Financial and economic costs of healthcare-associated infections in Africa.

BACKGROUND: Healthcare-associated infections (HAIs) remain a global health challenge, and have elevated rates in Sub-Saharan Africa. HAIs impact patients and their families by causing illness, prolonged hospital stay, potential disability, excess costs and, sometimes, death. The costs of HAIs are increasing due to spreading antimicrobial resistance. A major risk factor for HAIs is lack of water, sanitation and hygiene (WASH); environmental cleaning and healthcare waste management. In Sub-Saharan Africa, these services are lacking in at least 50% of healthcare facilities. AIM: To estimate the costs associated with HAIs at national level in 14 countries in Sub-Saharan Africa. METHODS: Economic methodologies were employed to estimate the medical costs, productivity losses and value of premature death from HAIs, drawing on national statistics and published studies to populate the economic model. RESULTS: In 2022, the number of HAIs was estimated at 4.8 million, resulting in 500,000 deaths. Health-related economic losses amounted to US$13 billion per year, equivalent to 1.14% of combined gross domestic product and US$15.7 per capita. Healthcare costs were US$500 per HAI, and represented 5.6% of total health expenditure. The costs of providing basic WASH were US$0.91 per capita, which, if they reduced HAIs by 50%, would result in benefit-cost ratios of 1.6 (financial healthcare savings alone) and 8.6 (all economic benefits). CONCLUSION: HAIs have a major health and economic burden on African societies, and a significant proportion can be prevented. It is critical that health policy makers and practitioners dedicate policy space, resources and training to address HAIs.

EffEctiveness of Prophylactic fOam dressings in the prevention of saCral pressure injuries in at-risk hospitalised patients: the EEPOC trial.

BACKGROUND: Prophylactic dressings are increasingly used to prevent pressure injuries in hospitalised patients. However, evidence regarding the effectiveness of these dressings is still emerging. This trial aims to determine the clinical and cost-effectiveness of a prophylactic silicone foam border dressing in preventing sacral pressure injuries in medical-surgical patients. METHODS: This is a multicentre, pragmatic, parallel group, randomised controlled trial. A sample size of 1320 was calculated to have >90% power to detect a 5% difference in the primary outcome at an alpha of 0.05. Adult patients admitted to participating medical-surgical wards are screened for eligibility: ≥18 years, admitted to hospital within the previous 36 h, expected length of stay of ≥24 h, and assessed high risk for hospital-acquired pressure injury. Consenting participants are randomly allocated to either prophylactic silicone foam dressing intervention or usual care without any dressing as the control group via a web-based randomisation service independent of the trial. Patients are enrolled across three Australian hospitals. The primary outcome is the cumulative incidence of patients who develop a sacral pressure injury. Secondary outcomes include the time to sacral pressure injury, incidence of severity (stage) of sacral pressure injury, cost-effectiveness of dressings, and process evaluation. Participant outcomes are assessed daily for up to 14 days by blinded independent outcome assessors using de-identified, digitally modified sacral photographs. Those who develop a sacral pressure injury are followed for an additional 14 days to estimate costs of pressure injury treatment. Analysis of clinical outcomes will be based on intention-to-treat, per-protocol, and sensitivity analyses. DISCUSSION: This trial aims to provide definitive evidence on the effect prophylactic dressings have on the development of hospital-acquired sacral pressure injuries in medical-surgical patients. A parallel economic evaluation of pressure injury prevention and treatment will enable evidence-informed decisions and policy. The inclusion of a process evaluation will help to explain the contextual factors that may have a bearing on trial results including the acceptability of the dressings to patients and staff. The trial commenced 5 March 2020 and has been significantly delayed due to COVID-19. TRIAL REGISTRATION: ANZCTR ACTRN12619000763145. Prospectively registered on 22 May 2019.

The provision of a time-critical elective surgical service during the COVID-19 Crisis: a UK experience.

INTRODUCTION: With the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic. MATERIALS AND METHODS: A protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 'clean' site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff. RESULTS: A total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive. CONCLUSION: This study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.

Transesophageal Speckle-Tracking Echocardiography Improves Right Ventricular Systolic Function Assessment in the Perioperative Setting.

