Cost-effectiveness of a decentralized, community-based "one-stop-shop" hepatitis C testing and treatment program in Yangon, Myanmar.

Background and Aim: The availability of direct-acting antiviral (DAA) treatment and point-of-care diagnostic testing has made hepatitis C (HCV) elimination possible even in low- and middle-income countries (LMICs); however, testing and treatment costs remain a barrier. We estimated the cost and cost-effectiveness of a decentralized community-based HCV testing and treatment program (CT2) in Myanmar. Methods: Primary cost data included the costs of DAAs, investigations, medical supplies and other consumables, staff salaries, equipment, and overheads. A deterministic cohort-based Markov model was used to estimate the average cost of care, the overall quality-adjusted life years (QALYs) gained, and the incremental cost-effectiveness ratio (ICER) of providing testing and DAA treatment compared with a modeled counterfactual scenario of no testing and no treatment. Results: From 30 January to 30 September 2019, 633 patients were enrolled, of whom 535 were HCV RNA-positive, 489 were treatment eligible, and 488 were treated. Lifetime discounted costs and QALYs of the cohort in the counterfactual no testing and no treatment scenario were estimated to be USD61790 (57 898-66 898) and 6309 (5682-6363) respectively, compared with USD123 248 (122 432-124 101) and 6518 (5894-6671) with the CT2 model of care, giving an ICER of USD294 (192-340) per QALY gained. This "one-stop-shop" model of care has a 90% likelihood of being cost-effective if benchmarked against a willingness to pay of US$300, which is 20% of Myanmar's GDP per capita (2020). Conclusions: The CT2 model of HCV care is cost-effective in Myanmar and should be expanded to meet the National Hepatitis Control Program's 2030 target, alongside increasing the affordability and accessibility of services.

Frequent and unpredictable changes in COVID-19 policies and restrictions reduce the accuracy of model forecasts.

Between June and August 2020, an agent-based model was used to project rates of COVID-19 infection incidence and cases diagnosed as positive from 15 September to 31 October 2020 for 72 geographic settings. Five scenarios were modelled: a baseline scenario where no future changes were made to existing restrictions, and four scenarios representing small or moderate changes in restrictions at two intervals. Post hoc, upper and lower bounds for number of diagnosed Covid-19 cases were compared with actual data collected during the prediction window. A regression analysis with 17 covariates was performed to determine correlates of accurate projections. It was found that the actual data fell within the lower and upper bounds in 27 settings and out of bounds in 45 settings. The only statistically significant predictor of actual data within the predicted bounds was correct assumptions about future policy changes (OR 15.04; 95% CI 2.20-208.70; p = 0.016). Frequent changes in restrictions implemented by governments, which the modelling team was not always able to predict, in part explains why the majority of model projections were inaccurate compared with actual outcomes and supports revision of projections when policies are changed as well as the importance of modelling teams collaborating with policy experts.

Cost optimisation analysis of the expanded programme for immunisation: balancing equity and coverage in Pakistan.

INTRODUCTION: With limited resources, attaining maximal average health service coverage can be at odds with maximising equity which attempts to promote greater reach among underserved populations. In this study, we examined the trade-offs in immunisation coverage levels and equity for children under 5 years of age in Pakistan across various subpopulations who can be targeted with different combinations of immunisation service modalities. METHODS: We conducted a detailed costing exercise across 16 geographically and demographically diverse districts in Pakistan. These data were the basis for (a) technical efficiency benchmarking via Data Envelopment Analysis to identify potential efficiency gains by location, delivery model and cost ingredient; (b) allocative efficiency optimisation modelling to understand how resource allocations could be optimised and to devise recommended budget allocations and operational metrics. Finally, the hypothetical overall efficiency gains attainable were estimated if available resources were allocated with the optimal emphases, and if service delivery models operated at productivity levels at the benchmarked frontier of efficiency. RESULTS: Benchmarking suggests that ~44% of delivery models are running efficiently and 37% are highly inefficient. While coverage and equity are usually at odds, surprisingly, the optimisation modelling revealed that substantial improvements in equity between subpopulations does not necessarily cost very much in overall immunisation coverage: theoretically, equity can be achieved while still attaining close to maximal immunisation coverage. Overall, analyses suggest greater emphases should be placed on outreach delivery models which particularly target rural areas and slum populations. CONCLUSION: The unit cost differentials within districts are not sufficiently large for there to be a large reduction in potential Fully Immunised Children coverage if one focuses on maximising equity. However, reallocations of programme budgets can have a significant impact on equity outcomes, particularly at current low spending amounts. Therefore, it is recommended to address equity as the key objective in national immunisation programming.

