Impact of the COVID-19 pandemic in childhood and adolescent cancer care in northern Tanzania: a cross-sectional study.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic has strained healthcare systems and presented unique challenges for children requiring cancer care, particularly in low- and middle-income countries. This study aimed to assess the impact of the COVID-19 pandemic on access to cancer care for children and adolescents in Northern Tanzania. METHODS: In this cross-sectional study, we assessed the demographic and clinical characteristics of 547 pediatric and adolescent cancer patients (ages 0-19 years old) between 2016 and 2022 using the population-based Kilimanjaro Cancer Registry (KCR). We categorized data into pre-COVID-19 (2016-2019) and COVID-19 (2020-2022) eras, and performed descriptive analyses of diagnostic, treatment, and demographic information. A secondary analysis was conducted on a subset of 167 patients with stage of diagnosis at presentation. RESULTS: Overall admissions nearly doubled during the pandemic (n = 190 versus 357). The variety of diagnoses attended at KCMC increased during the pandemic, with only five groups of diseases reported in 2016 to twelve groups of diseases in 2021. Most patients were diagnosed at a late stage (stage III or IV) across eras, with the proportion of under-five years old patients increasing late-diagnoses from 29.4% (before the pandemic), 52.8% (during the pandemic), when compared to the overall cohort. Around 95% of children in this age category reported late-stage diagnosis during the pandemic. Six out of the twelve cancer site groups also reported an increase in late-stage diagnosis. During the pandemic, the proportion of children receiving surgery increased from 15.8 to 30.8% (p < 0.001). CONCLUSION: Childhood and adolescent cancer care changed in Northern Tanzania during the COVID-19 pandemic, with increased late-stage diagnoses presentations among younger patients and the increased use of surgical therapies in the context of a growing practice. Understanding the impact of the COVID-19 pandemic on pediatric and adolescent cancer care can help us better adapt healthcare systems and interventions to the emerging needs of children and adolescents with cancer in the midst of a health crisis.

The Middle Pleistocene human metatarsal from Sedia del Diavolo (Rome, Italy).

The peopling of Europe during the Middle Pleistocene is a debated topic among paleoanthropologists. Some authors suggest the coexistence of multiple human lineages in this period, while others propose a single evolving lineage from Homo heidelbergensis to Homo neanderthalensis. The recent reassessment of the stratigraphy at the Sedia del Diavolo (SdD) site (Latium, Italy), now dated to the beginning of marine isotope stage (MIS) 8, calls for a revision of the human fossils from the site. In this paper, we present the morphometric, biomechanical and palaeopathological study of the second right metatarsal SdD2, to both re-evaluate its taxonomical affinities and possibly determine the levels of physical activity experienced by the individual during lifetime. Results demonstrate the persistence of archaic features in SdD2 suggesting new insights into the technology and hunting strategies adopted by Homo between MIS 9 and MIS 8.

Human-Centered Design and Development of a Fall Prevention Exercise App For Older Adults in Primary Care Settings.

BACKGROUND: Falls in older adults are a serious public health problem that can lead to reduced quality of life or death. Patients often do not receive fall prevention guidance from primary care providers, despite evidence that falls can be prevented. Mobile health technologies may help to address this disparity and promote evidence-based fall prevention. OBJECTIVE: Our main objective was to use Human-Centered Design (HCD) to develop a user-friendly, fall prevention exercise app using validated user requirements. The app features evidence-based behavior change strategies and exercise content to support older people initiating and adhering to a progressive fall prevention exercise program. METHODS: We organized our multi-stage, iterative design process into three phases: Gathering User Requirements, Usability Evaluation, and Refining App Features. Our methods include focus groups, usability testing, and subject matter expert meetings. RESULTS: Focus groups (Total n=6), usability testing (n=30) including a post-test questionnaire [Health-ITUES score: mean (SD)= 4.2 (1.1)], and subject matter expert meetings demonstrate participant satisfaction with the app concept and design. Overall, participants saw value in receiving exercise prescriptions from the app that would be recommended by their PCP and reported satisfaction with the content of the app, but several participants felt that they were not the right user for the app. CONCLUSIONS: This study demonstrates the development, refinement and usability testing of a fall prevention exercise app and corresponding tools that primary care providers may use to prescribe tailored exercise recommendations to their older patients as an evidence-based fall prevention strategy accessible in the context of busy clinical workflows.

