Risk assessment of survival and morbidity of infants born at <24 completed weeks of gestation.

BACKGROUND: Infants born at the threshold of viability have a high risk of mortality and morbidity. The British Association of Perinatal Medicine (BAPM) provided updated guidance in 2019 advising a risk-based approach to balancing decisions about active versus redirected care at birth. AIMS: To determine survival and morbidity of infants born between 22 and 24 completed weeks of gestation. To develop a scoring system to categorise infants at birth according to risk for mortality or severe adverse outcome. METHODS: A retrospective, single centre observational study of infants who received neonatal care from 2011 to 2021. Data were collected on mortality, morbidity and two-year neurodevelopmental outcomes. Each infant was risk categorised utilising the proposed tools in the BAPM (2019) framework. A composite adverse score for either dying or surviving with severe impairment was created. RESULTS: Four infants born at 22 weeks, 49 at 23 weeks and 105 at 24 weeks of gestation were included. The mortality rate was 23.4 %. Following risk categorisation there were 8 (5.1 %) extremely high risk, 44 (27.8 %) high risk and 106 (67.1 %) moderate risk infants. The rate of dying or surviving with severe impairment for extremely high risk, high risk and moderate risk were 100 %, 88.9 % and 53 % respectively. The proportions with the composite adverse outcome differed significantly according to the risk category (p < 0.001). CONCLUSIONS: When applying a scoring system to risk categorise infants at birth, high rates of dying or surviving with severe impairment were found in infants born at 22 or 23 weeks of gestation.

Understanding triage assessment of acuity by emergency nurses at initial adult patient presentation: A qualitative systematic review.

BACKGROUND: Nurses make complex triage decisions within emergency departments, which significantly affect patient outcomes. Understanding how nurses make these decisions and why they deviate from triage algorithms facilitates interventions that work with their decision-making processes, increasing acceptability and effectiveness. AIMS: This qualitative systematic review aimed to understand decision-making processes emergency nurses use to make acuity decisions during triage assessment at initial patient presentation. METHODOLOGY: Medline, CINAHL and Academic Search Complete were systematically searched to 15th December 2022. Data were analysed using thematic synthesis. Established themes were reviewed with GRADE-CERQual to evaluate certainty of evidence. RESULTS: 28 studies were included in the review. Data analysis uncovered three superordinate themes of holistic reasoning, situational awareness, and informed decision-making. The findings show nurses value holistic assessments over algorithms and rely on knowledge and experience. They also assess the wider situation in the emergency department. CONCLUSIONS: This review presents new perspectives on nurses' decision-making processes about patient's acuity. Nurses holistically gather information about patients before translating that information into acuity scores. These actions are informed by their knowledge and experience; however, the wider situation also impacts their decisions. In turn, the nurses use interpretations of patients' acuity to control the wider situation.

Determination of 24,25-dihydroxyvitamin D3 in Vitamin D External Quality Assessment Scheme samples using a reference measurement procedure.

Ninety archived human serum samples from the Vitamin D External Quality Assessment Scheme (DEQAS) were analyzed using a reference measurement procedure (RMP) based on isotope dilution liquid chromatography - tandem mass spectrometry (ID LC-MS/MS) for the determination of 24,25-dihydroxyvitamin D3 [24,25(OH)2D3]. These 24,25(OH)2D3 results, in conjunction with concentration values assigned using RMPs for 25-hydroxyvitamin D2 [25(OH)D2] and 25-hydroxyvitamin D3 [25(OH)D3], provide a valuable resource for assessing the accuracy of measurements for 24,25(OH)2D3 and for investigating the relationship between 24,25(OH)2D3 and 25(OH)D3. Results for 24,25(OH)2D3 using the RMP were compared to DEQAS consensus values demonstrating that the consensus values were not sufficient to assess the accuracy of measurements among different laboratories and methods. A multivariable regression analysis approach using historical DEQAS consensus values for various total 25(OH)D assays was used to assess the contribution of 24,25(OH)2D3 concentration on the assay response. The response of several ligand binding assays for total 25(OH)D was shown to be impacted by the presence of 24,25(OH)2D3.

