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Objectives: Hepatitis C virus (HCV) causes both acute and chronic infection, which can potentially develop into cirrhosis and liver cancer. Healthcare systems are struggling to finance costly direct-acting antiviral agents through public funding for uninsured patients, despite the unprecedented high cure rates of these agents. Vulnerable populations are at higher risk of HCV infection. The personal importation scheme is based on the legal right to import any unauthorized generics for personal use. This study was designed to assess the knowledge and perceptions of stakeholders on unauthorized generics. Methods: We conducted an anonymous online survey based on the fictitious situation of a patient diagnosed with HCV who lacked mandatory health insurance and personal financial resources. Results: We obtained a sample of 781 respondents: 445 physicians, 77 pharmacists, 51 patients and 207 non-healthcare professionals. We found that only 36% and 58% of respondents believe that the quality and efficacy, respectively, of unauthorized generics are equivalent to their corresponding brand. An overwhelming majority (98%) favoured quality control upon arrival, and 31% felt they could recognize fraudulent websites. A total of 79% expressed support for financial assistance for vulnerable patients, and support among physicians was 83%. Conclusions: Overall, the limited knowledge of the efficacy and quality of unauthorized generics, despite evidence in peer-reviewed literature, contrasts with the overwhelmingly positive attitudes toward financial assistance for personal import. This finding emphasizes the need for clearer information on imported generics and the potential safety provided by buyers' club schemes to complete the WHO agenda of eradicating viral hepatitis by 2030 within otherwise excluded vulnerable populations. [ABSTRACT FROM AUTHOR]

Background: In many low- and middle-income countries, data on the prevalence of surgical diseases have been derived primarily from hospital-based studies, which may lead to an underestimation of disease burden within the community. Community-based prevalence studies may provide better estimates of surgical need to enable proper resource allocation and prioritization of needs. This study aims to assess the prevalence of common surgical conditions among children in a diverse rural and urban population in Nigeria. Methods: Descriptive cross-sectional, community-based study to determine the prevalence of congenital and acquired surgical conditions among children in a diverse rural-urban area of Nigeria was conducted. Households, defined as one or more persons 'who eat from the same pot' or slept under the same roof the night before the interview, were randomized for inclusion in the study. Data was collected using an adapted and modified version of the interviewer-administered questionnaire—Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool and analysed using the REDCap web-based analytic application. Main results: Eight-hundred-and-fifty-six households were surveyed, comprising 1,883 children. Eighty-one conditions were identified, the most common being umbilical hernias (20), inguinal hernias (13), and wound injuries to the extremities (9). The prevalence per 10,000 children was 85 for umbilical hernias (95% CI: 47, 123), and 61 for inguinal hernias (95% CI: 34, 88). The prevalence of hydroceles and undescended testes was comparable at 22 and 26 per 10,000 children, respectively. Children with surgical conditions had similar sociodemographic characteristics to healthy children in the study population. Conclusion: The most common congenital surgical conditions in our setting were umbilical hernias, while injuries were the most common acquired conditions. From our study, it is estimated that there will be about 2.9 million children with surgically correctable conditions in the nation. This suggests an acute need for training more paediatric surgeons. [ABSTRACT FROM AUTHOR]

Introduction: Nurses encounter children who report of pain of diverse and unknown causes in their professional work. The current study therefore assessed and compared nursing students and nurses' knowledge and attitudes pertaining to children's pain in the Ghanaian context. The goal of this was to have a baseline information to guide the development and implementation of the content for a sustainable educational programme (short-course) for nursing students and nurses in Ghana. Methods: Between October and December 2018, a cross-sectional study was carried out among 554 final year nursing students and 65 nurses in Ghana. The Pediatric Nurses Knowledge and Attitudes Survey Regarding Pain (PNKAS) was used to collect data from participants who were affiliated to four educational institutions and eight hospitals. Data were descriptively and inferentially analyzed using chi-square test of independence, independent samples t-test and one-way analysis of variance (ANOVA). Results: Our findings revealed that nursing students and nurses generally had unsatisfactory knowledge and attitudes towards pain management in children. Nursing students however, had significantly higher scores than nurses in the total PNKAS score and in 10 out of the 13 identified item-areas. Greater scores were obtained by nursing students in areas which were related to pain physiology, pharmacokinetics, pharmacology of analgesics and pain perceptions (p < .05). All the participating nurses could not accurately determine: the onset of action of orally administered analgesics, equianalgesia of orally administered morphine, and the right dosage of prescribed morphine for a child who consistently reported of moderate to severe pain. Conclusion: Final year nursing students and nurses have unsatisfactory knowledge and attitudes regarding children's pain; which reiterates the need for urgent and effective educational efforts in this area. Regular in-service training should be offered to post-registration nurses to enhance their pediatric pain knowledge and attitudes for improved pain care in children. [ABSTRACT FROM AUTHOR]

Background: Rare diseases (RD) result in a wide variety of clinical presentations, and this creates a significant diagnostic challenge for health care professionals. We hypothesized that there exist a set of consistent and shared phenomena among all individuals affected by (different) RD during the time before diagnosis is established. Objective: We aimed to identify commonalities between different RD and developed a machine learning diagnostic support tool for RD. Methods: 20 interviews with affected individuals with different RD, focusing on the time period before their diagnosis, were performed and qualitatively analyzed. Out of these pre-diagnostic experiences, we distilled key phenomena and created a questionnaire which was then distributed among individuals with the established diagnosis of i.) RD, ii.) other common non-rare diseases (NRO) iii.) common chronic diseases (CD), iv.), or psychosomatic/somatoform disorders (PSY). Finally, four combined single machine learning methods and a fusion algorithm were used to distinguish the different answer patterns of the questionnaires. Results: The questionnaire contained 53 questions. A total sum of 1763 questionnaires (758 RD, 149 CD, 48 PSY, 200 NRO, 34 healthy individuals and 574 not evaluable questionnaires) were collected. Based on 3 independent data sets the 10-fold stratified cross-validation method for the answer-pattern recognition resulted in sensitivity values of 88.9% to detect the answer pattern of a RD, 86.6% for NRO, 87.7% for CD and 84.2% for PSY. Conclusion: Despite the great diversity in presentation and pathogenesis of each RD, patients with RD share surprisingly similar pre-diagnosis experiences. Our questionnaire and data-mining based approach successfully detected unique patterns in groups of individuals affected by a broad range of different rare diseases. Therefore, these results indicate distinct patterns that may be used for diagnostic support in RD. [ABSTRACT FROM AUTHOR]

Background: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality in Nigeria and in most low- and middle-income countries. The World Health Organization (WHO) strongly recommends oxytocin as effective, affordable, and the safest drug of first choice in the prevention and treatment of PPH in the third stage of labor. However, there are concerns about its quality. Very high prevalence of poor-quality oxytocin, especially in Africa and Asia, has been reported in literature. Excessive and inappropriate use of oxytocin is also common in low-resource settings. Objective: To assess clinical experiences with quality of oxytocin used by healthcare providers in Lagos State, Nigeria. Methods: This was a descriptive cross-sectional study conducted in 2017, with 705 respondents (doctors and nurses) who use oxytocin for obstetrics and gynecological services recruited from 195 health facilities (public and registered private) across Lagos State. Data collection was quantitative, using a pretested self-administered questionnaire. Data analysis was performed with IBM SPSS version 21. Statistical significance was set at 5 percent (p<0.05). Ethical approval was obtained from Lagos University Teaching Hospital Health Research Ethics Committee. Results: Only 52 percent of the respondents knew oxytocin should be stored at 2°C to 8°C. About 80 percent of respondents used oxytocin for augmentation of labor, 68 percent for induction of labor, 51 percent for stimulation of labor, and 78 percent for management of PPH. Forty-one percent used 20IU and as much as 10% used 30IU to 60IU for management of PPH. About 13 percent of respondents reported believing they had used an ineffective brand of oxytocin in their practice. Just over a third (36%) had an available means of documenting or reporting perceived ineffectiveness of drugs in their facility; of these, only about 12 percent had pharmacovigilance forms in their facilities to report the ineffectiveness. Conclusion: The inappropriate and inconsistent use of oxytocin, especially overdosing, likely led to the high perception of medicine effectiveness among respondents. This is coupled with lack of suspicion of medicine ineffectiveness by clinicians as a possible root cause of poor treatment response or disease progression. Poor knowledge of oxytocin storage and consequent poor storage practices could have contributed to the ineffectiveness reported by some respondents. It is necessary to establish a unified protocol for oxytocin use that is strictly complied with. Continuous training of healthcare providers in medicine safety monitoring is advocated. [ABSTRACT FROM AUTHOR]

To enable selection of a safer suspension site to use in face and neck lifting procedures, the spatial relationship between the tympanoparotid fascia and the great auricular nerve should be clarified. In this study, we aimed to elucidate the position of the tympanoparotid fascia and the pathway of the lobular branch of the great auricular nerve traversing the tympanoparotid fascia. Twenty hemifaces from non-preserved bequeathed Korean cadavers (5 males, 7 females; mean age, 77.0 years) were dissected to determine the great auricular nerve distribution close to the tympanoparotid fascia of clinical significance for face and neck lift procedures. We observed the tympanoparotid fascia in all specimens (20 hemifaces). The tympanoparotid fascia was located anteriorly between the tragus and intertragic notch. Regarding the spatial relationship between the tympanoparotid fascia and the great auricular nerve, we found the sensory nerve entering the tympanoparotid fascia in all specimens (100%), and the depth from the skin was approximately 4.5 mm; in 65% of the specimens, the lobular branch was found to run close to the tympanoparotid fascia before going into the earlobe. Provided with relatively safer surface mapping to access the tympanoparotid fascia free of the lobular branch of the great auricular nerve, surgeons may better protect the lobular branch by anchoring the SMAS-platysma flap and thread to the deeper superior and anterior portions of the expected tympanoparotid fascia. [ABSTRACT FROM AUTHOR]