Improved accuracy and efficiency of primary care fall risk screening of older adults using a machine learning approach.

BACKGROUND: While many falls are preventable, they remain a leading cause of injury and death in older adults. Primary care clinics largely rely on screening questionnaires to identify people at risk of falls. Limitations of standard fall risk screening questionnaires include suboptimal accuracy, missing data, and non-standard formats, which hinder early identification of risk and prevention of fall injury. We used machine learning methods to develop and evaluate electronic health record (EHR)-based tools to identify older adults at risk of fall-related injuries in a primary care population and compared this approach to standard fall screening questionnaires. METHODS: Using patient-level clinical data from an integrated healthcare system consisting of 16-member institutions, we conducted a case-control study to develop and evaluate prediction models for fall-related injuries in older adults. Questionnaire-derived prediction with three questions from a commonly used fall risk screening tool was evaluated. We then developed four temporal machine learning models using routinely available longitudinal EHR data to predict the future risk of fall injury. We also developed a fall injury-prevention clinical decision support (CDS) implementation prototype to link preventative interventions to patient-specific fall injury risk factors. RESULTS: Questionnaire-based risk screening achieved area under the receiver operating characteristic curve (AUC) up to 0.59 with 23% to 33% similarity for each pair of three fall injury screening questions. EHR-based machine learning risk screening showed significantly improved performance (best AUROC = 0.76), with similar prediction performance between 6-month and one-year prediction models. CONCLUSIONS: The current method of questionnaire-based fall risk screening of older adults is suboptimal with redundant items, inadequate precision, and no linkage to prevention. A machine learning fall injury prediction method can accurately predict risk with superior sensitivity while freeing up clinical time for initiating personalized fall prevention interventions. The developed algorithm and data science pipeline can impact routine primary care fall prevention practice.

Speed and surface steepness affect internal tibial loading during running.

BACKGROUND: Internal tibial loading is influenced by modifiable factors with implications for the risk of stress injury. Runners encounter varied surface steepness (gradients) when running outdoors and may adapt their speed according to the gradient. This study aimed to quantify tibial bending moments and stress at the anterior and posterior peripheries when running at different speeds on surfaces of different gradients. METHODS: Twenty recreational runners ran on a treadmill at 3 different speeds (2.5 m/s, 3.0 m/s, and 3.5 m/s) and gradients (level: 0%; uphill: +5%, +10%, and +15%; downhill: -5%, -10%, and -15%). Force and marker data were collected synchronously throughout. Bending moments were estimated at the distal third centroid of the tibia about the medial-lateral axis by ensuring static equilibrium at each 1% of stance. Stress was derived from bending moments at the anterior and posterior peripheries by modeling the tibia as a hollow ellipse. Two-way repeated-measures analysis of variance were conducted using both functional and discrete statistical analyses. RESULTS: There were significant main effects for running speed and gradient on peak bending moments and peak anterior and posterior stress. Higher running speeds resulted in greater tibial loading. Running uphill at +10% and +15% resulted in greater tibial loading than level running. Running downhill at -10% and -15% resulted in reduced tibial loading compared to level running. There was no difference between +5% or -5% and level running. CONCLUSION: Running at faster speeds and uphill on gradients ≥+10% increased internal tibial loading, whereas slower running and downhill running on gradients ≥-10% reduced internal loading. Adapting running speed according to the gradient could be a protective mechanism, providing runners with a strategy to minimize the risk of tibial stress injuries.

Effect of increased running speed and weight carriage on peak and cumulative tibial loading.

