Fast absolute 3D CGO-based electrical impedance tomography on experimental tank data.

Objective.To present the first 3D CGO-based absolute EIT reconstructions from experimental tank data.Approach.CGO-based methods for absolute EIT imaging are compared to traditional TV regularized non-linear least squares reconstruction methods. Additional robustness testing is performed by considering incorrect modeling of domain shape.Main Results.The CGO-based methods are fast, and show strong robustness to incorrect domain modeling comparable to classic difference EIT imaging and fewer boundary artefacts than the TV regularized non-linear least squares reference reconstructions.Significance.This work is the first to demonstrate fully 3D CGO-based absolute EIT reconstruction on experimental data and also compares to TV-regularized absolute reconstruction. The speed (1-5 s) and quality of the reconstructions is encouraging for future work in absolute EIT.

Improving Outcomes Among Young Adults with type 1 diabetes: The D1 Now Randomised Pilot Study Protocol.

BACKGROUND: Young adults (18-25 years old) living with type 1 diabetes mellitus often have sub-optimal glycaemic levels which can increase their risk of long term diabetes complications. Informed by health psychology theory and using a (public and patient involvement) young adult-centred approach, we have developed a complex intervention, entitled D1 Now, to improve outcomes in this target group. The D1 Now intervention includes three components; 1) a support-worker, 2) an interactive messaging system and 3) an agenda setting tool for use during clinic consultations. AIMS: The aim of the D1 Now pilot study is to gather and analyse acceptability and feasibility data to allow us to (1) refine the D1 Now intervention, and (2) determine the feasibility of a definitive Randomised Control Trial (RCT) of the intervention. METHODS: Diabetes clinics on the island of Ireland will be recruited and randomised to a D1 Now intervention arm or a usual care control arm. For a participant to be eligible they should be 18-25 years old and living with type 1 diabetes for at least 12 months. Participant outcomes (influenced by a Core Outcome Set) include change in HbA1c, clinic attendance, number of episodes of severe hypoglycaemia and of diabetic ketoacidosis, diabetes distress, self-management, quality of life and perceived level of control over diabetes; these will be will be measured at baseline and after 12 months follow-up for descriptive statistics only. An assessment of treatment fidelity, a health economic analysis and a qualitative sub-study will also be incorporated into the pilot study. ISRCTN (ref: ISRCTN74114336).

"Death is a better option than being treated like this": a prevalence survey and qualitative study of depression among multi-drug resistant tuberculosis in-patients.

BACKGROUND: Understanding of the relationship between multi-drug resistant tuberculosis and mental health is limited. With growing prevalence of multi-drug resistant tuberculosis, addressing mental ill-health has potential to improve treatment outcomes and well-being. In several low and middle-income contexts hospitalisation during treatment is common. Understanding of the impact on mental ill-health are required to inform interventions for patients with multi-drug resistant tuberculosis. Our aim was to identify the prevalence of comorbid depression among in-patients being treated for multi-drug resistant tuberculosis and to explore their experiences of comorbid disease and the care they received in a large specialist chest hospital in Dhaka, Bangladesh. METHODS: We conducted a quantitative cross-sectional survey among 150 multi-drug resistant tuberculosis in-patients (new cases = 34%, previously treated = 66%) in 2018. A psychiatrist assessed depression was assessed with the Structured Clinical Interview for Depression (SCID DSM-IV). We used multi-level modelling to identify associations with depression. Experience Bangladeshi researchers conducted qualitative interviews with 8 patients, 4 carers, 4 health professionals and reflective notes recorded. Qualitative data was analysed thematically. RESULTS: We found 33.8% (95% CI 26.7%; 41.7%) of patients were depressed. While more women were depressed 39.3% (95% CI 27.6%; 52.4%) than men 30.4% (95% CI 22%; 40.5%) this was not significant. After controlling for key variables only having one or more co-morbidity (adjusted odds ratio [AOR] = 2.88 [95% CI 1.13; 7.33]) and being a new rather than previously treated case (AOR = 2.33 [95% CI 1.06; 5.14]) were associated (positively) with depression. Qualitative data highlighted the isolation and despair felt by patients who described a service predominantly focused on providing medicines. Individual, familial, societal and health-care factors influenced resilience, nuanced by gender, socio-economic status and home location. CONCLUSIONS: Patients with multi-drug resistant tuberculosis are at high risk of depression, particularly those with co- and multi-morbidities. Screening for depression and psycho-social support should be integrated within routine TB services and provided throughout treatment.

