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Closing the policy gap in diabetes care for individuals with advanced CKD.
Get PDFAim The co-existence of diabetes and CKD poses significant challenges to healthcare systems, current frameworks often inadequately address the complex needs of individuals with both conditions. Recognising these gaps, we introduced a new diabetes care model for people with advanced CKD in renal satellite units.This paper aims to evaluate this new diabetes model care. Method We conducted a prospective audit of a new integrated diabetes kidney care model. Data were presented as mean ± SD or counts/percentages, and pre- and post-intervention differences were assessed using paired samples t-tests. Results A total of 291 individuals with diabetes and advanced CKD stages 4 or 5, or undergoing haemodialysis, were included. The mean age was 68.5 (±13.0) years, 58.4% were males. Nearly half of the cohort had four or more long-term conditions, while two-thirds experienced mild/severe frailty. Only 6% were receiving ongoing diabetes care from secondary care diabetes specialist services. For patients with CKD not receiving dialysis, comparing pre- and post-intervention, there were improvements in HbA1c (-13.0 mmol/mol, p < 0.001), SBP (-13.7 mm Hg, p < 0.0001), and weight (-2.9 kg, p < 0.0001). Furthermore, there was an increase in guideline-directed therapies, with notable usage of SGLT2i (62.9%) and GLP1-RA (28.4%), while access to diabetes technology increased to 89%. Conclusion This new model of care resulted in improved metabolic outcomes, increased utilisation of guideline-directed therapies, and enhanced access to diabetes technologies. However, the model also revealed significant unmet clinical needs in areas such as access to diabetes care, diabetes eye screening and foot surveillance
Precarity, agency and trust: Vaccination decision-making in the context of the UK asylum system.
Get PDFBACKGROUND: Individuals living in initial asylum accommodation are at increased risk of vaccine-preventable disease, yet confidence in vaccination may be low in these settings. Our aim was to understand the influence of experiences within the UK asylum system on vaccine confidence and decision-making from a sociological perspective. METHODS: In-depth semi-structured interviews were carried out on views and experiences around vaccination (09/2020-08/2021) with individuals seeking asylum or having recently been granted asylum (<10 years in the UK). Interviews were audio-recorded, transcribed and analysed in NVivo 12 using a reflexive thematic analysis through an inductive approach. RESULTS: 25 participants were interviewed (mean age: 37 years, mean time in UK: 6 years, 72% female), of whom 13 were living in asylum accommodation at the time of interview. Analysis generated three main themes: 1) the detrimental impact of trauma and fear, both within the UK asylum system and prior, on perceptions of risk and vaccination decisions, 2) the effect of marginalisation, discrimination and neglect within the asylum system on an individual's trust and 3) the structural violence and restricted agency imposed on asylum seekers and its effect on ability and motivation to vaccinate. Past trauma or negative experiences since arriving in the UK, such as feeling forced to receive 'invasive' healthcare interventions in asylum accommodation may lead to distrust, increased perception of danger and avoidance of perceived 'risks' such as vaccination. Participants described how their struggle to cover basic necessities, social isolation and precarious living conditions imposed by the asylum system left them with more pressing priorities than vaccination. Participants who perceived that they had been cared for with empathy in the healthcare system or who described feeling empowered to make their own decision about vaccination often suggested they would be likely to accept vaccination if offered. CONCLUSIONS: Asylum seekers and refugees have often experienced substantial trauma and precarity and have a lack of agency directly imposed on them by the asylum system. These factors are likely to impact trust and decision-making around vaccination, with some also representing systemic or structural barriers to accessing services. Formative experiences in the UK are key to establishing trust in healthcare settings; a trauma-informed approach should be central in developing vaccination interventions for these groups, particularly in asylum accommodation
Are school-based violence prevention interventions inclusive and effective for children with disabilities? A systematic review of global evidence.
Get PDFBACKGROUND: Children with disabilities are twice as likely to experience violence compared to peers without disabilities. While evaluations of school-based interventions targeting the prevention of violence against children in schools are growing in number, it is unclear whether these interventions are inclusive of, or effective for, children with disabilities. METHODS: We searched six databases (Medline, Cochrane Library, Embase, Global Health, PsycINFO, Web of Science) and utilised professional networks to identify systematic reviews which included randomised controlled trials (RCTs) of school-based violence prevention interventions up to May 2024. Once we identified our final sample of systematic reviews (n = 29) we hand searched the included papers within these reviews and included all RCTs of school-based violence prevention interventions. We applied criteria to assess disability inclusion and conducted a narrative synthesis of study characteristics, adaptations to intervention and/or data collection design, and effect estimates. We assessed risk of bias using the Cochrane Risk of Bias tool. This review was registered on PROSPERO (CRD42023463384). FINDINGS: We identified 160 articles of school-based violence prevention interventions. Of these, 13 articles reporting on 10 trials (8.13%) explicitly mentioned disability: 3/10 trials reported on the magnitude of intervention effects among children with disabilities; 4/10 trials mentioned adaptations to research or intervention design to include children with disabilities; 6/10 trials mentioned disability as part of the sample characteristics but did not report further sub-group analysis. 3 trials were effective in reducing violence in schools for children with disabilities, with risk of bias ranging from 'low' (n = 1) to 'some concerns' (n = 2). INTERPRETATION: Despite growing evidence on how to prevent school violence, there is limited research on the effect of such interventions for children with disabilities. There is a need for future evaluations to stratify effects by disability, conduct disability-inclusive research, and tailor interventions for children with disabilities. FUNDING: This research was partially funded by the Foreign, Commonwealth and Development Office under the PENDA project (PO8073)
Retinoblastoma in Albania: A 25-Year Retrospective Analysis.
