The effect of class 3 obesity on the functionality of supraglottic airway devices: a historical cohort analysis with propensity score matching.

PURPOSE: Supraglottic airway devices (SGAs) have been increasingly used as a primary airway in patients undergoing anesthesia as an alternative to endotracheal tubes. Second-generation devices have expanded their applicability to include uses in patients with obesity. Nevertheless, there is limited evidence of SGA suitability for patients with class 3 obesity (body mass index [BMI] ≥ 40 kg·m-2). As such, we compared rates of SGA functionality between patients with class 3 obesity and patients without class 3 obesity undergoing general anesthesia. METHODS: We performed a propensity score matching analysis using inverse probability of treatment weighting to compare the functionality of SGAs in adult patients with class 3 obesity vs without class 3 obesity. These patients underwent surgery at a hospital in Queensland, Australia from November 2017 to September 2020 and had a SGA inserted as part of their anesthetic care. All data were collected from patients' electronic medical records. We included 321 patients in the cohort with class 3 obesity and 471 in the cohort without class 3 obesity (control/comparison). The estimated effect of class 3 obesity on SGAs was calculated using adjusted odds ratios (AORs) with their 95% confidence intervals (CIs). RESULTS: The overall weighted prevalence of nonfunctional SGAs was 3.2%, with a significantly higher rate in the class 3 obesity cohort compared with the control cohort (4.7% vs 2.1%) (P = 0.04). This adjusted analysis illustrates that class 3 obesity was associated with an almost four times higher odds of a nonfunctional SGA (odds ratio [OR], 2.3; 95% CI, 1.0 to 5.1; AOR, 3.9; 95% CI, 1.4 to 10.6) than patients without class 3 obesity. CONCLUSION: Patients with class 3 obesity (BMI ≥ 40 kg·m-2) had greater than three-fold odds of nonfunctional intraoperative SGAs than patients without class 3 obesity.

RéSUMé: OBJECTIF: Les dispositifs supraglottiques (DSG) sont de plus en plus utilisés comme accès primaire aux voies aériennes en tant qu'alternative aux sondes endotrachéales chez les patient·es bénéficiant d'une anesthésie. Les dispositifs de deuxième génération ont élargi leur applicabilité pour inclure des utilisations chez les personnes souffrant d'obésité. Néanmoins, il existe des données probantes limitées concernant l'adéquation des DSG pour la patientèle souffrant d'obésité de classe 3 (indice de masse corporelle [IMC] ≥ 40 kg·m­2). Pour cette raison, nous avons comparé les taux de fonctionnalité des DSG entre une patientèle souffrant d'obésité de classe 3 et une patientèle sans obésité de classe 3 bénéficiant d'une anesthésie générale. MéTHODE: Nous avons réalisé une analyse d'appariement des scores de propension en utilisant la probabilité inverse de pondération du traitement pour comparer la fonctionnalité des DSG chez la patientèle adulte atteinte d'obésité de classe 3 vs sans obésité de classe 3. Ces patient·es ont bénéficié d'une intervention chirurgicale dans un hôpital du Queensland, en Australie, entre novembre 2017 et septembre 2020, et un DSG a été inséré dans le cadre de leurs soins anesthésiques. Toutes les données ont été recueillies à partir des dossiers médicaux informatisés des patient·es. Nous avons inclus 321 personnes dans la cohorte souffrant d'obésité de classe 3 et 471 dans la cohorte sans obésité de classe 3 (témoin/comparaison). L'effet estimé de l'obésité de classe 3 sur les DSG a été calculé à l'aide de rapports de cotes ajustés (RCA) avec leurs intervalles de confiance (IC) de 95%. RéSULTATS: La prévalence pondérée globale des DSG non fonctionnels était de 3,2 %, avec un taux significativement plus élevé dans la cohorte avec obésité de classe 3 que dans la cohorte témoin (4,7 % vs 2,1 %) (P = 0,04). Cette analyse ajustée illustre que l'obésité de classe 3 était associée à un risque presque quadruplé de non-fonctionnalité du DSG (rapport de cotes [RC], 2,3; IC 95 %, 1,0 à 5,1; RCA, 3,9; IC 95 %, 1,4 à 10,6) que chez des patient·es sans obésité de classe 3. CONCLUSION: Les personnes atteintes d'obésité de classe 3 (IMC ≥ 40 kg·m­2) présentaient plus de trois fois plus de risque de non-fonctionnalité péropératoire de DSG que les personnes sans obésité de classe 3.

Successes and challenges of primary health care in Australia: A scoping review and comparative analysis.

