Prevalence and determinants of contraception utilization over time in Migori County, Kenya: Repeated cross-sectional household surveys.

Contraception use and family planning have been shown to save lives and benefit women, their families, and their communities. We conducted a cross-sectional study analyzing data from a 2021 survey that was conducted across eight different regions in Migori County, Kenya to examine the potential role that different factors play in meeting family planning targets. Comparisons are made to data collected in 2018/2019 in order to estimate the change over time of contraception uptake. Descriptive statistics were calculated, the Cochran-Mantel-Haenszel test was used to compare contraception use over time, and multivariable logistic regression was used to model determinants of contraceptive use. Sixty-four percent of respondents in 2021 reported that they currently use some form of contraception, and implants are the most popular contraceptive method. Factors associated with higher contraception usage were region, ages 25-34 years, and marital status. Contraception uptake increased significantly in East Kamagambo following a community-driven sexual and reproductive health intervention by the Lwala Community Alliance, suggesting that increased investment in family planning may be influential. We recommend targeted outreach to population groups with low uptake of contraception and investment in both demand- and supply-side interventions to increase contraceptive uptake. Additional research, especially for populations under 18, is needed to further inform effective investment and policy.

Novel Cardiac Imaging Risk Score for Mortality Prediction in Duchenne Muscular Dystrophy.

Cardiovascular disease is the leading cause of death in patients with Duchenne Muscular Dystrophy (DMD), but there is significant cardiomyopathy phenotypic variability. Some patients demonstrate rapidly progressive disease and die at a young age while others survive into the fourth decade. Criteria to identify DMD subjects at greatest risk for early mortality could allow for increased monitoring and more intensive therapy. A risk score was created describing the onset and progression of left ventricular dysfunction and late gadolinium enhancement in subjects with DMD. DMD subjects prospectively enrolled in ongoing observational studies (which included cardiac magnetic resonance [CMR]) were used to validate the risk score. A total of 69 subjects had calculable scores. During the study period, 12 (17%) died from complications of DMD. The median risk score was 3 (IQR [2,5]; range [0,9]). The overall risk score applied at the most recent imaging age was associated with mortality at a median age of 17 years (IQR [16,20]) (HR 2.028, p < 0.001). There were no deaths in subjects with a score of less than two. Scores were stable over time. An imaging-based risk score allows risk stratification of subjects with DMD. This can be quickly calculated during a clinic visit to identify subjects at greatest risk of early death.

Determinants of modern contraceptive prevalence and unplanned pregnancies in Migori County, Kenya: results of a cross-sectional household survey.

Family planning and contraceptive utilization can have significant effects in reducing unplanned pregnancies and improving maternal and child health indicators. We conducted a retrospective cross-sectional study analyzing survey response data within six sub-locations of Migori County, Kenya in 2018 and 2019. We utilize this survey data to estimate both the prevalence of contraceptive uptake and unwanted pregnancies in the study populations, and to examine the potential role that different factors play in meeting related family planning targets. Descriptive statistics were calculated, and multivariable logistic regression was used to model determinants of contraceptive use and reported unplanned pregnancy. A total of 3,642 female heads of household were included. 63% of respondents reported that they currently use some form of contraception, and the prevalence of unplanned pregnancy was 36.7%. Our findings reflect the need for family planning programs to focus interventions on those at highest risk. There is a need for additional research and investigation into community and individual beliefs surrounding family planning in order to ensure that interventions are culturally sensitive and locally responsive.

Safe Anesthesia Care in Western Kenya: A Preliminary Assessment of the Impact of Nurse Anesthetists at Multiple Levels of Government Hospitals.

