Association between socio economic status and schistosomiasis infection in Jinja District, Uganda

Objective  To examine the role of socioeconomic situation in influencing the risk and intensity of infection with Schistosomiasis mansoni .
Methods  Cross-sectional study in Walukuba Division bordering Lake Victoria, Jinja District. We assessed a random sample of 463 individuals aged 10–20 years for Schistosoma mansoni infection, water contact behaviour and treatment status with praziquantel as of the last mass treatment. Socioeconomic conditions of the participants' households were assessed by calculating a wealth index (based on type of housing and ownership of assets). Households were classified in four classes; multivariate logistic regression analysis was used to identify independent predictors of being infected with schistosomiasis. Intensities of infection with S. mansoni were compared across the classes of wealth index.
Results  Wealth index emerged a risk factor for infection with S. mansoni after controlling for water contact and treatment with praziquantel. The adjusted odds ratio of being infected for the lowest level of wealth index compared to the highest was 10.42 (95% CI 3.38–32.36 P  <   0.001). The intensity of infection decreased with wealth index Linearity F -ratio 13.91, 1 df, P  <   0.001). The geometric egg count for those in the lowest wealth index was 230 (95% CI 199–279) compared to 114 (95% CI 80–162) for the highest wealth index.
Conclusions  In addition to mass treatment with praziquantel, improving the socio-economic conditions of the population should be given priority.     

Performance of OptiMAL-IT® compared to microscopy, for malaria detection in Burkina Faso

Objective  To compare the performance of OptiMAL-IT^®, a rapid diagnostic test for malaria, with that of microscopy in Burkina Faso.
Method  Finger-prick blood samples of 464 children attending hospital for suspected malaria were tested for malaria by microscopy and OptiMAL-IT^®.
Results  The sensitivity and specificity of OptiMAL-IT^® were 98.7% (CI 95% = 97.6–99.8) and 96.2% (CI 95% = 94.3–98.1) respectively, with a high positive likelihood ratio (25.97).
Conclusion  OptiMAL-IT^® can be considered a good method to diagnose malaria in Burkina Faso, particularly in remote areas with little or no access to microscopy services.     

Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage

Background and Aims:  Risk factors for mortality in acute variceal hemorrhage remain incompletely understood. Whether endoscopy timing is associated with risk of mortality has not been investigated. We aimed to investigate risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage, with emphasis on endoscopy timing.
Methods:  Three hundred and eleven (73% male and 23% female) consecutive cirrhotic patients presenting with acute variceal hemorrhage from July 2004 to July 2007 were investigated. The univariate association of endoscopy timing as the predictor for in-hospital mortality was examined. Independent risk factors for mortality were determined by multivariate logistic regression analysis consisting of clinical, laboratory and endoscopic parameters.
Results:  Twenty-five (8.04%) patients died within admission. By plotting the receiver operating curve of endoscopy timing for mortality, we selected 15 h as the optimal cut-off point to define delayed endoscopy. Multivariate regression analysis revealed that independent risk factors predictive for in-hospital mortality included delayed endoscopy performed 15 h after admission (adjusted odds ratio [aOR] = 3.67; 95% confidence interval [CI], 1.27–10.39), every point increment of model for end-stage liver disease (MELD) score (aOR = 1.16; 95% CI, 1.07–1.25), failure of the first endoscopy (aOR = 4.36; 95% CI, 1.54–12.30) and hematemesis as the chief complaint (compared with melena, aOR = 8.66; 95% CI, 1.06–70.94).
Conclusion:  Delayed endoscopy for more than 15 h, high MELD score, failure of the first endoscopy and hematemesis are independent risk factors for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage.     

