Replication of a local record keeping method for collecting road crash data in low resource settings: lessons from Bangladesh and Nepal.

BACKGROUND: Police road crash and injury data in low-income and middle-income countries are known to under-report crashes, fatalities and injuries, especially for vulnerable road users. Local record keepers, who are members of the public, can be engaged to provide an additional source of crash and injury data. METHODS: This paper compares the application of a local record keeper method to capture road crash and injury data in Bangladesh and Nepal, assesses the quality of the data collected and evaluates the replicability and value of the methodology using a framework developed to evaluate the impact of being a local record keeper. OUTCOME: Application in research studies in both Bangladesh and Nepal found the local record keeper methodology provided high-quality and complete data compared with local police records. The methodology was flexible enough to adapt to project and context differences. The evaluation framework enabled the identification of the challenges and unexpected benefits realised in each study. This led to the development of an 11-step process for conducting road crash data collection using local record keepers, which is presented to facilitate replication in other settings. CONCLUSION: Data collected by local record keepers are a flexible and replicable method to understand the strengths and limitations of existing police data, adding to the evidence base and informing local and national decision-making. The method may create additional benefits for data collectors and communities, help design and assess road safety interventions and support advocacy for improved routine police data.

Trends in Anthropometric Measurements of Internationally Adopted Children.

OBJECTIVE: The objective of this study was to describe anthropometric measures from internationally adopted children. Internationally adopted children are at risk for poor growth and development and there is no standardized growth chart evaluation for internationally adopted children due to variations in growth, genetics, and environmental exposures. METHODS: This is a retrospective chart review of 882 patients seen in an international adoption clinic between 2010 and 2017. Anthropometric measurements were converted to Z scores for weight, height, head circumference, and body mass index. RESULTS: A total of 41 countries and 16 subregions were represented. Central America, northern Africa, southern Africa, and southern Europe were the only subregions that had positive mean Z scores for weight, and southeast Asia had the lowest mean Z score for weight (n = 40, -1.76). No subregion had a positive mean Z score for height, and western Asia had the lowest overall mean Z score for height (n = 2, -2.44). Mean Z score for body mass index was positive in several subregions. CONCLUSIONS: Growth is an important predictor of health and development, and this study adds to the literature on growth patterns of internationally adopted children.

Diagnosis and management of isolated neutropenia: A survey of pediatric hematologist oncologists.

BACKGROUND: Isolated neutropenia is a common referral to pediatric hematology oncology (PHO) physicians. There are no established consensus guidelines in the diagnosis and management of patients with isolated, asymptomatic, and incidentally discovered neutropenia. METHODS: A survey was distributed to PHO physicians on the American Society of Pediatric Hematology Oncology member discussion page to determine the common diagnostic and management decisions regarding patients with isolated neutropenia and to explore beliefs regarding the term "benign ethnic neutropenia." RESULTS: One hundred twenty-six PHO attending physicians completed the survey. The most common tests reportedly ordered for this patient population included complete blood cell count (CBC) (98%), peripheral smear (75%), antineutrophil antibody testing (29%), and immunoglobulins (24%). Providers were more likely to order an antineutrophil antibody in toddlers (p = .0085), and antinuclear antibody (ANA) panels in adolescents (p < .001). Half of providers do not request additional CBCs prior to their initial consultation, and most suggest referring patients with mild neutropenia after confirming a declining absolute neutrophil count (ANC) (51%). The three most important factors influencing ongoing follow-up included: history of recurrent/severe infections (98%), family history of blood disorders (98%), and more severe/progressively worsening neutropenia (97%). Seventy percent of respondents have diagnosed patients with "benign ethnic neutropenia," and 75% support replacement of the term to "typical neutrophil count with Fy(a-/b-) status," if confirmed with red cell phenotyping. CONCLUSION: We identified practice patterns of PHO physicians for the diagnosis and management of patients referred for asymptomatic and isolated neutropenia. These data provide the framework to conduct cost-effectiveness studies.