BACKGROUND: Only 20% of the surgical burden in eastern sub-Saharan Africa is currently met, leaving >17 million surgical cases annually in need of safe surgery and anesthesia. Similarly, there is an extreme shortage of anesthesia providers in East Africa, with just 0.44 anesthesiologists per 100,000 people in Kenya compared to 20.82 per 100,000 in the United States. Additionally, surgical access is not equally distributed within countries, with rural settings often having the greatest unmet need. We developed and tested a set of tools to assess if graduates of the Kenya registered nurse anesthetist (KRNA) training program, who were placed in rural hospitals in Kenya, would have any impact on surgical numbers, referral patterns, and economics of these hospitals. METHODS: Cross-sectional data were collected from facility assessments in 9 referral hospitals to evaluate the possible impact of the KRNAs on anesthesia care. The hospitals were grouped based on both the number of beds and the assigned national hospital level. At each level, a hospital that had KRNA graduates (intervention) was matched with comparison hospitals in the same category with no KRNA graduates (control). The facility assessment survey included questions capturing data on personnel, infrastructure, supplies, medications, procedures, and outcomes. At the intervention sites, the medical directors of the hospitals and the KRNAs were interviewed. Descriptive statistics were used to present the findings. RESULTS: Intervention sites had a density of anesthesia providers that was 43% higher compared to the control sites. Intervention sites performed at least twice as many surgical cases compared to the control sites. Most KRNAs stated that the anesthesia training program had given them sufficient training and leadership skills to perform safe anesthesia in their clinical practice setting. Medical directors at the intervention sites reported increased surgical volumes and fewer referrals to larger hospitals due to the anesthesia gaps that had been addressed. CONCLUSIONS: Our findings from this study suggest that KRNAs may be associated with an increased volume of surgical cases completed in these rural Kenyan hospitals and may therefore be filling a known anesthetic void. The presence of skilled anesthesia providers is a first step toward providing safe surgery and anesthesia care for all; however, significant gaps still remain. Future analysis will focus on surgical outcomes, the appropriate anesthesia delivery model for a rural population, and how the availability of anesthesia infrastructure impacts referral patterns and safe surgery capacity.

Untargeted metabolomics analysis of ischemia-reperfusion-injured hearts ex vivo from sedentary and exercise-trained rats.

Introduction: The effects of exercise on the heart and its resistance to disease are well-documented. Recent studies have identified that exercise-induced resistance to arrhythmia is due to the preservation of mitochondrial membrane potential. Objectives: To identify novel metabolic changes that occur parallel to these mitochondrial alterations, we performed non-targeted metabolomics analysis on hearts from sedentary and exercise-trained rats challenged with isolated heart ischemia-reperfusion injury (I/R). Methods: Eight-week old Sprague-Dawley rats were treadmill trained 5 days/week for 6 weeks (exercise duration and intensity progressively increased to 1 h at 30 m/min up a 10.5% incline, 75-80% VO2max). The recovery of pre-ischemic function for sedentary rat hearts was 28.8 ± 5.4% (N = 12) compared to exercise trained hearts, which recovered 51.9% ± 5.7 (N = 14) (p < 0.001). Results: Non-targeted GC-MS metabolomics analysis of (1) sedentary rat hearts; (2) exercise-trained rat hearts; (3) sedentary rat hearts challenged with global ischemia-reperfusion (I/R) injury; and (4) exercise-trained rat hearts challenged with global I/R (10/group) revealed 15 statistically significant metabolites between groups by ANOVA using Metaboanalyst (p < 0.001). Enrichment analysis of these metabolites for pathway-associated metabolic sets indicated a > 10-fold enrichment for ammonia recycling and protein biosynthesis. Subsequent comparison of the sedentary hearts post-I/R and exercise-trained hearts post-I/R further identified significant differences in three metabolites (oleic acid, pantothenic acid, and campesterol) related to pantothenate and CoA biosynthesis (p ≤ 1.24E-05, FDR ≤ 5.07E-4). Conclusions: These studies shed light on novel mechanisms in which exercise-induced cardioprotection occurs in I/R that complement both the mitochondrial stabilization and antioxidant mechanisms recently described. These findings also link protein synthesis and protein degradation (protein quality control mechanisms) with exercise-linked cardioprotection and mitochondrial susceptibility for the first time in cardiac I/R.

Characterization of pediatric golf cart injuries to guide injury prevention efforts.