In patients with chronic disorders, control self-efficacy is the confidence with managing symptoms and coping with the demands of illness. Can do treatment (CDT) is an intensive, 3-day, social cognitive theory-based, multidisciplinary treatment that focuses on identification of stressors, goal setting, exploration of boundaries, and establishment of new boundaries. An uncontrolled study showed that patients with relapsing remitting multiple sclerosis (RRMS) and low-disability had improved control self-efficacy six months after CDT. Hence, in a 6-month, single-centre, randomized (1:1), unmasked, controlled trial in RRMS patients with Expanded Disability Status Scale (EDSS) score ≤4.0, we compared CDT with no intervention and the option to receive CDT after completion of study participation. Follow-up assessments were at one, three and six months. Primary endpoint was control self-efficacy (Multiple Sclerosis Self-Efficacy Scale Control [MSSES-C] (minimum 90, maximum 900) at six months. Secondary endpoints were functional self-efficacy (MSSES-F), participation and autonomy (Impact on Participation and Autonomy questionnaire [IPA]), health-related quality of life (MS Quality of Life-54 Items questionnaire [MSQoL-54]), anxiety, depression (Hospital Anxiety and Depression Scale [HADS]) and coping skills (Utrecht Coping List [UCL]) at six months. Tertiary endpoint was care-related strain on support partners (Caregiver Strain Index) at six months. Of the 158 patients that were included, 79 were assigned to CDT and 79 to the control group. Two CDT patients discontinued treatment prematurely. Sixty-one (77%) control patients chose to receive CDT after study participation. Intention-to-treat ANCOVA analyses were performed with follow-up values as dependent, and condition, baseline values, disease duration and gender as independent variables. The mean (standard deviation [SD]) MSSES-C score in the CDT group vs. control group at baseline was 468 (162) vs. 477 (136), and at six months 578 (166) vs. 540 (135) (p = 0.100). Secondary and tertiary endpoints did not differ between groups, except for the UCL palliative reaction score being slightly higher in the CDT group (p = 0.039). On post hoc analyses the MSSES-C score at one and three months was higher in the CDT vs. control group: 597 (114) vs. 491 (131) (p<0.0001) and 561 (160) vs. 514 (143) (p = 0.018), respectively; and at one month the MSSES-F, IPA Limitations, HADS Anxiety and Depression, and MSQoL-54 Mental and Physical scores were also in favour of the CDT group. We conclude that in low-disability RRMS patients, the intensive 3-day social cognitive theory-based CDT did not improve control self-efficacy at six months follow-up compared to waitlist controls. The absence of a between-group difference at six months relates to a gradual improvement in the control group. In all, this social cognitive theory-based approach for improving self-efficacy needs further investigation before being broadly applied in RRMS patients. [ABSTRACT FROM AUTHOR]

Background: Water Sanitation and Hygiene (WASH) in healthcare facilities is critical in the provision of safe and quality care. Poor WASH increases hospital-associated infections and contributes to the rise of antimicrobial resistance (AMR). It is therefore essential for governments and hospital managers to know the state of WASH in these facilities to set priorities and allocate resources. Methods: Using a recently developed survey tool and scoring approach, we assessed WASH across four domains in 14 public hospitals in Kenya (65 indicators) with specific assessments of individual wards (34 indicators). Aggregate scores were generated for whole facilities and individual wards and used to illustrate performance variation and link findings to specific levels of health system accountability. To help interpret and contextualise these scores, we used data from key informant interviews with hospital managers and health workers. Results: Aggregate hospital performance ranged between 47 and 71% with five of the 14 hospitals scoring below 60%. A total of 116 wards were assessed within these facilities. Linked to specific domains, ward scores varied within and across hospitals and ranged between 20% and 80%. At ward level, some critical indicators, which affect AMR like proper waste segregation and hand hygiene compliance activities had pooled aggregate scores of 45 and 35% respectively. From 31 interviews conducted, the main themes that explained this heterogenous performance across facilities and wards included differences in the built environment, resource availability, leadership and the degree to which local managers used innovative approaches to cope with shortages. Conclusion: Significant differences and challenges exist in the state of WASH within and across hospitals. Whereas the senior hospital management can make some improvements, input and support from the national and regional governments are essential to improve WASH as a basic foundation for averting nosocomial infections and the spread of AMR as part of safe, quality hospital care in Kenya. [ABSTRACT FROM AUTHOR]

We aim to determine whether a game-theoretic model between an insurer and a healthcare practice yields a predictive equilibrium that incentivizes either player to deviate from a fee-for-service to capitation payment system. Using United States data from various primary care surveys, we find that non-extreme equilibria (i.e., shares of patients, or shares of patient visits, seen under a fee-for-service payment system) can be derived from a Stackelberg game if insurers award a non-linear bonus to practices based on performance. Overall, both insurers and practices can be incentivized to embrace capitation payments somewhat, but potentially at the expense of practice performance. [ABSTRACT FROM AUTHOR]

Objective: Adoption of pre-exposure prophylaxis (PrEP) to prevent HIV infection has been slow. The purpose of this study was to evaluate knowledge, attitudes and referral practices for PrEP among non-prescribing providers, who may play key role. Methods: We performed a cross-sectional survey on PrEP knowledge, attitudes, and referral practices among 66 non-prescribing HIV prevention providers (1st August to 31st December, 2016), in Philadelphia, followed by qualitative interviews with 12 of them (5th April to 10th May, 2017). Results: Participants had a mean age of 36 years, with 62% females. Majority were HIV case managers and rapid testers. For half of the respondents, PrEP eligibility screening was part of rapid HIV testing at their organization, 40% never had PrEP training and only 27% indicated personally screening clients for eligibility. Qualitative data revealed that participants held positive attitudes about PrEP and perceived organizational support, but had concerns about potential negative impacts and barriers to routine HIV screening. Conclusion: Results highlight the importance of training non-prescribing HIV prevention providers about PrEP, addressing their concerns, and incorporating PrEP screening and referral into routine HIV testing. [ABSTRACT FROM AUTHOR]

Objective: To explore, through face to face interviews with a selection of General Dental Practitioners (GDPs), their views and experiences of having used the International Caries Detection and Assessment System (ICDAS) within primary care research studies for recording caries. Methods: This qualitative study involved one on one interviews with eight GDP’s who had previously used ICDAS on patients in their dental practices as part of a research study. The participants were selected from among those who had taken part in two clinical studies in the UK using convenient, but purposive sampling. The interviews were tape-recorded and transcribed; the data analysis was conducted by thematic analysis. Results: GDP’s indicated their beliefs that ICDAS had an important role in caries prevention but reported four main barriers while using the full (6 caries stages) ICDAS coding system in their practices: lack of simplicity of coding, financial implications and time consumption (in both training and use of ICDAS) and inadequate undergraduate training. An overarching theme identified from the GDPS was the willingness to offer potential solutions to their barriers which might improve the utilisation of the system in primary care. Conclusion: The GDPs experienced common obstacles in using ICDAS in the primary care setting, many of which have relatively straight-forward solutions which they put forward themselves such as: incentivisation, undergraduate-level training in ICDAS for both dentists and nurses and computerized data entry. Further qualitative and quantitative research is needed on how to facilitate the utilisation of the system in dental practice. It is also recommended to explore the influences of wider agencies on influencing primary dental care professionals’ caries management, including appropriate recording of diagnosis and risk assessment. [ABSTRACT FROM AUTHOR]

Objective: Anti-tumor necrosis factor (Anti-TNF) therapy improves the prognosis and reduces the morbidity and mortality associated with many chronic inflammatory autoimmune diseases. However, as it is linked to an increased infection risk, appropriate vaccination is required. The study aimed at investigating the vaccination status of patients receiving Anti-TNF therapy and physicians’ perceptions of and views about vaccinating these patients. Methods: A sequential explanatory mixed-methods approach was used. The study comprised a quantitative, retrospective drug utilization review for determining institutional consumption of Anti-TNF therapy and an assessment of vaccination status in patients prescribed Anti-TNF therapy to audit physicians’ adherence to Anti-TNF therapy-related vaccination recommendations. Patient data from electronic medical records (EMRs) obtained from tertiary care hospitals between September 2015 and September 2017 were used. Further, a qualitative study using a phenomenographic approach with semi-structured interviews of 12 physicians was carried out to explore the physicians’ perceptions, views, and recommendations of vaccinating patients who are undergoing Anti-TNF therapy and identifying factors that may cause poor adherence to vaccination recommendations. Results: Forty-three of 310 patients receiving Anti-TNF therapy were vaccinated. Infliximab was the most frequently prescribed agent, accounting for 96.7% of total orders. Eight of the 12 physicians stated that they were aware of vaccination guidelines and seven viewed pre–Anti-TNF therapy vaccination as essential because of the high infection risk and claimed to incorporate it in their daily practice. Barriers to adherence included ignorance of recommendations, workload, vaccine unavailability, and advanced disease state. Conclusion: Although the recommendations published by professional medical societies emphasized the importance of vaccination before initiating Anti-TNF therapy, few patients were vaccinated. Medical administration in hospitals should develop policies, procedures, and guidelines for vaccination; implement education programs for physicians and patients and procure vaccines in a timely way to improve their use. [ABSTRACT FROM AUTHOR]

