Prevalence of tuberculosis infection among contacts of drug-resistant tuberculosis patients: A systematic review and meta-analysis.

INTRODUCTION: Contact investigations with drug-susceptible tuberculosis (DS-TB) patients have demonstrated a high prevalence of tuberculosis infection (TBI). However, the prevalence of TBI among individuals in close contact with drug-resistant tuberculosis (DR-TB) patients is poorly understood. This systematic review and meta-analysis aimed to determine the prevalence of TBI among household and non-household contacts of DR-TB patients. METHOD AND ANALYSIS: We searched five databases (Medline, Embase, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) from inception to 2 June 2023. All studies that reported the prevalence of TBI among DR-TB contacts were included in the study. A random-effects meta-analysis was conducted to estimate the pooled prevalence of TBI with a 95% confidence interval (CI). Sub-group analyses were conducted using study characteristics as covariates. RESULTS: Thirty studies involving 7659 study participants from 19 countries were included. The pooled prevalence of TBI among DR-TB contacts was 36.52% (95% CI: 30.27-42.77). The sub-group analysis showed considerable heterogeneity in the estimates, with the highest prevalence reported in Southeast Asia (80.74%; 95% CI: 74.09-87.39), household contacts (38.60%; 95% CI: 30.07-47.14), lower-middle-income countries (LMICs) (54.72; 95% CI: 35.90, 73.55), children (43.27%; 95% CI: 25.50, 61.04), and studies conducted between 2004 and 2012 (45.10; 95% CI: 32.44, 57.76). CONCLUSION: The prevalence of TBI among DR-TB contacts was high, with substantial regional variations. Further research is needed to determine the drug susceptibility status of TBI in DR-TB contacts. PROTOCOL REGISTRATION: The protocol is registered in PROSPERO (CRD42023390339).

Anticholinergic burden among in-patients: a cross-sectional study on prevalence, determinants, and impact on mortality in Ethiopia.

Background: Numerous studies report that anticholinergic burden (ACB) has been linked with several health consequences, including increased hospital admissions, prolonged hospitalization, and physical and cognitive impairment. However, low- and middle-income settings, as well as younger individuals, are underrepresented. Objectives: To assess the prevalence and determinants of ACB, and to assess the impact of ACB on in-hospital mortality among adult in-patients at University of Gondar Comprehensive Specialized Hospital (UOGCSH). Design: A cross-sectional study was conducted from June to August 2022 at UOGCSH among adult in-patients. Methods: A pre-tested questionnaire was utilized to collect data from patients and their corresponding medical charts. A consecutive sampling technique was used to select the participants. Descriptive statistics were used to summarize socio-demographic and clinical characteristics. Chi-squared, Fisher's exact, and Wilcoxon rank sum tests, as appropriate, were used to determine associations between independent variables and ACB. Kaplan-Meier survival curve and Cox proportional hazards regression test were used to assess the impact of ACB on in-hospital mortality. Results: A total of 420 adult in-patients, median (interquartile range) age of 38 (26, 55) years, participated in this study. Over half (58.3%) were exposed to anticholinergic medicines, with a high ACB (⩾3) seen in 11.2% of participants. High ACB was associated with higher median number of medicines per patient (p = 0.003) higher median hospital length of stay (p = 0.033), and having mental and behavioral disorders (p < 0.001). No significant association was found between ACB and in-hospital mortality (log-rank test p = 0.26, Cox regression adjusted hazard ratio: 1.47, 95% CI: 0.335-6.453, p = 0.61). Conclusion: Among adult in-patients, a significant majority (58.3%) were subjected to medications possessing anticholinergic properties, with a noteworthy 11.2% of the study subjects exhibiting a high ACB. Participants with higher median length of hospital stay were more likely to have high ACB even in this relatively younger adult patient population.

