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Presently, research and development (R&D) and innovation have been discussed in diverse ways. However, the nexus of subsidy was relatively unexplored in emerging economies. Furthermore, the effects of age are observed to be inconclusive. Considering 1272 selected Chinese manufacturing firms over the period 2007–2017, we employ fixed effect models to examine the effects of Subsidy on R&D and innovation and whether age was a moderating factor. Consistent with the sandwich theoretical proposition, this article found that there exists a significantly transitive relationship between government subsidy, R&D, and innovation. Whereas young firms perform better in the short-term, state-owned firms outweigh the private ones in performance. Subsequently, age alternatively moderates the R&D and innovation relationship from the perspective of subsidy. Though subsidy is a short-term determinant of R&D, it has a long-term relationship with innovation. In contrast, R&D and innovation have short-term effects based on lag computations. Overall, our findings suggest that government subsidy plays a crucial role in R&D and innovation for emerging markets. We discuss our results within the theoretical frameworks of sandwich, the economics of subsidy, and behavioral theory of R&D.

BackgroundSchizophrenia is a heterogeneous neuropsychiatric disorder, categorized by positive, negative, and cognitive symptoms. In trying to improve diagnosis and treatment of schizophrenia researchers have turn to “dual hit” models of schizophrenia that are able to reproduce all symptoms of the disorder. The main objective of this protocol is to present a transparent process on how we plan to review the existing international literature on effectiveness of “dual hit” models used to induce schizophrenia on rodents. MethodsLiterature search strategies will be developed using medical search headings (MeSH). The MEDLINE (PubMed), EMBASE, and Google Scholar databases will be used to search for published studies electronically. We will search for studies involving inducing schizophrenic symptoms using “dual hit” rodent model (post-weaning social isolation and NMDA receptor antagonist). Studies will be screened by titles, abstracts, keywords, and synonyms followed by identifying the full-text articles. All studies that will pass the quality assessment will be included. Data will be extracted by two authors independently and in duplicate, from each eligible study in ensuring that there is consistency between reviews. If the design and comparator are sufficiently homogenous for all studies, meta-analysis will be conducted using a random-effect model.DiscussionThe results of this review will contribute in the development of new “dual hit” models that will be able to characterize schizophrenia symptoms better. It will also shed light to researchers on new developments that need to be made in improving animal models of schizophrenia.Systematic reviews registrationPROSPERO CRD42021247585

Purpose BRCA1/2 pathogenic variant (PV) mutations confer radiation sensitivity preclinically, but there are limited data regarding breast cancer outcomes after radiation therapy (RT) among patients with documented BRCA1/2 PV mutations versus no PV mutations. Methods and Materials This retrospective cohort study included women with clinical stage I-III breast cancer who received definitive surgery and RT and underwent BRCA1/2 genetic evaluation at the The University of Texas MD Anderson Cancer Center. Rates of locoregional recurrence (LRR), disease-specific death (DSD), toxicities, and second cancers were compared by BRCA1/2 PV status. Results Of the 2213 women who underwent BRCA1/2 testing, 63% self-reported their race as White, 13.6% as Black/African American, 17.6% as Hispanic, and 5.8% as Asian/American Indian/Alaska Native; 124 had BRCA1 and 100 had BRCA2 mutations; and 1394 (63%) received regional nodal RT. The median follow-up time for all patients was 7.4 years (95% confidence interval [CI], 7.1-7.7 years). No differences were found between the groups with and without BRCA1/2 PV mutations in 10-year cumulative incidences of LRR (with mutations: 11.6% [95% CI, 7.0%-17.6%]; without mutations: 6.6% [95% CI, 5.3%-8.0%]; P = .466) and DSD (with mutations: 12.3% [95% CI, 8.0%-17.7%]; without mutations: 13.8% [95% CI, 12.0%-15.8%]; P = .716). On multivariable analysis, BRCA1/2 status was not associated with LRR or DSD, but Black/African American patients (P = .036) and Asians/American Indians/Alaska Native patients (P = .002) were at higher risk of LRR compared with White patients, and Black/African American patients were at higher risk of DSD versus White patients (P = .004). No in-field, nonbreast second cancers were observed in the BRCA1/2 PV group. Rates of acute and late grade ≥3 radiation-related toxicity in the BCRA1/2 PV group were 5.4% (n = 12) and 0.4% (n = 1), respectively. Conclusions Oncologic outcomes in a diverse cohort of patients with breast cancer who had a germline BRCA1/2 PV mutation and were treated with RT were similar to those of patients with no mutation, supporting the use of RT according to standard indications in patients with a germline BRCA1/2 PV mutation.

Background: During the past century, socioeconomic and scientific advances have resulted in changes in the health and physique of European populations. Accompanying improvements in lung function, if unrecognised, could result in the misclassification of lung function measurements and misdiagnosis of lung diseases. We therefore investigated changes in population lung function with birth year across the past century, accounting for increasing population height, and examined how such changes might influence the interpretation of lung function measurements. Methods: In our analyses of cross-sectional data from ten European population-based studies, we included individuals aged 20–94 years who were born between 1884 and 1996, regardless of previous respiratory diagnoses or symptoms. FEV1, forced vital capacity (FVC), height, weight, and smoking behaviour were measured between 1965 and 2016. We used meta-regression to investigate how FEV1 and FVC (adjusting for age, study, height, sex, smoking status, smoking pack-years, and weight) and the FEV1/FVC ratio (adjusting for age, study, sex, and smoking status) changed with birth year. Using estimates from these models, we graphically explored how mean lung function values would be expected to progressively deviate from predicted values. To substantiate our findings, we used linear regression to investigate how the FEV1 and FVC values predicted by 32 reference equations published between 1961 and 2015 changed with estimated birth year. Findings: Across the ten included studies, we included 243 465 European participants (mean age 51·4 years, 95% CI 51·4–51·5) in our analysis, of whom 136 275 (56·0%) were female and 107 190 (44·0%) were male. After full adjustment, FEV1 increased by 4·8 mL/birth year (95% CI 2·6–7·0; p1 and FVC values predicted by published reference equations corroborated these findings. This height-independent increase in FEV1 and FVC across the last century will have caused mean population values to progressively exceed previously predicted values. However, the population mean adjusted FEV1/FVC ratio decreased by 0·11 per 100 birth years (95% CI 0·09–0·14; p

