Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic.

Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitals' ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patients' care and their transitions and not be focused on a single location providing 'critical care'. We propose a five-part strategy to support the system changes needed.

COVID-19 and unintended steps towards further equity in global health research.

There was, and possibly still is, potential for COVID-19 to disrupt power inequities and contribute to positive transformation in global health research that increases equity. While there is consensus about the need to decolonise by transforming global health, and a roadmap outlining how we could approach it, there are few examples of steps that could be taken to transform the mechanics of global health research. This paper contributes lessons learnt from experiences and reflections of our diverse multinational team of researchers involved in a multicountry research project. We demonstrate the positive impact on our research project of making further steps towards improving equity within our research practices. Some of the approaches adopted include redistributing power to researchers from the countries of interest at various stages in their career, by involving the whole team in decisions about the research; meaningfully involving the whole team in research data analysis; and providing opportunities for all researchers from the countries of interest to voice their perspectives as first authors in publications. Although this approach is consistent with how research guidance suggests research should be run, in reality it does not often happen in this way. The authors of this paper hope that by sharing our experience, we can contribute towards discussions about the processes required to continue developing a global health sector that is equitable and inclusive.

Prevalence and Risk Factors of Surgical Site Infections in a Teaching Medical College in the Trichy District of India.

Introduction Surgical site infection (SSI) remains a common and widespread problem, which contributes to significant morbidity and mortality, prolongs hospital stays, and consequently increases healthcare costs. The current study aimed to assess the prevalence of SSI and its associated risk factors among patients who underwent any surgical intervention in a tertiary care center in Trichy, Tamil Nadu, India. Methodology This was a hospital-based, cross-sectional study that was carried out over a period of one year in Trichy, Tamil Nadu, India. All adult patients of both genders older than 16 years who underwent surgery were included. Patients who underwent second surgery at the same site for any reason, patients on immunosuppressant therapy or immunodeficiency disease, patients on antibiotics already, and patients with infection elsewhere were excluded. After 48 hours of surgery, if there was evidence of wound infection, then the patient was considered to have SSI. The data obtained were analyzed using SPSS (Statistical Package for the Social Sciences) version 21 (IBM Corp., Armonk, NY). Results A total of 2076 patients underwent different types of surgeries. The prevalence of SSIs during the study period was 5.6% (n = 2076). SSIs were more common in abdominal surgeries (61.2%). Patients aged 16-24 years have a higher risk of getting SSI than other age groups (p = 0.040). Males have a higher risk of getting SSI than females (p = 0.022). Patients who underwent emergency surgery have a higher risk of getting SSI than those who underwent elective surgery (p = 0.025). Those with diabetes had a higher risk of getting SSI than those who were non-diabetics (p ≤ 0.0001). Conclusion SSIs were more common in abdominal surgeries. Patients who are male, younger in age, had emergency surgery, have diabetes, and have had a long hospital stay are at a higher risk of developing SSIs after any kind of surgery.

Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study.

INTRODUCTION: Prompt access to emergency obstetrical care (EmOC) reduces the risk of maternal mortality. We assessed institutional maternal mortality by distance and travel time for pregnant women with obstetrical emergencies in Lagos State, Nigeria. METHODS: We conducted a facility-based retrospective cohort study across 24 public hospitals in Lagos. Reviewing case notes of the pregnant women presenting between 1 November 2018 and 30 October 2019, we extracted socio-demographic, travel and obstetrical data. The extracted travel data were exported to Google Maps, where driving distance and travel time data were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on maternal death. FINDINGS: Of 4181 pregnant women with obstetrical emergencies, 182 (4.4%) resulted in maternal deaths. Among those who died, 60.3% travelled ≤10 km directly from home, and 61.9% arrived at the hospital ≤30 mins. The median distance and travel time to EmOC was 7.6 km (IQR 3.4-18.0) and 26 mins (IQR 12-50). For all women, travelling 10-15 km (2.53, 95% CI 1.27 to 5.03) was significantly associated with maternal death. Stratified by referral, odds remained statistically significant for those travelling 10-15 km in the non-referred group (2.48, 95% CI 1.18 to 5.23) and for travel ≥120 min (7.05, 95% CI 1.10 to 45.32). For those referred, odds became statistically significant at 25-35 km (21.40, 95% CI 1.24 to 36.72) and for journeys requiring travel time from as little as 10-29 min (184.23, 95% CI 5.14 to 608.51). Odds were also significantly higher for women travelling to hospitals in suburban (3.60, 95% CI 1.59 to 8.18) or rural (2.51, 95% CI 1.01 to 6.29) areas. CONCLUSION: Our evidence shows that distance and travel time influence maternal mortality differently for referred women and those who are not. Larger scale research that uses closer-to-reality travel time and distance estimates as we have done, rethinking of global guidelines, and bold actions addressing access gaps, including within the suburbs, will be critical in reducing maternal mortality by 2030.