Background: Anticholinergics refers to substances that block the action of the neurotransmitter acetylcholine in the body. Previous studies have shown that medicines exhibiting anticholinergic effects could lead to increased hospital admissions, longer hospital stays, and both physical and cognitive impairments. Objective: In this study, we aimed to assess how medicines exhibiting anticholinergic effects might affect patients in Ethiopian in-patient settings. Methods: We conducted a cross-sectional study from June to August 2022, collecting data from adult in-patients through a questionnaire and medical charts. We used a widely recognized tool called Anticholinergic Cognitive Burden Score to measure anticholinergic burden. We used statistical analyses to identify associations between the use of anticholinergic medicines and various factors, including the number of medicines per patient and the length of hospital stay. Additionally, we explored the impact of anticholinergic burden on in-hospital mortality. Results: Out of the 420 participants, 245 were exposed to medicines with anticholinergic properties. High anticholinergic burden was observed in 47 patients. Patients with mental and behavioral disorders were more likely to have high anticholinergic burden, while those with diseases of the digestive system were less likely. Moreover, a high anticholinergic burden was linked to a greater median number of medicines per patient and an extended median hospital length of stay. However, the study found no significant difference in in-hospital mortality between patients with high and low anticholinergic burden. Conclusion: The study highlights that a significant proportion of the participants were exposed to medicines with anticholinergic properties, and a notable percentage experienced a high anticholinergic burden. This burden was particularly associated with mental and behavioral disorders, the use of higher number of medicines, and longer hospital stay. Importantly, the research did not find a clear link between anticholinergic burden and in-hospital mortality after accounting for other factors.

Understanding the impact of medicines with anticholinergic properties on patients at University of Gondar Hospital.

Impacts of armed conflicts on tuberculosis burden and treatment outcomes: a systematic review.

OBJECTIVES: This systematic review aimed to summarise existing literature on the impacts of armed conflicts on tuberculosis burden and treatment outcomes. DESIGN: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature Plus, Scopus, ScienceDirect, Embase and medRxiv. DATA EXTRACTION AND SYNTHESIS: Three reviewers independently screened, selected eligible studies and extracted data. A narrative review was undertaken to summarise the findings qualitatively. RESULTS: Eleven studies were included in this review, reporting on tuberculosis incidence rates, prevalence and treatment outcomes, including mortality. Overall, the impact of armed conflicts on case notifications was variable. Six studies reported overall increases in tuberculosis case notifications following the onset of conflicts, while three studies reported overall decreases in tuberculosis case notifications. Factors, including limited access to healthcare services, challenges in surveillance and laboratory confirmation, the destruction of health systems and incapacitating the healthcare workforce, contributed to a decrease in the number of notified cases. The higher tuberculosis notification in some of the studies could be attributed to the disruption of tuberculosis prevention and control programmes as well as increased socioeconomic deprivation, including malnutrition, mass migration, poor living conditions and overcrowding that are worsened during conflicts. Armed conflicts without effective interventions were associated with worse tuberculosis treatment outcomes, including lower proportions of people with treatment success and higher proportions of people with loss to follow-up, mortality and treatment failure. However, implementing various interventions in conflict settings (such as establishing a National Tuberculosis Control Programme) led to higher tuberculosis notification rates and treatment success. CONCLUSION: The impact of armed conflicts on tuberculosis notification is complex and is influenced by multiple factors. The findings of this review underscore the importance of concerted efforts to control tuberculosis in conflict settings using available resources.

Protocol for spatial prediction of soil transmitted helminth prevalence in the Western Pacific region using a meta-analytical approach.

BACKGROUND: Soil transmitted helminth (STH) infections are estimated to impact 24% of the world's population and are responsible for chronic and debilitating morbidity. Disadvantaged communities are among the worst affected and are further marginalized as infection prevalence fuels the poverty cycle. Ambitious targets have been set to eliminate STH infections, but accurate epidemiological data will be required to inform appropriate interventions. This paper details the protocol for an analysis that aims to produce spatial prediction mapping of STH prevalence in the Western Pacific Region (WPR). METHODS: The protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. The study design will combine the principles of systematic review, meta-analysis, and geospatial analysis. Systematic searches will be undertaken in PubMed, Scopus, ProQuest, Embase, and Web of Science for studies undertaken post 2000, to identify surveys that enable the prevalence of human STH infection within the WPR to be calculated. Covariate data for multivariable analysis will be obtained from publicly accessible sources. Survey data will be geolocated, and STH prevalence and covariates will be linked to produce a spatially referenced dataset for analysis. Bayesian model-based geostatistics will be used to generate spatially continuous estimates of STH prevalence mapped to a resolution of 1 km2. A separate geospatial model will be constructed for each STH species. Predictions of prevalence will be made for unsampled locations and maps will be overlaid for each STH species to obtain co-endemicity maps. DISCUSSION: This protocol facilitates study replication and may be applied to other infectious diseases or alternate geographies. Results of the subsequent analysis will identify geographies with high STH prevalence's and can be used to inform resource allocation in combating this neglected tropical disease. TRIAL REGISTRATION: Open Science Framework: osf.io/qmxcj.