Background: Major societal guidelines recommend a 5-day stop interval before cardiac surgery for patients with acute coronary syndrome receiving clopidogrel. Yet, many such patients present with high acuity, generating surgeon inclination toward use of shorter stop intervals. Thus, this study aimed to determine the impact of the duration and timing of the interval of clopidogrel cessation on adverse bleeding events. Methods: Patients who underwent cardiac surgery between 2009 and 2016 at a tertiary-care centre were included in this retrospective cohort study. Multivariable logistic regression models adjusted for clopidogrel stop interval, age, urgency of procedure, and procedure type were used to quantify the effect of clinically relevant baseline demographic characteristics on incidence of massive transfusion as well as hemorrhagic complication outcomes. Results: A total of 5748 patients underwent cardiac surgery. In this cohort, 1743 patients (30.3%) received clopidogrel preoperatively, and 884 (50.7%) of these patients discontinued clopidogrel 5 days before presenting to the operating room. The administration of clopidogrel 1-2 days before surgery (odds ratio 1.97; 95% confidence interval: 1.18 to 3.29) was an independent predictor for massive transfusions and hemorrhagic complications (odds ratio 1.85; 95% confidence interval: 1.01 to 3.37). The 3-4 day group did not have an increased risk of major bleeding complications. The risk for both massive transfusions and hemorrhagic complications also increased with the urgency and complexity of surgery. Conclusion: A clopidogrel stop interval of 3-4 days preoperatively was not associated with an increased risk for major bleeding complications. Résumé: Introduction: Les grandes lignes directrices sociétales recommandent une interruption de cinq jours avant l’intervention chirurgicale du cœur des patients atteints d’un syndrome coronarien aigu qui prennent du clopidogrel. Toutefois, comme il s’agit pour plusieurs d’entre eux de patients de haute acuité, le chirurgien penche vers l’utilisation d’une interruption plus courte. Par conséquent, la présente étude avait pour objectif de déterminer les conséquences de la durée et du moment de la cessation du clopidogrel sur les événements hémorragiques indésirables. Méthodes: La présente étude de cohorte rétrospective portait sur les patients qui avaient subi une intervention chirurgicale au cœur entre 2009 et 2016 dans un centre de soins tertiaires. Nous avons utilisé les modèles multivariés de régression logistique ajustés à l’interruption du clopidogrel, à l’âge, à l’urgence de l’intervention chirurgicale et au type d’intervention chirurgicale pour quantifier les effets des caractéristiques démographiques initiales cliniquement pertinentes sur la fréquence des transfusions massives ainsi que sur les issues des complications hémorragiques. Résultats: Un total de 5 748 patients ont subi une intervention chirurgicale au cœur. Dans cette cohorte, parmi les 1 743 patients (30,3 %) qui avaient reçu du clopidogrel avant l’opération, 884 (50,7 %) avaient cessé le clopidogrel cinq jours avant leur admission à la salle d’opération. L’administration du clopidogrel un à deux jours avant l’intervention chirurgicale (ratio d’incidence approché 1,97; intervalle de confiance [IC] à 95 % : de 1,18 à 3,29) était un prédicteur indépendant des transfusions massives et des complications hémorragiques (ratio d’incidence approché 1,85; [IC] à 95 % : de 1,01 à 3,37). Le groupe de l’interruption de trois à quatre jours n’a pas montré de risque accru de complications hémorragiques graves. Le risque de transfusions massives et de complications hémorragiques a aussi contribué à l’augmentation de l’urgence et de la complexité de l’intervention chirurgicale. Conclusion: Une interruption du clopidogrel de trois à quatre jours avant l’opération n’a pas été associée à un risque accru de complications hémorragiques graves.

Purpose To define the burden of morbidity and mortality arising from COVID-19 in individuals with primary (PID) and secondary immunodeficiency (SID) in the United Kingdom. Methods In March 2020, the United Kingdom Primary Immunodeficiency Network (UKPIN) established a registry of cases to collate the outcomes of individuals with PID and SID following SARS-CoV-2 infection and treatment. Anonymised demographic data, pre-SARS-CoV-2 infection lymphocyte counts, co-morbidities, targeted treatments and outcomes were collected. Three groups were analysed in further detail: individuals with common variable immunodeficiency (CVID), individuals with any PID, including CVID, receiving immunoglobulin replacement therapy (IgRT) and individuals with secondary immunodeficiency. Results A total of 310 cases of SARS-CoV-2 infection in individuals with PID or SID have now been reported in the UK. The overall mortality within the cohort was 17.7% (n = 55/310). Individuals with CVID demonstrated an infection fatality rate (IFR) of 18.3% (n = 17/93), individuals with PID receiving IgRT had an IFR of 16.3% (n = 26/159) and individuals with SID, an IFR of 27.2% (n = 25/92). Individuals with PID and SID, had higher inpatient mortality and died at a younger age than the general population. Increasing age, low pre-SARS-CoV-2 infection lymphocyte count and the presence of common co-morbidities increased the risk of mortality in PID. Access to specific COVID-19 treatments in this cohort was limited: only 22.9% (n = 33/144) of patients admitted to hospital received dexamethasone, remdesivir, an anti-SARS-CoV-2 antibody-based therapeutic (e.g. REGN-COV2 or convalescent plasma) or tocilizumab as a monotherapy or in combination. Dexamethasone, remdesivir and anti-SARS-CoV-2 antibody-based therapeutics appeared efficacious in PID and SID. Conclusion Compared to the general population, individuals with PID or SID are at high risk of mortality following SARS-CoV-2 infection. Increasing age, low baseline lymphocyte count and the presence of co-morbidities are additional risk factors for poor outcome in this cohort.

Study background Back injuries are common among nurses worldwide with lifetime prevalence of lower back pain ranging from 35% to 80%, making nursing a profession at great risk for back injuries. Purpose This systematic scoping review explored and mapped existing evidence regarding the prevention of low back injury and pain among nurses and nursing students. Methods Using a scoping review methodology, six databases were searched initially in September 2017 and updated June 2020. Studies investigating interventions designed to reduce back injuries and pain among regulated nurses and student nurses, published in peer-review journals and written in English, were eligible for inclusion in this review. Quantitative, qualitative, and mixed methods studies of regulated nurses, nursing students, and nursing aides were included. Two independent reviewers screened, critically analysed studies using a quality appraisal tool, extracted data, and performed quality appraisals. Results Two searches yielded 3,079 abstracts and after title, abstract and screening, our final synthesis was based on 48 research studies. Conclusions Forty years of research has demonstrated improvements in quality over time, the efficacy of interventions to prevent back injury and pain remains unclear, given the lack of high-quality studies. Further research, using multi-dimensional approaches and rigorous study designs, are needed.