Hookworm, Ascaris lumbricoides infection and polyparasitism associated with poor cognitive performance in Brazilian schoolchildren

Objective  To investigate the relationship between hookworm and Ascaris lumbricoides infection and performance on three subsets of the Wechsler Intelligence Scale for Children – third edition (WISC-III) (Digit Span, Arithmetic and Coding) and Raven Colored Progressive Matrices.
Methods  Cross-sectional study of 210 children between the ages of 6 and 11 years in Americaninhas, Minas Gerais, Brazil. Separate proportional odds models were used to measure the association between the intensity of helminth infections and poor performance on each of the four cognitive tests.
Results  After adjusting for sex, age, socioeconomic status and other helminth infections, moderate-to-high-intensity hookworm infection was associated with poor performance on the WISC-III Coding subtest [OR = 3.20; 95% confidence interval (CI) = 1.43–7.17], low intensity of hookworm infection was associated with poor performance on the WISC-III Coding subtest [odds ratio (OR) = 3.71; 95% CI = 1.80–7.66] and moderate-to-high-intensity A. lumbricoides infection was associated with poor performance on the Raven test (OR = 2.03; 95% CI = 1.04–3.99), all in comparison with uninfected children. Children co-infected with A. lumbricoides infection and hookworm infection had greater odds of poor performance on some WISC-III subtests than children with only A. lumbricoides infection.
Conclusions  These findings suggest that hookworm infection may be associated with poorer concentration and information processing skills, as measured on the WISC-III Coding subtest, and that A. lumbricoides infection may be associated with poorer general intelligence, as measured through the Raven Colored Progressive Matrices. This study also presents evidence that polyparasitized children experience worse cognitive outcomes than children with only one helminth infection.     

Cross-sectional survey of the extent and indicators of hepatitis C virus infection in Houston Department of Health and Human Services' sexually transmitted disease clinics

summary. To evaluate the prevalence and indicators of hepatitis C virus (HCV) infection in Houston and determine the effectiveness of targeted HCV screening in sexually transmitted disease (STD) clinics. We performed a cross-sectional survey in low-risk and high-risk groups in Houston. This included a blinded survey of HCV conducted in 1010 STD clinic clients having serological syphilis tests, and 1885 multi-speciality group practice patients having metabolic blood work. This was followed with a targeted hepatitis C survey of 822 high-risk clients from STD clinics. The seroprevalence of hepatitis C infection in the blinded survey was 3.9% (95% CI 3.0–4.8) in the multi-speciality group and 5.0% (95% CI 3.7–6.3) in the STD clinics. Prevalence of hepatitis C infection among targeted STD clinic clients was significantly higher at 15.3% (95% CI 12.7–17.7). Risk factors that correlated with HCV infection after logistic regression included: injection drug use (OR = 10, 95% CI =  3.4–30.3), heroin use (OR = 6.6, 95% CI = 2.2–20.5), non-transfusion/ transplantation blood exposure (OR = 3.0, 95% CI = 1.3–6.9), sharing equipment to snort drugs (OR = 2.5, 95% CI 1.2–5.4), and age above 25 years (OR = 51, 95% CI = 9–47). This study demonstrates that targeting clients in STD clinics for known risk behaviours is an effective way to identify cases of HCV infection. STD clinics allow access to clients with both drug use and sexual risk behaviours and are a useful location for targeting hepatitis C screening and prevention efforts.     

Cross-border malaria control for internally displaced persons: observational results from a pilot programme in eastern Burma/Myanmar

Objectives  To document the feasibility of a cross-border community based integrated malaria control programme implemented by internally displaced persons in eastern Burma/Myanmar.
Methods  This pilot study was conducted from February 2003 through January 2005 in seven villages of displaced ethnic Karen. Interventions comprised early diagnosis of Plasmodium falciparum and treatment with mefloquine and artesunate, distribution of long-lasting insecticide treated nets (LLITNs), and educational messages. The primary outcome measure was P. falciparum prevalence during bi-annual universal screenings with the Paracheck-Pf^® (Orchid Biomedical Systems, Goa, India) device. Secondary outcomes were P. falciparum incidence and process indicators related to net use and malaria knowledge, attitudes and practices (KAP).
Results  P. falciparum prevalence in original programme areas declined from 8.4% [95% confidence interval (CI) 8.3–8.6] at baseline to 1.1% (95% CI 1.1–1.2) in the final screening. Annual incidence in original areas declined from 232 to 70 cases/1000/year [incidence rate ratio 0.30 (95% CI 0.24–0.39)]. The proportion of household members sleeping under a LLITN improved from 0% to 89% and malaria KAP improved in all areas.
Conclusions  Integrated malaria control organized and implemented by displaced persons is feasible in eastern Burma/Myanmar. The decline in P. falciparum prevalence and incidence suggest that it may be possible to reduce the burden of disease and the reservoir of malaria in eastern Burma/Myanmar, with implications for malaria control in the greater Mekong region.     