Risk factors for diagnosis and treatment delay among patients with multidrug-resistant tuberculosis in Hunan Province, China.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is a global health threat associated with high morbidity and mortality rates. Diagnosis and treatment delays are associated with poor treatment outcomes in patients with MDR-TB. However, the risk factors associated with these delays are not robustly investigated, particularly in high TB burden countries such as China. Therefore, this study aimed to measure the length of diagnosis and treatment delays and identify their risk factors among patients with MDR-TB in Hunan province. METHODS: A retrospective cohort study was conducted using MDR-TB data from Hunan province between 2013 and 2018. The main outcomes of the study were diagnosis and treatment delay, defined as more than 14 days from the date of symptom to diagnosis confirmation (i.e., diagnosis delay) and from diagnosis to treatment commencement (i.e., treatment delay). A multivariable logistic regression model was fitted, and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to identify factors associated with diagnosis and treatment delay. RESULTS: In total, 1,248 MDR-TB patients were included in this study. The median length of diagnosis delays was 27 days, and treatment delays were one day. The proportion of MDR-TB patients who experienced diagnosis and treatment delay was 62.82% (95% CI: 60.09-65.46) and 30.77% (95% CI: 28.27-33.39), respectively. The odds of experiencing MDR-TB diagnosis delay among patients coming through referral and tracing was reduced by 41% (AOR = 0.59, 95% CI: 0.45-0.76) relative to patients identified through consultations due to symptoms. The odds of experiencing diagnosis delay among ≥ 65 years were 65% (AOR = 0.35, 0.14-0.91) lower than under-15 children. The odds of developing treatment delay among foreign nationalities and people from other provinces were double (AOR = 2.00, 95% CI: 1.31-3.06) compared to the local populations. Similarly, the odds of experiencing treatment delay among severely ill patients were nearly 2.5 times higher (AOR = 2.49, 95% CI: 1.41-4.42) compared to patients who were not severely ill. On the other hand, previously treated TB cases had nearly 40% (AOR = 0.59, 95% CI: 0.42-0.85) lower odds of developing treatment delay compared with new MDR-TB cases. Similarly, other ethnic minority groups had nearly 40% (AOR = 0.57, 95% CI: 0.34-0.96) lower odds of experiencing treatment delay than the Han majority. CONCLUSIONS: Many MDR-TB patients experience long diagnosis and treatment delays in Hunan province. Strengthening active case detection can significantly reduce diagnosis delays among MDR-TB patients. Moreover, giving attention to patients who are new to MDR-TB treatment, are severely ill, or are from areas outside Hunan province will potentially reduce the burden of treatment delay among MDR-TB patients.

A Digitally Enabled, Pharmacist service to detecT medicine harms in residential aged care (nursing home) (ADEPT): protocol for a feasibility study.