With the rising prevalence of Lyme disease over the last 2 decades comes an increase in cases of Lyme carditis, a consequence of early disseminated infection. This case report focuses on a young man with a complicated case of Lyme carditis that required advanced therapy.

Background Obstetric fistula is one of themost serious and devastating childbirth-related injuries women suffer worldwide. This study investigated the association between delivery characteristics and the occurrence of obstetric fistula in Afghanistan. Methods The study analysed data from the 2015 Afghanistan Demographic and Health Survey. The association between place of delivery and assistance during delivery with experience of fistula symptoms was investigated by fitting two binary logistic regression models. Results Findings from this study revealed that 23.4% of the women surveyed ever heard about obstetric fistula and 3% reported symptoms of fistula. Women whose deliveries were assisted by traditional birth attendants were significantly more likely to experience fistula compared with those whose deliveries were assisted by doctors. Similarly, women whose deliveries were assisted by others were significantly more likely to experience fistula compared with women whose deliveries were assisted by doctors. Regarding place of delivery, women whose deliveries took place at a government hospital were less likely to experience fistula compared with those whose deliveries took place at home. Conclusions This study highlights the importance of skilled delivery in reducing the risk for obstetric fistula among women in Afghanistan. Therefore, it is important for the various stakeholders in Afghanistan's healthcare delivery system, including healthcare providers, local authorities and international non-governmental organisations, to collaborate and institute measures that will promote health facility deliveries and improve access to skilled delivery.

The purpose of this paper is to unpack the meanings and implications of mobility through the experiences of a group of Vietnamese women who decided to do doctorates in Australia. Drawing on the Deleuzian concepts of rhizome and becoming, our analysis of interview data suggests that mobility is made of multiple connections and is in constant movement, extending often reductive “push-pull” discussions of academic mobility. Each aspect shaping mobility connects to another that is multiscalar and multitemporal, where family, education ideologies, gender norms, economic globalization, neoliberalization within higher education, and the histories and biographies of mobile people come together. Power relations are immanent within structures associated with these connections and the women and mobility come together to create aspirations for educational, professional, and personal becoming. The paper offers a more nuanced understanding of international academic mobility rather than relying on economic perspectives and invites innovative approaches in supporting international doctoral students.

This research paper seeks to examine the challenges and opportunities for wireless technologies and the Internet of Things (IoT) to improve access to education for students with disabilities (SwDs). As technology integration into educational content and learning environments occurs, it becomes paramount for scholars to consider how the needs of students with disabilities are incorporated into these learning spaces. This paper synthesizes existing literature via an integrative review that explores barriers to accessing technology-mediated learning and the classroom. It also assesses the potential for technology-mediated learning to progress forward over the last five years. Finally, this article provides targeted recommendations for actualizing wireless technologies' potential on improving students with disabilities' educational outcomes.

Background: The current study determined the status of plasma albumin and the relationship between hypoalbuminemia and adverse/poor pregnancy outcomes among cases of HELLP syndrome (HELLPsyn) in Port Harcourt, Nigeria. Methods: A retrospective cross-sectional study was conducted among women diagnosed with HELLPsyn in the University of Port Harcourt Teaching Hospital (UPTH) between 2011 and 2020. Data of all eligible cases were extracted from hospital registers, case notes, nurses’ charts, laboratory, and medical files using pretested datasheet and analyzed. Results: Two hundred and ten (210) HELLPsyn cases certified the eligible criteria and were included in the analysis. The overall hypoalbuminemia was recorded among 140(66.6%) of which 73(52.1%) and 67(47.9%) were in the clinically significant hypoalbuminemic and clinically insignificant hypoalbuminemic subgroups, respectively. The overall hypoalbuminemia and the clinically significant hypoalbuminemia subtype were more predominant among the severe HELLPsyn cases. The clinically significant hypoalbuminemic HELLP cases had increased risk of acute kidney injury (OR:8.456;95%CI:6.854-11.345), sepsis/infection (OR:4.346;95%CI:2.761-6.709), intensive care unit admission (OR:6.412;95%CI:4.356-8.104), and emergency cesarean section (OR:2.308;95%CI:1.206-3.896) compared to the normoalbuminemic/clinically insignificant hypoalbuminemic HELLP cases. Offspring of the clinically significant hypoalbuminemic HELLP cases also had increased risk of preterm delivery (OR:6.843;95%CI:4.346-8.766), intrauterine growth restriction (OR:3.408;95%CI: 2.166-4.988), birth asphyxia (OR:5.233;95%CI:3.764-7.412), and special care baby unit admission (OR:2.077;95%CI:1.106-3.674) compared to the normoalbuminemic/clinically insignificant hypoalbuminemic HELLP cases. Conclusion: Hypoalbuminemia, especially the clinically significant hypoalbuminemia subtype, is associated with adverse/poor maternal and perinatal outcomes among cases of HELLPsyn. However, we recommend further studies with a robust design to evaluate the clinical relevance of our findings. Key words: KHELLP syndrome, hypoalbuminemia, clinically significant hypoalbuminemia.

This article uses the research findings from a study of the refurbishment of council tower blocks to reflect on what it means to be a leaseholder of a flat, and how this relates to ideas associated with property and ownership. The experiences of leaseholders (little input into decision-making, and the fear of crippling bills), together with the challenges for the building owner of upgrading blocks within a prevailing property narrative of exclusion, are also echoed in the unfolding building safety crisis in flats that has emerged following the Grenfell Tower fire. Both reveal the vulnerability of flat owners. Overall, it is shown that the property law regime does not currently meet the ownership expectations of those buying flats, and is poorly designed to provide for the longevity of safe and well maintained buildings.