BACKGROUND: Perioperative evaluation of right ventricular (RV) systolic function is important to follow intraoperative changes, but it is often not possible to assess with transthoracic echocardiographic (TTE) imaging, because of surgical field constraints. Echocardiographic RV quantification is most commonly performed using tricuspid annular plane systolic excursion (TAPSE), but it is not clear whether this method works with transesophageal echocardiographic (TEE) imaging. This study was performed to evaluate the relationship between TTE and TEE TAPSE distances measured with M-mode imaging and in comparison with speckle-tracking TTE and TEE measurements. METHODS: Prospective observational TTE and TEE imaging was performed during elective cardiac surgical procedures in 100 subjects. Speckle-tracking echocardiographic TAPSE distances were determined and compared with the TTE M-mode TAPSE standard. Both an experienced and an inexperienced user of the speckle-tracking echocardiographic software evaluated the images, to enable interobserver assessment in 84 subjects. RESULTS: The comparison between TTE M-mode TAPSE and TEE M-mode TAPSE demonstrated significant variability, with a Spearman correlation of 0.5 and a mean variance in measurement of 6.5 mm. There was equivalence within data pairs and correlations between TTE M-mode TAPSE and both speckle-tracking TTE and speckle-tracking TEE TAPSE, with Spearman correlations of 0.65 and 0.65, respectively. The average variance in measurement was 0.6 mm for speckle-tracking TTE TAPSE and 1.5 mm for speckle-tracking TEE TAPSE. CONCLUSIONS: Using TTE M-mode TAPSE as a control, TEE M-mode TAPSE results are not accurate and should not be used clinically to evaluate RV systolic function. The relationship between speckle-tracking echocardiographic TAPSE and TTE M-mode TAPSE suggests that in the perioperative setting, speckle-tracking TEE TAPSE might be used to quantitatively evaluate RV systolic function in the absence of TTE imaging.

Rapid Assessment of Distribution of Wildlife and Human Activities for Prioritizing Conservation Actions in a Patagonian Landscape.

Large landscapes encompassing reserves and areas with other human uses are necessary for conservation of many species. Generating information for conservation planning over such landscapes may be expensive and time-consuming, though resources for conservation are generally limited and conservation is often urgent. We developed a sign-based occupancy survey to help prioritize conservation interventions by simultaneously assessing the distribution of 3 species, the lesser rhea, guanaco, and mara, and their association with human activities in a 20,000-km2 landscape in the northern Patagonian steppe. We used a single-season occupancy model with spatial rather than temporal replication of surveys in order to reduce costs of multiple visits to sites. We used covariates related to detectability, environmental factors, and different human activities to identify the most plausible models of occupancy, and calculated importance weights of covariates from these models to evaluate relative impacts of human activities on each species. Abundance of goats had the strongest negative association with lesser rheas and guanacos, and road density with maras. With six months of fieldwork, our results provided initial hypotheses for adaptive conservation interventions for each species. Addressing high livestock densities for rheas and guanacos, poaching by urban hunters for all three species, and hunting by rural people for rheas are priorities for conservation in this landscape. Our methodology provided new insights into the responses of these species, although low detection probabilities for maras indicate that the sampling scheme should be altered for future monitoring of this species. This method may be adapted for any large landscape where a rapid, objective means for prioritizing conservation actions on multiple species is needed and data are scarce.

A comparison of caregiver burden in older persons and persons with Parkinson's disease or dementia in sub-Saharan Africa.

BACKGROUND: Caregiver burden includes the many physical, mental and socio-economic problems arising from caring for individuals with chronic and disabling diseases. Being a carer in sub-Saharan Africa (SSA), where little is known about chronic neurological conditions, may be extremely demanding. Conversely, multigenerational living may allow sharing of care among many caregivers. We wished to determine the relative burden of caring for two chronic neurodegenerative conditions (Parkinson's disease (PD) and dementia) in rural Tanzania. METHODS: All surviving patients from a PD prevalence study, newly identified people with PD from a neurological disorders study and all people with dementia from a dementia prevalence study in Hai, rural Tanzania, were invited to participate. The Zarit Burden Interview (ZBI) was used to determine level of caregiver strain (higher score reflects more strain). RESULTS: Of 25 PD patients ZBI was recorded in 20 (14 male). Five had no identifiable carer as they were largely independent. Three had PD dementia (PDD). Of 75 people with dementia (excluding 3 PDD), 43 (32 female) completed the ZBI. For the other 32, the caregivers felt the care they provided was a normal intergenerational expectation. Median ages were 78.5 and 85 years for PD and dementia, respectively. Median ZBI was 30.5 for PD and 14 for dementia (U = 166.0, z = -3.913, p < 0.001). Disease duration and disease type (PD or dementia) were univariate predictor of ZBI score, although only disease type was predictive by multivariable linear regression. CONCLUSIONS: Caring for an individual with PD may be more burdensome than caring for an individual with dementia in SSA. People with more advanced PD had higher caregiver burden.

