Tuberculosis is Associated with Chronic Hypoxemia among Kenyan Adults (CHAKA): A Case-Control Study.

RATIONALE: Data on risk factors for chronic hypoxemia in low and middle-income countries are lacking. OBJECTIVE: We aimed to quantify the association between potential risk factors and chronic hypoxemia among adults hospitalized in Kenya. METHODS: A hospital-based case-control study was conducted at Moi Teaching and Referral Hospital in Eldoret, Kenya. Adult inpatients were screened on admission and enrolled in a 1:2 case to control ratio. Cases were patients with chronic hypoxemia, defined as a resting oxygen saturation (SpO2) < 88% on admission and either a one-month post discharge SpO2 < 88% or, if they died prior to follow-up, a documented SpO2 < 88% in the 6 months prior to enrollment. Controls were randomly selected, stratified by sex, among non-hypoxemic inpatients. Data were collected via questionnaires and structured chart review. Regression was used to assess the association between chronic hypoxemia and age, sex, smoking status, biomass fuel use, elevation, and self-reported history of tuberculosis and HIV diagnosis. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: The study enrolled 108 chronically hypoxemic cases and 240 non-hypoxemic controls. In multivariable analysis, as compared to controls, chronically hypoxemic cases had significantly higher odds of older age (OR 1.2 per 5-year increase; 95% CI: 1.1-1.3), female sex (OR 3.6, 95% CI: 1.8-7.2), current or former tobacco use (OR 4.7, 95% CI: 2.3-9.6) and prior tuberculosis (OR 11.8, 95% CI: 4.7-29.6), but no increase in odds of HIV diagnosis and biomass fuel use. CONCLUSION: These findings highlight the potential impact of prior tuberculosis on chronic lung disease in Kenya and the need for further studies on post-tuberculosis lung disease.

Correction: Weight Gain Prevention Outcomes From a Pragmatic Digital Health Intervention With Community Health Center Patients: Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/50330.].

Weight Gain Prevention Outcomes From a Pragmatic Digital Health Intervention With Community Health Center Patients: Randomized Controlled Trial.

BACKGROUND: The prevalence of obesity and its associated comorbidities continue to rise in the United States. Populations who are uninsured and from racial and ethnic minority groups continue to be disproportionately affected. These populations also experience fewer clinically meaningful outcomes in most weight loss trials. Weight gain prevention presents a useful strategy for individuals who experience barriers to weight loss. Given the often-limited weight management resources available to patients in primary care settings serving vulnerable patients, evaluating interventions with pragmatic designs may help inform the design of comprehensive obesity care delivered in primary care. OBJECTIVE: This study aims to evaluate the effectiveness of Balance, a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention, delivered to patients receiving primary care within federally qualified community health centers. METHODS: Balance was a 2-arm, 12-month pragmatic randomized controlled trial of a digital weight gain prevention intervention delivered to individuals who had a BMI of 25-40 kg/m2, spoke English or Spanish, and were receiving primary care within a network of federally qualified community health centers in North Carolina. The Balance intervention was designed to encourage behavioral changes that result in a slight energy deficit. Intervention participants received tailored goal setting and tracking, skills training, self-monitoring, and responsive health coaching from registered dietitians. Weight was measured at regular primary care visits and documented in the electronic health record. We compared the percentage of ≤3% weight gain in each arm at 24 months after randomization-our primary outcome-using individual empirical best linear unbiased predictors from the linear mixed-effects model. We used individual empirical best linear unbiased predictors from participants with at least 1 electronic health record weight documented within a 6-month window centered on the 24-month time point. RESULTS: We randomized 443 participants, of which 223 (50.3%) participants were allocated to the intervention arm. At baseline, participants had a mean BMI of 32.6 kg/m2. Most participants were Latino or Hispanic (n=200, 45.1%) or non-Latino or Hispanic White (n=115, 26%). In total, 53% (n=235) of participants had at least 1 visit with weight measured in the primary time window. The intervention group had a higher proportion with ≤3% weight gain at 6 months (risk ratio=1.12, 95% CI 0.94-1.28; risk difference=9.5, 95% CI -4.5 to 16.4 percentage points). This difference attenuated to the null by 24 months (risk ratio=1.00, 95% CI 0.82-1.20; risk difference=0.2, 95% CI -12.1 to 11.0 percentage points). CONCLUSIONS: In adults with overweight or obesity receiving primary care at a community health center, we did not find long-term evidence to support the dissemination of a digital health intervention for weight gain prevention. TRIAL REGISTRATION: ClinicalTrials.gov NCT03003403; https://clinicaltrials.gov/study/NCT03003403. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-6926-7.

Antibacterial Utilization for Febrile Illnesses and Laboratory-Confirmed Bloodstream Infections in Northern Tanzania.

