Assessing the contributions of an urban population health initiative to shift political priority towards cardiovascular health: three case studies from Brazil, Mongolia and Senegal.

BACKGROUND: The urban population health initiative was designed as a multidisciplinary, multisector programme to address cardiovascular (CV) disease, specifically hypertension and its underlying causes in the cities of Ulaanbaatar, Mongolia; Dakar, Senegal; and São Paulo, Brazil. This article aims to provide an overview of the history and dynamics of CV disease policy making in the three countries, to present the policy reform contributions of the initiative and its role in the policy agenda-setting framework/process in each country and to identify the enablers and challenges to the initiative for doing so. METHODS: A qualitative case study was conducted for each setting from November 2020 to January 2021, comprised of a document review, semi-structured in-depth interviews and unstructured interviews with stakeholders involved in the initiative. The literature review included documents from the initiative and the peer-reviewed and grey literature with a total of 188 documents screened. Interviews were conducted with 21 stakeholders. Data collection and thematic analysis was guided by (i) the Kingdon multiple streams conceptual framework with the main themes being CV disease problems, policy, politics and the role of policy entrepreneurs; and (ii) the study question inquiring on the role of the urban population health initiative at the CV disease policy level and enabling and challenging factors to advancing CV disease policy. Data were thematically analysed using the Framework Method. RESULTS: Each setting was characterized by a high hypertension and CV disease burden combined with an aware and proactive political environment. Policy outcomes attributed to the initiative were updating the guidelines and/or algorithms of care for hypertension and including revised physical and nutritional education in school curricula, in each city. Overall, the urban health initiative's effects in the policy arena, were most prominent in Mongolia and Senegal, where the team effectively acted as policy entrepreneur, promoting the solutions/policies in alignment with the most pressing local problems and in strong involvement with the political actors. The initiative was also involved in improving access to CV disease drugs at primary health levels. Its success was influenced by the local governance structures, the proximity of the initiative to the policy makers and the local needs. In Brazil, needs were expressed predominantly in the clinical practice. CONCLUSIONS: This multi-country experience shows that, although the policy and political environment plays its role in shaping initiatives, often the local priority needs are the driving force behind wider change.

A Global Positioning System Used to Monitor the Physical Performance of Elite Beach Handball Referees in a Spanish Championship.

Beach handball is a fully developed sporting discipline on all five continents which has attracted the attention of researchers in the last decade, resulting in a proliferation of different studies focusing on players but not on referees. The main objective of this cross-sectional research was to determine the physical demands on elite male beach handball referees in four different competitions: U18 male; U18 female; senior male; and senior female. Twelve elite federated male referees (age: 30.86 ± 8 years; body height: 175.72 ± 4.51 cm; body weight: 80.18 ± 17.99 kg; fat percentage: 20.1 ± 4.41%; national or international experience) belonging to the Technical Committee of the Royal Spanish Handball Federation were recruited for this the study. The physical demands required of referees in official matches were measured by installing a GPS device. The sampling frequency used to record their speed and distance was 15 Hz. A triaxial accelerometer (100 Hz) was used to determine their acceleration. An analysis of variance (ANOVA) between competitions with post hoc comparisons using the Bonferroni adjustment was used to compare among categories. A higher distance covered in zone 1 and speeds of 0 to 6 km-h-1 were recorded. Most accelerations and decelerations occurred in zones 0 and 1 (zone 0: 0 to 1 m·s-2; zone 1: 1 to 2 m·s-2). The lack of differences (p > 0.05) between most analysed variables suggest quite similar physical demands of the four analysed competitions. These results provide relevant information to design optimal training plans oriented to the real physical demands on referees in an official competition.

A Retrospective Look at a Cervical Spine Clearance Protocol in Pediatric Trauma Patients at a Level-1 Trauma Center.