BackgroundChildhood diarrhea remains a major public health problem in sub-Saharan Africa (SSA). Women empowerment reduces child mortality, and wife beating attitude is one of the indicators of women empowerment. There is a dearth of evidence about wife beating attitudes and childhood diarrhea in SSA. Therefore, the present study aimed to examine the association between attitude towards wife beating and diarrhea among under-five children.MethodsWe used Demographic and Health Surveys from 25 countries in SSA that were conducted between 2010 and 2020. Using Stata version 14 software, we carried out the analysis on 153,864 children under five. Bivariate and multivariate logistic regression analyses were applied, and the results were presented using adjusted odd ratios (aOR) at 95% confidence interval (CI).ResultsThe pooled results show that 71.4% of married women disagreed with wife beating. About 20.5% of under-five children of married women had diarrhea. Childhood diarrhea varied from highest prevalence in Chad (27.9%) to the lowest prevalence in Sierra-Leone (8.5%). The study showed lower odds of diarrhea among children of married women who disagreed with wife beating (aOR = 0.66 95% CI; 0.54-0.80) compared to children of married women who agreed with wife beating. Moreover, the study results show that women's age (35-39 years-aOR = 0.48, 95% CI; 0.31-0.74, 40-44 years-aOR = 0.57, 95% CI; 0.35-0.93, 45-49 years-aOR = 0.35, 95% CI; 0.16-0.79) was negatively associated with childhood diarrhea, while husband's education (primary school-aOR = 1.36, 95% CI; 1.05-1.77), parity (ever born 3-4 children-aOR = 1.36, 95% CI; 1.09-1.70, and 5+ children-aOR = 1.56, 95% CI; 1.14-2.12), and religion (Muslim-aOR = 3.56, 95% CI; 1.44-8.83) were positively associated with diarrhea among under-five children.ConclusionsThe study shows association between women attitude towards wife beating and childhood diarrhea. Therefore, empowering women, especially young women by increasing awareness about domestic violence, their rights, and empowering them through education and economic advancement need to be considered in order to reduce childhood diarrhea. Moreover, fertility control or birth spacing and working closely with religious leaders are important factors to consider in reducing childhood diarrhea.

Background We examined the evidence derived from healthcare professionals’ interfacing with women with female genital mutilation (FGM) to comprehend the referral pathways available to these women in Australia. Main body Clinicians encountered FGM-related complications that included ruptured bladder and total urinary incontinence. Midwives and paediatricians indicated a lack of referral pathways for FGM, but used their discretion to refer such cases to social work departments, obstetric/gynaecological units, child protection service providers, psychological counsellors and surgeons. The continuum of care for women with FGM is characterised by inadequate and lack of clear referral pathways. This underscores the need to develop and strengthen referral pathways in response to physical, birthing and psychological complications of women with FGM to improve their care experiences in Australia. Short conclusion Capacity building initiatives on FGM-prevention and care for trainees and practising health providers and community involvement in high burden areas/populations should be implemented to promote uptake and utilization of the referral services. Provision of infrastructural support, including clinical management tools, job aids, posters, referral algorithms and electronic patient records with "drop-down menus" for referral sites for health complications of FGM to reinforce the providers’ efforts are critical.

In acknowledgment of the devastating consequences of environmental deterioration, the Mediterranean members are committed to adopt the 2015 treaty action plans of the Paris Climate Agreement (COP21) as carbon dioxide emission (CO2) are on the rise in the Mediterranean region, which seems to be a serious challenge to our world’s environment. To this end, our study examined the impact of Foreign Direct Investment (FDI) on environmental degradation for the Mediterranean members for the period between 1995 to 2016. However, variables such as, financial development, economic growth, renewable energy and fossil fuel were further examined by the use cross-sectional-Panel pooled Auto Regressive Distributed Lag methodology, Augmented Mean Group (AMG) and Dumitrescu and Hurlin panel causality test was used for causality analysis. The co-integration results from Westerlund (2007) shows a long-run equilibrium relationship between highlighted variables. The empirical result revealed a negative relation between FDI and CO2 indicating pollutant Hallo Hypothesis (PHH). Moreover, income and its square show an inverted U-Shaped curve indicating environmental Kuznets curve (EKC) hypothesis. Both financial development and renewable energy indicated an adverse association with CO2 emission whereas fossil fuel had a positive relationship with emissions. However, there was a feedback causality among income and carbon emission as well as financial development and carbon emission. Furthermore, we observe that FDI and carbon emission, renewable energy and carbon emission, as well as fossil fuel and carbon emission were found to have one-way causal relationship. Overall, the study suggests some policy prescriptions including the implementation of conservation initiatives and the establishment of clean energy regulation and strategies for the investigated bloc.

Background Hypertension is one of the leading causes of cardiovascular morbidities in Ghana and represents a major public health concern. There is dearth of information on the rural-urban disparity in hypertension among women in Ghana. Therefore, this study aimed at examining the rural-urban variation in hypertension among women in Ghana. Methods We extracted data from the women’s file of the 2014 Ghana Demographic and Health Survey. The sample included 9333 women aged 15–49 with complete data on hypertension. The analysis was done using Pearson Chi-square and binary logistic regression at 95% confidence interval. The results of the binary logistic regression were presented as Odds Ratios (ORs) and Adjusted Odds Ratios (AORs). Statistical significance was set at p Results Hypertension prevalence among urban and rural residents were 9.5% and 5.1% respectively. Rural women had lower odds of hypertension [OR = 0.59; 95% CI = 0.52, 0.67] compared to urban women, however, this was insignificant in the adjusted model [aOR = 0.84; 95% CI = 0.70, 1.00]. The propensity to be hypertensive was lower for women aged 15–19 [aOR = 0.07; 95% CI = 0.05, 0.11]. The poorest were less likely to be hypertensive [aOR = 0.63; 95% CI = 0.45, 0.89]. Single women were also less probable to have hypertension [aOR = 0.66; 95% CI = 0.46, 0.97]. Conclusions Women from urban and rural areas shed similar chance to be hypertensive in Ghana. Therefore, the health sector needs to target women from both areas of residence (rural/urban) when designing their programmes that are intended to modify women’s lifestyle in order to reduce their risks of hypertension. Other categories of women that need to be prioritised to avert hypertension are those who are heading towards the end of their reproductive age, richest women and the divorced.

