Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial.

BACKGROUND: In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania. METHODS: In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688. FINDINGS: Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted). INTERPRETATION: In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. FUNDING: European Union Horizon 2020 and Global Alliance for Chronic Diseases.

Malaria Infection in Patients with Sickle Cell Disease in Nigeria: Association with Markers of Hyposplenism.

Malaria is considered an important cause of morbidity and mortality among people living with sickle cell disease (SCD). This has partly been attributed to the loss of splenic function that occurs early in the disease process. We conducted a cross-sectional study and determined the frequency of malaria infection among SCD patients and explored the association with spleen's presence on ultrasonography and spleen function assessed using the frequency of Howell-Jolly bodies (HJBs). A total of 395 participants consisting of 119 acutely-ill SCD patients, 168 steady-state SCD controls, and 108 healthy non-SCD controls were studied. The prevalence of Plasmodium falciparum parasitemia was 51.3% in acutely-ill SCD patients, 31.7% in steady-state SCD controls, and 11.0% in the healthy non-SCD controls; however, the mean parasite density was significantly higher in the non-SCD controls compared to both SCD groups (p = 0.0001). Among the acutely-ill SCD patients, the prevalence of clinical malaria and severe malaria anemia were highest in children <5 years of age. The prevalence of parasitemia (p = 0.540) and parasite density (p = 0.975) showed no association with spleen presence or absence on ultrasonography. Similarly, the frequency of HJB red cells was not associated with the presence of parasitemia (p = 0.183). Our study highlights the frequency and role of malaria infection in acutely-ill SCD patients, especially in those younger than five years. Although we have found no evidence of an increased risk of malaria parasitemia or parasite density with markers of hyposplenism, the role played by an underlying immunity to malaria among SCD patients in malaria-endemic region is not clear and needs further studies.

Determinants of splenic preservation among patients with sickle cell disease in North-Eastern Nigeria.

OBJECTIVE: In patients with sickle cell disease (SCD), the spleen commonly enlarges during early childhood, but undergoes reduction in size and fibrosis from repeated episodes of vaso-occlusion and infarction. The rate of progression of this process varies markedly among these patients. The aim of current study was to explore clinical and laboratory factors associated with the preservation of the spleen among these patients. METHODS: Two hundred four patients with SCD (103 females; age 1-45 years) underwent abdominal ultrasonography at the University of Maiduguri Teaching Hospital, Nigeria between October 2020 and November 2021 to assess for splenic visualisation and echotexture. Steady-state clinical parameters and blood samples for full blood count, serum chemistry, high-performance liquid chromatography and malaria parasitemia were obtained from all the patients. RESULTS: The spleen was visualised in 107 (52.4%; 95% confidence interval [CI], 46%-59%) patients with SCD on ultrasonography. While the spleen was visualised in all children less than 5 years of age, it was visualised in only 23.5% of those aged 15 years and older. Visualisation of the spleen was significantly associated with low mean corpuscular haemoglobin concentration and high haemoglobin F (HbF) in those younger than 10 years. The odds of visualisation of the spleen on ultrasonography increased by a factor of 1.17% for every 1% increase in HbF level. Only 32 (15%) patients were on regular hydroxyurea therapy. The HbF level was significantly higher among patients on hydroxyurea (median 12.7 vs. 7.4; p < 0.0001). CONCLUSION: In patients with SCD, failure to visualise the spleen was not found in children less than 5 years old. Patients with visualised spleens had a higher level of HbF than those with non-visualised spleens. HbF was significantly associated with visualisation of the spleen before 10 years of age. Since early administration of hydroxyurea will increase HbF level, we expect that it would help to preserve the spleen.

How to improve research capacity strengthening efforts: learning from the monitoring and evaluation of four research consortia in Africa.

