27 research outputs found
A Population-Based Conceptual Framework for Evaluating the Role of Healthcare Services in Place of Death
No full textBackground: There is a significant geographical disparity in place of death. Socio-demographic and disease-related variables only explain less than a quarter of the variation. Healthcare service factors may account for some (or much) of the remaining variation but their effects have never been systematically evaluated, partly due to the lack of a conceptual framework. This study aims to propose a population-based framework to guide the evaluation of the role of the healthcare service factors in place of death. Methods: Review and synthesis of health service models that include the impact of a service component on either place of death/end of life care outcomes or service access/utilization. Results: The framework conceptualizes the impact of healthcare services on the place of death as starting from the end of life care policies that in turn influence service commissioning and shape healthcare service characteristics, including service type, service capacity—facilities, service location, and workforce, through which service utilization and ultimately place of death are affected. Patient socio-demographics, disease-related variables, family and community support and social care also influence place of death, but they are not the focus of this framework and therefore are grouped as needs and other environmental factors. Information on service utilization, together with the place of death, creates loop feedback to inform policy and service commission. Conclusions: The framework provides guidance for analysis aiming to understand the role of healthcare services in place of death. It aids the interpretation of results in the light of existing knowledge and potentially identifies service factors that can be addressed to improve end of life care
Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial.
No full textBACKGROUND: Peripartum hysterectomy can cause significant morbidity and mortality. Most studies of peripartum hysterectomy are from high income countries. This cohort study examined risk factors for peripartum hysterectomy using data from Africa, Asia, Europe and the Americas. METHODS: We used data from the World Maternal Antifibrinolytic (WOMAN) trial carried out in 193 hospitals in 21 countries. Peripartum hysterectomy was defined as hysterectomy within 6 weeks of delivery as a complication of postpartum haemorrhage. Univariable and multivariable random effects logistic regression models were used to analyse risk factors. A hierarchical conceptual framework guided our multivariable analysis. RESULTS: Five percent of women had a hysterectomy (1020/20,017). Haemorrhage from placenta praevia/accreta carried a higher risk of hysterectomy (17%) than surgical trauma/tears (5%) and uterine atony (3%). The adjusted odds ratio (AOR) for hysterectomy in women with placenta praevia/accreta was 3.2 (95% CI: 2.7-3.8), compared to uterine atony. The risk of hysterectomy increased with maternal age. Caesarean section was associated with fourfold higher odds of hysterectomy than vaginal delivery (AOR 4.3, 95% CI: 3.6-5.0). Mothers in Asia had a higher hysterectomy incidence (7%) than mothers in Africa (5%) (AOR: 1.2, 95% CI: 0.9-1.7). CONCLUSIONS: Placenta praevia/accreta is associated with a higher risk of peripartum hysterectomy. Other risk factors for hysterectomy are advanced maternal age, caesarean section and giving birth in Asia
Techniques for improving client relations in family planning programs
No full textDemand for children and demand for contraceptives are not independent of the system of supply. And client transactions are the major means for lowering costs. Family planning workers, providers of services and mass media campaigns, are the harbingers of new ideas and new delivery systems that could modify the demand for fertility regulation and patterns of contraceptive use. The authors describe four broad techniques for improving client relations, emphasizing their potential as entry points into program development (systematic change). These techniques are presented as a sampling of experience that can be brought to bear on dysfunctional client relations. Among examples described: Patient flow analysis (PFA). A self-administered time-and-motion diagnosis that allows computerized documentation of patient flow and personnel use in health service clinics. Using relatively unobtrusive data collection, PFA seeks to get a representative snapshot of a program and its dysfunctions, replicating a typical clinic session. Data are later diagnosed and remedies proposed for bottlenecks and inefficiencies. Training and visit (T&V). A managerial approach for dealing with geographically scattered outreach programs. The four main principles of T&V: focus on a few key tasks, frequent in-service training and supervision, regularity and predictability, and face-to-face communication. The T&V model focuses on what workers should be doing with their time in the field to meet client needs. A goal of T&V: to enable all clients to name their worker and the day of the week s/he visits, and identify a few themes from their most recent encounter. Activity planning. The antithesis of T&V, activity planning calls for abandoning rigid time-place-movement schedules and specific messages and replacing them with a fluid work schedule adapted to local conditions. Workers must be well-trained in collecting data, listening and building rapport, and communicating with conviction. The quality of the worker-client relationship is all-important. A weakness is that if the workers have no objective they lose control of the exchange with clients. Training and worker empowerment. Training by itself is not enough for systematic change - training for what? But training can serve as an entry