Highlights • HPV infection in men having sex with men (MSM) was studied in two cities of Vietnam • Prevalence of any HPV and HPV16/18 among MSM was 32.3% and 11.0%, respectively • High-risk HPV infections in MSM were associated with risky sexual behaviours • A targeted HPV vaccination strategy would be beneficial for MSM in Vietnam, Objectives Men who have sex with men (MSM) are at risk of human papillomavirus (HPV)-related cancers, while published data are scarce. This study determined HPV prevalence and risk factors in MSM in Vietnam to inform HPV prevention strategies in this key population. Methods A cross-sectional study of 799 MSM aged 16-50 years was conducted in Vietnam in 2017-2018. Information was collected on risk behaviours, and knowledge of HPV and anal cancer; rectal swabs were taken to detect anal HPV infection. An in-house polymerase chain reaction and Genoflow HPV array test kit were used for HPV detection and genotyping. Results The median age of the study participants was 25 years (range 18-52). Overall prevalence of any HPV and HPV16/18 infection was 32.3% and 11.0%, respectively. A higher prevalence of high-risk HPV infection to all 14 types tested was found in Ho Chi Minh City (30.9%) than in Hanoi (18.4%). High-risk HPV infection was associated with inconsistent condom use and history of engaging in sex under the influence of drugs (adjusted odds ratio (aOR), 2.27; 95% CI, 1.48-10.67), as well as having multiple sexual partners (aOR, 1.01; 95% CI, 1.00–1.02). Conclusions High-risk anal HPV infections in Vietnamese MSM were significantly associated with risky sexual behaviours. A targeted HPV vaccination strategy would have substantial benefit for MSM in Vietnam.

Background The sense of sight is one of the important human sensory abilities that is required for independent functioning and survival. The highest burden of sight-related problems is recorded in low-and middle-income countries, especially in sub-Saharan Africa. Despite the burden, nationally representative analyses to understand the prevalence and determinants of vision difficulties are hard to find. Therefore, this study addressed this knowledge gap by estimating the prevalence of vision difficulties and its correlates in gender-stratified models in three West African countries: Ghana, Gambia, and Togo. Methods The study used the most recent Multiple Indicator Cluster Surveys of Ghana (2017–2018), Gambia (2018), and Togo (2017). Summary statistics were used to describe the participants and logistic regression was used to perform the bivariate and multivariate analyses. The analyses were performed using Stata version 14 and the complex survey design of the datasets was accounted for using the ‘svyset’ command. Results Gendered differences were observed for vision difficulties. More women than men reported vision difficulties in Ghana (men: 14.67% vs women: 23.45%) and Togo (men: 14.86% vs women: 23.61%), but more men than women reported vision difficulties in Gambia (men: 11.64% vs women: 9.76%). We also observed gender differences in how age, education, marital status, and region of residence were significantly associated with reported vision difficulties. The direction and magnitude of these relationships were different among men and women across the survey data in Ghana, Gambia, and Togo. Conclusion The findings imply the need to tackle the existing gender inequities that are associated with vision difficulties to promote the quality of life of individuals, especially among older adults.

Background The African Surgical OutcomeS-2 (ASOS-2) trial tested an enhanced postoperative surveillance intervention to reduce postoperative mortality in Africa. We undertook a concurrent evaluation to understand the process of intervention delivery. Methods Mixed-methods process evaluation, including field notes, interviews, and post-trial questionnaire responses. Qualitative analysis used the framework method with subsequent creation of comparative case studies, grouping hospitals by intervention fidelity. A post-trial questionnaire was developed using initial qualitative analyses. Categorical variables were summarised as count (%) and continuous variables as median (inter-quartile range [IQR]). Odds ratios (OR) were used to rank influences by impact on fidelity. Results The dataset included eight in-depth case studies, and 96 questionnaire responses (response rate 67%) plus intervention fidelity data for each trial site. Overall, 57% (n=55/96) of hospitals achieved intervention delivery using an inclusive definition of fidelity. Delivery of the ASOS-2 interventions and data collection presented a significant burden to the investigators, outstripping limited resources. The influences most associated with fidelity were: surgical staff enthusiasm for the trial (OR=3.0; 95% confidence interval [CI], 1.3–7.0); nursing management support of the trial (OR=2.6; 95% CI, 1.1–6.5); performance of a dummy run (OR=2.6; 95% CI, 1.1–6.1); nursing colleagues seeing the value of the intervention(s) (OR=2.1; 95% CI, 0.9–5.7); and site investigators' belief in the effectiveness of the intervention (OR=3.2; 95% CI, 1.2–9.4). Conclusions ASOS-2 has proved that coordinated interventional research across Africa is possible, but delivering the ASOS-2 interventions was a major challenge for many investigators. Future improvement science efforts must include better planning for intervention delivery, additional support to investigators, and promotion of strong inter-professional teamwork. Clinical trial registration ClinicalTrials gov NCT03853824.

Background and Objective: Access to health care services is a major challenge to women and children in many developing countries such as Ethiopia. In this study, we investigated the individual- and community-level factors associated with barriers to accessing health care services among married women in Ethiopia. Methods: Data from the 2016 Ethiopia demographic and health survey on 9,824 married women of reproductive age (15-49 years) were analyzed. Multilevel logistic regression models were used to assess individual- and community-level factors associated with barriers to access health care services. Regression analysis results revealed adjusted odds ratios at 95% confidence intervals. Results: Over two-thirds (71.8%) of married women in Ethiopia reported barriers to accessing health care services. Some of the individual-level factors that were associated with lower odds of reporting barriers to access health care services include: having secondary education (aOR=0.49, 95% CI: 0.32-0.77), being in the richest quintile (aOR=0.34, 95% CI: 0.22-0.54), and indicating wife-beating as unjustified (aOR=0.66, 95% CI:0.55-0.81). Among the community-level factors, high community-level literacy (aOR=0.56, 95% CI: 0.34-0.92) and moderate community socioeconomic status (aOR=0.62, 95% CI: 0.45-0.85) were significantly associated with lower odds of reporting barriers to access health care services. Conclusion and Implications for Translation: The findings revealed high barriers to access health care services, and both individual- and community-level factors were significant contributing predictors. Therefore, it is important to consider multidimensional strategies and interventions to facilitate access to health care services in Ethiopia. Copyright © Zegeye et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

There is a massive unmet need for legal knowledge in prisons. The Open University Law School, through its Open Justice Centre, has trialled various ways in which to meet this unmet need. Most prison-university partnerships in England and Wales follow a model of prisoners and university students being taught together as one group in a traditional higher education learning format. The Open University Law School’s public legal education in prisons follows instead the Street Law model to disseminate knowledge of the law throughout a prison, either through prison radio or through the work of the charity St Giles Trust. While this article confirms other research findings which evidence the personal benefit law students derive in researching and delivering audience-appropriate public legal education, it also considers the benefit for those imprisoned in the context of rehabilitative prison culture.