Clinical profile of patients with inter vertebral disc disorders / clínica de pacientes con trastornos de los discos intervertebrales

Introduction: Intervertebral disc disorders (IDDs) are being commonly observed nowadays among the young and middle aged population. Objectives: This hospital record based study was done to study the risk factors, clinical presentation, imaging findings and management practices among patients with all types of IDDs. Methods: A validated proforma was used to obtain information of patients confirmed with IDDs over the past three years. Results: Mean age at onset of disc disorders among the 219 patients was 44.7±14.2 years. History of poor exercising habits were present among 72(32.9 percent) patients. The most common site of disc involvement was L4-L5 [151(68.9 percent)]. 143(65.3 percent) patients had single site disc involvement. The most common clinical symptom was lower back pain [180(82.2 percent)]. Nerve root compression was present among 154(70.3 percent) patients. Disc bulge, protrusion, extrusion and sequestration were present among 116(53 percent), 90(41.1 percent), 52(23.7 percent) and 4(1.8 percent) patients respectively. Age at onset >65 years (p=0.035), age at onset ≤55 years (p=0.004) and history of direct impact to the neck region (p=0.017) were associated with disc prolapse at L2-L3 level, L4-L5 level and C5-C6 level respectively, among patients with single site disc involvement. Risk of multiple level disc involvement was found to increase after 35 years (p<0.001). It was seen more involving cervical vertebrae (p=0.0068). Lumbar (p<0.0001) and lumbosacral vertebrae (p<0.0001) involvement were seenmore among patients with single site disc involvement. NSAIDs [155(70.8 percent)] were the most the commonly used medication. Microdiscectomy was done among 35(76.1 percent) out of the 46 patients who underwent surgical management. Conclusions: Exercising habits need to be encouraged among people for the prevention of IDDs. The various high risk groups identified in this study need to be periodically screened for IDDs(AU)

Introducción: Actualmente, los trastornos de los discos intervertebrales (TDI) son frecuentes en la población joven y de mediana edad. Objetivos: Este estudio hospitalario de las historias clínicas se realizó para examinar los factores de riesgo, la presentación clínica, los hallazgos imagenológicos y las prácticas de tratamiento entre los pacientes con todos los tipos de trastornos de los discos intervertebrales. Métodos: Se utilizó una proforma validada para obtener información de los pacientes confirmados con trastornos de los discos intervertebrales en los últimos tres años. Resultados: La edad media de aparición de los trastornos discales entre los 219 pacientes fue de 44,7 ± 14,2 años. El historial de malos hábitos de ejercicio estuvo presente en 72 (32,9 por ciento) pacientes. El sitio más común de afectación del disco fue L4-L5 [151 (68,9 por ciento)]. 143 (65,3 por ciento) pacientes tenían compromiso de disco en un solo sitio. El síntoma clínico más frecuente fue el dolor lumbar [180(82,2 por ciento)]. La compresión de la raíz nerviosa estuvo presente en 154 (70,3 por ciento) pacientes. Se mostró presencia de protuberancia, protrusión, extrusión y secuestro discal en 116 (53 por ciento), 90 (41,1 por ciento), 52 (23,7 por ciento) y 4 (1,8 por ciento) pacientes, respectivamente. La edad de inicio >65 años (p=0,035), la edad de inicio ≤55 años (p=0,004) y el antecedente de impacto directo en la región del cuello (p=0,017) se asociaron con prolapso discal a nivel L2-L3, L4- Nivel L5 y nivel C5-C6 respectivamente, entre pacientes con compromiso discal en un solo sitio. Se encontró que el riesgo de afectación del disco en múltiples niveles aumenta después de 35 años (p<0,001). Se vio más involucradas las vértebras cervicales (p=0,0068). La afectación de las vértebras lumbares (p<0,0001) y lumbosacras (p<0,0001) se observó más entre los pacientes con afectación del disco en un solo sitio. Los fármacos anti-inflamatorios no esteroideos (AINE) [155 (70,8 por ciento)] fueron los medicamentos más utilizados. La microdiscectomía se realizó en 35 (76,1 por ciento) de los 46 pacientes que se sometieron a manejo quirúrgico. Conclusiones: Es necesario fomentar hábitos de ejercicio entre las personas para la prevención de los TDI. Los diversos grupos de alto riesgo identificados en este estudio deben someterse a pruebas periódicas de IDD(AU)