point into organizational development when it is rooted in methodologies that help to develop the participant's technical and interpersonal skills and ability to innovate. But training must be accompanied by changes in the system of supply that supports and facilitates innovation and quality of care. Techniques to improve client relations can address either the client-provider interface directly or the system of underlying determinants. It is important to ask basic questions: Is the idea to fix a single worker-client dysfunction or is it to provide a continuous program for modification and growth? Who will be affected by the change? Whoor what will be responsible for initiating and overseeing the course of action? What are the short- and long-run goals of intervention?Health Monitoring&Evaluation,ICT Policy and Strategies,Adolescent Health,Poverty Monitoring&Analysis,Geographical Information Systems
NSEC5, DNSSEC authenticated denial of existence
No full textThe Domain Name System Security Extensions (DNSSEC) introduced two
resource records (RR) for authenticated denial of existence: the NSEC
RR and the NSEC3 RR. This document introduces NSEC5 as an
alternative mechanism for DNSSEC authenticated denial of existence.
NSEC5 uses verifiable random functions (VRFs) to prevent offline
enumeration of zone contents. NSEC5 also protects the integrity of
the zone contents even if an adversary compromises one of the
authoritative servers for the zone. Integrity is preserved because
NSEC5 does not require private zone-signing keys to be present on all
authoritative servers for the zone, in contrast to DNSSEC online
signing schemes like NSEC3 White Lies.https://datatracker.ietf.org/doc/draft-vcelak-nsec5/First author draf
Individual level covariate adjusted conditional autoregressive (indiCAR) model for disease mapping
No full text© 2016 The Author(s). Background: Mapping disease rates over a region provides a visual illustration of underlying geographical variation of the disease and can be useful to generate new hypotheses on the disease aetiology. However, methods to fit the popular and widely used conditional autoregressive (CAR) models for disease mapping are not feasible in many applications due to memory constraints, particularly when the sample size is large. We propose a new algorithm to fit a CAR model that can accommodate both individual and group level covariates while adjusting for spatial correlation in the disease rates, termed indiCAR. Our method scales well and works in very large datasets where other methods fail. Results: We evaluate the performance of the indiCAR method through simulation studies. Our simulation results indicate that the indiCAR provides reliable estimates of all the regression and random effect parameters. We also apply indiCAR to the analysis of data on neutropenia admissions in New South Wales (NSW), Australia. Our analyses reveal that lower rates of neutropenia admissions are significantly associated with individual level predictors including higher age, male gender, residence in an outer regional area and a group level predictor of social disadvantage, the socio-economic index for areas. A large value for the spatial dependence parameter is estimated after adjusting for individual and area level covariates. This suggests the presence of important variation in the management of cancer patients across NSW. Conclusions: Incorporating individual covariate data in disease mapping studies improves the estimation of fixed and random effect parameters by utilizing information from multiple sources. Health registries routinely collect individual and area level information and thus could benefit by using indiCAR for mapping disease rates. Moreover, the natural applicability of indiCAR in a distributed computing framework enhances its application in the Big Data domain with a large number of individual/group level covariates. CI NSW Study Reference Number: 2012/07/410. Dated: July 2012
Statistical analysis plan for the WOMAN-ETAPlaT study: Effect of tranexamic acid on platelet function and thrombin generation [version 1; referees: 2 approved, 2 approved with reservations]
No full textBackground. Postpartum haemorrhage (PPH) is a potentially life-threatening complication for women, and the leading cause of maternal mortality. Tranexamic acid (TXA) is an antifibrinolytic used worldwide to treat uterine haemorrhage and to reduce blood loss in general surgery. TXA may have effects on thrombin generation, platelet function and coagulation factors as a result of its inhibition on the plasmin. Methods. WOMAN ETAPlaT is a sub-study of the World Maternal Antifibrinolitic trial (WOMAN trial). All adult women clinically diagnosed with PPH after a vaginal delivery or caesarean section, are eligible for inclusion in the study. Blood samples will be collected at the baseline and 30 minutes after the first dose of study treatment is given. Platelet function will be evaluated in whole blood immediately after sampling with Multiplate® tests (ADPtest and TRAPtest). Thrombin generation, fibrinogen, D-dimer, and coagulation factors vW, V and VIII will be analysed using platelet poor plasma. Results. Recruitment to WOMAN ETAPlaT started on 04 November 2013 and closed on 13 January 2015, during this time 188 patients were recruited. The final participant follow-up was completed on 04 March 2015. This article introduces the statistical analysis plan for the study, without reference to unblinded data. Conclusion. The data from this study will provide evidence for the effect of TXA on thrombin generation, platelet function and coagulation factors in women with PPH. Trial registration: ClinicalTrials.gov Identifier: NCT00872469; ISRCTN7691219
No effect of tranexamic acid on platelet function and thrombin generation (ETAPlaT) in postpartum haemorrhage: a randomised placebo-controlled trial.