Implementing the Countrywide Mortality Surveillance in Action in Mozambique: How Much Did It Cost?

Complete sample registration systems are almost inexistent in sub-Saharan Africa. The Countrywide Mortality Surveillance in Action (COMSA) project in Mozambique, a national mortality and cause of death surveillance system, was launched in January 2017, began data collection in March 2018, and covers over 800,000 population. The objectives of this analysis are to quantify the costs of establishing and maintaining the project between 2017 and 2020 and to assess the cost per output of the surveillance system using data from financial reports produced by the National Institute of Health in Mozambique. The program cost analysis consists of start-up (fixed) costs and average annual operating costs covering the period of maximum implementation in 700 clusters. The cost per output analysis quantifies the annual operating cost of surveillance outputs during the same period. Approximately two million dollars were spent on setting up the system, with infrastructure, technological investments, and training making up over 80% of these start-up costs. The average annual operating costs of maintaining COMSA was $984,771 per year, of which 66% were spent on wages and data collection incentives. The cost per output analysis indicates costs of $37-$42 per vital event captured in the surveillance system (deaths, pregnancies, pregnancy outcomes), $303-$340 per verbal and social autopsy conducted on a reported death, and a per capita cost of $1-$1.3. In conclusion, establishing COMSA required large costs associated with infrastructure and technological investments. However, the system offers long-term benefits for real-time data generation and informing government decision-making for health.

Cost-Effectiveness of Arthroscopic Partial Meniscectomy and Physical Therapy for Degenerative Meniscal Tear.

OBJECTIVE: We examined the cost-effectiveness of treatment strategies for concomitant meniscal tear and knee osteoarthritis (OA) involving arthroscopic partial meniscectomy surgery and physical therapy (PT). METHODS: We used the Osteoarthritis Policy Model, a validated Monte Carlo microsimulation, to compare three strategies, 1) PT-only, 2) immediate surgery, and 3) PT + optional surgery, for participants whose pain persists following initial PT. We modeled a cohort with baseline meniscal tear, OA, and demographics from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of arthroscopic partial meniscectomy versus PT. We estimated risks and costs of arthroscopic partial meniscectomy complications and accounted for heightened OA progression post surgery using published data. We estimated surgery use rates and treatment efficacies using MeTeOR data. We considered a 5-year time horizon, discounted costs, and quality-adjusted life-years (QALYs) 3% per year and conducted sensitivity analyses. We report incremental cost-effectiveness ratios. RESULTS: Relative to PT-only, PT + optional surgery added 0.0651 QALY and $2,010 over 5 years (incremental cost-effectiveness ratio = $30,900 per QALY). Relative to PT + optional surgery, immediate surgery added 0.0065 QALY and $3080 (incremental cost-effectiveness ratio = $473,800 per QALY). Incremental cost-effectiveness ratios were sensitive to optional surgery efficacy in the PT + optional surgery strategy. In the probabilistic sensitivity analysis, PT + optional surgery was cost-effective in 51% of simulations at willingness-to-pay thresholds of both $50,000 per QALY and $100,000 per QALY. CONCLUSION: First-line arthroscopic partial meniscectomy has a prohibitively high incremental cost-effectiveness ratio. Under base case assumptions, second-line arthroscopic partial meniscectomy offered to participants with persistent pain following initial PT is cost-effective at willingness-to-pay thresholds between $31,000 and $473,000 per QALY. Our analyses suggest that arthroscopic partial meniscectomy can be a high-value treatment option for patients with meniscal tear and OA when performed following an initial PT course and should remain a covered treatment option.

Assessment of serum total 25-hydroxyvitamin D assays for Vitamin D External Quality Assessment Scheme (DEQAS) materials distributed at ambient and frozen conditions.