Community engagement interventions for communicable disease control in low- and lower- middle-income countries: evidence from a review of systematic reviews.

BACKGROUND: Community engagement (CE) interventions include a range of approaches to involve communities in the improvement of their health and wellbeing. Working with communities defined by location or some other shared interest, these interventions may be important in assisting equity and reach of communicable disease control (CDC) in low and lower-middle income countries (LLMIC). We conducted an umbrella review to identify approaches to CE in communicable disease control, effectiveness of these approaches, mechanisms and factors influencing success. METHODS: We included systematic reviews that: i) focussed on CE interventions; ii) involved adult community members; iii) included outcomes relevant to communicable diseases in LLMIC; iv) were written in English. Quantitative results were extracted and synthesised narratively. A qualitative synthesis process enabled identification of mechanisms of effect and influencing factors. We followed guidance from the Joanna Briggs Institute, assessed quality with the DARE tool and reported according to standard systematic review methodology. RESULTS: Thirteen systematic reviews of medium-to-high quality were identified between June and July 2017. Reviews covered the following outcomes: HIV and STIs (6); malaria (2); TB (1); child and maternal health (3) and mixed (1). Approaches included: CE through peer education and community health workers, community empowerment interventions and more general community participation or mobilisation. Techniques included sensitisation with the community and involvement in the identification of resources, intervention development and delivery. Evidence of effectiveness of CE on health outcomes was mixed and quality of primary studies variable. We found: i) significantly reduced neonatal mortality following women's participatory learning and action groups; ii) significant reductions in HIV and other STIs with empowerment and mobilisation interventions with marginalised groups; iii) significant reductions in malaria incidence or prevalence in a small number of primary studies; iv) significant reductions in infant diarrhoea following community health worker interventions. Mechanisms of impact commonly occurred through social and behavioural processes, particularly: changing social norms, increasing social cohesion and social capacity. Factors influencing effectiveness of CE interventions included extent of population coverage, shared leadership and community control over outcomes. CONCLUSION: Community engagement interventions may be effective in supporting CDC in LLMIC. Careful design of CE interventions appropriate to context, disease and community is vital.

Depression and anxiety in patients with multidrug-resistant tuberculosis in Nepal: an observational study.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) patients in the national TB treatment programme of Nepal. OBJECTIVE: To estimate the prevalence of depression and anxiety in people receiving treatment for MDR-TB, identify potential risk factors for depression and anxiety and determine temporal changes in their severity during treatment. DESIGN: An observational study using a screening tool, the Hopkins Symptom Checklist (HSCL-25) for depression and anxiety, administered monthly to a group of 135 patients in Nepal. Logistic and multilevel linear regression models were used to identify any patient characteristics associated with depression and anxiety. RESULTS: Most of the 135 patients were male (76%) and living with their families (68%). The period prevalences of depression and anxiety were respectively 22.2% and 15.6%. Patients reporting physical side effects of MDR-TB treatment had a higher depression score on HSCL by 2.63 points (95%CI 0.77-4.48) and a 1.59 point higher anxiety score (95%CI 0.45-2.73) than those who did not report any side effects. Being single was associated with having anxiety (aOR 0.2, 95%CI 0.03-1.0). CONCLUSION: Given the high rates of depression observed among MDR-TB patients, national TB treatment programmes should ensure their patients are routinely screened for depression and anxiety, and effective treatment offered.

Admission cardiotocography versus intermittent auscultation of the fetal heart in low-risk pregnancy during evaluation for possible labour admission - a multicentre randomised trial: the ADCAR trial.