Recent efforts to shift the control and leadership of health research on African issues to Africa have led to increased investments for scientific research capacity strengthening (RCS) on the continent and a greater demand for accountability, value for money and demonstration of return on investment. There is limited literature on monitoring and evaluation (M&E) of RCS systems and there is a clear need to further explore whether the M&E frameworks and approaches that are currently used are fit for purpose. The M&E approaches taken by four African RCS consortia funded under the Developing Excellence in Leadership, Training and Science in Africa (DELTAS) I initiative were assessed using several methods, including a framework comparison of the M&E approaches, semi-structured interviews and facilitated discussion sessions. The findings revealed a wide range in the number of indicators used in the M&E plans of individual consortium, which were uniformly quantitative and at the output and outcome levels. Consortia revealed that additional information could have been captured to better evaluate the success of activities and measure the ripple effects of their efforts. While it is beneficial for RCS consortia to develop and implement their own M&E plans, this could be strengthened by routine engagement with funders/programme managers to further align efforts. It is also important for M&E plans to consider qualitative data capture for assessment of RCS efforts. Efforts could be further enhanced by supporting platforms for cross-consortia sharing, particularly when trying to assess more complex effects. Consortia should make sure that processes for developmental evaluation, and capturing and using the associated learning, are in place. Sharing the learning associated with M&E of RCS efforts is vital to improve future efforts. Investing and improving this aspect of RCS will help ensure tracking of progress and impact of future efforts, and ensure accountability and the return on investment. The findings are also likely applicable well beyond health research.

Development of a machine-learning based voice disorder screening tool.

OBJECTIVE: Early recognition and referral are crucial for voice disorder management. Limited availability of subspecialists, poor primary care awareness, and the need for specialized equipment impede effective care. Thus, there is a need for a tool to improve voice pathology screening. Machine learning algorithms (MLAs) have shown promise in analyzing acoustic characteristics of phonation. However, few studies report clinical applications of MLAs for voice pathology detection. The objective of this study was to design and validate a MLA for detecting pathological voices. METHODS: A MLA was developed for voice analysis. Audio samples converted into spectrograms were inputted into a pre-existing VGG19 convolutional neural network (CNN) and image-classifier. The resulting feature map was classified as either pathological or healthy using a Support Vector Machine (SVM) binary linear classifier. This combined MLA was "trained" with 950 sustained "/i/" vowel audio samples from the Saarbrucken Voice Database (SVD), which contains subjects with and without voice disorders. The trained MLA was "tested" with 406 SVD samples to determine sensitivity, specificity, and overall accuracy. External validation of the MLA was performed using clinical voice samples collected from patients attending a subspecialty voice clinic. RESULTS: The MLA detected pathologies in SVD samples with 98.5% sensitivity, 97.1% specificity and 97.8% overall accuracy. In 30 samples obtained prospectively from voice clinic patients, the MLA detected pathologies with 100% sensitivity, 96.3% specificity and 96.7% overall accuracy. CONCLUSIONS: This study demonstrates that a MLA using a simple audio input can detect diverse vocal pathologies with high sensitivity and specificity. Thus, this algorithm shows promise as a potential screening tool.

Laryngoscopic findings of age-related vocal fold atrophy are reliable but not specific.

OBJECTIVES: We aimed to evaluate the reliability of laryngoscopic features of vocal fold atrophy as assessed by novice otolaryngology trainees and expert laryngologists. DESIGN: Two expert fellowship-trained laryngologists and three non-expert otolaryngology resident trainees were recruited to view 50 anonymised laryngo-stroboscopic examinations of patients presenting with dysphonia and non-voice, laryngeal complaints. Reviewers were asked to stratify the patient's age, provide an opinion about the presence of age-related vocal fold atrophy and specify which laryngoscopy features were present to make the diagnosis. SETTING: Tertiary care laryngology practice. PARTICIPANTS: Two fellowship-trained laryngologists and three trainee otolaryngologists. MAIN OUTCOME MEASURES: Accuracy of age categorisation was determined and Kappa analysis was performed to assess inter-rater agreement. RESULTS: The mean age of patients was 54.9 years old with near equal male to female distribution. The overall accuracy of age category determination by raters was only 30.8%. Kappa analysis demonstrated fair agreement regarding the presence of vocal fold atrophy in non-expert reviewers, and moderate agreement amongst expert reviewers. Features of glottic gap, muscular atrophy of vocal folds and prominent vocal processes were all identified with high agreement (>80.0%). CONCLUSION: Our study illustrates that while raters can agree on the presence of age-related vocal fold atrophy, the findings may be non-specific and do not necessarily correlate with age.

Difference in HIV prevalence by testing venue: results from population level survey in Uganda.