Introduction: Australia has achieved universal health insurance for its population since 1975 - a major step forward for increasing access to primary care (PC). Nevertheless, there are reports of several multi-layered challenges, including inequity, that persist. This analysis aims to undertake a scoping review of the success, explanatory factors, and challenges of Primary Health Care (PHC) in Australia guided by the World Health Organization (WHO)-defined key characteristics of good PC. Methods: We searched PubMed, Embase, Scopus and Web of Science using key terms related to PHC principles, attributes, system functioning and health care delivery modalities. We also used key PC terminologies used to assess key characteristics of good PC developed by WHO and key terms and attributes from Australia's health care landscape. We then integrated our search terms with the PHC Search Filters developed by Brown, L., et al. (2014). We restricted the search from 2013 to 2021. Two authors independently assessed study eligibility and performed a quality check on the extracted data. We presented findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: We identified 112 articles on primary health care (PHC), represented from all Australian states and territories. Overall, Australian PHC has achieved comprehensiveness, access and coverage, quality of care, patient / person centeredness and service coordination indicators with exemplary evidence-base practice/knowledge translation and clinical decision-making practices at the PC settings. Yet, we identified complex and multilayered barriers including geographic and socio-economic berries and inequality, staff dissatisfaction/turn over, low adoption of person-centred care, inadequate sectoral collaboration, and inadequate infrastructure in rural and remote primary care units. Conclusion: Primary health care in Australia, which has evolved through major reforms, has been adapting to the complex health care needs of the socio-culturally diversified nation, and has achieved many of the PC attributes, including service diversity, accessibility, acceptability, and quality of care. Yet, there are persistent gaps in service delivery to socio-economically disadvantaged populations, including indigenous people, culturally and linguistically diverse (CALD) populations, and rural- and remote-residents. These challenges could be mitigated through system-wide and targeted policy-level intervention to further improve service delivery through effective and functional local health service coordination, sectoral integration, and improving health care providers' cultural competence.

Epidemiology and management of traumatic brain injury in a regional Queensland Emergency Department.

BACKGROUND: There is a paucity of traumatic brain injury (TBI) data in Australia in the regional and rural context. This study aimed to investigate the epidemiology, severity, causes, and management of TBI in a regional north Queensland population to plan acute care, follow up, and prevention strategies. METHODS: This retrospective study analysed TBI patients presenting to Mackay Base Hospital Emergency Department (ED) in 2021. We identified patients using head injury SNOMED codes, and analysed patient characteristics with descriptive and multivariable regression analysis. RESULTS: There were 1120 head injury presentations, with an overall incidence of 909 per 100,000 people per year. The median (IQR) age was 18 (6-46) years. Falls were the most common injury mechanism (52.4% of presentations). 41.1% of patients had a Computed Tomography (CT) scan, while 16.5% of patients who met criteria had post traumatic amnesia (PTA) testing. Age, being male and Indigenous status were associated with higher odds of moderate to severe TBI. CONCLUSION: TBI incidence in this regional population was higher than metropolitan locations. CT scan was undertaken less frequently than in comparative literature, and low rates of PTA testing were undertaken. These data provide insight to assist in planning prevention and TBI-care services.

Effects of drug and hazardous alcohol use on having a detectable HIV viral load: An adherence mediation analysis.

Objectives: People living with HIV (PWH) with substance or alcohol use often have unsuppressed plasma HIV viral loads (pVL). The degree to which substance and alcohol use effects on HIV viral suppression are mediated through medication nonadherence is incompletely understood. Methods: We included PWH prescribed antiretroviral therapy and receiving care at an academic HIV clinic between 2014 and 2018 who completed both patient-reported outcomes (PRO) questionnaires and had subsequent pVL measurements. Measures included assessments of alcohol use (AUDIT-C), drug use (NIDA-ASSIST), and self-reported adherence measured using four different methods. Substances found in bivariate analysis to predict detectable pVL were modeled separately for mediation effects through adherence. We report natural direct (NDE) and indirect effect (NIE), marginal total effect (MTE), and percentage mediated. Results: Among 3125 PWH who met eligibility criteria, 25.8% reported hazardous alcohol use, 27.1% cannabis, 13.1% amphetamines, 1.9% inhalants, 5.3% cocaine, 4.5% sedative-hypnotics, 2.9% opioids, and 2.3% hallucinogens. Excellent adherence was reported by 58% of PWH, and 10% had detectable pVL. Except for sedatives, using other substances was significantly associated with worse adherence. Bivariate predictors of detectable pVL were [OR (95% CI)]: amphetamine use 2.4 (1.8-3.2) and opioid use 2.3 (1.3-4.0). The percent of marginal total effect mediated by nonadherence varied by substance: 36% for amphetamine use, 27% for opioid use, and 39% for polysubstance use. Conclusion: Use of amphetamines, opioids, and multiple substances predicted detectable pVL. Up to 40% of their effects were mediated by self-reported nonadherence. Confirmation using longitudinal measurement models will strengthen causal inference from this cross-sectional analysis.

