Patient-, health worker-, and health facility-level determinants of correct malaria case management at publicly funded health facilities in Malawi: results from a nationally representative health facility survey

BACKGROUND: Prompt and effective case management is needed to reduce malaria morbidity and mortality. However, malaria diagnosis and treatment is a multistep process that remains problematic in many settings, resulting in missed opportunities for effective treatment as well as overtreatment of patients without malaria. METHODS: Prior to the widespread roll-out of malaria rapid diagnostic tests (RDTs) in late 2011, a national, cross-sectional, complex-sample, health facility survey was conducted in Malawi to assess patient-, health worker-, and health facility-level factors associated with malaria case management quality using multivariate Poisson regression models. RESULTS: Among the 2,019 patients surveyed, 34% had confirmed malaria defined as presence of fever and parasitaemia on a reference blood smear. Sixty-seven per cent of patients with confirmed malaria were correctly prescribed the first-line anti-malarial, with most cases of incorrect treatment due to missed diagnosis; 31% of patients without confirmed malaria were overtreated with an anti-malarial. More than one-quarter of patients were not assessed for fever or history of fever by health workers. The most important determinants of correct malaria case management were patient-level clinical symptoms, such as spontaneous complaint of fever to health workers, which increased both correct treatment and overtreatment by 72 and 210%, respectively (p < 0.0001). Complaint of cough was associated with a 27% decreased likelihood of correct malaria treatment (p = 0.001). Lower-level cadres of health workers were more likely to prescribe anti-malarials for patients, increasing the likelihood of both correct treatment and overtreatment, but no other health worker or health facility-level factors were significantly associated with case management quality. CONCLUSIONS: Introduction of RDTs holds potential to improve malaria case management in Malawi, but health workers must systematically assess all patients for fever, and then test and treat accordingly, otherwise, malaria control programmes might miss an opportunity to dramatically improve malaria case management, despite better diagnostic tools

The SAMI Galaxy Survey : spatially resolving the main sequence of star formation

We present the ∼800 star formation rate maps for the Sydney-AAO Multi-object Integral field spectrograph (SAMI) Galaxy Survey based on H α emission maps, corrected for dust attenuation via the Balmer decrement, that are included in the SAMI Public Data Release 1. We mask out spaxels contaminated by non-stellar emission using the [O iii]/H β, [N ii]/H α, [S ii]/H α, and [O i]/H α line ratios. Using these maps, we examine the global and resolved star-forming main sequences of SAMI galaxies as a function of morphology, environmental density, and stellar mass. Galaxies further below the star-forming main sequence are more likely to have flatter star formation profiles. Early-type galaxies split into two populations with similar stellar masses and central stellar mass surface densities. The main-sequence population has centrally concentrated star formation similar to late-type galaxies, while galaxies >3σ below the main sequence show significantly reduced star formation most strikingly in the nuclear regions. The split populations support a two-step quenching mechanism, wherein halo mass first cuts off the gas supply and remaining gas continues to form stars until the local stellar mass surface density can stabilize the reduced remaining fuel against further star formation. Across all morphologies, galaxies in denser environments show a decreased specific star formation rate from the outside in, supporting an environmental cause for quenching, such as ram-pressure stripping or galaxy interactions.Publisher PDFPeer reviewe

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Robust estimation of bacterial cell count from optical density

Optical density (OD) is widely used to estimate the density of cells in liquid culture, but cannot be compared between instruments without a standardized calibration protocol and is challenging to relate to actual cell count. We address this with an interlaboratory study comparing three simple, low-cost, and highly accessible OD calibration protocols across 244 laboratories, applied to eight strains of constitutive GFP-expressing E. coli. Based on our results, we recommend calibrating OD to estimated cell count using serial dilution of silica microspheres, which produces highly precise calibration (95.5% of residuals &lt;1.2-fold), is easily assessed for quality control, also assesses instrument effective linear range, and can be combined with fluorescence calibration to obtain units of Molecules of Equivalent Fluorescein (MEFL) per cell, allowing direct comparison and data fusion with flow cytometry measurements: in our study, fluorescence per cell measurements showed only a 1.07-fold mean difference between plate reader and flow cytometry data