Background: We describe antibacterial use in light of microbiology data and treatment guidelines for common febrile syndromes in Moshi, Tanzania. Methods: We compared data from 2 hospital-based prospective cohort studies, cohort 1 (2011-2014) and cohort 2 (2016-2019), that enrolled febrile children and adults. A study team member administered a standardized questionnaire, performed a physical examination, and collected blood cultures. Participants with bloodstream infection (BSI) were categorized as receiving effective or ineffective therapy based upon antimicrobial susceptibility interpretations. Antibacterials prescribed for treatment of pneumonia, urinary tract infection (UTI), or presumed sepsis were compared with World Health Organization and Tanzania Standard Treatment Guidelines. We used descriptive statistics and logistic regression to describe antibacterial use. Results: Among participants, 430 of 1043 (41.2%) and 501 of 1132 (44.3%) reported antibacterial use prior to admission in cohorts 1 and 2, respectively. During admission, 930 of 1043 (89.2%) received antibacterials in cohort 1 and 1060 of 1132 (93.6%) in cohort 2. Inpatient use of ceftriaxone, metronidazole, and ampicillin increased between cohorts (P ≤ .002 for each). BSI was detected in 38 (3.6%) participants in cohort 1 and 47 (4.2%) in cohort 2. Of 85 participants with BSI, 81 (95.3%) had complete data and 52 (64.2%) were prescribed effective antibacterials. Guideline-consistent therapy in cohort 1 and cohort 2 was as follows: pneumonia, 87.4% and 56.8%; UTI, 87.6% and 69.0%; sepsis, 84.4% and 61.2% (P ≤ .001 for each). Conclusions: Receipt of antibacterials for febrile illness was common. While guideline-consistent prescribing increased over time, more than one-third of participants with BSI received ineffective antibacterials.

Asthma, Airflow Obstruction, and Eosinophilic Airway Inflammation Prevalence in Western Kenya: A Population-Based Cross-Sectional Study.

Objectives: Determine the prevalence of airway disease (e.g., asthma, airflow obstruction, and eosinophilic airway inflammation) in Kenya, as well as related correlates of airway disease and health-related quality of life. Methods: A three-stage, cluster-randomized cross-sectional study in Uasin Gishu County, Kenya was conducted. Individuals 12 years and older completed questionnaires (including St. George's Respiratory Questionnaire for COPD, SGRQ-C), spirometry, and fractional exhaled nitric oxide (FeNO) testing. Prevalence ratios with 95% confidence intervals (CIs) were calculated. Multivariable models were used to assess correlates of airflow obstruction and high FeNO. Results: Three hundred ninety-two participants completed questionnaires, 369 completed FeNO testing, and 305 completed spirometry. Mean age was 37.5 years; 64% were women. The prevalence of asthma, airflow obstruction on spirometry, and eosinophilic airway inflammation was 21.7%, 12.3% and 15.7% respectively in the population. Women had significantly higher SGRQ-C scores compared to men (15.0 vs. 7.7). Wheezing or whistling in the last year and SGRQ-C scores were strongly associated with FeNO levels >50 ppb after adjusting for age, gender, BMI, and tobacco use. Conclusion: Airway disease is a significant health problem in Kenya affecting a young population who lack a significant tobacco use history.

Prevalence and phenotypic trajectories of hypoxaemia among hospitalised adults in Kenya: a single-centre, prospective cohort study.

OBJECTIVE: Global medical oxygen security is limited by knowledge gaps in hypoxaemia burden and oxygen access in low-income and middle-income countries. We examined the prevalence and phenotypic trajectories of hypoxaemia among hospitalised adults in Kenya, with a focus on chronic hypoxaemia. DESIGN: Single-centre, prospective cohort study. SETTING: National tertiary referral hospital in Eldoret, Kenya between September 2019 and April 2022. PARTICIPANTS: Adults (age ≥18 years) admitted to general medicine wards. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was proportion of patients who were hypoxaemic (oxygen saturation, SpO2 ≤88%) on admission. Secondary outcomes were proportion of patients with hypoxaemia on admission who had hypoxaemia resolution, hospital discharge, transfer, or death among those with unresolved hypoxaemia or chronic hypoxaemia. Patients remaining hypoxaemic for ≤3 days after admission were enrolled into an additional cohort to determine chronic hypoxaemia. Chronic hypoxaemia was defined as an SpO2 ≤ 88% at either 1-month post-discharge follow-up or, for patients who died prior to follow-up, a documented SpO2 ≤88% during a previous hospital discharge or outpatient visit within the last 6 months. RESULTS: We screened 4104 patients (48.5% female, mean age 49.4±19.4 years), of whom 23.8% were hypoxaemic on admission. Hypoxaemic patients were significantly older and more predominantly female than normoxaemic patients. Among those hypoxaemic on admission, 33.9% had resolution of their hypoxaemia as inpatients, 55.6% had unresolved hypoxaemia (31.0% died before hospital discharge, 13.3% were alive on discharge and 11.4% were transferred) and 10.4% were lost to follow-up. The prevalence of chronic hypoxaemia was 2.1% in the total screened population, representing 8.8% of patients who were hypoxaemic on admission. Chronic hypoxaemia was determined at 1-month post-discharge among 59/86 patients and based on prior documentation among 27/86 patients. CONCLUSION: Hypoxaemia is highly prevalent among adults admitted to a general medicine ward at a national referral hospital in Kenya. Nearly 1 in 11 patients who are hypoxaemic on admission are chronically hypoxaemic.