Background Over the years, the focus of infectious diseases in many African countries has been mainly on viral, bacterial and parasitic infections. Serious fungal infections (SFI) with comparable morbidity rate in these countries, remain neglected. Objectives To estimate the burden of SFI in Togo and to stimulate efforts for improved attention. Methods Literature was thoroughly searched for epidemiological data on SFI in Togo. Incidence and/or prevalence of SFI was estimated using socio-demographics, health system's information, risk-groups data and SFI rates obtained from national and international studies. Results About 5.29% of the 7,265,286 Togolese population is estimated to suffer from SFI annually. Among HIV patients, 1,342, 1,650 and 330 may develop cryptococcal meningitis, Pneumocystis pneumonia and disseminated histoplasmosis respectively per year. Oral and oesophageal candidiasis may annually affect 19,800 and 7,535 persons living with HIV respectively. Estimated incidence of invasive aspergillosis (IA) was 283 cases. Prevalence of chronic pulmonary aspergillosis (CPA) was estimated at 191 cases. The annual incidence of allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS) was respectively 4,577 and 6,042 cases. Tinea capitis and recurrent Candida vaginitis presumably affects 232,271 children and 108,979 women respectively. Candidaemia incidence is estimated at 5 cases per 100, 000 inhabitants and fungal keratitis may affect 981 persons annually. Conclusions Serious fungal infections in Togo are probably more significant than expected. These findings underscore the need to increase awareness among healthcare professionals, enhance diagnostic and therapeutic capacities and intensify epidemiological studies for effective management of fungal infections in Togo.

This study obtained crude sorghum leaf sheath polysaccharide (39.99% wet matter (wm)) by subcritical ethanol-water (40% v/v) extraction (180°C, 40 min). The subcritical extraction solution was tran...

BACKGROUND A single state-wide upper gastrointestinal (GI) cancer video-linked multidisciplinary team (MDT) meeting guides management and evidence-based care for all newly diagnosed upper GI cancer patients in South Australia. This study determined the patterns of care and outcomes for patients diagnosed with gastric and gastro-oesophageal junction (GOJ) cancers. METHODS Patients diagnosed with gastric cancer and GOJ (Siewert III) cancer between June 2012 and June 2016 were included. Patient demographics, cancer stage, histology, diagnostic modalities and treatment data was analysed from a prospective database. Stage-specific survival outcomes were determined and analysed for each treatment modality. RESULTS The study included 218 patients and at diagnosis 132 (61%) patients had stage I-III and 86 (39%) patients had stage IV disease. One hundred and ninety-five (89%) patients had gastric cancer and 23 (11%) had GOJ cancer (Siewert III). One hundred and nine (50%) patients underwent surgery, with 92% R0 resection rate. Forty-six patients received perioperative chemotherapy and 111 (51%) patients received palliative intent treatment. Median overall survival for stage II, III and IV cancers was 57.6 (95% CI 57.6-NR), 22.8 (95% CI 20.4-43.2), and 6.0 months (95% CI 4.8-8.4) respectively (p

BackgroundEarly initiation of breastfeeding (EIB) is an inexpensive practice but has a substantial potential to reduce neonatal morbidity. Therefore, this study investigated the maternal and child-related factors associated with EIB and makes recommendations that could help improve the practice in Chad.MethodsWe used data from the children's recode file of the 2014–2015 Chad Demographic and Health Survey. A total of 3991 women ages 15–49 y who had last-born children in the 2 y preceding the survey were included in our study. The outcome variable for the study was EIB. Both descriptive (frequencies and percentages) and inferential (binary logistic regression) analyses were carried out. All results of the binary logistic analyses are presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).ResultsWe found the prevalence of EIB in Chad to be 23.8%. In terms of maternal factors, the likelihood of EIB was high among non-working women (aOR 1.37 [95% CI 1.18 to 1.59]), the richest wealth quintile women (aOR 1.37 [95% CI 1.04 to 1.79]) and non-media-exposed women (aOR 1.58 [95% CI 1.24 to 2.02]) compared with working women, the poorest wealth quintile women and media-exposed women, respectively. EIB was lower among children whose mothers had one to three antenatal care visits (ANC; aOR 0.73 [95% CI 0.61 to 0.87]) and four or more ANC visits (aOR 0.80 [95% CI 0.66 to 0.97]) compared with those who had no ANC visits. With the child factors, EIB was higher among mothers of children who were smaller than average size at birth compared with those of larger than average birth size (aOR 1.47 [95% CI 1.24 to 1.74]). Mothers of children of fifth-order or more births compared with those of first-order births (aOR 1.51 [95% CI 1.07 to 2.12]) and those who were delivered through vaginal birth compared with those delivered through caesarean section (aOR 4.71 [95% CI 1.36 to 16.24]) were more likely to practice EIB.ConclusionsMaternal and child-related factors play roles in EIB in Chad. Hence, it is important to consider these factors in maternal and neonatal health interventions. Such initiatives, including training of outreach health workers, health education, counselling sessions and awareness-raising activities on breastfeeding geared towards EIB should be undertaken. These should take into consideration the employment status, wealth quintile, exposure to mass media, size of the baby at birth, ANC visits, parity and delivery method.

Background A two-phase ‘respiratory symptoms’ mass media campaign was conducted in 2016 and 2017 in England raising awareness of cough and worsening shortness of breath as symptoms warranting a general practitioner (GP) visit. Method A prospectively planned pre–post evaluation was done using routinely collected data on 15 metrics, including GP attendance, GP referral, emergency presentations, cancers diagnosed (five metrics), cancer stage, investigations (two metrics), outpatient attendances, inpatient admissions, major lung resections and 1-year survival. The primary analysis compared 2015 with 2017. Trends in metrics over the whole period were also considered. The effects of the campaign on awareness of lung cancer symptoms were evaluated using bespoke surveys. Results There were small favourable statistically significant and clinically important changes over 2 years in 11 of the 15 metrics measured, including a 2.11% (95% confidence interval 1.02–3.20, p Conclusion There were small positive changes in most metrics relating to lung cancer diagnosis after this campaign. However, the pattern over time challenges whether the improvements are wholly attributable to the campaign. Given the importance of education on cancer in its own right, raising awareness of symptoms should remain important. However further research is needed to maximise the effect on health outcomes.

