The effects of short-term, progressive exercise training on disease activity in smouldering multiple myeloma and monoclonal gammopathy of undetermined significance: a single-arm pilot study.

BACKGROUND: High levels of physical activity are associated with reduced risk of the blood cancer multiple myeloma (MM). MM is preceded by the asymptomatic stages of monoclonal gammopathy of undetermined significance (MGUS) and smouldering multiple myeloma (SMM) which are clinically managed by watchful waiting. A case study (N = 1) of a former elite athlete aged 44 years previously indicated that a multi-modal exercise programme reversed SMM disease activity. To build from this prior case study, the present pilot study firstly examined if short-term exercise training was feasible and safe for a group of MGUS and SMM patients, and secondly investigated the effects on MGUS/SMM disease activity. METHODS: In this single-arm pilot study, N = 20 participants diagnosed with MGUS or SMM were allocated to receive a 16-week progressive exercise programme. Primary outcome measures were feasibility and safety. Secondary outcomes were pre- to post-exercise training changes to blood biomarkers of MGUS and SMM disease activity- monoclonal (M)-protein and free light chains (FLC)- plus cardiorespiratory and functional fitness, body composition, quality of life, blood immunophenotype, and blood biomarkers of inflammation. RESULTS: Fifteen (3 MGUS and 12 SMM) participants completed the exercise programme. Adherence was 91 ± 11%. Compliance was 75 ± 25% overall, with a notable decline in compliance at intensities > 70% V̇O2PEAK. There were no serious adverse events. There were no changes to M-protein (0.0 ± 1.0 g/L, P =.903), involved FLC (+ 1.8 ± 16.8 mg/L, P =.839), or FLC difference (+ 0.2 ± 15.6 mg/L, P =.946) from pre- to post-exercise training. There were pre- to post-exercise training improvements to diastolic blood pressure (- 3 ± 5 mmHg, P =.033), sit-to-stand test performance (+ 5 ± 5 repetitions, P =.002), and energy/fatigue scores (+ 10 ± 15%, P =.026). Other secondary outcomes were unchanged. CONCLUSIONS: A 16-week progressive exercise programme was feasible and safe, but did not reverse MGUS/SMM disease activity, contrasting a prior case study showing that five years of exercise training reversed SMM in a 44-year-old former athlete. Longer exercise interventions should be explored in a group of MGUS/SMM patients, with measurements of disease biomarkers, along with rates of disease progression (i.e., MGUS/SMM to MM). REGISTRATION: https://www.isrctn.com/ISRCTN65527208 (14/05/2018).

Mobility inhibition of arsenic in the soil: the role of green synthesized silica nanoparticles.

The studies showed the effectiveness of green-synthesized SiO2NPs in mitigating the toxicity of Arsenic. Density Functional Theory (DFT) is a computational method used to determine electronic structure, energy gap, and toxicity prediction. Experimentally, silicon nanoparticles of 0 (S0) and 100% v/v (S100) were applied to the surface of the soil. 150 mL of Arsenic trioxide was applied twice at a rate of 0 (As0) and 3.2 g/mL (As3.2) at an interval of three weeks. Green synthesized SiO2NPs possessed a higher chemical potential (µ) and electrophilicity index; consequently, charges could be transferred and easily polarized. The highest occupied molecular orbital (HOMO) and lowest unoccupied molecular orbital (LUMO) levels of the green synthesized SiO2NPs enable them to donate electrons and complex with arsenic, reducing their bioavailability and toxicity. Evidence from the studies further showed that SiO2NPs had buffered the soil acidity and electric conductivity, posing a high binding site and reactivity with exchangeable cations and micronutrients due to their smaller energy gap. Furthermore, the catalytic activities of the soil enzymes dehydrogenase (DHA) and peroxidase (POD) were greatly increased, which enhanced the electrostatic interaction between the SiO2NPs and As.

Green synthesis and characterization of silver nanoparticles using Morinda lucida leaf extract and evaluation of its antioxidant and antimicrobial activity.