Get PDFBackground: Retinoblastoma (RB), the most common intraocular cancer worldwide, has been extensively investigated. To the best of our knowledge, however, no reports exist on RB in Albania. We aimed to present the first case series of RB in Albania, including presentation, treatment, and outcome of patients. Materials and Methods: This was a retrospective case series of patients diagnosed with RB from 1998 to 2023 at a single country Mother Teresa University Hospital Center in Albania. Epidemiologic and clinical data were extracted from follow-up clinical charts. Results: During the 25-year study period, 22 patients were diagnosed with RB, of whom 59% were females. The average age at diagnosis was 21.8 months (SD-18.8 months). In 13 (59%) cases, the disease was diagnosed within the first year of life, and less than 5% were diagnosed after the age of 5 years. Overall, 18% of patients had family history of RB, and 41% had bilateral RB. The time from the first symptom to diagnosis was less than a month in 32% of cases, while 77% of patients were diagnosed within 4 months. The main presenting symptom was leukocoria in 6 (27%) cases, strabismus in 3 (14%) cases, and combination of both in 3 (14%) cases. Treatment was mainly a combination of enucleation and systemic chemotherapy in 15 (71%) cases. Only 13 (59%) patients continued treatment within Albania, with the rest being treated abroad. Conclusion: We present the first cohort of children with RB from Albania, a country with limited diagnostic and treatment resources. The advanced disease states of these children underscore the importance of implementing national pediatric screening programs
Outcomes following lower limb long bone intramedullary nail fixation in South Africa : a prospective cohort study of 495 patients.
Get PDFAIMS: Musculoskeletal injuries are more common in sub-Saharan Africa than anywhere else in the world, yet there is limited evidence to guide the management of these injuries in low- and middle-income countries. We aimed to evaluate the outcomes of lower limb intramedullary nailing (IMN) for long bone fractures in South Africa and identify predictors of these outcomes. METHODS: Adults who sustained tibia and femur shaft fractures, and were treated with IMN at two tertiary hospitals in South Africa from September 2017 to December 2018, were followed for at least 12 months. We compared fracture characteristics and outcomes between open and closed fractures. We employed multivariable logistic regression models to investigate the associations between union status at six months, infection, and quality of life (EuroQol five-dimension five-level questionnaire) in open and closed fractures. RESULTS: In total, 495 patients with tibia and femur fractures underwent IMN. Of these, 240 patients had open fractures, and 255 patients presented with closed fractures. Gunshot wound fractures comprised 52% (124/240) of the open fractures. The overall delayed and nonunion rate reported in our study was 18% (85/479) and 5.8% (28/479), respectively, across the study population. The rate of deep surgical site infection, superficial site infection, and late infection in the study population was 6%, 2%, and 2%, respectively. Open fractures had a higher odd of delayed union (adjusted odds ratio (aOR) 1.97 (95% CI 1.03 to 3.75)), nonunion (aOR 3.01 (95% CI 1.20 to 7.53)), and early surgical site infections (aOR 3.46 (95% CI 1.39 to 8.62)) when compared to closed injuries. The overall health-related quality of life outcomes were comparable between open and closed fractures at the nine-month follow-up. CONCLUSION: Our study demonstrates comparable outcomes of infection and fracture healing rates in patients who undergo internal fixation for lower limb fractures in a resource-limited setting, when compared to study populations in a high-income country
Adapting the QuinteT Recruitment Intervention (QRI) to optimize the recruitment of ethnic minority groups in clinical trials: insights from workshops with diverse public contributors.
