Health systems performance in sub-Saharan Africa: Governance, outcome and equity

Copyright @ 2011 Olafsdottir et al.BACKGROUND: The literature on health systems focuses largely on the performance of healthcare systems operationalised around indicators such as hospital beds, maternity care and immunisation coverage. A broader definition of health systems however, needs to include the wider determinants of health including, possibly, governance and its relationship to health and health equity. The aim of this study was to examine the relationship between health systems outcomes and equity, and governance as a part of a process to extend the range of indicators used to assess health systems performance. METHODS: Using cross sectional data from 46 countries in the African region of the World Health Organization, an ecological analysis was conducted to examine the relationship between governance and health systems performance. The data were analysed using multiple linear regression and a standard progressive modelling procedure. The under-five mortality rate (U5MR) was used as the health outcome measure and the ratio of U5MR in the wealthiest and poorest quintiles was used as the measure of health equity. Governance was measured using two contextually relevant indices developed by the Mo Ibrahim Foundation. RESULTS: Governance was strongly associated with U5MR and moderately associated with the U5MR quintile ratio. After controlling for possible confounding by healthcare, finance, education, and water and sanitation, governance remained significantly associated with U5MR. Governance was not, however, significantly associated with equity in U5MR outcomes. CONCLUSION: This study suggests that the quality of governance may be an important structural determinant of health systems performance, and could be an indicator to be monitored. The association suggests there might be a causal relationship. However, the cross-sectional design, the level of missing data, and the small sample size, forces tentative conclusions. Further research will be needed to assess the causal relationship, and its generalizability beyond U5MR as a health outcome measure, as well as the geographical generalizability of the results

Molecular signatures of a TLR4 agonist-adjuvanted HIV-1 vaccine candidate in humans

Systems biology approaches have recently provided new insights into the mechanisms of action of human vaccines and adjuvants. Here, we investigated early transcriptional signatures induced in whole blood of healthy subjects following vaccination with a recombinant HIV-1 envelope glycoprotein subunit CN54gp140 adjuvanted with the TLR4 agonist glucopyranosyl lipid adjuvant-aqueous formulation (GLA-AF) and correlated signatures to CN54gp140-specific serum antibody responses. Fourteen healthy volunteers aged 18-45 years were immunized intramuscularly three times at 1-month intervals and whole blood samples were collected at baseline, 6 h, and 1, 3, and 7 days post first immunization. Subtle changes in the transcriptomic profiles were observed following immunization, ranging from over 300 differentially expressed genes (DEGs) at day 1 to nearly 100 DEGs at day 7 following immunization. Functional pathway analysis revealed blood transcription modules (BTMs) related to general cell cycle activation, and innate immune cell activation at early time points, as well as BTMs related to T cells and B cell activation at the later time points post-immunization. Diverse CN54gp140-specific serum antibody responses of the subjects enabled their categorization into high or low responders, at early ( < 1 month) and late (up to 6 months) time points post vaccination. BTM analyses revealed repression of modules enriched in NK cells, and the mitochondrial electron chain, in individuals with high or sustained antigen-specific antibody responses. However, low responders showed an enhancement of BTMs associated with enrichment in myeloid cells and monocytes as well as integrin cell surface interactions. Flow cytometry analysis of peripheral blood mononuclear cells obtained from the subjects revealed an enhanced frequency of CD56 dim NK cells in the majority of vaccines 14 days after vaccination as compared with the baseline. These results emphasize the utility of a systems biology approach to enhance our understanding on the mechanisms of action of TLR4 adjuvanted human vaccines

Radiocarbon Date List XI: Radiocarbon Dates from Marine Sediment Cores of the Iceland, Greenland, and Northeast Canadian Arctic Shelves and Nares Strait

Radiocarbon Date List XI contains an annotated listing of 178 AMS radiocarbon dates on samples from marine (169 samples) and lake (9 samples) sediment cores. Marine sediment cores, from which the samples for dating were taken, were collected on the Greenland Shelf, Baffin Bay, and the Eastern Canadian Arctic shelf. About 80% of the marine samples for dating were collected on the SW to N Icelandic shelf. The lake sediment cores were collected in northwestern Iceland. For dating of the marine samples, we submitted molluscs (117 samples), benthic and planktic foraminifera (45 samples), plant macrofauna (3 samples), and one serpulid worm. For dating of the lake cores, we submitted wood (8 samples) and one peat sample. The Conventional Radiocarbon Ages range from 294±9114C yr BP to 34,600±640 14C yr BP. The dates have been used to address a variety of research questions. The dates constrain the timing of high northern latitude late Quaternary environmental fluctuations, which include glacier extent, sea level history, isostatic rebound, sediment input, and ocean circulation. The dates also allowed assessment of the accuracy of commonly used reservoir correction. The samples were submitted by INSTAAR and affiliated researchers