Growing demand for use of Health Facility (HF) HIV testing data, in addition to other testing data to obtain district level HIV prevalence requires understanding the comparability of these various sources. We analysed the 2011 Uganda AIDS indicator survey data to assess: the proportion of people tested for HIV across Uganda by venue of testing; HIV prevalence ratio for those tested in a HF compared to those tested in community setting; [Katz, D., Baptista, J., Azen, S. P., & Pike, M. C. (1978). Obtaining confidence intervals for the risk ratio in cohort studies. International Biometric Society, 34(3), 469-474. https://doi.org/10.2307/2530610] and factors associated with HIV positivity in each subgroup. Of the 11,685 individuals, 8978 (77.1%) had ever tested for HIV in a HF. Fifty nine per cent tested in a HF in the 12 months preceding the survey (female: 5507, 72.7% versus male: 1413, 34.9%). HIV prevalence ratio was 1.8 times among those tested in a HF compared to those tested at community setting (10.9% [95% CI: 10.0-11.7] versus 6.2% [95% CI: 5.4-7.0]). Among HF testers, older age group, previously married and having no sexual partner was associated with significantly higher HIV prevalence. Using facility testing data for planning and decisions should take into consideration the elevated and varying HIV prevalence among individuals accessing HIV testing services at HFs as well as differences in their social-demographic characteristics.

Hybrid prevalence estimation: Method to improve intervention coverage estimations.

Delivering excellent health services requires accurate health information systems (HIS) data. Poor-quality data can lead to poor judgments and outcomes. Unlike probability surveys, which are representative of the population and carry accuracy estimates, HIS do not, but in many countries the HIS is the primary source of data used for administrative estimates. However, HIS are not structured to detect gaps in service coverage and leave communities exposed to unnecessary health risks. Here we propose a method to improve informatics by combining HIS and probability survey data to construct a hybrid estimator. This technique provides a more accurate estimator than either data source alone and facilitates informed decision-making. We use data from vitamin A and polio vaccination campaigns in children from Madagascar and Benin to demonstrate the effect. The hybrid estimator is a weighted average of two measurements and produces SEs and 95% confidence intervals (CIs) for the hybrid and HIS estimators. The estimates of coverage proportions using the combined data and the survey estimates differ by no more than 3%, while decreasing the SE by 1-6%; the administrative estimates from the HIS and combined data estimates are very different, with 3-25 times larger CI, questioning the value of administrative estimates. Estimators of unknown accuracy may lead to poorly formulated policies and wasted resources. The hybrid estimator technique can be applied to disease prevention services for which population coverages are measured. This methodology creates more accurate estimators, alongside measured HIS errors, to improve tracking the public's health.

Combining national survey with facility-based HIV testing data to obtain more accurate estimate of HIV prevalence in districts in Uganda.

BACKGROUND: National or regional population-based HIV prevalence surveys have small sample sizes at district or sub-district levels; this leads to wide confidence intervals when estimating HIV prevalence at district level for programme monitoring and decision making. Health facility programme data, collected during service delivery is widely available, but since people self-select for HIV testing, HIV prevalence estimates based on it, is subject to selection bias. We present a statistical annealing technique, Hybrid Prevalence Estimation (HPE), that combines a small population-based survey sample with a facility-based sample to generate district level HIV prevalence estimates with associated confidence intervals. METHODS: We apply the HPE methodology to combine the 2011 Uganda AIDS indicator survey with the 2011 health facility HIV testing data to obtain HIV prevalence estimates for districts in Uganda. Multilevel logistic regression was used to obtain the propensity of testing for HIV in a health facility, and the propensity to test was used to combine the population survey and health facility HIV testing data to obtain the HPEs. We assessed comparability of the HPEs and survey-based estimates using Bland Altman analysis. RESULTS: The estimates ranged from 0.012 to 0.178 and had narrower confidence intervals compared to survey-based estimates. The average difference between HPEs and population survey estimates was 0.00 (95% CI: - 0.04, 0.04). The HPE standard errors were 28.9% (95% CI: 23.4-34.4) reduced, compared to survey-based standard errors. Overall reduction in HPE standard errors compared survey-based standard errors ranged from 5.4 to 95%. CONCLUSIONS: Facility data can be combined with population survey data to obtain more accurate HIV prevalence estimates for geographical areas with small population survey sample sizes. We recommend use of the methodology by district level managers to obtain more accurate HIV prevalence estimates to guide decision making without incurring additional data collection costs.