Risk-Factors for Soft-Tissue Injuries, Lacerations and Fractures During Racing in Greyhounds in New Zealand.

Recognition of injuries in racing animals is essential to identify potential risk factors so actions can be taken to reduce or mitigate the cause of the injury to safeguard the animal. Racing greyhounds are subject to musculoskeletal injuries associated with athletic pursuit, in particular soft-tissue injuries, lacerations, and fractures. The objective of this study was therefore to determine risk factors for soft-tissue injuries, lacerations and fractures occurring during racing, using a cohort of greyhounds racing in New Zealand between 10th September 2014 and 31st July 2020. Dog-level, race-level and track-level risk factors for each outcome were assessed using mixed-effects multivariable logistic regression including trainer as a random effect. Throughout the study period there were 218,700 race starts by 4,914 greyhounds, with a total of 4,385 injuries. Of these, 3,067 (69.94%) were classed as soft-tissue injuries, 641 (14.62%) were reported as lacerations, and 458 (10.44%) were fractures. Greyhounds with a low racing frequency (racing more than 7 days apart) had 1.33 [95% confidence interval (CI): 1.06-1.67] times the odds of fracture compared to those racing more frequently. Older greyhounds had a greater odds of fracture compared with younger greyhounds. Racing every 7 days had a lower odds of soft-tissue injury compared with racing more than once a week. Dogs over 39 months had 1.53 (95% CI: 1.35-1.73) times the odds of sustaining a soft-tissue injury compared to the younger dogs. Greyhounds originating from Australia had a higher odds of fracture and laceration compared with New Zealand dogs. Better performing dogs (higher class) had a greater odds of fracture and laceration whilst maiden dogs had a higher odds of soft-tissue injury. Greyhounds starting from the outside box had a higher odds of fracture. There was considerable variation in the odds of soft-tissue injury at different racetracks. In conclusion, although the incidence of soft-tissue injuries was higher than other injury types, the repercussion of such injuries was less than those for fractures. The results from this study will help to inform intervention strategies aimed at reducing the rate of injuries in racing greyhounds, enhancing racing safety and greyhound welfare.

A modelling analysis of financial incentives for hepatitis C testing and treatment uptake delivered through a community-based testing campaign.

Financial incentives may reduce opportunity costs associated with people who become lost to follow-up in hepatitis C treatment programs. We estimated the impact that different financial incentive amounts would need to have on retention in care to maintain the same unit cost per (1) RNA-positive person completing testing (defined as awareness of RNA status) and (2) RNA diagnosed person initiating treatment. Costing data were obtained from a 2019 community-based testing campaign focused on engaging people who inject drugs. For different financial incentive amounts, we modelled the corresponding improvements in retention in care that would be needed to maintain the same overall (1) unit cost per testing completion and (2) unit cost per treatment initiation. In the testing campaign, the unit cost per RNA-positive person completing testing was A$3215 and the unit cost per RNA diagnosed person initiating treatment was A$1055. Modelling found that an incentive of A$500 per RNA-positive person completing testing would result in more people completing testing for the same unit cost if the percentage of attendees receiving their test results increased from 63% to 74%. An incentive of A$200 per RNA diagnosed person initiating treatment would result in more people initiating treatment for the same unit cost if the percentage initiating treatment increased from 67% to 83%. Monetary incentives for completing testing and initiating treatment may be an effective way to increase retention in care without increasing the overall unit cost of completing testing/initiating treatment.