MASI, a Smartphone App to Improve Treatment Adherence Among South African Adolescents and Young Adults With HIV: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: Adolescents and young adults with HIV repeatedly demonstrate low rates of antiretroviral therapy (ART) adherence as well as low rates of viral suppression. Digital health interventions are a promising way to engage adolescents and young adults with HIV to support ART adherence. However, few digital health interventions have been developed and tested with adolescents and young adults in countries like South Africa, where the HIV burden among adolescents and young adults is greatest. Masakhane Siphucule Impilo Yethu (MASI; Xhosa for "Let's empower each other and improve our health") is a comprehensive ART adherence-supporting app for South African adolescents and young adults with HIV. It was culturally adapted using the HealthMpowerment platform. OBJECTIVE: The aim of this paper is to describe the protocol for a pilot randomized controlled trial examining the feasibility, acceptability, and preliminary efficacy of MASI on self-reported ART adherence and social support. METHODS: We will enroll 50 adolescents and young adults with HIV ages 15-21 years. Participants will be recruited from public ART clinics linked to a large government-funded teaching hospital in Cape Town, South Africa. Participants will be randomized 1:1 into either the intervention arm receiving a full version of MASI or the control arm receiving an information-only version of the app (n=25 per arm). Participants will be asked to engage with MASI daily for 6 months. All participants will complete baseline and follow-up assessments at 3 and 6 months. RESULTS: Study screening began in May 2022 and the first participant was enrolled on June 21, 2022. As of June 12, 2023, 81 participants have completed screeners, and 36 eligible participants have been enrolled in the pilot randomized controlled trial. Recruitment is anticipated to last through August 31, 2023, with study activities anticipated through February 29, 2024. CONCLUSIONS: There is an urgent need for innovative interventions to improve ART adherence among adolescents and young adults in settings like South Africa. If found to be feasible and acceptable, MASI could be implemented with adolescents and young adults with HIV in other parts of the country. TRIAL REGISTRATION: ClinicalTrials.gov NCT04661878; https://clinicaltrials.gov/ct2/show/study/NCT04661878. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47137.

Timeliness of Delivery Care and Maternal and Neonatal Health Outcomes in Private Facilities in Masaka Area, Uganda: A Quasi-Experimental Study.

OBJECTIVES: While access to basic emergency obstetric and newborn care is necessary to reduce maternal and neonatal morbidity in low- and middle-income countries, data on the timeliness and quality of care at lower-level facilities is limited. This study examines timeliness of labor and delivery interventions and maternal and neonatal health status following deliveries in Uganda. METHODS: Women were recruited from 6 rural, private facilities in the greater Masaka area, Uganda on admission to the labor ward. Research assistants directly observed timeliness and quality of care from admission through discharge. Research assistants also abstracted medical chart information. All 6 facilities received training from LifeNet International on quality-of-care interventions for maternal and newborn health. RESULTS: 321 participants were directly observed during delivery, and 304 participants were followed at 28 days postpartum. Labor and delivery processes were overall timely and reflect international guidance on labor interventions. Maternal and neonatal health was good at discharge (90.6% and 88.8%) and 28 days postpartum (93.1% and 87.5%). However, there was no association between health at discharge and at 28 days for mothers or neonates (p = 0.67, p = 1.0, respectively). Demographic characteristics associated with maternal and neonatal health on discharge were different than those associated with maternal and neonatal health at 28 days. CONCLUSIONS FOR PRACTICE: Evidence on timeliness and quality of care can help inform strategies to further decrease maternal and neonatal morbidity. Additional focus is needed to retain patients in care to identify those developing poor health after delivery.

Hopefulness among individuals living with schizophrenia and their caregivers in Tanzania: an actor-partner interdependence model.