Associations between social determinants of health and interpersonal violence-related injury in Cameroon: a cross-sectional study.

INTRODUCTION: Risk factors for interpersonal violence-related injury (IPVRI) in low-income and middle-income countries (LMICs) remain poorly defined. We describe associations between IPVRI and select social determinants of health (SDH) in Cameroon. METHODS: We conducted a cross-sectional analysis of prospective trauma registry data collected from injured patients >15 years old between October 2017 and January 2020 at four Cameroonian hospitals. Our primary outcome was IPVRI, compared with unintentional injury. Explanatory SDH variables included education level, employment status, household socioeconomic status (SES) and alcohol use. The EconomicClusters model grouped patients into household SES clusters: rural, urban poor, urban middle-class (MC) homeowners, urban MC tenants and urban wealthy. Results were stratified by sex. Categorical variables were compared via Pearson's χ2 statistic. Associations with IPVRI were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). RESULTS: Among 7605 patients, 5488 (72.2%) were men. Unemployment was associated with increased odds of IPVRI for men (aOR 2.44 (95% CI 1.95 to 3.06), p<0.001) and women (aOR 2.53 (95% CI 1.35 to 4.72), p=0.004), as was alcohol use (men: aOR 2.33 (95% CI 1.91 to 2.83), p<0.001; women: aOR 3.71 (95% CI 2.41 to 5.72), p<0.001). Male patients from rural (aOR 1.45 (95% CI 1.04 to 2.03), p=0.028) or urban poor (aOR 2.08 (95% CI 1.27 to 3.41), p=0.004) compared with urban wealthy households had increased odds of IPVRI, as did female patients with primary-level/no formal (aOR 1.78 (95% CI 1.10 to 2.87), p=0.019) or secondary-level (aOR 1.54 (95% CI 1.03 to 2.32), p=0.037) compared with tertiary-level education. CONCLUSION: Lower educational attainment, unemployment, lower household SES and alcohol use are risk factors for IPVRI in Cameroon. Future research should explore LMIC-appropriate interventions to address SDH risk factors for IPVRI.

Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.

INTRODUCTION: Despite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in low/middle-income countries (LMICs), such as Tanzania, compared with high-income countries. We evaluated the impact of a multicomponent safe surgery intervention in Tanzania, hypothesising it would (1) increase adherence to safety practices, such as the WHO Surgical Safety Checklist (SSC), (2) reduce SSI rates following caesarean section (CS) and (3) reduce CS-related perioperative mortality rates (POMRs). METHODS: We conducted a pre-cross-sectional/post-cross-sectional study design to evaluate WHO SSC utilisation, SSI rates and CS-related POMR before and 18 months after implementation. Our interventions included training of inter-professional surgical teams, promoting use of the WHO SSC and introducing an infection prevention (IP) bundle for all CS patients. We assessed use of WHO SSC and SSI rates through random sampling of 279 individual CS patient files. We reviewed registers and ward round reports to obtain the number of CS performed and CS-related deaths. We compared proportions of individuals with a characteristic of interest during pre-implementation and post implementation using the two-proportion z-test at p≤0.05 using STATA V.15. RESULTS: The SSC utilisation rate for CS increased from 3.7% (5 out of 136) to 95.1% (136 out of 143) with p<0.001. Likewise, the proportion of women with SSI after CS reduced from 14% during baseline to 1% (p=0.002). The change in SSI rate after the implementation of the safe surgery interventions is statistically significant (p<0.001). The CS-related POMR decreased by 38.5% (p=0.6) after the implementation of safe surgery interventions. CONCLUSION: Our findings show that our intervention led to improved utilisation of the WHO SSC, reduced SSIs and a drop in CS-related POMR. We recommend replication of the interventions in other LMICs.