Trends in Reporting of Swallowing Outcomes in Oropharyngeal Cancer Studies: A Systematic Review.

Over the last two decades, dysphagia is increasingly recognized as a significant short-term and long-term issue in oropharyngeal cancer patients. However, there remains a lack of standardization and agreement about reporting swallowing outcomes in studies that assess treatment outcomes in this population. A systematic review was performed following PRISMA Guidelines by searching Pubmed (MEDLINE) and Scopus. The inclusion criteria used included (1) prospective and retrospective clinical studies involving adult patients with oropharyngeal cancer, (2) reports swallowing outcomes, (3) English studies or studies with English translation, (4) full text retrievable and (5) publication between 1990 and 2016. 410 unique studies were identified, and 106 were analyzed. A majority (> 80%) of studies that reported swallowing outcomes were published after 2010. While 75.4% of studies reported subjective outcomes (e.g., patient-reported or clinician-reported outcome measures), only 30.2% of studies presented results of objective instrumental assessment of swallowing. The majority (61%) of studies reported short-term swallowing outcomes at 1 year or less, and only 10% of studies examined 5-year swallowing comes. One study examined late-dysphagia (> 10 years) in the oropharyngeal cancer population. Considerable heterogeneity remains in the reporting of swallowing outcomes after treatment of oropharyngeal cancer despite its importance for quality of life. Studies reporting long-term swallowing outcomes are lacking in the literature, and objective measures of swallowing function remain underutilized and nonstandardized.

Assessing delivery practices of mothers over time and over space in Uganda, 2003-2012.

BACKGROUND: It is well known that safe delivery in a health facility reduces the risks of maternal and infant mortality resulting from perinatal complications. What is less understood are the factors associated with safe delivery practices. We investigate factors influencing health facility delivery practices while adjusting for multiple other factors simultaneously, spatial heterogeneity, and trends over time. METHODS: We fitted a logistic regression model to Lot Quality Assurance Sampling (LQAS) data from Uganda in a framework that considered individual-level covariates, geographical features, and variations over five time points. We accounted for all two-covariate interactions and all three-covariate interactions for which two of the covariates already had a significant interaction, were able to quantify uncertainty in outputs using computationally intensive cluster bootstrap methods, and displayed outputs using a geographical information system. Finally, we investigated what information could be predicted about districts at future time-points, before the next LQAS survey is carried out. To do this, we applied the model to project a confidence interval for the district level coverage of health facility delivery at future time points, by using the lower and upper end values of known demographics to construct a confidence range for the prediction and define priority groups. RESULTS: We show that ease of access, maternal age and education are strongly associated with delivery in a health facility; after accounting for this, there remains a significant trend towards greater uptake over time. We use this model together with known demographics to formulate a nascent early warning system that identifies candidate districts expected to have low prevalence of facility-based delivery in the immediate future. CONCLUSIONS: Our results support the hypothesis that increased development, particularly related to education and access to health facilities, will act to increase facility-based deliveries, a factor associated with reducing perinatal associated mortality. We provide a statistical method for using inexpensive and routinely collected monitoring and evaluation data to answer complex epidemiology and public health questions in a resource-poor setting. We produced a model based on this data that explained the spatial distribution of facility-based delivery in Uganda. Finally, we used this model to make a prediction about the future priority of districts that was validated by monitoring and evaluation data collected in the next year.

Associations with HIV testing in Uganda: an analysis of the Lot Quality Assurance Sampling database 2003-2012.

Beginning in 2003, Uganda used Lot Quality Assurance Sampling (LQAS) to assist district managers collect and use data to improve their human immunodeficiency virus (HIV)/AIDS program. Uganda's LQAS-database (2003-2012) covers up to 73 of 112 districts. Our multidistrict analysis of the LQAS data-set at 2003-2004 and 2012 examined gender variation among adults who ever tested for HIV over time, and attributes associated with testing. Conditional logistic regression matched men and women by community with seven model effect variables. HIV testing prevalence rose from 14% (men) and 12% (women) in 2003-2004 to 62% (men) and 80% (women) in 2012. In 2003-2004, knowing the benefits of testing (Odds Ratio [OR] = 6.09, 95% CI = 3.01-12.35), knowing where to get tested (OR = 2.83, 95% CI = 1.44-5.56), and secondary education (OR = 3.04, 95% CI = 1.19-7.77) were significantly associated with HIV testing. By 2012, knowing the benefits of testing (OR = 3.63, 95% CI = 2.25-5.83), where to get tested (OR = 5.15, 95% CI = 3.26-8.14), primary education (OR = 2.01, 95% CI = 1.39-2.91), being female (OR = 3.03, 95% CI = 2.53-3.62), and being married (OR = 1.81, 95% CI = 1.17-2.8) were significantly associated with HIV testing. HIV testing prevalence in Uganda has increased dramatically, more for women than men. Our results concurred with other authors that education, knowledge of HIV, and marriage (women only) are associated with testing for HIV and suggest that couples testing is more prevalent than other authors.