BACKGROUND: Hopefulness is a positive orientation or state of mind that can aid in the recovery and treatment of mental illness, as it can have significant impacts on clinical and psychosocial outcomes. As resource-constrained settings work to implement recovery-oriented care, there is a need to better understand hopefulness among people living with schizophrenia (PLWS) and caregivers in their extended family networks. This study seeks to examine the dyadic relationship of hopefulness and its associated correlates among PLWS attending outpatient psychiatric clinics and their caregivers in Tanzania. METHODS: This study utilized baseline and immediate post-intervention data collected as part of a randomized controlled trial testing a culturally tailored model of Family Psychoeducation, KUPAA, in Tanzania. The Herth Hope Index was used to measure hopefulness among PLWS (n = 33) and their caregivers (n = 33) at baseline and immediate post-intervention. Univariable and multivariable regression models were conducted to determine correlates of hopefulness at baseline, while the Actor-Partner Interdependence Model (APIM) was employed to examine the longitudinal, dyadic relationship of hopefulness among and between PLWS and their caregivers. RESULTS: Better family functioning was associated with higher levels of hopefulness in PLWS and their caregivers. Lower levels of stigma, lower symptom severity, and lower disability were associated with higher levels of hopefulness in PLWS. For PLWS and their caregivers, actor effects from the APIM model were less than one (PLWS, [Formula: see text]; caregivers, [Formula: see text]), indicating stability (within each person) in hopefulness over time. Regarding partner effects, a caregiver's baseline hopefulness had a positive effect on the hopefulness of their PLWS at follow-up ([Formula: see text]). This indicates that higher caregiver hope at time 0 is associated with higher levels of hope in PLWS at time 1. Baseline hopefulness levels for PLWS had a negative effect on caregivers' hopefulness at follow-up ([Formula: see text]). This suggests that higher hopefulness among PLWS at baseline is associated with lower levels of hope in caregivers at follow-up. CONCLUSION: Hopefulness is important to consider in family or caregiver-based treatments for PLWS because caregiver hopefulness may influence improvements in hopefulness among PLWS over time. Future studies should further explore the longitudinal dyadic relationship of hopefulness for these populations, as hope is a non-pharmacological and modifiable mechanism of change that is underutilized in care and treatment plans for PLWS globally. TRIAL REGISTRATION: Clinical Trials #NCT04013932, July 10, 2019.

Prevalence of Childhood Hearing Loss in Rural Alaska.

OBJECTIVES: Childhood hearing loss has well-known lifelong consequences. Certain rural populations are at higher risk for infection-related hearing loss. For Alaska Native children, historical data on hearing loss prevalence suggest a higher burden of infection-related hearing loss, but updated prevalence data are urgently needed in this high-risk population. DESIGN: Hearing data were collected as part of two school-based cluster-randomized trials in 15 communities in rural northwest Alaska over two academic years (2017-2019). All enrolled children from preschool to 12th grade were eligible. Pure-tone thresholds were obtained using standard audiometry and conditioned play when indicated. The analysis included the first available audiometric assessment for each child (n = 1634 participants, 3 to 21 years), except for the high-frequency analysis, which was limited to year 2 when higher frequencies were collected. Multiple imputation was used to quantify the prevalence of hearing loss in younger children, where missing data were more frequent due to the need for behavioral responses. Hearing loss in either ear was evaluated using both the former World Health Organization (WHO) definition (pure-tone average [PTA] > 25 dB) and the new WHO definition (PTA ≥ 20 dB), which was published after the study. Analyses with the new definition were limited to children 7 years and older due to incomplete data obtained on younger children at lower thresholds. RESULTS: The overall prevalence of hearing loss (PTA > 25 dB; 0.5, 1, 2, 4 kHz) was 10.5% (95% confidence interval [CI], 8.9 to 12.1). Hearing loss was predominately mild (PTA >25 to 40 dB; 8.9%, 95% CI, 7.4 to 10.5). The prevalence of unilateral hearing loss was 7.7% (95% CI, 6.3 to 9.0). Conductive hearing loss (air-bone gap of ≥ 10 dB) was the most common hearing loss type (9.1%, 95% CI, 7.6 to 10.7). Stratified by age, hearing loss (PTA >25 dB) was more common in children 3 to 6 years (14.9%, 95% CI, 11.4 to 18.5) compared to children 7 years and older (8.7%, 95% CI, 7.1 to 10.4). In children 7 years and older, the new WHO definition increased the prevalence of hearing loss to 23.4% (95% CI, 21.0 to 25.8) compared to the former definition (8.7%, 95% CI, 7.1 to 10.4). Middle ear disease prevalence was 17.6% (95% CI, 15.7 to 19.4) and was higher in younger children (23.6%, 95% CI, 19.7 to 27.6) compared to older children (15.2%, 95% CI, 13.2 to 17.3). High-frequency hearing loss (4, 6, 8kHz) was present in 20.5% (95% CI, 18.4 to 22.7 [PTA >25 dB]) of all children and 22.8% (95% CI, 20.3 to 25.3 [PTA >25 dB]) and 29.7% (95% CI, 27.0 to 32.4 [PTA ≥ 20 dB]) of children 7 years and older (limited to year 2). CONCLUSIONS: This analysis represents the first prevalence study on childhood hearing loss in Alaska in over 60 years and is the largest cohort with hearing data ever collected in rural Alaska. Our results highlight that hearing loss continues to be common in rural Alaska Native children, with middle ear disease more prevalent in younger children and high-frequency hearing loss more prevalent with increasing age. Prevention efforts may benefit from managing hearing loss type by age. Lastly, continued research is needed on the impact of the new WHO definition of hearing loss on field studies.

A Hybrid Deep Learning Approach to Identify Preventable Childhood Hearing Loss.