Various agents including Ca. Piscichlamydia salmonis, Ca. Branchiomonas cysticola, Desmozoon lepeophtherii, Paramoeba perurans and salmon gill poxvirus may be associated with complex gill disease in Atlantic salmon. Co-infections involving two or more of these agents are common and histopathological interpretation of lesions is therefore challenging. In this study, we developed a semi-quantitative scoring system for examination of histopathological gill lesions in sea-farmed Atlantic salmon suffering from gill disease. Following qPCR analysis of gills sampled for Ca. P. salmonis, Ca. B. cysticola, D. lepeophtherii and P. perurans from 22 geographically spread outbreaks, five cases representing different infectious loads and combinations of agents were chosen for histopathological scoring. Twenty-eight histological features were evaluated and potential associations between individual pathological changes and the occurrence of individual agents studied. The inter-observer agreement in interpretation of histological parameters between the three pathologists involved, was calculated to validate robustness of the scoring scheme. Seventeen histological parameters met the criteria for inter-observer agreement analysis and were included in the calculation. The three most frequent findings were identification of subepithelial leukocytes, epithelial cell hyperplasia and mucus cell hyperplasia. While few findings could be specifically related to particular agents, necrosis in hyperplastic lesions, pustules and necrosis of subepithelial cells appeared to be associated with the presence of Ca. B. cysticola. Further, lesion profiles clearly support the previously identified association between P. perurans and pathological changes associated with AGD. Very few pathological changes were observed in the single case in which Ca. P. salmonis was the dominating agent. Some lesions were only very rarely observed e.g. chloride cell necrosis, epithelial cell apoptosis, lamellar deposition of melanin and haemophagocytosis. The scoring scheme developed and applied was robust and sensitive. A less extensive scheme for routine diagnostic use is proposed. [ABSTRACT FROM AUTHOR]

Objective: In clinical prediction/diagnostic rules aimed at early detection of critically ill patients, the respiratory rate plays an important role. We investigated the accuracy and interobserver-agreement of respiratory rate measurements by healthcare professionals, and the potential effect of incorrect measurements on the scores of 4 common clinical prediction/diagnostic rules: Systemic Inflammatory Response Syndrome (SIRS) criteria, quick Sepsis-related Organ Failure Assessment (qSOFA), National Early Warning Score (NEWS), and Modified Early Warning Score (MEWS). Methods: Using an online questionnaire, we showed 5 videos with a healthy volunteer, breathing at a fixed (true) rate (13–28 breaths/minute). Respondents measured the respiratory rate, and categorized it as low, normal, or high. We analysed how accurate the measurements were using descriptive statistics, and calculated interobserver-agreement using the intraclass correlation coefficient (ICC), and agreement between measurements and categorical judgments using Cohen’s Kappa. Finally, we analysed how often incorrect measurements led to under/overestimation in the selected clinical rules. Results: In total, 448 healthcare professionals participated. Median measurements were slightly higher (1-3/min) than the true respiratory rate, and 78.2% of measurements were within 4/min of the true rate. ICC was moderate (0.64, 95% CI 0.39–0.94). When comparing the measured respiratory rates with the categorical judgments, 14.5% were inconsistent. Incorrect measurements influenced the 4 rules in 8.8% (SIRS) to 37.1% (NEWS). Both underestimation (4.5–7.1%) and overestimation (3.9–32.2%) occurred. Conclusions: The accuracy and interobserver-agreement of respiratory rate measurements by healthcare professionals are suboptimal. This leads to both over- and underestimation of scores of four clinical prediction/diagnostic rules. The clinically most important effect could be a delay in diagnosis and treatment of (critically) ill patients. [ABSTRACT FROM AUTHOR]

Background: Active management of third stage of labor is the most indispensable intervention to avert post-partum hemorrhage which is one of the typical causes of maternal morbidity and mortality. Therefore, the aim of the study was to assess practice and factors associated with active management of third stage of labor among obstetric care providers in referral hospitals. Methods: Institution based cross-sectional study design was conducted from April 1–30, 2018. Simple random sampling technique was used to select a total of 356 obstetric care providers. Data were collected using pretested, structured and self-administered questionnaires. Data were entered to Epi data version 3.1 statistical software and exported to SPSS 23 for analysis. Bivariate and multivariate logistic regression analyses were performed to identify associated factors. P value <0.05 with 95% confidence level were used to declare statistical significance. Result: This study revealed that practice of active management of third stage of labor was 61.2%. Age group of 20–30 years [AOR = 1.95 (95%CI;1.13–3.38)], Being male obstetric care provider [AOR = 1.74 (95%CI;1.03–2.94)], having work experience ≥2 years [AOR = 1.95(95%CI;1.13–3.38)], availability of oxytocin [AOR = 5.46 (95%CI; 2.41–12.3)], having exposure to manage third stage of labor [AOR = 2.91(95%CI; 1.55–5.48)], and having good knowledge [AOR = 2.67 (95%CI; 1.46–4.90)], were the factors associated with practice. Conclusion: This study showed that practice of active management of third stage of labor was high. Age group between 20–30 years, being a male obstetric care provider, having ≥2years work experience, availability of oxytocin, exposure to third stage management and having good knowledge were factors associated with practice. Therefore, all referral hospitals and concerned bodies need efforts to focus on providing training to increase health care provider’s knowledge so as to sustain good practice through appropriate interventions. [ABSTRACT FROM AUTHOR]

Background and objective: To take full advantage of decision support, machine learning, and patient-level prediction models, it is important that models are not only created, but also deployed in a clinical setting. The KETOS platform demonstrated in this work implements a tool for researchers allowing them to perform statistical analyses and deploy resulting models in a secure environment. Methods: The proposed system uses Docker virtualization to provide researchers with reproducible data analysis and development environments, accessible via Jupyter Notebook, to perform statistical analysis and develop, train and deploy models based on standardized input data. The platform is built in a modular fashion and interfaces with web services using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to access patient data. In our prototypical implementation we use an OMOP common data model (OMOP-CDM) database. The architecture supports the entire research lifecycle from creating a data analysis environment, retrieving data, and training to final deployment in a hospital setting. Results: We evaluated the platform by establishing and deploying an analysis and end user application for hemoglobin reference intervals within the University Hospital Erlangen. To demonstrate the potential of the system to deploy arbitrary models, we loaded a colorectal cancer dataset into an OMOP database and built machine learning models to predict patient outcomes and made them available via a web service. We demonstrated both the integration with FHIR as well as an example end user application. Finally, we integrated the platform with the open source DataSHIELD architecture to allow for distributed privacy preserving data analysis and training across networks of hospitals. Conclusion: The KETOS platform takes a novel approach to data analysis, training and deploying decision support models in a hospital or healthcare setting. It does so in a secure and privacy-preserving manner, combining the flexibility of Docker virtualization with the advantages of standardized vocabularies, a widely applied database schema (OMOP-CDM), and a standardized way to exchange medical data (FHIR). [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to explore the experiences, needs, and preferences regarding follow-up perceived by people with stroke and healthcare professionals. Methods: This is a qualitative exploratory study using focus groups. Patients and healthcare professionals, participating in a clinical visit in primary care or specialised care, were purposively sampled. Data were analysed using a framework of analysis developed by Krueger. Results: Focus groups were conducted with two patient groups (n = 10, range 45–78 years) and two multidisciplinary healthcare professional groups (n = 8, range 35–55 years). The overarching theme elucidates stroke as a long-term condition requiring complex follow-up. Three organisational themes and six subthemes were identified. People with stroke discovered feelings and changes after returning home. In daily life, problems and feelings of abandonment became evident. Participants expressed experiences of unequal access to health care services. Barriers for accessing appropriate treatment and support included difficulties in communicating one’s needs and lack of coherent follow-up. Follow-up activities were well functioning in certain clinics but did not provide continuity over the long term. Participants made suggestions for a comprehensive, planned, and tailored follow-up to meet patient needs. Conclusion: Comprehensive long-term follow-up that is accessible to all patients is essential for equal support. Our findings raised awareness about problems discovered after returning home and the obstacles individuals face in communicating their needs. Structured follow-up, which is individually tailored, can empower patients. [ABSTRACT FROM AUTHOR]

Background/Objectives: This study examined the best practices with regard to infant and young child feeding in emergency (IYCF-E) program. This was done by observing a breastfeeding support scenario through wet nursing in Rohingya refugee camps in Cox’s Bazar, Bangladesh. Methods: Information on demographics, IYCF-E knowledge, wet nursing support, type of constraints faced, and possible ways to overcome such constraints was collected through face-to-face interviews with 24 conveniently selected wet nurses. Linear regression was used to analyze the associations. Results: Mean age of wet nurses was 21.6 years; 16.67% had adequate knowledge about IYCF-E; and 29.17% had prior knowledge about wet nursing. Mean age of supported infants was 1.29 months, and 58.33% had a familial relationship with the wet nurses. Duration of breastfeeding support was significantly associated with the wet nurse’s age, age of the wet nurses’ youngest children, familial relationship with infants, knowledge about IYCF-E, and follow-ups from community nutrition workers (Ps <0.05). The status of facing problems (58.33%) was negatively correlated with duration of wet nursing, although this association was not statistically significant. The most extensively reported problems were as follows: misunderstandings with the infant’s family (85.71%), family workload and time limitations (21.43%), household distance (42.86%), and family members’ poor compliance (21.43%). Counseling from community nutrition workers (64.29%) and mediation by community leaders (57.14%) played key roles in mitigating such problems. Self-satisfaction (37.50%), counseling (62.50%), and religious inspiration (58.33%) were key motivators behind dedicated breastfeeding support. Conclusion: Wet nursing in the Rohingya refugee camps in Cox’s Bazaar, Bangladesh, was associated with several factors involving both supply and demand. The present findings may help design better IYCF-E programs in similar context. [ABSTRACT FROM AUTHOR]

