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Benzodiazepine and z-drug prescribing in critical care survivors and the risk of rehospitalisation or death due to falls/trauma and due to any cause: a retrospective matched cohort study using the UK Clinical Practice Research Datalink.
Get PDFPURPOSE: Benzodiazepines and z-drugs are often prescribed to critical care survivors due to high prevalence of mental health problems and insomnia. However, their safety has not been studied in this population. METHODS: Retrospective cohort study of 28,678 adult critical care survivors hospitalised in 2010 and 2018: 4844 prescribed benzodiazepines or z-drugs, matched to 23,834 unexposed survivors using UK Clinical Practice Research Datalink linked datasets. Multivariable stratified Cox regression was used to estimate the adjusted hazards ratio (adjHR) with 95% confidence intervals (CI) of community benzodiazepine/z-drug prescribing and falls/trauma-related events, as well as all-cause 30-day rehospitalisation or death. We performed subgroup analyses on patients without pre-critical care admission prescription of benzodiazepines/z-drugs ('treatment-naïve'), and sensitivity analyses excluding patients receiving palliative care after discharge. RESULTS: Prescription of benzodiazepines or z-drugs showed no conclusive evidence of increased risk of falls/trauma-related events in the whole cohort (adjHR 1.27; 95%CI 0.76-2.14) or in treatment-naïve individuals (adjHR 1.79; 95%CI 0.61-5.26), because estimates lacked precision due to low event rates. For all-cause rehospitalisation or death, benzodiazepines/z-drugs were associated with increased risk (whole cohort adjHR 1.24, 95%CI 1.14-1.36; treatment-naïve adjHR 1.66, 95%CI 1.49-1.86). However, after excluding patients treated for palliative care, the association persisted only in treatment-naïve individuals (whole cohort adjHR 1.08, 95%CI 0.98-1.19; treatment-naïve adjHR 1.42, 95%CI1.25-1.62). CONCLUSIONS: Community benzodiazepine and z-drug prescribing was associated with increased risk of all-cause, but not falls/trauma-related, rehospitalisations and deaths in critical care survivors who had not been prescribed these before hospitalisation. Clinicians should balance the possible benefits with the likely harms of prescribing these drugs in this potentially vulnerable patient group
Women’s experiences of and interactions with the health system in post-Doi Moi Vietnam
Get PDFHow people experience their interactions with their health systems are central to the notion of health systems responsiveness. These experiences may be ‘personal’, but they are also shaped by the broader historical, political, cultural, social, and economic contexts within which they occur. Yet, few studies on people’s experiences of care, particularly those focused on health systems responsiveness, explicitly take this into account. In this study, and drawing on in-depth interviews with 28 pregnant and postpartum women in a rural province of Vietnam, we use a novel approach that draws on the work of Archer and Chalari to uncover and analyse women’s ‘internal conversations’, in which they reflect upon and make sense of their maternity care-related experiences. Women’s ‘internal conversations’ reflected their need for short waiting times and high-quality ultrasonography, concerns regarding privacy and confidentiality, expectations of receiving dignified care, and their experiences of decision-making relating to caesarean section. Our findings reveal how women’s preferences, demands, and expectations have likely evolved in response to the Doi Moi-related shifts that have changed the organisation and structure of Vietnam’s economy, society, and health system. We make the case for health systems researchers and actors to consciously take into account the society and health system-level evolutions and changes when researching or developing interventions for improving responsive health systems
Considerations for improving the relevance, use, and robustness of projections of the health risks of climate change.
Get PDFThe increased interest and investment in climate change and health research and policy should be a turning point for providing policy-relevant projections of how changing weather patterns and climate trends could alter the magnitude and distribution of climate-sensitive health outcomes. Decision makers recognise that future health burdens result from interactions between exposure, sensitivity, and the capacity to adapt. Fit-for-purpose projections to inform climate risk management should be based on a range of scenarios of greenhouse gas emissions and socioeconomic development. The relevance, use, and robustness of projections would be improved by addressing the considerations outlined here
Fifteen-minute consultation: Threadworm in children.