OBJECTIVE: Childhood hearing loss has well-known, lifelong consequences. Infection-related hearing loss disproportionately affects underserved communities yet can be prevented with early identification and treatment. This study evaluates the utility of machine learning in automating tympanogram classifications of the middle ear to facilitate layperson-guided tympanometry in resource-constrained communities. DESIGN: Diagnostic performance of a hybrid deep learning model for classifying narrow-band tympanometry tracings was evaluated. Using 10-fold cross-validation, a machine learning model was trained and evaluated on 4810 pairs of tympanometry tracings acquired by an audiologist and layperson. The model was trained to classify tracings into types A (normal), B (effusion or perforation), and C (retraction), with the audiologist interpretation serving as reference standard. Tympanometry data were collected from 1635 children from October 10, 2017, to March 28, 2019, from two previous cluster-randomized hearing screening trials (NCT03309553, NCT03662256). Participants were school-aged children from an underserved population in rural Alaska with a high prevalence of infection-related hearing loss. Two-level classification performance statistics were calculated by treating type A as pass and types B and C as refer. RESULTS: For layperson-acquired data, the machine-learning model achieved a sensitivity of 95.2% (93.3, 97.1), specificity of 92.3% (91.5, 93.1), and area under curve of 0.968 (0.955, 0.978). The model's sensitivity was greater than that of the tympanometer's built-in classifier [79.2% (75.5, 82.8)] and a decision tree based on clinically recommended normative values [56.9% (52.4, 61.3)]. For audiologist-acquired data, the model achieved a higher AUC of 0.987 (0.980, 0.993), had an equivalent sensitivity of 95.2 (93.3, 97.1), and a higher specificity of 97.7 (97.3, 98.2). CONCLUSIONS: Machine learning can detect middle ear disease with comparable performance to an audiologist using tympanograms acquired either by an audiologist or a layperson. Automated classification enables the use of layperson-guided tympanometry in hearing screening programs in rural and underserved communities, where early detection of treatable pathology in children is crucial to prevent the lifelong adverse effects of childhood hearing loss.

Changing the Paradigm for School Hearing Screening Globally: Evaluation of Screening Protocols From Two Randomized Trials in Rural Alaska.

OBJECTIVES: Diagnostic accuracy was evaluated for various screening tools, including mobile health (mHealth) pure-tone screening, tympanometry, distortion product otoacoustic emissions (DPOAE), and inclusion of high frequencies to determine the most accurate screening protocol for identifying children with hearing loss in rural Alaska where the prevalence of middle ear disease is high. DESIGN: Hearing screening data were collected as part of two cluster randomized trials conducted in 15 communities in rural northwest Alaska. All children enrolled in school from preschool to 12th grade were eligible. Analysis was limited to data collected 2018 to 2019 (n = 1449), when both trials were running and measurement of high frequencies were included in the protocols. Analyses included estimates of diagnostic accuracy for each screening tool, as well as exploring performance by age and grade. Multiple imputation was used to assess diagnostic accuracy in younger children, where missing data were more prevalent due to requirements for conditioned responses. The audiometric reference standard included otoscopy, tympanometry, and high frequencies to ensure detection of infection-related and noise-induced hearing loss. RESULTS: Both the mHealth pure-tone screen and DPOAE screen performed better when tympanometry was added to the protocol (increase in sensitivity of 19.9%, 95% Confidence Interval (CI): 15.9 to 24.1 for mHealth screen, 17.9%, 95% CI: 14.0 to 21.8 for high-frequency mHealth screen, and 10.4%, 95% CI: 7.5 to 13.9 for DPOAE). The addition of 6 kHz to the mHealth pure-tone screen provided an 8.7 percentage point improvement in sensitivity (95% CI: 6.5 to 11.3). Completeness of data for both the reference standard and the mHealth screening tool differed substantially by age, due to difficulty with behavioral testing in young children. By age 7, children were able to complete behavioral testing, and data indicated that high-frequency mHealth pure-tone screen with tympanometry was the superior tool for children 7 years and older. For children 3 to 6 years of age, DPOAE plus tympanometry performed the best, both for complete data and multiply imputed data, which better approximates accuracy for children with missing data. CONCLUSIONS: This study directly evaluated pure-tone, DPOAE, and tympanometry tools as part of school hearing screening in rural Alaskan children (3 to 18+ years). Results from this study indicate that tympanometry is a key component in the hearing screening protocol, particularly in environments with higher prevalence of infection-related hearing loss. DPOAE is the preferred hearing screening tool when evaluating children younger than 7 years of age (below 2nd grade in the United States) due to the frequency of missing data with behavioral testing in this age group. For children 7 years and older, the addition of high frequencies to pure-tone screening increased the accuracy of screening, likely due to improved identification of hearing loss from noise exposure. The lack of a consistent reference standard in the literature makes comparing across studies challenging. In our study with a reference standard inclusive of otoscopy, tympanometry, and high frequencies, less than ideal sensitivities were found even for the most sensitive screening protocols, suggesting more investigation is necessary to ensure screening programs are appropriately identifying noise- and infection-related hearing loss in rural, low-resource settings.

Hearing-related quality of life in children and adolescents in rural Alaska.

