Increasing women’s access to skilled care to reduce maternal and perinatal mortality in Nigeria

The presentation reviews the study aims and methodology. Both demand and supply factors must be addressed if women are to use primary health care (PHC) for maternal and child health (MCH) services in Nigeria, where 750,000 children under the age of 5 die each year. The project aims to explore the socio-economic and cultural factors of use or non-use of PHC services in two selected rural areas in Edo State, Nigeria; and to implement a series of multi-facetted interventions for improving demand and use of PHC services

Evidence of survival bias in the association between APOE-ϵ4 and age of ischemic stroke onset.

Large genome-wide association studies (GWAS) employing case-control study designs have now identified tens of loci associated with ischemic stroke (IS). As a complement to these studies, we performed GWAS in a case-only design to identify loci influencing age at onset (AAO) of ischemic stroke. Analyses were conducted in a Discovery cohort of 10,857 ischemic stroke cases using a linear regression framework. We meta-analyzed all SNPs with p-value C allele was associated with a 1.29 years earlier stroke AOO (meta p-value = 2.48×10 -11). This APOE variant has previously been associated with increased mortality and ischemic stroke AAO. We hypothesized that the association with AAO may reflect a survival bias attributable to an age-related decline in mortality among APOE-ϵ4 carriers and have no association to stroke AAO per se. Using a simulation study, we found that a variant associated with overall mortality might indeed be detected with an AAO analysis. A variant with a two-fold increase on mortality risk would lead to an observed effect of AAO that is comparable to what we found. In conclusion, we detected a robust association of the APOE locus with stroke AAO and provided simulations to suggest that this association may be unrelated to ischemic stroke per se but related to a general survival bias

Biomarker Validation of Recent Unprotected Sexual Intercourse in a Prospective Study of Young Women Engaged in Sex Work in Phnom Penh, Cambodia

Summary—A study of female sex workers in Phnom Penh, Cambodia found self-reported condom use to be of questionable validity, particularly among amphetamine-type stimulant (ATS) users and those with multiple partners. Background—Accurate measurement of unprotected sex is essential in HIV prevention research. Since 2001, the 100% Condom Use Program targeting female sex workers (FSW) has been a central element of the Cambodian National HIV/AIDS Strategy. We sought to assess the validity of self-reported condom use using the rapid prostate-specific antigen (PSA) test among Cambodian FSW. Methods—From 2009 to 2010 we enrolled 183 FSW in Phnom Penh in a prospective study of HIV risk behavior. PSA test results from the OneStep ABAcard® were compared to self-reported condom use in the past 48 hours at quarterly follow-up visits. Results—Among women positive for seminal fluid at the first follow-up visit, 42% reported only protected sex or no sex in the detection period. Discordant results were more likely among brothel and street-based FSW vs. entertainment (56% vs. 17%), recent (last 3 months) ATS users (53% vs. 20%), and those with \u3e5 partners in the past month (58% vs. 13%). In multivariable regression models, positive PSA results were associated with recent ATS use (Adjusted Risk Ratio (ARR) = 1.5; 95% confidence interval (CI):1.1 – 2.2), having a non-paying last sex partner (ARR=1.7; CI: 1.2 – 2.5), and sex work venue (ARR=3.0; CI:1.4 – 6.5). Correspondingly, women with a nonpaying last sex partner were more likely to report unprotected sex (ARR=1.5; CI:1.1 – 2.2), but no associations were found with sex work venue or ATS use. Conclusions—Results confirm the questionable validity of self-reported condom use among FSW. The PSA biomarker assay is an important monitoring tool in HIV/STI research including prevention trials