Summary Background Data are scarce from low-income and middle-income countries (LMICs) to support the choice of vaccination schedule for the introduction of pneumococcal conjugate vaccines (PCV). We aimed to compare the immunogenicity of four different infant PCV10 schedules in infants in Vietnam. Methods In this single-blind, parallel-group, open-label, randomised controlled trial, infants aged 2 months were recruited by community health staff in districts 4 and 7 of Ho Chi Minh City, Vietnam. Eligible infants had no clinically significant maternal or prenatal history and were born at or after 36 weeks' gestation. Participants were randomly assigned (3:3:5:4:5:4) using block randomisation, stratified by district, to one of six PCV10 or PCV13 vaccination schedules. Here we report results for four groups: group A, who were given PCV10 at ages 2, 3, 4, and 9 months (a 3 + 1 schedule); group B, who were vaccinated at ages 2, 3, and 4 months (3 + 0 schedule); group C, who were vaccinated at ages 2, 4, and 9·5 months (2 + 1 schedule); and group D, who were vaccinated at ages 2 and 6 months (two-dose schedule). Laboratory-based assessors were masked to group allocation. Blood samples were collected at different prespecified timepoints between ages 3–18 months depending on group allocation, within 27–43 days after vaccination, and these were analysed for serotype-specific IgG and opsonophagocytic responses. Participants were followed-up until age 24 months. The primary outcome was the proportion of infants with serotype-specific IgG levels of 0·35 μg/mL or higher at age 5 months, analysed as a non-inferiority comparison (10% margin) of the two-dose and three-dose primary series (group C vs groups A and B combined). We also compared responses 4 weeks after two doses administered at either ages 2 and 4 months (group C) or at ages 2 and 6 months (group D). The primary endpoint was analysed in the per-protocol population. Reactogenicity has been reported previously. This study is registered with ClinicalTrials.gov , NCT01953510 , and is now closed to accrual. Findings Between Sept 30, 2013, and Jan 9, 2015, 1201 infants were enrolled and randomly assigned to group A (n=152), group B (n=149), group C (n=250), group D (n=202), or groups E (n=251) and F (n=197). In groups A–D, 388 (52%) of 753 participants were female and 365 (48%) were male. 286 (95%) participants in groups A and B combined (three-dose primary series) and 237 (95%) in group C (two-dose primary series) completed the primary vaccination series and had blood samples taken within the specified time window at age 5 months (per-protocol population). At this timepoint, a two-dose primary series was non-inferior to a three-dose primary series for eight of ten vaccine serotypes; exceptions were 6B (84·6% [95% CI 79·9–88·6] of infants had protective IgG concentrations after three doses [groups A and B combined] vs 76·8% [70·9–82·0] of infants after two doses [group C]; risk difference 7·8% [90% CI 2·1–13·6]) and 23F (90·6% [95% CI 86·6–93·7] vs 77·6% [71·8–82·2]; 12·9% [90% CI 7·7–18·3]). Two doses at ages 2 and 6 months produced higher antibody levels than two doses at ages 2 and 4 months for all serotypes except 5 and 7F. Interpretation A two-dose primary vaccination series was non-inferior to a three-dose primary vaccination series while two doses given with a wider interval between doses increased immunogenicity. The use of a two-dose primary vaccination schedule using a wider interval could be considered in LMIC settings to extend protection in the second year of life. Funding Australian National Health and Medical Research Council, and The Bill & Melinda Gates Foundation.

Oncology trials are the cornerstone of effective and safe therapeutic discoveries. However, there is increasing demand for pragmatism and patient engagement in the design, implementation and dissemination of oncology trials. Many researchers are uncertain about making trials more practical and even less knowledgeable about how to meaningfully engage patients without compromising scientific rigor to meet regulatory requirements. The present work provides practical guidance for addressing both pragmaticism and meaningful patient engagement. Applying evidence-based approaches like PRECIS-2-tool and the 10-Step Engagement Framework offer practical guidance to make future trials in oncology truly pragmatic and patient-centered. Consequently, such patient-centered trials have improved participation, faster recruitment and greater retention, and uptake of innovative technologies in community-based care.

Patients with scleroderma often suffer from dysphagia and gastroesophageal reflux disease (GERD). Partial fundoplication is a validated anti-reflux procedure for GERD but may worsen dysphagia in scleroderma patients. Its utility in these patients is unknown. Here, we evaluate the efficacy and acceptability of partial fundoplication for the treatment of medically refractory GERD in patients with scleroderma. Analysis of a prospectively maintained database of patients who underwent fundoplication across 14 hospitals between 1991 and 2019. Perioperative outcomes, reintervention rates, heartburn, dysphagia, and patient satisfaction were assessed at 3 months, 1- and 3-years post-surgery. A total of 17 patients with scleroderma were propensity score matched to 526 non-scleroderma controls. All underwent a partial fundoplication. Perioperative outcomes including complication rate, length of stay, and need for reoperation were similar between the two groups. Compared to baseline, both groups reported significantly improved heartburn at 3 months, 1- and 3-years following partial fundoplication. Surgery was equally effective at controlling heartburn across all follow-up timepoints in patients with or without scleroderma. Dysphagia to solids was more common in patients with scleroderma than controls at 3-months post-surgery, but was not significantly different to controls at 1- and 3-year follow-up. Satisfaction scores were high and comparable between both groups across all postoperative timepoints, with 100% of patients with scleroderma reporting that their initial choice to undergo surgery was correct. Partial fundoplication controls reflux and is associated with a transient period of dysphagia to solids in patients with scleroderma. This approach is safe, effective and acceptable for patients with scleroderma and medically refractory GERD.

Background Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. Methods We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. Results The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering. Conclusions Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.