Features of physician services databases in Canada.

INTRODUCTION: Physician services databases (PSDs) are a valuable resource for research and surveillance in Canada. However, because the provinces and territories collect and maintain separate databases, data elements are not standardized. This study compared major features of PSDs. METHODS: The primary source was a survey of key informants that collected information about years of data, patient/provider characteristics, database inclusions/exclusions, coding of diagnoses, procedures and service locations. Data from the Canadian Institute for Health Information's (CIHI) National Physician Database were used to examine physician remuneration methods, which may affect PSD completeness. Survey data were obtained for nine provinces and two territories. RESULTS: Most databases contained post-1990 records. Diagnoses were frequently recorded using ICD-9 codes. Other coding systems differed across jurisdictions and time, although all PSDs identified in-hospital services and distinguished family medicine from other specialties. Capture of non-fee-for-service records varied and CIHI data revealed an increasing proportion of non-fee-for-service physicians over time. CONCLUSION: Further research is needed to investigate the potential effects of PSD differences on comparability of findings from pan-Canadian studies.

Social-cultural aspects of epilepsy in Kilimanjaro Region, Tanzania: knowledge and experience among patients and carers.

OBJECTIVE: Understanding the social-cultural aspects of epilepsy in sub-Saharan Africa will help to improve the situation of people with epilepsy (PWE) in this region. METHODS: This qualitative study comprised interviews with 41 PWE and their carers. Participants were identified from a large community-based epidemiological study of epilepsy conducted in 2009. RESULTS: Epilepsy was commonly ascribed to witchcraft and curses. Nearly all PWE demonstrated pluralistic care-seeking behavior, including the use of prayers and traditional healers alongside modern care. PWE reported discrimination as a result of their condition. The majority of PWE had suffered burns during seizures. CONCLUSIONS: Poor knowledge and strong cultural and religious beliefs characterize the experience of PWE in this population. Epilepsy-related stigma contributes to overall disease burden, and PWE face exclusion across major life domains. There is a need to educate communities and inculcate perceptions and attitudes that promote early detection of epilepsy and early care-seeking behavior.

A constructive Indian country response to the evidence-based program mandate.

Over the last 20 years governmental mandates for preferentially funding evidence-based "model" practices and programs has become doctrine in some legislative bodies, federal agencies, and state agencies. It was assumed that what works in small sample, controlled settings would work in all community settings, substantially improving safety, effectiveness, and value-for-money. The evidence-based "model" programs mandate has imposed immutable "core components," fidelity testing, alien programming and program developers, loss of familiar programs, and resource capacity requirements upon tribes, while infringing upon their tribal sovereignty and consultation rights. Tribal response in one state (Oregon) went through three phases: shock and rejection; proposing an alternative approach using criteria of cultural appropriateness, aspiring to evaluability; and adopting logic modeling. The state heard and accepted the argument that the tribal way of knowing is different and valid. Currently, a state-authorized tribal logic model and a review panel process are used to approve tribal best practices for state funding. This constructive response to the evidence-based program mandate elevates tribal practices in the funding and regulatory world, facilitates continuing quality improvement and evaluation, while ensuring that practices and programs remain based on local community context and culture. This article provides details of a model that could well serve tribes facing evidence-based model program mandates throughout the country.

Effect of cricoid force on airway calibre in children: a bronchoscopic assessment.

BACKGROUND: Cricoid pressure or to be more exact cricoid force (CF) can cause airway obstruction and subsequent difficulty with airway management during an emergency induction. METHODS: We studied 30 children with an age range of 3 months to 15 yr who presented for routine bronchoscopy or other surgical procedures requiring tracheal intubation. We looked at the effect of CF on the calibre of the subglottic airway and objectively measured the force which caused 50% or greater distortion/compression of the subglottic airway. RESULTS: There was a linear relationship between both age and weight and CF. No patient suffered any adverse effects. Overall, the mean force required to compress the airway was 10.5 N. However, this force could be as low as 5 N in children <1 yr of age, and up to between 15 and 25 N in teenagers. CONCLUSIONS: Forces well below the recommended value of 30 N will cause significant compression/distortion of the airway in a child.

Risk assessment of micronutrients.