Where does spinal cord stimulation fit into the international guidelines for refractory painful diabetic neuropathy? a consensus statement.

BACKGROUND: Although pharmacotherapy with anticonvulsants and/or antidepressants can be effective for many people with painful diabetic neuropathy (PDN), albeit with frequent side-effects, a critical juncture occurs when neuropathic pain no longer responds to standard first- and second-step mono- and dual therapy and becomes refractory. Subsequent to these pharmacotherapeutic approaches, third-line treatment options for PDN may include opioids (short-term), capsaicin 8% patches, and spinal cord stimulation (SCS). AIM: This document summarizes consensus recommendations regarding appropriate treatment for refractory peripheral diabetic neuropathy (PDN), based on outcomes from an expert panel convened on December 10, 2022, as part of the Worldwide Initiative for Diabetes Education Virtual Global Summit, "Advances in the Management of Painful Diabetic Neuropathy." PARTICIPANTS: Nine attendees, eminent physicians and academics, comprising six diabetes specialists, two pain specialists, and one health services expert. EVIDENCE: For individuals with refractory PDN, opioids are a high-risk option that do not provide a long-term solution and should not be used. For appropriately selected individuals, SCS is an effective, safe, and durable treatment option. In particular, high-frequency (HF) SCS (10 kHz) shows strong efficacy and improves quality of life. To ensure treatment success, strict screening criteria should be used to prioritize candidates for SCS. CONSENSUS PROCESS: Each participant voiced their opinion after reviewing available data, and a verbal consensus was reached during the meeting. CONCLUSION: Globally, the use of opioids should rarely be recommended for refractory, severe PDN. Based on increasing clinical evidence, SCS, especially HF-SCS, should be considered as a treatment for PDN that is not responsive to first- or second-line monotherapy/dual therapy.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence.

BACKGROUND: High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services. METHODS: We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output). RESULTS: Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services. CONCLUSION: Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

Systematic Review of the Diagnostic and Clinical Utility of Salivary microRNAs in Traumatic Brain Injury (TBI).

Research in traumatic brain injury (TBI) is an urgent priority, as there are currently no TBI biomarkers to assess the severity of injury, to predict outcomes, and to monitor recovery. Small non-coding RNAs (sncRNAs) including microRNAs can be measured in saliva following TBI and have been investigated as potential diagnostic markers. The aim of this systematic review was to investigate the diagnostic or prognostic ability of microRNAs extracted from saliva in human subjects. PubMed, Embase, Scopus, PsycINFO and Web of Science were searched for studies that examined the association of saliva microRNAs in TBI. Original studies of any design involving diagnostic capacity of salivary microRNAs for TBI were selected for data extraction. Nine studies met inclusion criteria, with a heterogeneous population involving athletes and hospital patients, children and adults. The studies identified a total of 188 differentially expressed microRNAs, with 30 detected in multiple studies. MicroRNAs in multiple studies involved expression change bidirectionality. The study design and methods involved significant heterogeneity that precluded meta-analysis. Early data indicates salivary microRNAs may assist with TBI diagnosis. Further research with consistent methods and larger patient populations is required to evaluate the diagnostic and prognostic potential of saliva microRNAs.

Alterations of tibialis anterior muscle activation pattern in subjects with type 2 diabetes and diabetic peripheral neuropathy.

Diabetic peripheral neuropathy (DPN) is associated with loss of motor units (MUs), which can cause changes in the activation pattern of muscle fibres. This study investigated the pattern of muscle activation using high-density surface electromyography (HD-sEMG) signals from subjects with type 2 diabetes mellitus (T2DM) and DPN. Thirty-five adults participated in the study: 12 healthy subjects (HV), 12 patients with T2DM without DPN (No-DPN) and 11 patients with T2DM with DPN (DPN). HD-sEMG signals were recorded in the tibialis anterior muscle during an isometric contraction of ankle dorsiflexion at 50% of the maximum voluntary isometric contraction (MVIC) during 30-s. The calculated HD-sEMG signals parameters were the normalised root mean square (RMS), normalised median frequency (MDF), coefficient of variation (CoV) and modified entropy (ME). The RMS increased significantly (p = 0.001) with time only for the DPN group, while the MDF decreased significantly (p < 0.01) with time for the three groups. Moreover, the ME was significantly lower (p = 0.005), and CoV was significantly higher (p = 0.003) for the DPN group than the HV group. Using HD-sEMG, we have demonstrated a reduction in the number of MU recruited by individuals with DPN. This study provides proof of concept for the clinical utility of this technique for identifying neuromuscular impairment caused by DPN.

