208 research outputs found
sj-docx-1-car-10.1177_19476035241229026 – Supplemental material for Reporting of Morphology, Location, and Size in the Treatment of Osteochondral Lesions of the Talus in 11,785 Patients: A Systematic Review and Meta-Analysis
No full textSupplemental material, sj-docx-1-car-10.1177_19476035241229026 for Reporting of Morphology, Location, and Size in the Treatment of Osteochondral Lesions of the Talus in 11,785 Patients: A Systematic Review and Meta-Analysis by Pascal R. van Diepen, Frank F. Smithuis, Julian J. Hollander, Jari Dahmen, Kaj S. Emanuel, Sjoerd A.S. Stufkens and Gino M.M.J. Kerkhoffs in CARTILAGE</p
Artemisinin resistant falciparum malaria in Myanmar: Artemisinin resistant malaria
No full textArtemisinin-based combination therapy (ACT) is first-line treatment for Plasmodium falciparum malaria globally but artemisinin resistance is now prevalent across Southeast Asia. Myanmar has the highest malaria burden in the region, and determining the prevalence of artemisinin resistance and current therapeutic efficacy of first-line antimalarial drugs is critical for both clinicians and policy makers planning malaria control and elimination programmes. The aim of this research was to study the geographical extent, prevalence, degree and optimum treatment of artemisinin-resistant falciparum malaria in Myanmar through a countrywide molecular survey and two multicentre clinical trials supported by parasitological and pharmacological investigations. In a molecular survey of clinical falciparum malaria cases carried out in 55 sites across 10 administrative regions and border sites in neighbouring countries 39% of cases (371/940) were associated with parasites carrying a kelch13 propeller mutation. Kelch13 mutation prevalence exceeded 10% in much of the east and north of the country and was 47% in an area 25 km from the border with India. In a trial conducted in central and northern Myanmar treatment efficacy of dihydroartemisinin-piperaquine (DP) was 100% but there was delayed parasite clearance associated with the kelch13 mutation F446I (median clearance half-life 4.7 hours, IQR, 3.7 to 6.2). In a randomised controlled trial of 3-days versus 5-days artemether-lumefantrine (AL) treatment efficacy was 100% (95%CI, 94.9-100) and 97% (95%CI, 90-99.7) respectively and the two arms showed equal clearance rates (measured by an ultrasensitive quantitative polymerase chain reaction assay, uqPCR)..There was no association between the presence of kelch13 propeller mutations and residual parasite density at day 21, measured using uqPCR. Gametocyte carriage rates were high reinforcing the need to implement single low-dose primaquine (0.25 mg/kg) with ACTs to kill gametocytes in this area of artemisinin resistance. In conclusion, artemisinin resistant falciparum malaria is widespread in Myanmar. While DP and AL remain efficacious, the partner drugs are vulnerable and if resistance develops treatment efficacy is likely to decline rapidly. Greater efforts are urgently needed to monitor treatment efficacy of first-line antimalarial drugs and develop alternative treatment regimens
Priority-setting for malaria control and elimination in Myanmar
No full textIn Myanmar, Plasmodium falciparum malaria is important because of both the burden of disease and the emergence of parasites resistant to artemisinin-based therapies. In 2012, concomitant with the lifting of international economic sanctions, funding for malaria control and elimination in Myanmar rose significantly. The University of Oxford was asked to support priority setting by assessing the relative cost-effectiveness of insecticide- treated bed nets and community health workers, particularly with respect to planning in the Myanmar Artemisinin Resistance Containment region along the east of the country. In the context of rising artemisinin resistance and, later, the goal of regional malaria elimination by 2030, reduction in malaria transmission was an important consideration in prioritising between interventions.
A cost-effectiveness analysis was undertaken using both a static decision tree model and a dynamic disease transmission model. Supporting work towards this analysis included a systematic review of dynamic-transmission economic-evaluations and the creation of a data repository to collate governmental and non-governmental malaria case records. In addition, initially unplanned work on economic evaluation methodology was completed; identifying challenges in the application of cost utility analysis to this decision problem and proposing a framework for budget-based geographic resource allocation as an adaptation of standard methods.
The results of this work include a tripling of the number of malaria diagnostic reports available between 2012 and 2014 (71% increase in Plasmodium falciparum cases) with this data showing a decrease in Plasmodium falciparum cases over time, alongside rising testing rates. Cost utility analysis found that, in general, malaria community health workers are more costly yet more effective than insecticide treated bed nets, though in both cases cost effectiveness is very much context dependent. Geographic allocation analyses using both static and dynamic models illustrate the potential for economic evaluation to provide both more detailed and more practical policy recommendations. Parameter uncertainty was explored in both cases. Some township recommendations were robust to both parameter uncertainty and model variation (structural uncertainty). Viewed through the lens of the Reference Case for Economic Evaluation in Low and Middle Income Countries (published during the course of this DPhil), budget-based geographic resource allocation largely adheres to the healthcare economic evaluation principles and offers improvements to dealing with heterogeneity and resource constraints. This DPhil recommends that Myanmar malaria policy is tailored to reflect geographic variation in intervention cost-effectiveness, rather than focusing on universal coverage, and illustrates a framework for economic evaluation to support budget-based geographic allocation.</p
Defining empirical management of acute febrile illness in Myanmar
No full textFever is a common presenting symptom in primary care in low- and middle- income countries (LMICs). Non-malaria pathogens are now responsible in most cases after a decline of malaria in previously malaria endemic regions of Myanmar. It is important to provide appropriate treatment to those patients after malaria is ruled out by rapid tests or microscopy.