Maternal diet in early and late pregnancy in relation to weight gain

To access Publisher full text version of this article. Please click on the hyperlink in Additional Links fieldOBJECTIVE: To identify dietary factors related to the risk of gaining weight outside recommendations for pregnancy weight gain and birth outcome.Design:An observational study with free-living conditions.Subjects:Four hundred and ninety five healthy pregnant Icelandic women. METHODS: The dietary intake of the women was estimated with a semiquantitative food frequency questionnaire covering food intake together with lifestyle factors for the previous 3 months. Questionnaires were filled out at between 11 and 15 weeks and between 34 and 37 weeks gestation. Comparison of birth outcome between the three weight gain groups was made with ANOVA and Bonferroni post hoc tests. Dietary factors related to at least optimal and excessive weight gain during pregnancy were represented with logistic regression controlling for potential confounding. RESULTS: Of the women, 26% gained suboptimal and 34% excessive weight during pregnancy. Women in late pregnancy with at least optimal, compared with women with suboptimal, weight gain were eating more (OR = 3.32, confidence interval (CI)=1.81-6.09, P < 0.001) and drinking more milk (OR = 3.10, CI = 1.57-6.13, P = 0.001). The same dietary factors were related to excessive, compared with optimal, weight gain. Furthermore, eating more sweets early in pregnancy increased the risk of gaining excessive weight (OR=2.52, CI=1.10-5.77, P=0.029). Women with a body mass index of 25.0-29.9 kg/m(2) before pregnancy were most likely to gain excessive weight (OR = 7.37, CI 4.13-13.14, P < 0.001). Women gaining suboptimal weight gave birth to lighter children (P < 0.001) and had shorter gestation (P = 0.008) than women gaining optimal or excessive weight. CONCLUSION: Women who are overweight before pregnancy should get special attention regarding lifestyle modifications affecting consequent weight gain during pregnancy. They are most likely to gain excessive weight and therefore most likely to suffer pregnancy and delivery complications and struggle with increasing overweight and obesity after giving birth

Development and Validation of a Photographic Method to Use for Dietary Assessment in School Settings.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked Files. This article is open access.To develop and validate a photographic method aimed at making assessment of dietary intake in school canteens non-obstrusive, practical and feasible.The study was conducted in two elementary schools representing two different school canteen systems; main dish being served by canteen staff (Iceland), and complete self-serving (Sweden). Food items in serving and leftovers were weighed and photographed. Trained researchers estimated weights of food items by viewing the photographs and comparing them with pictures of half and full reference portions with known weights. Plates of servings and leftovers from 48 children during five school days (n = 448 plates) and a total of 5967 food items were estimated. The researchers' estimates were then compared with the true weight of the foods and the energy content calculated.Weighed and estimated amounts correlated across meals both in grams and as total energy (0.853-0.977, p<0.001). The agreement between estimated energy content in school meals was close to the true measurement from weighed records; on average 4-19 kcal below true values. Organisation of meal service impacted the efficacy of the method as seen in the difference between countries; with Iceland (served by canteen staff) having higher rate of acceptable estimates than Sweden (self-serving), being 95% vs 73% for total amount (g) in serving. Iceland more often had serving size between or above the half and full reference plates compared with Sweden.The photographic method provides acceptable estimates of food and energy intake in school canteens. However, greater accuracy can be expected when foods are served by canteen staff compared with self-serving

