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Effective cataract surgical and refractive error coverages in the state of Qatar.
Get PDFPURPOSE: To evaluate the progress in Qatar's eye care since 2009, focusing on effective cataract surgical and refractive error coverages, leading to enhanced eye health strategies and action plans. METHODS: A modified Rapid Assessment of Avoidable Blindness (RAAB) survey was employed using multi-stage sampling in all persons 50 years and older in Qatar. The study focused on uncorrected refractive errors, cataract surgery coverage and effectiveness, and visual acuity assessment. RESULTS: There were 339 individuals out of 3,206 examined participants who underwent cataract surgery, out of which 66.1% of 559 operated eyes obtained good post-operative outcomes (presenting visual acuity ≥ 6/12). Age -sex - adjusted eCSC for a cataract surgical threshold < 6/12 was 61.2% (95%CI 54.9-67.4). A poor post-operative outcome (presenting visual acuity < 6/60) was observed in 9.3% of all operated eyes, lower than the 14.9% reported in 2009. Cataract surgical coverage at the 6/18 threshold showed good coverage (94%) improving since 2009 (87%). Effective refractive coverage (eREC) was 74.3% (95%CI 70.9-77.7). Effective coverage of both services was lower among Qatari women compared to other population groups. CONCLUSION: Qatar's CSC improved since the 2009 RAAB, but there are disparities in effective coverage based on gender and nationality. WHO set a global target to achieve a 30%-point increase in eCSC and a 40%-point increase in eREC by 2030; accordingly, Qatar's targets should be 91.2% and 100% retrospectively by 2030. To meet these targets, efforts are needed to improve the quality of cataract surgery and access to refractive correction
Impact of tree-based interventions in addressing health and wellbeing outcomes in rural low-income and middle-income settings: a systematic review and meta-analysis.
Get PDFThe impact of nature-based solutions on human health is increasingly recognised; however, our understanding of the strength of evidence and the extent to which it supports policy and practice is insufficient. We aimed to assess the health and wellbeing impacts of solutions in low-income and middle-income settings in which trees are a central feature in the protection, restoration, and sustainable management of landscapes. For this systematic review and meta-analysis, we searched Web of Science, Embase, APA PsycInfo, MEDLINE ALL, Global Health, Global Index Medicus, GreenFILE, SciELO, EconLit, and Africa-Wide Information for studies that evaluated the impacts of relevant interventions on health and wellbeing. Searches were limited to records published from Jan 1, 2000, to the search date; an initial search was conducted on Nov 23, 2021, and was updated on Feb 27-28, 2023. We extracted data from studies comparing interventions with matched controls, calculated standardised mean differences, and pooled the effects using random-effects meta-analysis with adjustments for potential effect dependence. Studies were assessed for quality using seven risk-of-bias domains. Our search identified 23 402 studies, of which 54 were included in the meta-analysis. We found significant positive pooled effects for agricultural yields (standardised mean difference 0·41 [95% CI 0·11 to 0·70]), dietary diversity (0·10 [0·02 to 0·18]), total household income (0·21 [0·09 to 0·33]), poverty reduction (0·17 [0·07 to 0·27]), child growth (0·11 [0·00 to 0·22]), and self-reported wellbeing (0·21 [0·00 to 0·43]). Loss of income from timber production could be a negative outcome (-0·13 [-0·29 to 0·02]); however, these effects might be partially offset by increased income from non-timber forest products (0·32 [0·04 to 0·61]). Effects varied substantially by intervention type, with more positive effects associated with interventions in which the primary target was livelihood improvement than with interventions that targeted biodiversity or carbon mitigation. However, cautious interpretation is urged owing to the low certainty of the evidence. In conclusion, evidence suggests that tree-based solutions can support the health and wellbeing of the implementing communities. Such evidence strengthens the case for aligning health objectives with the goals of nature-based solutions by making community wellbeing an integral component of conservation programmes. Future studies should examine a wider range of outcomes that have direct relevance for health
Intrinsic multiplication rate variation of Plasmodium falciparum in clinical isolates prior to elimination in Malaysia.
Get PDFReplication rates and virulence of pathogens are hypothesised to evolve in response to varying intensity of transmission and competition among genotypes. Under exponential growth conditions in culture, clinical isolates of the malaria parasite Plasmodium falciparum have variable intrinsic multiplication rates, but comparisons of samples from different areas are needed. To analyse parasites from an area of low endemicity, Malaysian clinical isolates cryopreserved prior to malaria elimination were studied. The mean and range of P. falciparum multiplication rates in Malaysian isolates were no less than that seen among isolates from more highly endemic populations in Africa, which does not support a hypothesis of adaptation to prevailing levels of infection endemicity. Moreover, the distribution of multiplication rates was similar between isolates with single parasite genotypes and those containing multiple genotypes, which does not support a hypothesis of facultative adjustment to competing parasites. Based solely on clinical isolates, the findings indicate that parasites may not evolve lower multiplication rates under conditions of reduced transmission, and that the virulence potential is likely to be undiminished in pre-elimination settings. This encourages efforts to eliminate endemic infection completely, as has been achieved at the national level in Malaysia
A multi-country mixed method evaluation of the HERA (Healthcare Responding to Domestic Violence and Abuse) intervention: A comparative analysis.