Prevalence of Potential Indicators of Welfare Status in Young Calves at Meat Processing Premises in New Zealand.

In New Zealand, over two million dairy calves between four and seven days of age are sent to meat processing premises every year. There is a need to develop protocols for holistically assessing the welfare of calves sent to slaughter in the first week of life. This study aimed to determine the prevalence of potential animal-based indicators of the welfare state in bobby calves in lairage. The study observed calves in lairage between June and October 2016. Data collection involved assessing groups of calves in pens followed by non-invasive measurements on up to five calves within each pen. We made 23 visits to 12 meat processing premises with group-level observations made on 5910 calves in 102 pens, followed by a non-invasive examination of 504 calves. During the group level observations, none of the calves had their heads tilted or were panting, and coughing and play behaviour were observed in only 1% of pens. In contrast, at least one calf had faecal soiling in all the observed pens, with the percentage of calves affected in each pen ranging from 1% to 48%. In the individual observations, more than 60% of calves had signs of some degree of dehydration, and nearly 40% had some faecal soiling present. In addition, 24% of calves had a respiratory rate over 36 breaths per minute, considered higher than normal. The change in prevalence of some indicators-as time spent in lairage increased or as the calving season progressed-is worth further exploration. Identification of prevalent animal-based indicators facilitates better understanding of the welfare status of young calves in lairage, and these should be incorporated into more holistic calf welfare assessment schemes.

Covasim: An agent-based model of COVID-19 dynamics and interventions.

The COVID-19 pandemic has created an urgent need for models that can project epidemic trends, explore intervention scenarios, and estimate resource needs. Here we describe the methodology of Covasim (COVID-19 Agent-based Simulator), an open-source model developed to help address these questions. Covasim includes country-specific demographic information on age structure and population size; realistic transmission networks in different social layers, including households, schools, workplaces, long-term care facilities, and communities; age-specific disease outcomes; and intrahost viral dynamics, including viral-load-based transmissibility. Covasim also supports an extensive set of interventions, including non-pharmaceutical interventions, such as physical distancing and protective equipment; pharmaceutical interventions, including vaccination; and testing interventions, such as symptomatic and asymptomatic testing, isolation, contact tracing, and quarantine. These interventions can incorporate the effects of delays, loss-to-follow-up, micro-targeting, and other factors. Implemented in pure Python, Covasim has been designed with equal emphasis on performance, ease of use, and flexibility: realistic and highly customized scenarios can be run on a standard laptop in under a minute. In collaboration with local health agencies and policymakers, Covasim has already been applied to examine epidemic dynamics and inform policy decisions in more than a dozen countries in Africa, Asia-Pacific, Europe, and North America.

A costing analysis of a state-wide, nurse-led hepatitis C treatment model in prison.

BACKGROUND: Hepatitis C is highly prevalent among prisoners. The simplicity of direct-acting antiviral (DAA) treatment for hepatitis C makes it possible to use novel models of care to increase treatment uptake within prisons. We estimate the average non-drug cost of initiating a prisoner on treatment using real world data from the State-wide Hepatitis Program (SHP) in Victoria, Australia - a coordinated nurse-led model of care. METHODS: Data were considered from prisoners presenting to the SHP (following antibody-positive diagnosis) during the evaluation period, November 2015 to December 2016. All costs associated with the SHP were estimated, including staffing salaries, medical tests, pharmacy costs and overhead costs. DAA costs were excluded as in Australia an unlimited number are available, covered by a federal government risk-sharing agreement with pharmaceutical companies. The average non-drug cost of treatment initiation through the SHP was compared to equivalent costs from primary and hospital-based models of care in the community. RESULTS: The total non-drug cost accumulated by prisoners in the SHP was AUD$749,470 (uncertainty range: AUD$728,905-794,111). 659/803 were PCR positive, 424/659 had sentences long enough to be eligible for treatment, and 416/424 were initiated on treatment, resulting in an average non-drug cost of AUD$1,802 (95% CI: AUD$1799-1841) per prisoner initiated. A protocol change allowing prisoners with short sentences to start treatment reduced the average non-drug cost to AUD$1263 (95% CI: AUD$1263-1287) per prisoner initiating treatment - 11% and 56% cheaper than estimated equivalent costs in primary (AUD$1654) and hospital-based (AUD$2847) models of care in the community, respectively. CONCLUSION: Delivering hepatitis C treatment in prison using a nurse-led model of care is cheaper than delivering treatment in the community. These findings provide an economic rationale for implementing coordinated prison-based hepatitis C treatment programs.