No full textBackground: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity. The WOMAN trial showed that tranexamic acid (TXA) reduces death due to bleeding in women with PPH. To determine whether TXA has pro-thrombotic effects in women with PPH, we measured endogenous thrombin potential (ETP), coagulation factors V, VIII, von Willebrand (vW), fibrinogen, D-Dimers and platelet function. Methods: We conducted a sub-study within the WOMAN trial, an international randomized, parallel-group, double blind, placebo-controlled trial. Women with primary PPH were randomly allocated to receive 1 gram of tranexamic acid or matching placebo. Baseline blood samples were collected just prior to the first dose and a follow up sample was collected 30±15 minutes afterwards. We compared before and after changes in coagulation parameters between treatment groups using repeated measurement ANOVA. Change in ETP was the primary outcome. We did an intention-to-treat analysis using ANCOVA with adjustment for baseline and the time interval between the blood samples. Findings: A total of 187 patients were randomized to receive TXA (n=93) or matching placebo (n=94). Six patients were excluded due to incomplete data. The reduction in ETP from baseline to follow up was 43.2 nM*min (95%CI, -16.6 to 103.1) in the TXA group and 4.6 nM*min (95%CI, -51.4 to 60.6) in the placebo group. The difference was not statistically significant (95%CI, -42.9 to 120). There were no significant effects of TXA treatment on any other parameters (ADPtest, TRAPtest, coagulation factors activity, fibrinogen levels, D-Dimer level). Conclusion: We found no evidence that tranexamic acid treatment for PPH has substantial pro-coagulant effects. However, larger studies are needed to confirm or refute more modest effects. Trial registration: ISRCTN76912190 (initially registered 10/12/2008, WOMAN-ETAPlat included on 28/10/2013) and NCT00872469 (initially registered 31/03/2009, WOMAN-ETAPlat included on 28/10/2013)
Can NSEC5 be practical for DNSSEC deployments?