OBJECTIVE: To assess the effect of admission cardiotocography (ACTG) versus intermittent auscultation (IA) of the fetal heart (FH) in low-risk pregnancy during assessment for possible labour on caesarean section rates. DESIGN: A parallel multicentre randomised trial. SETTING: Three maternity units in the Republic of Ireland. POPULATION: Healthy, low-risk pregnant women, at term and ≥ 18 years old, who provided written informed consent. METHODS: Women were randomised to receive IA of the FH or 20 minutes ACTG on admission for possible labour onset, using remote telephone randomisation. Both groups received IA during labour, with conversion to continuous CTG as clinically indicated. MAIN OUTCOME MEASURES: Caesarean section (primary outcome), obstetric interventions (e.g. continuous CTG during labour, fetal blood sampling, augmentation of labour) and neonatal morbidity (e.g. metabolic acidosis, admission to the neonatal intensive care unit, neonatal death). RESULTS: Based on 3034 women (1513 and 1521 randomised to IA and ACTG, respectively), there was no statistical difference between the groups in caesarean section [130 (8.6%) and 105 (6.9%) for IA and ACTG groups, respectively; relative risk (RR) 1.24; 95% CI 0.97-1.58], or in any other outcome except for use of continuous CTG during labour, which was lower in the IA group (RR 0.90, 95% CI 0.86-0.93). CONCLUSION: Our study demonstrates no differences in obstetric or neonatal outcomes between IA and ACTG for women with possible labour onset, other than an increased risk for continuous CTG in women receiving ACTG. TWEETABLE ABSTRACT: No differences in outcomes between intermittent auscultation and admission cardiotocography for women with possible labour onset.

Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh.

BACKGROUND: Almost three quarters of non-communicable disease (NCD) deaths, and 82% of premature NCD deaths, occur in low- and middle-income countries. Bangladesh has an estimated 7 million hypertensives and 10 million diabetics, and primary care is struggling to respond. Our aim was to develop and support implementation of a diabetes and hypertension case management package, and assess its appropriateness, feasibility and acceptability in two NCD clinics within two primary-care centres in Bangladesh. METHODS: We used a convergent mixed methods design. We first assessed the level of appropriate hypertension and cardiovascular disease patient management, based on a composite outcome indicator using data from patients' treatment cards. Appropriate management was primarily informed by International Diabetes Federation (IDF) and World Health Organisation (WHO) guidelines. We then performed qualitative in-depth interviews with doctors and patients to explain these quantitative findings and to understand the challenges to achieving appropriate patient management in the NCD clinics. RESULTS: Eighty-one newly diagnosed patients were recruited. Over 3 months, 53.1% (95% CI 42.3% to 63.6%) of patients were appropriately managed. We found incomplete diagnosis (especially missing hypertension diagnosis alongside diabetes) and non-provision of follow-up appointments were the main causes of the relatively low level of appropriate management. We conducted interviews with 11 patients and 8 health professionals and found a shortage of human resources, reporting materials, available drugs and diagnostic equipment. This undermined patients' willingness to attend clinics and doctors' willingness to offer follow-ups. Hands-on skill-building training was valuable in increasing doctors' competence for appropriate management, but was seen as a novel training method and faced constraints to implementation. CONCLUSIONS: A clinical guide, skill-based training and recording package can be implemented in routine primary care and can lead to appropriate management of around half of diabetic and hypertensive patients in a low-income country. However, considerable health systems challenges must be addressed before more patients can be managed appropriately.

Comparative effectiveness of physical activity interventions and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: protocol for a systematic review and network meta-analysis.