Objective: This study evaluated the Hearing Environments and Reflection on Quality of Life (HEAR-QL) questionnaire in rural Alaska, including an addendum crafted through community feedback to reflect the local context. The objectives were to assess whether HEAR-QL score was inversely correlated with hearing loss and middle ear disease in an Alaska Native population. Methods: The HEAR-QL questionnaires for children and adolescents were administered as part of a cluster randomized trial in rural Alaska from 2017 to 2019. Enrolled students completed an audiometric evaluation and HEAR-QL questionnaire on the same day. A cross-sectional evaluation of questionnaire data was utilized. Results: A total of 733 children (ages 7-12 years) and 440 adolescents (ages ≥13 years) completed the questionnaire. Median HEAR-QL scores were similar among children with and without hearing loss (Kruskal-Wallis, p = .39); however, adolescent HEAR-QL scores significantly decreased with increasing hearing loss (p < .001). Median HEAR-QL scores were significantly lower in both children (p = .02) and adolescents (p < .001) with middle ear disease compared with those without. In both children and adolescents, the addendum scores were strongly correlated with total HEAR-QL score (ρSpearman = 0.72 and 0.69, respectively). Conclusions: The expected negative association between hearing loss and HEAR-QL score was observed in adolescents. However, there was significant variability that could not be explained by hearing loss, and further investigation is warranted. The expected negative association was not observed in children. HEAR-QL scores were associated with middle ear disease in both children and adolescents, making it potentially valuable in populations where the prevalence of ear infections is high. Level of Evidence: Level 2 Clinicaltrials.gov registration numbers: NCT03309553.

Environmental Factors for Hearing Loss and Middle Ear Disease in Alaska Native Children and Adolescents: A Cross-Sectional Analysis from a Cluster Randomized Trial.

OBJECTIVES: Infection-related childhood hearing loss is one of the few preventable chronic health conditions that can affect a child's lifelong trajectory. This study sought to quantify relationships between infection-mediated hearing loss and middle ear disease and environmental factors, such as exposure to wood smoke, cigarette smoke, household crowding, and lack of access to plumbed (running) water, in a northwest region of rural Alaska. DESIGN: This study is a cross-sectional analysis to estimate environmental factors of infection-related hearing loss in children aged 3 to 21 years. School hearing screenings were performed as part of two cluster randomized trials in rural Alaska over two academic years (2017-2018 and 2018-2019). The first available screening for each child was used for this analysis. Sociodemographic questionnaires were completed by parents/guardians upon entry into the study. Multivariable regression was performed to estimate prevalence differences and prevalence ratios (PR). A priori knowledge about the prevalence of middle ear disease and the difficulty inherent in obtaining objective hearing loss data in younger children led to analysis of children by age (3 to 6 years versus 7 years and older) and a separate multiple imputation sensitivity analysis for pure-tone average (PTA)-based infection-related hearing loss measures. RESULTS: A total of 1634 children participated. Hearing loss was present in 11.1% of children sampled based on otoacoustic emission as the primary indicator of hearing loss and was not associated with exposure to cigarette smoke (PR = 1.07; 95% confidence interval [CI], 0.48 to 2.38), use of a wood-burning stove (PR = 0.85; 95% CI, 0.55 to 1.32), number of persons living in the household (PR = 1.06; 95% CI, 0.97 to 1.16), or lack of access to running water (PR = 1.38; 95% CI, 0.80 to 2.39). Using PTA as a secondary indicator of hearing loss also showed no association with environmental factors. Middle ear disease was present in 17.4% of children. There was a higher prevalence of middle ear disease in homes without running water versus those with access to running water (PR = 1.53; 95% CI, 1.03 to 2.27). There was little evidence to support any cumulative effects of environmental factors. Heterogeneity of effect models by age found sample prevalence of hearing loss higher for children aged 3 to 6 years (12.2%; 95% CI, 9.3 to 15.7) compared to children 7 years and older (10.6%; 95% CI, 8.9 to 2.6), as well as for sample prevalence of middle ear disease (22.7%; 95% CI, 18.9 to 26.9 and 15.3%; 95% CI, 13.3 to 17.5, respectively). CONCLUSIONS: Lack of access to running water in the home was associated with increased prevalence of middle ear disease in this rural, Alaska Native population, particularly among younger children (aged 3 to 6 years). There was little evidence in this study that cigarette smoke, wood-burning stoves, and greater numbers of persons in the household were associated with infection-mediated hearing loss or middle ear disease. Future research with larger sample sizes and more sensitive measures of environmental exposure is necessary to further evaluate these relationships. Children who live in homes without access to running water may benefit from earlier and more frequent hearing health visits.

Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030.