Background: There have been growing recommendations to include education in multi-disciplinary interventions targeting chronic pain management. However, effects of this strategy on short- and long-term self-management of chronic pain, remain largely unexplored. Objectives: 1. To provide an updated overview of studies that report on the impact of patient education in multi-disciplinary interventions, on self-management of chronic pain; 2. To explore associations between education and chronic pain self-management techniques; and 3. To identify the format and duration of suitable chronic pain interventions targeted at patient self-management. Methods: Design: Narrative systematic literature review of randomised or controlled study designs. Data Sources: PubMed, CINAHL, EMBASE, PsycINFO. Participants: Adult patients with chronic pain of any aetiology participating in multi-disciplinary programs that included education. Main outcome measures: Assessments of level of pain, function, quality of life, self-efficacy, self-management, and any other relevant assessments. Study Appraisal and Synthesis Methods: PRISMA guidelines, Cochrane Risk of Bias tool, and TIDieR model. Results: Database searching identified 485 potential papers. After removal of duplicates, and irrelevant articles by title and abstract, 120 full-text articles were reviewed and 27 studies were included in this systematic review. Studies were predominantly from the United States (n = 8; 29.6%). Over one hundred outcome measures were identified across all studies, with significant variation also observed in terms of how chronic pain duration was defined, and how education was delivered to participants. Overall, positive benefits of education were reported. Conclusions: Education, as part of multi-disciplinary programs, is likely to improve self-management and self-efficacy in people with chronic pain of any aetiology. Heterogeneity in terms of: chronic pain duration; educational resources; healthcare professionals; and outcome measures, were identified as limitations. Further research, in the form of Randomised Controlled Trials addressing these limitations, is recommended. [ABSTRACT FROM AUTHOR]

Context: An estimated 21% of non-U.S.-born persons in the United States have a reactive tuberculin skin test (TST) and are at risk of progressing to TB disease. The effectiveness of strategies by healthcare facilities to improve targeted TB infection testing and linkage to care among this population is unclear. Evidence acquisition: Following Cochrane guidelines, we searched several sources to identify studies that assessed strategies directed at healthcare providers and/or non-U.S.–born patients in U.S. healthcare facilities. Evidence synthesis: Seven studies were eligible. In a randomized controlled trial (RCT), patients with reactive TST who received reminders for follow-up appointments were more likely to attend appointments (risk ratio, RR = 1.05, 95% confidence interval 1.00–1.10), but rates of return in a quasi-RCT study using patient reminders did not significantly differ between study arms (P = 0.520). Patient-provider language concordance in a retrospective cohort study did not increase provider referrals for testing (P = 0.121) or patient testing uptake (P = 0.159). Of three studies evaluating pre and post multifaceted interventions, two increased TB infection testing (from 0% to 77%, p < .001 and RR 2.28, 1.08–4.80) and one increased provider referrals for TST (RR 24.6, 3.5–174). In another pre-post study, electronic reminders to providers increased reading of TSTs (RR 2.84, 1.53–5.25), but only to 25%. All seven studies were at high risk of bias. Conclusions: Multifaceted strategies targeting providers may improve targeted TB infection testing in non-U.S.-born populations visiting U.S. healthcare facilities; uncertainties exist due to low-quality evidence. Additional high-quality studies on this topic are needed. [ABSTRACT FROM AUTHOR]

Background: Noncommunicable diseases including cancer are widespread amongst the 5.6 million Syrian refugees currently hosted in the Middle East. Given its prevalence as the third leading cause of death in Syria, cancer is likely to be an important health burden among Syrian refugees. Against this background, our aim was to describe the clinical, ethical and policy decision-making experiences of health actors working within the current refugee cancer care system; the impact of refugee cancer care health policies on health care providers and policy makers in this context; and provide suggestions for the way delivery of care should be optimised in a sustained emergency situation. Methods: From April-July 2016, we conducted in-depth interviews with 12 purposively sampled health officials and health care workers from the Jordanian Ministry of Health, multilateral donors and international non-governmental organisations. Data were analysed using a framework analysis approach to identify systemic, practical and ethical challenges to optimising care for refugees, through author agreement on issues emerging from the data and those linked more directly to areas of questioning. Results: As has been previously reported, central challenges for policy makers and health providers were the lack of quality cancer prevalence data to inform programming and care delivery for this refugee population, and insufficient health resource allocation to support services. In addition, limited access to international funding for the host country, the absence of long-term funding schemes, and barriers to coordination between institutions and frontline clinicians were seen as key barriers. In this context where economic priorities inevitably drive decision-making on public health policy and individual care provision, frontline healthcare workers and policy makers experienced significant moral distress where duties of care and humanitarian values were often impossible to uphold. Conclusions: Our findings confirm and expand understanding of the challenges involved in resource allocation decisions for cancer care in refugee populations, and highlight these for the particular situation of long term Syrian refugees in Jordan. The insights offered by frontline clinicians and policy makers in this context reveal the unintended personal and moral impact of resource allocation decisions. With many countries facing similar challenges in the provision of cancer care for refugees, the lessons learned from Jordan suggest key areas for policy revision and international investment in developing cancer care policies for refugees internationally. [ABSTRACT FROM AUTHOR]

Background: It is well established that Ebola Survivors experience a myriad of physical and psychological sequelae. However, little is known about how they seek care to address their health needs. Our study determines the current healthcare seeking behaviour among Ebola survivors and determines the prevalence, pattern of use and correlates of traditional and complementary medicine (T&CM) use among Ebola survivors in Sierra Leone. Methods: We conducted a nationwide questionnaire survey among a cross-sectional sample of Ebola Survivors in Sierra Leone between January and August 2018. We employed descriptive statistics, chi-square test, Fisher exact two-tailed test and backward stepwise binary regression analysis for data analysis. A p-value less than 0.05 was considered statistically significant. Results: Ebola Survivors who participated in our study (n = 358), visited a healthcare provider (n = 308, 86.0%), self-medicated with conventional medicines (n = 255, 71.2%) and visited a private pharmacy outlet (n = 141, 39.4%). Survivors also self-medicated with T&CM products (n = 107, 29.9%), concurrently self-medicated with conventional and T&CM products (n = 62, 17.3%), and visited a T&CM practitioner (n = 41, 11.5%). Almost half of (n = 163, 45.5%) Ebola survivors reported using T&CM treatments for post ebola related symptoms and non-Ebola related symptoms since their discharge from an Ebola treatment centre. Ebola survivors who considered their health to be fair or poor (AOR = 4.08; 95%CI: 2.22–7.50; p<0.01), presented with arthralgia (AOR = 2.52; 95%CI: 1.11–5.69, p = 0.026) and were discharged three years or less (AOR = 3.14; 95%CI: 1.13–8.73, p = 0.028) were more likely to use T&CM. Family (n = 101,62.0%) and friends (n = 38,23.3%) were the common sources of T&CM information. Abdominal pain (n = 49, 30.1%) followed by joint pain (n = 46, 28.2%) and back pain (n = 43, 26.4%) were the most cited post–Ebola indications for T&CM use. More than three-quarters of T&CM users (n = 135, 82.8%) failed to disclose their use of T&CM to their healthcare providers. Conclusion: Ebola survivors in Sierra Leone employ a myriad of healthcare options including T&CM in addressing their healthcare needs. Researchers, health policy makers and healthcare providers should be aware of the substantial role of T&CM in the health seeking of survivors, and this topic that should be factored into future research, policy formulation and implementation as well as routine practice regarding Ebola survivors. [ABSTRACT FROM AUTHOR]

Background: Knowledge of antibiotic prescription practices in low- and middle-income countries is limited due to a lack of adequate surveillance systems. Objective: To assess the prescription of antibiotics for the treatment of acute respiratory tract infections (ARIs) in primary care. Method: An explanatory sequential mixed-methods study was conducted in 4 private not-for-profit outreach clinics located in slum areas in Nairobi, Kenya. Claims data of patients who received healthcare between April 1 and December 27, 2016 were collected in real-time through a mobile telephone-based healthcare data and payment exchange platform (branded as M-TIBA). These data were used to calculate the percentage of ARIs for which antibiotics were prescribed. In-depth interviews were conducted among 12 clinicians and 17 patients to explain the quantitative results. Results: A total of 49,098 individuals were registered onto the platform, which allowed them to access healthcare at the study clinics through M-TIBA. For 36,210 clinic visits by 21,913 patients, 45,706 diagnoses and 85,484 medication prescriptions were recorded. ARIs were the most common diagnoses (17,739; 38.8%), and antibiotics were the most frequently prescribed medications (21,870; 25.6%). For 78.5% (95% CI: 77.9%, 79.1%) of ARI diagnoses, antibiotics were prescribed, most commonly amoxicillin (45%; 95% CI: 44.1%, 45.8%). These relatively high levels of prescription were explained by high patient load, clinician and patient perceptions that clinicians should prescribe, lack of access to laboratory tests, offloading near-expiry drugs, absence of policy and surveillance, and the use of treatment guidelines that are not up-to-date. Clinicians in contrast reported to strictly follow the Kenyan treatment guidelines. Conclusion: This study showed successful quantification of antibiotic prescription and the prescribing pattern using real-world data collected through M-TIBA in private not-for-profit clinics in Nairobi. [ABSTRACT FROM AUTHOR]

Background: Multi-substance use is accompanied by increased morbidity and mortality and responsible for a large number of emergency department (ED) consultations. To improve the treatment for this vulnerable group of patients, it is important to quantify and break down in detail the ED resources used during the ED treatment of multi-substance users. Methods: This retrospective single centre case-control study included all ED consultations of multi-substance users over a three-year study period at a university hospital in Switzerland. Resource consumption of these patients was compared to an age-matched control group of non-multi-substance users. Results: The analysis includes 867 ED consultations of multi-substance users compared to 4,335 age-matched controls (5:1). Multi-substance users needed more total resources (median tax points [medical currency] (IQR): 762 (459–1226) vs. 462 (196–833), p<0.001), especially physician, radiology, and laboratory resources. This difference persisted in multivariable analysis (geometric mean ratio (GMR) 1.2, 95% CI: 1.1–1.3, p = 0.001) adjusted for sociodemographic parameters, consultation characteristics, and patient comorbidity; the GMR was highest in ED laboratory and radiology resource consumption. Among multi-substance user, indirect and non-drug-related consultations had higher ED resource consumption compared to drug-related consultations. Furthermore, leading discipline as well as urgency were predictors of ED resource consumption. Moreover, multi-substance users had more revisits (55.2% vs. 24.9%, p<0.001) as well as longer ED and in-hospital stays (both: GMR 1.2, 95% CI: 1.1–1.3, p<0.001). Conclusion: ED consultations of multi-substance users are expensive and resource intensive. Multi-substance users visited the ED more often and stayed longer at the ED and in-hospital. The findings of our study underline the importance of this patient group. Additional efforts should be made to improve their ED care. Special interventions should target this patient group in order to decrease the high frequency and costs of emergency consultations caused by multi-substance users. [ABSTRACT FROM AUTHOR]

