Using epidemiological methods in the exploration of context:Four case studies in HIV and tuberculosis research in Southern Africa

This thesis investigated how prevailing epidemiological methods can contribute to the exploration of context from an ecosocial perspective in HIV and tuberculosis (TB) research, using four case studies. In the first case study, we examined the association between a guideline change in antiretroviral therapy (ART) access and HIV status disclosure to partner and family, ART adherence, and healthcare interactions in Eswatini, using a repeated cross-sectional survey. We found no difference in disclosure and ART adherence, and improved healthcare interactions, comparing before and after the introduction of immediate ART. The second case study investigated reasons for traditional and complementary alternative medicine (TCAM) use and the association with interrupted care in people living with HIV on ART, using mixed methods. We found different reasons for TCAM use, categorized into contextual and individual factors. No difference was found in interrupted care between never, past, and current users. In the third case study, we used register and census data to examine the association between neighborhood factors and TB recurrence in Cape Town. Multilevel survival analysis revealed a negative association between recurrent TB and socioeconomic index and a positive association with mean household size and neighborhood TB burden.The fourth case study examined the association between neighborhood factors and the incidence of the first episode of TB disease, aggregated at the neighborhood level. We found a negative association between TB incidence and wealth measures and a positive association with neighborhood TB burden. Additionally, there was a hotspot of first-episode TB incidence and evidence of spatial dependency

Changes in disclosure, adherence and healthcare interactions after the introduction of immediate ART initiation: an analysis of patient experiences in Swaziland.

INTRODUCTION: There are concerns that immediate ART initiation (regardless of CD4 count) negatively affects HIV status disclosure, ART adherence and healthcare interactions. We assessed changes in these factors after the 'Early access to ART for all' intervention, a universal test-and-treat study in Swaziland. METHODS: We recruited two samples of participants between 2014 and 2017. The first group was interviewed before the intervention (control); the second group at the implementation and 6 months thereafter (intervention). RESULTS: High levels of disclosure to partners (controls and intervention: 94%) and family members (controls: 78%, intervention: 79%) were reported, and high levels of adherence (85% did not miss a dose among the controls, 84% in the intervention group). There were no changes in patients reporting feeling pressured to initiate ART (controls: 10%, intervention: 11%). The quality of interaction with healthcare workers improved after the intervention; healthcare workers explained more often the choice of ART initiation (controls: 88%, intervention: 93%) and the meaning of both CD4 and viral load test results (controls: 15%, intervention: 47%). More patients in the intervention group reported receiving test results (controls: 13%, intervention: 46%). We observed no changes in disclosure, adherence or patient experiences 6 months into the intervention compared to its start. CONCLUSION: Our results suggest that both reported adherence and disclosure levels remain high after the introduction of immediate ART in Swaziland. We observed an improvement in the healthcare interactions, possibly due to training at participating facilities, which will be an important element for a successful roll-out of immediate ART

Expansion of prosodic abilities at the transition from babble to words: a comparison between children with cochlear implants and normally hearing children

Objectives: This longitudinal study examined the impact of emerging vocabulary production on the ability to produce the phonetic cues to prosodic prominence in babbled and lexical disyllables of infants with Cochlear Implants (CI) and normally hearing infants (NH). Current research on typical language acquisition emphasizes the importance of vocabulary development for phonological and phonetic acquisition. Children with cochlear implants (CI) experience significant difficulties with the perception and production of prosody, and the role of possible top-down effects is therefore particularly relevant for this population. Design: Isolated disyllabic babble and first words were identified and segmented in longitudinal audio-video recordings and transcriptions for 9 NH infants and 9 infants with CI interacting with their parents. Monthly recordings were included from the onset of babbling until children had reached a cumulative vocabulary of 200 words. Three cues to prosodic prominence, F0, intensity and duration, were measured in the vocalic portions of stand-alone disyllables. In order to represent the degree of prosodic differentiation between two syllables in an utterance, the raw values for intensity and duration were transformed to ratios, and for f0 a measure of the perceptual distance in semitones was derived. The degree of prosodic differentiation for disyllabic babble and words for each cue was compared between groups. In addition, group and individual tendencies on the types of stress patterns for babble and words were also examined. Results: The CI group had overall smaller pitch and intensity distances than the NH group. For the NH group, words had greater pitch and intensity distances than babbled disyllables. Especially for pitch distance, this was accompanied by a shift towards a more clearly expressed stress pattern that reflected the influence of the ambient language. For the CI group, the same expansion in words did not take place for pitch. For intensity, the CI group gave evidence of some increase of prosodic differentiation. The results for the duration measure showed evidence of utterance-final lengthening in both groups. In words, the CI group significantly reduced durational differences between syllables so that a more even-timed, less differentiated pattern emerged. Conclusions: The onset of vocabulary production did not have the same facilitatory effect for the CI infants on the production of phonetic cues for prosody, especially for pitch. It was argued that the results for duration may reflect greater articulatory difficulties in words for the CI group than the NH group. It was suggested that the lack of clear top-down effects of the vocabulary in the CI group may be due to a lag in development caused by an initial lack of auditory stimulation, possibly compounded by the absence of auditory feedback during the babble phase