The Vitamin D External Quality Assessment Scheme (DEQAS) distributes human serum samples four times per year to over 1000 participants worldwide for the determination of total serum 25-hydroxyvitamin D [25(OH)D)]. These samples are stored at -40 °C prior to distribution and the participants are instructed to store the samples frozen at -20 °C or lower after receipt; however, the samples are shipped to participants at ambient conditions (i.e., no temperature control). To address the question of whether shipment at ambient conditions is sufficient for reliable performance of various 25(OH)D assays, the equivalence of DEQAS human serum samples shipped under frozen and ambient conditions was assessed. As part of a Vitamin D Standardization Program (VDSP) commutability study, two sets of the same nine DEQAS samples were shipped to participants at ambient temperature and frozen on dry ice. Twenty-eight laboratories participated in this study and provided 34 sets of results for the measurement of 25(OH)D using 20 ligand binding assays and 14 liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods. Equivalence of the assay response for the frozen versus ambient DEQAS samples for each assay was evaluated using multi-level modeling, paired t-tests including a false discovery rate (FDR) approach, and ordinary least squares linear regression analysis of frozen versus ambient results. Using the paired t-test and confirmed by FDR testing, differences in the results for the ambient and frozen samples were found to be statistically significant at p < 0.05 for four assays (DiaSorin, DIAsource, Siemens, and SNIBE prototype). For all 14 LC-MS/MS assays, the differences in the results for the ambient- and frozen-shipped samples were not found to be significant at p < 0.05 indicating that these analytes were stable during shipment at ambient conditions. Even though assay results have been shown to vary considerably among different 25(OH)D assays in other studies, the results of this study also indicate that sample handling/transport conditions may influence 25(OH)D assay response for several assays.

Assessment of serum total 25-hydroxyvitamin D assay commutability of Standard Reference Materials and College of American Pathologists Accuracy-Based Vitamin D (ABVD) Scheme and Vitamin D External Quality Assessment Scheme (DEQAS) materials: Vitamin D Standardization Program (VDSP) Commutability Study 2.

An interlaboratory study was conducted through the Vitamin D Standardization Program (VDSP) to assess commutability of Standard Reference Materials® (SRMs) and proficiency testing/external quality assessment (PT/EQA) samples for determination of serum total 25-hydroxyvitamin D [25(OH)D] using ligand binding assays and liquid chromatography-tandem mass spectrometry (LC-MS/MS). A set of 50 single-donor serum samples were assigned target values for 25-hydroxyvitamin D2 [25(OH)D2] and 25-hydroxyvitamin D3 [25(OH)D3] using reference measurement procedures (RMPs). SRM and PT/EQA samples evaluated included SRM 972a (four levels), SRM 2973, six College of American Pathologists (CAP) Accuracy-Based Vitamin D (ABVD) samples, and nine Vitamin D External Quality Assessment Scheme (DEQAS) samples. Results were received from 28 different laboratories using 20 ligand binding assays and 14 LC-MS/MS methods. Using the test assay results for total serum 25(OH)D (i.e., the sum of 25(OH)D2 and 25(OH)D3) determined for the single-donor samples and the RMP target values, the linear regression and 95% prediction intervals (PIs) were calculated. Using a subset of 42 samples that had concentrations of 25(OH)D2 below 30 nmol/L, one or more of the SRM and PT/EQA samples with high concentrations of 25(OH)D2 were deemed non-commutable using 5 of 11 unique ligand binding assays. SRM 972a (level 4), which has high exogenous concentration of 3-epi-25(OH)D3, was deemed non-commutable for 50% of the LC-MS/MS assays.

The impact of transfers from neonatal intensive care to paediatric intensive care.