Oral nutritional supplements (ONS) are multi-nutrient products used to increase the energy and nutrient intakes of patients. The aim of this study was to examine whether or not the adherence of patients varies according to their receiving prescription or over-the-counter ONS. Data were obtained from an online cross-sectional survey conducted with patients in Japan. A total of 107 patients who matched the inclusion criteria for the prescription ONS group and 148 who matched the criteria for the over-the-counter ONS group were further analyzed. In the prescription and over-the-counter ONS groups, the main medical reason for ONS consumption were “malnutrition” (48 patients [44.9%] vs. 63 patients [42.6%] p = 0.798], “frailty” (29 patients [27.1%] vs. 36 patients [24.3%] p = 0.663) and “aging” (25 patients [23.4%] vs. 30 patients [20.3%] p = 0.644). The proportion of “No particular disease” for prescription ONS consumption was significantly lower than that for over-the-counter ONS (6 patients [5.6%] vs. 24 patients [16.2%] p = 0.001). The body mass index of the prescription ONS group was significantly higher than that of the over-the-counter ONS group (21.1±4.38 kg/m2 vs. 19.9±3.75 kg/m2, p = 0.0161). In the prescription ONS group, all patients were given medical advice by doctors or registered dietitians. In contrast, in the over-the-counter ONS group, only 46 patients (31.1%) were given advice by doctors or registered dietitians (p<0.001). In the prescription ONS group, ONS was taken significantly more times and for a longer duration than in the over-the-counter ONS group (p<0.0001). However, among patients given advice by doctors or registered dietitians, there were no significant differences between the groups. Greater support by the medical team is still needed in order to maximize adherence to supplementation, especially concerning the calories, timing and period, so that benefits can be achieved and sustained. [ABSTRACT FROM AUTHOR]

Background: The second largest Ebola virus disease (EVD) epidemic in history is currently raging in Eastern Democratic Republic of Congo (DRC). Stubbornly persistent EVD transmission has been associated with social resistance, ranging from passive non-compliance to overt acts of aggression toward EVD reponse teams. Methods: We explored community resistance using focus group discussions and assessed the prevalence of resistant views using standardized questionnaires. Results: Despite being generally cooperative and appreciative of the EVD response (led by the government of DRC with support from the international community), focus group participants provided eyewitness accounts of aggressive resistance to control efforts, consistent with recent media reports. Mistrust of EVD response teams was fueled by perceived inadequacies of the response effort (“herd medicine”), suspicion of mercenary motives, and violation of cultural burial mores (“makeshift plastic morgue”). Survey questionnaires found that the majority of respondents had compliant attitudes with respect to EVD control. Nonetheless, 78/630 (12%) respondents believed that EVD was fabricated and did not exist in the area, 482/630 (72%) were dissatisfied with or mistrustful of the EVD response, and 60/630 (9%) sympathized with perpetrators of overt hostility. Furthermore, 102/630 (15%) expressed non-compliant intentions in the case of EVD illness or death in a family member, including hiding from the health authorities, touching the body, or refusing to welcome an official burial team. Denial of the biomedical discourse and dissatisfaction/mistrust of the EVD response were statistically significantly associated with indicators of social resistance. Conclusions: We concluded that social resistance to EVD control efforts was prevalent among focus group and survey participants. Mistrust, with deep political and historical roots in this area besieged by chronic violence and neglected by the outside world, may fuel social resistance. Resistant attitudes may be refractory to short-lived community engagement efforts targeting the epidemic but not the broader humanitarian crisis in Eastern DRC. [ABSTRACT FROM AUTHOR]

Introduction: In cases with residual-hearing (RH) loss after cochlear implantation, a safe method is needed to provide full spectral resolution and as much auditory information as possible without implant replacement. Aim of this study was to prove the feasibility of accessing a partially inserted cochlear-implant-electrode for complete insertion to its maximum length through the external ear canal using a transcanal approach. Methods: Two CI electrodes were customized with 18 stimulating channels. The electrode design enables the use of 12 active channels available for electrical stimulation inside the cochlea both after partial and full insertion. 10 CI electrodes were implanted in 10 fresh human cadaveric temporal bones. After initial partial insertion by posterior tympanotomy, the electrode was inserted to its maximum length via a transcanal approach. Radiographs and CT scans were performed to confirm the electrode position. The electrodes were investigated via x-ray after removal. Results: X-ray and CT-scans confirmed the electrode prototypes covering an angular insertion depth between 236° to 307° after initial insertion. Accessing the electrode in the middle ear space was feasible and insertion to its full length was successful. Post-insertion CT confirmed insertion of the 28mm and 31.5mm electrode arrays covering an angular insertion depth between 360° and 540° respectively. No tip foldovers were detected. Conclusion: This study confirms the feasibility of extending the electrode insertion to its maximum insertion length using a transcanal approach in temporal bone specimens. This constitutes a second stage procedure on demand in EAS-surgery. This may be beneficial for EAS-patients providing electrical stimulation beyond the basal turn of the cochlea once the functional residual hearing is lost, without replacing the entire CI. [ABSTRACT FROM AUTHOR]

Background: The aims of the study were to assess the level of knowledge, the attitudes and the adherence to evidence-based recommendations for surgical site infection (SSI) prevention and to describe any influences that may motivate nurses to adopt evidence-based practices for SSI prevention. Methods: The present study was a national cross-sectional survey conducted from June to November 2017. For each hospital that agreed to participate, 30 nurses were randomly selected. The questionnaire was aimed at exploring socio-demographic and practice characteristics, knowledge of, attitudes toward, and reported practices regarding evidence-based procedures for SSI prevention. Results: Out of 55 hospitals that were contacted, 36 agreed to participate (a response rate of 65%). Of the original sample of 1313 nurses, a total of 1305 returned the questionnaire, a response rate of 99.4%. Regarding knowledge, only 53.8% knew that preoperative hair removal, if necessary, should take place shortly before surgery, and 28.9% of the sample did not know the right definition of “bundle”. Over three quarters of participants stated that they always perform hand antisepsis before and after biological sample collection while 9.7% considered that wearing gloves during this practice is sufficient to prevent SSI. Furthermore, 91% of nurses reported that they always performed hand antisepsis before and after invasive procedures. Conclusion: The study findings highlight the areas that were most lacking in nurses’ training and for which targeted activities are needed. These data could support healthcare managers to implement interventions focused at enabling adherence to effective prevention practices to reduce risk to all patients. [ABSTRACT FROM AUTHOR]

Objectives: A lack of physician training is a major obstacle for effective tobacco dependence treatment. This study assessed the feasibility of an active learning training program and its effects on smoking cessation counselling skills of medical residents in Armenia, an Eastern European country with high smoking prevalence. Study design: The study used a pre-post assessment of smoking cessation counselling activities and a course evaluation survey to assess the feasibility of the intervention in a different environment. Methods: We adapted an active learning training model developed in Switzerland. Residents were trained in Yerevan, Armenia, using video-taped counselling sessions, role plays, standardized patients (actors), group discussions and immediate feedback. The training evaluation was done using a semi-structured anonymous questionnaire. The study assessed the physicians’ self-reported smoking cessation counselling activities before and 6 months after the training. A non-parametric Mann-Whitney test was used to assess pre-post differences in physicians’ counselling skills measured on ordinal scale. Results: Of the 37 residents trained, 75% were female, 89% aged 20–29 years and 83% were never-smokers. Twenty-eight trainees (76%) returned the course evaluation survey and 32 (86%) answered a questionnaire on skills self-assessment at 6 months follow-up. The majority agreed the course was successful in achieving its learning objectives (64%-96%) and increased their confidence in assisting their patients to quit (74%). After 6 months, the physicians were more likely than at baseline to adhere to evidence-based counselling strategies, including assessing the smoking status and dependence and matching the advice to the patient motivation. The training did not, however, improve the prescription of tobacco dependence medications. Conclusions: Six months after the training, several self-reported smoking cessation counselling activities had significantly improved compared to baseline. This training model is acceptable for medical residents in Yerevan, Armenia and offers a promising approach in addressing the lack of physician counselling skills in similar settings and populations. [ABSTRACT FROM AUTHOR]

Objective: Many jurisdictions lack comprehensive population-based antibiotic use data and rely on third party companies, most commonly IQVIA. Our objective was to validate the accuracy of the IQVIA Xponent antibiotic database in identifying high prescribing physicians compared to the reference standard of a highly accurate population-wide database of outpatient antimicrobial dispensing for patients ≥65 years. Methods: We conducted this study between 1 March 2016 and 28 February 2017 in Ontario, Canada. We evaluated the agreement and correlation between the databases using kappa statistics and Bland-Altman plots. We also assessed performance characteristics for Xponent to accurately identify high prescribing physicians with sensitivity, specificity, positive predictive value (PPV), and negative predictive value. Results: We included 9,272 physicians. The Xponent database has a specificity of 92.4% (95%CI 92.0%-92.8%) and PPV of 77.2% (95%CI 76.0%-78.4%) for correctly identifying the top 25th percentile of physicians by antibiotic volume. In the sensitivity analysis, 94% of the top 25th percentile physicians in Xponent were within the top 40th percentile in the reference database. The mean number of antibiotic prescriptions per physician were similar with a relative difference of -0.4% and 2.7% for female and male patients, respectively. The error was greater in rural areas with a relative difference of -8.4% and -5.6% per physician for female and male patients, respectively. The weighted kappa for quartile agreement was 0.68 (95%CI 0.67–0.69). Conclusion: We validated the IQVIA Xponent antibiotic database to identify high prescribing physicians for patients ≥65 years, and identified some important limitations. Collecting accurate population-based antibiotic use data will remain vital to global antimicrobial stewardship efforts. [ABSTRACT FROM AUTHOR]