Cardiac arrest during endotracheal intubation of children with systolic dysfunction.

This multicenter study aimed to describe peri-intubation cardiac arrest in paediatric cardiac patients with significant (moderate or severe) systolic dysfunction of the systemic ventricle. Intubation data were collected from 4 paediatric cardiac ICUs in the United States (January 2015 - December 2017). Clinician practices during intubation of patients with significant dysfunction were compared to practices during intubation of patients without significant systolic dysfunction. There were 67 intubations in patients with significant systolic dysfunction. Peri-intubation cardiac arrest rate in this population was 14.9% (10/67); peri-intubation mortality was 3%. Majority (6/10; 60%) of the cardiac arrests were classified as pulseless electrical activity. Patients with cardiac arrest upon intubation had a higher serum lactate and lower serum pH than patients without peri-intubation cardiac arrest in the significant systolic dysfunction group.In comparing cardiac ICU patients with significant systolic dysfunction (n = 67) to patients from the same time period with normal ventricular function or mild dysfunction (n = 183), clinicians were less likely to use midazolam (11.9% versus 25.1%; p = 0.03) and more likely to use etomidate (16.4% versus 4.4%; p = 0.002) for intubation. Use of other sedative agents, video laryngoscopy, atropine, inotrope initiation, and consultation of an anaesthesiologist for intubation were not statistically different between the groups.This is the first study to describe the rate of and risk factors for peri-intubation cardiac arrest in paediatric cardiac ICU patients with systolic dysfunction. There was a higher peri-intubation cardiac arrest rate compared to published rates in critically ill children with heart disease and compared to children with significant systolic dysfunction undergoing elective general anaesthesia.

Children's exposure to psychological abuse and neglect: A population-based study in rural Bangladesh.

AIM: We aimed to estimate the prevalence and risk factors of child psychological abuse and neglect in a rural area of Bangladesh. METHODS: Data were obtained from interviewing 1416 children aged 11-17 years administering the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool for Children between March and April 2017. Linear regression analysis was used to estimate the risks of child psychological abuse and neglect. RESULTS: The prevalence rates of at least one form of psychological abuse both in the past year and lifetime were more than 97 per cent. Moreover, the rates of at least one form of neglect were about 58 per cent during the past year and 78 per cent over lifetime. Living separately from parents posed children to significant risks of neglect and psychological abuse. Working children and greater number of siblings in a family were risk factors for neglect, whereas witnessing family violence and being bullied were risk factors for psychological abuse. Children with more years of schooling experienced less neglect and psychological abuse. CONCLUSION: The high prevalence of child psychological abuse and neglect in this study shows child maltreatment as an ignored issue in Bangladesh.

Positive Airway Pressure Versus High-Flow Nasal Cannula for Prevention of Extubation Failure in Infants After Congenital Heart Surgery.

OBJECTIVES: Compare the impact of initial extubation to positive airway pressure versus high-flow nasal cannula on postoperative outcomes in neonates and infants after congenital heart surgery. DESIGN: Retrospective cohort study with propensity-matched analysis. SETTING: Cardiac ICU within a tertiary care children's hospital. PATIENTS: Patients less than 6 months old initially extubated to either high-flow nasal cannula or positive airway pressure after cardiac surgery with cardiopulmonary bypass were included (July 2012 to December 2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 258 encounters, propensity matching identified 49 pairings of patients extubated to high-flow nasal cannula versus positive airway pressure. Extubation failure was 12% for all screened encounters. After matching, there was no difference in extubation failure rate between groups (positive airway pressure 16% vs high-flow nasal cannula 10%; p = 0.549). However, compared with high-flow nasal cannula, patients initially extubated to positive airway pressure experienced greater resource utilization: longer time to low-flow nasal cannula (83 vs 28 hr; p = 0.006); longer time to room air (159 vs 110 hr; p = 0.013); and longer postsurgical hospital length of stay (22 vs 14 d; p = 0.015). CONCLUSIONS: In this pediatric cohort, primary extubation to positive airway pressure was not superior to high-flow nasal cannula with respect to prevention of extubation failure after congenital heart surgery. Compared with high-flow nasal cannula, use of positive airway pressure was associated with increased hospital resource utilization. Prospective initiatives aimed at establishing best clinical practice for postoperative noninvasive respiratory support are needed.