Get PDFBACKGROUND: The global majority, often called ethnic minority (EM) groups in the United Kingdom (UK), are underserved in clinical trials despite a greater disease burden. This means that the trial results are often not applicable to the global majority, perpetuating inequities. Despite extensive evidence on barriers to inclusive research, there is little evidence on strategies to achieve successful EM participation. The QuinteT Recruitment Intervention (QRI) has been successfully employed in over 80 trials to optimize recruitment and informed consent in the general population. We aimed to adapt the QRI to optimize EM recruitment in trials through public contributor workshops in the UK. METHODS: We conducted five workshops with 43 public contributors from diverse ethnic backgrounds. We explored concerns of interest to contributors and sought their views on adapting three QRI components (audio-recordings of trial discussions and patient interviews and feedback provided to health-care professionals, HCPs) and QRI information sheets and consent forms. RESULTS: Contributors were most interested in discussing barriers to EM research participation (mistrust, inadequate compensation, lack of workforce diversity in research, and inadequate community outreach). Key suggestions for QRI adaptation included: a) offering a copy of the audio-recorded trial consultation, providing patient interview questions in advance and avoiding small print in patient-facing documentation (to foster trust); b) involving EM groups with lived experience of health conditions in training HCPs (to avoid perpetuating harmful stereotypes; ensure training is "with" EM and not "about" EM); c) providing QRI team's expectations of participants in advance (clarity on emotional/mental labor involved); d) discussing participants' expectations of the research team (QRI interviews are not for medical information provision); and e) providing ample reassurance around confidentiality (to avoid identity disclosure to their communities, HCPs, or the government). CONCLUSION: It is important to initiate community engagement by focusing on key concerns in the community, though this has been previously well studied (eg, barriers to EM research participation). Providing the space for this prior to discussing our research topic of interest fostered trust. This led to contributors' insightful suggestions to ensure QRI adaptation and acceptability to EM groups, with the aim of ensuring their representation in clinical trials. PLAIN LANGUAGE SUMMARY: People from ethnic minority (EM) groups are more affected by health conditions than the general population. Yet, they are missing from trials, including those on health conditions affecting them the most (eg, diabetes). Researchers have a good understanding of issues that may prevent EM trial participation (barriers), but there is little knowledge of which recruitment methods are effective for such groups. The QuinteT Recruitment Intervention (QRI) is a set of methods successfully used to improve recruitment and informed consent in trials in the general population. We wanted to adapt the QRI so that it can be used to recruit people from EM groups to trials. Over five workshops, we asked 43 public contributors from diverse ethnic backgrounds what changes to make to the following QRI methods: audio-recording of trial discussions, feedback provided to doctors and nurses, interviews with patients, and QRI information sheets and consent forms. We did not intend to discuss barriers to research participation as this has been well explored in multiple studies, but this tended to be what our contributors most wanted to talk about (such as their lack of trust in research, researchers, and health-care professionals). After this discussion, they were open to providing suggestions for QRI adaptations, including ways to foster trust (such as offering a copy of the audio-recorded trial consultation to participants). They felt that training for health-care professionals (HCPs) should be "with" input from people from EM groups rather than "about" such groups. They also provided other suggestions, including clarifying that research interviews are not for medical information provision. Overall, we learnt the importance of providing the space to discuss the community's key concerns before discussing our research topic of interest, even when these concerns have been well explored in the existing research. This helped foster trust among contributors and led to important suggestions on how best to adapt the QRI to help ethnic minority participation in trials. We will now work with a wider group of people, including researchers, doctors, and nurses, to take these suggestions forward in our future QRIs
Mental Health Outcomes in Transgender and Nonbinary People: An Umbrella Review.
Get PDFIMPORTANCE: Experiences of marginalization by gender minority people may predispose them to poorer mental health outcomes than their cisgender peers. Understanding mental health conditions in transgender (trans) and nonbinary people is an essential step in addressing potential inequities in outcome for gender minority people. OBJECTIVE: To synthesize reviews of mental health and neurodevelopmental conditions in trans and nonbinary people to describe epidemiology, key themes, and research gaps. EVIDENCE REVIEW: Three bibliographic databases (Embase, MEDLINE, and PsycINFO) were systematically searched from inception to August 21, 2023, to identify reviews addressing mental health and neurodevelopmental outcomes in trans and nonbinary people. Articles were screened by 2 reviewers and prespecified data were extracted. Quality of included reviews was appraised against AMSTAR2 criteria. FINDINGS: Of 7496 unique records, 41 met inclusion criteria with 24 reviews synthesized after excluding those containing overlapping primary studies. Pooled prevalence estimates from meta-analyses were identified for 5 outcomes: suicidal ideation (50%; 95% CI, 42-57), suicide attempts (29%; 95% CI, 25-34), nonsuicidal self-injury (47%; 95% CI, 40-54), eating disorders (18%; 95% CI, 16-19), and autistic spectrum conditions (11%; 95% CI, 8-16). Meta-analyses comparing trans and cisgender groups reported higher odds of suicidal ideation (odds ratio [OR], 3.48; 95% CI, 2.41-4.91), suicide attempts (OR, 3.45; 95% CI, 2.40-4.64), nonsuicidal self-injury (OR, 3.42; 95% CI, 1.99-5.89), and posttraumatic stress disorder (OR, 2.52; 95% CI, 2.22-2.87). Worse outcomes were reported across all narrative syntheses comparing trans and cisgender or general population groups, except for problem gambling, where the limited evidence base was conflicting. No reviews assessed incidence or mortality, and there was limited disaggregation of nonbinary people or by specific gender subgroups (eg, trans men and trans women). Review quality was generally poor. Reviews highlighted heterogeneity in definitions of gender identity and outcome ascertainment, and unrepresentative sample populations as limitations of primary studies. CONCLUSIONS AND RELEVANCE: A growing body of evidence suggests trans people experience worse mental health outcomes than cisgender people, but there are substantial gaps and methodological weaknesses in existing literature. Research applying an intersectional lens, using longitudinal data and reflecting diversity and the experience of multiple disadvantages in the gender minority population is required to ensure evidence-informed policy and health service development
Prevalence and risk factors of pre-senile lens opacities in the 1969-73 Vellore Birth Cohort.