Get PDFBACKGROUND: Domestic violence (DV) against women has adverse health consequences and demands a comprehensive healthcare response. Interventions adapted from high-income countries encounter implementation challenges in low-and-middle-income countries, due to diverse socio-cultural, political and economic contexts. This study explored HERA (Healthcare Responding to Violence and Abuse) implementation, that aimed to strengthen the healthcare response to DV in Brazil, Nepal, the occupied Palestinian territory (oPt), and Sri Lanka. METHODS: Parallel mixed method study (2019 - 2022). Quantitative data included the Provider Intervention Measure (PIM), training attendance records and DV documentation before and after the intervention. Qualitative data included semi-structured interviews with providers and DV survivors, field notes and stakeholder meetings. Data were integrated at the level of interpretation and reporting using a narrative approach, drawing on theories of Complex Adaptive Systems and sensemaking. RESULTS: HERA enhanced healthcare provider readiness to address DV and fostered a women-centred approach. The interaction between HERA and the diverse contexts impacted the reciprocal relationship between sensemaking and sensegiving within health systems, leading to adaptive behaviours among providers and women. This included mediation practices, negotiating DV documentation, modified roles, and containment of DV cases within the clinic. Normative gender roles, normalised DV attitudes, biomedical sensemaking frameworks, community violence, austerity policies, scarce resources, and weak leadership and management support affected implementation success. CONCLUSION: It is important to consider the interplay between context and intervention goals during development, implementation and evaluation of health system responses to DV. Managers require specific intervention components to support organisational change. Culturally appropriate support for women should acknowledge limitations to their agency
Strengthening implementation science research to improve adolescent and young adult HIV-prevention and care in Sub-Saharan Africa: PATC3H-IN.
Get PDFBACKGROUND: Despite significant progress in HIV prevention and treatment, uptake of evidence-based interventions among adolescents and young adults (AYA), particularly in low- and middle-income countries (LMICs), remains low. Implementation research can optimize strategies to enhance reach, uptake, and equitable access to these innovations. The Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource-Constrained Settings Implementation Science Network (PATC3H-IN) leverages implementation science to strengthen the delivery and sustainability of evidence-based HIV prevention and care for AYA across six countries in sub-Saharan Africa. This paper outlines PATC3H-IN's goals, summarizes the implementation science (IS) data that will be collected, and highlights the advantages of research networks in advancing science.
METHODS: The PATC3H-IN builds on the existing PATC3H consortium to advance IS research targeting AYA in LMICs. The PATC3H-IN comprises eight Clinical Research Centers (CRCs) located in Nigeria, Uganda, Malawi, South Africa, Zambia, and Tanzania. Representatives from the CRCs were asked to provide information on the IS components of their proposed studies, including details on study populations, IS frameworks, outcomes, and strategies, mechanisms of change, effectiveness outcomes, and documentation of intervention adaptations. The reports from the CRCs were compared to identify opportunities for advancing science across study sites.
RESULTS: The PATC3H-IN studies will enroll AYA aged 12-24 years, with some emphasizing key subpopulations, namely AYA living with HIV, sexual and gender minorities, and adolescent girls and young women. All PATC3H-IN studies will be guided by one or more implementation science frameworks and theories, with the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework most frequently cited (n = 4/8). Across the CRCs, 54 unique implementation strategies will be used, with community engagement being the most common. Several studies will document intervention adaptations, and all studies will collect a set of common data elements to facilitate secondary data analyses across projects.
CONCLUSIONS: The PATC3H-IN represents a significant contribution to advancing HIV prevention and care research for AYA in resource-constrained settings. Findings from PATC3H-IN will extend our understanding of IS in sub-Saharan Africa, a region particularly burdened by HIV, and for AYA who are traditionally under-represented in IS research.
CLINICAL TRIAL NUMBER: Not Applicable
Mind the Gaps: Literature Survey Reveals Shortcomings in Handling Missing Data in Clinical Practice Research Datalink (CPRD), a UK Primary Care Health Records Database.