Nonparametric Regression Method for Broad Sense Agreement.

Characterizing the correspondence between an ordinal measurement and a continuous measurement is often of interest in mental health studies. To this end, Peng, Li, Guo, and Manatunga (2011) introduced the concept of broad sense agreement (BSA) and developed nonparametric estimation and inference for a BSA measure. In this work, we propose a non-parametric regression framework for BSA, which provides a robust tool to further investigate population heterogeneity in BSA. We develop inferential procedures including regression function estimation and hypothesis testing. Extensive simulation studies demonstrate satisfactory performance of the proposed method. We also apply the new method to a recent Grady Trauma Study and reveal an interesting impact of depression severity on the alignment between a self-reported symptom instrument and clinician diagnosis in posttraumatic stress disorder (PSTD) patients.

A general approach to categorizing a continuous scale according to an ordinal outcome.

In practice, disease outcomes are often measured in a continuous scale, and classification of subjects into meaningful disease categories is of substantive interest. To address this problem, we propose a general analytic framework for determining cut-points of the continuous scale. We develop a unified approach to assessing optimal cut-points based on various criteria, including common agreement and association measures. We study the nonparametric estimation of optimal cut-points. Our investigation reveals that the proposed estimator, though it has been ad-hocly used in practice, pertains to nonstandard asymptotic theory and warrants modifications to traditional inferential procedures. The techniques developed in this work are generally adaptable to study other estimators that are maximizers of nonsmooth objective functions while not belonging to the paradigm of M-estimation. We conduct extensive simulations to evaluate the proposed method and confirm the derived theoretical results. The new method is illustrated by an application to a mental health study.

Burns in South Asia: Outcomes from South Asian Burn Registry (SABR).

BACKGROUND: South Asian region contributes 59 % to the global mortality due to burns. However, we find a paucity of literature on the outcomes of burns from low- and middle-income countries (LMICs). South Asian Burn Registry (SABR) is a facility-based burns registry that collected data on in-patient burn care. This study assesses factors associated with mortality, length of hospital stay at the burns center, and functional status of burn patients. METHODS: Prospective data was collected from two specialized public sector burn centers between September 2014 - January 2015 from Bangladesh and Pakistan. Multivariable logistic, linear, and ordinal logistic regression was conducted to assess factors associated with inpatient-mortality, length of hospital stay, and functional status at discharge, respectively. RESULTS: Data on 883 patients was analyzed. Increased association with mortality was observed with administration of blood product (OR:3, 95 % CI:1.18-7.58) and nutritional support (OR:4.32, 95 % CI:1.55-12.02). Conversely, antibiotic regimens greater than 8 days was associated with decreased mortality (OR:0.1, 95 % CI:0.03-0.41). Associated increase in length of hospital stay was observed in patients with trauma associated with their burn injury, history of seizures (CE:47.93, 95 % CI 12.05-83.80), blood product (CE:22.09, 95 % CI:0.83-43.35) and oxygen administration (CE:23.7, 95 % CI:7.34-40.06). Patients who developed sepsis (OR:6.89, 95 % CI:1.92-24.73) and received blood products during hospitalization (OR:2.55, 95 % CI:1.38- 4.73) were more likely to have poor functional status at discharge. CONCLUSION: This study identified multiple factors associated with worse clinical outcomes for burn patients in South Asia. Understanding these parameters can guide targeted efforts to improve the process and quality of burn care in LMICs.

Factors associated with emergency department disposition among burn injury patients: Analysis of prehospital and emergency care characteristics using South Asia Burn Registry (SABR) data.