Objective: A clinical decision support system (CDSS) for empirical antibiotic treatment has the potential to increase appropriate antibiotic use. Before using such a system on a broad scale, it needs to be tailored to the users preferred way of working. We have developed a CDSS for empirical antibiotic treatment in hospitalized adult patients. Here we determined in a usability study if the developed CDSS needed changes. Methods: Four prespecified patient cases, based on real life clinical scenarios, were evaluated by 8 medical residents in the study. The “think-aloud” method was used, and sessions were recorded and analyzed afterwards. Usability was assessed by 3 evaluators using an augmented classification scheme, which combines the User Action Framework with severity rating of the usability problems and the assessment of the potential impact of these problems on the final task outcomes. Results: In total 51 usability problems were identified, which could be grouped into 29 different categories. Most (n = 17/29) of the usability problems were cosmetic problems or minor problems. Eighteen (out of 29) of the usability categories could have an ordering error as a result. Classification of the problems showed that some of the problems would get a low priority based on their severity rating, but got a high priority for their impact on the task outcome. This effectively provided information to prioritize system redesign efforts. Conclusion: Usability studies improve lay-out and functionality of a CDSS for empirical antibiotic treatment, even after development by a multidisciplinary system. [ABSTRACT FROM AUTHOR]

Evaluating the absolute difference in pain intensity and the percentage difference in pain intensity could facilitate an understanding of pain reduction among cancer patients during repeated hospitalizations. Examinations of the absolute differences in pain intensity and the percentage differences in pain intensity according to the worst pain intensity and last evaluated pain intensity before discharge are lacking. The aim of this study was to evaluate the absolute and percentage difference in pain intensities among cancer patients with moderate or severe pain from their 1st to 18th hospitalizations from 2011–2013. A population-based retrospective cohort study was conducted. Pain intensity was assessed using scales and was recorded in a nursing information system. The absolute and percentage difference in pain intensities were examined via the one-sample Kolmogorov-Smirnov test, and group differences in moderate or severe pain were evaluated with the Mann-Whitney U test. For moderate pain patients, the mean absolute difference in pain intensity was 1.52, and the percentage difference in pain intensity was 29.0%; both these values were significant. More significant changes in the absolute and percentage difference in pain intensities were associated with severe pain patients. Both the average absolute difference in pain intensity (3.09) and the percentage difference in pain intensity (38.5%) in patients with severe pain were significantly higher than the average absolute difference in pain intensity (1.52) and the percentage difference in pain intensity (29.0%) in patients with moderate pain. Cancer patients with moderate and severe pain experienced pain reductions of approximately 30% and 40%, respectively. Early pain management intervention in patients with severe pain is necessary to achieve an obvious analgesic effect, and the formula of the percentage difference in pain intensity should be incorporated into the nursing information system to alert clinicians for early detection of the effectiveness of cancer pain management. [ABSTRACT FROM AUTHOR]

Background: The performance of primary health care providers regarding DM management is poor in rural China, and effective training methods for providers are urgently needed. This study aimed to evaluate the effect of web-based training for improving knowledge about DM management among primary health care providers in rural China and to further compare the effects of the training effect between primary health care providers with different backgrounds. Methods: A pre-post intervention study was conducted from April to August 2014. In this study, a total of 901 primary health care workers were recruited from six counties in Hubei province. To evaluate the effect of the web-based training, the knowledge achievement of participants was measured with multiple choice questions (MCQ) at baseline, at the end of two weeks of training and at three months after training. A mixed linear model (MLM) was used to measure group differences in the mean scores at baseline and follow-up. Results: After the web-based training, the knowledge scores of the village doctors increased from 73.58 at baseline to 89.98 at posttest and to 84.57 three months after the training. For township health workers, we observed an upward trend in scores from 78.87 at the pre-test to 91.72 at the second test, and at the three months after the training, the scores increased to 94.91. For village doctors, greater knowledge achievement was observed between the scores at baseline and after two weeks of training(adjusted difference: 3.55, P = 0.03) compared to that observed for the township health workers, while decreased their knowledge achievement between baseline and the third-test compared with that of township health workers (adjusted difference: 5.05, P = 0.01). Conclusions: This study suggested that web-based training was an effective method for improving the knowledge of primary health care providers about management of DM in remote areas. Compared with the effect of the training on village doctors, the training had a poor short-term effect on township health workers but a better long-term effect. [ABSTRACT FROM AUTHOR]

Background: Suicide prevention is a global priority. Psychiatric hospitalization presents an opportunity to intervene positively with, for example, psychological therapies. However, evidenced-based suicide-prevention psychological treatments are rarely available on in-patient wards. Understanding staff engagement with research investigating suicide-prevention psychological treatments is crucial for their effective, efficacious, and pragmatic implementation. A pilot randomised control trial and feasibility study of Cognitive Behavioural Suicide Prevention therapy provided the opportunity for a qualitative investigation of staff experiences and views of a psychological intervention for people with suicidal experiences on psychiatric in-patient wards. Aims: To investigate staff acceptability of Cognitive Behavioural Suicide Prevention therapy for psychiatric inpatients based on their perceptions of their experiences during the conduct of a clinical trial. Method: Transcribed audio-recordings of qualitative interviews and a focus group (n = 19) of purposively sampled staff from eight psychiatric wards were analysed using inductive Thematic Analysis. Results: Facilitators and barriers were identified for: i) the conduct of the research, and, ii) the suicide-prevention intervention (Cognitive Behavioural Suicide Prevention therapy). Research-related barriers comprised communication difficulties between staff and researchers, and increased staff workload. Research-related facilitators included effective staff/researcher relationships, and alignment of the intervention with organisational goals. Suicide-prevention intervention-related barriers comprised staffs’ negative beliefs about suicide which impacted on their referral of inpatients to the clinical trial, and staff perceptions of insufficient information and unfulfilled expectations for involvement in the therapy. Facilitators included staff beliefs that the therapy was beneficial for inpatients, the service and their own clinical practice. Conclusions: Staff beliefs that ‘suicide-talk’ could precipitate suicidal behaviour resulted in covert gatekeeping and restricted referral of only inpatients judged as stable or likely to engage in therapy, which may not be those who could most benefit. Such threats to sample representativeness have implications for future therapy research design. The findings provide novel information for researchers and practitioners regarding the conduct of psychological treatment and research in psychiatric units. [ABSTRACT FROM AUTHOR]

This study aims to evaluate the quality of clinical practice guidelines(CPGs) for patients with diabetic foot worldwide. A search of guidelines websites, databases and academic institutions websites was performed from January 1st, 2010, until June 30th, 2018. Four assessors independently rated the quality of each CPG using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Twelve CPGs satisfied the inclusion criteria. The median scores for the 6 AGREE II domains (scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence) were 92.5%, 72.5%, 71.5%, 89%, 47%, and 77%, respectively. The overall quality of the CPGs was good since the majority of the CPGs reached an overall guideline quality between 5 and 7 points. Different CPGs had widely varying scores in the same area, ranging from 25 to 94 points. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury in hospital patients is common and associated with reduced survival and higher healthcare costs. The Tackling Acute Kidney Injury (TAKI) quality improvement project aimed to reduce mortality rates in patients with acute kidney injury by implementing a multicomponent intervention comprising of an electronic alert, care bundle and education in five UK hospitals across a variety of wards. A parallel developmental evaluation using a case study approach was conducted to provide the implementation teams with insights into factors that might impact intervention implementation and fidelity. The qualitative element of the evaluation will be reported. Methods: 29 semi-structured interviews with implementation teams across the five hospitals were carried out to identify perceived barriers and enablers to implementation. Interviews were taped and transcribed verbatim and Framework analysis was conducted. Results: Interviews generated four ‘barriers and enablers’ to implementation themes: i) practical/contextual factors, ii) skills and make-up of the TAKI implementation team, iii) design, development and implementation approach, iv) staff knowledge, attitudes, behaviours and support. Enablers included availability of specialist teams (e.g. educational teams), multi-disciplinary implementation teams with strong leadership, team-based package completion and proactive staff. Barriers were frequently the converse of facilitators. Conclusions: Despite diversity of sites, a range of common local factors–contextual, intervention-based and individual–were identified as potential barriers and enablers to fidelity, including intervention structure/design and process of/approach to implementation. Future efforts should focus on early identification and management of barriers and tailored optimisation of known enablers such as leadership and multidisciplinary teams to encourage buy-in. Improved measures of real-time intervention and implementation fidelity would further assist local teams to target their support during such quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Importance: Despite its efficacy, low tidal volume ventilation (LTVV) remains severely underutilized for patients with acute respiratory distress syndrome (ARDS). Physician under-recognition of ARDS is a significant barrier to LTVV use. We propose a computational method that addresses some of the limitations of the current approaches to automated measurement of whether ARDS is recognized by physicians. Objective: To quantify patient and physician factors affecting physicians’ tidal volume selection and to build a computational model of physician recognition of ARDS that accounts for these factors. Design, setting, and participants: In this cross-sectional study, electronic health record data were collected for 361 ARDS patients and 388 non-ARDS hypoxemic (control) patients in nine adult intensive care units at four hospitals between June 24 and December 31, 2013. Methods: Standardized tidal volumes (mL/kg predicted body weight) were chosen as a proxy for physician decision-making behavior. Using data-science approaches, we quantified the effect of eight factors (six severity of illness, two physician behaviors) on selected standardized tidal volumes in ARDS and control patients. Significant factors were incorporated in computational behavioral models of physician recognition of ARDS. Results: Hypoxemia severity and ARDS documentation in physicians’ notes were associated with lower standardized tidal volumes in the ARDS cohort. Greater patient height was associated with lower standardized tidal volumes (which is already normalized for height) in both ARDS and control patients. The recognition model yielded a mean (99% confidence interval) physician recognition of ARDS of 22% (9%-42%) for mild, 34% (19%-49%) for moderate, and 67% (41%-100%) for severe ARDS. Conclusions and relevance: In this study, patient characteristics and physician behaviors were demonstrated to be associated with differences in ventilator management in both ARDS and control patients. Our model of physician ARDS recognition measurement accounts for these clinical variables, providing an electronic approach that moves beyond relying on chart documentation or resource intensive approaches. [ABSTRACT FROM AUTHOR]