No full textNSEC5 is proposed modification to DNSSEC that simultaneously guarantees two security properties: (1) privacy against offline zone enumeration, and (2) integrity of zone contents, even if an adversary compromises the authoritative nameserver responsible for responding to DNS queries for the zone. This paper redesigns NSEC5 to make it both practical and performant. Our NSEC5 redesign features a new fast verifiable random function (VRF) based on elliptic curve cryptography (ECC), along with a cryptographic proof of its security. This VRF is also of independent interest, as it is being standardized by the IETF and being used by several other projects. We show how to integrate NSEC5 using our ECC-based VRF into the DNSSEC protocol, leveraging precomputation to improve performance and DNS protocol-level optimizations to shorten responses. Next, we present the first full-fledged implementation of NSEC5—extending widely-used DNS software to present a nameserver and recursive resolver that support NSEC5—and evaluate their performance under aggressive DNS query loads. Our performance results
indicate that our redesigned NSEC5 can be viable even for high-throughput scenarioshttps://eprint.iacr.org/2017/099.pdfFirst author draf
Measuring Coverage in MNCH:A Validation Study Linking Population Survey Derived Coverage to Maternal, Newborn, and Child Health Care Records in Rural China
No full textBackground: Accurate data on coverage of key maternal, newborn, and child health (MNCH) interventions are crucial for monitoring progress toward the Millennium Development Goals 4 and 5. Coverage estimates are primarily obtained from routine population surveys through self-reporting, the validity of which is not well understood. We aimed to examine the validity of the coverage of selected MNCH interventions in Gongcheng County, China. Method and Findings: We conducted a validation study by comparing women's self-reported coverage of MNCH interventions relating to antenatal and postnatal care, mode of delivery, and child vaccinations in a community survey with their paper- and electronic-based health care records, treating the health care records as the reference standard. Of 936 women recruited, 914 (97.6%) completed the survey. Results show that self-reported coverage of these interventions had moderate to high sensitivity (0.57 [95% confidence interval (CI): 0.50-0.63] to 0.99 [95% CI: 0.98-1.00]) and low to high specificity (0 to 0.83 [95% CI: 0.80-0.86]). Despite varying overall validity, with the area under the receiver operating characteristic curve (AUC) ranging between 0.49 [95% CI: 0.39-0.57] and 0.90 [95% CI: 0.88-0.92], bias in the coverage estimates at the population level was small to moderate, with the test to actual positive (TAP) ratio ranging between 0.8 and 1.5 for 24 of the 28 indicators examined. Our ability to accurately estimate validity was affected by several caveats associated with the reference standard. Caution should be exercised when generalizing the results to other settings. Conclusions: The overall validity of self-reported coverage was moderate across selected MNCH indicators. However, at the population level, self-reported coverage appears to have small to moderate degree of bias. Accuracy of the coverage was particularly high for indicators with high recorded coverage or low recorded coverage but high specificity. The study provides insights into the accuracy of self-reports based on a population survey in low- and middle-income countries. Similar studies applying an improved reference standard are warranted in the future.</p
The Lifetime Health and Economic Burden of Smokeless Tobacco use in Bangladesh, India, and Pakistan: Results From ASTRAMOD
No full textData Availability:
The data that were used in the ASTRAMOD model are provided in various appendices under the Supplementary Materials. The corresponding author can be contacted for any future adaptation of ASTRAMOD.Supplementary data are available online at: https://academic.oup.com/ntr/article/27/4/684/7666810#supplementary-data .Introduction:
Under the current policy landscapes, the lifetime health and economic burden of smokeless tobacco (ST) products, consumed by over 297 million ST users in South Asia, is unknown. The aim of this study was to estimate the lifetime health effects and costs attributable to current and future ST use in Bangladesh, India, and Pakistan where the majority of ST users live.
Aims and Methods:
We developed a Markov-based state-transition model (ASTRAMOD) to predict the lifetime costs of treatment of four diseases (oral, pharyngeal, esophageal cancers, and stroke) and disability-adjusted life years (DALYs), attributable to the current and future use of ST under existing ST policy scenario. Country-specific Global Adult Tobacco Surveys, life tables, and meta-analyses of South Asian and South East Asian studies were used to populate the model. A probabilistic sensitivity analysis evaluated the uncertainty in model predictions.
Results:
If there were no change in the current ST policies, the lifetime ST-attributable treatment costs would be over US1.5 billion in Bangladesh, and over US7–21 on healthcare spending if ST policies were changed to eliminate ST use.
Conclusions:
Policy interventions aimed at decreasing the uptake of ST and increasing quitting success have the potential to substantially decrease the economic and health burden of ST.
Implications:
This study provides the most comprehensive estimates of the lifetime health and economic burden of ST by 5-year age and sex cohorts. This is also the first study that highlights the scale of health and economic burden of ST in Bangladesh, India, and Pakistan if there were no changes in the current ST policies. Policymakers and practitioners can use the reported data to justify their decisions to improve current ST policies and practices in their country. Researchers can use the ASTRAMOD methodology to estimate the impact of future ST policy changes.NIHR [Grant Number: 17/63/76] using UK aid from the UK Government to support global health research