This study emphasizes the production of eco-friendly silver nanoparticles from a medicinal plant extract of Morinda lucida (M. lucida) and investigated its antioxidant and antimicrobial activity. Phytochemical screening of M. lucida (ML) leave extract was carried out and observed to contain some fundamental phyto-reducing agents such as reducing sugar, proteins, and alkaloids. The green synthesized AgNPs (ML-AgNPs) were characterized by UV-vis spectroscopy, Fourier transform infrared spectroscopy (FTIR), transmission emission microscopy (TEM), scanning electron microscopy (SEM), X-ray diffraction (XRD), and Energy dispersive X-ray analysis (EDX). Thermo gravimetric analysis (TGA) was performed on the synthesized ML-capped AgNPs to determine the thermal stability and the formation of the green synthesized AgNPs. The formation of AgNPs was confirmed by the UV-vis absorption spectra, which showed an absorption band at 420 nm. The morphology of ML extract-mediated AgNPs was mostly spherical and rough-edged crystallite nanostructures, with an average particle size of 11 nm. The FTIR analyses revealed distinctive functional groups which were directly involved in the synthesis and stability of AgNPs. The crystallite size was 8.79 nm, with four intense peaks at 2θ angles of 38°, 44°, 64°, and 77°. At an energy level of 3.4 keV, a significant signal was observed indicating the production of thermally stable and pure crystallite AgNPs. The antioxidant property of green synthesized ML-AgNPs was determined to be 40% higher than that of crude M. lucida leaf extract. The ability of green synthesized ML-AgNPs to scavenge free radicals also increased in the order of OH- < NO < H2O2. The ML-AgNPs have strong activities with a maximum against P. vulgaris and a minimum with E. faecalis.

Computed tomographic and clinical features of pulmonary veno-occlusive disease: raising the radiologist's awareness.

Pulmonary veno-occlusive disease (PVOD) is a rare subtype of pulmonary arterial hypertension (PAH) characterised by preferential remodelling of the pulmonary venules. Differentiation from other subtypes of PAH is essential as the management can differ significantly; for example, initiation of vasodilator therapy may cause fatal pulmonary oedema in a patient with PVOD misdiagnosed with idiopathic PAH. PVOD also carries a substantially worse prognosis. Lung biopsy is required for definitive diagnosis, but this is hazardous, and ideally, should be avoided in pulmonary hypertension. Computed tomography (CT) may suggest the diagnosis, directing the patient towards specialist review. Potential distinguishing CT features between PVOD and other subtypes of PAH include interlobular septal thickening, mediastinal lymphadenopathy, and centrilobular ground-glass opacities. No evidence-based medical therapy exists for PVOD at present and lung transplantation remains the definitive treatment for eligible patients. Therefore, early radiological identification of this challenging diagnosis facilitates timely referral for transplant.

"I go I die, I stay I die, better to stay and die in my house": understanding the barriers to accessing health care in Timor-Leste.

BACKGROUND: Despite public health care being free at the point of delivery in Timor-Leste, wealthier patients access hospital care at nearly twice the rate of poorer patients. This study seeks to understand the barriers driving inequitable utilisation of hospital services in Timor-Leste from the perspective of community members and health care managers. METHODS: This multisite qualitative study in Timor-Leste conducted gender segregated focus groups (n = 8) in eight districts, with 59 adults in urban and rural settings, and in-depth interviews (n = 8) with the Director of community health centres. Communication was in the local language, Tetum, using a pre-tested interview schedule. Approval was obtained from community and national stakeholders, with written consent from participants. RESULTS: Lack of patient transport is the critical cross-cutting issue preventing access to hospital care. Without it, many communities resort to carrying patients by porters or on horseback, walking or paying for (unaffordable) private arrangements to reach hospital, or opt for home-based care. Other significant out-of-pocket expenses for hospital visits were blood supplies from private suppliers; accommodation and food for the patient and family members; and repatriation of the deceased. Entrenched nepotism and hospital staff denigrating patients' hygiene and personal circumstances were also widely reported. Consequently, some respondents asserted they would never return to hospital, others delayed seeking treatment or interrupted their treatment to return home. Most considered traditional medicine provided an affordable, accessible and acceptable substitute to hospital care. Obtaining a referral for higher level care was not a significant barrier to gaining access to hospital care. CONCLUSIONS: Onerous physical, financial and socio-cultural barriers are preventing or discouraging people from accessing hospital care in Timor-Leste. Improving access to quality primary health care at the frontline is a key strategy for ensuring universal access to health care, pursued alongside initiatives to overcome the multi-faceted barriers to hospital care experienced by the vulnerable. Improving the availability and functioning of patient transport services, provision of travel subsidies to patients and their families and training hospital staff in standards of professional care are some options available to government and donors seeking faster progress towards universal health coverage in Timor-Leste.