INTRODUCTION: Tibial stress injuries are a burdensome injury among military recruits. Military activities include running and the carriage of additional weight, and this may be related to the high risk of bone stress injuries. The aim of this study was to quantify tibial loading when running at two different speeds, with and without additional weight, and to quantify their combined influence. METHODS: Fourteen male distance runners who ran at least 40 km per week ran barefoot on a force-instrumented treadmill in four conditions representing preferred running speed (mean (SD) 3.1 (0.3) m/s) and 20% increased running speed (3.8 (0.4) m/s), with and without 20% of body weight carried in a weight vest. Kinematics and kinetics were synchronously collected. Bending moments were estimated about the medial-lateral axis of the tibial centroid located 1/3rd of the length from distal to proximal. Static equilibrium was ensured at each 1% of stance. Peak bending moments were obtained in addition to cumulative-weighted loading, where weighted loading accounted for the relative importance of the magnitude of the bending moment and the quantity of loading using a bone-dependent weighting factor. RESULTS: There were no interaction effects for running speed and weight carriage on peak or cumulative tibial loading. Running at a 20% faster speed increased peak and cumulative loading per kilometer by 8.0% (p < 0.001) and 4.8% (p < 0.001), respectively. Carriage of an additional 20% of body weight increased peak and cumulative loading per kilometer by 6.6% (p < 0.001) and 8.5% (p < 0.001), respectively. INTERPRETATION: Increasing the physical demand of running by increasing speed or weight carriage increased peak tibial loading and cumulative tibial loading per kilometer, and this may increase the risk of tibial stress injury. Running speed and weight carriage independently influenced tibial loading.

Financial burden of men with localized prostate cancer: a process paper.

Background: Many individuals undergoing cancer treatment experience substantial financial hardship, often referred to as financial toxicity (FT). Those undergoing prostate cancer treatment may experience FT and its impact can exacerbate disparate health outcomes. Localized prostate cancer treatment options include: radiation, surgery, and/or active surveillance. Quality of life tradeoffs and costs differ between treatment options. In this project, our aim was to quantify direct healthcare costs to support patients and clinicians as they discuss prostate cancer treatment options. We provide the transparent steps to estimate healthcare costs associated with treatment for localized prostate cancer among the privately insured population using a large claims dataset. Methods: To quantify the costs associated with their prostate cancer treatment, we used data from the Truven Health Analytics MarketScan Commercial Claims and Encounters, including MarketScan Medicaid, and peer reviewed literature. Strategies to estimate costs included: (1) identifying the problem, (2) engaging a multidisciplinary team, (3) reviewing the literature and identifying the database, (4) identifying outcomes, (5) defining the cohort, and (6) designing the analytic plan. The costs consist of patient, clinician, and system/facility costs, at 1-year, 3-years, and 5-years following diagnosis. Results: We outline our specific strategies to estimate costs, including: defining complex research questions, defining the study population, defining initial prostate cancer treatment, linking facility and provider level related costs, and developing a shared understanding of definitions on our research team. Discussion and next steps: Analyses are underway. We plan to include these costs in a prostate cancer patient decision aid alongside other clinical tradeoffs.

Childhood and Adolescent Cancer Care at a Tertiary Hospital in Northern Tanzania: A Retrospective Study.

PURPOSE: Over 400,000 children are diagnosed with cancer around the world each year, with over 80% of these children residing in low- and middle-income countries. This study aims to summarize the epidemiology and care patterns of newly diagnosed childhood cancer patients in Northern Tanzania. METHODS: Data from all children and adolescents (age 0-19 years) with newly diagnosed cancers were collected from the Kilimanjaro Cancer Registry located at the Kilimanjaro Christian Medical Centre. Descriptive and inferential analyses were used to compare the demographic and clinical characteristics of the participants over time, stage, and status at last contact. Statistical significance was set at P < .05. Secondary descriptive analysis was conducted on a subset sample with available staging data. RESULTS: A total of 417 patients were diagnosed with cancer between 2016 and 2021. There was an increase in the rate of patients with newly diagnosed pediatric cancer each year, particularly among children under age 5 years and 10 years. Leukemias and lymphomas were the leading diagnoses and accounted for 183 (43.8%) of all patients. Over 75% of patients were diagnosed at stage III or above. From a subset analysis of patients with available staging data (n = 101), chemotherapy was the most common treatment (87.1%), compared with radiotherapy and surgery. CONCLUSION: There is a significant burden of children with cancer in Tanzania. Our study fills crucial gaps in the literature related to the large burden of disease and survival for children with cancer in the Kilimanjaro region. Furthermore, our results can be used to understand the regional needs and guide research and strategic interventions to improve childhood cancer survival in Northern Tanzania.

Management of Fall Risk Among Older Adults in Diverse Primary Care Settings.