Get PDFBACKGROUND: In the United Kingdom (UK) primary care electronic health records (EHR), key demographic, clinical, and lifestyle variables such as ethnicity, social deprivation, body mass index and smoking status are often incomplete. This incompleteness can compromise research validity by introducing bias and reducing statistical power. There are a number of frequently used approaches to handling missing data, including complete records analysis (CRA), missing indicator method and multiple imputation (MI), however it is not clear to what extent these are used in primary care EHR analyses or whether their use is appropriate. This study examines current practice for applying methodologies and reporting of missing data, in one of the largest UK primary care EHR databases, the Clinical Practice Research Datalink (CPRD).
METHODS: A random ~10% sample of observational studies from the CPRD bibliography, published between 01 January 2013 and 31 December 2023, was selected. Article screening and data extraction for each paper was completed by two reviewers, who used pre-prepared pro-forma to independently extract reporting and methods for handling missing data.
RESULTS: From 2,481 publications during the study period, a random 220 were selected for detailed review. Missing data were reported in 163 (74%) studies. CRA was applied in 50 studies (23%), missing indicator method was used in 44 studies (20%), MI in 18 studies (8%), and alternative methods such as reclassification and mean imputation, in 15 studies (6%).
CONCLUSION: Many studies fail to follow published best practice, often relying on flawed methods like the missing indicator method. Greater transparency, rigorous missing data techniques, and clearer reporting are needed. Improved guidance with practical examples would enhance research quality. Without methodological consistency and scrutiny, the risk of bias and misinterpretation remains high, making it essential to integrate missing data considerations into study design and analysis
Antibiotic stewardship in suspected neutropenic fever (ASTERIC trial): a multicentre, type 1 hybrid effectiveness-implementation, stepped-wedge, randomised controlled trial study protocol.
Get PDFINTRODUCTION: Neutropenic fever (NF) has a crude mortality rate of 3-18%. International guidelines recommend that all patients with NF receive ultrabroad-spectrum antibiotics (UBSAs) within 1 hour of emergency department (ED) registration. However, over 70% patients presenting to hospital with suspected NF (sNF) cannot access absolute neutrophil count (ANC) result within 1 hour, do not have NF and do not require UBSAs. In ED and hospitalised patients with sNF, we hypothesise that the ASTERIC protocol effectively and safely reduces the use of UBSAs compared with standard care alone.
METHODS AND ANALYSIS: This pragmatic, parallel, multicentre, type 1, hybrid effectiveness-implementation, stepped-wedge, before-and-after, cluster randomised controlled trial aims to evaluate whether antibiotic prescribing can be safely reduced through implementing a multifaceted antibiotic stewardship intervention (ASTERIC) in adult patients with sNF presenting to EDs. The sNF was defined as a fever with a single oral temperature of ≥38.3°C (101°F) within 24 hours before ED registration or a temperature of ≥38.0°C (100.4°F) sustained over a 1-hour period, following last chemotherapy or targeted therapy within 6 weeks for any solid tumour, or in any period following therapies against leucaemia, lymphoma, myelodysplastic syndrome, aplastic anaemia, multiple myeloma or recipient of HSCT. The study will involve eight hospitals in Hong Kong with variable baseline practice. We will include 704 adult patients (352 patients in pre-implementation and post-implementation periods, respectively) with sNF (tympanic temperature ≥38.3°C) and 48 staff participants (6 staff participants in each hospital). Healthcare professionals will receive a multifaceted stewardship intervention consisting of risk assessment tools, fast-track ANCs, a decision tool for patient management and antibiotic use, supported by an educational package and staff interaction programmes (ASTERIC protocol). Patients' blood ANC, and cancer therapy and chronic illness therapy scores will be measured. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) and Proctor conceptual frameworks will be followed for evaluation of implementation. The main outcome measures are the mean total dose of UBSAs prescribed in 7 days and serious adverse events at 30 days. Data analysis will incorporate intention-to-treat, per-protocol and as-treated analyses for service outcomes (effectiveness, safety, quality of life assessments and cost-effectiveness) and mixed methods for implementation outcomes, informed by the Theoretical Domains Framework. We expect that the study results will inform health policy with improvement in hospital services in treating stable sNF, evidenced by improved safe antibiotic stewardship, early antibiotic de-escalation and reduced costs and length of stay.
ETHICS AND DISSEMINATION: The institutional review boards of all study sites approved this study. This study will establish the ASTERIC protocol safely improves antibiotic stewardship and clinical management in adult patients with sNF. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities. All patients with sNF will be influenced by the new protocol which is agreed at hospital level. Randomisation is at hospital level, not patient level. Patient consent is sought for follow-up and data access, not for treatment. Staff consent is sought for interviewing.
TRIAL REGISTRATION NUMBER: NCT06794320
Disparities in stillbirth rates according to municipal deprivation levels: a nationwide study in Brazil.
Get PDFBACKGROUND: Investigating the relationship between stillbirth and deprivation is essential to guide healthcare improvements, as evidence is scarce in LMIC contexts. This study estimated the stillbirth rate (SBR) and the odds ratios (OR) of stillbirth in Brazil's municipal deprivation context.