INTRODUCTION: This feasibility study aims to develop and test a new model of practice in Australia using digital technologies to enable pharmacists to monitor early signs and symptoms of medicine-induced harms in residential aged care. METHODS AND ANALYSIS: Thirty residents will be recruited from an aged care facility in South Australia. The study will be conducted in two phases. In phase I, the study team will work with aged care software providers and developers of digital technologies (a wearable activity tracker and a sleep tracking sensor) to gather physical activity and sleep data, as well as medication and clinical data from the electronic medication management system and aged care clinical software. Data will be centralised into a cloud-based monitoring platform (TeleClinical Care (TCC)). The TCC will be used to create dashboards that will include longitudinal visualisations of changes in residents' health, function and medicine use over time. In phase II, the on-site pharmacist will use the centralised TCC platform to monitor each resident's medicine, clinical, physical activity and sleep data to identify signs of medicine-induced harms over a 12-week period.A mixed methods process evaluation applying the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework will be used to assess the feasibility of the service. Outcome measures include service reach, changes in resident symptom scores (measured using the Edmonton Symptom Assessment System), number of medication adverse events detected, changes in physical activity and sleep, number of pharmacist recommendations provided, cost analysis and proportion of all pharmacists' recommendations implemented at 4-week, 8-week and 12-week postbaseline period. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the University of South Australia's Human Research Ethics Committee (205098). Findings will be disseminated through published manuscripts, conference presentations and reporting to the study funder. TRIAL REGISTRATION NUMBER: ACTRN12623000506695.

Burden of drug-resistant tuberculosis among contacts of index cases: a protocol for a systematic review.

INTRODUCTION: People having close contact with drug-resistant tuberculosis (DR-TB) patients are at increased risk of contracting and developing the disease. However, no comprehensive review has been undertaken to estimate the burden of DR-TB among contacts of DR-TB patients. Therefore, the current systematic review will quantify the prevalence and incidence of DR-TB among contacts of DR-TB patients. METHOD AND ANALYSIS: Systematic searches will be conducted in Medline, Embase, Web of Science, Scopus, Cochrane Central Register of Controlled trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases. The search will be conducted without restrictions on time, language and geography. A random-effects meta-analysis will be conducted for effect estimates. The pooled prevalence and incidence of DR-TB will be compared between people with and without contact with DR-TB patients. The presence of heterogeneity between studies will be assessed by Higgins I2 statistics. Subgroup analysis will be conducted to determine the source of heterogeneity. The risk of bias will be assessed using a visual inspection of the funnel plot and Egger's regression test statistics. Trim and fill analysis will be done in the presence of publication bias. A sensitivity analysis will be conducted by trimming low-quality studies. The systematic review will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines. ETHICS AND DISSEMINATION: Ethical approval will not be required for this study as it will be a systematic review and meta-analysis based on previously published evidence. The findings of the systematic review will be presented at scientific conferences and published in scientific journals. PROTOCOL REGISTRATION: The protocol is published in PROSPERO with registration number CRD42023390339.

Patients' Perspectives on Commencing Oral Anticoagulants in Atrial Fibrillation: An Exploratory Qualitative Descriptive Study.

BACKGROUND: Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices. METHODS: A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022. RESULTS: Ten patients (60% male, median age = 78.5 years) completed interviews. Patients' passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients' overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers. CONCLUSION: Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment.

Treatment burden and health-related quality of life of patients with multimorbidity: a cross-sectional study.

PURPOSE: The aim of this study was to investigate treatment burden and its relationship with health-related quality of life (HRQoL) among patients with multimorbidity (two or more chronic diseases) who were taking prescription medications and attending the outpatient department of the University of Gondar Comprehensive Specialized Teaching Hospital. METHODS: A cross-sectional study was conducted between March 2019 and July 2019. Treatment burden was measured using the Multimorbidity Treatment Burden Questionnaire (MTBQ), while HRQoL was captured using the Euroqol-5-dimensions-5-Levels (EQ-5D-5L). RESULTS: A total of 423 patients participated in the study. The mean global MTBQ, EQ-5D index, and EQ-VAS scores were 39.35 (± 22.16), 0.83 (± 0.20), and 67.32 (± 18.51), respectively. Significant differences were observed in the mean EQ-5D-Index (F [2, 81.88] 33.1) and EQ-VAS (visual analogue scale) scores (F [2, 75.48] = 72.87) among the treatment burden groups. Follow up post-hoc analyses demonstrated significant mean differences in EQ-VAS scores across the treatment burden groups and in EQ-5D index between the no/low treatment burden and high treatment burden, as well as between the medium treatment burden and high treatment burden. In the multivariate linear regression model, every one SD increase in the global MTBQ score (i.e., 22.16) was associated with a decline of 0.08 in the EQ-5D index (ß - 0.38, 95%CI - 0.48, - 0.28), as well as a reduction of 9.4 in the EQ-VAS score (ß - 0.51, 95%CI -0.60, - 0.42). CONCLUSION: Treatment burden was inversely associated with HRQoL. Health care providers should be conscious in balancing treatment exposure with patients' HRQoL.