Background. In 2016, the World Health Organization (WHO) introduced a minimum of eight antenatal care (ANC) visits for positive pregnancy outcomes. This study examined the prevalence of noncompliance with 8+ ANCvisits and its associated factors in sub-Saharan Africa (SSA). Methods. We used data from the Demographic and Health Surveys of eight countries in SSA. A pooled sample of 63,266 pregnant women aged 15-49 years who had given birth to children within 5 years prior to the surveys was included in this study. To examine the factors associated with noncompliance with ANC 8+ visits, multilevel binary logistic regression analysis was conducted, and the results were reported using odds radios at 95% confidence interval (CI). Results. The pooled prevalence of noncompliance with ANC 8+ visits was 92.3% (95% CI: 91.1%-93.3%) with the highest and lowest prevalence in Zambia (98.7%, 95% CI: 98.3%-99.1%) and Libya (73.4%, 95% CI: 70.4%-76.2%), respectively. With the individual level factors, women’s age (44-49 years- aOR = 0.33 , 9% CI: 0.14-0.78), health insurance registration, (yes- aOR = 0.53 , 95% CI: 0.29-0.98), and economic status (richest- aOR = 0.16 , 95% CI: 0.05-0.49) were negatively associated with noncompliance with 8+ ANC visits, while parity (five or more children- aOR = 1.68 , 95% CI: 1.12-2.52) was positively associated with noncompliance with 8+ ANC visit. With the community level factors, community level literacy was negatively associated with noncompliance with 8+ ANC visit (high- aOR = 0.56 , 95% CI: 0.32-0.99). Conclusion. About eight out of ten pregnant women did not comply with the WHO’s recommended minimum of eight ANC visits for positive pregnancy outcomes in SSA. Empowering the economic status of women , enhancing health insurance and education coverage, and giving more attention to young pregnant women and those with more children are crucial for improving the coverage of ANC 8+ visits in the region.

Background. Family caregivers provide the bulk of care to children living with HIV. This places an enormous demand and care burden on the caregivers who often struggle to cope in various ways, some of which may be maladaptive. This may adversely affect their quality of care. Very little literature exists in resource-limited contexts on the burden of care experienced by caregivers on whom children living with HIV/AIDS depend for their long-term care. We assessed care burden and coping strategies among the caregivers of paediatric HIV/AIDS patients in Lira district, northern Uganda. Methods. A mixed-method cross-sectional study was conducted among 113 caregivers of paediatric HIV patients attending the ART clinic at a tertiary healthcare facility in Lira district, northern Uganda. A consecutive sampling method was used to select participants for the quantitative study, while 15 respondents were purposively sampled for the qualitative data. Quantitative data were collected using standard interviewer-administered questionnaires, while in-depth interview guides were used to collect qualitative data. Data were entered, cleaned, and analysed using SPSS version 23. Qualitative data were analysed thematically. Results. The majority of the caregivers, 65.5% (74), experienced mild-to-moderate burden. The mean burden scores significantly differed by caregivers’ age ( P = 0.017 ), marital status ( P = 0.017 ), average monthly income ( P = 0.035 ), and child’s school attendance ( P = 0.039 ). Accepting social support, seeking spiritual support, and reframing were the three most commonly used strategies for coping. Marital status and occupation were, respectively, positively and negatively correlated with information-seeking as a coping strategy, while monthly income was positively correlated with psychosocial support as a strategy. Seeking community support was negatively correlated with the duration of the child’s care. Conclusions. Our findings show that care burden is a common problem among the caregivers of children living with HIV in the study context.

A large volume of environmental science and pollution research has focused on the contributions of various forms of energy consumption to emissions. However, little attention is given to the impact of human activities such as tourism. Hence, this study investigates the impact of tourist arrivals, energy use, and economic growth on CO2 emissions in the G7 countries for the period 1995–2018. The study employed the use of dynamic panel estimations, namely dynamic ordinary least square, fully modified ordinary least squares and panel pooled mean group-autoregressive distributed lag model (PMG-ARDL) estimation techniques to establish long-run and short-run relationships between the study variable of interest, while the Dumitrescu Hurlin non-causality test was used to test for causality direction among the variables outlined. Empirical findings from the regression revealed that economic growth, tourism and energy use are strong drivers of emission levels in the G7 bloc, while the causality analysis revealed that there is unidirectional causality from CO2 to energy use, CO2 to economic growth (GDP) and GDP to tourist arrivals. These outcomes imply that tourism, energy use and economic growth have no direct effect on emissions, but rather emissions predict economic growth and energy use. Furthermore, tourist arrivals predict energy use; economic growth predicts tourism. Overall based on the study of empirical outcomes, we suggest that to achieve more significant results in reducing emissions, governments of the G7 countries should continue to emphasize green tourism as well as increase the share of renewable energy in their regional energy mix. More policy direction was outlined in the concluding section of this study.

Background: Evidence suggests that poor sleep increases risk of delirium. Because delirium is associated with poor outcomes, institutions have developed protocols to improve sleep in critically ill patients. Objective: To assess the impact of implementing a multicomponent sleep protocol. Methods: In this prospective, preimplementation and postimplementation evaluation, adult patients admitted to the medical intensive care unit (ICU) over 42 days were included. Outcomes evaluated included median delirium-free days, median Richards-Campbell Sleep Questionnaire (RCSQ) score, median optimal sleep nights, duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and in-hospital mortality. Results: The preimplementation group included 78 patients and postimplementation group, 84 patients. There was no difference in median delirium-free days (1 day [interquartile range, IQR, = 0-2.5] vs 1 day [IQR = 0-2]; P = 0.48), median RCSQ score (59.4 [IQR = 43.2-71.6] vs 61.2 [IQR = 49.9-75.5]; P = 0.20), median optimal sleep nights (1 night [IQR = 0-2] vs 1 night [IQR = 0-2]; P = 0.95), and in-hospital mortality (16.7% vs 17.9%, P = 1.00). Duration of MV (8 days [IQR = 4-10] vs 4 days [IQR = 2-7]; P = 0.03) and hospital LOS (13 days [IQR = 7-22.3] vs 8 days [IQR = 6-17]; P = 0.05) were shorter in the postimplementation group, but both were similar between groups after adjusting for age and severity of illness. Conclusions and Relevance: This report demonstrates that implementation of a multicomponent sleep protocol in everyday ICU care is feasible, but limitations exist when evaluating impact on measurable outcomes. Additional evaluations are needed to identify the most meaningful interventions and best practices for quantifying impact on patient outcomes.