BACKGROUND: The prevalence of hypertension is a major public health challenge. Despite it being highly preventable, hypertension is responsible for a significant proportion of global morbidity and mortality. Common methods for controlling hypertension include prescribing anti-hypertensive medication, a pharmacological approach, and increasing physical activity, a behavioural approach. In general, little is known about the comparative effectiveness of pharmacological and behavioural approaches for reducing blood pressure in hypertension. A previous network meta-analysis suggested that physical activity interventions may be just as effective as many anti-hypertensive medications in preventing mortality; however, this analysis did not provide the comparative effectiveness of these disparate modes of intervention on blood pressure reduction. The primary objective of this study is to use network meta-analysis to compare the relative effectiveness, for blood pressure reduction, of different approaches to increasing physical activity and different first-line anti-hypertensive therapies in people with hypertension. METHODS: A systematic review will be conducted to identify studies involving randomised controlled trials which compare different types of physical activity interventions and first-line anti-hypertensive therapy interventions to each other or to other comparators (e.g. placebo, usual care) where blood pressure reduction is the primary outcome. We will search the Cochrane Library, MEDLINE and PsycInfo. For studies which meet our inclusion criteria, two reviewers will extract data independently and assess the quality of the literature using the Cochrane Risk of Bias Tool. Network meta-analyses will be conducted to generate estimates of comparative effectiveness of each intervention class and rankings of their effectiveness, in terms of reduction of both systolic and diastolic blood pressure. DISCUSSION: This study will provide evidence regarding the comparability of two common first-line treatment options for people with hypertension. It will also describe the extent to which there is direct evidence regarding the comparative effectiveness of increasing physical activity and initiating anti-hypertensive therapy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017070579.

[Treatment-resistant constipation and the need for chronic use of laxatives following lithium administration]. / Onderhoudsbehandeling met laxativa wegens hardnekkige constipatie bij behandeling met lithium.

Just a few days after the introduction of lithium therapy to treat a 35-year old man suffering from a bipolar disorder, complaints of constipation arose. The issue persisted despite numerous trials with first and second line laxatives at adequate dose and duration over a period of several weeks. After the singular administration of highly dosed macrogol laxatives with electrolytes, a lower dosage was established as maintenance treatment, yielding promising results. However, the potential interactions as well as the possible fluctuations in serum lithium levels when combining a maintenance treatment of both lithium and laxatives remains to be evaluated.

Impact of advanced detector technology and iterative reconstruction on low-dose quantitative assessment of lung computed tomography density in a biological lung model.

PURPOSE: Quantitative computed tomography (QCT)-derived measures of lung density are valued methods for objectively characterizing lung parenchymal and peripheral airways disease and are being used in a growing number of lung disease focused trials. Detector and reconstruction improvements in CT technology have allowed for significant radiation dose reduction in image acquisition with comparable qualitative image quality. We report the impact of detector type and reconstruction type on QCT lung density measures in relation to decreasing dose indices. METHODS: Two sets of studies were completed in an in vivo pig model with a SOMATOM Definition Flash CT system: (a) prior to system upgrade with conventional detectors (UFC) and filtered back projection (FBP), and (b) post system upgrade with integrated electronic detectors (STELLAR) and iterative reconstruction (SAFIRE). CT data were acquired across estimated CT volume dose indices (CTDIvol ) ranging from 0.75 to 15 mGy at both inspiratory and expiratory breath holds. Semiautomated lung segmentations allowed calculation of histogram median, kurtosis, and 15th percentile. Percentage of voxels below -910 HU and -950 HU (inspiratory), and -856 HU (expiratory) were also examined. The changes in these QCT metrics from dose reduction (15 mGy down to 0.75 mGy) were calculated relative to paired reference values (15 mGy). Results were compared based on detector and reconstruction type. RESULTS: In this study, STELLAR detectors improved concordance with 15 mGy values down to 3 mGy for inspiratory scans and 6 mGy for expiratory scans. The addition of SAFIRE reconstruction in all acquired measurements resulted in minimal deviation from reference values at 0.75 mGy. CONCLUSION: The use of STELLAR integrated electronic detectors and SAFIRE iterative reconstruction may allow for comparable lung density measures with CT dose indices down to 0.75 mGy.

Network meta-analysis in health psychology and behavioural medicine: a primer.

