Sleep Management in Posttraumatic Stress Disorder (PTSD): A Systematic Review.

Posttraumatic stress disorder (PTSD) is a condition that can emerge after exposure to a traumatic event. It involves several symptoms, including distressing memories or dreams and/or dissociative reactions; psychological distress at exposure to trauma cues; physiologic reactions to cues; avoidance of stimuli associated with the event; negative alterations in cognitions and mood associated with the trauma; and alterations in arousal and reactivity, including sleep disturbance. The purpose of this systematic review is to synthesize the evidence from randomized controlled trials on the effects that interventions for adults with PTSD have on sleep outcomes. The authors searched research databases and bibliographies of existing systematic reviews to identify pertinent trials published in English; literature was identified by the searches using predetermined eligibility criteria. The primary outcome domain included sleep quality, insomnia, and nightmares. Secondary outcomes were PTSD symptoms and adverse events. Risk of bias and the quality of evidence were assessed for each outcome. The identified interventions addressed pharmacological, psychological, behavioral, complementary, and integrative medicine treatments aimed at improving sleep or lessening other PTSD symptoms. Interventions in general showed an effect on sleep. Interventions explicitly targeting sleep-particularly psychotherapy targeting sleep-showed larger effects on sleep than did interventions not targeting sleep. Heterogeneity was considerable, but sleep effect estimates were not systematically affected by trauma type, setting, or modality. Comparative effectiveness studies are needed to support the findings.

Effects of Medication-Assisted Treatment (MAT) for Opioid Use Disorder on Functional Outcomes: A Systematic Review.

This systematic review addresses the question: What are the effects of medication-assisted treatment (MAT) that use buprenorphine, buprenorphine combined with naloxone, methadone, or naltrexone for opioid use disorder (OUD) on functional outcomes compared with wait-list, placebo, treatment without medication, any other comparator, or each other (e.g., buprenorphine versus naltrexone)? Functional outcomes investigated included cognitive (e.g., memory), physical (e.g., fatigue), occupational (e.g., employment status), social/behavioral (e.g., criminal activity), and neurological (e.g., balance) function. The authors searched five scientific research databases from inception to 2017 and reference mined existing reviews. Two independent literature reviewers screened 6,292 citations; 1,327 full-text publications were reviewed in detail and 37 studies met inclusion criteria. Critical appraisals assessed studies in detail, and quality of evidence was rated using established criteria. Results were synthesized in meta-analyses and presented in comprehensive evidence tables. Although MAT patients performed significantly better on some functional outcomes than persons with OUD who did not receive MAT, MAT patients performed worse on several cognitive measures than did matched "healthy" controls with no history of substance use disorder (SUD) or OUD. Because of the moderate-to-high risk of bias of most studies, quality of evidence is low or very low for all findings. The small number of studies reporting on outcomes of interest and the weaknesses in the body of evidence prevent making strong conclusions about MAT effects on functional outcomes. The literature shows that more research is needed that targets functional outcomes specifically, and there is, in particular, a lack of research evaluating potential differences in functional effects among medication types, the route of administration, treatment modality, and length of treatment.

Evaluating Measures of Pre-ART Adherence Readiness Through Associations with ART Adherence in the Early Months of Treatment.

Determining a patient's readiness to adhere well prior to the start of ART provides an opportunity to address adherence barriers before poor pill taking habits form, and ultimately improve clinical outcomes and resource utilization. Three methods of measuring adherence readiness and their comparative utility in predicting early ART adherence were examined in a sample of 176 patients preparing to start ART. Data were analyzed data from a randomized controlled trial of a cognitive-behavioral adherence intervention. Three measures of pre-ART adherence readiness (provider estimate, 1 week vitamin practice trials, and self-report [HIV Medication Readiness Scale; Transtheoretical Stages of Change item (TSOC)] were examined in association with measures of (1) ART initiation, (2) ART retention, (3) mean electronic dose-taking adherence, and (4) achievement of optimal (85+ % dose-taking) adherence, over the first 3 months of ART. Of the 176 patients, 166 (94.3%) started ART; 124 (74.7% of those who started ART; 70.5% of whole sample) completed the first 3 months of ART. Among the 124 still on ART at month 3, mean dose-taking adherence was 79.3%, and 62 (35.2% of whole sample) achieved optimal adherence. The provider estimate was the only readiness measure significantly associated with each of the four measures of early ART adherence, and it had the highest concordance statistics (71% PPV and 62.3% NPV) with optimal early ART adherence. Practice trial adherence was only associated with ART initiation and retention. Dose-taking adherence over 3 months was significantly correlated with the provider estimate and the two self-reports. Each method of early treatment adherence has its own utility, but the provider estimate had the best overall performance in predicting early ART adherence.