INTRODUCTION: Improvement in burn injury data collections and the quality of databanks has allowed meaningful study of the epidemiologic trends in burn care. The study assessed factors associated with disposition of burn injury patients from emergency department accounting for pre-hospital care and emergency care. METHODS: This prospective observational pilot study of the South Asia Burn Registry project was conducted at selected public sector burn centers in Bangladesh and Pakistan (September 2014 - January 2015). All age groups with an initial presentation to the burn centers were enrolled. Descriptive and regression analysis is presented. RESULTS: A total of 2749 patients were enrolled. The mean age was 21.7 ± 18.0 years, 55.3% were males, and about a quarter were children < 5 years. About 46.9% of the females were housewives. Scald burns were common among children (67.6%) while flame burns were common among adults (44.3%). About 75% of patients were brought in via non-ambulance mode of transport. More than 55% of patients were referrals from other facilities or clinics. The most common first aid given pre-hospital was the use of water or oil. About 25% were admitted for further care. The adjusted odds of being admitted compared to being sent home were highest for children < 5 yrs, those with higher total body surface area burnt, having arrived via ambulance, scald and electrical burn, having an associated injury and inhalational injury. CONCLUSION: The study provides insight into emergency burn care and associated factors that influenced outcomes for patients with burn injuries.

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites.

INTRODUCTION: Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes. METHODS: The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars. RESULTS: Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted. CONCLUSION: MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

Evaluation and management of pediatric thyroid nodules and thyroid cancer at a single institution after adoption of the American Thyroid Association 2015 guidelines.

OBJECTIVES: The study purpose is to correlate clinical findings with rates of differentiated thyroid cancer (DTC) in a cohort of children presenting with thyroid nodules at a single institution since the adoption of the 2015 American Thyroid Association (ATA) Guidelines Task Force on Pediatric Thyroid Cancer. METHODS: Clinical, radiographic, and cytopathologic findings were retrospectively analyzed in a pediatric cohort (≤19 years) identified with ICD-10 codes for thyroid nodules and thyroid cancer from January 2017 until May 2021. RESULTS: We analyzed 183 patients with thyroid nodules. The mean patient age was 14 years (interquartile range 11-16) with a female (79.2 %) and white Caucasian (78.1 %) predominance. The overall DTC in our pediatric patient cohort was 12.6 % (23 out of 183). Most of the malignant nodules measured from 1-4 cm (65.2 %) with TI-RADS score of ≥4 (69.6 %). Among the fine-needle aspiration results (n=49), the highest frequency of DTC was within the malignant category (16.33 %), followed by suspicious for malignancy (6.12 %), then atypia or follicular lesion of undetermined significance (8.16 %), and lastly follicular lesion or neoplasm and benign with 4.08 % and 2.04 % respectively. Of the forty-four thyroid nodules that underwent surgical intervention, pathology was remarkable for 19 papillary thyroid carcinoma (43.18 %) and 4 follicular thyroid carcinoma (9.09 %). CONCLUSIONS: Based on the analysis of our pediatric cohort in the southeast region at a single institution, adoption of the 2015 ATA guidelines could lead to an increased accuracy in detecting DTC while reducing the number of patients requiring interventions, such as FNA biopsy and/or surgeries. Further, based on our small cohort, it would be reasonable for thyroid nodules 1 cm or less to be monitored clinically with physical exam and ultrasonography, with further therapeutic or diagnostic intervention considered based on concerning features or parental shared decision making.

Baseline prevalence of hyperglycemia and its predictors among community clinic users of a selected rural area of Bangladesh: A cross-sectional study using the WHO PEN Protocol 1.