Progress in the science and practice of health psychology depends on the systematic synthesis of quantitative psychological evidence. Meta-analyses of experimental studies have led to important advances in understanding health-related behaviour change interventions. Fundamental questions regarding such interventions have been systematically investigated through synthesising relevant experimental evidence using standard pairwise meta-analytic procedures that provide reliable estimates of the magnitude, homogeneity and potential biases in effects observed. However, these syntheses only provide information about whether particular types of interventions work better than a control condition or specific alternative approaches. To increase the impact of health psychology on health-related policy-making, evidence regarding the comparative efficacy of all relevant intervention approaches - which may include biomedical approaches - is necessary. With the development of network meta-analysis (NMA), such evidence can be synthesised, even when direct head-to-head trials do not exist. However, care must be taken in its application to ensure reliable estimates of the effect sizes between interventions are revealed. This review paper describes the potential importance of NMA to health psychology, how the technique works and important considerations for its appropriate application within health psychology.

Multidrug-resistant tuberculosis treatment programmes insufficiently consider comorbid mental disorders.

The successful treatment of multidrug-resistant tuberculosis (MDR-TB) is a global health priority and a key pillar of the World Health Organization's (WHO's) End TB strategy. There has been significant global investment in diagnostic capabilities in recent years. However, we argue that the mental distress of those with MDR-TB and their families continues to be overlooked by TB programmes. Priorities in the End TB Strategy of 'patient-centred care' and 'patient support' are still to be delivered in practice in many low-income settings, and in particular consideration of mental distress. Our experience of undertaking MDR-TB operational research in China, Pakistan, Bangladesh, Nepal and Swaziland has given us detailed insight into the challenges facing patients, their families, health professionals and wider health systems. We are increasingly concerned that psychosocial support, and particularly support focused on mental health, is being insufficiently addressed in national MDR-TB programmes. We suggest that the presence of comorbid mental disorders reduces treatment adherence. We recommend the trialling within TB programmes of brief screening tools for common mental disorders and the incorporation of principles from the WHO Mental Health Gap Action Programme programme into TB programme treatment guidance. Our work in Nepal also suggests that brief psychological counselling delivered by non-specialist counsellors may be feasible.

A pilot evaluation of the SPARX-R gaming intervention for preventing depression and improving wellbeing among adolescents in alternative education.

AIM: The use of computerized mental health programs with vulnerable youth, such as early school leavers, remains relatively unstudied. This pilot study examined the feasibility of delivering a computerized cognitive behavioral therapy (cCBT) gaming intervention (SPARX-R) for young people (age 15-20 years) who have left school early and are attending Youthreach, an alternative education (AE) program in Ireland. METHOD: Students (n = 146) from twenty-one Youthreach Centers were randomized to SPARX-R and no-intervention control. All students within the group were included in the study whether or not they were exhibiting heightened levels of depression. Program impact was examined on both negative and positive indicators of mental health, including depression (primary outcome), generalized anxiety, general mental wellbeing, coping and emotion regulation. Assessments were conducted at baseline and post-intervention (7 weeks). Participants that provided data at post-assessment (n = 66) were included in the analysis. RESULTS: The participants completed on average 5.3 modules of SPARX-R with 30% (n = 9) completing the entire program. A significant improvement in emotion regulation strategies was detected, with expressive suppression decreasing significantly in the SPARX-R group in comparison to the control (- 2.97, 95% CI - 5.48 to - 0.46, p = 0.03). CONCLUSIONS: Findings suggest that SPARX-R has a positive impact on emotion regulation. The lack of significant findings on other outcome measures may be attributed to inadequate sample size, and therefore, further research with larger samples are required to establish the effectiveness of the program in reducing depression and anxiety and improving psychological wellbeing among young people attending AE.

Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh.