OBJECTIVES: Infants receiving care from neonatal intensive care unit (NICU) can develop chronic problems and be transferred to a paediatric intensive care unit (PICU) for on-going care. There is concern that such infants may take up a large amount of PICU resource, but this is not evidence based. We determined the impact of such transfers. METHODS: We reviewed 10 years of NICU admissions to two tertiary PICUs, which had approximately 12,000 admissions during that period. RESULTS: Sixty-seven infants, gestational age at birth 34.7 (IQR 27.1-38.8) weeks and postnatal age on transfer 81 (IQR 9-144) days were admitted from NICUs. The median (IQR) length of stay was 12 (4-41) days. The 19 infants born <28 weeks of gestation had a greater median length of stay (32, range IQR 10-93 days) than more mature born infants (7.5, IQR 4-26 days) (p=0.003). The median cost of PICU stay for NICU transfers was £23,800 (range 1,205-1,034,000) per baby. The total cost of care for infants transferred from NICUs was £6,457,955. CONCLUSIONS: Infants transferred from NICUs were a small proportion of PICU admissions but, particularly those born <28 weeks of gestation, had prolonged stays which needs to be considered when determining bed capacity.

Antenatal care and perinatal outcomes of asylum seeking women and their infants.

OBJECTIVES: Asylum seekers have been highlighted as a particularly vulnerable group of expectant mothers due to complex medical and psychosocial needs, as well as the difficulties they may face in accessing care. Our aim was to examine if there were differences in the antenatal care and perinatal outcomes for asylum seeking women when compared to age- and ethnicity-matched controls delivering at the same hospital. METHODS: Two age- and ethnicity-matched non-asylum seeking controls were identified for each asylum-seeking woman. Electronic patient records were analysed to determine the amount of antenatal care received and neonatal outcomes. RESULTS: Thirty-four asylum-seeking women were identified who had term born infants. The median number of antenatal care episodes at the delivering hospital was significantly fewer amongst asylum-seeking women compared to controls (three vs. nine, p<0.0001). The median number of antenatal ultrasound examinations at the delivering hospital amongst asylum-seeking women was one (IQR 1-2), compared to three (IQR 3-4) in the controls (p<0.0001). The postnatal length of stay was significantly longer for infants of asylum-seeking women (median three vs. two days, p=0.002). Thirty-seven percent of asylum seeking women but none of the controls required assistance from social services. There was a significant correlation between antenatal and postnatal costs for asylum seeking women (r=0.373, p=0.042), but not for controls (r=0.171, p=0.181). CONCLUSIONS: The increased postnatal length of stay in the infants of asylum seeking mothers may reflect their mother's reduced antenatal care and hence insufficient discharge planning for mothers and infants with increased social needs.

Revision total elbow arthroplasty: Is it safe to perform a single-stage revision for presumed aseptic loosening based on clinical assessment, normal inflammatory markers, and a negative aspiration?

BACKGROUND: Revision total elbow arthroplasty (TEA) is a challenging procedure that is becoming increasingly common. In our unit, we regard it as essential to exclude infection as the underlying cause of TEA loosening. In all patients with arthroplasty loosening, we undertake a careful history and examination, perform radiographs, monitor inflammatory markers, and undertake a joint aspiration. If any investigation suggests infection as the etiology, then a 2-stage revision is undertaken. Open biopsies are not routinely performed. The aim was to ascertain from our outcomes whether it is safe to perform a single-stage revision for presumed aseptic loosening using these criteria. METHODS: A retrospective review of a consecutive series of revision TEAs was performed in our unit over a 10-year period (2008-2018). Single-stage revisions performed for presumed aseptic loosening were identified. Case notes, radiographs, bloods, aspiration results, and microbiology of tissue samples taken at revision were reviewed. RESULTS: A total of 123 revision elbow arthroplasty cases were performed in the study period. Sixty cases were revised for preoperatively proven infection, instability, or implant failure and were excluded from this study. In 63 cases, aseptic loosening was diagnosed based on history, clinical examination, blood markers, and aspiration. There were 21 dual-component and 42 single-component revisions. In the dual-component revision group, tissue samples taken at the time of revision were positive in only 1 case (5%). In the single-component revision group, positive culture samples were present in 3 cases (7%). χ2 analysis showed no significant difference between single- and dual-component revisions (P = .76). No cases with positive culture samples from either group have required subsequent revision surgery. CONCLUSION: Given the results of this study, we conclude that is safe to perform single-stage revision arthroplasty for implant loosening based on history, examination, normal inflammatory markers, and negative aspiration results without the need for open biopsy.