Acceptability of programme budgeting and marginal analysis as a tool for routine priority setting in Indigenous health.

OBJECTIVE: This study aimed to examine the acceptability of programme budgeting and marginal analysis (PBMA) as a tool for priority setting in the Indigenous health sector. METHODS: The study uses a mix of quantitative and qualitative methods. A survey of key decision makers in Indigenous health in Victoria was conducted to assess the acceptability of PBMA as a potential tool for priority setting. Respondents comprised 24 bureaucrats from the Victorian Department of Human Services (DHS) and 26 senior executives from the aboriginal community controlled health sector (ACCHS) in Victoria. The survey instrument included both closed-ended and open-ended questions and was administered face-to-face by a trained researcher in 2007-2008. Closed-ended questions were analysed using descriptive statistics, and content analysis was used for the open-ended ones. RESULTS: The PBMA was well received as having the potential to improve priority setting processes in Indigenous health. Sixty-nine percent of the DHS respondents felt that PBMA was acceptable as a routine decision-making tool, and nearly 80% of ACCHS respondents thought that PBMA was intuitively appealing and would most probably be an acceptable priority setting approach in their organisations. The challenges of using PBMA were related to resource constraints and data intensity. CONCLUSION: Programme budgeting and marginal analysis is potentially acceptable within the ACCHS and was perceived as useful in terms of assisting the decision maker to maximise health outcomes, but data systems need to be re-oriented to address its significant data needs. IMPLICATION: Proper guidelines need to be developed to facilitate PBMA application within the Indigenous-controlled community health sector. Copyright © 2015 John Wiley & Sons, Ltd.

Retaining doctors in rural Timor-Leste: a critical appraisal of the opportunities and challenges.

Timor-Leste is in the process of addressing a key issue for the country's health sector: a medical workforce that is too small to provide adequate care. In theory, a bilateral programme of medical cooperation with Cuba created in 2003 could solve this problem. By the end of 2013, nearly 700 new doctors trained in Cuba had been added to Timor-Leste's medical workforce and by 2017 a further 328 doctors should have been trained in the country by Cuban and local health professionals. A few more doctors who have been trained in Indonesia and elsewhere will also soon enter the workforce. It is expected that the number of physicians in Timor-Leste in 2017 will be more than three times the number present in the country in 2003. Most of the new physicians are expected to work in rural communities and support the national government's goal of improving health outcomes for the rural majority. Although the massive growth in the medical workforce could change the way health care is delivered and substantially improve health outcomes throughout the country, there are challenges that must be overcome if Timor-Leste is to derive the maximum benefit from such growth. It appears crucial that most of the new doctors be deployed in rural communities and managed carefully to optimize their rural retention.

Le Timor-Leste s'occupe actuellement d'un problème essentiel du secteur de la santé du pays: l'effectif médical est trop restreint pour pouvoir dispenser des soins adéquats. En théorie, un programme bilatéral de coopération médicale avec Cuba créé en 2003 pourrait résoudre ce problème. À la fin de 2013, près de 700 nouveaux médecins formés à Cuba ont rejoint l'effectif médical du Timor-Leste et d'ici 2017, 328 médecins supplémentaires devraient avoir été formés dans le pays par des professionnels de la santé locaux et cubains. Quelques autres médecins, formés en Indonésie et ailleurs, intégreront bientôt cet effectif médical. On s'attend à ce que le nombre de médecins exerçant dans le Timor-Leste en 2017 soit trois fois supérieur au nombre de médecins présents dans le pays en 2003. La plupart des nouveaux médecins devraient travailler dans les communautés rurales et soutenir l'objectif du gouvernement national d'améliorer l'état de santé de la majorité rurale. Bien que l'augmentation importante de l'effectif médical puisse changer la manière de dispenser les soins de santé et améliorer considérablement la santé dans l'ensemble du pays, des défis doivent être surmontés pour que le Timor-Leste puisse tirer le bénéfice maximal de cette augmentation. Il semble crucial que la majorité des nouveaux médecins soient déployés dans les communautés rurales et gérés soigneusement pour qu'ils restent le plus possible dans les zones rurales.