SETTING: Community health care providers (CHCPs) in 40 rural community clinics of Comilla district, Bangladesh, were trained using a newly developed case-management job aid based on the World Health Organization Integrated Management of Childhood Illness and a communication guide. OBJECTIVES: To assess 1) the change in knowledge of the CHCPs after training; 2) the absolute quality of care provided by the CHCPs (determined as the proportion of children aged <5 years [under-fives] correctly diagnosed, treated and referred); and 3) the consultation behaviour of the CHCPs. DESIGN: Change in knowledge was assessed by tests pre-and post-training. The quality of care was determined by reassessments at the clinic exit by a medical officer, without a baseline comparison. Consultation behaviour was assessed through direct observation. The study was performed during 2014-2015. RESULTS: The mean standard knowledge score of the CH-CPs increased from 19 to 25 (P < 0.001). Of 1490 under-fives examined, 91% were correctly diagnosed, 86% were correctly treated and 99.5% received a correct referral decision. The CHCPs performed well on most of the measures of good communication, although one third did not explain the diagnosis and treatment to patients. CONCLUSION: The training was effective in changing knowledge. The CHCPs applied the knowledge gained and provided good quality care. Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide. The lessons learnt should be useful for other countries.

Contexte : Les prestataires des soins de santé communautaires (CHCP) de 40 communautés rurales du district de Comilla, au Bangladesh, ont été formés grâce à une aide au travail de prise en charge des cas, récemment élaborée, basée sur la « prise en charge intégrée des maladies de l'enfant ¼ de l'Organisation Mondiale de la Santé et sur un guide de communication.Objectifs : Evaluer l'amélioration des connaissances des CHCP après la formation ; la qualité absolue des soins prodigués par les CHCP (déterminée comme la proportion d'enfants âgés de <5 ans ayant eu un diagnostic, un traitement et une référence corrects) ; et le comportement des CHCP pendant la consultation.Schéma : L'amélioration des connaissances a été évaluée à l'aide de tests pré- et post-formation. La qualité des soins a été déterminée par des réévaluations lors de la sortie du centre par un officier médical, sans comparaison avec le statut de départ. Le comportement lors des consultations a été évalué par observation directe. L'étude a été réalisée en 2014­2015.Résultats : Le score moyen de connaissance des CHCP a augmenté de 19 à 25 (P < 0.001). Sur 1490 enfants âgés de <5 ans examinés, 91% ont eu un diagnostic correct, 86% un traitement correct et 99,5% ont bénéficié d'une décision de référence correcte. Les CHCP se sont bien comportés en ce qui concerne la plupart des mesures de bonne communication ; cependant, un tiers d'entre eux n'a pas expliqué le diagnostic et le traitement aux patients.Conclusion : La formation a été efficace en termes d'amélioration des connaissances. Les CHCP ont mis en application les connaissances acquises et ont fourni des soins de bonne qualité. Au vu de ces résultats, le Ministère de la Santé et du Bien-être Familial du Bangladesh a étendu la formation à tout le pays. Les leçons apprises devraient être utiles à d'autres pays.

Marco de referencia: Los agentes comunitarios de salud de 40 consultorios rurales del distrito de Comilla, en Bangladesh, recibieron capacitación con una ayuda de trabajo desarrollada recientemente sobre el manejo de los casos basado en el enfoque de 'la atención integrada de las enfermedades prevalentes de la infancia' de la Organización Mundial de la Salud y también una guía en materia de comunicación.Objetivos: Evaluar las modificaciones en los conocimientos de los agentes comunitarios de salud después de la capacitación; la calidad absoluta de la atención que prestaban (medida según la proporción de niños en edad <5 años que recibieron un diagnóstico, tratamiento y remisión correctos); y su comportamiento durante las consultas.Método: Las modificaciones en los conocimientos se analizaron mediante pruebas realizadas antes y después de la capacitación. Un médico de planta evaluó la calidad de la atención a la salida de la consulta, sin un punto de comparación. El comportamiento durante la consulta se evaluó mediante la observación directa. El estudio se llevó a cabo en el 2014 y el 2015.Resultados: La puntuación promedio de los agentes comunitarios de salud en la escala de conocimientos corrientes mejoró de 19 a 25 (P < 0,001). De los 1490 niños en edad <5 años examinados, el diagnóstico fue acertado en el 91%, el tratamiento fue apropiado en el 86% y 99,5% de los niños obtuvieron una remisión correcta. El desempeño de los agentes comunitarios en la mayoría de las medidas de comunicación fue adecuado, aunque un tercio de ellos no explicó el diagnóstico y el tratamiento a los pacientes.Conclusión: La capacitación modificó eficazmente los conocimientos de los agentes comunitarios de salud. Los agentes aplicaron los conocimientos adquiridos y prestaron una atención de buena calidad. Con base en estos resultados, el Ministerio de Salud y Bienestar Familiar de Bangladesh ha ampliado la escala de la capacitación a todo el país. Las enseñanzas extraídas en esta experiencia serán muy útiles en otros países.