Factors Associated with Increased Risk of Early Severe Neonatal Morbidity in Late Preterm and Early Term Infants.

Although the risk of neonatal mortality is generally low for late preterm and early term infants, they are still significantly predisposed to severe neonatal morbidity (SNM) despite being born at relatively advanced gestations. In this study, we investigated maternal and intrapartum risk factors for early SNM in late preterm and early term infants. This was a retrospective cohort study of non-anomalous, singleton infants (34+0-38+6 gestational weeks) born at the Mater Mother's Hospital in Brisbane, Australia from January 2015 to May 2020. Early SNM was defined as a composite of any of the following severe neonatal outcome indicators: admission to neonatal intensive care unit (NICU) in conjunction with an Apgar score <4 at 5 min, severe respiratory distress, severe neonatal acidosis (cord pH < 7.0 or base excess <-12 mmol/L). Multivariable binomial logistic regression analyses using generalized estimating equations (GEE) were used to identify risk factors. Of the total infants born at 34+0-38+6 gestational weeks, 5.7% had at least one component of the composite outcome. For late preterm infants, pre-existing diabetes mellitus, instrumental birth and emergency caesarean birth for non-reassuring fetal status were associated with increased odds for early SNM, whilst for early term infants, pre-existing and gestational diabetes mellitus, antepartum hemorrhage, instrumental, emergency caesarean and elective caesarean birth were significant risk factors. In conclusion, we identified several risk factors contributing to early SNM in late preterm and early term cohort. Our results suggest that predicted probability of early SNM decreased as gestation increased.

Antigen-Specific Cytokine and Chemokine Gene Expression for Diagnosing Latent and Active Tuberculosis.

Tuberculosis infection exhibits different forms, namely, pulmonary, extrapulmonary, and latent. Here, diagnostic markers based on the gene expression of cytokines and chemokines for differentiating between tuberculosis infection state(s) were identified. Gene expression of seven cytokines (Interferon gamma (IFN-γ), Interferon gamma-induced protein 10 (IP-10), Interleukin-2 receptor (IL-2R), C-X-C Motif Chemokine Ligand 9 (CXCL-9), Interleukin 10 (IL-10), Interleukin 4 (IL-4), and Tumor Necrosis Factor alpha (TNF-α)) in response to tuberculosis antigen was analyzed using real-time polymerase reaction. The sensitivity and specificity of relative quantification (2^-ΔΔCt) of mRNA expression were analyzed by constructing receiver operating characteristic curves and measuring the area under the curve (AUC) values. Combinations of cytokines were analyzed using the R statistical software package. IFN-γ, IP-10, IL2R, and CXCL-9 showed high expression in latent and active tuberculosis patients (p = 0.001), with a decrease in IL10 expression, and no statistical difference in IL-4 levels among all the groups (p = 0.999). IL-10 differentiated pulmonary tuberculosis patients from latent cases with an AUC of 0.731. IL10 combined with CXCL-9 distinguished pulmonary tuberculosis patients from extrapulmonary cases with a sensitivity, specificity, and accuracy of 85.7%, 73.9%, and 81.0%, respectively. IL-10 together with IP-10 and IL-4 differentiated pulmonary tuberculosis from latent cases with a sensitivity and specificity of 77.1% and 88.1%, respectively. Decision tree analysis demonstrated that IFN-γ IL-2R, and IL-4 can diagnose tuberculosis infection with a sensitivity, specificity, and accuracy of 89.7%, 96.1%, and 92.7%, respectively. A combination of gene expression of cytokines and chemokines might serve as an effective marker to differentiate tuberculosis infection state(s).

Modelling climate change impacts on maize yields under low nitrogen input conditions in sub-Saharan Africa.