AIMS/INTRODUCTION: Our objective was to estimate the prevalence of hyperglycemia at baseline, and identify its predictors among community clinic (CC) users from a selected rural area of Bangladesh. MATERIALS AND METHODS: This cross-sectional study partly used the baseline data of implementation research in which a total of 11,244 adults visited the CC, and their blood glucose, blood pressure and anthropometry were evaluated according to 'Action 2' of the World Health Organization (WHO) Package of Essential Noncommunicable Disease Interventions (PEN) protocol 1. Of these, 11,144 had complete information on demography, chronic diseases and their risk factors, which were collected during the implementation of 'Action 1' of WHO PEN protocol 1 at the household level. Hyperglycemia, prediabetes (PreD) and type 2 diabetes were diagnosed using the WHO criteria. RESULTS: Using WHO PEN protocol 1, the estimated baseline prevalence was 12.5% for hyperglycemia, 3.4% for PreD and 9.2% for type 2 diabetes, and was more prevalent among men compared with women. PreD and type 2 diabetes had significantly higher odds ratio (OR >1) of having common risk factors as follows: age ≥40 years (PreD, P < 0.001; type 2 diabetes, P < 0.001), generalized obesity (PreD, P < 0.001; type 2 diabetes, P = 0.005) and hypertension (PreD, P < 0.000; type 2 diabetes, P < 0.001). Furthermore, participants with a family history of diabetes appeared to be a significant predictor of type 2 diabetes (P < 0.001), but not for PreD (P = 0.303). CONCLUSIONS: Hyperglycemia, preD and type 2 diabetes showed a comparatively high prevalence among the CC users of the selected rural area. Obesity and hypertension are the key modifiable risk factors that should be reduced using a CC-centered risk reduction strategy.

Self-reported prevalence of asthma and its associated factors among adult rural population in Bangladesh: a cross-sectional study using WHO PEN protocol.

OBJECTIVE: For over a decade, the prevalence of asthma remained unchanged at around 7% in Bangladesh. Although asthma causes significant morbidity among both children and adults, updates on epidemiological data are limited on the prevalence in Bangladesh. This study attempted to determine the prevalence of asthma, and its modifiable and non-modifiable lifestyle predictors in a rural population of Bangladesh. METHOD: This study was part of a cross-sectional study that applied the WHO Package of Essential Noncommunicable Disease Interventions via census in a rural area of Bangladesh, where self-reported data on asthma were recorded. Data on anthropometric measurement, sociodemographic characteristics and behavioural risk factors were collected following the standard protocol described in the WHO STEP-wise approach to surveillance (STEPS) questionnaire. Analysis included descriptive statistics to assess the prevalence of asthma and its risk factors, and binary logistic regression to determine contributing factors. RESULT: The overall prevalence of asthma was 4.2%. Asthma was predominant among people above 60 years (8.4%). Higher asthma was noted among males (4.6%), self-employed (5.1%), with a family history of asthma (9.1%), with comorbidities besides asthma (7.8%) and underweight (6.0%) compared with their counterparts. The OR of having asthma was 1.89, 1.93, 1.32, 1.50, 2.60, 0.67, 0.67 and 0.78 if a respondent was 45 years old or more, married, underweight, ever smoker, with a family history of asthma, housewife, employed and consumed red meat, respectively, while considering all other variables constant, compared with their counterparts. CONCLUSION: The study emphasised asthma to be a public health concern in Bangladesh, although it seems to have decreased over the last decade. Among others, red meat intake and nutritional status were strongly associated with asthma, and the linkage among these is still a grey area that needs further exploration.

Infant Safe Sleep Knowledge, Attitudes, and Behaviors by Physicians at an Academic Children's Hospital.

Sudden unexpected infant death (SUID) is the leading cause of death for infants. Physician advice on safe sleep is an important source of information for families. We sought to evaluate the safe sleep knowledge, attitudes, and behaviors of physicians by distributing a cross-sectional survey at a freestanding children's hospital. The survey included demographics, knowledge items, attitudinal assessment, and frequency of providing safe sleep guidance. Multivariable linear regression and logistic regression were used to evaluate associations between variables. 398 physicians were surveyed with 124 responses (31%). Females, those who received safe sleep training, and those who see infants in daily practice had higher knowledge scores. Physicians with higher knowledge scores had more positive attitudes toward safe sleep and provided safe sleep education to patients more often. Our study underlies the importance of education and repeated exposure in forming positive attitudes toward safe sleep recommendations and leads to increased provision of safe sleep guidance.