Estimating the number of new hepatitis C infections in Australia in 2015, prior to the scale-up of direct-acting antiviral treatment.

BACKGROUND AND AIM: The recent downward revision of the estimated number of people living with chronic hepatitis C in Australia means that the annual number of new hepatitis C infections should also be revised. We aimed to estimate the annual number of new hepatitis C infections among people who inject drugs (PWID) in Australia in 2015, prior to the introduction of direct-acting antiviral (DAA) treatment for hepatitis C, as an updated baseline measure for assessing the impact of DAAs on hepatitis C incidence over the next 10 years. METHODS: A systematic review identified articles estimating hepatitis C incidence rates among PWID between 2002 and 2015. Reported incidence rates were adjusted to account for unrepresentative needle and syringe program (NSP) coverage among study participants compared with PWID overall. The total number of PWID in Australia and the hepatitis C RNA prevalence among PWID were taken from published estimates. The annual number of new infections was estimated by multiplying the pooled NSP coverage-adjusted incidence rate by the number of susceptible PWID in 2015. RESULTS: Five studies were included, with unadjusted incidence rates ranging from 7.6 to 12.8 per 100 person-years. The overall pooled incidence rate (after adjusting for NSP coverage) was 9.9 per 100 person-years (95% confidence interval: 8.3-11.8). This led to an estimate of 4126 (range 2499-6405) new hepatitis C infections in 2015. CONCLUSIONS: Our updated estimate provides an important baseline for evaluating the impact of hepatitis C elimination efforts and can be used to validate outcomes of future modeling studies.

Modelling the impact of relaxing COVID-19 control measures during a period of low viral transmission.

OBJECTIVES: To assess the risks associated with relaxing coronavirus disease 2019 (COVID-19)-related physical distancing restrictions and lockdown policies during a period of low viral transmission. DESIGN: Network-based viral transmission risks in households, schools, workplaces, and a variety of community spaces and activities were simulated in an agent-based model, Covasim. SETTING: The model was calibrated for a baseline scenario reflecting the epidemiological and policy environment in Victoria during March-May 2020, a period of low community viral transmission. INTERVENTION: Policy changes for easing COVID-19-related restrictions from May 2020 were simulated in the context of interventions that included testing, contact tracing (including with a smartphone app), and quarantine. MAIN OUTCOME MEASURE: Increase in detected COVID-19 cases following relaxation of restrictions. RESULTS: Policy changes that facilitate contact of individuals with large numbers of unknown people (eg, opening bars, increased public transport use) were associated with the greatest risk of COVID-19 case numbers increasing; changes leading to smaller, structured gatherings with known contacts (eg, small social gatherings, opening schools) were associated with lower risks. In our model, the rise in case numbers following some policy changes was notable only two months after their implementation. CONCLUSIONS: Removing several COVID-19-related restrictions within a short period of time should be undertaken with care, as the consequences may not be apparent for more than two months. Our findings support continuation of work from home policies (to reduce public transport use) and strategies that mitigate the risk associated with re-opening of social venues.

Prevalence and correlates of simultaneous, multiple substance injection (co-injection) among people who inject drugs in Melbourne, Australia.