Treatment outcomes of diabetic ketoacidosis among diabetes patients in Ethiopia. Hospital-based study.

BACKGROUND: There was limited data on treatment outcomes among patients with diabetic ketoacidosis (DKA) in Ethiopia. OBJECTIVE: The aim of the study was to determine the treatment outcomes of DKA patients attending Debre Tabor General Hospital. METHOD: A retrospective study was conducted at Debre Tabor General Hospital and data were collected from June 1 to June 30 of 2018. Participants included in the study were all diabetic patients with DKA admitted from August 2010 to May 31, 2018. The primary outcomes were the treatment outcomes of DKA including (in-hospital glycemic control, the length of hospital stay and in-hospital mortality). The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics was presented in the form of means with standard deviation and binary regression was conducted to determine factors that affect length of hospital stay among DKA patients. RESULT: 387 patients were included in the study. The mean age of patients was 33.30± 14.96 years. The most common precipitating factor of DKA was new onset diabetes mellitus 150(38.8%). The mean length of hospital stay was 4.64(±2.802) days. The mean plasma glucose at admission and discharge was 443.63(±103.33) and 172.94 (±80.60) mg/dL, respectively. The majority 370 (95.60%) of patients improved and discharged whereas 17 (4.40%) patients died in the hospital. Patients with mild and moderate DKA showed short hospital stay; AOR: 0.16 [0.03-0.78] and AOR:0.17[0.03-0.96] compared with severe DKA. Diabetic ketoacidosis precipitated by infection were nearly five times more likely to have long hospital stay than DKA precipitated by other causes; AOR: 4.59 [1.08-19.42]. In addition, serum glucose fluctuation during hospitalization increased the likelihood of long hospital stay, AOR: 2.15[1.76-2.63]. CONCLUSIONS: New onset type 1 diabetes was the major precipitating factor for DKA. Admitted DKA patients remained in hospital for a duration of approximately five days. About five out of hundred DKA patients ended up with death in the hospital. Infection, serum glucose fluctuations and severity of DKA were determinants of long hospital stay. Early prevention of precipitating factors and adequate management of DAK are warranted to reduce length of hospital stay and mortality.

Use of thromboprophylaxis guidelines and risk stratification tools in atrial fibrillation: A survey of general practitioners in Australia.

RATIONALE AND OBJECTIVES: Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources. METHOD: We conducted an online survey of Australian GPs. Descriptive statistics were used to summarise the findings. RESULTS: Responses from 115 GPs were included for analysis. Respondents reported various ways of accessing thromboprophylaxis-related information (n = 113), including clinical guidelines (13.3%), 'Therapeutic Guidelines© ' (37.2%) and Royal Australian College of General Practitioners websites (16.8%). Of those who reported reasons against accessing information from clinical guidelines (n = 97), the most frequent issues were: too many AF guidelines to choose from (34.0%; 33/97), different guidelines for different diseases (32.0%; 31/97), time-consuming to read guidelines (21.6%; 21/97), disagreements between different guideline recommendations (20.0%; 19/97), conflict with criteria for government subsidy (17.5%; 17/97) and GPs' busy schedules (15.5%; 15/97). When assessing patients' risk of stroke (n = 112) and bleeding (n = 111), the majority of the respondents reported primarily relying on a formal stroke risk (67.0%) and bleeding risk (55.0%) assessment tools, respectively. Respondents reported using formal stroke and bleeding risk assessment tools mainly when newly initiating patients on therapy (72.4%; 76/105 and 65.3%; 65/101, respectively). CONCLUSION: Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review.