An Assessment Method for Identifying Acceptable and Effective Ways to Present Demands to an Adult With Dementia.

Simple instructions are often recommended for presenting demands to people with dementia; however, simple instructions may be perceived as authoritative and may not be appropriate for all individuals. We conducted a demand assessment with a woman with dementia who engaged in problem behaviors in response to direct instructions. We measured latency to compliance and verbal behavior when demands were presented as questions, rules, simple instructions, or demands embedded in social chatter. In contrast to the other conditions, simple instructions resulted in the most undesirable behavior and were least likely to evoke compliance. We conducted an intervention in which demands were phrased as requests for assistance.

Assessment of sidestream end-tidal capnography in ventilated infants on the neonatal unit.

OBJECTIVES: Continuous monitoring of carbon dioxide (CO2 ) levels can be achieved by capnography. Our aims were to compare the performance of a sidestream capnograph with a low dead space and sampling rate to a mainstream device and evaluate whether its results correlated with arterial/capillary CO2 levels in infants with different respiratory disease severities. WORKING HYPOTHESES: End-tidal carbon dioxide (EtCO2 ) results by sidestream and mainstream capnography would correlate, but the divergence of EtCO2 and CO2 results would occur in more severe lung disease. STUDY DESIGN: Prospective cohort study. PATIENT-SUBJECT SELECTION: Fifty infants with a median (interquartile range) gestational age of 31.1 (27.1-37.4) weeks and birth weight of 1.37 (0.76-2.95) kg. METHODOLOGY: Concurrent measurements of EtCO2 in ventilated infants were made using a new Microstream sidestream device and a mainstream capnograph (gold standard). Results from both devices were compared with arterial or capillary CO2 levels. The ratio of dead space to tidal volume (Vd/Vt) was calculated to assess respiratory disease severity. RESULTS: The mean difference between the concurrent measurements of EtCO2 was -0.54 ± 0.67 kPa (95% agreement levels - 1.86 to 0.77 kPa), the correlation between the two was r = .85 (P < .001). Sidestream capnography results correlated better with partial pressure of CO2 (PCO2 ) levels in infants with less (Vd/Vt < 0.35; r2 = .66, P < .001) rather than more severe (Vd/Vt > 0.35; r2 = .33, P = .01) lung disease. CONCLUSIONS: The sidestream capnography performed similarly to the mainstream capnography. The poorer correlation of EtCO2 to PCO2 levels in infants with severe respiratory disease should highlight to clinicians increased ventilation-perfusion mismatch.

Strengthening and monitoring health system's capacity to improve availability, utilization and quality of emergency obstetric care in northern Nigeria.