Distinct pattern of class and subclass antibodies in immune complexes of children with cerebral malaria and severe malarial anaemia

Plasmodium falciparum infection can lead to deadly complications such as severe malaria-associated anaemia (SMA) and cerebral malaria (CM). Children with severe malaria have elevated levels of circulating immune complexes (ICs). To further investigate the quantitative differences in antibody class/subclass components of ICs in SMA and CM , we enrolled 75 children with SMA and 32 children with CM from hospitals in western Kenya and matched them to 74 and 52 control children, respectively, with uncomplicated symptomatic malaria. Total IgG IC levels were always elevated in children with malaria upon enrolment, but children with CM had the highest levels of any group. Conditional logistic regression showed a borderline association between IgG4-containing IC levels and increased risk of SMA (OR = 3·11, 95% CI 1·01–9·56, P  = 0·05). Total IgG ICs (OR = 2·84, 95% CI 1·08–7·46, P  = 0·03) and IgE-containing ICs (OR = 6·82, OR 1·88–24·73, P  ≤ 0·01) were associated with increased risk of CM. These results point to differences in the contribution of the different antibody class and subclass components of ICs to the pathogenesis of SMA and CM and give insight into potential mechanisms of disease.     

Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis

Aims   To assess the effectiveness of current treatment approaches to assist benzodiazepine discontinuation.
Methods   A systematic review of approaches to benzodiazepine discontinuation in general practice and out-patient settings was undertaken. Routine care was compared with three treatment approaches: brief interventions, gradual dose reduction (GDR) and psychological interventions. GDR was compared with GDR plus psychological interventions or substitutive pharmacotherapies.
Results   Inclusion criteria were met by 24 studies, and a further eight were identified by future search. GDR [odds ratio (OR) = 5.96, confidence interval (CI) = 2.08–17.11] and brief interventions (OR = 4.37, CI = 2.28–8.40) provided superior cessation rates at post-treatment to routine care. Psychological treatment plus GDR were superior to both routine care (OR = 3.38, CI = 1.86–6.12) and GDR alone (OR = 1.82, CI = 1.25–2.67). However, substitutive pharmacotherapies did not add to the impact of GDR (OR = 1.30, CI = 0.97–1.73), and abrupt substitution of benzodiazepines by other pharmacotherapy was less effective than GDR alone (OR = 0.30, CI = 0.14–0.64). Few studies on any technique had significantly greater benzodiazepine discontinuation than controls at follow-up.
Conclusions   Providing an intervention is more effective than routine care. Psychological interventions may improve discontinuation above GDR alone. While some substitutive pharmacotherapies may have promise, current evidence is insufficient to support their use.     

Spatial clustering of pulmonary tuberculosis and impact of the care factors in Antananarivo City

Objective  To analyse the spatial distribution of TB in Antananarivo and investigate risk factors.
Methods  Pulmonary TB data were collected through passive case detection in 16 Tuberculosis Diagnostic and Treatment Centers (DTC). New cases listed in the DTC registers from 2004 to 2006 and resident in Antananarivo were included in the study. Field workers of the national control program conducted household surveys of all cases to collect complementary information on socio-economic status. TB spatial organization and risk factors were analysed over two successive periods (August 2004–July 2005, August 2005–July 2006); analysis was done at the neighbourhood level, by searching for spatial clusters with the spatial scan test.
Results  3075 pulmonary tuberculosis new cases were reported in Antananarivo from 2004 to 2006. The average incidence during the study period was 74/100 000 inhabitants (95% CI: 64.9–84.5). Spatial clusters occurred in three of the six arrondissements (districts) of the city (192 neighbourhoods). A decrease in clustering was observed with movement towards the southern neighbourhood.
Conclusion  The change in risk of a TB cluster was linked to socio-economic (e.g. household amount of ownership of tap water) and patient care factors (e.g. patients lost to follow-up).     

