup-0001-ICMJES1.pd

Global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

Background Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980–2017 and forecast these estimates to 2030 for 195 countries and territories. Methods We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package—a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections. Findings Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87–2·04) and has since decreased to 0·95 million deaths (0·91–1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79–3·67) and since then have gradually decreased to 1·94 million (1·63–2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8–39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets. Interpretation Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact

Hand osteoarthritis: clinical phenotypes, molecular mechanisms and disease management

Osteoarthritis (OA) is a highly prevalent condition and the hand is the most commonly affected site. Patients with hand OA frequently report symptoms of pain, functional limitations, and frustration in undertaking everyday activities. The condition presents clinically with changes to the bone, ligaments, cartilage and synovial tissue, which can be observed using radiography, ultrasonography or MRI. Hand OA is a heterogeneous disorder and is considered to be multifactorial in aetiology. This review provides an overview of the epidemiology, presentation and burden of hand OA, including an update on hand OA imaging (including the development of novel techniques), disease mechanisms and management. In particular, areas for which new evidence has substantially changed the way we understand, consider and treat hand OA are highlighted. For example, genetic studies, clinical trials and careful prospective imaging studies from the past 5 years are beginning to provide insights into the pathogenesis of hand OA that might uncover new therapeutic targets in disease

“If You Need a Psychiatrist, It’s BAD”: Stigma Associated with Seeking Mental Health Care Among Obstetric Providers in Ghana

Emma R Lawrence,1 Bela J Parekh,2 Ruth Owusu-Antwi,3 Noah Newman,2 Colin B Russell,1 Titus K Beyuo,4,5 Michael Yeboah,6 Samuel A Oppong,4,5 Cheryl A Moyer1,7 1Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; 2University of Michigan Medical School, Ann Arbor, MI, USA; 3Department of Behavioural Sciences, Kwame Nkrumah University of Science and Technology/ Psychiatry Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana; 4Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana; 5Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Korle Bu, Accra, Ghana; 6Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana; 7Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USACorrespondence: Ruth Owusu-Antwi, Department of Behavioural Sciences, Kwame Nkrumah University of Science and Technology/ Psychiatry Unit, Komfo Anokye Teaching Hospital, Accra Road, Kumasi, Ashanti Region, Ghana, Tel +233244650245, Email [email protected]: Globally, the COVID-19 pandemic has brought attention to the impact of negative patient outcomes on healthcare providers. In Ghana, obstetric providers regularly face maternal and neonatal mortality, yet limited research has focused on provision of mental health support for these providers. This study sought to understand how obstetric providers viewed seeking mental health support after poor clinical outcomes, with a focus on the role of mental health stigma.Patients and Methods: Participants were 52 obstetric providers (20 obstetrician/gynecologists and 32 midwives) at two tertiary care hospitals in Ghana. Five focus groups, led by a trained facilitator and lasting approximately two hours, were conducted to explore provider experiences and perceptions of support following poor maternal and neonatal outcomes. Discussions were audiotaped and transcribed verbatim, then analyzed qualitatively using grounded theory methodology.Results: Most participants (84.3%, N=43) were finished with training, and 46.2% (N=24) had been in practice more than 10 years. Emerging themes included pervasive stigma associated with seeking mental health care after experiencing poor clinical outcomes, which was derived from two overlapping dimensions. First, societal-level stigma resulted from a cultural norm to keep emotions hidden, and the perception that psychiatry is equated with severe mental illness. Second, provider-level stigma resulted from the belief that healthcare workers should not have mental health problems, a perception that mental health care is acceptable for patients but not for providers, and a fear about lack of confidentiality. Despite many providers acknowledging negative mental health impacts following poor clinical outcomes, these additive layers of stigma limited their willingness to engage in formal mental health care.Conclusion: This study demonstrates that stigma creates significant barriers to acceptance of mental health support among obstetric providers. Interventions to support providers will need to respect provider concerns without reinforcing the stigma associated with seeking mental health care.Keywords: provider burnout, therapy, sub-Saharan Africa, LMI