Addressing Inequities in Urban Health: Do Decision-Makers Have the Data They Need? Report from the Urban Health Data Special Session at International Conference on Urban Health Dhaka 2015.

Rapid and uncontrolled urbanisation across low and middle-income countries is leading to ever expanding numbers of urban poor, defined here as slum dwellers and the homeless. It is estimated that 828 million people are currently living in slum conditions. If governments, donors and NGOs are to respond to these growing inequities they need data that adequately represents the needs of the urban poorest as well as others across the socio-economic spectrum.We report on the findings of a special session held at the International Conference on Urban Health, Dhaka 2015. We present an overview of the need for data on urban health for planning and allocating resources to address urban inequities. Such data needs to provide information on differences between urban and rural areas nationally, between and within urban communities. We discuss the limitations of data most commonly available to national and municipality level government, donor and NGO staff. In particular we assess, with reference to the WHO's Urban HEART tool, the challenges in the design of household surveys in understanding urban health inequities.We then present two novel approaches aimed at improving the information on the health of the urban poorest. The first uses gridded population sampling techniques within the design and implementation of household surveys and the second adapts Urban HEART into a participatory approach which enables slum residents to assess indicators whilst simultaneously planning the response. We argue that if progress is to be made towards inclusive, safe, resilient and sustainable cities, as articulated in Sustainable Development Goal 11, then understanding urban health inequities is a vital pre-requisite to an effective response by governments, donors, NGOs and communities.

Behaviour change techniques and contraceptive use in low and middle income countries: a review.

We aimed to identify effective behaviour change techniques to increase modern contraceptive use in low and middle income countries (LMICs). Literature was identified in Global Health, Web of Science, MEDLINE, PsycINFO and Popline, as well as peer reviewed journals. Articles were included if they were written in English, had an outcome evaluation of contraceptive use, modern contraceptive use, contraceptive initiation/uptake, contraceptive adherence or continuation of contraception, were a systematic review or randomised controlled trial, and were conducted in a low or middle income country. We assessed the behaviour change techniques used in each intervention and included a new category of male partner involvement. We identified six studies meeting the inclusion criteria. The most effective interventions were those that involve male partner involvement in the decision to initiate contraceptive use. The findings also suggest that providing access to contraceptives in the community promotes their use. The interventions that had positive effects on contraceptive use used a combination of behaviour change techniques. Performance techniques were not used in any of the interventions. The use of social support techniques, which are meant to improve wider social acceptability, did not appear except in two of the interventions. Our findings suggest that when information and contraceptives are provided, contraceptive use improves. Recommendations include reporting of behaviour change studies to include more details of the intervention and techniques employed. There is also a need for further research to understand which techniques are especially effective.

Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice.