BACKGROUND: Golf cart injuries represent an increasing source of morbidity and mortality in the United States. Characterization of the circumstances of these injuries can inform injury prevention efforts. METHODS: This study retrospectively reviews a prospective trauma registry at a level-one pediatric trauma center for golf cart-related injuries in patients under 18years of age admitted to the hospital between 2008 and 2016. RESULTS: The 40 identified crashes were associated with 82 hospital days, 17 ICU days, and more than $1 million in hospital charges over the study period. The median hospital stay was 1.5days, and the median hospital charge was $20,489. Severe injuries with an Injury Severity Score of >15 were identified in 25% of patients, and moderate injuries with scores between nine and 15 were identified in an additional 30%. The most common injures were head and neck (60%) and external injuries to the body surface (52.5%). Only a single child was wearing a seatbelt, and the vast majority was not using any safety equipment. Children as young as nine years old were driving golf carts, and child drivers were associated with the cart overturning (p=0.007). CONCLUSIONS: Golf cart crashes were a source of substantial morbidity at a level-one trauma center. Increased safety measures, such as higher hip restraints, seatbelts, and front-wheel breaks could substantially increase the safety of golf carts. Increased regulation of driving age as well as driver education may also reduce these injuries.

Prediction of Prolonged Ventilation after Coronary Artery Bypass Grafting: Data from an Artificial Neural Network.

OBJECTIVES: The need for mechanical ventilation 24 hours after coronary artery bypass grafting (CABG) is considered a morbidity by the Society of Thoracic Surgeons. The purpose of this investigation was twofold: to identify simple preoperative patient factors independently associated with prolonged ventilation and to optimize prediction and early identification of patients prone to prolonged ventilation using an artificial neural network (ANN). METHODS: Using the institutional Adult Cardiac Database, 738 patients who underwent CABG since 2005 were reviewed for preoperative factors independently associated with prolonged postoperative ventilation. Prediction of prolonged ventilation from the identified variables was modeled using both "traditional" multiple logistic regression and an ANN. The two models were compared using Pearson r2 and area under the curve (AUC) parameters. RESULTS: Of 738 included patients, 14% (104/738) required mechanical ventilation ≥ 24 hours postoperatively. Upon multivariate analysis, higher body-mass index (BMI; odds ratio [OR] 1.10 per unit, P < 0.001), lower ejection fraction (OR 0.97 per %, P = 0.01) and use of cardiopulmonary bypass (OR 2.59, P = 0.02) were independently predictive of prolonged ventilation. The Pearson r2 and AUC of the multivariate nominal logistic regression model were 0.086 and 0.698 ± 0.05, respectively; analogous statistics of the ANN model were 0.159 and 0.732 ± 0.05, respectively.BMI, ejection fraction and cardiopulmonary bypass represent three simple factors that may predict prolonged ventilation after CABG. Early identification of these patients can be optimized using an ANN, an emerging paradigm for clinical outcomes modeling that may consider complex relationships among these variables.

Metadata from data: identifying holidays from anesthesia data.

The increasingly large databases available to researchers necessitate high-quality metadata that is not always available. We describe a method for generating this metadata independently. Cluster analysis and expectation-maximization were used to separate days into holidays/weekends and regular workdays using anesthesia data from Vanderbilt University Medical Center from 2004 to 2014. This classification was then used to describe differences between the two sets of days over time. We evaluated 3802 days and correctly categorized 3797 based on anesthesia case time (representing an error rate of 0.13%). Use of other metrics for categorization, such as billed anesthesia hours and number of anesthesia cases per day, led to similar results. Analysis of the two categories showed that surgical volume increased more quickly with time for non-holidays than holidays (p < 0.001). We were able to successfully generate metadata from data by distinguishing holidays based on anesthesia data. This data can then be used for economic analysis and scheduling purposes. It is possible that the method can be expanded to similar bimodal and multimodal variables.

Automated Case Cancellation Review System Improves Systems-Based Practice.