BACKGROUND: Adult studies have demonstrated the efficacy of written protocols for clearance of the cervical spine. However, less than half of recently surveyed pediatric trauma centers report using a documented protocol. Little data exists on such protocols in pediatric populations, but interest remains because of potential reductions in radiation exposure, time to clearance, hospital stay, and specialist referral. However, missed injury can have devastating consequences. The purpose of this study is to examine the efficacy in detecting injury of an implemented cervical spine clearance protocol at a level-1 pediatric trauma hospital. METHODS: A retrospective review was performed on pediatric patients presenting as activated traumas to the emergency department of a single level-1 pediatric trauma hospital between May 2010 and October 2018. This institution has utilized a written cervical spine clearance protocol throughout this time. Presence of cervical spine injury, documented clearance, cervical spine imaging, and follow-up documentation were reviewed for any missed injuries. RESULTS: There were no missed cervical spine injuries. Five-hundred sixty-three clinically significant cervical spine injuries were identified, representing 16.5% of patients. Of these, 96 were fractures, dislocations, or ligamentous injuries, representing 2.8% of all patients. Most cervical spine clearances were performed by trauma surgery. Advanced imaging of the cervical spine was ordered for 43.2% of patients overall and trended down over time. CONCLUSION: Documented cervical spine clearance protocols are effective for detection of significant injury in pediatric trauma patients. This study suggests these protocols minimize risk of missed injury and may prevent unnecessary radiation exposure, delayed clearance, prolonged hospitalization, or unnecessary specialist referral. CLINICAL RELEVANCE: Utilization of a standard written protocol for cervical spine clearance likely prevents missed injury and helps to minimize radiation exposure in pediatric populations. Further research is needed on evaluation and management of pediatric cervical spine trauma.

Improving quality of medical certification of causes of death in health facilities in Tanzania 2014-2019.

BACKGROUND: Monitoring medically certified causes of death is essential to shape national health policies, track progress to Sustainable Development Goals, and gauge responses to epidemic and pandemic disease. The combination of electronic health information systems with new methods for data quality monitoring can facilitate quality assessments and help target quality improvement. Since 2015, Tanzania has been upgrading its Civil Registration and Vital Statistics system including efforts to improve the availability and quality of mortality data. METHODS: We used a computer application (ANACONDA v4.01) to assess the quality of medical certification of cause of death (MCCD) and ICD-10 coding for the underlying cause of death for 155,461 deaths from health facilities from 2014 to 2018. From 2018 to 2019, we continued quality analysis for 2690 deaths in one large administrative region 9 months before, and 9 months following MCCD quality improvement interventions. Interventions addressed governance, training, process, and practice. We assessed changes in the levels, distributions, and nature of unusable and insufficiently specified codes, and how these influenced estimates of the leading causes of death. RESULTS: 9.7% of expected annual deaths in Tanzania obtained a medically certified cause of death. Of these, 52% of MCCD ICD-10 codes were usable for health policy and planning, with no significant improvement over 5 years. Of certified deaths, 25% had unusable codes, 17% had insufficiently specified codes, and 6% were undetermined causes. Comparing the before and after intervention periods in one Region, codes usable for public health policy purposes improved from 48 to 65% within 1 year and the resulting distortions in the top twenty cause-specific mortality fractions due to unusable causes reduced from 27.4 to 13.5%. CONCLUSION: Data from less than 5% of annual deaths in Tanzania are usable for informing policy. For deaths with medical certification, errors were prevalent in almost half. This constrains capacity to monitor the 15 SDG indicators that require cause-specific mortality. Sustainable quality assurance mechanisms and interventions can result in rapid improvements in the quality of medically certified causes of death. ANACONDA provides an effective means for evaluation of such changes and helps target interventions to remaining weaknesses.

Global Positioning System Analysis of Physical Demands in Elite Women's Beach Handball Players in an Official Spanish Championship.

This cross-sectional study aims to analyze the physical demands of elite beach handball players during an official competition. Nine elite female (mean age: 24.6 ± 4.0 years; body weight: 62.4 ± 4.6 kg; body height: 1.68 ± 0.059 m; training experience: 5 years; training: 6 h/week) beach handball players of the Spanish National Team were recruited for this study. A Global Positioning System was incorporated on each player's back to analyze their movement patterns. Speed and distance were recorded at a sampling frequency of 15 Hz, whereas acceleration was recorded at 100 Hz by means of a built-in triaxial accelerometer. The main finding of the study is that 53% of the distance travelled is done at speeds between 1.5 and 5 km/h and 30% of the distance is between 9 and 13 km/h (83% of the total distance covered), which shows the intermittent efforts that beach handball involves at high intensity, as reflected in the analysis of the internal load with 62.82 ± 14.73% of the game time above 80% of the maximum heart rate. These data help to orientate training objectives to the physical demands required by the competition in order to optimize the players' performance.

Excess mortality during COVID-19 pandemic in Bangladesh - evidence from a rural survey.