Risk assessment of micronutrients has to take into account two different intake-response relationships; the risk of deficiency, which decreases with increase in intake, and the risk of toxicity, which increases with increase in intake. The available databases on micronutrients tend to focus on benefits at low intakes, and there are usually few reliable data on hazard identification and characterisation at high intakes. Application of the usual default uncertainty factors for species differences, human variability and database inadequacy could result in "recommended" upper intake levels that would cause deficiency. There have been a number of comprehensive reviews that have used low, and largely arbitrary, uncertainty factors to establish tolerable upper intake levels for vitamins and minerals. A recent FAO/WHO Workshop developed a structured approach to the application of a single composite uncertainty factor. Risk-benefit approaches have been developed recently that balance the risk of toxicity against the risk of deficiency, and offer the potential for more scientifically based methods.

The challenge of Parkinson's disease management in Africa.

Parkinson's disease (PD) is said to be less common in Africa than elsewhere in the world, but previous studies have been based on small numbers. Also, the differences may be due to the diagnostic criteria used, case finding methods and different population age structures. Developing countries have few facilities for chronic disease management and non-communicable diseases, although on the increase, tend to play second fiddle to malaria and HIV/AIDS. Previous reports suggest that, at least from anecdotal information, under-diagnosis of PD is common and long-term availability of medication, follow-up, patient education and multidisciplinary input is lacking. Published literature is scarce and there is a lack of recent information. We are currently conducting a door-to-door prevalence study in northern Tanzania in a population of 161,162. We have reviewed previous literature on PD in Africa and illustrate our personal experience of PD and its management in Africa with three cases.

Evaluation of certain food additives and contaminants.

This report represents the conclusions of a Joint FAO/WHO Expert Committee convened to evaluate the safety of various food additives, including flavouring agents, with a view to recommending acceptable daily intakes (ADIs) and to preparing specifications for identity and purity. The Committee also evaluated the risk posed by two food contaminants, with the aim of advising on risk management options for the purpose of public health protection. The first part of the report contains a general discussion of the principles governing the toxicological evaluation and assessment of intake of food additives (in particular flavouring agents) and contaminants. A summary follows of the Committee's evaluations of technical, toxicological and intake data for certain food additives (acidified sodium chlorite, asparaginase from Aspergillus oryzae expressed in Aspergillus oryzae, carrageenan and processed Eucheuma seaweed, cyclotetraglucose and cyclotetraglucose syrup, isoamylase from Pseudomonas amyloderamosa, magnesium sulfate, phospholipase A1 from Fusarium venenatum expressed in Aspergillus oryzae, sodium iron(III) ethylenediaminetetraacetic acid (EDTA) and steviol glycosides); eight groups of related flavouring agents (linear and branched-chain aliphatic, unsaturated, unconjugated alcohols, aldehydes, acids and related esters; aliphatic acyclic and alicyclic terpenoid tertiary alcohols and structurally related substances; simple aliphatic and aromatic sulfides and thiols; aliphatic acyclic dials, trials and related substances; aliphatic acetals; sulfur-containing heterocyclic compounds; aliphatic and aromatic amines and amides; and aliphatic alicyclic linear alpha, beta -unsaturated di- and trienals and related alcohols, acids and esters); and two food contaminants (aflatoxin and ochratoxin A). Specifications for the following food additives were revised: maltol and ethyl maltol, nisin preparation, pectins, polyvinyl alcohol, and sucrose esters of fatty acids. Specifications for the following flavouring agents were revised: maltol and ethyl maltol, maltyl isobutyrate, 3-acetyl-2,5-dimethylfuran and 2,4,5-trimethyl-delta-oxazoline (Nos 1482, 1506 and 1559), and monomenthyl glutarate (No. 1414), as well as the method of assay for the sodium salts of certain flavouring agents. Annexed to the report are tables summarizing the Committee's recommendations for intakes and toxicological evaluations of the food additives and contaminants considered.

Quantification of immunohistochemistry--issues concerning methods, utility and semiquantitative assessment I.

Immunohistochemistry is no longer a technique used only for research but is employed increasingly for diagnosis and for the assessment of therapeutic biomarkers. The latter, in particular, often require a semiquantitative evaluation of the extent of their presence. There are many factors that can affect this that relate to the method: fixation of tissue, duration and type of antigen retrieval, antibody specificity, antibody dilution and detection systems. Other complexities relate to assessment. Different scoring systems are used for either the same or different antigens. Cut-off levels for assessing whether a tissue is 'positive' or 'negative' can vary for the same antigen. Whilst there are quality assurance schemes for the methodology that have improved standards of staining, there are no similar schemes that relate to interpretation, although errors here can create as many problems. There have been improvements in automated analysis but availability is limited and it is still predominantly a research tool. In order for quantification of immunohistochemistry to be a reliable and reputable tool, there must be easy to use, reproducible, standardized protocols for assessment which are international. Improvements in automated analysis with wider applicability could lead to standardization.

