Access to paediatric surgery: the geography of inequality in Nigeria.

BACKGROUND: About 96.3 million children and adolescents aged 0-19 years reside in Nigeria, comprising 54% of the population. Without adequate access to surgery for commonly treatable diseases, many face disability and increased risk of mortality. Due to this population's unique perioperative needs, increasing access to paediatric surgical care requires a situational evaluation of the distribution of paediatric surgeons and anaesthesiologists. This study's aim is to identify the percentage of Nigerian youth who reside within 2 hours of paediatric surgical care at the state and national level. METHODS: The Association of Paediatric Surgeons of Nigeria and the Nigeria Society of Anaesthetists provided surgical and anaesthesia workforce data by state. Health facilities with paediatric surgeons were converted to point locations and integrated with ancillary geospatial layers and population estimates from 2016 and 2017. Catchment areas of 2 hours of travel time around a facility were deployed as the benchmark indicator to establish timely access. RESULTS: Across Nigeria's 36 states and Federal Capital Territory, the percentage of Nigeria's 0-19 population residing within 2 hours of a health facility with a paediatric surgical and anaesthesia workforce ranges from less than 2% to 22.7%-30.5%. In 3 states, only 2.1%-4.8% of the population can access a facility within 2 hours, 12 have 4.9%-13.8%, and 8 have 13.9%-22.6%. CONCLUSION: There is significant variation across Nigerian states regarding access to surgical care, with 69.5%-98% of Nigeria's 0-19 population lacking access. Developing paediatric surgical services in underserved Nigerian states and investing in the training of paediatric surgical and anaesthesia workforce for those states are key components in improving the health of Nigeria's 0-19 population and reducing Nigeria's burden of surgical disease, in line with Nigeria's National Surgical, Obstetrics, Anaesthesia and Nursing Plan.

Nurse staffing and outcomes for pulmonary lobectomy: Cost and mortality trade-offs.

BACKGROUND: Nurse staffing impacts patient outcomes, but little is known about the relationship between nurse staffing and outcomes for lung cancer patients undergoing pulmonary lobectomy. OBJECTIVES: To examine the association between nurse staffing and outcomes following lobectomy for lung cancer. METHODS: Patients (N = 16,994) with lung cancer between who underwent lobectomy between 2008-2011 were identified in the National Inpatient Sample. Nurse staffing was quantified using registered nurse full-time equivalents per adjusted patient days. Multivariable models were used to estimate the effect of RN FTEs on mortality, length of stay, and costs, controlling for covariates. RESULTS: Patients treated at hospitals using 5.6 or more RN FTEs had shorter hospitals stays by 0.37 days (p = 0.008), had 36% lower odds of mortality (OR = 0.64, p = 0.014), but incurred $4,388 (p < 0.0001) in additional costs. CONCLUSIONS: Hospital administrators face a troubling trade-off between costs and outcomes in decisions about nurse staffing mix for pulmonary lobectomy.

A Longitudinal Study of Symptoms of Oropharyngeal Dysphagia in an Elderly Community-Dwelling Population.

Dysphagia has been estimated to affect around 8-16 % of healthy elderly individuals living in the community. The present study investigated the stability of perceived dysphagia symptoms over a 3-year period and whether such symptoms predicted death outcomes. A population of 800 and 550 elderly community-dwelling individuals were sent the Sydney Swallow Questionnaire (SSQ) in 2009 and 2012, respectively, where an arbitrary score of 180 or more was chosen to indicate symptomatic dysphagia. The telephone interview cognitive screen measured cognitive performance and the Geriatric Depression Scale measured depression. Regression models were used to investigate associations with dysphagia symptom scores, cognition, depression, age, gender and a history of stroke; a paired t test was used to examine if individual mean scores had changed. A total of 528 participants were included in the analysis. In 2009, dysphagia was associated with age (P = 0.028, OR 1.07, CI 1.01, 1.13) and stroke (P = 0.046, OR 2.04, CI 1.01, 4.11) but these associations were no longer present in 2012. Those who had symptomatic dysphagia in 2009 (n = 75) showed a shift towards improvement in swallowing (P < 0.001, mean = -174.4, CI -243.6, -105.3), and for those who died from pneumonia, there was no association between the SSQ derived swallowing score and death (P = 0.509, OR 0.10, CI -0.41, -0.20). We conclude that swallowing symptoms are a temporally dynamic process, which increases our knowledge on swallowing in the elderly.

Characterisation and carriage ratio of Clostridium difficile strains isolated from a community-dwelling elderly population in the United Kingdom.