Impact of zero-mark-up medicines policy on hospital revenue structure: a panel data analysis of 136 public tertiary hospitals in China, 2012-2020.

OBJECTIVE: To quantify the overall and dynamic effects of the implementation of the zero-mark-up medicines policy on the proportionate revenue generated from medicines, medical services and government subsidies at Chinese tertiary public hospitals. METHODS: The revenue data of 136 tertiary public hospitals from 2012 to 2020 and the implementation-time framework of zero-mark-up medicines policy of these hospitals were obtained from the institutional survey of the third-party evaluation of the China Healthcare Improvement Initiative. The study adopted the time-varying difference-in-differences method and combined it with the event study approach to estimate the effects of the zero-mark-up medicines policy. RESULTS: Following the implementation of the policy, the proportionate medicines revenue decreased by 3.23% (p<0.001); the proportionate medical services revenue increased by 3.48% (p=0.001); and the difference in the proportionate government subsidies revenue was not significant. In the year of implementation, the proportion of revenue generated from medicines decreased by 7.76% (p=0.0148); and that from medical services increased by 8.62% (p=0.0167). The effect of the policy gradually strengthened thereafter. In 2020, the sixth year after some hospitals started the implementation of the policy, the share of revenue generated from medicines decreased the most by 18.43% (p=0.0151), and that generated from medical services increased the most by 15.29% (p=0.0219). The share of revenue generated from government subsidies increased by 2%-5% in the second, third, fifth and sixth years following implementation (p<0.05). CONCLUSIONS: Although the policy goal of adjusting hospital revenue structure has been achieved, the findings were insufficient to conclude whether the policy goal of establishing a scientific compensation mechanism was met by increasing the price of medical services and government input. Additionally, whether there was an unexpected policy effect requires further analysis.

Influence of travel time and distance to the hospital of care on stillbirths: a retrospective facility-based cross-sectional study in Lagos, Nigeria.

INTRODUCTION: Access to emergency obstetric care can lead to a 45%-75% reduction in stillbirths. However, before a pregnant woman can access this care, she needs to travel to a health facility. Our objective in this study was to assess the influence of distance and travel time to the actual hospital of care on stillbirth. METHODS: We conducted a retrospective cross-sectional study of pregnant women who presented with obstetric emergencies over a year across all 24 public hospitals in Lagos, Nigeria. Reviewing clinical records, we extracted sociodemographic, travel and obstetric data. Extracted travel data were exported to Google Maps, where typical distance and travel time for period-of-day they travelled were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on stillbirth. RESULTS: Of 3278 births, there were 408 stillbirths (12.5%). Women with livebirths travelled a median distance of 7.3 km (IQR 3.3-18.0) and over a median time of 24 min (IQR 12-51). Those with stillbirths travelled a median distance of 8.5 km (IQR 4.4-19.7) and over a median time of 30 min (IQR 16-60). Following adjustments, though no significant association with distance was found, odds of stillbirth were significantly higher for travel of 10-29 min (OR 2.25, 95% CI 1.40 to 3.63), 30-59 min (OR 2.30, 95% CI 1.22 to 4.34) and 60-119 min (OR 2.35, 95% CI 1.05 to 5.25). The adjusted OR of stillbirth was significantly lower following booking (OR 0.37, 95% CI 0.28 to 0.49), obstetric complications with mother (obstructed labour (OR 0.11, 95% CI 0.07 to 0.17) and haemorrhage (OR 0.30, 95%CI 0.20 to 0.46)). Odds were significantly higher with multiple gestations (OR 2.40, 95% CI 1.57 to 3.69) and referral (OR 1.55, 95% CI 1.13 to 2.12). CONCLUSION: Travel time to a hospital was strongly associated with stillbirth. In addition to birth preparedness, efforts to get quality care quicker to women or women quicker to quality care will be critical for efforts to reduce stillbirths in a principally urban low-income and middle-income setting.