OBJECTIVES: Falls are persistent among community-dwelling older adults despite existing prevention guidelines. We described how urban and rural primary care staff and older adults manage fall risk and factors important to integration of computerized clinical decision support (CCDS). METHODS: Interviews, contextual inquiries, and workflow observations were analyzed using content analysis and synthesized into a journey map. Sociotechnical and PRISM domains were applied to identify workflow factors important to sustainable CCDS integration. RESULTS: Participants valued fall prevention and described similar approaches. Available resources differed between rural and urban locations. Participants wanted evidence-based guidance integrated into workflows to bridge skills gaps. DISCUSSION: Sites described similar clinical approaches with differences in resource availability. This implies that a single intervention would need to be flexible to environments with differing resources. Electronic Health Record's inherent ability to provide tailored CCDS is limited. However, CCDS middleware could integrate into different settings and increase evidence use.

Delays in cancer care for children in low-income and middle-income countries: development of a composite vulnerability index.

BACKGROUND: Early access to diagnosis and care is essential to improve rates of survival from childhood cancer, particularly in low-income and middle-income countries (LMICs). Composite indices are increasingly used to compare country performance in many health fields. We aimed to develop a composite vulnerability index of risk of mortality associated with delays in care for childhood cancer in LMICs, and to compare the vulnerability index scores across countries. METHODS: The composite vulnerability index was built in ten steps. A previous systematic review of determinants of delays in cancer care for children guided data selection. We collected exposure variables (determinants of delays in care) and outcome variables (childhood cancer-related mortality) from several large datasets. Data were analysed with regression models to identify determinants of delays in care that contribute to childhood cancer mortality. Significant indicators were aggregated into domains according to the socio-ecological model. We used geospatial tools to summarise and compare the composite vulnerability index scores across countries. FINDINGS: We found that life expectancy, maternal education, fertility rate, availability of pathology services, bone marrow transplantation capacity, availability of treatment services (chemotherapy, radiotherapy, or surgery), number of pharmacists per 10 000 population, country income level, and out-of-pocket health expenditure were significantly associated with cancer mortality for children in LMICs. The highest levels of vulnerability were found in sub-Saharan Africa. INTERPRETATION: Our composite vulnerability index can potentially serve as a valuable policy decision tool to help monitor country performance and guide interventions to reduce delays in care for children with cancer in LMICs. FUNDING: None. TRANSLATIONS: For the Chinese, Portuguese, Arabic, Spanish and Swahili translations of the abstract see Supplementary Materials section.

Usability Testing of an Interoperable Computerized Clinical Decision Support Tool for Fall Risk Management in Primary Care.

BACKGROUND: Falls are a widespread and persistent problem for community-dwelling older adults. Use of fall prevention guidelines in the primary care setting has been suboptimal. Interoperable computerized clinical decision support systems have the potential to increase engagement with fall risk management at scale. To support fall risk management across organizations, our team developed the ASPIRE tool for use in differing primary care clinics using interoperable standards. OBJECTIVES: Usability testing of ASPIRE was conducted to measure ease of access, overall usability, learnability, and acceptability prior to pilot . METHODS: Participants were recruited using purposive sampling from two sites with different electronic health records and different clinical organizations. Formative testing rooted in user-centered design was followed by summative testing using a simulation approach. During summative testing participants used ASPIRE across two clinical scenarios and were randomized to determine which scenario they saw first. Single Ease Question and System Usability Scale were used in addition to analysis of recorded sessions in NVivo. RESULTS: All 14 participants rated the usability of ASPIRE as above average based on usability benchmarks for the System Usability Scale metric. Time on task decreased significantly between the first and second scenarios indicating good learnability. However, acceptability data were more mixed with some recommendations being consistently accepted while others were adopted less frequently. CONCLUSION: This study described the usability testing of the ASPIRE system within two different organizations using different electronic health records. Overall, the system was rated well, and further pilot testing should be done to validate that these positive results translate into clinical practice. Due to its interoperable design, ASPIRE could be integrated into diverse organizations allowing a tailored implementation without the need to build a new system for each organization. This distinction makes ASPIRE well positioned to impact the challenge of falls at scale.

A systematic literature review of evidence for the use of assistive exoskeletons in defence and security use cases.