Dosing accuracy of artesunate and amodiaquine as treatment for falciparum malaria in Casamance, Senegal

Objectives  Several products of artesunate plus amodiaquine (AS + AQ) are being deployed in malaria-endemic countries for treating uncomplicated falciparum malaria but dosing accuracy and consequential effects on efficacy and tolerability have not been examined.
Methods  Patients with parasitologically confirmed, uncomplicated falciparum malaria were treated and followed by research teams or local health centre staff in Casamance, Senegal. AS + AQ was given as: (i) loose combination (AS 50 mg, AQ 200 mg), dosed on body weight, or (ii) co-blistered product (AS 50 mg, AQ 153 mg) dosed by weight or age. Target doses were: (i) AS 4 (2–10) mg/kg/day and (ii) AQ 10 (7.5–15) mg/kg/day. Patients receiving therapeutic doses defined dosing accuracy. Treatment-emergent signs and symptoms (TESS) were recorded.
Results  A total of 3277 patients were treated with loose ( n  = 1972, weight-dosed) or co-blistered ( n  = 1305, 962 age-dosed, 343 weight-dosed) AS + AQ by the research team ( n  = 966) or clinic staff ( n  = 2311). AS was dosed correctly in >99% with all regimens. Loose AQ by weight was 98% correct. The co-blister AQ overdosed 18% of patients when dosed by age and underdosed 13% by weight. Low weight was an independent risk factor for overdosing. The co-blister had significantly more TESS than the loose product [117/1305 (9%) vs. 41/1972 (2%), relative risk = 4.3 (95% CI: 3.0–6.1, P  < 0.0001)]. Age-based dosing accounted for the difference. TESS occurred mostly within one day (72%) and were mild or moderate (75%).
Conclusion  Artesunate is easier to dose than AQ. Currently available age-dosed, co-blistered AS + AQ tends to overdose AQ and is less well tolerated than loose tablets. It is not the optimal presentation of AS + AQ.     

Environmental, socio-demographic and behavioural determinants of malaria risk in the western Kenyan highlands: a case–control study

Objective  To identify risk factors for uncomplicated malaria in highland areas of East Africa at higher risk of malaria epidemics, in order to design appropriate interventions.
Methods  Prospective, population-based, case–control study in the Nandi Hills, a highland area of western Kenya, to identify environmental, sociodemographic and behavioural factors associated with clinical malaria. Data were collected using field observation, a structured questionnaire, and a global positioning system device.
Results  We interviewed 488 cases of slide-confirmed malaria and 980 age-matched controls. Multivariate analyses associated higher malaria risk with living <250 m of a forest [OR = 3.3 (95% CI 1.5, 7.1)], <250 m of a swamp [2.8 (1.3, 5.9)], <200 m of maize fields [2.0 (1.2, 3.4)], in the absence of trees <200 m [1.6 (1.2, 2.2)], on flat land [1.6 (1.2, 2.2)], in houses without ceilings [1.5 (1.1, 2.2)], in houses with a separate kitchen building [1.8 (1.4, 2.3)] and in households where the female household head had no education [1.9 (1.1, 3.1)]. Travelling out of the study site [2.2 (1.2, 4.1)] was also associated with increased risk.
Conclusions  In this East African highland area, risk of developing uncomplicated malaria was multifactorial with a risk factor profile similar to that in endemic regions. Households within close proximity to forest and swamp borders are at higher risk of malaria and should be included in indoor residual spraying campaigns.     

Intermittent slow sand filtration for preventing diarrhoea among children in Kenyan households using unimproved water sources: randomized controlled trial