Background: Little is known about outpatient health services use following critical illness and intensive care. We examined the association of intensive care with outpatient consultations and quality of life in a population-based sample. Methods: Cross-sectional analysis of data from 6,686 participants of the Study of Health in Pomerania (SHIP), which consists of two independent population-based cohorts. Statistical modeling was done using Poisson regression, negative binomial and generalized linear models for consultations, and a fractional response model for quality of life (EQ-5D-3L index value), with results expressed as prevalence ratios (PR) or percent change (PC). Entropy balancing was used to adjust for observed confounding. Results: ICU treatment in the previous year was reported by 139 of 6,686 (2,1%) participants, and was associated with a higher probability (PR 1.05 [CI:1.03;1.07]), number (PC +58.0% [CI:22.8;103.2]) and costs (PC +64.1% [CI:32.0;103.9]) of annual outpatient consultations, as well as with a higher number of medications (PC +37.8% [CI:17.7;61.5]). Participants with ICU treatment were more likely to visit a specialist (PR 1.13 [CI:1.09; 1.16]), specifically internal medicine (PR 1.67 [CI:1.45;1.92]), surgery (PR 2.42 [CI:1.92;3.05]), psychiatry (PR 2.25 [CI:1.30;3.90]), and orthopedics (PR 1.54 [CI:1.11;2.14]). There was no significant effect regarding general practitioner consultations. ICU treatment was also associated with lower health-related quality of life (EQ-5D index value: PC -13.7% [CI:-27.0;-0.3]). Furthermore, quality of life was inversely associated with outpatient consultations in the previous month, more so for participants with ICU treatment. Conclusions: Our findings suggest that ICU treatment is associated with an increased utilization of outpatient specialist services, higher medication intake, and impaired quality of life. [ABSTRACT FROM AUTHOR]

Background: Multiple sclerosis (MS) requires multidisciplinary management. We evaluated differences in healthcare resource utilization and costs between Federico II and Vanvitelli MS Centres of Naples (Italy), representative of centralised (i.e., MS Care Unit) and local service-based models of multidisciplinary care, respectively. Methods: We included MS patients continuously seen at the same local healthcare services and MS Centre (Federico II = 187; Vanvitelli = 90) from 2015 to 2017. Healthcare resources for MS treatment and management were collected and costs were calculated. Adherence was estimated as the rate of medication possession ratio (MPR) during 3-years of follow-up. Mixed-effect linear regression models were used to estimate differences in all outcomes between Federico II and Vanvitelli. Results: Patients at Federico II had more consultations within the MS centre (p<0.001), blood tests (p<0.001), and psychological/cognitive evaluations (p = 0.040). Patients at Vanvitelli had more consultations at local services (p<0.001). Adherence was not-significantly lower at Vanvitelli (p = 0.060), compared with Federico II. Costs for MS treatment and management were 10.6% lower at Vanvitelli (12417.08±8448.32EUR) (95%CI = -19.0/-2.7%;p = 0.007), compared with Federico II (15318.57±10919.59EUR). Discussion: Healthcare services were more complete (and expensive) at the Federico II centralised MS Care Unit, compared with the Vanvitelli local service-based organizational model. Future research should evaluate whether better integration between MS Centres and local services can lead to improved MS management and lower costs. [ABSTRACT FROM AUTHOR]

Objective: Healthcare workers (HCWs) are one of the target groups for systematic testing and treatment of latent tuberculosis infection (LTBI) in a setting of low TB incidence. We performed this study to describe the testing of HCWs for LTBI and analyse the acceptance and completion of treatment of LTBI. Methods: This retrospective cohort study was conducted in four university-affiliated hospitals between January 1 and December 31, 2018. HCWs with positive interferon-gamma release assay (IGRA) during LTBI screening were analysed. We assessed the acceptance and completion of LTBI treatment. Results: Overall, 893 HCWs were IGRA positive. Among them, 609 HCWs visited the clinic for evaluation of LTBI. Of 609 HCWs who were evaluated, 302 (49.6%) were offered treatment for LTBI. The proportion of acceptance for treatment was 64.5% (195 of 302 HCWs). The treatment course was completed by 143 of 195 HCWs (73.3%). Three months of isoniazid and rifampin (3HR) was used in 137 HCWs (70.3%) and 4 months of rifampin (4R) in 58 (29.7%). 72 HCWs (36.9%) experienced at least one adverse drug events, but there was no different characteristics between completer and non-completer. Conclusion: The acceptance and completion of LTBI treatment were unsatisfactory. Subjective perspective regarding obstacles to treatment of LTBI needs to be explored to increase compliance to LTBI treatment. [ABSTRACT FROM AUTHOR]

The botanical product silymarin, an extract of milk thistle, is commonly used by patients to treat chronic liver disease and may be a treatment for NASH due to its antioxidant properties. We aimed to assess the safety and efficacy of higher than customary doses of silymarin in non-cirrhotic patients with NASH. This exploratory randomized double-blind placebo controlled multicenter Phase II trial tested a proprietary standardized silymarin preparation (Legalon®, Rottapharm|Madaus, Mylan) and was conducted at 5 medical centers in the United States. Eligible adult patients had liver biopsy within 12 months showing NASH without cirrhosis with NAFLD Activity Score (NAS) ≥4 per site pathologist’s assessment. Participants were randomized to Legalon® 420 mg, 700 mg, or placebo t.i.d. for 48 weeks. The primary endpoint was histological improvement ≥2 points in NAS. Of 116 patients screened, 78 were randomized. There were no significant differences in adverse events among the treatment groups. After 48–50 weeks, 4/27 (15%) in the 700 mg dose, 5/26 (19%) participants randomized to 420 mg, and 3/25 (12%) of placebo recipients reached the primary endpoint (p = 0.79) among all randomized participants, indicating no benefit from silymarin in the intention to treat analysis Review by a central pathologist demonstrated that a substantial number of participants (49, 63%) did not meet histological entry criteria and that fibrosis stage improved most in the placebo treated group, although not significantly different from other groups. Silymarin (Legalon®) at the higher than customary doses tested in this study is safe and well tolerated. The effect of silymarin in patients with NASH remains inconclusive due to the substantial number of patients who entered the study but did not meet entry histological criteria, the lack of a statistically significant improvement in NAS of silymarin treated patients, and the unanticipated effect of placebo on fibrosis indicate the need for additional clinical trials. Trial Registration: clinicaltrials.gov, Identifier: . [ABSTRACT FROM AUTHOR]

Objective: Previous reports have highlighted the suboptimal utilization and prescription of statin therapy among patients with type 2 diabetes mellitus (T2DM) in the Malaysian clinical practice. This study aims to test the impact of a pharmacist-led academic detailing program on improving the overall statin therapy prescribing in Malaysian hospital and primary care settings. Methods: As a quasi-experimental design with a control group and pre-tests., we examined 1,598 medical records of T2DM subjects in six healthcare facilities in the state of Pahang, Malaysia. In all study sites, there was a pre and post-intervention assessment of the percentage of appropriate statin therapy prescribing that complied with the clinical guidelines with no potential safety issues. The intervention was an academic detailing program offered to the health care providers in three study sites, while the other three sites served as the control group. A comparison of the overall percentage of appropriate statin therapy prescribing before and after the academic detailing was performed in all intervention and control sites. Results: Overall, 797 medical records were examined in the pre-intervention phase, and 801 records were evaluated in the post-intervention phase. The academic detailing program was associated with a statistically significant difference in the proportion of appropriate statin therapy prescribing between the post-intervention phase compared to the pre-intervention phase (n = 246, 61.7% versus n = 188, 47.1%), p = 0.001. Whereas, the appropriate statin therapy prescribing in the control study sites experienced a modest change from 53.8% (214/398) to 56.7% (228/402), p = 0.220. The academic detailing showed significant increases in the proportions of appropriate statin therapy prescribing in both hospital and primary care settings. Conclusions: The academic detailing program was found to be significantly associated with a positive impact on the overall statin therapy prescribing among patients with T2DM in Malaysian hospital and primary care settings. [ABSTRACT FROM AUTHOR]

Background: Despite a proven association between the implementation of prevention guidelines for central line associated blood stream infections (CLABSI) and reduction in CLABSI rates, in practice there is poor adherence. Furthermore, current guidelines fail to address the multiple process on the care continuum. This research is based on the bottom-up "Positive Deviance" (PD) approach, through which multiple creative and safer solutions for central line (CL) insertion were identified that were not previously described in the guidelines. The aim of the study was to deconstruct CLABSI prevention guidelines ("during insertion" process only) through the PD approach, working with physicians to identify additional actions that, in practice, help maintain a sterile environment and contribute to patient safety. Methods and findings: Our study included a qualitative ethnographic study involving 76 physicians, working in a division of internal medicine and two intensive care units (ICUs). We triangulated findings from a combination of data-collection methods: semi-structured interviews, focused observations, video documentation, Discovery & Action Dialogue (DAD), and simulations. Deconstruction analysis was performed. A total of 23 creative extensions and variations of CL insertion practices were identified. Conclusions: The PD approach enables the identification of vital nuggets of hidden wisdom missing from the formal explicit CLABSI guidelines, and therefore helps bridge the gap between theory and praxis. During the guideline's deconstruction process, through collaborative staff learning, the written procedure is transformed into a living, breathing and cooperative one. It can reduce hospital stays and save lives, and therefore needs careful attention of healthcare scholars and practitioners. [ABSTRACT FROM AUTHOR]