Etude des disparités de la chirurgie élective en Belgique

La chirurgie élective recouvre les interventions qui peuvent normalement être programmées calmement sans danger immédiat pour la santé du patient. Naïvement, on pourrait s’attendre à ce que cette caractéristique contribue à des décisions d’intervention mûrement réfléchies et donc à peu de disparités entre les pratiques. Et pourtant on découvre dans la littérature internationale que le lieu de résidence du patient influence nettement la probabilité de subir certaines interventions. Ces différences sont-elles aussi observées en Belgique ? Quelle intervention, de la cataracte, du syndrome du canal carpien ou de la sténose carotidienne, présente la plus grande variabilité ? Où fait-on le plus d’arthroscopies en Belgique ? La prothèse totale de hanche et la prothèse totale de genou sont-elles liées géographiquement ? Et qu’en est-il de la césarienne, dont on a encore récemment beaucoup entendu parler dans l’actualité, pour la proportion inquiétante de césariennes dans certains hôpitaux ? Illustrer simplement les différences de pratique ne suffit pas. Classiquement, il s’agit ensuite d’essayer d’éliminer l’effet de plusieurs variables qui pourraient objectivement expliquer les différences observées, comme des comorbidités, des variables socioéconomiques, des facteurs d’offre médicale, … Mais les disparités de pratique subsistent en Belgique même après avoir éliminé l’effet de ces variables. Ceci avait déjà été mis en évidence dans des études précédentes. On débouche alors inévitablement sur un questionnement à propos de l’opportunité des soins. Cette recherche démontre que pour certaines interventions, il est possible de mettre en évidence une association entre « trop de soins donnés » et des « soins médicalement inopportuns ». Mais ce n’est pas toujours le cas, le questionnement reste alors entier et l’instauration de mesures qui viseraient à diminuer des différences non justifiées reste à l’ordre du jour. Une collaboration de fond avec les acteurs de terrain pour chaque domaine spécifique est un « must », comme le prouve cette étude. En outre, cette étude a montré une fois de plus que la Belgique est riche en bases de données qui ne demandent qu’à être exploitées, pas seulement par le KCE mais aussi par tous les autres acteurs qui cherchent à utiliser le plus efficacement possible les moyens disponibles pour offrir à tous les patients les meilleurs soins

Predicting Neisseria gonorrhoeae and Chlamydia trachomatis Infection Using Risk Scores, Physical Examination, Microscopy, and Leukocyte Esterase Urine Dipsticks Among Asymptomatic Women Attending a Family Planning Clinic in Kenya

Background: Sexually transmitted infections (STIs) continue to exert a tremendous health burden on women in developing countries. Poor socioeconomic status, inadequate knowledge, lack of diagnostic facilities, and shortages of effective treatment all contribute to the high incidence of STIs. The use of clinical algorithms for the detection and management of STIs has gained widespread acceptance in settings where there are limited resources. Evaluation of these algorithms have been few, especially in women who are not recognized as members of high-risk groups. Objectives: To develop a simple scoring system based on historical and demographic data, physical findings, microscopy, and leukocyte esterase (LE) urine dipsticks to predict cervical gonococcal and chlamydial infection among asymptomatic women. Methods: One thousand and forty-eight women attending an urban family planning clinic in Nairobi were randomly selected to participate. After the identification of factors that were associated with infection, we assigned one point each for: age 25 or younger, single status, two or more sex partners in the past year, cervical discharge, cervical swab leukocytes, and a positive LE urine dipstick. Identification of any one of these six factors gave a sensitivity of 85% and a specificity of 30% for the detection of cervical infections. A positive LE urine dipstick had a sensitivity of 63 % and a specificity of 47% when used alone and did not contribute to the identification of infection if a physical examination was performed. The application of existing clinical algorithms to this population performed poorly. Conclusions: The use of risk scores, physical examination, microscopy, and the urine LE dipstick, used alone or in combination, as predictors of gonococcal or chlamydial cervical infection was of limited utility in low-risk, asymptomatic women. Accurate diagnostic testing is necessary to optimize treatment