BACKGROUND: Community-associated Clostridium difficile infection (CDI) appears to be an increasing problem. Reported carriage rates by C. difficile are debatable with suggestions that primary asymptomatic carriage is associated with decreased risk of subsequent diarrhoea. However, knowledge of potential reservoirs and intestinal carriage rates in the community, particularly in the elderly, the most susceptible group, is limited. We have determined the presence of C. difficile in the faeces of a healthy elderly cohort living outside of long-term care facilities (LCFs) in the United Kingdom. METHODS: Faecal samples from 149 community-based healthy elderly volunteers (median age 81 years) were screened for C. difficile using direct (Brazier's CCEY) and enrichment (Cooked Meat broth) culture methods and a glutamate dehydrogenase (GDH) immunoassay. Isolates were PCR-ribotyped and analysed for toxin production and the presence of toxin genes. RESULTS: Of 149 faecal samples submitted, six (4%) were found to contain C. difficile. One particular sample was positive by both the GDH immunoassay and direct culture, and concurrently produced two distinct strain types: one toxigenic and the other non-toxigenic. The other five samples were only positive by enrichment culture method. Overall, four C. difficile isolates were non-toxigenic (PCR-ribotypes 009, 026 (n = 2) and 039), while three were toxigenic (PCR-ribotypes 003, 005 and 106). All individuals who had a positive culture were symptom-free and none of them had a history of CDI and/or antibiotics use in the 3 month period preceding recruitment. CONCLUSIONS: To our knowledge, this is the first study of the presence of C. difficile in healthy elderly community-dwelling individuals residing outside of LCFs. The observed carriage rate is lower than that reported for individuals in LCFs and interestingly no individual carried the common epidemic strain PCR-ribotype 027 (NAP1/BI). Further follow-up of asymptomatic carriers in the community, is required to evaluate host susceptibility to CDI and identify dynamic changes in the host and microbial environment that are associated with pathogenicity.

Examining the dimensions of hospital safety climate and psychosocial risk factors among Japanese nurses.

PURPOSE: The purpose of this study was to examine the dimensions, reliability, and main loading factors associated with a Japanese safety climate and psychosocial risk factor scale. DESIGN: The authors used a cross-sectional survey of nurses from a university teaching hospital in Japan during 2008 (N = 996). The survey tools were based on components previously identified in a variety of international studies, including the Hospital Safety Climate Scale (HSCS) originally developed by Gershon et al. in 2000. RESULTS: Factor analysis of the Japanese HSCS demonstrated key themes in the areas of workplace-related issues, protective devices or mechanisms, and managerial dimensions (Cronbach's α = .887). Factor analysis of the psychosocial scale revealed key themes comprising individually related items and group dynamics (Cronbach's α = .882). CONCLUSIONS: This study revealed high internal consistency in the Japanese-language safety climate and psychosocial risk factor scales. The authors also identified various factors and themes consistent with previous international research. IMPLICATIONS FOR PRACTICE: Transcultural research using standard psychosocial tools can reveal important and reliable findings if carefully translated and adapted for the host environment.

Safety and anti-HIV assessments of natural vaginal cleansing products in an established topical microbicides in vitro testing algorithm.

BACKGROUND: At present, there is no effective vaccine or other approved product for the prevention of sexually transmitted human immunodeficiency virus type 1 (HIV-1) infection. It has been reported that women in resource-poor communities use vaginally applied citrus juices as topical microbicides. These easily accessible food products have historically been applied to prevent pregnancy and sexually transmitted diseases. The aim of this study was to evaluate the efficacy and cytotoxicity of these substances using an established topical microbicide testing algorithm. Freshly squeezed lemon and lime juice and household vinegar were tested in their original state or in pH neutralized form for efficacy and cytotoxicity in the CCR5-tropic cell-free entry and cell-associated transmission assays, CXCR4-tropic entry and fusion assays, and in a human PBMC-based anti-HIV-1 assay. These products were also tested for their effect on viability of cervico-vaginal cell lines, human cervical explant tissues, and beneficial Lactobacillus species. RESULTS: Natural lime and lemon juice and household vinegar demonstrated anti-HIV-1 activity and cytotoxicity in transformed cell lines. Neutralization of the products reduced both anti-HIV-1 activity and cytotoxicity, resulting in a low therapeutic window for both acidic and neutralized formulations. For the natural juices and vinegar, the IC50 was

Hospital safety climate, psychosocial risk factors and needlestick injuries in Japan.