Comparing two survey methods of measuring health-related indicators: Lot Quality Assurance Sampling and Demographic Health Surveys.

OBJECTIVES: Two common methods used to measure indicators for health programme monitoring and evaluation are the demographic and health surveys (DHS) and lot quality assurance sampling (LQAS); each one has different strengths. We report on both methods when utilised in comparable situations. METHODS: We compared 24 indicators in south-west Uganda, where data for prevalence estimations were collected independently for the two methods in 2011 (LQAS: n = 8876; DHS: n = 1200). Data were stratified (e.g. gender and age) resulting in 37 comparisons. We used a two-sample two-sided Z-test of proportions to compare both methods. RESULTS: The average difference between LQAS and DHS for 37 estimates was 0.062 (SD = 0.093; median = 0.039). The average difference among the 21 failures to reject equality of proportions was 0.010 (SD = 0.041; median = 0.009); among the 16 rejections, it was 0.130 (SD = 0.010, median = 0.118). Seven of the 16 rejections exhibited absolute differences of <0.10, which are clinically (or managerially) not significant; 5 had differences >0.10 and <0.20 (mean = 0.137, SD = 0.031) and four differences were >0.20 (mean = 0.261, SD = 0.083). CONCLUSION: There is 75.7% agreement across the two surveys. Both methods yield regional results, but only LQAS provides information at less granular levels (e.g. the district level) where managerial action is taken. The cost advantage and localisation make LQAS feasible to conduct more frequently, and provides the possibility for real-time health outcomes monitoring.

Attracting female sex workers to HIV testing and counselling in Ethiopia: a qualitative study with sex workers in Addis Ababa.

Despite growing efforts to increase HIV testing and counselling (HTC) services for most at risk populations in Ethiopia, the use of these services by female sex workers (FSWs) remains low. With rising numbers of FSWs in Addis Ketema and concerns about their high risk behaviours, exploring and addressing the barriers to uptake is crucial. This qualitative study explores the barriers to utilising HTC facilities and identifies the motives and motivations of FSWs who seek HTC through in-depth and semi-structured interviews with female sex workers, healthcare workers and key informants. Results indicate that FSWs face numerous barriers including inability to seek treatment if found to be positive due to the requirement of an identity (ID) card many do not own. Many FSWs reported discriminatory behaviour from healthcare workers and a lack of dedicated services. What is clear from the findings is that distinct strategies, which differ from those of the broader population, are required to attract FSWs--strategies which take into account the barriers and maximise the reported motives and motivations for testing.

The effect of spatial aggregation on performance when mapping a risk of disease.

BACKGROUND: Spatial data on cases are available either in point form (e.g. longitude/latitude), or aggregated by an administrative region (e.g. zip code or census tract). Statistical methods for spatial data may accommodate either form of data, however the spatial aggregation can affect their performance. Previous work has studied the effect of spatial aggregation on cluster detection methods. Here we consider geographic health data at different levels of spatial resolution, to study the effect of spatial aggregation on disease mapping performance in locating subregions of increased disease risk. METHODS: We implemented a non-parametric disease distance-based mapping (DBM) method to produce a smooth map from spatially aggregated childhood leukaemia data. We then simulated spatial data under controlled conditions to study the effect of spatial aggregation on its performance. We used an evaluation method based on ROC curves to compare performance of DBM across different geographic scales. RESULTS: Application of DBM to the leukaemia data illustrates the method as a useful visualization tool. Spatial aggregation produced expected degradation of disease mapping performance. Characteristics of this degradation, however, varied depending on the interaction between the geographic extent of the higher risk area and the level of aggregation. For example, higher risk areas dispersed across several units did not suffer as greatly from aggregation. The choice of centroids also had an impact on the resulting mapping. CONCLUSIONS: DBM can be implemented for continuous and discrete spatial data, but the resulting mapping can lose accuracy in the second setting. Investigation of the simulations suggests a complex relationship between performance loss, geographic extent of spatial disturbances and centroid locations. Aggregation of spatial data destroys information and thus impedes efforts to monitor these data for spatial disturbances. The effect of spatial aggregation on cluster detection, disease mapping, and other useful methods in spatial epidemiology is complex and deserves further study.