Objective  Measure effectiveness of intermittent slow sand filtration for reducing child diarrhoea among households using unimproved water sources in rural Kenya.
Methods  A randomized controlled trail was conducted among populations meeting a high-risk profile for child diarrhoea from drinking river water in the River Njoro watershed. Intervention households (30) were provided the concrete BioSand Filter and instructed on filter use and maintenance. Control households (29) continued normal practices. Longitudinal monthly monitoring of diarrhoea (seven-day daily prevalence recall) and of influent, effluent, and drinking water quality for fecal coliform was conducted for 6 months.
Results  Intervention households had better drinking water quality than control households (fecal coliform geometric mean, 30.0 CFU vs. 89.0 CFU/100 ml, P  < 0.001) and reported significantly fewer diarrhoea days (86 days over 626 child-weeks) compared to controls (203 days over 558 child-weeks) among children up to 15 (age-adjusted RR 0.46; 95 % CI = 0.22, 0.96). Greater child diarrhoea reduction due to the intervention (age-adjusted RR 0.23, 95 % CI = 0.10, 0.51) was observed among the sub-group using unimproved water sources all of the time.
Conclusion  Intermittent slow sand filtration, a non-commercial technology, produces similar observed effects on child diarrhoea as commercial POU products, adding to the range of effective options for poor populations (chlorination, ceramic filtration, solar disinfection, flocculation/disinfection).     

Default during TB diagnosis: quantifying the problem

Objectives  To quantify default during diagnosis in TB suspects and in smear-positive cases; to investigate sex differences in default during diagnosis, in all of Pakistan.
Methods  Data from laboratory registers were collected on 12 216 suspects in nine districts over the period July–September 2008.
Results  A total of 1573 TB suspects (12.9%, 95% CI = 12.3–13.5) dropped out of the diagnostic process after initial sputum submission. A total of 2058 smear-positive cases were detected, and of these 107 (5.2%, 95% CI = 4.2–6.2) defaulted during diagnosis and therefore could not be started on treatment. Male suspects defaulted slightly more frequently than female suspects ( P  =   0.0268).
Conclusion  Default during diagnosis is a frequent occurrence in Pakistan that should be monitored and addressed by TB control programs.     

Effectiveness of chemoprophylaxis and other determinants of malaria in travellers to Kenya

Summary objective  To investigate the effectiveness of chemoprophylaxis and the determinants of malaria importation from Kenya.
method  In a population-based case-control study, 51 travellers from Bavaria diagnosed with falciparum malaria imported from Kenya (cases) and a sample of 383 healthy Bavarian travellers returning from Kenya (controls) were interviewed. Data were analysed by multiple logistic regression.
results  Mefloquine (OR = 0.055; 95% Cl 0.019-0.16) and chloroquine combined with proguanil (OR = 0.128; 95% CI 0.039-0.419) were highly protective against P. falciparum malaria, whereas other drugs were ineffective (OR = 1.225; 95% CI 0.536-2.803). Ineffective prophylaxis (10.4%) and non-prophylaxis (11.2%) were the main reasons for malaria importation. Travelling alone or with friends, male sex, and travel duration over 4 weeks could be identified as additional risk factors. The main reason for inadequate chemoprophylaxis was inappropriate medical advice (87.5%). Prophylaxis refusal occurred frequently despite correct advice (58.1%). Diagnosis was often delayed unnecessarily (27.5%).
conclusion  Malaria importation from Kenya could be reduced substantially (34%) by eliminating inappropriate medical advice.     

A socioenvironmental composite index as a tool for identifying urban areas at risk of lymphatic filariasis

Objective  To describe the spatial distribution of lymphatic filariasis and its relationship with the socioenvironmental risk indicator, thus identifying priority localities for interventions in endemic urban areas.
Methods  The study area was the municipality of Jaboatão dos Guararapes, State of Pernambuco, Brazil. The data sources were a parasitological survey and the 2000 demographic census. From these data, a socioenvironmental composite risk indicator was constructed using the 484 census tracts (CT) as the analysis units, based on the score-formation technique. Census tracts with higher indicator values presented higher risk of occurrences of filariasis.
Results  Six thousand five hundred and seven households were surveyed and 23 673 individuals were examined, among whom 323 cases of microfilaremia were identified. The mean prevalence rate for the municipality was 1.4%. The indicator showed that 73% (237/323) of the cases of microfilaremia were in high-risk areas (third and fourth quartiles) with worse socioenvironmental conditions (RR = 4.86, CI = 3.09–7.73, P  <   0.05).
Conclusions  The socioenvironmental composite risk indicator demonstrated sensitivity, since it was able to identify the localities with greater occurrence of infection. Because it can stratify spaces by using official and available data, it constitutes an important tool for use in the worldwide program for eliminating lymphatic filariasis.     