Timor-Leste se encuentra en proceso de abordar una cuestión clave para el sector sanitario del país: un personal médico demasiado escaso para proporcionar una atención adecuada. En teoría, un programa bilateral de cooperación médica con Cuba, creado en el año 2003, podría solucionar este problema. A finales de 2013, casi 700 médicos nuevos formados en Cuba se unieron al personal médico de Timor-Leste, y se espera que profesionales de la salud nacionales y cubanos formen a otros 328 médicos en el país hasta 2017. En Indonesia y otros lugares han recibido formación algunos médicos más, que se sumarán pronto a este personal. Se espera que el número de médicos en Timor-Leste triplique en el año 2017 el número de médicos existentes en el país en 2003. La mayoría de estos médicos nuevos trabajarán en comunidades rurales y respaldarán el objetivo del gobierno nacional de mejorar los resultados sanitarios de la mayoría rural. Aunque el incremento masivo del personal médico podría cambiar el modo de proporcionar la atención sanitaria y mejorar notablemente los resultados sanitarios en todo el país, hay desafíos que es necesario superar si Timor-Leste pretende obtener el máximo beneficio de dicho crecimiento. Parece fundamental que la mayor parte de los nuevos médicos se despliegue en comunidades rurales y se gestione con gran atención para optimizar su permanencia en dichas zonas.

Right ventricular assessment of the adolescent footballer's heart.

INTRODUCTION: Athletic training can result in electrical and structural changes of the right ventricle that may mimic phenotypical features of arrhythmogenic right ventricular cardiomyopathy (ARVC), such as T-wave inversion and right heart dilatation. An erroneous interpretation may have consequences ranging from false reassurance in an athlete vulnerable to cardiac arrhythmias, to unnecessary sports restriction in a healthy individual. The primary aim of this study was to define normal RV dimension reference ranges for academy adolescent footballers of different ethnicities. Secondary aims include analysis of potential overlap between this adolescent group with ARVC criteria and comparison with normal adult ranges. RESULTS: Electrocardiographic (ECG) and echocardiographic data of 1087 academy male footballers aged between 13 and 18 years old (mean age 16.0 ± 0.5 years), attending mandatory cardiac screening were analysed. Ethnicity was categorised as white (n = 826), black (African/Caribbean; n = 166) and mixed-race (one parent white and one parent black; n = 95). Arrhythmogenic right ventricular cardiomyopathy major criteria for T-wave inversion was seen in 3.3% of the cohort. This was more prevalent in black footballers (12%) when compared to mixed race footballers (6.3%) or white footballers (1%), P < 0.05. Up to 59% of the cohort exceeded adult reference ranges for some of the right ventricular parameters, although values were similar to those seen in adult footballers. There were no differences in right ventricular dimensions between ethnicities. In particular, the right ventricular outflow tract diameter would fulfil major criteria for ARVC dimension in 12% of footballers. Overall, 0.2% of the cohort would fulfil diagnosis for 'definite' arrhythmogenic right ventricular cardiomyopathy and 2.2% would fulfil diagnosis for 'borderline' arrhythmogenic right ventricular cardiomyopathy for RV dimensions and ECG changes. This was seen more frequently in black footballers (9.9%) than mixed race footballers (3.9%) or white footballer (0.6%), P < 0.05. Among athletes meeting definite or borderline arrhythmogenic right ventricular cardiomyopathy criteria, no cardiomyopathy was identified after comprehensive clinical assessment, including with cardiac magnetic resonance imaging, exercise testing, ambulatory electrocardiograms and familial evaluation. CONCLUSION: Right heart sizes in excess of accepted adult ranges occurred in as many as one in two adolescent footballers. Structural adaptations in conjunction with anterior T-wave inversion may raise concern for ARVC, highlighting the need for evaluation in expert settings.