Get PDFIntroduction: Enterobiasis (‘threadworm’, ‘pinworm’) is likely the most common parasitic infection, with an estimated 1 billion people infected worldwide.(1) Up to 30% of children globally are affected. (2) The causative parasite is the nematode (roundworm), Enterobius vermicularis, transmitted via the faeco-oral route. Gravid adult females migrate from the gastrointestinal tract to lay eggs on perianal folds, usually at night. The eggs become infectious within 4–6 hours. Infection occurs via autoinfection (transfer of eggs to the mouth through hands that have scratched the perianal area) or from exposure to egg in the environment (ie, bed sheets, clothes). The success of E. vermicularis as a parasite lies in the number of eggs produced by a single female (estimated at around 10 000) (3) and the tenacity of the eggs, which can survive for up to 20 days outside the host and have a strong adherence to fingers and fingernails. (4) There is very little evidence base regarding this ubiquitous parasite, which is often viewed merely as a ‘nuisance’. The most common symptoms are pruritus ani and subsequent irritability due to poor sleep, but, as a 1962 paper vividly puts it: “Other symptoms to which lay people in general attach great value are nose scratching, teeth gnashing, fingernail chewing, nightmares, inattention in school or at home, and agitation”. (5) Infection, particularly when recurrent, can cause significant distress to families, and threadworm infestation is a common clinical scenario for the general practitioner and general paediatrician
Safety, immunogenicity, and effectiveness of chikungunya vaccines in pregnant persons, children, and adolescents: a protocol for a living systematic review and meta-analysis.
Get PDFBACKGROUND: Chikungunya virus significantly impacts public health, primarily affecting regions in Africa and the Americas (predominantly Latin America and the Caribbean). Despite the global spread of the virus and its clinical manifestations and complications in vulnerable populations such as children and pregnant persons, no widely available vaccine is currently available. With recent advancements in vaccine development, there is a need to systematically evaluate the emerging evidence on the safety, immunogenicity, and efficacy of chikungunya vaccine candidates. This protocol outlines a living systematic review designed to continuously assess the growing research on chikungunya vaccines, focusing on diverse populations, including children and pregnant persons. We aim to provide up-to-date evidence to inform public health decisions and vaccine recommendations as new data is available. METHODS: Our objective is to carry out a living systematic review and meta-analysis through biweekly searches in medical databases and clinical trial registries, aiming to identify relevant chikungunya vaccines studies on pregnant individuals, children, and adolescents. Pairs of reviewers will independently screen studies, extract data, and assess the risk of bias. Clinical trials, quasi-experimental studies, and observational studies, including case reports, will be considered for inclusion. Main outcomes will include the safety, efficacy, and effectiveness of chikungunya vaccines in pregnant individuals (including neonatal outcomes), as well as in children and adolescents. Reactogenicity and immunogenicity will be considered as secondary outcomes. Paired meta-analyses, incorporating predefined subgroup and sensitivity analyses, will be performed. Evidence certainty will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION: This living systematic review and meta-analysis will continuously assess the safety, immunogenicity, and effectiveness of chikungunya vaccines in pregnant persons, children, and adolescents. Given the significant disease burden and potential complications in these populations, synthesizing emerging evidence is crucial for guiding immunization policies and clinical recommendations. By maintaining an updated analysis, this review will provide timely insights for public health agencies, researchers, and clinicians involved in vaccine implementation and maternal-child health. STUDY REGISTRATION: Two protocols were registered in the International Prospective Register of Systematic Reviews database, CRD42024514513 and CRD42024516754
Compartmentalised mucosal and blood immunity to SARS-CoV-2 is associated with high seroprevalence before the Delta wave in Africa.