Smallholder farmers in sub-Saharan Africa (SSA) currently grow rainfed maize with limited inputs including fertilizer. Climate change may exacerbate current production constraints. Crop models can help quantify the potential impact of climate change on maize yields, but a comprehensive multimodel assessment of simulation accuracy and uncertainty in these low-input systems is currently lacking. We evaluated the impact of varying [CO2 ], temperature and rainfall conditions on maize yield, for different nitrogen (N) inputs (0, 80, 160 kg N/ha) for five environments in SSA, including cool subhumid Ethiopia, cool semi-arid Rwanda, hot subhumid Ghana and hot semi-arid Mali and Benin using an ensemble of 25 maize models. Models were calibrated with measured grain yield, plant biomass, plant N, leaf area index, harvest index and in-season soil water content from 2-year experiments in each country to assess their ability to simulate observed yield. Simulated responses to climate change factors were explored and compared between models. Calibrated models reproduced measured grain yield variations well with average relative root mean square error of 26%, although uncertainty in model prediction was substantial (CV = 28%). Model ensembles gave greater accuracy than any model taken at random. Nitrogen fertilization controlled the response to variations in [CO2 ], temperature and rainfall. Without N fertilizer input, maize (a) benefited less from an increase in atmospheric [CO2 ]; (b) was less affected by higher temperature or decreasing rainfall; and (c) was more affected by increased rainfall because N leaching was more critical. The model intercomparison revealed that simulation of daily soil N supply and N leaching plays a crucial role in simulating climate change impacts for low-input systems. Climate change and N input interactions have strong implications for the design of robust adaptation approaches across SSA, because the impact of climate change in low input systems will be modified if farmers intensify maize production with balanced nutrient management.

The Impact of Severe Maternal Morbidity on Perinatal Outcomes in High Income Countries: Systematic Review and Meta-Analysis.

While there is clear evidence that severe maternal morbidity (SMM) contributes significantly to poor maternal health outcomes, limited data exist on its impact on perinatal outcomes. We undertook a systematic review and meta-analysis to ascertain the association between SMM and adverse perinatal outcomes in high-income countries (HICs). We searched for full-text publications in PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus databases. Studies that reported data on the association of SMM and adverse perinatal outcomes, either as a composite or individual outcome, were included. Two authors independently assessed study eligibility, extracted data, and performed quality assessment using the Newcastle-Ottawa Scale. We used random-effects modelling to calculate odds ratios (ORs) with 95% confidence intervals. We also assessed the risk of publication bias and statistical heterogeneity using funnel plots and Higgins I2, respectively. We defined sub-groups of SMM as hemorrhagic disorders, hypertensive disorders, cardiovascular disorders, hepatic disorders, renal disorders, and thromboembolic disorders. Adverse perinatal outcome was defined as preterm birth (before 37 weeks gestation), small for gestational age (SGA) (birth weight (BW) < 10th centile for gestation), low birthweight (LBW) (BW < 2.5 kg), Apgar score < 7 at 5 min, neonatal intensive care unit (NICU) admission, stillbirth and perinatal death (stillbirth and neonatal deaths up to 28 days). A total of 35 studies consisting of 38,909,426 women were included in the final analysis. SMMs associated with obstetric hemorrhage (OR 3.42, 95% CI: 2.55-4.58), severe hypertensive disorders (OR 6.79, 95% CI: 6.06-7.60), hepatic (OR 3.19, 95% CI: 2.46-4.13) and thromboembolic disorders (OR 2.40, 95% CI: 1.67-3.46) were significantly associated with preterm birth. SMMs from hypertensive disorders (OR 2.86, 95% CI: 2.51-3.25) or thromboembolic disorders (OR 1.48, 95% CI: 1.09-1.99) were associated with greater odds of having SGA infant. Women with severe hemorrhage had increased odds of LBW infant (OR 2.31, 95% CI: 1.57-3.40). SMMs from obstetric hemorrhage (OR 4.16, 95% CI: 2.54-6.81) or hypertensive disorders (OR 4.61, 95% CI: 1.17-18.20) were associated with an increased odds of low 5-min Apgar score and NICU admission (Severe obstetric hemorrhage: OR 3.34, 95% CI: 2.26-4.94 and hypertensive disorders: OR 3.63, 95% CI: 2.63-5.02, respectively). Overall, women with SMM were 4 times more likely to experience stillbirth (OR 3.98, 95%C 3.12-7.60) compared to those without SMM with cardiovascular disease (OR 15.2, 95% CI: 1.29-180.60) and thromboembolic disorders (OR 9.43, 95% CI: 4.38-20.29) conferring greatest risk of this complication. The odds of neonatal death were significantly higher in women with SMM (OR 3.98, 95% CI: 2.44-6.47), with those experiencing hemorrhagic (OR 7.33, 95% CI: 3.06-17.53) and hypertensive complications (OR 3.0, 95% CI: 1.78-5.07) at highest risk. Overall, SMM was also associated with higher odds of perinatal death (OR 4.74, 95% CI: 2.47-9.12) mainly driven by the increased risk in women experiencing severe obstetric hemorrhage (OR 6.18, 95% CI: 2.55-14.96). Our results highlight the importance of mitigating the impact of SMM not only to improve maternal health but also to ameliorate its consequences on perinatal outcomes.