Background: The coronavirus disease 2019 (COVID-19) had a profound impact worldwide. In Bangladesh, the official number of deaths for COVID-19 was around 29 000. However, many countries including Bangladesh experienced substantial underreporting of COVID-19 deaths due to lack of complete national civil registration system. This study aims to estimate excess mortality in 2020, identify risk factors, and determine leading causes of death in Bangladesh. Methods: In February 2021, we conducted a cross-sectional household survey in Sitakunda, a subdistrict of Chattogram, identifying deaths from January 2018 to December 2020. Excess mortality was quantified using the p-score and incidence rate ratio (IRR) utilising Poisson segmented regression. We employed the InterVA-5 algorithm to attribute causes of death. Proportional distribution and cause-specific mortality rates (CSMR) per 100 000 individuals were compared between pre-pandemic and pandemic periods. Results: Among 1748 deaths from 25 669 households, we found 1.4 (95% confidence interval (CI) = 1.2-1.4) times excess mortality in 2020 compared to 2018-2019. Leading causes of death in 2020 included cardiac disease (CSMR = 121.0, CI = 115.8-127.3), stroke (CSMR = 108.0, CI = 102.6-114.0), and acute respiratory infection (CSMR = 61.0, CI = 55.1-66.5), all displaying significantly higher mortality rates than in previous years. Older age (IRR = 1.6), less education (IRR = 1.8), and lower socio-economic groups (IRR = 2.1) had higher mortality rates in 2020 compared to pre-pandemic years. Conclusion: Our study suggests high rural excess mortality during COVID-19 including cardiac disease, stroke and acute respiratory infection as the leading causes of deaths. We require targeted strategies to identify high-risk patients with comorbidity and social vulnerabilities that contribute to mortality to guide the preparedness strategy for future pandemics.

Thoracic Spine Fracture After Cardiopulmonary Resuscitation in a Patient with Ankylosing Spondylitis: A Case Report.

CASE: A 32-year-old man with a history of ankylosing spondylitis presented to the emergency department because of sepsis secondary to Fournier's gangrene and subsequently went into cardiac arrest requiring cardiopulmonary resuscitation (CPR). On the twelfth hospital day, a fracture through the T5-T6 intervertebral disk space was incidentally found on a chest, abdominal, and pelvic Computed Tomography (CT) scan. The rounds of CPR were the only traumatic event that the patient underwent before the discovery of the spine fracture. CONCLUSION: A low threshold for advanced imaging should be held to rule out occult spine fractures in patients with ankylosed spines after receiving CPR.

The Biomedical Entrepreneurship Skills Development Program (BEEP): Educating a New Generation of Medical Innovators.

Innovative, new technologies are rapidly being introduced into the medical world, as scientists and inventors continually discover solutions to all kinds of health issues. However, comprehensive education in medical product development, business process and strategy is distinctly lacking for science students who aspire to become commercial medical innovators and entrepreneurs. Entrepreneurially minded professionals at the New York University Grossman School of Medicine developed, implemented, and integrated programs to train early scientists in the business side of science to accelerate the pace of commercialisation and encourage individuals to pursue venture creation and entrepreneurship to impact highly relevant healthcare solutions.

Cause of Death estimation from Verbal Autopsies: Is the Open Response redundant or synergistic?

Civil registration and vital statistics systems capture birth and death events to compile vital statistics and to provide legal rights to citizens. Vital statistics are a key factor in promoting public health policies and the health of the population. Medical certification of cause of death is the preferred source of cause of death information. However, two thirds of all deaths worldwide are not captured in routine mortality information systems and their cause of death is unknown. Verbal autopsy is an interim solution for estimating the cause of death distribution at the population level in the absence of medical certification. A Verbal Autopsy (VA) consists of an interview with the relative or the caregiver of the deceased. The VA includes both Closed Questions (CQs) with structured answer options, and an Open Response (OR) consisting of a free narrative of the events expressed in natural language and without any pre-determined structure. There are a number of automated systems to analyze the CQs to obtain cause specific mortality fractions with limited performance. We hypothesize that the incorporation of the text provided by the OR might convey relevant information to discern the CoD. The experimental layout compares existing Computer Coding Verbal Autopsy methods such as Tariff 2.0 with other approaches well suited to the processing of structured inputs as is the case of the CQs. Next, alternative approaches based on language models are employed to analyze the OR. Finally, we propose a new method with a bi-modal input that combines the CQs and the OR. Empirical results corroborated that the CoD prediction capability of the Tariff 2.0 algorithm is outperformed by our method taking into account the valuable information conveyed by the OR. As an added value, with this work we made available the software to enable the reproducibility of the results attained with a version implemented in R to make the comparison with Tariff 2.0 evident.