AIMS: To estimate the prevalence of and risk factors associated with concurrent injection of multiple substances (co-injection) among a community-recruited cohort of people who inject drugs. DESIGN: Cross-sectional study. SETTING: Melbourne, Australia. PARTICIPANTS: A sample of 720 actively injecting participants from the Melbourne Injecting Drug User Cohort Study (33% female) was extracted. MEASUREMENTS: We constructed two statistical models: a logistic regression model analysing correlates of co-injection of any substance combination in the past month and a multinomial logistic regression model analysing correlates of three mutually exclusive groups: heroin-diphenhydramine co-injection only, co-injection of other substances and no co-injection. Risk factors examined included drug use characteristics, demographic characteristics, health service use, hepatitis C status, injection risk behaviours and previous experience of non-fatal overdose. FINDINGS: One-third [n = 226, 31%; 95% confidence interval (CI): 28-34%] of participants reported co-injecting substances within the past month, with equal numbers of participants reporting injecting combinations of heroin-diphenhydramine (n = 121, 54%; 95% CI = 48-60%) and heroin-methamphetamine (n = 121, 54%; 95% CI = 48-60%). In logistic regression analyses, reporting co-injection of any substance combination was associated with male sex [adjusted odds ratio (aOR) = 1.80, 95% CI = 1.18-2.74, P = 0.006] and injecting daily or more frequently (aOR = 2.04, 95% CI = 1.31-3.18, P = 0.002). In multinomial logistic regression analyses, participants reporting heroin-diphenhydramine co-injection only were significantly more likely to report groin injecting [adjusted relative risk ratio (aRRR) = 6.16, 95% CI = 2.80-13.56, P < 0.001] and overdose (requiring an ambulance) in the past 12 months (aRRR = 2.81, 95% CI = 1.17-6.72, P = 0.021) compared with participants reporting no co-injection or co-injection of other substances. CONCLUSIONS: A substantial proportion of people who inject drugs report co-injection of multiple substances, which is associated with a range of socio-demographic, drug use and health service use risk factors.

Cross-Sectional Survey of the Training Practices of Racing Greyhounds in New Zealand.

The aim of this study was to conduct a cross-sectional survey of racing greyhound trainers in New Zealand in order to provide an overview of their training practices. A survey regarding training practices was posted to all registered greyhound training license holders in New Zealand in August 2019. Data were collected from a convenience sample of 48 trainers (35.6%; n = 48/137) who completed the survey. Other than the differences in the number of greyhounds in race training, the training programmes described by public trainers and owner trainers were similar. Trainers reported that the primary reason for registering young dogs for racing and for qualifying for racing was the ability to meet time milestones. Young dogs had a median of six (interquartile range (IQR): 4-10) trials before they commenced their racing career. Trainers described training practices that aimed to prepare greyhounds for race-day. Regardless of whether the dogs raced once or twice a week, most training programmes demonstrated high specificity where training involved two periods of load cycles through high-intensity workload. Trainers racing their greyhounds once a week simulated the workload of trainers racing their greyhounds twice a week by introducing one high-intensity (speed) workout during the week. Training programmes were structured to condition the dogs to the physiological and metabolic requirements of sprint racing. This study highlights the importance of the need for an improved understanding of training and competition load in order to enable future research in the field of racing greyhounds.

Patterns of Racing and Career Duration of Racing Greyhounds in New Zealand.

The welfare and wastage of racing greyhounds is a topic of public concern. Little is published about the racing patterns of these dogs in New Zealand. The aim of this study is to describe the pattern of greyhound racing in New Zealand. Data on all race starts between 1 August 2011 and 25 March 2018 were supplied by Greyhound Racing New Zealand. A cohort was created containing dogs that had a racing career between 1 August 2013 and 31 July 2017. Data were collated within a customized Microsoft Access database from electronic records of all racing starts for every dog within the 2013-2016 racing seasons. For this cohort of racing dogs, there were 97,973 race starts across 22,277 races involving 2393 individual greyhounds. The median number of days between racing starts was 7 days (inter-quartile range (IQR): 4-10 days). The median career length was 424 days (IQR: 206-647 days) and the median number of racing starts throughout a racing career was 35 (IQR: 16-59 starts). Dogs of similar ability finished their career at a similar age.