The effect of simulated radiation induced fibrosis on tongue protrusion.

Radiation therapy (RT) is an important adjuvant and primary treatment modality for head and neck cancers. A severe side effect of RT is fibrosis or scarring of muscle tissues of the oral cavity including the tongue. Previous studies have demonstrated that increased radiation doses to the oral cavity structures have led to decrements in function, hypothesized to result from changes in muscle tissue properties that affect the tongue's function. To understand the complex relationship between tongue muscle fibrosis and tongue function, the current study used a virtual biomechanical model of the tongue. Fibrosis parameters including density (high, low), area (large, small) and location (946 node centres) were systematically varied in the model to test its impact on a target tongue tip motion (protrusion). The impact of fibrosis lesion parameters on three directional components of the tip (anterior-inferior, lateral-medial, and superior-inferior) were analyzed using multi linear regression models. Increases in density and area of fibrosis significantly predicted tongue protrusion movements compared to baseline. In the anterior-posterior direction, reductions in the tongue protrusion were observed. In the inferior-superior direction, the tongue height remained above baseline for the majority of cases. In the lateral-medial direction, ipsilateral deviations were observed. The location of fibrosis modulated these three main effects by either amplifying the observed effect or minimizing it. The findings support the hypothesis that changes in muscle tissue properties because of fibrosis impact tongue function. Increases in density and area of fibrosis impact key muscles in the target motion. The range of modulating effects of the lesion location (i.e., either amplifying or minimizing certain impact patterns) highlights the intricacy of tongue anatomy/soft tissue biomechanics and may suggest that lesions in any location will compromise the tongue's movement.

Assessing attitudes towards violence against women and girls, their determinants and health-seeking behaviour among women and men in South Sudan: a cross-sectional national survey.

OBJECTIVE: Investigating attitudes accepting two categories of violence against women and girls (VAWG) (intimate partner violence-IPV-and other expressions of VAWG) and their association with seven demographic/social determinants and health-seeking behaviours in South Sudan. DESIGN: Cross-sectional study using data from the South Sudan National Household Survey 2020. SETTING: South Sudan. PARTICIPANTS AND METHODS: 1741 South Sudanese women and 1739 men aged 15-49 years; data captured between November 2020 and February 2021 and analysed using binary logistic regression. RESULTS: People with secondary or higher education displayed attitudes rejecting acceptance of IPV (OR 0.631, 95% CI 0.508 to 0.783). Women and men living in states with more numerous internally displaced people (IDP) or political/military violence had attitudes accepting IPV more than residents of less violence-affected regions (OR 1.853, 95% CI 1.587 to 2.164). Women had a higher odd of having attitudes accepting IPV than men (OR 1.195, 95% CI 1.014 to 1.409). People knowing where to receive gender-based violence healthcare and psychological support (OR 0.703, 95% CI 0.596 to 0.830) and with primary (OR 0.613, 95% CI 0.515 to 0.729), secondary or higher education (OR 0.596, 95% CI 0.481 to 0.740) displayed attitudes rejecting acceptance of other expressions of VAWG. People residing in states with proportionately more IDP and who accepted IPV were more likely to have attitudes accepting other expressions of VAWG (OR 1.699, 95% CI 1.459 to 1.978; OR 3.195, 95% CI 2.703 to 3.775, respectively). CONCLUSION: Attitudes towards accepting VAWG in South Sudan are associated with women's and men's education, gender, residence and knowledge about health-seeking behaviour. Prioritising women's empowerment and gender transformative programming in the most conflict-affected areas where rates of VAWG are higher should be prioritised along with increasing girls' access to education. A less feasible strategy to decrease gender inequalities is reducing insecurity, military conflict, and displacement, and increasing economic stability.