Prevalence of Polypharmacy and Risks of Potentially Inappropriate Medication Use in the Older Population in a Developing Country: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIM: Polypharmacy and potentially inappropriate medication (PIM) use in older populations (65+ years) have not yet been investigated by meta-analyses in developing countries. This systematic literature review and meta-analysis aimed to investigate the prevalence of polypharmacy and PIM use and major risk factors associated with PIM prescribing in older adults in Ethiopia. METHODS: We searched PubMed/MEDLINE, Scopus, Embase, and Google Scholar databases to identify relevant studies published between January 1990 and October 2020. Observational studies reporting the prevalence and association of risk factors with polypharmacy and PIM use in the older population were meta-analyzed. A multilevel meta-analysis was conducted to pool the prevalence estimates, and the risk of PIM use was reported as a relative risk (RR) with a 95% confidence interval (CI). RESULTS: We identified by systematic literature review 404 articles. Of those, 8 studies fulfilled inclusion criteria, comprising a total sample of 2,608 participants. The overall prevalence of polypharmacy and PIM use pooled by meta-analysis in the Ethiopian older population was 33 and 37%, respectively. The risk factors of PIM use were analyzed in the meta-analysis (particularly polymorbidity, polypharmacy, gender, and older age), and only older age of 65+ (RR: 1.71, 95% CI: 1.16-2.51) was significantly associated with PIM use. CONCLUSION: This first meta-analysis from a developing country revealed a high prevalence of polypharmacy and PIM use in the Ethiopian older population. There was no awareness about the risk of PIMs in patients with polypharmacy and polymorbidity, and older age significantly predicted PIM use. Interventions ensuring rational geriatric pharmacotherapy are essential in developing countries in order to reduce the expected burden of PIM-related geriatric morbidity, higher costs, and mortality.

Risk of Gastrointestinal Bleeding on Treatment With Statin Alone or With Concomitant Administration of Warfarin: A Systematic Review and Meta-analysis of 5.3 Million Participants.

OBJECTIVE: This study aimed to comprehensively evaluate the risk of gastrointestinal bleeding (GIB) with statin monotherapy or with concomitant warfarin use. DATA SOURCES: PubMed, Web of Science, and EMBASE (via Scopus) were searched for observational studies that reported the risk of GIB in adults on statin therapy or with concomitant warfarin use until August 28, 2021. STUDY SELECTION AND DATA EXTRACTION: Observational studies evaluating the risk of GIB in adults (age >18 years) on statin medication or concomitant use with warfarin were included. DATA SYNTHESIS: In all, 14 studies with a total of 5 235 123 participants, reporting 48 677 GIB events (43 734 from statin users and 4943 from users of statin combined with warfarin), were included in the analyses. The pooled analysis revealed no difference in the risk of GIB with statin monotherapy (relative risk [RR]: 0.65; 95% CI: 0.42-1.02) or concomitant statin + warfarin use (RR: 0.97; 95% CI: 0.91-1.02). Prior use of statin was not associated with GIB risk (RR: 0.88; 95% CI: 0.63-1.22), whereas a shorter duration of statin use (<5 years) was associated with a lower risk of GIB (RR: 0.42; 95% CI: 0.18-0.97). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This analysis provides strong evidence on the association between statin use (with/without warfarin) and risk of GIB. CONCLUSION: Statin alone or combined with warfarin was not significantly associated with either an increased or decreased risk of GIB. The GIB risk was significantly lower when statins were used for a short duration (<5 years). The putative relationship between statins and GIB in warfarin users warrant further investigation.

Mapping national, regional and local prevalence of hypertension and diabetes in Ethiopia using geospatial analysis.