BACKGROUND: Accreditation Council for Graduate Medical Education (ACGME) core competencies of systems-based practice and practice-based learning and improvement are difficult to assess, as they are often not directly measurable or observable. Reviewing day-of-surgery cancellations could provide resident learning opportunities in these areas. OBJECTIVE: An automated system to facilitate anesthesiology resident review of cancelled cases was implemented on the Preoperative Evaluation Clinic (PEC) rotation at the authors' institution. This study aims to evaluate its impact on resident education. METHODS: Residents on the PEC rotation during the 6 months preceding (n = 22) and following (n = 13) implementation in 2014 were surveyed about their experience performing cancelled case reviews in order to ascertain the effect of the intervention on their training. RESULTS: Significant changes were reported in the number of cases reviewed by each resident (p < 0.0001), perceived importance of review (p = 0.03), and ease of review (p = 0.03) after system implementation. There was also an increase in the proportion of cancelled cases reviewed from 17.3% (34 of 196) to 95.6% (194 of 203) (p < 0.0001). Non-significant trends were seen in perceived rotation effect on ACGME competencies, including systems-based practice. Several specific improvements to our clinical practice, including the creation of standardized guidelines, arose from these case reviews. CONCLUSION: Implementation of automated systems can improve compliance with educational goals by clarifying priorities and simplifying workflow. This system increased the number of cases reviewed by residents and the perceived importance of this review as a part of their educational experience.

Rate of Change in Cardiac Magnetic Resonance Imaging Measures Is Associated With Death in Duchenne Muscular Dystrophy.

BACKGROUND: Cardiovascular disease is the leading cause of death among patients with Duchenne muscular dystrophy (DMD). Identifying patients at risk of early death could allow for increased monitoring and more intensive therapy. Measures that associate with death could serve as surrogate outcomes in clinical trials. METHODS AND RESULTS: Duchenne muscular dystrophy subjects prospectively enrolled in observational studies were included. Models using generalized least squares were used to assess the difference of cardiac magnetic resonance measurements between deceased and alive subjects. A total of 63 participants underwent multiple cardiac magnetic resonance imaging and were included in the analyses. Twelve subjects (19.1%) died over a median follow-up of 5 years (interquartile range, 3.1-7.0). Rate of decline in left ventricular ejection fraction was faster in deceased than alive subjects (P<0.0001). Rate of increase in indexed left ventricular end-diastolic (P=0.0132) and systolic (P<0.0001) volumes were higher in deceased subjects. Faster worsening in midcircumferential strain was seen in deceased subjects (P=0.049) while no difference in global circumferential strain was seen. The rate of increase in late gadolinium enhancement, base T1, and mid T1 did not differ between groups. CONCLUSIONS: Duchenne muscular dystrophy death is associated with the rate of change in left ventricular ejection fraction, midcircumferential strain, and ventricular volumes. Aggressive medical therapy to decrease the rate of progression may improve the mortality rate in this population. A decrease in the rate of progression may serve as a valid surrogate outcome for therapeutic trials.

Interpersonal violence against women and maternity care in Migori County, Kenya: evidence from a cross-sectional survey.