Epidemiology of Neonatal Acute Kidney Injury After Cardiac Surgery Without Cardiopulmonary Bypass.

BACKGROUND: The purpose of this Neonatal and Pediatric Heart and Renal Outcomes Network study was to describe the epidemiology and outcomes of cardiac surgery-associated acute kidney injury (CS-AKI) after cardiac surgery without cardiopulmonary bypass (non-CPB). METHODS: We performed a retrospective study of neonates (≤30 days) who underwent non-CPB cardiac surgery at 22 centers affiliated with the Pediatric Cardiac Critical Care Consortium. CS-AKI was defined using the modified Kidney Disease: Improving Global Outcomes serum creatinine and urine output criteria from postoperative days 0 to 6. CS-AKI defined by serum creatinine was further subclassified into transient (resolved by postoperative day 3) and persistent/late (≥3 days). Multivariable regression analyses were used to determine risk factors for CS-AKI and associations with outcomes of ventilation hours and cardiac intensive care unit length of stay. RESULTS: Five hundred eighty-two neonates (median age at surgery, 9 days [interquartile range, 5-15], 25% functional single ventricle] were included. CS-AKI occurred in 38.3%: Rate and severity varied across centers. Aggregate daily CS-AKI prevalence peaked on postoperative day 1 (17.1%). No stage of CS-AKI was associated with ventilation hours or length of stay. Persistent/late CS-AKI occurred in 48 patients (8%). Prostaglandin use and single-ventricle surgery were associated with persistent/late CS-AKI. Higher baseline serum creatinine but not persistent/late CS-AKI was associated with longer ventilation duration and intensive care unit length of stay after adjusting for confounders. CONCLUSIONS: Kidney Disease: Improving Global Outcomes-defined CS-AKI occurred commonly in neonates undergoing non-CPB cardiac surgery. However most CS-AKI was transient, and no CS-AKI classification was associated with worse outcomes. Further work is needed to determine the CS-AKI definition that best associates with outcomes in this cohort.

Effect of intensive blood pressure lowering on left atrial remodeling in the SPRINT.

Upstream therapy of atrial remodeling may decrease atrial fibrillation and associated thromboembolism. We examined the impact of intensive BP lowering on ECG-defined left atrial abnormalities in the SPRINT. SPRINT was a randomized clinical trial comparing outcomes when a systolic BP of <120 mmHg (standard treatment) was the target. We included SPRINT participants without baseline atrial fibrillation who had a technically interpretable baseline ECG and at least one follow-up ECG. The primary outcome was incident left atrial abnormality, defined as P-wave terminal force in V1 (PTFV1) > 4000 µV × ms. Secondary outcomes were regression of the left atrial abnormality and the change in PTFV1 from baseline across follow-up ECGs. Cox regression was used to examine the associations between treatment assignment and incident left atrial abnormality and its regression. We used linear mixed models to examine the changes in PTFV1. Of 9361 SPRINT participants, 7738 qualified for this analysis, of whom 5544 did not have baseline left atrial abnormalities. Intensive BP management was not associated with incident left atrial abnormality (HR, 0.96; 95% CI, 0.87-1.07) or regression of the baseline left atrial abnormality (HR, 1.09; 95% CI, 0.98-1.21). The change in PTFV1 from baseline through follow-up did not differ significantly between treatment groups (difference in µV × ms per year, 6; 95% CI, -67 to 79). Thus, among patients in a randomized clinical trial, we found no difference in the progression or regression of ECG-defined left atrial abnormalities with intensive BP management compared to standard BP management.

Challenges in Preventive Practices and Risk Communication towards COVID-19: A Cross-Sectional Study in Bangladesh.