Complexation and immobilization of arsenic in maize using green synthesized silicon nanoparticles (SiNPs).

Arsenic (As) is a heavy metal that is toxic to both plants and animals. Silicon nanoparticles (SiNPs) can alleviate the detrimental effects of heavy metals on plants, but the underlying mechanisms remain unclear. The study aims to synthesize SiNPs and reveal how they promote plant health in Arsenic-polluted soil. 0 and 100% v/v SiNPs were applied to soil, and Arsenic 0 and 3.2 g/ml were applied twice. Maize growth was monitored until maturity. Small, irregular, spherical, smooth, and non-agglomerated SiNPs with a peak absorbance of 400 nm were synthesized from Pycreus polystachyos. The SiNPs (100%) assisted in the development of a deep, prolific root structure that aided hydraulic conductance and gave mechanical support to the maize plant under As stress. Thus, there was a 40-50% increase in growth, tripled yield weights, and accelerated flowering, fruiting, and senescence. SiNPs caused immobilization (As(III)=SiNPs) of As in the soil and induced root exudates Phytochelatins (PCs) (desGly-PC2 and Oxidized Glutathione) which may lead to formation of SiNPs=As(III)-PCs complexes and sequestration of As in the plant biomass. Moreover, SiNPs may alleviate Arsenic stress by serving as co-enzymes that activate the antioxidant-defensive mechanisms of the shoot and root. Thus, above 70%, most reactive ROS (OH) were scavenged, which was evident in the reduced MDA content that strengthened the plasma membrane to support selective ion absorption of SiNPs in place of Arsenic. We conclude that SiNPs can alleviate As stress through sequestration with PCs, improve root hydraulic conductance, antioxidant activity, and membrane stability in maize plants, and could be a potential tool to promote heavy metal stress resilience in the field.

Anatomical adaptation of water-stressed Eugenia uniflora using green synthesized silver nanoparticles and melatonin.

Cell and sub-cellular anatomical adjustments are adaptations utilized by plants to tolerate abiotic stress. Both melatonin and Morinda lucida-silver nanoparticles (ML-AgNPs) are recognized as bio-stimulants. The study examined the morphological changes and adaptive characteristics of these bio-stimulants under water-stress Eugenia uniflora. Twenty-four hours was spent priming the seeds with melatonin (0.06 mg/L), ML-AgNPs (0.06 mg/L), and a mixture (1:1) of the two. The seeds were sown and subjected to water stress for 7 days. The leaves, stems, and roots of water-stressed E. uniflora were sectioned, dried, and examined using a microscope. Drought stress led to the production of non-glandular trichomes on the abaxial and the transformation of paracytic stomata into diacytic stomata. During water stress, melatonin enlarges intercellular gaps and stomata, increases sponge and palisade parenchyma, and thickens epidermis (stem and root) and fibers. The ML-AgNPs diminished the size of mesophyll, intercellular gaps, stomata, and stem fiber. The ML-AgNPs increased the size of bulliform cells and activated the mechanical resistance features of sclerophyllous leaves (thick-celled epidermis and sclerieds) and ray parenchyma (root and stem). Equally, Melatonin and ML-AgNPs increased stem and root anatomical characteristics (xylem, bark, pith, cortex, epidermis, and vascular bundles). Stomata of E. uniflora are susceptible to alterations and undergo cell division into two new stomata (stomatogensis) in response to varying conditions (melatonin and ML-AgNPs). Melatonin adopted a strategy for maintaining a high plant water status, possibly by osmoregulation, whereas E. uniflora primed with ML-AgNPs survived by minimizing transpirational water loss through morphological changes.

Analysis of policy implications and challenges of the Cuban health assistance program related to human resources for health in the Pacific.