BACKGROUND: Quality improvement in emergency obstetric care (EmOC) is a critical and cost-effective suite of interventions for the reduction of maternal and newborn mortality and morbidity. This study was undertaken to evaluate the impact of quality improvement interventions following a baseline assessment in Bauchi state, Nigeria. METHODS: This was a prospective before and after study between June 2012, and April 2015 in Bauchi State, Nigeria. The surveys included 21 hospitals designated by Ministry of Health (MoH) as comprehensive EmOC centers and 38 primary healthcare centers (PHCs) designated as basic EmOC centers. Data on EmOC services was collected using structured established EmOC tools developed by the Averting Maternal Death and Disability (AMDD), and analyzed using univariate and bivariate statistical analyses. RESULTS: Facilities providing seven or nine signal EmOC functions increased from 6 (10.2%) in 2012 to 21 (35.6%) in 2015. Basic EmOC facilities increased from 1 (2.6%) to 7 (18.4%) and comprehensive EmOC facilities rose from 3 (14.3%) to 13 (61.9%). Facility birth increased from 3.6% to 8.0%. Cesarean birth rates increased from 3.8% in 2012 to 5.6% in 2015. Met need for EmOC more than doubled from 3.3% in 2012 to 9.9% in 2015. Direct obstetric case fatality rates increased from 3.1% in 2012 to 4.0% in 2015. Major direct obstetric complications as a percent of total maternal deaths was 70.9%, down from 80.1% in 2012. CONCLUSION: The rise in the percent of facility-based births and in met need for EmOC suggest that interventions recommended and implemented after the baseline study resulted in increased availability, access and utilization of EmOC. Higher patient load, late arrival and better record keeping may explain the associated increase in case fatality rates.

Feasibility assessment of an ergonomic baby wrap for kangaroo mother care: A mixed methods study from Nepal.

BACKGROUND: Kangaroo mother care, an evidence based practice and a national policy for management of low birth weight newborns in Nepal, is not widely practiced. This implementation research study aimed to explore the consumer preference and acceptability of the traditional and a new ergonomic wrap on the continuation of kangaroo mother care in the facility and community following discharge. METHODS: A mixed method feasibility study was done from May to October 2015. Ninety-six families of stable low birth weight newborns weighing 1800 to 2499 grams were counseled and taught to practice kangaroo mother care using both wraps. They were randomized into two groups of 48 with one group trying out the traditional wrap for the first six hours and the new wrap for the next six, and vice versa. Mothers were allowed to choose between the wraps for continuation of kangaroo mother care at the facility and post discharge. They were followed up telephonically weekly over 28 days postpartum to ascertain practice of kangaroo mother care. In-depth interviews with mothers (n = 12) and focus group discussions with health workers (n = 16) further evaluated the intervention. Descriptive statistics are presented for the quantitative part of the study. RESULTS: Mothers in the two groups chose the new wrap with no significant difference (81.3% vs 89.6%, p = 0.24). Of the 96 randomized mothers, 85% chose the new wrap. During the hospital stay, six mothers dropped out and remaining 90 mothers who were discharged with the intention of continuing Kangaroo Mother Care, 78 and 12 mothers did so with the new and traditional wrap respectively. New wrap users (429.1 hours, 95% confidence interval [CI]: 351.7-470.3) performed skin-to-skin contact for an extra 77.4 hours overall than traditional wrap (351.7 hours, 95%CI: 259.3-444) users from first day to 28 day postpartum. Health workers and mothers reported positive experience with the new wrap as it was easy to wear without assistance, secure and flexible to move around in kangaroo mother care position. CONCLUSIONS: Involvement of mothers and families with provision of ergonomic wraps showed improvement in kangaroo mother care practice during hospital stay and at home.

The use and misuse of herbarium specimens in evaluating plant extinction risks.

Herbarium specimens provide verifiable and citable evidence of the occurrence of particular plants at particular points in space and time, and are vital resources for assessing extinction risk in the tropics, where plant diversity and threats to plants are greatest. We reviewed approaches to assessing extinction risk in response to the Convention on Biological Diversity's Global Strategy for Plant Conservation Target 2: an assessment of the conservation status of all known plant species by 2020. We tested five alternative approaches, using herbarium-derived data for trees, shrubs and herbs in five different plant groups from temperate and tropical regions. All species were previously fully assessed for the IUCN Red List. We found significant variation in the accuracy with which different approaches classified species as threatened or not threatened. Accuracy was highest for the machine learning model (90%) but the least data-intensive approach also performed well (82%). Despite concerns about spatial, temporal and taxonomic biases and uncertainties in herbarium data, when specimens represent the best available evidence for particular species, their use as a basis for extinction risk assessment is appropriate, necessary and urgent. Resourcing herbaria to maintain, increase and disseminate their specimen data is essential to guide and focus conservation action.This article is part of the theme issue 'Biological collections for understanding biodiversity in the Anthropocene'.