Impact of severe maternal morbidity on adverse perinatal outcomes in high-income countries: systematic review and meta-analysis protocol.

INTRODUCTION: Severe maternal morbidity (SMM) includes conditions that are on a continuum of maternal morbidity to maternal death. Rates of SMM are increasing both in high-income countries (HICs) as well as in low/middle-income countries (LMICs). There is evidence that analysis of SMM trends and detailed investigation of factors implicated in these cases may reflect the standard of maternal healthcare both in HICs and LMICs. SMM is also associated with poorer perinatal outcomes. The aim of this protocol is to describe the proposed methodology for the synthesis and analyses of the data describing the relationship between SMM and adverse perinatal outcomes in a systematic review and meta-analysis. METHODS: This systematic review and meta-analysis will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and will be registered with the International Prospective Register of Systematic Reviews (PROSPERO). Original peer-reviewed epidemiologic/clinical studies of observational (cross-sectional, cohort, case-control) and randomised controlled trial studies conducted in high-income countries will be included. An electronic search of PubMed, Embase, CINAHL and Scopus databases will be performed without restricting publication date/year. Two authors will independently screen the titles, review abstracts and perform data extraction. Where possible, meta-analyses will be done to calculate pooled estimates. ETHICS AND DISSEMINATION: As this is a protocol for systematic review and meta-analysis of published data, ethics review and approval are not required. The findings will be published in peer-reviewed journals and disseminated at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42019130933.

Serological evidence for a decline in malaria transmission following major scale-up of control efforts in a setting selected for Plasmodium vivax and Plasmodium falciparum malaria elimination in Babile district, Oromia, Ethiopia.

BACKGROUND: Following successful malaria control during the last decade, Ethiopia instituted a stepwise malaria elimination strategy in selected low-transmission areas. METHODS: Cross-sectional surveys were conducted in Babile district, Oromia, Ethiopia from July to November 2017 to evaluate malaria infection status using microscopy and nested polymerase chain reaction (nPCR) and serological markers of exposure targeting Plasmodium falciparum and Plasmodium vivax apical membrane antigen-1 (AMA-1). RESULTS: Parasite prevalence was 1.2% (14/1135) and 5.1% (58/1143) for P. falciparum and 0.4% (5/1135) and 3.6% (41/1143) for P. vivax by microscopy and nPCR, respectively. Antibody prevalence was associated with current infection by nPCR for both P. falciparum (p<0.001) and P. vivax (p=0.014) and showed an age-dependent increase (p<0.001, for both species). Seroconversion curves indicated a decline in malaria exposure 15 y prior to sampling for P. falciparum and 11.5 y prior to sampling for P. vivax, broadly following malaria incidence data from district health offices, with higher antibody titres in adults than children for both species. CONCLUSIONS: Malaria transmission declined substantially in the region with continuing heterogeneous but measurable local transmission, arguing in favour of continued and tailored control efforts to accelerate the progress towards elimination efforts.

Reduced vitamin D levels in painful diabetic peripheral neuropathy.

AIM: Recent studies have reported an association between low vitamin D levels and diabetic peripheral neuropathy. However, many of these did not differentiate between people with painful diabetic peripheral neuropathy and those with painless diabetic peripheral neuropathy, or assess major confounding factors including sunlight exposure and daily activity. Our study addressed these limitations and evaluated vitamin D levels in people with carefully phenotyped diabetic peripheral neuropathy and controls. METHODS: Forty-five white Europeans with Type 2 diabetes and 14 healthy volunteers underwent clinical and neurophysiological assessments. People with Type 2 diabetes were then divided into three groups (17 with painful diabetic peripheral neuropathy, 14 with painless diabetic peripheral neuropathy and 14 with no diabetic peripheral neuropathy). All had seasonal sunlight exposure and daily activity measured, underwent a lower limb skin biopsy and had 25-hydroxyvitamin D measured during the summer months, July to September. RESULTS: After adjusting for age, BMI, activity score and sunlight exposure, 25-hydroxyvitamin D levels (nmol/l) (se) were significantly lower in people with painful diabetic peripheral neuropathy [painful diabetic peripheral neuropathy 34.9 (5.8), healthy volunteers 62.05 (6.7), no diabetic peripheral neuropathy 49.6 (6.1), painless diabetic peripheral neuropathy 53.1 (6.2); ANCOVAP = 0.03]. Direct logistic regression was used to assess the impact of seven independent variables on painful diabetic peripheral neuropathy. Vitamin D was the only independent variable to make a statistically significant contribution to the model with an inverted odds ratio of 1.11. Lower 25-hydroxyvitamin D levels also correlated with lower cold detection thresholds (r = 0.39, P = 0.02) and subepidermal nerve fibre densities (r = 0.42, P = 0.01). CONCLUSIONS: We have demonstrated a significant difference in 25-hydroxyvitamin D levels in well-characterized people with painful diabetic peripheral neuropathy, while accounting for the main confounding factors. This suggests a possible role for vitamin D in the pathogenesis of painful diabetic peripheral neuropathy. Further prospective and intervention trials are required to prove causality between low vitamin D levels and painful diabetic peripheral neuropathy.