BACKGROUND: Cuba has extended its medical cooperation to Pacific Island Countries (PICs) by supplying doctors to boost service delivery and offering scholarships for Pacific Islanders to study medicine in Cuba. Given the small populations of PICs, the Cuban engagement could prove particularly significant for health systems development in the region. This paper reviews the magnitude and form of Cuban medical cooperation in the Pacific and analyses its implications for health policy, human resource capacity and overall development assistance for health in the region. METHODS: We reviewed both published and grey literature on health workforce in the Pacific including health workforce plans and human resource policy documents. Further information was gathered through discussions with key stakeholders involved in health workforce development in the region. RESULTS: Cuba formalised its relationship with PICs in September 2008 following the first Cuba-Pacific Islands ministerial meeting. Some 33 Cuban health personnel work in Pacific Island Countries and 177 Pacific island students are studying medicine in Cuba in 2010 with the most extensive engagement in Kiribati, the Solomon Islands, Tuvalu and Vanuatu. The cost of the Cuban medical cooperation to PICs comes in the form of countries providing benefits and paying allowances to in-country Cuban health workers and return airfares for their students in Cuba. This has been seen by some PICs as a cheaper alternative to training doctors in other countries. CONCLUSIONS: The Cuban engagement with PICs, while smaller than engagement with other countries, presents several opportunities and challenges for health system strengthening in the region. In particular, it allows PICs to increase their health workforce numbers at relatively low cost and extends delivery of health services to remote areas. A key challenge is that with the potential increase in the number of medical doctors, once the local students return from Cuba, some PICs may face substantial rises in salary expenditure which could significantly strain already stretched government budgets. Finally, the Cuban engagement in the Pacific has implications for the wider geo-political and health sector support environment as the relatively few major bilateral donors, notably Australia (through AusAID) and New Zealand (through NZAID), and multilaterals such as the World Bank will need to accommodate an additional player with whom existing links are limited.

Exclusive breast-feeding in the first six months: findings from a cross-sectional survey in Mulago hospital, Uganda.

Background: Improving maternal and child health, one of the key UN Sustainable Development Goals (SDGs), is a major challenge in sub-Saharan Africa. Exclusive breast-feeding contributes significantly to child survival and development, but many mothers in Africa do not exclusively breastfeed their infants. This paper reports a study in Mulago hospital in Kampala. The study aims to identify factors influencing mothers' choices of infant feeding practices. Methods: Mixed methods were used. Respondents included 362 lactating mothers and health workers. Participants were who came for treatment were selected using simple random sampling. EpiInfor and SPSS were used for analysing the data and presented as descriptive study. Results: Results indicate that socio-demographic factors including age and education level influence mothers' ability and willingness to breastfeed exclusively for the first six months. Awareness about breast-feeding was mainly obtained from health centres, leaving mothers unable to attend these centres to miss out on vital information about exclusive breast-feeding. Around 43% of health workers were unaware of the country's Young and Infant Feeding Policy Guidelines. Conclusions: To increase the rate of exclusive breast-feeding in Uganda, it is important that community health is strengthened, and health workers are trained on national breast-feeding policies.

P-FLUX: A phosphorus budget dataset spanning diverse agricultural production systems in the United States and Canada.

Quantifying spatial and temporal fluxes of phosphorus (P) within and among agricultural production systems is critical for sustaining agricultural production while minimizing environmental impacts. To better understand P fluxes in agricultural landscapes, P-FLUX, a detailed and harmonized dataset of P inputs, outputs, and budgets, as well as estimated uncertainties for each P flux and budget, was developed. Data were collected from 24 research sites and 61 production systems through the Long-term Agroecosystem Research (LTAR) network and partner organizations spanning 22 U.S. states and 2 Canadian provinces. The objectives of this paper are to (a) present and provide a description of the P-FLUX dataset, (b) provide summary analyses of the agricultural production systems included in the dataset and the variability in P inputs and outputs across systems, and (c) provide details for accessing the dataset, dataset limitations, and an example of future use. P-FLUX includes information on select site characteristics (area, soil series), crop rotation, P inputs (P application rate, source, timing, placement, P in irrigation water, atmospheric deposition), P outputs (crop removal, hydrologic losses), P budgets (agronomic budget, overall budget), uncertainties associated with each flux and budget, and data sources. Phosphorus fluxes and budgets vary across agricultural production systems and are useful resources to improve P use efficiency and develop management strategies to mitigate environmental impacts of agricultural systems. P-FLUX is available for download through the USDA Ag Data Commons (https://doi.org/10.15482/USDA.ADC/1523365).