Replacing Myths With Facts: Sex-Selective Abortion Laws In The United States

Sex selection is the practice of attempting to control the sex of one’s offspring in order to achieve a desired sex. One method of sex selection is sex-selective abortion. Laws banning sex-selective abortion are proliferating in the United States. Eight states have enacted laws prohibiting sexselective abortion. Twenty-one states and the federal government have considered such laws since 2009. Those laws prohibit the performance of an abortion if sought based on the sex of the fetus and provide for both criminal and civil penalties in most cases. A great deal of misinformation exists regarding sex selection in the United States. We have identified six inaccuracies commonly associated with sex-selective abortion and laws prohibiting it. They appear, among other places, in statements made by legislators, testimony submitted to legislatures, and reports issued by legislative committees that have considered or adopted laws banning sexselective abortion. We present each piece of inaccurate information as a “myth.” This Report draws on legal research, empirical analysis of U.S. birth data, field-work, and an extensive review of scholarly publications in social sciences, law and other disciplines to replace these myths with facts. Legislators and proponents of sex-selective abortion bans have consistently referred to the existence of male-biased sex ratios and the practice of sex selection in other parts of the world. Discussions have focused on the problem of “missing women” in China and India in particular. However, China and India are not the only countries with male-biased sex ratios. On the contrary, the two countries with the highest sex ratios at birth are Liechtenstein and Armenia (see discussion of Myth #2 below). Both have higher sex ratios at birth than China and India. Legislators and major news outlets have stated that the United States is one of the few countries that does not prohibit abortion for sex selection purposes. However, the eight states in the United States that currently ban sex-selective abortion are among a small minority of places in the world where it is banned. Only four other countries explicitly prohibit sex-selective abortion: China, Kosovo, Nepal and Vietnam (see discussion of Myth #3 below). Instead, many countries that are concerned about sex selection prohibit the use of technology to sex select prior to implantation of the embryo in the uterus. The main empirical support for the view that Asian Americans are obtaining sex-selective abortions based on son preference in the United States is from a study by economists Douglas Almond and Lena Edlund published in 2008. That study, using United States census data from 2000, found that when foreign-born Chinese, Indians and Koreans have two girls, the sex ratios at the third birth in those families is skewed towards boys. However, in analyzing more recent data from the 2007 to 2011 American Community Survey (ACS), we found that the sex ratios at birth of foreign-born Chinese, Indians and Koreans are not male-biased when all their births are taken into account. In fact, foreign-born Chinese, Indians and Koreans have proportionally more girls than white Americans (see discussion of Myth #5 below). Proponents of sex-selective abortion bans claim they are needed to “prohibit discrimination against the unborn on the basis of sex” and to stop the practice of sex selection among Asian Americans in the United States. As noted, sex-selective abortion is only one among several methods available to select the sex of one’s offspring. None of the laws enacted or proposed in the United States prohibit methods other than abortion, such as sperm sorting or preimplantation genetic diagnosis (see discussion of Myth #1 below). Instead, the laws focus solely on abortion. Moreover, sex-selective abortion bans have not been shown to impact sex ratios in the United States. On the contrary, our study shows that laws in Illinois and Pennsylvania—adopted in 1984 and 1989, respectively—are not associated with changes in sex ratios at birth in those states (see discussion of Myth #4 below). Sex-selective abortion laws are part of the legislative campaign of groups opposed to reproductive rights. The laws are generally proposed by legislators who are anti-abortion. Our analysis found that over 90% of Republican representatives in the six states that enacted bans in the last four years voted for the laws. In contrast, less than 10% of Democrats voted for the bans in four of the six states. In the two states where sex-selective abortion bans achieved meaningful support from Democrats— Oklahoma and South Dakota—laws that restrict access to abortion consistently receive bipartisan support (see discussion of Myth #6 below)

Exploring the Use of Cost-Benefit Analysis to Compare Pharmaceutical Treatments for Menorrhagia