European survey on criteria of aesthetics for periodontal evaluation: The ESCAPE study

Objective: The ESCAPE multicentre survey was designed to (a) compare the agreement of three relevant aesthetic scoring systems among different centres, and (b) evaluate the reproducibility of each question of the questionnaires. / Materials and Methods: EFP centres (n = 14) were involved in an e‐survey. Forty‐two participants (28 teachers, 14 postgraduate students) were asked to score the one‐year aesthetic outcomes of photographs using the Before–After Scoring System (BASS), the Pink Esthetic Score (PES) and the Root coverage Esthetic Score (RES). Mean values of kappa statistics performed on each question were provided to resume global agreement of each method. / Results: Between teachers, a difference of kappa ≥ 0.41 (p = .01) was found for BASS (75%) and PES (57%). Similarly, RES (84%) and PES (57%) were different (p < .001). No difference was found between BASS (75%) and RES (84%). No difference was found between students, whatever the scoring system. Questions of each scoring system showed differences in their reproducibility. / Conclusions: The outcomes of this study indicate that BASS and RES scoring systems are reproducible tools to evaluate aesthetic after root coverage therapies between different centres. Among the various variables, lack of scar, degree of root coverage, colour match and gingival margin that follows the CEJ show the best reliability

Expressive Vocabulary Growth After Pediatric Auditory Brainstem Implantation in Two Cases' Spontaneous Productions: A Comparison With Children With Cochlear Implants and Typical Hearing

Auditory brainstem implants (ABI) are recently being used to restore hearing of children with a congenital hearing loss, due to for instance the absence of auditory nerves. Thus far, the literature has focused on perceptual outcomes. The present study is among the first ones to investigate the spoken language development after implantation. The lexical development of children with ABI is examined longitudinally in comparison to children with typical hearing and children with cochlear implants. Results show that children with ABI still have smaller spoken vocabularies as compared to (hearing) age-matched children with cochlear implants and children with typical hearing. Implications will be discussed

EU-wide cross-sectional observational study of lipid-modifying therapy use in secondary and primary care: the DA VINCI study

Aims To provide contemporary data on the implementation of European guideline recommendations for lipid-lowering therapies (LLTs) across different settings and populations and how this impacts low-density lipoprotein cholesterol (LDL-C) goal achievement.Methods and results An 18 country, cross-sectional, observational study of patients prescribed LLT for primary or secondary prevention in primary or secondary care across Europe. Between June 2017 and November 2018, data were collected at a single visit, including LLT in the preceding 12 months and most recent LDL-C. Primary outcome was the achievement of risk-based 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) LDL-C goal while receiving stabilized LLT; 2019 goal achievement was also assessed. Overall, 5888 patients (3000 primary and 2888 secondary prevention patients) were enrolled; 54% [95% confidence interval (CI) 52-56] achieved their risk-based 2016 goal and 33% (95% CI 32-35) achieved their risk-based 2019 goal. High-intensity statin monotherapy was used in 20% and 38% of very high-risk primary and secondary prevention patients, respectively. Corresponding 2016 goal attainment was 22% and 45% (17% and 22% for 2019 goals) for very high-risk primary and secondary prevention patients, respectively. Use of moderate-high-intensity statins in combination with ezetimibe (9%), or any LLT with PCSK9 inhibitors (1%), was low; corresponding 2016 and 2019 goal attainment was 53% and 20% (ezetimibe combination), and 67% and 58% (PCSK9i combination).Conclusion Gaps between clinical guidelines and clinical practice for lipid management across Europe persist, which will be exacerbated by the 2019 guidelines. Even with optimized statins, greater utilization of non-statin LLT is likely needed to reduce these gaps for patients at highest risk.Cardiolog

Using epidemiological methods in the exploration of context:Four case studies in HIV and tuberculosis research in Southern Africa

This thesis investigated how prevailing epidemiological methods can contribute to the exploration of context from an ecosocial perspective in HIV and tuberculosis (TB) research, using four case studies. In the first case study, we examined the association between a guideline change in antiretroviral therapy (ART) access and HIV status disclosure to partner and family, ART adherence, and healthcare interactions in Eswatini, using a repeated cross-sectional survey. We found no difference in disclosure and ART adherence, and improved healthcare interactions, comparing before and after the introduction of immediate ART. The second case study investigated reasons for traditional and complementary alternative medicine (TCAM) use and the association with interrupted care in people living with HIV on ART, using mixed methods. We found different reasons for TCAM use, categorized into contextual and individual factors. No difference was found in interrupted care between never, past, and current users. In the third case study, we used register and census data to examine the association between neighborhood factors and TB recurrence in Cape Town. Multilevel survival analysis revealed a negative association between recurrent TB and socioeconomic index and a positive association with mean household size and neighborhood TB burden.The fourth case study examined the association between neighborhood factors and the incidence of the first episode of TB disease, aggregated at the neighborhood level. We found a negative association between TB incidence and wealth measures and a positive association with neighborhood TB burden. Additionally, there was a hotspot of first-episode TB incidence and evidence of spatial dependency