Motivations for crystal methamphetamine-opioid co-injection/co-use amongst community-recruited people who inject drugs: a qualitative study.

AIMS: We report on motivations for crystal methamphetamine-opioid co-use/co-injection through narratives of people who inject drugs during a period of increased crystal methamphetamine use reporting in Australia. METHODS: Fourteen in-depth interviews were undertaken with selected participants (12 male, 2 female) from the Melbourne Injecting Drug User Cohort Study, including those in and out of opioid substitution therapy (OST). RESULTS: The main motivations for co-use reported by participants were as follows: (1) that heroin could be used to reduce the negative side effects of heavy crystal methamphetamine use, particularly during the 'comedown' phase; (2) that small quantities of crystal methamphetamine used with heroin could prolong the intoxication effect of heroin, and hence the time before opioid withdrawal; (3) that co-injection of crystal methamphetamine and heroin produced a more desirable intoxication effect than using either substance on its own and; (4) that crystal methamphetamine provided a substitute 'high' for heroin after commencing OST treatment. CONCLUSIONS: Co-use of methamphetamine and opioids has been used by people who inject drugs to facilitate intoxication, sometimes as the result of ineffective opioid substitution therapy (OST) treatment and perceived lack of pleasure after stabilisation on OST treatment.

Risk factors for bobby calf mortality across the New Zealand dairy supply chain.

The objective of this study was to identify risk factors for morbidity and mortality of bobby calves across the whole dairy supply chain in New Zealand. A case-control study was carried out in the 2016 spring calving season. A total of 194 bobby calves, comprising 38 cases (calves that died or were condemned for health or welfare reasons before the point of slaughter) and 156 controls (calves deemed acceptable and presented for slaughter) were included in the study. Case and control calves were selected by veterinarians located at 29 processing premises across New Zealand. Information regarding management of selected calves on-farm, during transport and at the processor was obtained retrospectively via questionnaires administered to supplying farmers, transport operators and processing premises personnel. Associations between management variables and calf mortality (death or condemnation) were examined using multivariable logistic regression models. Factors associated with an increased risk of calf mortality included time in the farm of origin's calving season, duration of travel from farm to the processor and processing slaughter schedule (same day or next day). Every additional week into the farm's calving season increased the odds of mortality by a factor of 1.2 (95%CI 1.06, 1.35). Similarly, each additional hour of travel time increased the odds of mortality by a factor of 1.45 (95% CI 1.18, 1.76). Risk of mortality was significantly greater for calves processed at premises with a next day slaughter schedule than those processed at premises with a same day slaughter schedule (OR 3.82, 95% CI 1.51, 9.67). However, when the data set was limited to those cases that died or were condemned in the yards (i.e. excluding calves that were dead or condemned on arrival) the effect of same day slaughter was not significant. In order to reduce bobby calf mortality and morbidity, transport duration should be kept as short as possible and a same day slaughter schedule applied. While these factors can be regulated, New Zealand's pastoral dairy system means that calves will inevitably be transported for slaughter across several months each spring. Although farm management factors did not apparently influence the risk of mortality in this study, the effect of time in farm's calving season suggests there may be farm-management related factors that change over the season. This requires further investigation.

A cost-effectiveness analysis of primary versus hospital-based specialist care for direct acting antiviral hepatitis C treatment.