Advances in assistive exoskeleton technology, and a boom in related scientific literature, prompted a need to review the potential use of exoskeletons in defence and security. A systematic review examined the evidence for successful augmentation of human performance in activities deemed most relevant to military tasks. Categories of activities were determined a priori through literature scoping and Human Factors workshops with military stakeholders. Workshops identified promising opportunities and risks for integration of exoskeletons into military use cases. The review revealed promising evidence for exoskeletons' capacity to assist with load carriage, manual lifting, and working with tools. However, the review also revealed significant gaps in exoskeleton capabilities and likely performance levels required in the use case scenarios. Consequently, it was recommended that a future roadmap for introducing exoskeletons to military environments requires development of performance criteria for exoskeletons that can be used to implement a human-centred approach to research and development.

We assessed the state-of-the-art for the use of wearable assistive exoskeletons in UK defence and security use cases. A full systematic review of the literature was undertaken, informed by use cases developed in military stakeholder workshops. Clear gaps in exoskeleton capability and use case requirements were identified, leading to recommendations for future work.

Development and Usability Testing of an Exercise-Based Primary Care Fall Prevention Clinical Decision Support Tool.

For older patients, falls are the leading cause offatal and nonfatal injuries. Guidelines recommend that at-risk older adults are referred to appropriate fall-prevention exercise programs, but many do not receive support for fall-risk management in the primary care setting. Advances in health information technology may be able to address this gap. This article describes the development and usability testing of a clinical decision support (CDS) tool for fall prevention exercise. Using rapid qualitative analysis and human-centered design, our team developed and tested the usability of our CDS prototype with primary care team members. Across 31 Health-Information Technology Usability Evaluation Scale surveys, our CDS prototype received a median score of 5.0, mean (SD) of 4.5 (0.8), and a range of 4.1-4.9. This study highlights the features and usability offall prevention CDS for helping primary care providers deliver patient-centeredfall prevention care.

Clinical Decision Support for Fall Prevention: Defining End-User Needs.

BACKGROUND AND SIGNIFICANCE: Falls in community-dwelling older adults are common, and there is a lack of clinical decision support (CDS) to provide health care providers with effective, individualized fall prevention recommendations. OBJECTIVES: The goal of this research is to identify end-user (primary care staff and patients) needs through a human-centered design process for a tool that will generate CDS to protect older adults from falls and injuries. METHODS: Primary care staff (primary care providers, care coordinator nurses, licensed practical nurses, and medical assistants) and community-dwelling patients aged 60 years or older associated with Brigham & Women's Hospital-affiliated primary care clinics and the University of Florida Health Archer Family Health Care primary care clinic were eligible to participate in this study. Through semi-structured and exploratory interviews with participants, our team identified end-user needs through content analysis. RESULTS: User needs for primary care staff (n = 24) and patients (n = 18) were categorized under the following themes: workload burden; systematic communication; in-person assessment of patient condition; personal support networks; motivational tools; patient understanding of fall risk; individualized resources; and evidence-based safe exercises and expert guidance. While some of these themes are specific to either primary care staff or patients, several address needs expressed by both groups of end-users. CONCLUSION: Our findings suggest that there are many care gaps in fall prevention management in primary care and that personalized, actionable, and evidence-based CDS has the potential to address some of these gaps.

Monitoring Attacks on Health Care as a Basis to Facilitate Accountability for Human Rights Violations.

Violence against health care systems is an assault on health and human rights. Despite the evolution of global standards to protect health workers and ensure the delivery of health care in times of conflict, attacks against health systems have continued throughout the world-violating humanitarian law, undermining human rights, and threatening public health. The persistence of such violence against health care, especially in humanitarian crises related to armed conflict, has prompted global institutions to develop systematic monitoring mechanisms in an effort to alleviate these harms, seeking to protect health workers from being harmed for their healing efforts. This article examines the development and implementation of the World Health Organization (WHO) Surveillance System of Attacks on Healthcare (SSA) as a systematic mechanism to collect and disseminate data concerning attacks on health care systems. Although the SSA provides a foundation for monitoring attacks in conflict zones, this research considers whether the SSA has collected the necessary data, categorized these data appropriately, and disseminated sufficient information to facilitate human rights accountability, analyzing the political, methodological, and institutional challenges faced by WHO. The article concludes that refinements to this monitoring mechanism are needed to strengthen the political prioritization, research methodology, and institutional implementation necessary to ensure accountability for violations of health and human rights.