Association between serum chlamydial antibody levels and tubal infertility in tertiary health facility in South-East Nigeria: a case-control study.

Objectives: This study evaluates the association between genital Chlamydial infection and tubal factor infertility in a tertiary health facility in South-East Nigeria. Design: This was a case-control analytical study. Setting: Gynaecology Clinic and Maternity Unit of the Department of Obstetrics and Gynaecology of the Federal Medical Centre (FMC), Owerri, Imo State, Nigeria. Participants: Ninety-six (96) women with confirmed tubal factor infertility served as the cases, and 96 women with normal intra-uterine pregnancy matched in age served as the control. Data Collection/Intervention: A structured questionnaire was used to extract information on the sociodemographic data and the sexual history of the participants. About 2mls of blood was collected, the blood was allowed to clot, and the sera were used for the test. Statistical analysis/Main outcome measure: Pearson Chi-square, Fisher's exact test, likelihood ratio and multivariate logistic regression were used to determine risk associations and identify factors independently related to tubal factor infertility. P-value < 0.05 was considered significant. Results: The sociodemographic characteristics of both cases and control did not differ (P = 0.975). The Chlamydial antibody seropositivity was significantly higher in the cases than the control 78(81.2%) versus 13(13.5%) respectively {(P < 0.001; OR (95% CI) = 27.7(12.7-60.2)}. Only lower abdominal pain {(P = 0.011); OR (95% CI) = 4.3(1.4-13.3)}; was independently associated with tubal factor infertility. Conclusion: Tubal factor infertility is strongly associated with chlamydial IgG antibodies, and a history of lower abdominal pain significantly predicted tubal factor infertility. Funding: The authors paid the cost of procuring the anti-chlamydial ELIZA test kits, plain sample bottles, syringes, gloves and other consumables and stationaries.

The Coincidence of 2 Epidemics, Coccidioidomycosis and SARS-CoV-2: A Case Report.

In the middle of a pandemic, patients with cough and fever are thought to have SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2). It should be remembered that in the desert southwest of the United States, we have an ongoing epidemic of coccidioidomycosis (CM). There are additionally many other respiratory illnesses that could be confused with CoV-2 or overlooked. This is a case report of CoV-2 engrafted on chronic cavitary pulmonary CM. In a time where the coronavirus pandemic is becoming rampant, we demonstrate the case of a coinfection with cavitary pulmonary CM. In this case, the importance of detection of the coronavirus and treatment of the coinfection is explored.

Exploring the determinants of distress health financing in Cambodia.

Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty-the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt-even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.

Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy.

Cambodia's healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012-14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of -0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.

Prevalence, Causes, and Factors Associated with Visual Impairment and Blindness among Registered Pensioners in Ghana.

PURPOSE: To determine the prevalence, causes, and factors associated with presenting visual impairment and blindness among pensioners. DESIGN: A nationwide cross-sectional study. This study was part of the analysis on data obtained in the pensioners' medical survey conducted among members of the National Pensioners Association in Ghana. METHOD: (i) Setting: it was a multicenter study involving thirteen centers throughout Ghana with a center in each regional capital. (ii) Study population: the study involved 4813 pensioners. (iii) Observation procedures: data were captured through the use of questionnaires, physical examinations including eye examinations, and urine and blood sample analysis. (iv) Main outcome measure: presenting visual impairment and blindness (as defined by the WHO ICD-10 classification). RESULTS: The overall prevalence of blindness among pensioners in Ghana was 3.8% (95% CI = 3.2-4.4), while the prevalence of moderate and severe visual impairment was 21.7% (95% CI = 20.5-23.0). The prevalence of blindness was lowest in the 60-65-year-old age group (2.1% (95% CI = 1.3-2.8)) and highest in the above 80-year-old age group (12.2% (95% CI = 6.6-17.8)). Cataract was the leading cause of blindness (62.4%) and moderate and severe visual impairment (55.7%). Factors significantly associated with blindness and visual impairment include educational status, vegetarianism, arthritis, and having proteins in urine. CONCLUSION: There is a high prevalence of visual impairment and blindness among the pensioners in Ghana. Sadly, the greatest cause was cataract, which is correctable. Increase in formal education status will be important in the prevention of blindness and visual impairment.