Model for developing context-sensitive responses to vulnerability in research: managing ethical dilemmas faced by frontline research staff in Kenya.

Health research in low-resource settings often involves individuals and populations defined as 'vulnerable'. There is growing attention in the literature to the ethical dilemmas that frontline research staff face while conducting such research. However, there is little documented as to how research staff might support one another in identifying and handling these dilemmas in different contexts. Over the course of conducting empirical ethics research embedded in the Childhood Acute Illness & Nutrition Network, we developed an approach to examine and respond to the ethical issues and dilemmas faced by the study teams, particularly frontline staff. In this paper we describe the specific tools and approach we developed, which centred on regular cross-team ethics reflection sessions, and share lessons learnt. We suggest that all studies involving potentially vulnerable participants should incorporate activities and processes to support frontline staff in identifying, reflecting on and responding to ethical dilemmas, throughout studies. We outline the resources needed to do this and share piloted tools for further adaptation and evaluation. Such initiatives should complement and feed into-and certainly not in any way replace or substitute for-strong institutional ethics review, safeguarding and health and safety policies and processes, as well broader staff training and career support initiatives.

How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco.

BACKGROUND: In Morocco's health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals. METHODS: We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of 'negotiated order' and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco. RESULTS: Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care. CONCLUSION: The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.

Clinical and etiological profile of epilepsy at the regional hospital center of Tahoua (Niger): A 4-year retrospective study.

OBJECTIVE: We aimed to evaluate epilepsy management at the regional hospital center (RHC) of Tahoua (Niger) to determine the intrahospital deficiencies to optimize to improve the management of people with epilepsy. METHODS: A descriptive retrospective study was carried out at the Psychiatric Unit of the RHC of Tahoua between January 1, 2016 and December 31, 2019. We collected from the registers of consultation all patients followed by nurse technicians in mental health for epilepsy whose diagnosis was made by nonspecialist physicians or internists. The study included patients with epilepsy who had a medical follow-up at least 6 months. RESULTS: Of the 2022 patients seen during the period of the study, 246 patients were consulted for epilepsy with a hospital frequency of 12.2%. The mean age was 22.38 years, with a slight predominance of men (57.7%). Only generalized tonic-clonic seizures (95.1%) and focal-aware seizures (4.9%) were reported. The main etiologies were cerebral malaria (18.7%), bacterial meningitis (8.1%), and head trauma (4.9%). In 60.2% of cases, the etiology was undetermined, but the etiological diagnosis investigation was incomplete (CT scan not done). Only the first-generation antiepileptic drugs were used. Only 2.8% of the patients had drug-resistant epilepsy, and 97.2% of the patients had controlled seizures. CONCLUSION: The study shows a predominance of infectious causes, particularly cerebral malaria. We found a high proportion of epilepsies with unknown etiologies with incomplete workup. The RHC of Tahoua should facilitate access to the CT scan for people with epilepsy to improve etiological diagnosis investigation.

Austerity, resilience and the management of actors in public hospitals: a qualitative study from South Africa.

BACKGROUND: Global economic recession coupled with internal inefficiencies and corruption has led to a period of austerity in the South African healthcare system.This paper examines the strategies used by management in response to austerity in the three public hospitals and their effect on organisational functioning. METHODS: We used a comparative qualitative case study approach, collecting data using a combination of in-depth interviews with managers, and focus group discussion and interviews with shop stewards and staff. RESULTS: Austerity, imposed by the introduction of a provincial cost containment committee, has led to a reduction in staff, benefits, shortages of equipment and delayed procurement and recruitment processes. Managers in the first hospital maintained training on labour relations for staff and managers, they jointly planned how to cope with reduced staff and initiated a new forum for HR and finance staff. These strategies improved the way actors engaged, enabling them to resolve problems. Good communication ensured that staff understood what was within the hospitals control and what was not. A second hospital relied on absorptive strategies, such as asking staff to do more with less. The result was resistance, and greater use of sick leave. Some staff gave their own money to help feed patients but were angry at management for putting them in this difficult position. Leadership in the third hospital did not manage actors well either; help from the Government's Expanded Public Works Programme was rejected by the unions, managers did not attend meetings as they felt their contributions were not listened to. Poor communication meant that the managers and staff did not understand what was within the hospital's control and what was not; a misunderstanding led to a physical fight between managers. CONCLUSION: Organisational resilience in the face of austerity requires leaders to manage different stakeholders well. Hospital managers who promote democratic or participatory leadership and management, open communication, teamwork and trust among all stakeholders will lead better functioning organisations. A special focus should be placed on such practices to develop the resilience of health systems' organisations.