OBJECTIVES: This study aimed to map the national, regional and local prevalence of hypertension and diabetes in Ethiopia. DESIGN AND SETTING: Nationwide cross-sectional survey in Ethiopia combined with georeferenced ecological level data from publicly available sources. PARTICIPANTS: 9801 participants aged between 15 and 69 years. PRIMARY OUTCOME MEASURES: Prevalence of hypertension and diabetes were collected using the WHO's STEPS survey approach. Bayesian model-based geostatistical techniques were used to estimate hypertension and diabetes prevalence at national, regional and pixel levels (1×1 km2) with corresponding 95% credible intervals (95% CrIs). RESULTS: The national prevalence was 19.2% (95% CI: 18.4 to 20.0) for hypertension and 2.8% (95% CI: 2.4 to 3.1) for diabetes. Substantial variation was observed in the prevalence of these diseases at subnational levels, with the highest prevalence of hypertension observed in Addis Ababa (30.6%) and diabetes in Somali region (8.7%). Spatial overlap of high hypertension and diabetes prevalence was observed in some regions such as the Southern Nations, Nationalities and People's region and Addis Ababa. Population density (number of people/km2) was positively associated with the prevalence of hypertension (ß: 0.015; 95% CrI: 0.003-0.027) and diabetes (ß: 0.046; 95% CrI: 0.020-0.069); whereas altitude in kilometres was negatively associated with the prevalence of diabetes (ß: -0.374; 95% CrI: -0.711 to -0.044). CONCLUSIONS: Spatial clustering of hypertension and diabetes was observed at subnational and local levels in Ethiopia, which was significantly associated with population density and altitude. The variation at the subnational level illustrates the need to include environmental drivers in future NCDs burden estimation. Thus, targeted and integrated interventions in high-risk areas might reduce the burden of hypertension and diabetes in Ethiopia.

The COVID-19 pandemic and healthcare systems in Africa: a scoping review of preparedness, impact and response.

BACKGROUND: The COVID-19 pandemic has overwhelmed health systems in both developed and developing nations alike. Africa has one of the weakest health systems globally, but there is limited evidence on how the region is prepared for, impacted by and responded to the pandemic. METHODS: We conducted a scoping review of PubMed, Scopus, CINAHL to search peer-reviewed articles and Google, Google Scholar and preprint sites for grey literature. The scoping review captured studies on either preparedness or impacts or responses associated with COVID-19 or covering one or more of the three topics and guided by Arksey and O'Malley's methodological framework. The extracted information was documented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension checklist for scoping reviews. Finally, the resulting data were thematically analysed. RESULTS: Twenty-two eligible studies, of which 6 reported on health system preparedness, 19 described the impacts of COVID-19 on access to general and essential health services and 7 focused on responses taken by the healthcare systems were included. The main setbacks in health system preparation included lack of available health services needed for the pandemic, inadequate resources and equipment, and limited testing ability and surge capacity for COVID-19. Reduced flow of patients and missing scheduled appointments were among the most common impacts of the COVID-19 pandemic. Health system responses identified in this review included the availability of telephone consultations, re-purposing of available services and establishment of isolation centres, and provisions of COVID-19 guidelines in some settings. CONCLUSIONS: The health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. Interventions that will improve and strengthen health system resilience and financing through local, national and global engagement should be prioritised.

Reasons for non-adherence to thromboprophylaxis prescribing guidelines in atrial fibrillation in Western Australia: A qualitative descriptive study of general practitioners' views.

BACKGROUND: A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change. METHODS: An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model. RESULTS: Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools). CONCLUSION: GPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs.

Prevalence and Determinants of Multimorbidity, Polypharmacy, and Potentially Inappropriate Medication Use in the Older Outpatients: Findings from EuroAgeism H2020 ESR7 Project in Ethiopia.

Few studies have been conducted on multimorbidity (two or more chronic diseases) and rational geriatric prescribing in Africa. This study examined the prevalence and determinants of multimorbidity, polypharmacy (five or more long-term medications), and potentially inappropriate medication (PIM) use according to the 2019 Beers criteria among the older adults attending chronic care clinics from a single institution in Ethiopia. A hospital-based cross-sectional study was conducted among 320 randomly selected older adults from 12 March 2020 to 30 August 2020. A multivariable logistic regression analysis was performed to identify the predictor variables. The prevalence of multimorbidity, polypharmacy, and PIM exposure was 59.1%, 24.1%, and 47.2%, respectively. Diuretics (10%), insulin sliding scale (8.8%), amitriptyline (7.8%), and aspirin (6.9%) were among the most frequently prescribed PIMs. Older patients experiencing pain flare-ups were more likely to have multimorbidity (adjusted odds ratio (AOR): 1.64, 95% confidence intervals: 1.13-2.39). Persistent anger (AOR: 3.33; 1.71-6.47) and use of mobility aids (AOR: 2.41, 1.35-4.28) were associated with polypharmacy. Moreover, cognitive impairment (AOR: 1.65, 1.15-2.34) and health deterioration (AOR: 1.61, 1.11-2.32) increased the likelihood of PIM exposure. High prevalence of multimorbidity and PIM use was observed in Ethiopia. Several important determinants that can be modified by applying PIM criteria in routine practice were also identified.