Background: Interpersonal violence (IPV) is an issue of major public health concern, with 24% of Kenyan women reporting physical violence perpetrated by a current husband or partner. IPV has profound impacts on physical and mental health outcomes, particularly for pregnant women; it has been found to increase the risk of perinatal mortality, low birth weight, and preterm birth. This study aims to identify variables associated with IPV and assess the effects of IPV experience on prenatal and peripartum maternal healthcare in Migori County, Kenya. Findings build on a previous study that investigated a smaller region of Migori County. Methods: Responses to cross-sectional household surveys conducted in six wards of Migori County, Kenya in 2021 from female respondents aged 18 and older were analyzed. The survey contained validated screening tools for interpersonal violence. Group-wise comparisons, and bivariate and multivariate logistic regression analyses were performed to describe community prevalence, factors associated with IPV against women, and the effect of IPV exposure on prenatal and peripartum health care. Results: This study finds that 2,306 (36.7%) of the 6,290 respondents had experienced lifetime IPV. IPV experience was associated with the age group 25-49 (adjusted odds ratio (aOR) 1.208; 95%CI: [1.045-1.397]; p = 0.011), monogamous marriage [aOR 2.152; 95%CI: (1.426-3.248); p < 0.001], polygamous marriage [aOR 2.924; 95%CI: (1.826-4.683); p < 0.001], being widowed/divorced/separated [aOR 1.745; 95%CI: (1.094-2.786); p < 0.001], feeling an attitude of "sometimes okay" toward wife beating [aOR 2.002 95%CI: (1.651, 2.428); p < 0.001], having been exposed to IPV in girlhood [aOR 2.525; 95%CI: (2.202-2.896); p < 0.001] and feeling safe in the current relationship [aOR 0.722; 95%CI: (0.609, 0.855); p < 0.001]. A depression score of mild [aOR 1.482; 95%CI: (1.269, 1.73); p < 0.001] and severe [aOR 2.403; 95%CI: (1.429, 4.039); p = 0.001] was also associated with IPV experience, and women who experienced emotional abuse were much more likely to have experienced IPV [aOR 10.462; 95% CI: (9.037, 12.112); p < 0.001]. Adjusted analyses showed that having experienced IPV was negatively associated with attending at least four antenatal care visits during the most recent pregnancy (OR 0.849, p = 0.044) and with having a skilled birth attendant (OR 0.638, p = 0.007). Conclusions: IPV is prevalent in Migori County, Kenya, with increased prevalence among women aged 25-49, those residing in West Kanyamkago, those in a monogamous or polygamous marriage, those who have been widowed/divorced/separated, and those with severe depressive symptoms. Further, IPV exposure is associated with lower use of maternal care services and may lead to worse maternal health outcomes. There is need for enhanced effort in addressing social and gender norms that perpetuate IPV, and this study can contribute to guiding policy interventions and community responses towards IPV.

Clinical prediction model: Multisystem inflammatory syndrome in children versus Kawasaki disease.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious complication of severe acute respiratory syndrome coronavirus 2 infection. Features of MIS-C overlap with those of Kawasaki disease (KD). OBJECTIVE: The study objective was to develop a prediction model to assist with this diagnostic dilemma. METHODS: Data from a retrospective cohort of children hospitalized with KD before the coronavirus disease 2019 pandemic were compared to a prospective cohort of children hospitalized with MIS-C. A bootstrapped backwards selection process was used to develop a logistic regression model predicting the probability of MIS-C diagnosis. A nomogram was created for application to individual patients. RESULTS: Compared to children with incomplete and complete KD (N = 602), children with MIS-C (N = 105) were older and had longer hospitalizations; more frequent intensive care unit admissions and vasopressor use; lower white blood cell count, lymphocyte count, erythrocyte sedimentation rate, platelet count, sodium, and alanine aminotransferase; and higher hemoglobin and C-reactive protein (CRP) at admission. Left ventricular dysfunction was more frequent in patients with MIS-C, whereas coronary abnormalities were more common in those with KD. The final prediction model included age, sodium, platelet count, alanine aminotransferase, reduction in left ventricular ejection fraction, and CRP. The model exhibited good discrimination with AUC 0.96 (95% confidence interval: [0.94-0.98]) and was well calibrated (optimism-corrected intercept of -0.020 and slope of 0.99). CONCLUSIONS: A diagnostic prediction model utilizing admission information provides excellent discrimination between MIS-C and KD. This model may be useful for diagnosis of MIS-C but requires external validation.

Conjugated linoleic acid reduces adiposity and increases markers of browning and inflammation in white adipose tissue of mice.