To investigate the interactions between safety climate, psychosocial issues and Needlestick and Sharps Injuries (NSI), a cross-sectional study was undertaken among nurses at a university teaching hospital in Japan (89% response rate). NSI were correlated with various aspects of hospital safety climate including supporting one another at work, the protection of staff against blood-borne diseases being a high management priority, managers doing their part to protect staff from blood-borne disease, having unsafe work practices corrected by supervisors, having the opportunity to use safety equipment to protect against blood-borne disease exposures, having an uncluttered work area, and having minimal conflict within their department. In conclusion, this study has demonstrated the importance of hospital safety climate in Japanese health care practice, particularly its relationship with NSI. Although the provision of safer devices remains critical in preventing injuries, ensuring a positive safety climate will also be essential in meeting these important challenges for nurses' occupational health.

Developing a self-reported comorbidity index to predict mortality of community-dwelling older adults.

Current common comorbidity measures have poor to moderate predictive validity of mortality of community-dwelling older adults. Hence, our aim is to develop a simpler resource-efficient self-reported comorbidity index in the prediction of survival. 113 older adults in Greater Manchester, United Kingdom attended a routine medical examination whereby information gathered was used to construct Charlson Comorbidity Index (CCI). They completed the Cornell Medical Index (CMI) questionnaire and reported the number of medication prescribed to them. We compared the ability of CCI, CMI, number of medication, age and sex to predict mortality of the sample over 7-year period using Cox-regression and Kaplan-Meier plot and rank test. None of the variables individually was significant when tested using either Cox-regression via ENTER method or Kaplan-Meier test. Remarkably, by means of forward step-wise Cox-regression, two variables emerged significant: (i) number of medicine (beta coefficient=0.229, SE=0.090 and p=0.011) and (ii) age (beta coefficient=0.106, SE=0.051 and p=0.037). We demonstrated that simple count of medication predicted mortality of community-dwelling older adults over the next 7 years more accurately than CMI or CCI. Further works involving a larger scale of subjects is needed for use in epidemiological study of survival where cost and resources are concerned.

Examining the dimensions and correlates of workplace stress among Australian veterinarians.

BACKGROUND: Although stress is known to be a common occupational health issue in the veterinary profession, few studies have investigated its broad domains or the internal validity of the survey instrument used for assessment. METHODS: We analysed data from over 500 veterinarians in Queensland, Australia, who were surveyed during 2006-07. RESULTS: The most common causes of stress were reported to be long hours worked per day, not having enough holidays per year, not having enough rest breaks per day, the attitude of customers, lack of recognition from the public and not having enough time per patient. Age, gender and practice type were statistically associated with various aspects of work-related stress. Strong correlations were found between having too many patients per day and not having enough time per patient; between not having enough holidays and long working hours; and also between not enough rest breaks per day and long working hours. Factor analysis revealed four dimensions of stress comprising a mixture of career, professional and practice-related items. The internal validity of our stress questionnaire was shown to be high during statistical analysis. CONCLUSION: Overall, this study suggests that workplace stress is fairly common among Australian veterinarians and represents an issue that occupies several distinct areas within their professional life.

Multisite comparison of anti-human immunodeficiency virus microbicide activity in explant assays using a novel endpoint analysis.

Microbicide candidates with promising in vitro activity are often advanced for evaluations using human primary tissue explants relevant to the in vivo mucosal transmission of human immunodeficiency virus type 1 (HIV-1), such as tonsil, cervical, or rectal tissue. To compare virus growth or the anti-HIV-1 efficacies of candidate microbicides in tissue explants, a novel soft-endpoint method was evaluated to provide a single, objective measurement of virus growth. The applicability of the soft endpoint is shown across several different ex vivo tissue types, with the method performed in different laboratories, and for a candidate microbicide (PRO 2000). The soft-endpoint method was compared to several other endpoint methods, including (i) the growth of virus on specific days after infection, (ii) the area under the virus growth curve, and (iii) the slope of the virus growth curve. Virus growth at the assay soft endpoint was compared between laboratories, methods, and experimental conditions, using nonparametric statistical analyses. Intra-assay variability determinations using the coefficient of variation demonstrated higher variability for virus growth in rectal explants. Significant virus inhibition by PRO 2000 and significant differences in the growth of certain primary HIV-1 isolates were observed by the majority of laboratories. These studies indicate that different laboratories can provide consistent measurements of anti-HIV-1 microbicide efficacy when (i) the soft endpoint or another standardized endpoint is used, (ii) drugs and/or virus reagents are centrally sourced, and (iii) the same explant tissue type and method are used. Application of the soft-endpoint method reduces the inherent variability in comparisons of preclinical assays used for microbicide development.

Folate nutritional genetics and risk for hypertension in an elderly population sample.