BACKGROUND: Hepatitis C virus elimination may be possible by scaling up direct-acting antiviral (DAA) treatment. Due to the safety and simplicity of DAA treatment, primary care-based treatment delivery is now feasible, efficacious and may be cheaper than hospital-based specialist care. In this paper, we use Prime Study data - a randomised controlled trial comparing the uptake of DAA treatment between primary and hospital-based care settings amongst people who inject drugs (PWID) - to estimate the cost of initiating treatment for PWID diagnosed with hepatitis C in primary care compared to hospital-based care. METHODS: The total economic costs associated with delivering DAA treatment (post hepatitis C diagnosis) within the Prime study - including health provider time/training, medical tests, equipment, logistics and pharmacy costs - were collected. Appointment data were used to estimate the number/type of appointments required to initiate treatment in each case, or the stage at which loss to follow up occurred. RESULTS: Among the hepatitis C patients randomised to be treated within primary care, 43/57 (75%) commenced treatment at a mean cost of A$885 (95% CI: A$850-938) per patient initiating treatment. In hospital-based care, 18/53 hepatitis C patients (34%) commenced treatment at a mean cost of A$2078 (range: A$2052-2394) per patient initiating treatment - more than twice as high as primary care. The lower cost in the primary care arm was predominantly the result of increased retention in care compared to the hospital-based arm. CONCLUSIONS: Compared to hospital-based care, providing hepatitis C services for PWID in primary care can improve treatment uptake and approximately halve the average cost of treatment initiation. To improve treatment uptake and cure, countries should consider primary care as the main model for hepatitis C treatment scale-up.

A randomized controlled trial to examine the effect of two teaching methods on preschool children's language and communication, executive functions, socioemotional comprehension, and early math skills.

BACKGROUND: During the preschool years, children's development of skills like language and communication, executive functions, and socioemotional comprehension undergo dramatic development. Still, our knowledge of how these skills are enhanced is limited. The preschool contexts constitute a well-suited arena for investigating these skills and hold the potential for giving children an equal opportunity preparing for the school years to come. The present study compared two pedagogical methods in the Swedish preschool context as to their effect on language and communication, executive functions, socioemotional comprehension, and early math. The study targeted children in the age span four-to-six-year-old, with an additional focus on these children's backgrounds in terms of socioeconomic status, age, gender, number of languages, time spent at preschool, and preschool start. An additional goal of the study was to add to prior research by aiming at disentangling the relationship between the investigated variables. METHOD: The study constitutes a randomized controlled trial including 18 preschools and 29 preschool units, with a total of 431 children, and 98 teachers. The interventions lasted for 6 weeks, preceded by pre-testing and followed by post-testing of the children. Randomization was conducted on the level of preschool unit, to either of the two interventions or to control. The interventions consisted of a socioemotional and material learning paradigm (SEMLA) and a digitally implemented attention and math training paradigm (DIL). The preschools were further evaluated with ECERS-3. The main analysis was a series of univariate mixed regression models, where the nested structure of individuals, preschool units and preschools were modeled using random variables. RESULTS: The result of the intervention shows that neither of the two intervention paradigms had measurable effects on the targeted skills. However, there were results as to the follow-up questions, such as executive functions predicting all other variables (language and communication, socioemotional comprehension, and math). Background variables were related to each other in patterns congruent with earlier findings, such as socioeconomic status predicting outcome measures across the board. The results are discussed in relation to intervention fidelity, length of intervention, preschool quality, and the impact of background variables on children's developmental trajectories and life prospects.

Staying hepatitis C negative: A systematic review and meta-analysis of cure and reinfection in people who inject drugs.

BACKGROUND AND AIMS: Direct-acting antivirals (DAAs) are highly effective in treating hepatitis C. However, there is concern that cure rates may be lower, and reinfection rates higher, among people who inject drugs. We conducted a systematic review of treatment outcomes achieved with DAAs in  people who inject drugs (PWID). METHODS: A search strategy was used to identify studies that reported sustained viral response (SVR), treatment discontinuation, adherence or reinfection in recent PWID and/or opioid substitution therapy (OST) recipients. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis of proportions was used to estimate pooled SVR and treatment discontinuation rates. The pooled relative risk of achieving SVR and pooled reinfection rate were calculated using generalized mixed effects linear models. RESULTS: The search identified 8075 references; 26 were eligible for inclusion. The pooled SVR for recent PWID was 88% (95% CI, 83%-92%) and 91% (95% CI 88%-95%) for OST recipients. The relative risk of achieving SVR for recent PWID compared to non-recent PWID was 0.99 (95% CI, 0.94-1.06). The pooled treatment discontinuation was 2% (95% CI, 1%-4%) for both recent PWID and OST recipients. Amongst recent PWID, the pooled incidence of reinfection was 1.94 per 100 person years (95% CI, 0.87-4.32). In OST recipients, the incidence of reinfection was 0.55 per 100 person years (95% CI, 0.17-1.76). CONCLUSIONS: Treatment outcomes were similar in recent PWID compared to non-PWID treated with DAAs. People who report recent injecting or OST recipients should not be excluded from hepatitis C treatment.