The objective of this study was to examine the mechanism by which conjugated linoleic acid (CLA) reduces body fat. Young male mice were fed three combinations of fatty acids at three doses (0.06%, 0.2%, and 0.6%, w/w) incorporated into AIN76 diets for 7 weeks. The types of fatty acids were linoleic acid (control), an equal mixture of trans-10, cis-12 (10,12) CLA plus linoleic acid, and an equal isomer mixture of 10,12 plus cis-9, trans-11 (9,11) CLA. Mice receiving the 0.2% and 0.6% dose of 10,12 CLA plus linoleic acid or the CLA isomer mixture had decreased white adipose tissue (WAT) and brown adipose tissue (BAT) mass and increased incorporation of CLA isomers in epididymal WAT and liver. Notably, in mice receiving 0.2% of both CLA treatments, the mRNA levels of genes associated with browning, including uncoupling protein 1 (UCP1), UCP1 protein levels, and cytochrome c oxidase activity, were increased in epididymal WAT. CLA-induced browning in WAT was accompanied by increases in mRNA levels of markers of inflammation. Muscle cytochrome c oxidase activity and BAT UCP1 protein levels were not affected by CLA treatment. These data suggest a linkage between decreased adiposity, browning in WAT, and low-grade inflammation due to consumption of 10,12 CLA.

Exercise alters the regulation of myocardial Na(+)/H(+) exchanger-1 activity.

The myocardial Na(+)/H(+) exchanger-1 (NHE1) plays a major role in regulation of intracellular pH, and its upregulation has been implicated in increased ischemia-reperfusion injury and other pathologies. Hydrogen peroxide (H2O2) increases NHE1 activity acutely via ERK1/2 signaling. Chronic strenuous exercise upregulates NHE1 in skeletal muscle, but we hypothesize this will not occur in the heart, because exercise creates a cardioprotective phenotype. NHE1 activity and its regulation by H2O2 were examined at physiological pH using isolated cardiomyocytes from female Sprague-Dawley rats exercised on a treadmill for 5 wk (E; n = 11). Compared with sedentary (S; n = 15), E displayed increases (P < 0.05) in heart-to-body weight ratio (6.8%) and plantaris mitochondria content (89%). NHE1 activity (acid efflux rate following an acid load) was 209% greater in E (0.65 ± 0.12 vs. 2.01 ± 0.29 fmol/min). The difference was attributed primarily to greater cell volume (22.2 ± 0.6 vs. 34.3 ± 1.1 pl) and intracellular pH-buffering capacity (33.94 ± 1.59 vs. 65.82 ± 5.20 mM/pH unit) of E myocytes. H2O2 stimulation (100 µM) raised NHE1 activity significantly less in E (45%) than S (167%); however, activity remained 185% greater in E. ERK1/2 inhibition abrogated the increases. H2O2-stimulated ERK1/2 phosphorylation levels normalized to total ERK1/2 were similar between groups. Content of NHE1 and activities of H2O2 scavengers were also similar. We observed that intracellular pH-buffering capacity differences between groups became progressively less with declining pH, which may be an exercise-induced cardioprotective adaptation to lower NHE1 activity during certain pathological situations. We conclude that strenuous endurance exercise increases myocardial NHE1 activity at physiological pH, which would likely enhance cardiac performance under physiological conditions.

Training and experience outperform literacy and formal education as predictors of community health worker knowledge and performance, results from Rongo sub-county, Kenya.

Introduction: There is a growing recognition that Community Health Workers are effective at improving health outcomes and expanding health access. However, the design elements that lead to high-quality Community Health Worker programing are relatively understudied. We looked at the predictors of Community Health Worker knowledge of obstetric and early infant danger signs as well as performance in achieving antenatal care and immunization uptake among their clients. Methods: The study takes place in the context of an intervention implemented jointly by Lwala Community Alliance and the Kenya Ministry of Health which sought to professionalize Community Health Worker cadres through enhanced training, payment, and supervision. There were four cohorts included in the study. Two cohorts started receiving the intervention prior to the baseline, one cohort received the intervention between the baseline and endline, and a final cohort did not receive the intervention. Data on Community Health Worker demographics, knowledge tests, and key performance indicators were collected for 234 Community Health Workers. Regression analyses were used to explore education, literacy, experience, training, and gender as potential predictors of CHW performance. Results: We found that clients of Community Health Workers trained through the intervention were 15% more likely to be fully immunized and 14% more likely to have completed four or more antenatal care visits. Additionally, recency of training and experience caring for pregnant women were associated with increased Community Health Worker knowledge. Finally, we found no association between gender and CHW competency and tenuous associations between education/literacy and Community Health Worker competency. Discussion: We conclude that the intervention was predictive of increased Community Health Worker performance and that recency of training and experience were predictive of increased knowledge. Though education and literacy are often used in the selection processes of Community Health Workers globally, the link between these characteristics and Community Health Worker knowledge and performance are mixed. Thus, we encourage further research into the predictive value of common Community Health Worker screening and selection tools. Further, we encourage policymakers and practitioners to reconsider the use of education and literacy as means of Community Health Worker selection.