BACKGROUND/AIMS: 118 elderly participants (65-90 years) were assessed for any relationship between folate, related genes and hypertension. METHODS: Six B-vitamin-related SNPs were genotyped in 80 normotensive and 38 hypertensive subjects. RESULTS: Of six polymorphisms (677C>T-MTHFR, 1298A>C-MTHFR, 80G>A-RFC, 2756A>G-MS, 66A>G- MSR, 19bpDHFR and 1561C>T-GCPII), only 677C>T-MTHFR was a significant risk for hypertension: OR 1.89; 95% CI 1.07-3.32 (chi2 p = 0.038). Additionally, hypertensive subjects had a significantly lower intake of dietary folate than normotensive individuals (p = 0.0221), although this did not markedly alter blood metabolite levels. Several significant linear associations between dietary folate and related blood metabolites were found in normotensive subjects (p < 0.001 for Hcy, red cell and serum folate) and were as predicted on an a priori basis -- generally weaker associations existed in hypertensive subjects (p < 0.05 for serum folate). This was true for data examined collectively or by genotype. Multiple-regression analysis for diastolic or systolic blood pressure showed significant interaction for gender and folate intake (p = 0.014 and 0.019, respectively). In both cases this interaction occurred only in females, with higher folate intake associated with decreased blood pressure. Regressing diastolic blood pressure and 677C>T-MTHFR genotype showed significance (males; p = 0.032) and borderline significance (all subjects). CONCLUSION: Dietary folate and 677C>T-MTHFR genotype may modify blood pressure.

Perceptions of risk and prevention of dementia in the healthy elderly.

OBJECTIVES: (1) To determine the attitudes and perceptions of the elderly with regard to dementia. (2) To correlate these beliefs with demographic variables of age, sex, intelligence scores and social class. METHOD: A postal questionnaire survey of a sample of 562 subjects of the Manchester University Age and Cognitive Performance longitudinal study group. RESULTS: The response rate was 95%. Most responders (69%) did not worry about dementia, although they were more likely to think about it if they had a family member with dementia (p < 0.005). There is no link between social class, sex, intelligence scores and age with regard to worries and concerns of dementia. The majority of responders (82%) took action to maintain their health but demonstrated poor awareness of risks or protective factors for dementia. CONCLUSION: The elderly on the whole were not fearful of dementia or of acquiring it. There was poor awareness of risks or protective factors for dementia.

Naturally occurring capsid substitutions render HIV-1 cyclophilin A independent in human cells and TRIM-cyclophilin-resistant in Owl monkey cells.

In this study, we asked if a naturally occurring HIV-1 variant exists that circumvents CypA dependence in human cells. To address this issue, we sought viruses for CypA independence using Debio-025, a cyclosporine A (CsA) analog that disrupts CypA-capsid interaction. Surprisingly, viral variants from the Main group replicate even in the presence of the drug. Sequencing analyses revealed that these viruses encode capsid substitutions within the CypA-binding site (V86P/H87Q/I91V/M96I). When we introduced these substitutions into viruses that normally rely on CypA for replication, these mutants no longer depended on CypA, suggesting that naturally occurring capsid substitutions obviate the need for CypA. This is the first demonstration that isolates from the Main group naturally develop CypA-independent strategies to replicate in human cells. Surprisingly, we found that these capsid substitutions render HIV-1 capable of infecting Owl monkey (OMK) cells that highly restrict HIV-1. OMK cell resistance to HIV-1 is mediated via TRIM-Cyp, which arose from a retrotransposition of CypA into the TRIM5 alpha gene. Interestingly, saturation experiments suggest that the Pro86/Gln87/Val91/Ile96 capsid core is "invisible" to TRIM-Cyp. This study demonstrates that specific capsid substitutions can release HIV-1 from both CypA dependence in human cells and TRIM-Cyp restriction in monkey cells.

Concordance of Cornell medical index self-reports to structured clinical assessment for the identification of physical health status.

Self-reported questionnaires are frequently used to assess health status in epidemiological studies. The Cornell medical index is one such tool used to determine the presence of physical and psychiatric illness but its accuracy and value have been questioned. In this study we have assessed the ability of the CMI to predict health status in two separate patient populations (n = 101, 88) by comparison to a structured medical assessment based on the SENIEUR protocol by two physicians. There was good agreement between medication use reported on the CMI and on medical assessment (k = 0.79; CI: 0.70-0.88). Accuracy of prediction of the CMI for specific medical conditions was good 89-99%. A threshold score from the CMI was not predictive of health as determined by the SENIEUR protocol. In our older populations, we conclude that the CMI accurately predicted health status. The determination of normal health by a threshold score was poorly predictive of heath status. Self-reported medication use was the best predictor of health status.