Advancing our Understanding of Heat Wave Criteria and Associated Health Impacts to Improve Heat Wave Alerts in Developing Country Settings.

Health effects of heat waves with high baseline temperatures in areas such as India remain a critical research gap. In these regions, extreme temperatures may affect the underlying population's adaptive capacity; heat wave alerts should be optimized to avoid continuous high alert status and enhance constrained resources, especially under a changing climate. Data from registrars and meteorological departments were collected for four communities in Northwestern India. Propensity Score Matching (PSM) was used to obtain the relative risk of mortality and number of attributable deaths (i.e., absolute risk which incorporates the number of heat wave days) under a variety of heat wave definitions (n = 13) incorporating duration and intensity. Heat waves' timing in season was also assessed for potential effect modification. Relative risk of heat waves (risk of mortality comparing heat wave days to matched non-heat wave days) varied by heat wave definition and ranged from 1.28 [95% Confidence Interval: 1.11-1.46] in Churu (utilizing the 95th percentile of temperature for at least two consecutive days) to 1.03 [95% CI: 0.87-1.23] in Idar and Himmatnagar (utilizing the 95th percentile of temperature for at least four consecutive days). The data trended towards a higher risk for heat waves later in the season. Some heat wave definitions displayed similar attributable mortalities despite differences in the number of identified heat wave days. These findings provide opportunities to assess the "efficiency" (or number of days versus potential attributable health impacts) associated with alternative heat wave definitions. Findings on both effect modification and trade-offs between number of days identified as "heat wave" versus health effects provide tools for policy makers to determine the most important criteria for defining thresholds to trigger heat wave alerts.

Evaluation of the Mental Health Services Act in Los Angeles County: Implementation and Outcomes for Key Programs.

Los Angeles County used Mental Health Services Act (MHSA) funds to greatly expand access to Full-Service Partnership (FSP) services and offer new prevention and early intervention (PEI) services. This study examines the reach of key MHSA-funded activities and what the impact of those activities has been, with a focus on PEI programs for children and transition-age youth (TAY) and FSP programs for children, TAY, and adults. The evaluation found evidence that the Los Angeles County Department of Mental Health (LAC DMH) is reaching the highly vulnerable population it seeks to reach with its FSP and youth PEI programs. Furthermore, those reached by the programs experience improvements in their mental health and life circumstances. Refining data collection will enable more-thorough evaluation of processes of care and would inform the program's quality-improvement efforts.

Participatory Modeling of Climate Change Impacts on Public Health in Long Beach, California: Discussion from a Workshop Hosted by the RAND Frederick S. Pardee Center for Longer Range Global Policy and the Future Human Condition.

Participatory modeling aims to incorporate stakeholders into the process of developing models for the purpose of eliciting information, appropriately reflecting stakeholder interests and concerns, and improving stakeholder understanding, and acceptance of the analysis. Participatory modeling, using causal loop diagramming (CLD), was used to explore the impact of climate change on public health in Long Beach, California. CLD, commonly used in participatory modeling, provided useful information to serve as the basis for a quantitative system dynamics model to protect the citizens of Long Beach, and potentially other cities or regions affected by climate change. Diverse stakeholders constructed CLDs depicting the impacts of climate change on public health in Long Beach. This exercise aimed to (1) identify public health issues that might be caused or exacerbated by climate change; (2) examine the systemic connections between climate change and other drivers of public health/illness and mortality; and (3) identify feedback loops to gain an understanding of how climate change could impact public health over coming decades. Six groups of five stakeholders were tasked with depicting the impacts of climate change on public health. Each group designated a key health outcome of concern on a citywide scale, including critical drivers of the outcome at higher and lower scales if necessary (for example, state laws, or household-level decisions that affect health outcomes in the aggregate). Social, environmental, political, and economic variables were all considered. After the small group diagramming exercise, groups presented diagram results to other participants, and the discussion around the diagrams was recorded.

Perceived heat stress and health effects on construction workers.