The overall aim of this thesis is to improve management of acute non-malaria febrile illness in Myanmar. Empirical treatment strategies with selected antibiotics were devised and their cost-effectiveness was evaluated using a decision tree modelling approach.
A systematic review on infectious neglected tropical diseases (NTDs) was conducted to collate all reports of NTDs in Myanmar (Chapter 2). The review identified diseases (rickettsial infection and leptospirosis) commonly associated with acute fever and this finding partly informed selection of antibiotics for empirical treatment. A cost- effectiveness analysis of empirical treatment showed empirical treatments being cost- saving and C-reactive protein (CRP) guided empirical treatments being highly cost- effective compared to current practice of care in rural Myanmar (Chapter 3). Alongside this, antibiotic use for acute febrile illness was also explored from the prescriber’s perspective by secondary analysis of the data derived from a clinical trial (Chapter 4) and the user’s perspective by public engagement activities (Chapter 6). The secondary data analysis found a substantial variation of antibiotic prescription among primary care doctors for acute febrile illness and the variation remained after accounting for patients’ clinical presentations and CRP test results. Widespread environmental distribution of Burkholderia pseudomallei, the causal organism of melioidosis, which commonly presents as community acquired pneumonia and sepsis, was confirmed by a large nationwide study (Chapter 5).
In conclusion, this thesis uses a multifaceted approach to improve management of acute febrile illness in Myanmar. Findings from this thesis point towards an empirical antibiotic treatment strategy as a potential approach for management of non-malaria febrile illness in rural Myanmar which could be evaluated in field trials
Case report: Children with severe nutritional rickets in the Naga region in northwest Myanmar, on the border with India
No full textRickets is an often-neglected, painful, and disabling childhood condition of impaired bone mineralization. In this case series we describe a cluster of 29 children with severe, painful bone deformities who live in the very remote region of Nagaland in northwest Myanmar. Children were found to have low 25-hydroxyvitamin D, elevated parathyroid hormone, and elevated alkaline phosphatase levels, consistent with nutritional rickets secondary to vitamin D deficiency, calcium deficiency, or a combination of the two. After treatment with vitamin D3 and calcium carbonate, significant improvement was seen in symptoms, biochemistry, and radiography. This is the first report of nutritional rickets in Myanmar in more than 120 years. Vitamin D and calcium supplementation, and food fortification for pregnant women and young children may be required to prevent this potentially devastating disease
MORU Tropical Health Network Annual Report 2021
No full text2021 Annual Report for the MORU Tropical Health Network, Mahidol Oxford Tropical Medicine Research Uni
Trajecting Territories: A Spatial Reconfiguration towards Multipurpose Foodscapes
No full textWith an average cheese production of 947 mln kg/year, the dairy industry (in the Netherlands) is responsible for 6.3 % of agricultural/dairy/commodity greenhouse gas (GHG) emissions in Northwestern (NW) Europe. This report brings the production of dairy and its effects on the spatiotemporal and environmental footprints. By performing a material analysis flow of an everyday consumption product-cheese, a by-product from the milk produced by cattle raised on the vast flat pasture lands in the Netherlands, we determine its harmful role in GHG emissions. Using a mixed-method approach, this study combines qualitative and quantitative analysis methodologies, extensive literature reviews, group discussions, available QGIS datasets, farmers sharing their experiences and knowledge on YouTube channels, case studies and a stakeholder interview. This led us to the formulation of a sustainable polyculture agriculture catalogue and toolbox where the dairy sector shifts from a core polluter and extractor role to a regenerative one. A future for farming is formulated where healthy soil is at the core of agricultural thinking. We outline a cow reduction spectrum resulting in opportunities for NW Europe leading to ecological improvements of the soil. Applying this toolbox to the South-Holland scale led to a multipurpose foodscape using an Integrated Crop-Livestock System (ICLS), where cows play the primary role of fertilisers of the land and secondarily, the role of milk producers. In conclusion, the research proves that the adoption of ICLS can significantly reduce GHG emissions in dairy production territories and optimise the existing land use. Implementing this system requires a shift in mindset and has significant implications for the dairy industry, policymakers and society at large. The strategy and action plan in this research seeks to inform policymakers, urban planners and other stakeholders in the dairy farming industry on how to transition towards a more regenerative and sustainable system that benefits the environment, society and the economy in the long duree. It suggests a socially just transition to the groups of farmers via a symbiotic approach.AR2U086 R&D Studio – Spatial Strategies for the Global MetropolisArchitecture, Urbanism and Building Sciences | Urbanis
