Evaluating urban-rural access to pathology and laboratory medicine services in Tanzania.

Placement of pathology and laboratory medicine (PALM) services requires balancing efficiency (maximizing test volume) with equitable urban-rural access. We compared the association between population density (proxy for efficiency) and travel time to the closest facility (proxy for equitable access) across levels of Tanzania's public sector health system. We linked geospatial data for Tanzania from multiple sources. Data on facility locations and other geographic measures were collected from government and non-governmental databases. We classified facilities assuming increasing PALM availability by tier: (1) dispensaries, (2) health centres, (3) district hospitals and (4) regional/referral hospitals. We used the AccessMod 5 algorithm to estimate travel time to the closest facility for each tier across Tanzania with 500-m resolution. District-level average population density and travel time to the closest facility were calculated and presented using medians and interquartile ranges. Spatial correlations between these variables were estimated using the global Moran's I and bivariate Local Indicator of Spatial Autocorrelation, specifying a queen's neighbourhood matrix. Spatial analysis was restricted to 171 contiguous districts. The study included 5406 dispensaries, 675 health centres, 186 district hospitals and 37 regional/referral hospitals. District-level travel times were shortest for Tier 1 (median: [IQR]: 45.4 min [30.0-74.7]) and longest for Tier 4 facilities (160.2 min [107.3-260.0]). There was a weak spatial autocorrelation across tiers (Tier 1: -0.289, Tier 2: -0.292, Tier 3: -0.271 and Tier 4: -0.258) and few districts were classified as significant spatial outliers. Across tiers, geographic patterns of populated districts surrounded by neighbours with short travel time and sparsely populated districts surrounded by neighbours with long travel time were observed. Similar spatial correlation measures across health system levels suggest that Tanzania's health system reflects equitable urban-rural access to different PALM services. Longer travel times to hospital-based care could be ameliorated by shifting specialized diagnostics to more accessible lower tiers.

Age-Standardized Mortality Rates in the Caribbean: One Source, Three Different Interpretations.

Purpose A recent publication in Morbidity and Mortality Weekly Report ( MMWR) provided the opportunity to calculate differences in published cancer mortality estimates for Caribbean jurisdictions from three organizations: MMWR, the International Agency for Research on Cancer, and the Institute for Health Metrics and Evaluation. This comparison study serves to educate end users of these data. Methods We downloaded the publicly available cancer mortality estimates for 15 jurisdictions and the United States from the three organizations. We compared reported age-standardized mortality rates for each jurisdiction and calculated the range among estimates for each jurisdiction. We repeated this analysis after applying the same world population standard to all estimates. Results For males, the ranges of the Caribbean estimates were between 49% (Grenada and Trinidad) and 201% (US Virgin Islands) of the MMWR value, with an average of 88%. For females, the ranges were between 15% (Trinidad) and 171% (US Virgin Islands) of the MMWR value, with an average of 64%. After all estimates were compared using the same population standard, the ranges of the Caribbean estimates for males were between 6% (Grenada) and 111% (US Virgin Islands) of the MMWR value, with an average of 34%. For females, the ranges were between 7% (Grenada) and 97% (US Virgin Islands), with an average of 28%. Conclusion The use of different standard populations complicates comparisons across organizations. Data modeling does not completely compensate for quality of source data, as our analysis demonstrated by the differences in mortality rates despite the good quality of the vital registration in the Caribbean.

Global Health Pathology Research: Purpose and Funding.

Like in all areas of science, it is important for funders and investigators of pathology to work together to develop a well-designed, well-executed clinical research agenda. In the first section of this article, the authors discuss how the National Institutes of Health (NIH) peer-review process applies to global health pathology research projects. Then, the authors present an illustrative sampling of NIH-funded projects with performance sites in low- and middle-income countries with 2 examples focused on cancer and anatomic pathology. Finally, the authors relate the research agenda to overarching strategic recommendations for enhancing global pathology.

Hypertensive emergency and severe hypertension: what to treat, who to treat, and how to treat.

Remember to treat patients, not numbers. Use fast acting shortterm medicines only when convincing evidence of rapidly evolving end-organ damage is present. For all patients, emergent or asymptomatic, the treatment goal is long-term control of hypertension. Potent IV agents for the im-mediate control of elevated blood pressure need to be used cautiously,bearing in mind both the side effects and the hazards of overly rapid control of hypertension. Conventional oral medication regimens demonstrated to modify the risks of chronic hypertension should be used whenever possible and as early as is practical to promote gradual control of hypertension. Whenever a patient presents for the evaluation of severe hypertension in an emergent setting, take the opportunity to encourage appropriate ongoing follow-up; after all, hypertension is not a single episode, it is an ongoing threat to good health.