Get PDFBACKGROUND: The reported number of SARS-CoV-2 cases and deaths are lower in Africa compared to many high-income countries. However, in African cohorts, detailed characterisation of SARS-CoV-2 mucosal and T cell immunity are limited. We assessed the SARS-CoV-2-specific immune landscape in The Gambia during the presence of the pre-Delta variant in July 2021. METHODS: A cross-sectional assessment of SARS-CoV-2 immunity in 349 unvaccinated individuals from 52 Gambian households was performed between March-June 2021. SARS-CoV-2 spike (S) and nucleocapsid (N) specific binding antibodies were measured by ELISA, variant-specific serum neutralizing-antibodies (NAb) by viral pseudotype assays and nasal fluid IgA by mesoscale discovery assay. SARS-CoV-2 T-cell responses were evaluated using ELISpot assay. RESULTS: We show that adjusted anti-Spike antibody seroprevalence is 56.7% (95% confidence interval (CI) 49.0-64.0), with lower rates in children 1:50. T-cell responses are higher in spike-seropositive individuals, although 34% of spike-seronegative individuals show responses to at least one antigen pool. We observe strong correlations within SARS-CoV-2 T-cell, mucosal IgA, and serum NAb responses. CONCLUSIONS: High SARS-CoV-2 seroprevalence in The-Gambia induce mucosal and blood immunity, reducing Delta and Omicron impact. Children are relatively protected from infection. T-cell responses in seronegative individuals may indicate either pre-pandemic cross-reactivity or individuals with a T-cell dominated response to SARS-CoV-2 infection with absent or poor humoral responses
Awareness, access to and uptake of HIV prevention interventions among youth in Zimbabwe: a population-based survey.
Get PDFBACKGROUND: Youth in southern Africa continue to be at high risk of HIV infection. We investigated the awareness of, access to, and uptake of HIV prevention interventions (pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), voluntary medical male circumcision and condoms) among youth in Zimbabwe. METHODS: A population-based survey of youth aged 18-24 years in 24 communities across three provinces was conducted between October 2021 and June 2022. An interviewer-administered questionnaire collected sociodemographic and sexual behaviour data including awareness of, access to, and use of HIV preventative interventions. Data were analysed using descriptive statistics and mixed-effects logistic regression weighted for clustering. RESULTS: We recruited 17,682 youth (60.8% female, median age 20 years (Interquartile range 19-22)). Altogether 46.8% (n = 3634) of unmarried youth and 5.6% (n = 3538) of married youth reported consistent condom use and 49.8% (n = 3369) of men reported being circumcised. Awareness of PrEP and PEP was 11.2% and 11.9% respectively. 6900 participants (38.4%) reported at least one eligibility criterion for PrEP. Eligibiltiy criteria included having multiple partners or receiving money or goods for sex in the last year, HIV-negative individuals in serodiscordant relationships, those who had ever been treated for an STI, ever injected drugs, been pregnant or taken PEP. In comparison to the non-eligible population (n = 10782), the eligible population were more likely to have heard of PrEP (13.5% vs. 9.9%, p < 0.001), been offered PrEP if they had heard of it (17.0% vs. 6.3%, p < 0.001) and to have ever taken PrEP if offered it (60.7% vs. 27.0%, p < 0.001). Those in the richest wealth quintiles and with higher education level were more likely to have heard of PrEP and report regular condom use. Forty-two of 199 (20.2%) who reported having experienced forced sex in the last year sought healthcare afterwards, of these 17 of 42 (36.0%) had been offered PEP and 12 of 17 (63.7%) had ever taken it. CONCLUSIONS: Use of HIV preventive interventions remains limited among youth despite longstanding HIV programmes. Lack of awareness limits use of PrEP and PEP. There are underlying socioeconomic barriers limiting awareness of and demand for condoms, circumcision and pharmacological prophylaxis. These must be urgently addressed. TRIAL REGISTRATION NUMBER: NCT03719521
Integrating Digital Health Innovations to Achieve Universal Health Coverage: Promoting Health Outcomes and Quality Through Global Public Health Equity.