Burden of dengue infection in India, 2017: a cross-sectional population based serosurvey.

BACKGROUND: The burden of dengue virus (DENV) infection across geographical regions of India is poorly quantified. We estimated the age-specific seroprevalence, force of infection, and number of infections in India. METHODS: We did a community-based survey in 240 clusters (118 rural, 122 urban), selected from 60 districts of 15 Indian states from five geographical regions. We enumerated each cluster, randomly selected (with an Andriod application developed specifically for the survey) 25 individuals from age groups of 5-8 years, 9-17 years, and 18-45 years, and sampled a minimum of 11 individuals from each age group (all the 25 randomly selected individuals in each age group were visited in their houses and individuals who consented for the survey were included in the study). Age was the only inclusion criterion; for the purpose of enumeration, individuals residing in the household for more than 6 months were included. Sera were tested centrally by a laboratory team of scientific and technical staff for IgG antibodies against the DENV with the use of indirect ELISA. We calculated age group specific seroprevalence and constructed catalytic models to estimate force of infection. FINDINGS: From June 19, 2017, to April 12, 2018, we randomly selected 17 930 individuals from three age groups. Of these, blood samples were collected and tested for 12 300 individuals (5-8 years, n=4059; 9-17 years, n=4265; 18-45 years, n=3976). The overall seroprevalence of DENV infection in India was 48·7% (95% CI 43·5-54·0), increasing from 28·3% (21·5-36·2) among children aged 5-8 years to 41·0% (32·4-50·1) among children aged 9-17 years and 56·2% (49·0-63·1) among individuals aged between 18-45 years. The seroprevalence was high in the southern (76·9% [69·1-83·2]), western (62·3% [55·3-68·8]), and northern (60·3% [49·3-70·5]) regions. The estimated number of primary DENV infections with the constant force of infection model was 12 991 357 (12 825 128-13 130 258) and for the age-dependent force of infection model was 8 655 425 (7 243 630-9 545 052) among individuals aged 5-45 years from 30 Indian states in 2017. INTERPRETATION: The burden of dengue infection in India was heterogeneous, with evidence of high transmission in northern, western, and southern regions. The survey findings will be useful in making informed decisions about introduction of upcoming dengue vaccines in India. FUNDING: Indian Council of Medical Research.

How to do (or not to do) a health financing incidence analysis.

Financing incidence analysis (FIA) assesses how the burden of health financing is distributed in relation to household ability to pay (ATP). In a progressive financing system, poorer households contribute a smaller proportion of their ATP to finance health services compared to richer households. A system is regressive when the poor contribute proportionately more. Equitable health financing is often associated with progressivity. To conduct a comprehensive FIA, detailed household survey data containing reliable information on both a cardinal measure of household ATP and variables for extracting contributions to health services via taxes, health insurance and out-of-pocket (OOP) payments are required. Further, data on health financing mix are needed to assess overall FIA. Two major approaches to conducting FIA described in this article include the structural progressivity approach that assesses how the share of ATP (e.g. income) spent on health services varies by quantiles, and the effective progressivity approach that uses indices of progressivity such as the Kakwani index. This article provides some detailed practical steps for analysts to conduct FIA. This includes the data requirements, data sources, how to extract or estimate health payments from survey data and the methods for assessing FIA. It also discusses data deficiencies that are common in many low- and middle-income countries (LMICs). The results of FIA are useful in designing policies to achieve an equitable health system.