OBJECTIVE: Africa contributes significantly to the global neurosurgical disease burden but has only 1% of the neurosurgery workforce. This study appraises the neurosurgical workforce and training capacity in Africa and projects the workforce capacity by 2030. METHODS: The authors conducted a systematic review of the online literature on neurosurgical workforce and training in Africa obtained from three journal databases (PubMed, Embase, and African Index Medicus), as well as from a gray literature search, between September and December 2020. Included literature passed a two-level screening conducted using a systematic review software by a team of two independent reviewers. Data were extracted from selected articles and documented and analyzed on spreadsheets. RESULTS: One hundred and fifty-nine eligible articles were analyzed: 1974 neurosurgeons serve 1.3 billion people in Africa (density 0.15 per 100,000 persons, ratio 1:678,740), with uneven distribution between the regions. North Africa has 64.39% of the neurosurgical workforce (n = 1271), followed by Southern Africa (12.66%, n = 250), West Africa (11.60%, n = 229), East Africa (8.26%, n = 163), and Central Africa (3.09%, n = 61). At an exponential growth rate of 7.03% (95% CI 5.83%-8.23%) per annum, Africa will have 3418 (95% CI 1811-6080) neurosurgeons by 2030, with a deficit of 5191 neurosurgeons, based on population workforce targets. In terms of training, there are 106 neurosurgery training institutions in 26 African countries. North Africa has 52 training centers (49.05%), West Africa 23 (21.70%), East Africa 15 (14.15%), Southern Africa 14 (13.21%), and Central Africa 2 (1.89%). The major regional training programs are those of the West African College of Surgeons (24 sites in 7 countries) and the College of Surgeons of East, Central, and Southern Africa (17 sites in 8 countries). CONCLUSIONS: The study is limited as it is based on the online literature, some of which includes modeled estimates with questionable reliability. However, the results indicate that while countries in North Africa are expected to surpass their population workforce requirements, sub-Saharan African countries are likely to have significant workforce deficits accentuated by the paucity of neurosurgery training programs. To meet the 2030 population workforce requirements, the continent's exponential growth rate should be scaled up to 15.87% per annum. Scaling up neurosurgical training would help to meet this target and requires collaborative efforts from continental, regional, and national agencies and international organizations.

Temporal Dynamics of Subclinical Malaria in Different Transmission Zones of Myanmar.

Countries in the Greater Mekong Subregion have committed to eliminate Plasmodium falciparum malaria by 2025. Subclinical malaria infections that can be detected by highly sensitive polymerase chain reaction (PCR) testing in asymptomatic individuals represent a potential impediment to this goal, although the extent to which these low-density infections contribute to transmission is unclear. To understand the temporal dynamics of subclinical malaria in this setting, a cohort of 2,705 participants from three epidemiologically distinct regions of Myanmar was screened for subclinical P. falciparum and P. vivax infection using ultrasensitive PCR (usPCR). Standard rapid diagnostic tests (RDTs) for P. falciparum were also performed. Individuals who tested positive for malaria by usPCR were followed for up to 12 weeks. Regression analysis was performed to estimate whether the baseline prevalence of infection and the count of repeated positive tests were associated with demographic, behavioral, and clinical factors. At enrollment, the prevalence of subclinical malaria infection measured by usPCR was 7.7% (1.5% P. falciparum monoinfection, 0.3% mixed P. falciparum and P. vivax, and 6.0% P. vivax monoinfection), while P. falciparum prevalence measured by RDT was just 0.2%. Prevalence varied by geography and was higher among older people and in those with outdoor exposure and travel. No difference was observed in either the prevalence or count of subclinical infection by time of year, indicating that even in low-endemicity areas, a reservoir of subclinical infection persists year-round. If low-density infections are shown to represent a significant source of transmission, identification of high-risk groups and locations may aid elimination efforts.

Mobile health school screening and telemedicine referral to improve access to specialty care in rural Alaska: a cluster- randomised controlled trial.

BACKGROUND: School-based programmes, including hearing screening, provide essential preventive services for rural children. However, minimal evidence on screening methodologies, loss to follow-up, and scarcity of specialists for subsequent care compound rural health disparities. We hypothesised telemedicine specialty referral would improve time to follow-up for school hearing screening compared with standard primary care referral. METHODS: In this cluster-randomised controlled trial conducted in 15 rural Alaskan communities, USA, we randomised communities to telemedicine specialty referral (intervention) or standard primary care referral (control) for school hearing screening. All children (K-12; aged 4-21 years) enrolled in Bering Straight School District were eligible. Community randomisation occurred within four strata using location and school size. Participants were masked to group allocation until screening day, and assessors were masked throughout data collection. Screening occurred annually, and children who screened positive for possible hearing loss or ear disease were monitored for 9 months from the screening date for follow-up. Primary outcome was the time to follow-up after a positive hearing screen; analysis was by intention to treat. The trial was registered with ClinicalTrials.gov, NCT03309553. FINDINGS: We recruited participants between Oct 10, 2017, and March 28, 2019. 15 communities were randomised: eight (750 children) to telemedicine referral and seven (731 children) to primary care referral. 790 (53·3%) of 1481 children screened positive in at least one study year: 391 (52∤1%) in the telemedicine referral communities and 399 (50∤4%) in the primary care referral communities. Of children referred, 268 (68·5%) in the telemedicine referral communities and 128 (32·1%) in primary care referral communities received follow-up within 9 months. Among children who received follow-up, mean time to follow-up was 41·5 days (SD 55·7) in the telemedicine referral communities and 92·0 days (75·8) in the primary care referral communities (adjusted event-time ratio 17·6 [95% CI 6·8-45·3] for all referred children). There were no adverse events. INTERPRETATION: Telemedicine specialty referral significantly improved the time to follow-up after hearing screening in Alaska. Telemedicine might apply to other preventive school-based services to improve access to specialty care for rural children. FUNDING: Patient-Centered Outcomes Research Institute.