Get PDFDigital health innovations are reshaping global healthcare systems by enhancing access, efficiency, and quality of care. Technologies such as artificial intelligence, telemedicine, mobile health applications, and big data analytics have been widely applied to support disease surveillance, enable remote care, and improve clinical decision making. This review critically identifies persistent implementation challenges that hinder the equitable adoption of digital health solutions, such as the digital divide, limited infrastructure, and weak data governance, particularly in low- and middle-income countries (LMICs). It aims to propose strategic pathways for integrating digital innovations to strengthen universal health coverage (UHC) and bridge health disparities in the region. By analyzing the best global practices and emerging innovations, this study contributes to the ongoing dialogue on leveraging digital health for inclusive, scalable, and sustainable healthcare delivery in underserved regions
Impact of helminth co-infection and treatment on mycobacterial growth inhibition in UK migrants with TB infection.
Get PDFBACKGROUND: TB and helminth infections are co-endemic in many parts of the world. This has led to the hypothesis that immunomodulation due to helminth infections could adversely affect the ability to control Mycobacterium tuberculosis infection. Anti-helminthic treatment has been associated with improved anti-mycobacterial cellular responses and decreases in the frequency of regulatory T-cells. We therefore investigated how control of mycobacterial growth and anti-mycobacterial immune responses are modulated in helminth and TB co-infected individuals using a mycobacterial growth inhibition assay (MGIA). METHODS: Migrants with eosinophilia or suspected/diagnosed helminth infection and/or TB infection (TBI) were recruited when attending University College London Hospitals (London, UK) and followed up after completing anti-helminthic treatment. Mycobacterial growth inhibition was assessed using the BACTEC™ MGIT™ system after 72 hours of co-culture of peripheral blood mononuclear cells (PBMC) with M. bovis bacille Calmette-Guérin (BCG) or M. tuberculosis Erdman. RESULTS: Anti-helminthic treatment reduced total and helminth-specific antibodies in helminth-infected and TBI-helminth co-infected individuals. Helminth-infected individuals displayed lower growth inhibition in the MGIA than those without helminth infections, and mycobacterial growth inhibition improved after anti-helminthic treatment. Blocking interleukin-10 (IL-10) and transforming growth factor-beta (TGF-β) improved mycobacterial growth inhibition, while blocking interferon-gamma (IFN-γ) did not alter growth inhibition. CONCLUSION: Infection with helminths such as Schistosoma mansoni and Strongyloides spp. may reduce the ability to control mycobacterial growth
What do Australian primary care clinicians need to provide long-acting reversible contraception and early medical abortion? A content analysis of a virtual community of practice.
Get PDFBACKGROUND: Uptake of long-acting reversible contraception (LARC) is lower in Australia compared with other high-income countries, and access to early medical abortion (EMA) is variable with only 11% of general practitioners (GPs) providing EMA. The AusCAPPS (Australian Contraception and Abortion Primary Care Practitioner Support) Network is a virtual community of practice established to support GPs, nurses and pharmacists to provide LARC and EMA in primary care. Evaluating participant engagement with AusCAPPS presents an opportunity to understand clinician needs in relation to LARC and EMA care. METHODS: Data were collected from July 2021 until July 2023. Numbers of online resource views on AusCAPPS were analysed descriptively and text from participant posts underwent qualitative content analysis. RESULTS: In mid-2023 AusCAPPS had 1911 members: 1133 (59%) GPs, 439 (23%) pharmacists and 272 (14%) nurses. Concise point-of-care documents were the most frequently viewed resource type. Of the 655 posts, most were created by GPs (532, 81.2%), followed by nurses (88, 13.4%) then pharmacists (16, 2.4%). GPs most commonly posted about clinical issues (263, 49% of GP posts). Nurses posted most frequently about service implementation (24, 27% of nurse posts). Pharmacists posted most about health system and regulatory issues (7, 44% of pharmacist posts). CONCLUSIONS: GPs, nurses and pharmacists each have professional needs for peer support and resources to initiate or continue LARC and EMA care, with GPs in particular seeking further clinical education and upskilling. Development of resources, training and implementation support may improve LARC and EMA provision in Australian primary care