OBJECTIVE: To determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease. DESIGN: A 6-year follow-up of a cluster randomised controlled trial, which found after 18 months that both total and cardiovascular hospital admissions were significantly reduced in intervention practices (8% absolute reduction). SETTING: 48 general practices in the Republic of Ireland and Northern Ireland. PARTICIPANTS: 903 patients with established coronary heart disease at baseline in the original trial. INTERVENTION: The original intervention consisted of tailored practice and patient plans; training sessions for practitioners in medication prescribing and behavioural change; and regular patient recall system. Control practices provided usual care. Following the intervention period, all supports from the research team to intervention practices ceased. PRIMARY OUTCOME: hospital admissions, all cause and cardiovascular; secondary outcomes: mortality; blood pressure and cholesterol control. RESULTS: At 6-year follow-up, data were collected from practice records of 696 patients (77%). For those who had died, we censored their data at the point of death and cause of death was established. There were no significant differences between the intervention and control practices in either total (OR 0.83 (95% CI 0.54 to 1.28)) or cardiovascular hospital admissions (OR 0.91 (95% CI 0.49 to 1.65)). We confirmed mortality status of 886 of the original 903 patients (98%). There were no significant differences in mortality (15% in intervention and 16% in control) or in the proportions of patients above target control for systolic blood pressure or total cholesterol. CONCLUSIONS: Initial significant differences in the numbers of total and cardiovascular hospital admissions were not maintained at 6 years and no differences were found in mortality or blood pressure and cholesterol control. Policymakers need to continue to assess the effectiveness of previously efficacious programmes. TRIAL REGISTRATION NUMBER: Current Controlled Trials ISRCTN24081411.

A MultiCenter Pilot Randomized Controlled Trial of Remote Ischemic Preconditioning in Major Vascular Surgery.

A pilot randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on clinical outcomes following major vascular surgery was performed. Eligible patients were those scheduled to undergo open abdominal aortic aneurysm repair, endovascular aortic aneurysm repair, carotid endarterectomy, and lower limb revascularization procedures. Patients were randomized to RIPC or to control groups. The primary outcome was a composite clinical end point comprising any of cardiovascular death, myocardial infarction, new-onset arrhythmia, cardiac arrest, congestive cardiac failure, cerebrovascular accident, renal failure requiring renal replacement therapy, mesenteric ischemia, and urgent cardiac revascularization. Secondary outcomes were components of the primary outcome and myocardial injury as assessed by serum troponin values. The primary outcome occurred in 19 (19.2%) of 99 controls and 14 (14.1%) of 99 RIPC group patients (P = .446). There were no significant differences in secondary outcomes. Our trial generated data that will guide future trials. Further trials are urgently needed.

Quantification of biological variation in blood-based therapy--a summary of a meta-analysis to inform manufacturing in the clinic.

BACKGROUND AND OBJECTIVES: Biological raw materials, the basis for cellular therapies such as stem cells, have a significantly greater degree of complexity than their traditional pharmaceutical counterparts. This can be attributed to the inherent variation of its source - human beings. Currently, cell therapies are made in small, ad hoc batches, but larger scale production is a prerequisite to meeting future demand and will require a quality-by-design approach to manufacturing that will be designed around, or be robust to this variation. Quantification of variation will require understanding of the current baseline and stratification of its sources. MATERIALS AND METHODS: Haematopoietic stem cell therapy was chosen as a case study to explore this variation, and a PRISMA-guided (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) systematic meta-analysis was carried out for a number of predetermined cell measurements. RESULTS: From this data set, it appears that the extent of variation in therapeutic dose (in terms of transplanted total nucleated cells and CD34(+) cells per kilogram) for HSCT is between one and four orders of magnitude of the median. CONCLUSIONS: This is tolerated under the practice of medicine but would be unmanageable from a biomanufacturing perspective and raises concerns about comparable levels of efficacy and treatment. A number of sources that will contribute towards this variation are also reported, as is the direction of travel for 4 greater clarity of the scale of this challenge.

Estimating a regional ventilation-perfusion index.

This is a methods paper, where an approximation to the local ventilation-perfusion ratio is derived. This approximation, called the ventilation-perfusion index since it is not exactly the physiological ventilation-perfusion ratio, is calculated using conductivity reconstructions obtained using electrical impedance tomography. Since computation of the ventilation-perfusion index only requires knowledge of the internal conductivity, any conductivity reconstruction method may be used. The method is explained and results are presented using conductivities obtained from two EIT systems, one using an iterative method and the other a linearization method.