Health system resilience: a critical review and reconceptualisation.

This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neglect of equity and of who is bearing the costs of resilience strategies. Resilience depends crucially on relationships between system actors and components, and-as amply shown during the COVID-19 pandemic-relationships with wider systems (eg, economic, political, and global governance structures). Resilience is therefore connected to power imbalances, which need to be addressed to enact the transformative strategies that are important in dealing with more persistent shocks and stressors, such as climate change. We discourage the framing of resilience as an outcome that can be measured; instead, we see it emerge from systemic resources and interactions, which have effects that can be measured. We propose a more complex categorisation of shocks than the common binary one of acute versus chronic, and outline some of the implications of this for resilience strategies. We encourage a shift in thinking from capacities towards capabilities-what actors could do in future with the necessary transformative strategies, which will need to encompass global, national, and local change. Finally, we highlight lessons emerging in relation to preparing for the next crisis, particularly in clarifying roles and avoiding fragmented governance.

The Biomedical Entrepreneurship Skills Development Program for the Advancement of Research Translation: Foundations of Biomedical Startups course, metrics, and impact.

Background/Objective: A growing number of biomedical doctoral graduates are entering the biotechnology and industry workforce, though most lack training in business practice. Entrepreneurs can benefit from venture creation and commercialization training that is largely absent from standard biomedical educational curricula. The NYU Biomedical Entrepreneurship Educational Program (BEEP) seeks to fill this training gap to prepare and motivate biomedical entrepreneurs to develop an entrepreneurial skill set, thus accelerating the pace of innovation in technology and business ventures. Methods: The NYU BEEP Model was developed and implemented with funding from NIDDK and NCATS. The program consists of a core introductory course, topic-based interdisciplinary workshops, venture challenges, on-line modules, and mentorship from experts. Here, we evaluate the efficacy of the core, introductory course, "Foundations of Biomedical Startups," through the use of pre/post-course surveys and free-response answers. Results: After 2 years, 153 participants (26% doctoral students, 23% post-doctoral PhDs, 20% faculty, 16% research staff, 15% other) have completed the course. Evaluation data show self-assessed knowledge gain in all domains. The percentage of students rating themselves as either "competent" or "on the way to being an expert" in all areas was significantly higher post-course (P < 0.05). In each content area, the percentages of participants rating themselves as "very interested" increased post-course. 95% of those surveyed reported the course met its objectives, and 95% reported a higher likelihood of pursuing commercialization of discoveries post-course. Conclusion: NYU BEEP can serve as a model to develop similar curricula/programs to enhance entrepreneurial activity of early-stage researchers.

Express improvement of acute stroke care accessibility in large regions using a centralized telestroke network.

Introduction: Acute ischemic stroke therapy has improved in recent decades, decreasing the rates of disability and death among stroke patients. Unfortunately, all health care systems have geographical disparities in infrastructure for stroke patients. A centralized telestroke network might be a low-cost strategy to reduce differences in terms of geographical barriers, equitable access, and quality monitoring across different hospitals. Aims: We aimed to quantify changes in stroke patients' geographic access to specialized evaluation by neurologists and to intravenous acute stroke reperfusion treatments following the rapid implementation of a centralized telestroke network in the large region of Andalusia (8.5 million inhabitants). Methods: We conducted an observational study using spatial and analytical methods to examine how a centralized telestroke network influences the quality and accessibility of stroke care for a large region. Results: In the pre-implementation period, 5,005,477 (59.72% of the Andalusian population) had access to specialized stroke care in less than 30 min. After the 5-month process of implementing the telestroke network, 7,832,988 (93.5%) inhabitants had an access time of less than 30 min, bridging the gap in acute stroke care in rural hospitals. Conclusions: A centralized telestroke network may be an efficient tool to reduce the differences in stroke care access and quality monitoring across different hospitals, especially in large regions with low population density.

Extracting Cause of Death From Verbal Autopsy With Deep Learning Interpretable Methods.

The international standard to ascertain the cause of death is medical certification. However, in many low and middle-income countries, the majority of deaths occur outside of health facilities. In these cases, Verbal Autopsy (VA), the narrative provided by a family member or friend together with a questionnaire is designed by the World Health Organization as the main information source. Until now technology allowed us to automatically analyze the responses of the VA questionnaire with the narrative captured by the interviewer excluded. Our work addresses this gap by developing a set of models for automatic Cause of Death (CoD) ascertainment in VAs with a focus on the textual information. Empirical results show that the open response conveys valuable information towards the ascertainment of the Cause of Death, and the combination of the closed-ended questions and the open response lead to the best results. Model interpretation capabilities position the Deep Learning models as the most encouraging choice.