Cost-benefit analysis of acoustic recorders as a solution to sampling challenges experienced monitoring cryptic species.

The inferences that can be made from any study are limited by the quality of the sampling design. By bad luck, when monitoring species that are difficult to detect (cryptic), sampling designs become dictated by what is feasible rather than what is desired. We calibrated and conducted a cost-benefit analysis of four acoustic recorder options that were being considered as potential solutions to several sampling restrictions experienced while monitoring the Australasian bittern, a cryptic wetland bird. Such sampling restrictions are commonly experienced while monitoring many different endangered species, particularly those that are cryptic. The recorder options included mono and stereo devices, with two sound file processing options (visual and audible analysis). Recording devices provided call-count data similar to those collected by field observers but at a fraction of the cost, which meant that "idealistic" sampling regimes, previously thought to be too expensive, became feasible for bitterns. Our study is one of the few to assess the monetary value of recording devices in the context of data quality, allowing trade-offs (and potential solutions) commonly experienced while monitoring cryptic endangered species to be shown and compared more clearly. The ability to overcome challenges of monitoring cryptic species in this way increases research possibilities for data deficient species and is applicable to any species with similar monitoring challenges.

Health needs and co-morbidity among detainees in contact with healthcare professionals within police custody across the London Metropolitan Police Service area.

AIMS: Detainees requiring access to healthcare services in police custody have been shown to suffer from poor physical and mental health, often exacerbated by substance misuse. This study examines the extent and nature of health needs in police custody across the Metropolitan Police Service (MPS), London. METHODS: A survey (n = 1657) was administered by Healthcare Professionals (HCP) for one month in 2015 across all MPS custody suites representing a 73% response rate. A logistic regression model was created using four binary outcomes (whether a detainee was a drug user, had mental health issues including self-harm and had an alcohol use disorder) with ten prognostics to test for co-morbid associations. A multiple imputation method using chained equations was used to manage missing cases. FINDINGS: High rates of physical health conditions, drug use, problematic alcohol use were noted but are within the upper range of existing studies. Mental health, self-harm and overall substance misuse levels (illicit drug user and a current drinker) were shown to be higher than other published studies. The logistic regression model found statistically significant associations between drug use, alcohol consumption and mental health including self-harm. Age was also found to be a key confounding factor. Physical health was broadly negatively associated with the four main outcomes. DISCUSSION: Levels of need for health interventions among the detainee population in London are broadly consistent with other European centres. There is a need for police custody staff to consider detainees' dual diagnosis needs. The development of integrated interventions alongside the enhanced clinical management of alcohol, drug use and mental health was considered.

Perspectives of basic wheelchair users on improving their access to wheelchair services in Kenya and Philippines: a qualitative study.

BACKGROUND: The United Nations has called for countries to improve access to mobility devices when needed. The World Health Organization has published guidelines on the provision of manual wheelchairs in less-resourced settings. Yet little is known about the extent to which appropriate wheelchairs are available and provided according to international guidelines. This study's purpose was to describe wheelchair users' experiences receiving services and acquiring wheelchair skills in urban and peri-urban areas of Kenya and the Philippines. METHODS: Local researchers in Nairobi and Manila interviewed 48 adult basic wheelchair users, with even distribution of those who had and had not received wheelchair services along with their wheelchair. Recordings were transcribed in the local language and translated into English. The study team coded transcripts for predetermined and emergent themes, using Atlas-ti software. A qualitative content analysis approach was taken with the WHO service delivery process as an organizing framework. RESULTS: Wheelchair users frequently described past experiences with ill-fitting wheelchairs and little formal training to use wheelchairs effectively. Through exposure to multiple wheelchairs and self-advocacy, they learned to select wheelchairs suitable for their needs. Maintenance and repair services were often in short supply. Participants attributed shorter duration of wheelchair use to lack of repair. Peer support networks emerged as an important source of knowledge, resources and emotional support. Most participants acknowledged that they received wheelchairs that would have been difficult or impossible for them to pay for, and despite challenges, they were grateful to have some means of mobility. Four themes emerged as critical for understanding the implementation of wheelchair services: barriers in the physical environment, the need for having multiple chairs to improve access, perceived social stigma, and the importance of peer support. CONCLUSIONS: Interventions are needed to provide wheelchairs services efficiently, at scale, in an environment facilitating physical access and peer support, and reduced social stigma. TRIAL REGISTRATION: Not applicable since this was a descriptive study.