Willingness to participate in preventive HIV vaccine trials in a community-based cohort in south western Uganda

Objectives  To assess willingness to participate in HIV vaccine trials and possible barriers to participation.
Methods  Questionnaire survey of participants completing a 2-year community-based HIV Vaccine Preparedness Study, followed by cross sectional analysis of data.
Results  95% of participants were willing to participate in a trial with similar attributes to the Vaccine Preparedness Study. Certain hypothetical trial attributes significantly reduced willingness to participate: The requirement to delay pregnancy (for females) had the largest effect, reducing willingness to participate from 97% to 23% ( P  < 0.0001). Larger blood draws had the second largest effect: 95–55% ( P  < 0.0001). The possibility of receiving either candidate vaccine or placebo had the third largest effect: 95–73% ( P  < 0.0001). Monthly study visits had the fourth largest effect: 95–92% ( P  < 0.0001). Trial duration longer than 2 years had the least effect: 95–93% ( P  = 0.0025). Combined attributes reduced willingness to participate from 95% to 43% (McNemar's χ² = 521.00; P  < 0.0001) overall and 97–11% (McNemar's χ² = 531.00; P  < 0.0001) for female participants. Physical harm concerns (adjusted OR = 34.9; 95% CI, 10.4–118) and a low risk behaviour index (adjusted OR = 0.09; 95% CI, 0.01–0.73) were associated with unwillingness to participate.
Conclusions  We found a high level of willingness to participate in HIV vaccine trials in this population. However, certain HIV vaccine trial requirements were associated with reduced willingness to participate. Community as well as individual concerns will have to be carefully addressed in planned HIV vaccine trials.     

The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection

Abstract. Leibovici L, Shraga I, Drucker M, Konigsberger H, Samra Z, Pitlik SD (Rabin Medical Center, Petah-Tiqva, and Tel-Aviv University, Tel-Aviv, Israel). The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med 1998; 244 : 379–86.

Objectives

To test whether empirical antibiotic treatment that matches the in vitro susceptibility of the pathogen (appropriate treatment) improves survival in patients with bloodstream infections; and to measure the improvement.

Design

Observational, prospective cohort study.

Setting

University hospital in Israel.

Subjects

All patients with bloodstream infections detected during 1988–94.

Interventions

None.

Main outcome measures

In-hospital fatality rate and length of hospitalization.

Results

Out of 2158 patients given appropriate empirical antibiotic treatment, 436 (20%) died, compared with 432 of 1255 patients (34%) given inappropriate treatment (P = 0.0001). The median durations of hospital stay for patients who survived were 9 days for patients given appropriate treatment and 11 days for patients given inappropriate treatment. For patients who died, the median durations were 5 and 4 days, respectively (P < 0.05), for both comparisons. In a stratified analysis, fatality was higher in patients given inappropriate treatment than in those given appropriate treatment in all strata but two: patients with infections caused by streptococci other than Streptococcus gr. A and Streptoccocus pneumoniae (odds ratio (OR) of 1.0, 95% confidence interval (95% CI) 0.4–2.5); and hypothermic patients (OR = 0.9, 95% CI = 0.3–2.4). Even in patients with septic shock, inappropriate empirical treatment was associated with higher fatality rate (OR = 1.6, 95% CI = 1.0–2.7). The highest benefit associated with appropriate treatment was observed in paediatric patients (OR = 5.1, 95% CI = 2.4– 10.7); intra-abdominal infections (OR = 3.8, 95% CI = 2.0–7.1); infections of the skin and soft tissues (OR = 3.1, 95% CI = 1.8–5.6); and infections caused by Klebsiella pneumoniae (OR = 3.0, 95%  CI = 1.7–5.1) and S. pneumoniae (OR = 2.6, 95%  C = 1.1–5.9). On a multivariable logistic regression analysis, the contribution of inappropriate empirical treatment to fatality was independent of other risk factors (multivariable adjusted OR = 1.6, 95% CI = 1.3–1.9).