Clinical Characteristics and In-Hospital Outcome of Acute Heart Failure Patients Admitted to the Medical Ward of University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

BACKGROUND: Despite the growing burden of heart failure in developing countries, data describing the clinical characteristics and in-hospital outcomes of acute heart failures are limited. Therefore, this study aimed at describing the clinical characteristics and in-hospital outcomes of acute heart failure patients admitted to the medical ward of University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. METHODS: A prospective observational hospital-based cross-sectional study was conducted on 226 patients with acute heart failure at the University of Gondar Comprehensive Specialized Hospital from November 2019 to October 2020. Data were collected by using a pretested data abstraction format and analyzed with Statistical Package for Social Sciences version 21. Bivariable and multivariable binary logistic regression model were fitted to identify factors associated with in-hospital outcome and reported with 95% confidence interval (CI). P-value <0.05 was considered as statistically significant. RESULTS: The mean (± standard deviation) age of the study participant was 51.17±19.03 years and 59.3% were females. Majority, 60.6% of patients were admitted with new onset heart failure. Dyspnea (88.05%) and peripheral edema (80.5%) were the most frequent clinical findings. The in-hospital mortality was 10.6% (95% CI: 7.1-14.7). Atrial fibrillation (AOR=9.46; 95% CI: 1.49-60.29), concurrent ischemic heart disease (AOR=8.23; 95% CI: 1.15-58.89), being admitted with reduced left ventricular ejection fraction (AOR=5.36; 95% CI: 2.81-35.52), presence of orthopnea (AOR=6.63; 95% CI: 2.94-46.76), and using intranasal oxygen therapy (AOR=9.41; 95% CI: 1.35-65.82) were significantly associated with in-hospital mortality in patients with acute heart failure. CONCLUSION: The in-hospital mortality of acute heart failure patients was relatively higher in the study area. Therefore, specific preventative and therapeutic strategies focusing on heart failure patients with reduced left ventricular ejection fraction, atrial fibrillation, ischemic heart disease, orthopnea, and intranasal oxygen therapy are required to reduce the mortality rate.

Strategies for improving guideline adherence of anticoagulants for patients with atrial fibrillation in primary healthcare: A systematic review.

BACKGROUND: Clinical guidelines on atrial fibrillation management help optimize the use of oral anticoagulants. However, guideline non-adherence is common, particularly in the primary care setting. The primary aim of this systematic review was to identify effective strategies for improving adherence to guideline-directed thromboprophylaxis to patients with atrial fibrillation in the primary care setting. METHODS: A search was conducted on 6 electronic databases (Medline, Embase, ScienceDirect, Scopus, the Cumulative Indexing of Nursing and Allied Health Literature, and Web of Science) supplemented by a Google advanced search. Studies aimed at improving oral thromboprophylaxis guideline adherence in patients with atrial fibrillation, in the primary care setting, were included in the study. RESULTS: A total of 33 studies were included in this review. Nine studies employed electronic decision support (EDS), of which 4 reported modest improvements in guideline adherence. Five of 6 studies that utilized local guidelines as quality improvement measures reported improvement in guideline adherence. All 5 studies that employed coordinated care and the use of specialist support and 4 of the 5 studies that involved pharmacist-led interventions reported improvements in guideline adherence. Interventions based mainly on feedback from audits were less effective. CONCLUSIONS: Multifaceted interventions, especially those incorporating coordinated care and specialist support, pharmacists, or local adaptations to and implementation of national and/or international guidelines appear to be more consistently effective in improving guideline adherence in the primary care setting than interventions based mainly on EDS and feedback from audits.