Incidence and types of congenital heart disease at a referral hospital in Jordan: retrospective study from a tertiary center.

Background: Congenital heart disease (CHD) is the most common birth defect and accounts for significant global morbidity and mortality. Relatively little is known about the epidemiology of CHD in Jordan or the manner in which CHD is identified. Methods: A retrospective medical record review was conducted for all neonates who had an abnormal echocardiogram performed at a tertiary referral hospital. All included neonates had echocardiography performed by the same pediatric cardiologist at the discretion of the treatment team. Descriptive statistics were used to describe CHD incidence, types of CHD identified, and mechanism of identification. Results: The incidence of congenital heart disease was 17.8 per 1,000 live births. This rose to 24.6 per 1,000 if patent ductus arteriosus in preterm infants was included. The most common identified abnormalities were PDA, atrial septal defects, persistent pulmonary hypertension, septal hypertrophy, and ventricular septal defects. Most children were evaluated either for a murmur heard on exam or as a part of screening due to other comorbidities or risk factors. Less than 1% of children had a prenatal diagnosis. There was a higher rate of persistent pulmonary hypertension during the COVID-19 pandemic than before (p < 0.001). Conclusions: There is a high incidence of CHD in Jordan. Increased prenatal and perinatal screening for CHD may allow for earlier detection.

Childhood mortality and associated factors in Migori County, Kenya: evidence from a cross-sectional survey.

OBJECTIVES: The under-five mortality (U5M) rate in Kenya (41 per 1000 live births) remains significantly above international goals (25 per 1000 live births). This is further exacerbated by regional inequalities in mortality. We aimed to describe U5M in Migori County, Kenya, and identify associated factors that can serve as programming targets. DESIGN: Cross-sectional observational survey. SETTING: Areas served by the Lwala Community Alliance and control areas in Migori County, Kenya. PARTICIPANTS: This study included 15 199 children born to respondents during the 18 years preceding the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mortality in the first 5 years of life. The survey was powered to detect a 10% change in various health metrics over time with 80% power. RESULTS: A total of 15 199 children were included in the primary analyses, and 230 (1.5%) were deceased before the fifth birthday. The U5M rate from 2016 to 2021 was 32.2 per 1000 live births. Factors associated with U5M included year of birth (HR 0.926, p<0.001), female sex (HR 0.702, p=0.01), parental marriage (HR 0.642, p=0.036), multiple gestation pregnancy (HR 2.776, p<0.001), birth spacing less than 18 months (HR 1.894, p=0.005), indoor smoke exposure (HR 1.916, p=0.027) and previous familial contribution to the National Hospital Insurance Fund (HR 0.553, p=0.009). The most common cause of death was malaria. CONCLUSIONS: We describe factors associated with childhood mortality in a Kenyan community using survival analyses of complete birth histories. Mortality rates will serve as the baseline for future programme evaluation as a part of a 10-year study design. This provides both the hyperlocal information needed to improve programming and generalisable conclusions for other organisations working in similar environments.

Reactive oxygen species are not a required trigger for exercise-induced late preconditioning in the rat heart.