Conclusion

Appropriate empirical antibiotic treatment was associated with a significant reduction in fatality in patients with bloodstream infection.

     

Smoker sensitivity to retail tobacco displays and quitting: a cohort study

Aims   To assess whether sensitivity to point of sale (POS) cigarette displays influences quitting behaviour.
Design   Prospective cohort study.
Setting   Victoria, Australia.
Participants   A total of 222 adult smokers were surveyed at baseline in 2006 and followed-up 18 months later.
Measurements   Baseline sensitivity to POS displays, which included the frequency of 'noticing displays', 'impulse purchasing behaviour' and 'deciding on brand based on POS displays'; smoking status at follow-up.
Findings   At follow-up, 17.0% were no longer smokers. After adjusting for covariates, compared to those with low POS display sensitivity, smokers who had a medium or high level of sensitivity to POS displays were significantly less likely to have quit at follow-up [odds ratio (OR) = 0.32, 95% confidence interval (CI) = 0.14–0.74; OR = 0.27, 95% CI = 0.08–0.91, respectively].
Conclusions   The presence of cigarette pack displays in stores may make it more difficult for smokers to quit smoking successfully.     

Mental and motor development before and during growth hormone treatment in infants and toddlers with Prader-Willi syndrome

Background  Prader–Willi syndrome (PWS) is a neurogenetic disorder characterized by muscular hypotonia, psychomotor delay, feeding difficulties and failure to thrive in infancy. GH treatment improves growth velocity and body composition. Research on the effects of GH on psychomotor development in infants with PWS is limited.
Objective  To evaluate psychomotor development in PWS infants and toddlers during GH treatment compared to randomized controls.
Design/patients  Forty-three PWS infants were evaluated at baseline. Twenty-nine of them were randomized into a GH group ( n  = 15) receiving 1 mg/m²/day GH or a non-GH-treated control group ( n  = 14). At baseline and after 12 months of follow-up, analysis with Bayley Scales of Infant Development II (BSID-II) was performed. Data were converted to percentage of expected development for age (%ed), and changes during follow-up were calculated.
Results  Infants in the GH group had a median age of 2·3 years [interquartile range (IQR) 1·7–3·0] and in the control group of 1·5 years (IQR 1·2–2·7) ( P =  0·17). Both mental and motor development improved significantly during the first year of study in the GH group vs. the control group: median (IQR) change was +9·3% (–5·3 to 13·3) vs. –2·9% (–8·1 to 4·9) ( P  < 0·05) in mental development and +11·2% (–4·9 to 22·5) vs. –18·5% (–27·9 to 1·8) ( P  < 0·05) in motor development, respectively.
Conclusion  One year of GH treatment significantly improved mental and motor development in PWS infants compared to randomized controls.     

Household burden of malaria in South Africa and Mozambique: is there a catastrophic impact?

Objectives  To evaluate treatment-seeking behaviour, financial impact and time lost due to malaria events, in southern Mozambique and eastern South Africa.
Methods  In-depth household surveys (828 in Mozambique and 827 in South Africa) were analysed. An asset index was calculated using principal component analysis to allow comparison across socio-economic groups. Direct costs of seeking care and the time lost due to malaria were determined. The extent of catastrophic payments was assessed using as thresholds the traditional 10% of household income and 40% of non-food income, as recently recommended by WHO.
Results  Poverty was highly prevalent: 70% of the South African and 95% of Mozambican households studied lived on less than $1 per capita per day. Around 97% of those with recent malaria sought healthcare, mainly in public facilities. Out-of-pocket household expenditure per malaria episode averaged $2.30 in South Africa and $6.50 in Mozambique. Analysis at the individual household level found that 32–34% of households in Mozambique, compared with 9–13% of households in South Africa, incurred catastrophic payments for malaria episodes. Results based on mean values underestimated the prevalence of catastrophic payments. Days off work/school were higher in Mozambique.
Conclusions  The high rate of health seeking in public health facilities seems unusual in the African context, which bodes well for high coverage with artemisinin-based combinations, even if only deployed within the public sector. However, despite no or modest charges for public sector primary healthcare, households frequently incur catastrophic expenditure on a single malaria episode.