Int J Infect Dis
No full textObjectivesThis study investigated causes of fever in the primary levels of care in Southeast Asia, and evaluated whether C-reactive protein (CRP) could distinguish bacterial from viral pathogens.MethodsBlood and nasopharyngeal swab specimens were taken from children and adults with fever (>37.5 \ub0C) or history of fever (<14 days) in Thailand and Myanmar.ResultsOf 773 patients with at least one blood or nasopharyngeal swab specimen collected, 227 (29.4%) had a target organism detected. Influenza virus type A was detected in 85/227 cases (37.5%), followed by dengue virus (30 cases, 13.2%), respiratory syncytial virus (24 cases, 10.6%) and Leptospira spp. (nine cases, 4.0%). Clinical outcomes were similar between patients with a bacterial or a viral organism, regardless of antibiotic prescription. CRP was higher among patients with a bacterial organism compared with those with a viral organism (median 18 mg/L, interquartile range [10\u201349] versus 10 mg/L [ 648\u201322], p = 0.003), with an area under the curve of 0.65 (95% CI 0.55\u20130.75).ConclusionsSerious bacterial infections requiring antibiotics are an exception rather than the rule in the first line of care. CRP testing could assist in ruling out such cases in settings where diagnostic uncertainty is high and routine antibiotic prescription is common
Inter-prescriber variability in the decision to prescribe antibiotics to febrile patients attending primary care in Myanmar
No full textBACKGROUND: Most antibiotic prescribing occurs in primary care. Even within the same health facility, there may be differences between prescribers in their tendency to prescribe antibiotics, which may be masked by summary data. We aimed to quantify prescriber variability in antibiotic prescription to patients with acute fever in primary care clinics in Myanmar. METHODS: We conducted a secondary analysis of prescribing data from 1090 patient consultations with 40 prescribing doctors from a trial investigating the effect of point-of-care C-reactive protein (CRP) tests on antibiotic prescription for acute fever. We used multilevel logistic regression models to assess inter-prescriber variability in the decision to prescribe antibiotics. RESULTS: The median odds ratio (MOR) in the unadjusted model was 1.82 (95% CI: 1.47-2.56) indicating that when two prescribers from this population are randomly selected then in half of these pairs the odds of prescription will be greater than 1.82-fold higher in one prescriber than the other. The estimated variability from this sample of prescribers corresponds to a population of prescribers where the top 25% of prescribers will prescribe antibiotics to over 41% of patients while the bottom 25% will prescribe antibiotics to less than 23% of patients. Inter-prescriber variation in antibiotic prescribing remained after adjustment for patient characteristics and CRP information (P < 0.001). CONCLUSIONS: Despite sharing the same management guidelines, there was substantial inter-prescriber variation in antibiotic prescription to patients with acute fever. This variation should be considered when designing trials and stewardship programmes aiming to reduce inappropriate antibiotic prescribing
Malaria community health workers in Myanmar: a cost analysis.
No full textMyanmar has the highest malaria incidence and attributed mortality in South East Asia with limited healthcare infrastructure to manage this burden. Establishing malaria Community Health Worker (CHW) programmes is one possible strategy to improve access to malaria diagnosis and treatment, particularly in remote areas. Despite considerable donor support for implementing CHW programmes in Myanmar, the cost implications are not well understood.An ingredients based micro-costing approach was used to develop a model of the annual implementation cost of malaria CHWs in Myanmar. A cost model was constructed based on activity centres comprising of training, patient malaria services, monitoring and supervision, programme management, overheads and incentives. The model takes a provider perspective. Financial data on CHWs programmes were obtained from the 2013 financial reports of the Three Millennium Development Goal fund implementing partners that have been working on malaria control and elimination in Myanmar. Sensitivity and scenario analyses were undertaken to outline parameter uncertainty and explore changes to programme cost for key assumptions.The range of total annual costs for the support of one CHW was US$ 966-2486. The largest driver of CHW cost was monitoring and supervision (31-60 % of annual CHW cost). Other important determinants of cost included programme management (15-28 % of annual CHW cost) and patient services (6-12 % of annual CHW cost). Within patient services, malaria rapid diagnostic tests are the major contributor to cost (64 % of patient service costs).The annual cost of a malaria CHW in Myanmar varies considerably depending on the context and the design of the programme, in particular remoteness and the approach to monitoring and evaluation. The estimates provide information to policy makers and CHW programme planners in Myanmar as well as supporting economic evaluations of their cost-effectiveness
- …