The Association Between Lithium in Drinking Water and Incidence of Suicide Across 15 Alabama Counties.

BACKGROUND: Recent studies have shown that lithium may be effective at reducing suicide at low doses, such as those found in drinking water. AIMS: The purpose of this study was to compare suicide rates with natural lithium levels in the drinking water of various Alabama counties. METHOD: Five drinking water samples from each of 15 Alabama counties were collected. Lithium levels were measured in triplicate using an inductively coupled plasma emission spectrophotometer and compared with suicide rate data for the period 1999-2013. Age, gender, and poverty were evaluated as potential confounding variables. RESULTS: The average measured lithium concentrations ranged from 0.4 ppb to 32.9 ppb between the counties tested. The plot of suicide rate versus lithium concentration showed a statistically significant inverse relationship ( r = -.6286, p = .0141). Evaluation of male-only suicide rate versus lithium concentration data also yielded significant results; however, the female-only rate was not significant. Age standardized suicide rates and poverty when individually compared against lithium levels were also found to be statistically significant; unexpectedly, however, poverty had a parallel trend with suicide rate. CONCLUSION: Lithium concentration in drinking water is inversely correlated with suicide rate in 15 Alabama counties.

A protocol for a three-arm cluster randomized controlled superiority trial investigating the effects of two pedagogical methodologies in Swedish preschool settings on language and communication, executive functions, auditive selective attention, socioemotional skills and early maths skills.

BACKGROUND: During the preschool years, children develop abilities and skills in areas crucial for later success in life. These abilities include language, executive functions, attention, and socioemotional skills. The pedagogical methods used in preschools hold the potential to enhance these abilities, but our knowledge of which pedagogical practices aid which abilities, and for which children, is limited. The aim of this paper is to describe an intervention study designed to evaluate and compare two pedagogical methodologies in terms of their effect on the above-mentioned skills in Swedish preschool children. METHOD: The study is a randomized control trial (RCT) where two pedagogical methodologies were tested to evaluate how they enhanced children's language, executive functions and attention, socioemotional skills, and early maths skills during an intensive 6-week intervention. Eighteen preschools including 28 units and 432 children were enrolled in a municipality close to Stockholm, Sweden. The children were between 4;0 and 6;0 years old and each preschool unit was randomly assigned to either of the interventions or to the control group. Background information on all children was collected via questionnaires completed by parents and preschools. Pre- and post-intervention testing consisted of a test battery including tests on language, executive functions, selective auditive attention, socioemotional skills and early maths skills. The interventions consisted of 6 weeks of intensive practice of either a socioemotional and material learning paradigm (SEMLA), for which group-based activities and interactional structures were the main focus, or an individual, digitally implemented attention and math training paradigm, which also included a set of self-regulation practices (DIL). All preschools were evaluated with the ECERS-3. DISCUSSION: If this intervention study shows evidence of a difference between group-based learning paradigms and individual training of specific skills in terms of enhancing children's abilities in fundamental areas like language, executive functions and attention, socioemotional skills and early math, this will have big impact on the preschool agenda in the future. The potential for different pedagogical methodologies to have different impacts on children of different ages and with different backgrounds invites a wider discussion within the field of how to develop a preschool curriculum suited for all children.