Get PDFPURPOSE: To estimate the prevalence and determine predictors of lens opacities (LO) among South Asian Indians aged 41-44 years. METHODS: This cross-sectional study included 1080 participants from the Vellore Birth Cohort, Vellore, South India. All underwent anthropometric measurements, detailed ophthalmic examination including assessment of LO by LOCS III classification and biochemical metabolic measurements. 'Any cataract' was defined as any opacity type with a score of >2 or evidence of cataract surgery in either eye. Data collected included information on ocular history, life-style factors, socio-economic and educational status, cooking fuel and sunlight exposure. Multivariable logistic regression analysis was used to examine the association between risk predictors and LO. RESULTS: The mean age (SD) of participants was 41.8 (1.0) years; 53.8% were male and 50% were rural residents. The overall prevalence of 'any cataract' was 13.8% (148/1075, 95% confidence interval (CI) 11.8,16.0). The types of cataract were nuclear 59.1%, cortical 16.9%, posterior subcapsular 4.1%, mixed cataracts 18.9% and pseudophakia 0.7%. Increased risk for LO was observed with a history of asthma (OR 4.51; 95% CI 2.1, 9.7), HbA1C of ≥6.5% (OR 2.29; 95% CI 1.4, 3.7), hypertension (OR 1.73; 95% CI 1.1, 2.7) and, in a subgroup (n = 372), lower 25(OH) vitamin D levels (≤20 ng/dL)(OR 5.56; 95% CI 2.3, 13.2). CONCLUSION: The high prevalence of LO at a relatively young age in South Asian Indians suggests earlier onset of ageing. History of asthma, higher HbA1C, hypertension and lower 25(OH) vitamin D levels were associated with LO
Prevalence of common mental disorders and associated factors among pregnant women attending antenatal care at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2023.
Get PDFBACKGROUND: Common mental disorders (CMDs) such as depression and anxiety are prevalent during pregnancy. CMDs are public health concerns because of the implications for the health of both the mother and the fetus. This study aimed to determine the prevalence of CMDs and associated factors among pregnant women attending antenatal care at the University of Gondar Comprehensive Specialized Hospital (UoG CSH), Northwest Ethiopia. METHODS: An institution-based cross-sectional study was conducted from 26 September to 28 October 2023 among pregnant women attending antenatal care at the UoG CSH. Study participants were selected using a systematic random sampling technique. Data were collected using pre-designed tools like the Self-Reporting Questionnaire (SRQ-20) and the Oslo-3 Social Support Scale through face-to-face interviews. The collected data were entered into Epi data version 4.6.02 and analyzed using STATA version 14. Bivariable and multivariable logistic regression were used to identify factors associated with CMDs. RESULTS: Of the 407 pregnant women, 170 (41.8%) fulfilled the criteria for CMDs. In the multivariable analysis, financial instability (AOR = 1.66, 95% CI: 1.02, 2.69), poor social support (AOR = 2.60, 95% CI: 1.41, 4.81), emotional or physical abuse (AOR = 3.86, 95% CI: 1.79, 8.30), history of mental illness (AOR = 4.00, 95% CI: 1.24, 12.86), and unwanted pregnancy (AOR = 3.02, 95% CI: 1.02, 8.94) were significantly associated with CMDs. CONCLUSION AND RECOMMENDATION: This study indicated that the prevalence of CMDs was high among pregnant women attending antenatal care at the UoG CSH. Those who had financial instability, poor social support, emotional or physical abuse, history of mental illness, and unwanted pregnancy were prone to CMDs. Therefore, early screening and monitoring of CMDs among pregnant women are important to reduce possible negative impacts on the health of women