METHODS: This observational study included births in Brazil registered in the SINASC and SIM databases, employing two epidemiological designs. First, a cross-sectional analysis assessed the association between stillbirths and municipal deprivation, using data from January 1 to December 31, 2018. Logistic regression was used to estimate OR for stillbirths across deprivation levels, adjusting for sociodemographic, gestational, and fetal variables, with 95% confidence intervals. Deprivation was classified into quintiles based on Brazilian deprivation index (IBP) levels 1 to 5. Second, an ecological analysis examined time trends in SBR by deprivation level from January 1, 2000, to December 31, 2018. Time trends in SBR from 2000 to 2018 were analyzed using Prais-Winsten regression, both overall and stratified by IBP level.
RESULTS: In 2018, the OR of stillbirth, including both antepartum and intrapartum cases, increased with higher levels of deprivation. Compared to the least deprived areas, level 2 had a 9% greater OR of stillbirth (95%CI: 1.03-1.15), level 3 had a 30% higher OR (95% CI: 1.23-1.27), level 4 showed a 34% increase (95%CI: 1.27-1.41), and level 5 had the highest OR, with a 68% increase (95%CI: 1.60-1.77). From 2000 to 2018, SBR in Brazil declined by 1.1% per year (p < 0.001). Significant declines were observed across deprivation levels 1 (-1.6% per year; p < 0.001) to 4 (-1.5% per year; p < 0.001), while level 5 showed persistently high stillbirth rates with no significant improvement (p ≥ 0.05).
CONCLUSION: These results highlight the stark inequalities in stillbirth chances across Brazil. Targeted action is needed to close the gap in the most deprived municipalities and reduce stillbirth rates and perinatal health disparities
Intensified Treatment of Tuberculous Meningitis in Adults: A Systematic Review and Meta-analysis.
Get PDFBACKGROUND: Tuberculous meningitis (TBM) remains the deadliest form of tuberculosis. Inadequate penetration of rifampicin and ethambutol into the brain and cerebrospinal fluid (CSF) may contribute to mortality. Over the last decade, research has focused on "intensified" treatment (higher-dose first-line drugs or addition of second-line drugs with good CSF penetration). This systematic review and meta-analysis evaluates the impact of intensified TBM treatment on mortality, disability, and safety.
METHODS: A systematic literature search was conducted of clinical trials examining intensified TBM treatments compared with a rifampicin-based standard-of-care regimen in adults. Odds ratios (ORs) were calculated using a random-effects model with mortality as the primary outcome, with OR <1 indicating lower mortality. Disability and safety were examined as secondary outcomes. Subgroup analyses included (1) higher-dose rifampicin, (2) addition of fluoroquinolones, and (3) addition of linezolid.
RESULTS: Ten trials meeting eligibility criteria, involving 1369 participants, were included. Higher-dose rifampicin (n = 1050; OR, 0.86; 95% CI, 0.54-1.35; P = .50), adjunctive fluoroquinolones (n = 1115; OR, 0.85; 95% CI, 0.56-1.27; P = .42), and linezolid (n = 79; OR, 0.73; 95% CI, 0.22-2.43; P = .61) did not significantly reduce TBM mortality. Due to heterogeneity in disability and safety endpoints, secondary outcomes could not be meta-analyzed.
CONCLUSIONS: Current clinical trial evidence does not support the use of intensified TBM treatment in adults. However, these analyses are limited by diverse TBM case definitions, absence of MRC grading at enrollment, variable rifampicin dosing, limited data on linezolid and higher-dose isoniazid, and heterogeneous disability and safety outcomes. Use of uniform case definitions and consistent endpoints is essential to standardize data
WHF Position Statement for United Nations Fourth High-Level Meeting-2025.
Get PDFAs the world gauges progress towards the SDG targets set for 2030, it is becoming evident that most countries are not on track to achieving them. Collective resolve among all nations and pooled global resources are needed to accelerate progress to reach as close to those targets as possible. It is also clear that commitment to those targets must continue beyond 2030 since many low- and middle-income countries (LMIC) will most likely experience rising burdens of non-communicable diseases (NCD) for some decades beyond the SDG dateline and to ensure commitment from the global community. This is especially true for target 3.4, including cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases, and mental health, which are responsible for over 43 million deaths worldwide every year, with 18 million dying prematurely before the age of 70 years, and also cause the majority of morbidity and disability.1 This is because ongoing demographic, nutritional, and environmental transitions in those countries will result in an accelerated incidence of NCD in the future. The inequities between and within countries are huge. The probability of premature deaths in Western Europe and Canada is as low as 15 percent, while it remains as high as 52 percent in Sub-Saharan Africa