Laryngeal Plasmacytosis Responsive to Inhaled Budesonide.

Mucous membrane plasmacytosis (MMP) is rare condition characterized by diffuse plasma cell infiltration of upper aero-digestive tract mucosa. It results in epithelial hyperplasia that has a classic papillary appearance. We describe a case of MMP primarily affect laryngeal and oropharyngeal mucosa resulting in progressive airway obstruction. We highlight airway management and histopathology. The patient had near complete clinical response with inhaled budesonide, which has not yet been described as a treatment option in the literature. Laryngoscope, 133:70-72, 2023.

Late laryngeal dysfunction in head and neck cancer survivors.

Objectives: Head and neck cancer (HNC) survivorship issues are areas of increasing research interest. Laryngeal dysfunction in HNC patients is particularly important given the importance of the larynx in voice, swallowing, and airway protection. The objective of our study is to characterize late laryngeal dysfunction in a cohort of long-term HNC survivors. Methods: HNC survivors who were at least 2 years post-treatment were recruited prospectively for standard collection of videolaryngoscopy findings, videofluoroscopic swallowing studies, and assessment of clinical outcomes. Descriptive statistics were performed and clinical presentation and outcomes were compared between survivors >10 years and <10 years post-treatment. Additional factor analysis to correlate clinical outcomes with clinical variables was performed. Results: Thirty participants were analyzed with a mean age of 66 years. The majority were male (80%) patients treated for oropharyngeal squamous cell carcinoma (67%). Within the cohort, 43% underwent primary chemoradiation therapy and had 13% radiation alone. Common presenting symptoms included swallowing dysfunction (83%), voice change (67%), and chronic cough (17%). Laryngeal findings on video laryngoscopy include vocal fold motion abnormalities (VFMA) in over half of participants (61%) and mucosal changes in 20%. A weak correlation was found between time since treatment and laryngeal dysfunction (r = .182, p = .34), and no correlation was found between age, sex, time since treatment, or primary site and the presence or absence of VFMA, G-tube status, or tracheostomy-tube status. Conclusion: Late laryngeal dysfunction in HNC survivors contributes to significant morbidity, is difficult to treat, and remains static decades after treatment for their original cancer. Lay Summary: The voice-box, or the larynx, plays an important role in voice, swallowing and airway protection. It is particularly vulnerable to radiation-related damage and changes. This study demonstrates the sequelae of long-term damage of the larynx in head and cancer survivors. Level of Evidence: IV.

Formation and Assessment of a Laryngology Pathology Video Atlas for Resident Education.

OBJECTIVE: Conventional reference images of laryngeal pathologies may provide educational value for Otolaryngology-Head & Neck Surgery (OHNS) residents, but observing dynamic vocal fold function is critical for diagnosis. Our aim was to develop and validate a video atlas of laryngeal pathologies for resident education in OHNS. DESIGN: A multi-institution, prospective case-control study. SETTING/PARTICIPANTS: Ten videos showing 10 representative laryngeal pathologies were verified by two laryngologists. Six videos per category with kappa>0.8 were included in the video database. A collection of the videos was shown to a group of OHNS residents in a quiz fashion to determine if senior trainees would score higher than junior trainees. Another group of residents in OHNS was recruited and randomized to control or intervention. The control group was shown a quiz of 10 laryngeal videos at baseline and 24 weeks later. The intervention group was shown quizzes at baseline and every 6 weeks, ending at 24 weeks. Free-text diagnoses were scored for accuracy. Descriptive statistics, two-tailed tests, and analysis of covariance were performed. RESULTS: Twenty-nine residents participated, with 14 (48.3%) randomized to control, and 15 (51.7%) to the intervention. The postgraduate year (PGY) level had a significant impact on diagnostic performance. PGY1 and 2 had a significantly lower score than PGY5 (P = 0.017 and P = 0.035, respectively). PGY3 and PGY4 scores were not statistically different from PGY5 scores. The mean score difference between groups decreases as the PGY level increases (mean difference between groups = 0.87, P = 0.153), but this was not significant. CONCLUSIONS: The current study has created a validated collection of videos that are representative of common laryngeal pathologies and can be easily incorporated into resident video-based learning. Future directions include larger multi-site studies to further elucidate whether repeated viewing of this video atlas can improve OHNS resident laryngology knowledge.