Bangladesh recently experienced a COVID-19 second wave, resulting in the highest number of new cases and deaths in a single day. This study aims to identify the challenges for COVID-19 preventive practices and risk communications and associated factors among Bangladeshi adults. A cross-sectional survey was conducted between December 2020 and January 2021 involving 1382 Bangladeshi adults (aged ≥ 18-years) in randomly selected urban and rural areas from all eight divisions in Bangladesh. Descriptive data analysis was conducted to highlight the challenges for preventive practices and risk communications for COVID-19. Multiple logistic regression analysis was used to determine the sociodemographic groups vulnerable to these challenges. Lack of availability of protective equipment (44.4%), crowded living situations/workspaces (36.8%), inadequate information on the proper use of protective measures (21.9%), inadequate handwashing and sanitation facilities (17.6%), and negative influences on family/friends (17.4%) were identified as barriers to COVID-19 preventive practices. It was also found that males (OR = 1.3, 95% CI = 1.01, 1.7), rural residents (OR = 1.5, 95% CI = 1.2, 2), respondents with a low level of education: no schooling vs. ≥higher secondary (OR = 3.5, 95% CI = 2.3, 5.2), primary vs. ≥higher secondary (OR = 2.5, 95% CI = 1.7, 3.8), respondents engaged in agricultural (OR = 1.7, 95% CI = 1.2, 2.4), laboring (OR = 3.2, 95% CI = 2, 5), and domestic works (OR = 1.6, 95% CI = 1.07, 2.5), and people with disabilities (OR = 1.7, 95% CI = 1.1, 2.6) were all likely to have difficulty in practicing effective COVID-19 protective behaviors. Respondents' education and occupation were significant predictors of inadequate understanding of COVID-19 risk communications and was identified as a problem among 17.4% of the respondents. A substantial percentage of Bangladeshi adults have difficulty practising COVID-19 protective behaviours and have poor comprehension of risk communications, particularly in rural areas and among those with low education. This research can aid policymakers in developing tailored COVID-19 risk communications and mitigation strategies to help prevent future waves of the pandemic.

Concurrent diabetic ketoacidosis with hyperosmolality and/or severe hyperglycemia in youth with type 2 diabetes.

INTRODUCTION: Prevalence of diabetic ketoacidosis (DKA) complicated by severe hyperglycaemia and hyperosmolality and its outcomes in youth with type 2 diabetes (T2DM) are not well-described. Our aim is to determine the frequency and clinical outcomes of isolated DKA, DKA with severe hyperglycaemia (DKA + SHG) and DKA with hyperglycaemia and hyperosmolality (DKA + HH) in youth with T2DM admitted for acute hyperglycaemic crisis. METHODS: Through retrospective medical record review, patients with T2DM were identified and categorized into isolated DKA, DKA + SHG (DKA + glucose ≥33.3 mmol/L) and DKA + HH (DKA + glucose ≥33.3 mmol/L + osmolality ≥320 mmol/kg). RESULTS: Forty-eight admissions in 43 patients ages 9-18 were included: 28 (58%) had isolated DKA, six (13%) had DKA + SHG and 14 (29%) had DKA + HH. Subgroups' demographics and medical history were similar. Seventeen patients (35%) had acute kidney injury (AKI). Odds of AKI were higher in DKA + SHG and DKA + HH relative to isolated DKA (P = .015 and .002 respectively). Frequency of altered mental status (AMS) was similar among groups. Three patients (6%) had concurrent soft-tissue infections at presentation with no differences among subgroup. Three patients (6%) had other medical complications. These occurred only in patients with AKI and DKA + SHG or AKI and DKA + HH. CONCLUSIONS: In youth with T2DM, severe hyperglycaemia ± hyperosmolality frequently complicates DKA. Youth with DKA and features of hyperglycaemic hyperosmolar syndrome, including isolated severe hyperglycaemia, have increased odds of AKI.