Background: The extra-welfarist theoretical framework tends to focus on health-related quality of life, whilst the welfarist framework captures a wider notion of well-being. EQ-5D and SF-6D are commonly used to value outcomes in chronic conditions with episodic symptoms, such as heavy menstrual bleeding (clinically termed menorrhagia). Because of their narrow-health focus and the condition’s periodic nature these measures may be unsuitable. A viable alternative measure is willingness to pay (WTP) from the welfarist framework. Objective: We explore the use of WTP in a preliminary cost-benefit analysis comparing pharmaceutical treatments for menorrhagia. Methods: A cost-benefit analysis was carried out based on an outcome of WTP. The analysis is based in the UK primary care setting over a 24-month time period, with a partial societal perspective. Ninety-nine women completed a WTP exercise from the ex-ante (pre-treatment/condition) perspective. Maximum average WTP values were elicited for two pharmaceutical treatments, levonorgestrel-releasing intrauterine system (LNG-IUS) and oral treatment. Cost data were offset against WTP and the net present value derived for treatment. Qualitative information explaining the WTP values was also collected. Results: Oral treatment was indicated to be the most cost-beneficial intervention costing £107 less than LNG-IUS and generating £7 more benefits. The mean incremental net present value for oral treatment compared with LNG-IUS was £113. The use of the WTP approach was acceptable as very few protests and non-responses were observed. Conclusion: The preliminary cost-benefit analysis results recommend oral treatment as the first-line treatment for menorrhagia. The WTP approach is a feasible alternative to the conventional EQ-5D/SF-6D approaches and offers advantages by capturing benefits beyond health, which is particularly relevant in menorrhagia

Physical activity and body mass shape quality of life trajectories in mid-age women

To determine the combined longitudinal effect of body mass index (BMI) and physical activity (PA) on health-related quality of life (HrQoL), using the SF-6D (SF-36) utility measure.Five waves of self-reported data from the 1946-51 cohort (n=5,200; data collection, 2001-2013) of the Australian Longitudinal Study on Women's Health were used. Mixed effect models were employed to address the objective.Women with high PA experienced higher HrQoL regardless of BMI group, however, for those healthy or overweight, there was a very small decline in HrQoL over time. Women reporting no PA levels experienced the lowest baseline mean SF-6D score within each BMI group, with decreasing trajectories over the follow-up period. The rate of decline was greatest in women with obesity. Within each BMI group, there was a large, increasing gap in HrQoL between those who reported no and low PA over time. Women with obesity and high PA experienced similar HrQoL trajectories to women with normal weight or overweight with low PA levels. Overweight women with moderate PA experienced similar HrQoL to those with low PA but normal weight.PA may mitigate the adverse effect of overweight and obesity on HrQoL at mid-life, at higher activity levels. Implications for public health: PA benefits HrQoL regardless of body mass, with larger gains for those currently not physically active. Moderate to high PA may mitigate the effect of overweight and obesity

Impact of new diagnostic criteria for gestational diabetes

Background: In January 2015, the diagnostic and therapeutic criteria for gestational diabetes changed, with the goal of increasing the sensitivity of diagnosis and improving overall glycaemic control, and thus reducing adverse pregnancy outcomes. Aim: Our primary aim was to evaluate the effect of the new guidelines on the incidence of diagnosis of gestational diabetes and the incidence of therapeutic interventions. Our secondary aim was to look at the incidence of adverse pregnancy outcomes. Materials and Methods: A retrospective clinical audit was conducted at a regional hospital to compare the incidence of gestational diabetes, and specific maternal and neonatal outcomes before and after the change in guidelines was implemented. Data were collected via chart review for a six month period before and after the change in guidelines in January 2015. Data collected included demographics, neonatal and maternal outcomes and the treatment type used for patients diagnosed with gestational diabetes. Results: There was a significant increase in the incidence of diagnosis of gestational diabetes (9.8% to 19.6%) p<0.001, and an overall increase in the use of pharmacological treatments for gestational diabetes. There was no significant difference in the incidence of the adverse outcomes measured, including caesarean delivery and incidence of macrosomia. There was no significant change in mean fetal weight. Conclusions: Despite a doubling of the incidence of diagnosis of gestational diabetes, and a consequent increase in pharmacological interventions, the change in diagnostic and therapeutic criteria did not significantly reduce the neonatal or maternal adverse outcomes measured

Interventional studies for preventing surgical site infections in sub-Saharan Africa - A systematic review.