One-stop microvascular screening service: an effective model for the early detection of diabetic peripheral neuropathy and the high-risk foot.

AIMS: To evaluate the feasibility of a one-stop microvascular screening service for the early diagnosis of diabetic distal symmetrical polyneuropathy, painful distal symmetrical polyneuropathy and the at-risk diabetic foot. METHODS: People with diabetes attending retinal screening in hospital and community settings had their feet examined by a podiatrist. Assessment included: Toronto Clinical Neuropathy Score evaluation; a 10-g monofilament test; and two validated, objective and quick measures of neuropathy obtained using the point-of-care devices 'DPN-Check', a hand-held device that measures sural nerve conduction velocity and amplitude, and 'Sudoscan', a device that measures sudomotor function. The diagnostic utility of these devices was assessed against the Toronto Clinical Neuropathy Score as the 'gold standard'. RESULTS: A total of 236 consecutive people attending the retinal screening service, 18.9% of whom had never previously had their feet examined, were evaluated. The prevalence of distal symmetrical polyneuropathy, assessed using the Toronto Clinical Neuropathy Score, was 30.9%, and was underestimated by 10-g monofilament test (14.4%). The prevalence of distal symmetrical polyneuropathy using DPN-check was 51.5% (84.3% sensitivity, 68.3% specificity), 38.2% using Sudoscan foot electrochemical skin conductance (77.4% sensitivity, 68.3% specificity), and 61.9% using abnormality in either of the results (93.2% sensitivity, 52.8% specificity). The results of both devices correlated with Toronto Clinical Neuropathy Score (P<0.001). A new diagnosis of painful distal symmetrical polyneuropathy was made in 59 participants (25%), and 56.6% had moderate- or high-risk foot. Participants rated the service very highly. CONCLUSIONS: Combined, eye, foot and renal screening is feasible, has a high uptake, reduces clinic visits, and identifies painful distal symmetrical polyneuropathy and the at-risk foot. Combined large- and small-nerve-fibre assessment using non-invasive, quantitative and quick point-of-care devices may be an effective model for the early diagnosis of distal symmetrical polyneuropathy.

Molecular epidemiology of fluoroquinolone resistant Salmonella in Africa: A systematic review and meta-analysis.

BACKGROUND: Wide-ranging evidence on the occurrence of fluoroquinolone (FQ) resistance genetic determinants in African Salmonella strains is not available. The main objectives of this study were to assess the heterogeneity, estimate pooled proportions and describe the preponderance of FQ-resistance determinants in typhoidal and non-typhoidal Salmonella (NTS) isolates of Africa. METHODS: Genetic and phenotypic data on 6103 Salmonella isolates were considered. Meta- and frequency analyses were performed depending on the number of studies by category, number of isolates and risks of bias. A random effects model was used to assess heterogeneity and estimate pooled proportions. Relative and cumulative frequencies were calculated to describe the overall preponderance of FQ-resistance determinants in quinolone resistant isolates. RESULTS: The pooled proportion of gyrA mutants (Salmonella enterica serovar Typhi, Salmonella enterica serovar Typhimurium, and Salmonella enterica serovar Enteritidis) was estimated at 5.7% (95% Confidence interval (CI) = 2.6, 9.8; Tau squared (T2) = 0.1105), and was higher in S. Typhi than in S. Typhimurium (odds ratio (OR) = 3.3, 95%CI = 2, 5.7). The proportions of each of gyrB and parC mutants, and strains with Plasmid Mediated Quinolone Resistance genes (qnrA, qnrB and qnrS) were low (≤ 0.3%). Overall, 23 mutant serotypes were identified, and most strains had mutations at codons encoding Ser83 and Asp87 of gyrA (82%, 95%CI = 78, 86). CONCLUSIONS: Mutations at gyrA appear to account for ciprofloxacin non-susceptibility in most clinical Salmonella strains in Africa. The estimates could be harnessed to develop a mismatch-amplification mutation-assay for the detection of FQ-resistant strains in Africa.