INTRODUCTION: Increasing heat waves-particularly in urban areas where construction is most prevalent, highlight a need for heat exposure assessment of construction workers. This study aims to characterize the effects of heat on construction workers from a site in Gandhinagar. MATERIALS AND METHODS: This study involved a mixed methods approach consisting of a cross sectional survey with anthropometric measurements (n = 219) and four focus groups with construction workers, as well as environmental measurements of heat stress exposure at a construction site. Survey data was collected in two seasons i.e., summer and winter months, and heat illness and symptoms were compared between the two time periods. Thematic coding of focus group data was used to identify vulnerability factors and coping mechanisms of the workers. Heat stress, recorded using a wet bulb globe temperature monitor, was compared to international safety standards. RESULTS: The survey findings suggest that heat-related symptoms increased in summer; 59% of all reports in summer were positive for symptoms (from Mild to Severe) as compared to 41% in winter. Focus groups revealed four dominant themes: (1) Non-occupational stressors compound work stressors; (2) workers were particularly attuned to the impact of heat on their health; (3) workers were aware of heat-related preventive measures; and (4) few resources were currently available to protect workers from heat stress. Working conditions often exceed international heat stress safety thresholds. Female workers and new employees might be at increased risk of illness or injury. CONCLUSION: This study suggests significant health impacts on construction workers from heat stress exposure in the workplace, showed that heat stress levels were higher than those prescribed by international standards and highlights the need for revision of work practices, increased protective measures, and possible development of indigenous work safety standards for heat exposure.

Drinking Water Quality Surveillance in a Vulnerable Urban Ward of Ahmedabad.

The World Bank estimates that 21% of all communicable diseases in India are related to unsafe water with diarrhoea alone causing more than 0.1 million deaths annually. The WHO drinking water surveillance parameters of quality, quantity, accessibility, affordability and continuity were assessed in one vulnerable ward of Ahmedabad-a fast growing city in Western India. Interviews with key informants of the ward office, health centre and water supply department, secondary analysis and mapping of field test reports and a questionnaire-based survey of different household types were conducted. We found that Ahmedabad Municipal Corporation (AMC) supplies water to the ward intermittently for two hours during the day. Housing society clusters supplement their AMC water supply with untested bore-well water. The water quality surveillance system is designed for a twenty-four-hour piped distribution of treated surface water. However, in order to maintain surveillance over an intermittent supply that includes ground water, the sampling process should include periodic surveys of water actually consumed by the citizens. The laboratory capacity of the Central Water Testing Laboratory should expand to include more refined tests for microbial and chemical contamination.

Neonates in Ahmedabad, India, during the 2010 heat wave: a climate change adaptation study.

Health effects from climate change are an international concern with urban areas at particular risk due to urban heat island effects. The burden of disease on vulnerable populations in non-climate-controlled settings has not been well studied. This study compared neonatal morbidity in a non-air-conditioned hospital during the 2010 heat wave in Ahmedabad to morbidity in the prior and subsequent years. The outcome of interest was neonatal intensive care unit (NICU) admissions for heat. During the months of April, May, and June of 2010, 24 NICU admissions were for heat versus 8 and 4 in 2009 and 2011, respectively. Both the effect of moving the maternity ward and the effect of high temperatures were statistically significant, controlling for each other. Above 42 degrees Celsius, each daily maximum temperature increase of a degree was associated with 43% increase in heat-related admissions (95% CI 9.2-88%). Lower floor location of the maternity ward within hospital which occurred after the 2010 heat wave showed a protective effect. These findings demonstrate the importance of simple surveillance measures in motivating a hospital policy change for climate change adaptation-here relocating one ward-and the potential increasing health burden of heat in non-climate-controlled institutions on vulnerable populations.

Infectious disease burden in Gujarat (2005-2011): comparison of selected infectious disease rates with India.

BACKGROUND: India is known to be endemic to numerous infectious diseases. The infectious disease profile of India is changing due to increased human environmental interactions, urbanisation and climate change. There are also predictions of explosive growth in infectious and zoonotic diseases. The Integrated Disease Surveillance Project (IDSP) was implemented in Gujarat in 2004. METHODS: We analysed IDSP data on seven laboratory confirmed infectious diseases from 2005-2011 on temporal and spatial trends and compared this to the National Health Profile (NHP) data for the same period and with other literature. We chose laboratory cases data for Enteric fever, Cholera, Hepatitis, Dengue, Chikungunya, Measles and Diphtheria in the state since well designed vertical programs do not exist for these diseases. Statistical and GIS analysis was done using appropriate software. RESULTS: Our analysis shows that the existing surveillance system in the state is predominantly reporting urban cases. There are wide variations among reported cases within the state with reports of Enteric fever and Measles being less than half of the national average, while Cholera, Viral Hepatitis and Dengue being nearly double. CONCLUSIONS: We found some limitations in the IDSP system with regard to the number of reporting units and cases in the background of a mixed health system with multiplicity of treatment providers and payment mechanisms. Despite these limitations, IDSP can be strengthened into a comprehensive surveillance system capable of tackling the challenge of reversing the endemicity of these diseases and preventing the emergence of others.