Documentation of individualized preoperative risk assessment: a multi-center study

Seven hundred fifty-six of 140,756 inpatient charts met inclusion criteria (0.54%, 95% CI 0.50 to 0.58%). ISRAs were documented by 16.08% of surgeons and 4.76% of anesthesiologists (p < 0.0001, 95% CI -0.002 to 0.228). Cardiac surgeons documented ISRAs more frequently than non-cardiac surgeons (25.87% vs 16.15%) [p = 0.0086, R-squared = 0.970%]. Elective surgical patients were more likely than emergency surgical patients (19.57 vs 12.03%) to have risk documented (p = 0.023, R-squared = 0.730%). Patients over the age of 65 were more likely than patients under the age of 65 to have ISRA documentation (20.31 vs 14.61%) [p = 0.043, R-squared = 0.580%]. Only 10 of 756 (1.3%) records included documentation of a named ISRA tool.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda

Abstract Background To increase access to antiretroviral therapy in resource-limited settings, several experts recommend "task shifting" from doctors to clinical officers, nurses and midwives. This study sought to identify task shifting that has already occurred and assess the antiretroviral therapy training needs among clinicians to whom tasks have shifted. Methods The Infectious Diseases Institute, in collaboration with the Ugandan Ministry of Health, surveyed health professionals and heads of antiretroviral therapy clinics at a stratified random sample of 44 health facilities accredited to provide this therapy. A sample of 265 doctors, clinical officers, nurses and midwives reported on tasks they performed, previous human immunodeficiency virus training, and self-assessment of knowledge of human immunodeficiency virus and antiretroviral therapy. Heads of the antiretroviral therapy clinics reported on clinic characteristics. Results Thirty of 33 doctors (91%), 24 of 40 clinical officers (60%), 16 of 114 nurses (14%) and 13 of 54 midwives (24%) who worked in accredited antiretroviral therapy clinics reported that they prescribed this therapy (p Conclusion Training initiatives should be an integral part of the support for task shifting and ensure that antiretroviral therapy is used correctly and that toxicity or drug resistance do not reverse accomplishments to date.</p

Seeking international consensus on approaches to primary tumour treatment in Ewing sarcoma.

BACKGROUND The local treatment of Ewing sarcoma of bone involves surgery, radiotherapy or both. The selection of treatment depends on the anatomical extent of the tumour, the effectiveness of the proposed treatment, its morbidity, and the expectation of cure. However, not only are there variations in the approach to local treatment between individual patients, but also between treatment centres and countries. Our aim was to explore variation in practice and develop consensus statements about local treatment. METHODS A three stage modified Delphi technique was used with international collaborators. This involved an expert panel to identify areas of controversy, an online survey of international collaborators and a consensus meeting in London, UK in June 2017. In the consensus meeting, teams of clinicians discussed the local management of selected cases and their responses were collected with electronic voting. RESULTS Areas of greater or less consensus were identified. The lack of evidence underpinning different approaches was noted and areas for collaborative research became apparent. CONCLUSION This has demonstrated that there is an international consensus around many aspects of the local treatment of Ewing sarcoma of bone, including the use of specialist MultiDisciplinary Team (MDT) meetings with access to all appropriate treatments. However, considerable variation remains including the use of different staging investigations, decision making, definitions of response, and radiotherapy doses and timing. Further collaborative work should be undertaken to determine the impact of these variations in order to define best practice