Feasibility of Cardiac Rehabilitation Models in Kenya.

BACKGROUND: Heart failure (HF), is a leading cause of cardiovascular morbidity and mortality in Sub-Saharan Africa. Cardiac rehabilitation (CR) is known to improve functional capacity and reduce morbidity associated with HF. Although CR is a low-cost intervention, global access and adherence rates to CR remain poor. In regions such as Western Kenya, CR programs do not exist. We sought to establish the feasibility CR for HF in this region by testing adherence to institution and home-based models of CR. METHODS: One hundred participants with New York Heart Association (NYHA) class II and III HF symptoms were prospectively enrolled from a tertiary health facility in Western Kenya. Participants were non-randomly assigned to participate in one of two CR models based on their preference. Institution based cardiac rehabilitation (IBCR) comprised 36 facility-based exercise sessions over a period of 12 weeks. Home based cardiac rehabilitation (HBCR) comprised weekly pedometer guided exercise targets over a period of 12 weeks. An observational arm (OA) receiving usual care was also enrolled. The primary endpoint of CR feasibility was assessed based on study participants to adherence to at least 25% of exercise sessions. Secondary outcomes of change in NYHA symptom class, and six-minute walk time distance (6MWTD) were also evaluated. Data were summarized and analyzed as means (SD) and frequencies. Paired t-tests, Chi Square, Fisher's, and ANOVA tests were used for comparisons. FINDINGS: Mean protocol adherence was greater than 25% in both CR models; 46% ± 18 and 29% ± 11 (P < 0.05) among IBCR and HBCR participants respectively. Improvements by at least one NYHA class were observed among 71%, 41%, and 54%, of IBCR, HBCR and OA participants respectively. 6MWTD increased significantly by a mean of 31 ± 65 m, 40 ± 55 m and 38 ± 71 m in the IBCR, HBCR and OA respectively (P < 0.05). CONCLUSIONS: IBCR and HBCR, are feasible rehabilitation models for HF in Western Kenya. Whereas improvement in functional capacity was observed, effectiveness of CR in this population remains unknown. Future randomized studies evaluating effect size, long term efficacy, and safety of cardiac rehabilitation in low resource settings such as Kenya are recommended.

Medical record bias in documentation of obstetric and neonatal clinical quality of care indicators in Uganda.

OBJECTIVE: To achieve a high quality of care (QoC), accurate measurements are needed. This study evaluated the validity of QoC data from the medical records for childbirth deliveries and assessed whether medical records can be used to evaluate the efficacy of interventions to improve QoC. STUDY DESIGN AND SETTING: This study was part of a larger study of QoC training program in Uganda. Study data were collected in two phases: (1) validation data from 321 direct observations of deliveries paired with the corresponding medical records; (2) surveillance data from 1,146 medical records of deliveries. Sensitivity, specificity, and predictive values were used to measure the validity of the medical record from the validation data. Quantitative bias analysis was conducted to evaluate QoC program efficacy in the surveillance data using prevalence ratio and odds ratio. RESULTS: On average, sensitivity (84%) of the medical record was higher than the specificity (34%) across 11 QoC indicators, showing a higher validity in identifying the performed procedure. For 5 out of 11 indicators, bias-corrected odds ratios and prevalence ratios deviated significantly from uncorrected estimates. CONCLUSION: The medical records demonstrated poor validity in measuring QoC compared with direct observation. Using the medical record to assess QoC program efficacy should be interpreted carefully.

Epic Allies: A Gamified Mobile App to Improve Engagement in HIV Care and Antiretroviral Adherence among Young Men Who have Sex with Men.

HIV incidence among young men who have sex with men (YMSM) is disproportionally high. Youth living with HIV demonstrate low rates of sustained virologic suppression (VS). Epic Allies, a theory-based behavioral intervention mobile app, utilizes self-management tools, gamification, and social support to improve engagement in care and antiretroviral adherence among YMSM living with HIV. A two-arm individually randomized-controlled trial enrolled 146 participants aged 16 to 24 years old to test the efficacy of Epic Allies to achieve VS. Both study arms showed improved VS at 26-weeks (62.9% intervention; 73.5% control; ARR = 0.93 (95% CI 0.73, 1.18)) and antiretroviral adherence; intervention effects were amplified in regular app users. Issues with recruitment and app usage metrics limit the ability to definitively say that the app was effective in causing behavior changes resulting in improved health outcomes. (ClinicalTrials.gov Identifier: NCT02782130).