Heat-related mortality in India: excess all-cause mortality associated with the 2010 Ahmedabad heat wave.

INTRODUCTION: In the recent past, spells of extreme heat associated with appreciable mortality have been documented in developed countries, including North America and Europe. However, far fewer research reports are available from developing countries or specific cities in South Asia. In May 2010, Ahmedabad, India, faced a heat wave where the temperatures reached a high of 46.8 °C with an apparent increase in mortality. The purpose of this study is to characterize the heat wave impact and assess the associated excess mortality. METHODS: We conducted an analysis of all-cause mortality associated with a May 2010 heat wave in Ahmedabad, Gujarat, India, to determine whether extreme heat leads to excess mortality. Counts of all-cause deaths from May 1-31, 2010 were compared with the mean of counts from temporally matched periods in May 2009 and 2011 to calculate excess mortality. Other analyses included a 7-day moving average, mortality rate ratio analysis, and relationship between daily maximum temperature and daily all-cause death counts over the entire year of 2010, using month-wise correlations. RESULTS: The May 2010 heat wave was associated with significant excess all-cause mortality. 4,462 all-cause deaths occurred, comprising an excess of 1,344 all-cause deaths, an estimated 43.1% increase when compared to the reference period (3,118 deaths). In monthly pair-wise comparisons for 2010, we found high correlations between mortality and daily maximum temperature during the locally hottest "summer" months of April (r = 0.69, p<0.001), May (r = 0.77, p<0.001), and June (r = 0.39, p<0.05). During a period of more intense heat (May 19-25, 2010), mortality rate ratios were 1.76 [95% CI 1.67-1.83, p<0.001] and 2.12 [95% CI 2.03-2.21] applying reference periods (May 12-18, 2010) from various years. CONCLUSION: The May 2010 heat wave in Ahmedabad, Gujarat, India had a substantial effect on all-cause excess mortality, even in this city where hot temperatures prevail through much of April-June.

Development and implementation of South Asia's first heat-health action plan in Ahmedabad (Gujarat, India).

Recurrent heat waves, already a concern in rapidly growing and urbanizing South Asia, will very likely worsen in a warming world. Coordinated adaptation efforts can reduce heat's adverse health impacts, however. To address this concern in Ahmedabad (Gujarat, India), a coalition has been formed to develop an evidence-based heat preparedness plan and early warning system. This paper describes the group and initial steps in the plan's development and implementation. Evidence accumulation included extensive literature review, analysis of local temperature and mortality data, surveys with heat-vulnerable populations, focus groups with health care professionals, and expert consultation. The findings and recommendations were encapsulated in policy briefs for key government agencies, health care professionals, outdoor workers, and slum communities, and synthesized in the heat preparedness plan. A 7-day probabilistic weather forecast was also developed and is used to trigger the plan in advance of dangerous heat waves. The pilot plan was implemented in 2013, and public outreach was done through training workshops, hoardings/billboards, pamphlets, and print advertisements. Evaluation activities and continuous improvement efforts are ongoing, along with plans to explore the program's scalability to other Indian cities, as Ahmedabad is the first South Asian city to address heat-health threats comprehensively.

DOTS for TB relapse in India: A systematic review.

In India, under the Revised National Tuberculosis Control Program (RNTCP), the percentage of smear-positive re-treatment cases is high. The causes of re-treatment include relapse of the disease after successful completion of treatment, treatment failure, and default in treatment. RNTCP does not follow up the patients for any period of time after successful completion of treatment to determine whether they relapse. Given the high cost of treatment for each patient under RNTCP and the potential for spread of disease from these patients, it is crucial for the success of the program and control of the disease in the country to find out more about the reasons behind this. T0 o conduct a systematic review of literature and determine evidence regarding recurrence of TB after its successful treatment with standard short course chemotherapy under DOTS guidelines. T0 en databases were searched including Medline, Cochrane database, Embase and others and reference lists of articles. 255 papers resulted from these searches. Seven studies were finally included in the review after applying the inclusion, exclusion and quality assessment criteria. R0 elapse rate is high (almost 10%) in India which is higher than international studies. Majority of relapse cases present soon after completion of treatment (first six months). Risk factors for relapse included drug irregularity, initial drug resistance, smoking and alcoholism Sex and weight were not risk factors in India. The outcome of relapse cases put on treatment is positive but less effective than new cases. There are sound arguments and sketchy evidence that DOTS Category 2 treatment may not be adequate for retreatment patients.