Organization and financing of alcohol and substance abuse programs for American Indians and Alaska Natives.

OBJECTIVES: Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997-2002 to describe recent trends in organizational and financial arrangements. METHODS: Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures. RESULTS: Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal. CONCLUSIONS: Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

Impact of a national external quality assessment scheme for breast pathology in the UK.

BACKGROUND: This article presents the results and observed effects of the UK National Health Service Breast Screening Programme (NHSBSP) external quality assurance scheme in breast histopathology. AIMS/METHODS: The major objectives were to monitor and improve the consistency of diagnoses made by pathologists and the quality of prognostic information in pathology reports. The scheme is based on a twice yearly circulation of 12 cases to over 600 registered participants. The level of agreement was generally measured using kappa statistics. RESULTS: Four main situations were encountered with respect to diagnostic consistency, namely: (1) where consistency is naturally very high-this included diagnosing in situ and invasive carcinomas (and certain distinctive subtypes) and uncomplicated benign lesions; (2) where the level of consistency was low but could be improved by making guidelines more detailed and explicit-this included histological grading; (3) where consistency could be improved but only by changing the system of classification-this included classification of ductal carcinoma in situ; and (4) where no improvement in consistency could be achieved-this included diagnosing atypical hyperplasia and reporting vascular invasion. Size measurements were more consistent for invasive than in situ carcinomas. Even in cases where there is a high level of agreement on tumour size, a few widely outlying measurements were encountered, for which no explanation is readily forthcoming. CONCLUSIONS: These results broadly confirm the robustness of the systems of breast disease diagnosis and classification adopted by the NHSBSP, and also identify areas where improvement or new approaches are required.

Cost effectiveness of a community based research project to help women quit smoking.

OBJECTIVE: To estimate the cost effectiveness of a four year, multifaceted, community based research project shown previously to help women quit smoking. DESIGN: A quasi-experimental matched control design. SETTING: Two counties in Vermont and two in New Hampshire, USA. SUBJECTS: Women aged 18-64 years. METHODS: Costs were the grant related expenditures converted to 2002 US dollars. Survey results at the end of the intervention were used to estimate the numbers of never smokers, former smokers, light smokers, and heavy smokers in the intervention and comparison counties, and 1986 life tables for populations of US women categorised by smoking status to estimate the gain in life expectancy. MAIN OUTCOME MEASURES: Cost effectiveness ratios, as dollars per life-year saved, for the intervention only and for total grant costs (intervention, evaluation and indirect costs). RESULTS: The cost effectiveness ratio for the intervention, in 2002 US dollars per life-year saved, discounted at 3%, was 1156 dollars (90% confidence interval (CI) 567 dollars to infinity), and for the total grant, 4022 dollars (90% CI 1973 dollars to infinity). When discounted at 5%, these ratios were 1922 dollars (90% CI 1024 dollars to 15,647 dollars), and 6683 dollars (90% CI 3555 dollars to 54,422 dollars), respectively. CONCLUSION: The cost effectiveness ratios of this research project are economically attractive, and are comparable with other smoking cessation interventions for women. These observations should encourage further research and dissemination of community based interventions to reduce smoking.

Criteria for risk assessment of botanical food supplements.

The increasing use of botanical food supplements has raised concerns among scientific and regulatory communities. Occasional cases of intoxication have occurred from misuse, misidentification of the botanical species or contamination with extraneous plants. Consequently, risk assessment of botanical products requires adequate specification of identity and composition. Sources vary from staple food plants to herbals used in folk medicine; the supplement may comprise the whole plant, extracts thereof or purified components. This variability poses problems in adopting a generic approach to their risk assessment. The nature and extent of toxicological testing required will depend on: nature of the supplement, prior knowledge of human consumption, likely exposure and nutritional impact, and intended beneficial effects. Generally, for herbs or complex extracts, it is not possible to make a risk assessment on the basis of a single active component as more than one may be of toxicological significance and matrix effects may affect bioavailability. Nevertheless, studies on single components may be useful in elucidating potential interactions. Botanical supplements are intended to produce physiological effects, so there is a need to distinguish a No Observed Effect Level from a No Observed 'Adverse' Effect Level and the margin of exposure between that producing the desired effect and the upper safe level may be smaller than that adopted for food additives and contaminants. Human studies of efficacy and possible side effects may help in determining the acceptable margin of exposure. A decision tree will be presented to assist in determining the extent of data requirements based on the nature of the product.