Exploration of the risk factors of essential hypertension with hyperhomocysteinemia: A hospital-based study and nomogram analysis

OBJECTIVES: To explore the risk factors of essential hypertension with hyperhomocysteinemia (H-type hypertension) and design a nomogram to predict this risk. METHODS: A hospital-based study was conducted on 1,712 individuals, including 282 patients with H-type hypertension, 105 patients with simple hypertension, 645 individuals with hyperhomocysteinemia, and 680 healthy controls. Logistic regression and nomogram models were applied to evaluate the risk factors. RESULTS: Logistic regression showed that advanced age, male sex, high body mass index (BMI), high total cholesterol levels, high glucose levels, and high creatinine levels were risk factors of H-type hypertension in the healthy population and were integrated into the nomogram model. Advanced age, male sex, high BMI, high total cholesterol levels, and high glucose levels were shown to be risk factors of H-type hypertension in the hyperhomocysteinemia population. Male sex and high creatinine levels were shown to be risk factors of H-type hypertension in the hypertension population. Nomogram analysis showed that the total factor score ranged from 106 to 206, and the corresponding risk rate ranged from 0.05 to 0.95. CONCLUSIONS: Men are more likely to have H-type hypertension, and advanced age, high BMI, high total cholesterol levels, and high glucose levels are risk factors of H-type hypertension in healthy and hyperhomocysteinemia populations. Furthermore, high creatinine level is a risk factor of H-type hypertension in healthy and hypertension populations. Nomogram models may be used to intuitively evaluate H-type hypertension risk and provide a basis for personalized interventions.

Determinants of anxiety and depression in patients with cubital tunnel syndrome.

BACKGROUND: The aim of this cross-sectional study to assess the proportions of anxiety and depression in patients with CuTS, and to explore the associated demographic and clinical features. METHODS: From May 2011 to January 2017, 246 patients diagnosed with CuTS were recruited. The Hospital Anxiety and Depression Scale was used to assess the proportions of depression and anxiety. Patient demographic and clinical data were collected. Univariate analysis and multivariate regression were carried out to identify the variables that were independently associated with anxiety and depression. RESULTS: The proportions of depression and anxiety were 17.9% (n = 44) and 14.2% (n = 35), respectively. Five patients had both possible/probable anxiety and depression. Logistic regression analysis revealed that diabetes mellitus was independently associated with depression; and the modified McGowan grade was independently associated with anxiety. CONCLUSIONS: In patients with CuTS, the proportions of depression and anxiety were 17.9% and 14.2%, respectively. Early screening for anxiety and depression is beneficial for patients with CuTS.

The impact of demonetisation on the utilisation of hospital services, patient outcomes and finances: a multicentre observational study from India.