Biomechanical Basis of Predicting and Preventing Lower Limb Stress Fractures During Arduous Training.

PURPOSE OF REVIEW: Stress fractures at weight-bearing sites, particularly the tibia, are common in military recruits and athletes. This review presents recent findings from human imaging and biomechanics studies aimed at predicting and preventing stress fractures. RECENT FINDINGS: Peripheral quantitative computed tomography (pQCT) provides evidence that cortical bone geometry (tibial width and area) is associated with tibial stress fracture risk during weight-bearing exercise. The contribution of bone trabecular microarchitecture, cortical porosity, and bone material properties in the pathophysiology of stress fractures is less clear, but high-resolution pQCT and new techniques such as impact microindentation may improve our understanding of the role of microarchitecture and material properties in stress fracture prediction. Military studies demonstrate osteogenic outcomes from high impact, repetitive tibial loading during training. Kinetic and kinematic characteristics may influence stress fracture risk, but there is no evidence that interventions to modify biomechanics can reduce the incidence of stress fracture. Strategies to promote adaptive bone formation, in combination with improved techniques to assess bone strength, present exciting opportunities for future research to prevent stress fractures.

Physiological demands of running at 2-hour marathon race pace.

The requirements of running a 2-h marathon have been extensively debated but the actual physiological demands of running at ∼21.1 km/h have never been reported. We therefore conducted laboratory-based physiological evaluations and measured running economy (O2 cost) while running outdoors at ∼21.1 km/h, in world-class distance runners as part of Nike's "Breaking 2" marathon project. On separate days, 16 world-class male distance runners (age, 29 ± 4 yr; height, 1.72 ± 0.04 m; mass, 58.9 ± 3.3 kg) completed an incremental treadmill test for the assessment of V̇O2peak, O2 cost of submaximal running, lactate threshold and lactate turn-point, and a track test during which they ran continuously at 21.1 km/h. The laboratory-determined V̇O2peak was 71.0 ± 5.7 mL/kg/min with lactate threshold and lactate turn-point occurring at 18.9 ± 0.4 and 20.2 ± 0.6 km/h, corresponding to 83 ± 5% and 92 ± 3% V̇O2peak, respectively. Seven athletes were able to attain a steady-state V̇O2 when running outdoors at 21.1 km/h. The mean O2 cost for these athletes was 191 ± 19 mL/kg/km such that running at 21.1 km/h required an absolute V̇O2 of ∼4.0 L/min and represented 94 ± 3% V̇O2peak. We report novel data on the O2 cost of running outdoors at 21.1 km/h, which enables better modeling of possible marathon performances by elite athletes. Using the value for O2 cost measured in this study, a sub 2-h marathon would require a 59 kg runner to sustain a V̇O2 of approximately 4.0 L/min or 67 mL/kg/min.NEW & NOTEWORTHY We report the physiological characteristics and O2 cost of running overground at ∼21.1 km/h in a cohort of the world's best male distance runners. We provide new information on the absolute and relative O2 uptake required to run at 2-h marathon pace.

Measuring implicit attractiveness bias in the context of innocence and guilt evaluations

Previous research on mock-jury trials has shown an explicit attractiveness bias in participant attributes of innocence. This study used the Implicit Relational Assessment Procedure (IRAP) to measure attractiveness-bias in implicit evaluations of innocence or guilt with a sample of 46 college students. Alternate IRAP trial-blocks required participants to affirm relations consistent and inconsistent with attractiveness bias (attractive-innocent/unattractive guilty versus unattractive-innocent/ attractive-guilty). Faster responding across consistent trial-blocks was interpreted in terms of implicit stereotype. Participants' beliefs about the importance of their own appearances were examined using the Beliefs about Appearances Scale (BAAS) and explicit attractiveness ratings for the IRAP photographic stimuli were measured using Likert scales; analysis examined relationships between these beliefs and IRAP scores. Results revealed statistically significant attractiveness bias for both male and female participants; specifically, both a pro-attractiveness and anti-unattractive bias. Findings are discussed regarding research in implicit evaluations of innocence or guilt and effects of attractiveness bias

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