Cultivating a New Generation of Biomedical Entrepreneurs.

In recent years, scientific and technological advances have brought great innovation within the life sciences industry, introducing the need for entrepreneurship training for medical and engineering graduates. With this in mind, Michal Gilon-Yanai, Dr Robert Schneider and their collaborators developed an academic program designed to provide students and faculty members with the skills they need to become successful entrepreneurs. The team of collaborators includes Dr Gabrielle Gold-von Simson, an expert in implementing academic programs, and Dr Colleen Gillespie, who specialises in education, evaluation and dissemination science. Their pioneering program trains students on how to bring new biomedical technologies to the market.

Surgical removal of a migrating intraspinal bullet: illustrative case.

BACKGROUND: Management of gunshot wounds to the spine with subsequent spinal cord injury is a controversial topic among spine surgeons. Possible complications of retained intradural bullets include delayed neurological deficits, spinal instability, and lead toxicity. The authors' purpose is to review the potential complications of retained intraspinal bullets and the surgical indications for intraspinal bullet removal. OBSERVATIONS: The authors describe a case of a patient who developed cauda equina symptoms following a gunshot wound to the lumbar spine with a migrating retained intraspinal bullet. Because of neurological changes, the patient underwent surgical removal of the bullet. At the postoperative clinic visit 2 weeks following bullet removal, the patient reported resolution of her symptoms. LESSONS: Gunshot wounds to the spine are challenging cases. The decision to proceed with surgical management in the event of retained bullet fragments is multifactorial and relies heavily on the patient's neurological status. A current review of the literature suggests that, in cases of cauda equina injuries and the development of neurological deficits in patients with retained intraspinal fragments, there is benefit from surgical decompression and bullet removal. Careful preoperative planning is required, and consideration of spinal alignment with positional changes is crucial.

Mediterranean Diet Adherence, Body Composition and Performance in Beach Handball Players: A Cross Sectional Study.

BACKGROUND: Beach handball (BH) is a sport in which sporting performance is influenced, together with team interaction, by individual performance in terms of strength. Body composition is one of the main factors for sports performance and eating habits can condition this variable. The Mediterranean diet (MD) can significantly reduce the risk of mortality or cardiovascular disease. In addition, the Spanish Ministry of Agriculture, Food and Environment carries out different campaigns to promote it among young athletes, establishing it as a suitable diet for sports. OBJECTIVES: The main aims of the study are to assess body composition, physical activity and adherence to the MD of beach handball players. It also aims to evaluate age group differences in male and female players, as well as studying the possible relationship between MD, body composition and performance variables. METHODS: A total of 59 Spanish BH players were recruited in the national championship of BH in the province of Alicante. Thirty-eight male (14 junior; 17.0 ± 0.1 years and 24 seniors; 25.5 ± 4.7 years) and twenty-one female (7 junior; 16.1 ± 1.46 years and 14 seniors; 23.2 ± 2.0 years) BH players participated in this study. The questionnaire to evaluate eating habits was Mediterranean diet adherence (KIDMED). Body composition was measured with electrical bioimpedance. Strength was evaluated by means of a maximum isometric handgrip test of the dominant hand with handgrip and height of jump by counter-jump on contact platform. In the statistical analysis, descriptions and correlations between the study variables were made. RESULTS: In females, when the adherence to the MD is lower, the weight is higher, the lean body mass is lower and worse results are observed in performance tests. As for males, there are differences in weight and lean body mass according to category. CONCLUSIONS: Adequate eating habits are related to the weight of beach handball athletes. In addition, specifically with junior players, it has been observed that adherence to the MD correlates with weight.

Racial/ethnic differences in CD4 T cell count and viral load at presentation for medical care and in follow-up after HIV-1 infection.

The baseline characteristics of antiretroviral-naive patients were compared by ethnic/racial groups. First CD4 T cell counts were lower for Latino (P = 0.0004) and black patients (P = 0.10) when compared with white patients. First HIV-1-RNA levels were higher in Latino patients (P = 0.08), who were also more likely to present with major opportunistic infections (P < 0.004). Once in care, changes in CD4 T cell counts and viral loads over time did not differ significantly between groups.