Reactive oxygen species (ROS) have been reported to play a primary role in triggering the cardioprotective adaptations by some preconditioning procedures, but whether they are required for exercise-induced preconditioning is unclear. Thus in this study we used the free radical scavenger N-(2-mercaptopropionyl)glycine (MPG) to test the hypothesis that ROS is the trigger for exercise-induced preconditioning of the heart against ischemia-reperfusion injury. Male F344 rats were assigned to four groups: sedentary (SED, n = 7), SED/MPG (100 mg/kg ip daily for 2 days, n = 12), exercised on a treadmill for 2 days at 20 m/min, 6° grade, for 60 min (RUN, n = 7), and RUN/MPG with 100 mg/kg MPG injected 15 min before exercise (n = 10). Preliminary experiments verified that MPG administration maintained myocardial redox status during the exercise bout. Twenty-four hours postexercise or MPG treatment isolated perfused working hearts were subjected to global ischemia for 22.5 min followed by reperfusion for 30 min. Recovery of myocardial external work (percentage of preischemic systolic pressure times cardiac output) for SED (50.4 ± 4.5) and SED/RUN (54.7 ± 6.6) was similar and improved in both exercise groups (P < 0.05) to 77.9 ± 3.0 in RUN and 76.7 ± 4.5 in RUN/MPG. A 2 × 2 ANOVA also revealed that exercise decreased lactate dehydrogenase release from the heart during reperfusion (marker of cell damage) without MPG effects or interactions. Expression of the cytoprotective protein inducible heat shock protein 70 increased by similar amounts in the left ventricles of RUN and RUN/MPG compared with sedentary groups (P < 0.05). We conclude that ROS are not a necessary trigger for exercise-induced preconditioning in rats.

Feasibility of focused cardiac ultrasound training for non-cardiologists in a resource-limited setting using a handheld ultrasound machine.

BACKGROUND: Heart disease remains a leading cause of morbidity and mortality, particularly in low- and middle-income countries. Access to diagnostic modalities is limited in these settings. Limited echocardiographic studies performed by non-cardiologists can increase access, improve diagnosis and allow for earlier medical therapy. METHODS: Two internal medicine residents at a tertiary-level hospital in Ghana were trained to perform limited echocardiographic studies. Each trainee performed 50 echocardiograms and interpreted 20 studies across three predetermined timepoints. Interpretation was compared to expert interpretation. RESULTS: Agreement improved over time. At the final evaluation, there was high agreement across all aspects: left ventricular structure (70%, kappa 0.52, p = 0.01), left ventricular function (80%, kappa 0.65, p = 0.004), right ventricular structure (90%, kappa 0.71, p = 0.002), right ventricular function (100%, kappa 1.00, p < 0.001), and presence of effusion (100%, kappa 1.00, p < 0.001). CONCLUSIONS: Non-cardiologists can be trained in focused echocardiography using handheld machines. Such training can increase access to diagnostic capabilities in resource-limited settings.

Predictors of under-five healthcare utilization in Rongo sub-county of Migori County, Kenya: results of a population-based cross-sectional survey.

Introduction: to achieve the sustainable development goal for child survival, we must better understand the socioeconomic characteristics, household behaviors and access to community health services which predict care utilization for children. This study assessed predictors of health care utilization for children under five in Migori County, Kenya. Methods: we used multivariable logistic regression in the context of an integrated health intervention which employed paid, trained, and supervised community health workers (CHWs), inclusive of traditional birth attendants (TBAs). The intervention was delivered with Ministry of Health in one of five geographies included in the study. Results: community health workers (CHW) home visits were associated with a two-fold increase in care seeking for children with respiratory symptoms. Following implementation of a CHW-led malaria intervention, the use of malaria rapid diagnostic tests increased, while fever prevalence decreased. Households in the intervention area were three times more likely to seek care for their child´s fever. Increased care utilization for children with fever was positively associated with male partner attendance at antenatal care visits and negatively associated with skilled delivery and recognition of warning signs. Care utilization for respiratory symptoms was positively associated with caregiver education and negatively associated with household size. Care utilization for diarrhea was positively associated with having a recent under-five death in the household. Conclusion: the study suggests that trained and motivated CHWs may be an effective tool for improving care utilization for children. Further, the study builds on evidence of male partner involvement and caregiver education as predictors of child care utilization.