BACKGROUND: This study assessed trends in healthcare utilisation in relation to the implementation of an economic policy in India wherein 500 and 1000 rupee notes were demonetised. METHODS: In this ambidirectional observational study of private not-for-profit hospitals, data on hospital outpatient and inpatient numbers, surgeries, emergency department (ED) visits, obstetric admissions and mortality were obtained for pre-demonetisation (September/October 2016), early (November/December 2016) and late demonetisation (January/February 2017), and post-demonetisation periods (March/April 2017) and compared with the control period (2015-2016) from 11 centres (three tertiary hospitals; eight secondary). A Bayesian regression analysis was performed to adjust for seasonal (winter) effect. Monthly financial data, including the proportion of cash versus non-cash transactions, were collected. FINDINGS: Overall, at the pooled all-hospital level, Bayesian analysis showed non-significant increase in outpatients (535.4, 95% CI -7097 to 8116) and decrease in deaths (-6.3 per 1000 inpatients, 95% CI -15.45 to 2.75) and a significant decrease in inpatients (-145.6, 95% CI -286.4 to -10.63) during demonetisation. Analysis at the level of secondary and tertiary hospitals showed a variable effect. For individual hospitals, after adjusting for the seasonal effect, some hospitals observed a significant reduction in outpatient (n=2) and inpatient (n=3) numbers, ED visits (n=4) and mortality (n=2) during demonetisation, while others reported significantly increased outpatient numbers (n=3) and ED visits (n=2). Deliveries remained unchanged during demonetisation in the hospitals that provided the service. There was no significant reduction in hospital incomes during demonetisation. In tertiary hospitals, there was a significant increase in non-cash component of transactions from 35% to 60% (p=0.02) that persisted beyond the demonetisation period. CONCLUSIONS: The effect of demonetisation on healthcare utilisation was variable. Some hospitals witnessed a significant reduction in utilisation in some areas, while others reported increased utilisation. There was an increase in non-cash transactions that persisted beyond the period of demonetisation.

Incidence of treatment for postabortion complications in India, 2015.

Abortion has been legal under broad criteria in India since 1971. However, access to legal abortion services remains poor. In the past decade, medication abortion (MA) has become widely available in India and use of this method outside of health facilities accounts for over 70% of all abortions. Morbidity from unsafe abortion remains an important health issue. The informal providers who are the primary source of MA may have poor knowledge of the method and may offer inadequate or inaccurate advice on use of the method. Misuse of the method can result in women seeking treatment for true complications as well as during the normal processes of MA. An estimated 5% of all abortions are done using highly unsafe methods and performed by unskilled providers, also contributing to abortion morbidity. This paper provides new representative abortion-related morbidity measures at the national and subnational levels from a large-scale 2015 study of six Indian states-Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh. The outcomes include the number and treatment rates of women with complications resulting from induced abortion and the type of complications. The total number of women treated for abortion complications at the national level is 5.2 million, and the rate is 15.7 per 1000 women of reproductive age per year. In all six study states, a high proportion of all women receiving postabortion care were admitted with incomplete abortion from use of MA-ranging from 33% in Tamil Nadu to 65% in Assam. The paper fills an important gap by providing new evidence that can inform policy-makers and health planners at all levels and lead to improvements in the provision of postabortion care and legal abortion services-improvements that would greatly reduce abortion-related morbidity and its costs to Indian women, their families and the healthcare system.

Effects of chronic physical disease and systemic inflammation on suicide risk in patients with depression: a hospital-based case-control study.

BACKGROUND: Few studies have examined the concurrent effects of physical disease and systemic inflammation on suicide risk in patients with depression. The authors investigated the independent contributions of chronic physical disease and systemic inflammation as indexed by C-reactive protein (CRP), on risk of suicide attempt. METHODS: In this case-control study, 1468 cases of suicide attempters and 14 373 controls, both aged 18-65 years with a diagnosis of depression during 2011-2015, were identified from the hospital-wide database. Regression models were implemented to identify separate effects of physical diseases and systemic inflammation indexed by CRP, on risk of suicide attempt. RESULTS: Compared with having no physical disease, having one, two, and three or more physical diseases was associated with a 3.6-, 6.4-, and 14.9-fold increase in odds of making a suicide attempt, respectively, after adjusting for age, sex, and race/ethnicity. In a sub-sample of cases and controls with available CRP values, patients with high CRP (>3 mg/L) had 1.9 times the odds of suicide attempt compared with patients with low CRP (<1 mg/L). This association was no longer significant when controlling for the effect of physical disease. CONCLUSIONS: The presence of physical disease is an important risk factor for suicide attempt among patients with depression. Systemic inflammation is likewise associated with increased risk for suicide attempt, however, this association appears to be accounted for by the presence of physical disease among patients receiving care in a medical center setting. Healthcare providers should consider the risk of suicide attempt in depressed patients burdened with multiple comorbidities.

Clinical and Etiological Characteristics of Epilepsy in the Elderly: A Hospital-Based Study from a Tertiary Care Referral Center of Niamey, Niger.

