"I Need to Be the First One with a Different Approach and to Make a Difference to the People": A Mixed Methods Pilot Study on Non-Physician Clinicians Training in Malawi.

Purpose: To improve child health care depends on the availability of sufficient numbers of skilled healthcare workers. To achieve this, the German Society of Tropical Paediatrics & International Child Health supported the existing three-year Bachelor of Science in Paediatrics and Child Health training for Clinical Officers, a non-physician clinician cadre, from 09/2017 to 08/2019. This study aims to evaluate the project to inform forthcoming training. Methods: All 17 students who were in training took part in this study. Quantitative data collection took place between 01/2018 to 06/2019 using the post-self-assessment bloc course survey, Research Self-Efficacy Scale (RSES), and Stages of Change (SOC) model. Students and key informants participated in three focus group discussions and five in-depth interviews during April 1-10, 2019. Results: Students mostly perceived bloc course contents "At their level" (92%) and "Very important/relevant" (61%) with "Good quality" teaching (70.5%). The mean (SD) score for RSES (10-point scale) was 9.10 (0.91). The SOC (4-point scale) scores were higher for "Attitude" and "Intention" statements than "Action". Students found the program well-paced, felt that their clinical knowledge and skills had improved, and valued the acquired holistic disease management approach. They reported increased confidence and being more prepared for leadership roles in their future work. The involvement of international teachers and supervisors enriched their global perspectives. Conclusion: Students improved their clinical and non-clinical skills, developed self-efficacy and attitudes toward research, and were confident to build and utilize their networks. These transformative experiences could facilitate the development of change agents among current and future trainees.

Thrombin generation in cardiovascular disease and mortality - results from the Gutenberg Health Study.

Thrombin generation may be a potential tool to improve risk stratification for cardiovascular diseases. This study aims to explore the relation between thrombin generation and cardiovascular risk factors, cardiovascular diseases, and total mortality. For this study, N=5000 subjects from the population-based Gutenberg Health Study were analysed in a highly standardized setting. Thrombin generation was assessed by the Calibrated Automated Thrombogram method at 1 and 5 pM tissue factors trigger in platelet poor plasma. Lag time, endogenous thrombin potential, and peak height were derived from the thrombin generation curve. Sex-specific multivariable linear regression analysis adjusted for age, cardiovascular risk factors, cardiovascular diseases and therapy, was used to assess clinical determinants of thrombin generation. Cox regression models adjusted for age, sex, cardiovascular risk factors and vitamin K antagonists investigated the association between thrombin generation parameters and total mortality. Lag time was positively associated with obesity and dyslipidaemia for both sexes (p<0.0001). Obesity was also positively associated with endogenous thrombin potential in both sexes (p<0.0001) and peak height in males (1 pM tissue factor, p=0.0048) and females (p<0.0001). Cox regression models showed an increased mortality in individuals with lag time (1 pM tissue factor, hazard ratio=1.46, [95% CI: 1.07; 2.00], p=0.018) and endogenous thrombin potential (5 pM tissue factor, hazard ratio = 1.50, [1.06; 2.13], p=0.023) above the 95th percentile of the reference group, independent of the cardiovascular risk profile. This large-scale study demonstrates traditional cardiovascular risk factors, particularly obesity, as relevant determinants of thrombin generation. Lag time and endogenous thrombin potential were found as potentially relevant predictors of increased total mortality, which deserves further investigation.

Progranulin serum levels and gene expression in subcutaneous vs visceral adipose tissue of severely obese patients undergoing bariatric surgery.

BACKGROUND: Progranulin represents an adipokine putatively mediating insulin resistance and inflammation. Data in humans are sparse, and the source of circulating progranulin in obesity is unknown. OBJECTIVES: Serum progranulin concentrations and subcutaneous (sc) as well as visceral (vis) adipose tissue (AT) progranulin expression were quantified in a large cohort of patients with obesity undergoing bariatric surgery (BS) (n = 153) or a low-calorie diet (LCD) (n = 121). COHORTS AND METHODS: Paired serum and AT mRNA samples were obtained from patients with severe obesity undergoing BS (ROBS cohort; Research in Obesity and Bariatric Surgery). Serum progranulin was measured by ELISA in both cohorts, and AT mRNA expression was analysed by quantitative real-time PCR in bariatric patients. RESULTS: There was no gender-specific effect in serum progranulin or AT progranulin expression. Importantly, circulating progranulin was independent from adipose tissue gene expression in paired samples. sc AT progranulin expression was higher than in vis AT (P = 0.027), and there was a positive correlation between sc AT and vis AT gene expression (P < 0.001; r = +0.34). Serum progranulin strongly and rapidly increased after BS within 3 days and remained elevated up to 12 months. Serum progranulin was strongly correlated with serum CTRP-3 levels. CONCLUSIONS: The present study provides detailed progranulin gene expression data in sc and vis AT in a large, prospective and observational cohort of patients with severe obesity. Serum progranulin concentrations are not predicted by sc or vis AT progranulin gene expression. Thus, AT seems not to be the main source of circulating progranulin levels in obesity.

Is the WHO Guide on Essential Practice of Postpartum Newborn Care Used in a District Health Care Facility?

BACKGROUND: It is unclear whether algorithms with evidence-based interventions are used in a setting where the work load is high and qualified staff is scarce to identify neonates with life-threatening conditions. METHODS: The nurse-midwives' knowledge and opinion about the World Health Organization (WHO) guide on postpartum newborn care were assessed in a hospital in Tanzania before and after training. Their adherence to this guide was evaluated by analysing 100 neonatal records. RESULTS: Before training, 44% of the nurse-midwives were familiar with the WHO guide. All nurse-midwives supported the implementation of the guide. In all, 21% of the postpartum record forms were fully completed. Risk factors for illness were missed in 27%. CONCLUSION: Nurse-midwives' expertise in the WHO guide on postpartum newborn care cannot be taken for granted. The complexity of this guide demands expertise and makes its use time-consuming and thus its practicability disputable in a setting with limited resources.