Monitoring maternal and newborn health outcomes in Bauchi State, Nigeria: an evaluation of a standards-based quality improvement intervention.

OBJECTIVE: This study assessed the correlation between compliance with set performance standards and maternal and neonatal deaths in health facilities. DESIGN: Baseline and three annual follow-up assessments were conducted, and each was followed by a quality improvement initiative using the Standards Based Management and Recognition (SBM-R) approach. SETTING: Twenty-three secondary health facilities of Bauchi state, Nigeria. PARTICIPANTS: Health care workers and maternity unit patients. MAIN OUTCOME MEASURES: We examined trends in: (i) achievement of SBM-R set performance standards based on annual assessment data, (ii) the use of maternal and newborn health (MNH) service delivery practices based on data from health facility registers and supportive supervision and (iii) MNH outcomes based on routine service statistics. RESULTS: At the baseline assessment in 2010, the facilities achieved 4% of SBM-R standards for MNH, on average, and this increased to 86% in 2013. Over the same time period, the study measured an increase in the administration of uterotonic for active management of third stage of labor from 10% to 95% and a decline in the incidence of postpartum hemorrhage from 3.3% to 1.9%. Institutional neonatal mortality rate decreased from 9 to 2 deaths per 1000 live births, while the institutional maternal mortality ratio dropped from 4113 to 1317 deaths per 100 000 live births. CONCLUSION: Scaling up SBM-R for quality improvement has the potential to prevent maternal and neonatal deaths in Nigeria and similar settings.

A Randomized Evaluation of a Demand Creation Lottery for Voluntary Medical Male Circumcision Among Adults in Tanzania.

BACKGROUND: Uptake of voluntary medical male circumcision (VMMC) among adult men has fallen short of targets in Tanzania. We evaluated a smartphone raffle intervention designed to increase VMMC uptake in three regions. METHODS: Among 7 matched pairs of health facilities, 1 in each pair was randomly assigned to the intervention, consisting of a weekly smartphone raffle for clients returning for follow-up and monthly raffle for peer promoters and providers. VMMC records of clients aged 20 and older were analyzed over three months, with the number performed compared with the same months in the previous year. In multivariable models, the intervention's effect on number of VMMCs was adjusted for client factors and clustering. Focus groups with clients and peer promoters explored preferences for VMMC incentives. RESULTS: VMMCs increased 47% and 8% in the intervention and control groups, respectively; however, the changes were not significantly different from one another. In the Iringa region subanalysis, VMMCs in the intervention group increased 336% (exponentiated coefficient of 3.36, 95% CI: 1.14 to 9.90; P = 0.028), after controlling for facility pair, percentage of clients ≥ age 30, and percentage testing HIV positive; the control group had a more modest 63% significant increase (exponentiated coefficient 1.63, 95% CI: 1.18 to 2.26; P = 0.003). The changes were not significantly different. Focus group respondents expressed mixed opinions about smartphone raffles; some favored smaller cash incentive or transportation reimbursement. IMPLICATIONS: A smartphone raffle might increase VMMC uptake in some settings by helping late adopters move from intention to action; however, there is no recommendation for this intervention more generally.