Objectives The aim of this study is to evaluate the management of epilepsy in the elderly at a tertiary referral center in Niger to obtain a comprehensive understanding to determine the intrahospital deficiencies to improve and to make recommendations in terms to improve the management of epilepsy in the elderly in Niger. Materials and Methods We conducted a retrospective study at the Neurology Outpatient Clinic of the National Hospital of Niamey (Niger) over a period of 5 years from May 2013 to May 2018, collecting all cases of patients aged 60 years or over diagnosed with epilepsy by neurologists. From the registers of consultation, we collected and analyzed for each patient the demographic, clinical, etiological, and therapeutic data, as well as the outcomes during follow-up visits. Results Of the 4,576 patients of all ages seen during the period of our study, we included 62 patients aged 60 years or over diagnosed with epilepsy with a hospital frequency of 1.35%. The mean age of patients was 65.82 ± 5.72 years (range: 60 and 83 years) with a predominance of the male sex (sex ratio at 1.6). Patients aged 60 to 64 years were the most represented (43.5%). Generalized tonic-clonic seizures were the most frequent (41.9%), followed by focal to bilateral tonic-clonic seizures (25.8%). All patients underwent electroencephalogram. Only 30 patients (48.4%) underwent brain imaging, and mainly brain computed tomography scan. The etiologies included poststroke epilepsy (25.8%), brain tumors (3.2%), cerebral toxoplasmosis (3.2%), and cerebral meningioma (1.6%). We found 41 cases (66.1%) of epilepsy without definite etiology and with an incomplete workup. Carbamazepine and phenobarbital were the only two antiepileptic drugs (AEDs) used. Conclusion The present study shows limited access to newer generation AEDs and diagnostic tests of epilepsy in Niger. Considerable efforts should be made to facilitate for people living with epilepsy the accessibility to diagnostic tests and the newer generation AEDs to improve the quality of epilepsy management in Niger.

A Hospital-based Study of the Prevalence and Usage of Complementary and Alternative Medicine Among Saudi Psychiatric Patients.

Introduction Complementary and alternative medicine (CAM) therapies, used singularly or in combination with more conventional therapies, are routinely used by citizens of the Kingdom of Saudi Arabia (KSA) for medical care or seeking wellness. However, the prevalence of CAM therapies among Saudi psychiatric patients is not yet documented. To better understand the importance of CAM in today's medical field, particularly within the KSA and for psychiatric patients, this descriptive study aims to characterize the use of CAM therapies by a sample of psychiatric patients in the KSA. Methods This cross-sectional hospital-based study describes the use of CAM therapies by Saudi psychiatric patients being treated at one of the largest government hospitals in the KSA. Using a pretested questionnaire, adult psychiatric patients waiting for their appointment or during their stay at a government hospital in Riyadh were interviewed regarding the use of CAM therapies after agreeing to participate. Results Forty-five adult psychiatric patients agreed to participate in this study. The average age of the participants in the study was 35. Of the participants, 62% were females, 91.1% were outpatients, and 44.4% were diagnosed with depression. Moreover, 82.2% of the participants reported using one or more types of CAM therapies within the past year to address mental illness. Of those who used CAM therapies, 62.2% did so to improve their quality of life; 59.5% did so for treatment, supportive treatment, or both, and 54.1% used CAM therapies to help control symptoms. The most frequent CAM therapies used by psychiatric patients were spiritual therapies such as Quran recitation; body therapies, mainly exercise; and mind therapies, mainly relaxation techniques. These CAM therapies were used mainly as treatments or supportive treatments for depression. Most of the participants who used CAM therapies were satisfied with the use of these therapies (75.7%). Finally, 45.9% of the participants had not discussed the use of CAM therapies with their doctors, primarily because of their reluctance to share private information, especially spiritual matters, with the treating physicians. Conclusions The study results suggest a high prevalence of CAM therapy use among Saudi adult psychiatric patients, as well as a high level of satisfaction with such therapies. However, since about half of the patients had not discussed the use of CAM therapies with their physicians, and since some of the CAM therapies may cause unfavorable interactions when used alongside certain medications or medical interventions, healthcare providers should be diligent about inquiring of their psychiatric patients any use of CAM therapies, not only during the initial visit but also during the follow-up visits as well.