Is there a connection between postprandial hyperglycemia and IGT related sensory nerve dysfunction?

BACKGROUND AND AIMS: To assess the risk factors for sensory nerve dysfunction in subjects with isolated impaired glucose tolerance (IGT). METHODS AND RESULTS: Seventy-two people with isolated IGT (WHO 1999 criteria) and 39 gender and age-matched healthy volunteers underwent detailed clinical and neurological assessment including quantitative sensory testing using the Neurometer device (current perception threshold measurement on four limbs at three different frequencies). Sensory nerve dysfunction was defined as at least two abnormalities on any frequencies on the upper or lower limbs. Sensory nerve dysfunction was more prevalent among subjects with IGT compared to controls (58.3 vs. 10.3%, OR: 11.23, 95%CI: 3.57-35.35). This association was not influenced by BMI, systolic and diastolic blood pressure, heart rate and autonomic neuropathy (multiple adjusted OR: 13.87, 95%CI: 3.18-60.58), but further adjustment for glycaemic measures abolished the association (OR: 1.58, 95%CI: 0.07-35.68). Assessing the components of glycaemic measures separately, the association between sensory nerve dysfunction and IGT was not affected by HbA1c (OR: 13.94, 95%CI: 1.84-105.5). It was, however, substantially attenuated by fasting plasma glucose (OR: 6.75, 95%CI: 1.33-34.27) while the significance was lost after adjustment for 120 min postload glucose level (OR: 3.76, 95%CI: 0.26-54.10). In the pooled population assessed, independent determinants of sensory nerve dysfunction were older age, 120 min glucose, higher height and cardiovascular autonomic neuropathy at near significance. CONCLUSIONS: Sensory nerve dysfunction amongst subjects with IGT was not explained by cardiovascular covariates, only by glycaemic measures. In addition to 120 min glucose, cardiovascular autonomic neuropathy at borderline significance, age, and height were the independent determinants of sensory nerve dysfunction.

Are there different predictors of analgesic response between antidepressants and anticonvulsants in painful diabetic neuropathy?

BACKGROUND: To investigate baseline demographics and disease characteristics as predictors of the analgesic effect of duloxetine and pregabalin on diabetic peripheral neuropathic pain (DPNP). METHODS: Based on data from the COMBO-DN study, a multinational clinical trial in DPNP, the potential impact of baseline characteristics on pain relief after 8-week monotherapy with 60 mg/day duloxetine or 300 mg/day pregabalin was assessed using analyses of covariance. Subgroups of interest were characterized regarding their baseline characteristics and efficacy outcomes. RESULTS: A total of 804 patients were evaluated at baseline. A significant interaction with treatment was observed in the mood symptom subgroups with a larger pain reduction in duloxetine-treated patients having no mood symptoms [Hospital Anxiety and Depression Scale (HADS) depression or anxiety subscale score <11; -2.33 (duloxetine); -1.52 (pregabalin); p = 0.024]. There were no significant interactions between treatment for subgroups by age (<65 or ≥65 years), gender, baseline pain severity [Brief Pain Inventory Modified Short Form (BPI-MSF) average pain <6 or ≥6], diabetic neuropathy duration (≤2 or >2 years), baseline haemoglobin A1c (HbA1c) (<8% or ≥8%), presence of comorbidities and concomitant medication use. CONCLUSIONS: Our analyses suggest that the efficacy of duloxetine and pregabalin for initial 8-week treatment in DPNP was consistent across examined subgroups based on demographics and disease characteristics at baseline except for the presence of mood symptoms. Duloxetine treatment appeared to be particularly beneficial in DPNP patients having no mood symptoms.

A meta-analysis of the prevalence of Salmonella in food animals in Ethiopia.

BACKGROUND: The globalization of the food supply and the increased movements of people, animals and goods have increased the threat of Salmonella infections in several countries. The objective of this study was to estimate the prevalence of Salmonella in food animals in Ethiopia by using meta-analytical methods. RESULTS: The prevalence of Salmonella in slaughtered cattle, sheep, goats and pigs were 7.07%, 8.41%, 9.01% and 43.81% respectively. The occurrence of Salmonella was significantly higher in pigs than in slaughtered true ruminants (p <0.001) but not significantly different between cattle, sheep and goats (p >0. 05). S. Mishmarhaemek, S. Infantis and S. Hadar were the predominant isolates in cattle, small ruminants and pigs respectively. S. Typhimurium was isolated from all host species. CONCLUSIONS: All food animals are considerable reservoirs of Salmonella and pose a significant risk to public health. Safety measures in slaughter houses and butcheries and education of the public could reduce the risk of transmission of Salmonella from animals to humans.