Background: Ensuring effective clinical management and continuity of TB care across hospital and primary health-care services remains challenging in South Africa. The high burden of TB, coupled with numerous health system problems, influence the TB care delivered by hospital staff. Objective: To understand factors from the perspectives of hospital staff that influence the clinical management and discharge of TB patients, and to elicit recommendations to improve continuity of care for TB patients. Design: Participatory action research was used to engage hospital staff working with TB patients admitted to a central public hospital in the Western Cape province, South Africa. Data were collected through eight focus group discussions with nurses, junior doctors and ward administrators. Data analysis was done using Miles and Huberman’s framework to identify emerging patterns and to develop categories with themes and sub-themes. The participants influenced all phases of the research process to inform better practices in TB clinical management and discharge planning at the hospital. Results: The emerging themes and sub-themes were categorized into two overall sections: The clinical care management process and the discharge and referral process. Nurses expressed a fear of exposure to TB and MDR-TB due to challenges in clinical and infection-prevention control. Clinical hierarchies, poor interdisciplinary teamwork, limited task shifting and poor communication interfered with effective clinical and discharge processes. A high workload, staff shortages and inadequate skills resulted in insufficient information and health education for TB patients and their caregivers. Despite awareness of the patients’ socio-economic challenges, some aspects of care were not patient-centered, and caregivers were not included in discharge planning. Communication between the hospital and referral points was inefficient and poorly supported by information systems. Hospital staff recommended improved infection prevention and control practices and interdisciplinary teamwork in the hospital, that TB education for patients be integrated with hospital staff functions, with more patient-centered discharge planning, and improved communication across hospitals and primary health care levels. Conclusions: Interdisciplinary teamwork, more patient-centered care, and better communication within the hospital and with primary health-care services are needed for improved continuity of care for TB patients. Further studies on factors contributing to, and interventions to improve, continuity of TB care in similar hospital settings are needed. [ABSTRACT FROM AUTHOR]

Objective: Medical Psychiatry Units (MPUs), also known as Complexity Intervention Units (CIUs), provide care for complex patients suffering from both psychiatric and physical disorders. Because there is no consensus on the indications for admission to an MPU, daily practice and effectiveness research are hampered. This study therefore used a concept mapping approach to investigate which organizational and medical factors determine the decision to admit a patient to an MPU. Methods: The first step of the concept mapping approach was to create a list of factors determining MPU admission from literature. Secondly, clinical experts sorted and ranked these factors. The sorted and ranked data were then analyzed, and a draft conceptual framework was created. A final conceptual MPU admission framework was then drawn during an expert consensus meeting and recommendations for implementation were suggested. Results: Thirteen clinical experts defined 90 factors from literature, which were sorted and ranked by 40 experts from 21 Dutch hospitals. This concept mapping approach resulted in a five-cluster solution for an MPU admission framework based on: 1. Staff competencies and organizational pre-requisites; 2. Patient context; 3. Patient characteristics; 4. Medical needs and capabilities; and 5. Psychiatric symptoms and behavioral problems. Furthermore, three inclusion and two exclusion criteria were formulated to help the clinicians decide whether or not to admit patients to an MPU. These criteria can be implemented in daily practice. Conclusion: Implementing the five criteria derived from this conceptual framework will help make the admission decision for complex patients with psychiatric and physical disorders to an MPU more correct, consistent, and transparent. [ABSTRACT FROM AUTHOR]

Purpose: To investigate intraocular pressure (IOP) readings by non-contact tonometry (NCT) and Goldmann applanation tonometry (GAT) for patients with different degrees of bilateral tearing. Methods: In this study, we reviewed the medical charts of patients complaining of different degrees of bilateral tearing. The tear meniscus height (TMH) and IOP with NCT and GAT were measured. In each patient, a comparison of IOP readings between the eye with lower TMH and the contralateral eye with higher TMH was evaluated. The TMH was graded as follows: grade 1 (low): TMH < 0.2 mm; grade 2 (moderate): 0.2 mm ≤ TMH < 0.6 mm; grade 3 (high): TMH ≥ 0.6 mm. Subsequently, a comparison of IOP readings among eyes with low, moderate, and high TMH was also performed. Results: A total of 120 eyes of 60 patients were enrolled. When comparing the two eyes of a patient, the eye with higher TMH showed higher NCT readings and larger difference in IOP readings between the two tonometries than the eye with lower TMH (P < 0.001 and P < 0.001, respectively). When TMH was classified into grades according to the degree, the high TMH eyes showed higher NCT readings than did the low and moderate TMH eyes (P < 0.001 and P = 0.001, respectively). In addition, the high TMH eyes showed a larger difference in IOP readings between the two tonometries than did the low and moderate TMH eyes (P < 0.001 and P < 0.001, respectively). Conclusion: Eyes with higher TMH showed higher NCT readings and a larger difference in IOP between the two tonometries (NCT and GAT) than those with lower TMH. In patients with tearing, the NCT value may be inaccurate, so it is necessary to measure the GAT. [ABSTRACT FROM AUTHOR]

Background: Veteran patients with traumatic brain injury (TBI) and their family members regularly receive care from nurses. Understanding nurses’ training and beliefs can provide direction for intervention work aimed at ensuring the best possible care is delivered to this population. Aims: We examined Veterans Health Administration (VHA) nurses’ training and beliefs related to care of patients with moderate-to-severe TBI. Design and methods: We conducted an exploratory, cross-sectional survey with 211 VHA nurses and analyzed data using descriptive statistics. Results: The average years of nursing experience was 18 years, and 90% reported ever caring for a patient with TBI. Most nurses (70%) reported only seeing patients with TBI ≤1–2 times per year in their current role; 20% reported seeing these patients 1–2 times per month. Even with infrequent care, almost 50% reported previously receiving TBI-related training. Beliefs items with the highest accuracy indicated nurses agreed that they need specialized training to care for patients with TBI and that TBI recovery may continue for several years (96.39% accuracy respectively). The beliefs item with the lowest accuracy indicated focus on whether nurses agreed that TBI severity was important in developing care plans (27.84% accuracy). Nurses reported the need for clarity of the nursing role in caring for patients with TBI (77.32% agreement). Conclusion: VHA nurses do have accurate beliefs about caring for Veteran patients with moderate-to-severe TBI; however, there is the need for further role clarification regarding nursing care of patients with TBI. Impact: These findings have implications for development of education and training interventions for nurses who care for Veteran patients with TBI. [ABSTRACT FROM AUTHOR]

Purpose: Asthma is an important cause of morbidity and mortality worldwide and information on the prevalence of asthma in Nigeria is inconsistent. Nationally representative data, important for health planning is unavailable. We aimed to determine the current prevalence of asthma and allergic rhinitis in Nigeria. Materials and methods: A cross-sectional population survey conducted between June 2017 and March 2018 across five cities representing five geo-political zones in Nigeria. Validated screening questionnaires were used to identify persons with asthma and allergic rhinitis respectively. Asthma was defined as physician diagnosed asthma, clinical asthma and by presence of wheeze in the last 12 months respectively. Socio-demographic information, tobacco smoking, sources of household cooking fuel were also obtained. Results: A total of 20063 participants from 6024 households were screened. The prevalence (95% confidence interval) of physician diagnosed asthma, clinical asthma and wheeze was 2.5% (2.3–2.7%), 6.4% (6.0–6.64%) and 9.0% (8.6–9.4%) respectively. The prevalence of allergic rhinitis was 22.8% (22.2–23.4%). The prevalence of asthma and rhinitis increased with age (prevalence of clinical asthma: 3.1% (2.8–3.4%), 9.8% (9.1–10.5) and 10.7% (9.4%-12.0) among 6–17 years, 18–45 years and >45 years respectively). Prevalence also varied across different cities with the highest prevalence of clinical asthma occurring in Lagos (8.0%) and the lowest in Ilorin (1.1%). The frequency of allergic rhinitis among persons with clinical asthma was 74.7%. Presence of allergic rhinitis, family history of asthma, current smoking and being overweight were independent determinants of current asthma among adults. Conclusion: The prevalence of asthma and allergic rhinitis in Nigeria is high with variabilities across regions and age groups. The number of persons with clinical asthma in Nigeria (approximately 13 million) is likely to rank among the highest in Africa. This warrants prioritization by stakeholders and policy makers to actively implement risk reduction measures and increase investment in capacity building for the diagnosis and treatment of asthma and allergic rhinitis. [ABSTRACT FROM AUTHOR]

Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits. [ABSTRACT FROM AUTHOR]

Background: Repetitive transcranial magnetic stimulation (rTMS) is an evidence-based treatment for depression that is increasingly implemented in healthcare systems across the world. A new form of rTMS called intermittent theta burst stimulation (iTBS) can be delivered in 3 min and has demonstrated comparable effectiveness to the conventional 37.5 min 10Hz rTMS protocol in patients with depression. Objectives: To compare the direct treatment costs per course and per remission for iTBS compared to 10Hz rTMS treatment in depression. Methods: We conducted a cost analysis from a healthcare system perspective using patient-level data from a large randomized non-inferiority trial (THREE-D). Depressed adults 18 to 65 received either 10Hz rTMS or iTBS treatment. Treatment costs were calculated using direct healthcare costs associated with equipment, coils, physician assessments and technician time over the course of treatment. Cost per remission was estimated using the proportion of patients achieving remission following treatment. Deterministic sensitivity analyses and non-parametric bootstrapping was used to estimate uncertainty. Results: From a healthcare system perspective, the average cost per patient was USD$1,108 (SD 166) for a course of iTBS and $1,844 (SD 304) for 10Hz rTMS, with an incremental net savings of $735 (95% CI 688 to 783). The average cost per remission was $3,695 (SD 552) for iTBS and $6,146 (SD 1,015) for 10Hz rTMS, with an average incremental net savings of $2,451 (95% CI 2,293 to 2,610). Conclusions: The shorter session durations and treatment capacity increase associated with 3 min iTBS translate into significant cost-savings per patient and per remission when compared to 10Hz rTMS. [ABSTRACT FROM AUTHOR]