BACKGROUND: There is a great need for safe surgical services in sub-Saharan Africa, but a major difficulty of performing surgery in this region is the high risk of post-operative surgical site infection (SSI). METHODS: We aimed to systematically review which interventions had been tested in sub-Saharan Africa to reduce the risk of SSI and to synthesize their findings. We searched Medline, Embase and Global Health databases for studies published between 1995 and 2010 without language restrictions and extracted data from full-text articles. FINDINGS: We identified 24 relevant articles originating from nine countries in sub-Saharan Africa. The methodological quality of these publications was diverse, with inconsistency in definitions used for SSI, period and method of post-operative follow-up and classification of wound contamination. Although it was difficult to synthesise information between studies, there was consistent evidence that use of single-dose pre-operative antibiotic prophylaxis could reduce, sometimes dramatically, the risk of SSI. Several studies indicated that alcohol-based handrubs could provide a low-cost alternative to traditional surgical hand-washing methods. Other studies investigated the use of drains and variants of surgical technique. There were no African studies found relating to several other promising SSI prevention strategies, including use of checklists and SSI surveillance. CONCLUSIONS: There is extremely limited research from sub-Saharan Africa on interventions to curb the occurrence of SSI. Although some of the existing studies are weak, several high-quality studies have been published in recent years. Standard methodological approaches to this subject are needed

Development of processes allowing near real-time refinement and validation of triage tools during the early stage of an outbreak in readiness for surge: the FLU-CATs Study

BACKGROUND: During pandemics of novel influenza and outbreaks of emerging infections, surge in health-care demand can exceed capacity to provide normal standards of care. In such exceptional circumstances, triage tools may aid decisions in identifying people who are most likely to benefit from higher levels of care. Rapid research during the early phase of an outbreak should allow refinement and validation of triage tools so that in the event of surge a valid tool is available. The overarching study aim is to conduct a prospective near real-time analysis of structured clinical assessments of influenza-like illness (ILI) using primary care electronic health records (EHRs) during a pandemic. This abstract summarises the preparatory work, infrastructure development, user testing and proof-of-concept study. OBJECTIVES: (1) In preparation for conducting rapid research in the early phase of a future outbreak, to develop processes that allow near real-time analysis of general practitioner (GP) assessments of people presenting with ILI, management decisions and patient outcomes. (2) As proof of concept: conduct a pilot study evaluating the performance of the triage tools 'Community Assessment Tools' and 'Pandemic Medical Early Warning Score' to predict hospital admission and death in patients presenting with ILI to GPs during inter-pandemic winter seasons. DESIGN: Prospective near real-time analysis of structured clinical assessments and anonymised linkage to data from EHRs. User experience was evaluated by semistructured interviews with participating GPs. SETTING: Thirty GPs in England, Wales and Scotland, participating in the Clinical Practice Research Datalink. PARTICIPANTS: All people presenting with ILI. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Study outcome is proof of concept through demonstration of data capture and near real-time analysis. Primary patient outcomes were hospital admission within 24 hours and death (all causes) within 30 days of GP assessment. Secondary patient outcomes included GP decision to prescribe antibiotics and/or influenza-specific antiviral drugs and/or refer to hospital - if admitted, the need for higher levels of care and length of hospital stay. DATA SOURCES: Linked anonymised data from a web-based structured clinical assessment and primary care EHRs. RESULTS: In the 24 months to April 2015, data from 704 adult and 159 child consultations by 30 GPs were captured. GPs referred 11 (1.6%) adults and six (3.8%) children to hospital. There were 13 (1.8%) deaths of adults and two (1.3%) of children. There were too few outcome events to draw any conclusions regarding the performance of the triage tools. GP interviews showed that although there were some difficulties with installation, the web-based data collection tool was quick and easy to use. Some GPs felt that a minimal monetary incentive would promote participation. CONCLUSIONS: We have developed processes that allow capture and near real-time automated analysis of GP's clinical assessments and management decisions of people presenting with ILI. FUTURE WORK: We will develop processes to include other EHR systems, attempt linkage to data on influenza surveillance and maintain processes in readiness for a future outbreak. STUDY REGISTRATION: This study is registered as ISRCTN87130712 and UK Clinical Research Network 12827. FUNDING: The National Institute for Health Research Health Technology Assessment programme. MGS is supported by the UK NIHR Health Protection Research Unit in Emerging and Zoonotic Infections