SciKit-SurgeryGlenoid, an Open Source Toolkit for Glenoid Version Measurement

Correct understanding of the geometry of the glenoid (the socket of the shoulder joint) is key to successful planning of shoulder replacement surgery. This surgery typically involves placing an implant in the shoulder joint to restore joint function. The most relevant geometry is the glenoid version, which is the angular orientation of the glenoid surface relative to the long axis of the scapula in the axial plane. However, measuring the glenoid version is not straightforward and there are multiple measurement methods in the literature and used in commercial planning software. In this paper we introduce SciKit-SurgeryGlenoid, an open source toolkit for the measurement of glenoid version. SciKit-SurgeryGlenoid contains implementations of the 4 most frequently used glenoid version measurement algorithms enabling easy and unbiased comparison of the different techniques. We present the results of using the software on 10 sets of pre-operative CT scans taken from patients who have subsequently undergone shoulder replacement surgery. We further compare these results with those obtained from a commercial implant planning software. SciKit-SurgeryGlenoid currently requires manual segmentation of the relevant anatomical features for each method. Future work will look at automating the segmentation process to build an automatic and repeatable pipeline from CT or radiograph to quantitative glenoid version measurement

The interaction of adiposity with the CRP gene affects CRP levels: age, gene/environment susceptibilty-Reykjavik study

To access publisher full text version of this article. Please click on the hyperlink in Additional Links fieldOBJECTIVE: Common diseases often have an inflammatory component reflected by associated markers such as serum C-reactive protein (CRP) levels. Circulating CRP levels have also been associated with adipose tissue as well as with specific CRP genotypes. We examined the interaction between measures of body mass index (BMI), waist circumference and fat percent (total fat measured by bioimpedance) with genotypes of the CRP gene in the determination of CRP levels. METHODS: The first 2296 participants (mean age 76+/-6 years, 42% men) in the Age, Gene/Environment Susceptibility-Reykjavik Study, a multidisciplinary epidemiological study to determine risk factors in aging, were genotyped for 10 single nucleotide polymorphisms (SNPs) in the CRP gene. General linear models with age and terms for interaction of CRP genotypes with BMI, waist circumference and percent fat were used to evaluate the association of genotypes to CRP levels (high-sensitivity method, range 0-10 mg l(-1)) in men and women separately. RESULTS: We focused on the SNP rs1205 that represents the allele that captures the strongest effects of the gene on CRP levels. Carriers of the rs1205 G allele had significantly higher CRP levels than noncarriers in a dose-dependent manner. Compared to the AA genotype, the slope of the increase in CRP with increasing BMI (P=0.045) and waist circumference (P=0.014) was different for the G allele carriers and of similar magnitude in both men and women. The rs1205 interactions were not significant for fat mass percent, suggesting a possible association with fat localization. CONCLUSIONS: This study further illuminates the known association between measures of adiposity and CRP levels and is shown to be dependent on variation in the rs1205 SNP of the CRP gene. The correlated increase in CRP levels with adiposity is accentuated by presence of the G allele

Individual risk assessment and information technology to optimise screening frequency for diabetic retinopathy.

To access publisher full text version of this article. Please click on the hyperlink in Additional Links field.AIMS/HYPOTHESIS: The aim of this study was to reduce the frequency of diabetic eye-screening visits, while maintaining safety, by using information technology and individualised risk assessment to determine screening intervals. METHODS: A mathematical algorithm was created based on epidemiological data on risk factors for diabetic retinopathy. Through a website, www.risk.is , the algorithm receives clinical data, including type and duration of diabetes, HbA(1c) or mean blood glucose, blood pressure and the presence and grade of retinopathy. These data are used to calculate risk for sight-threatening retinopathy for each individual's worse eye over time. A risk margin is defined and the algorithm recommends the screening interval for each patient with standardised risk of developing sight-threatening retinopathy (STR) within the screening interval. We set the risk margin so that the same number of patients develop STR within the screening interval with either fixed annual screening or our individualised screening system. The database for diabetic retinopathy at the Department of Ophthalmology, Aarhus University Hospital, Denmark, was used to empirically test the efficacy of the algorithm. Clinical data exist for 5,199 patients for 20 years and this allows testing of the algorithm in a prospective manner. RESULTS: In the Danish diabetes database, the algorithm recommends screening intervals ranging from 6 to 60 months with a mean of 29 months. This is 59% fewer visits than with fixed annual screening. This amounts to 41 annual visits per 100 patients. CONCLUSION: Information technology based on epidemiological data may facilitate individualised determination of screening intervals for diabetic eye disease. Empirical testing suggests that this approach may be less expensive than conventional annual screening, while not compromising safety. The algorithm determines individual risk and the screening interval is individually determined based on each person's risk profile. The algorithm has potential to save on healthcare resources and patients' working hours by reducing the number of screening visits for an ever increasing number of diabetic patients in the world