Task shifting for cataract surgery in eastern Africa: productivity and attrition of non-physician cataract surgeons in Kenya,Malawi and Tanzania

Background

This project examined the surgical productivity and attrition of non-physician cataract surgeons (NPCSs) in Tanzania, Malawi, and Kenya.

Methods

Baseline (2008-9) data on training, support, and productivity (annual cataract surgery rate) were collected from officially trained NPCSs using mailed questionnaires followed by telephone interviews. Telephone interviews were used to collect follow-up data annually on productivity and semi-annually on attrition. A detailed telephone interview was conducted if a surgeon left his/her post. Data were entered into and analysed using STATA.

Results

Among the 135 NPCSs, 129 were enrolled in the study (Kenya 88, Tanzania 38, and Malawi 3) mean age 42 years; average time since completing training 6.6 years. Employment was in District 44%, Regional 24% or mission/ private 32% hospitals. Small incision cataract surgery was practiced by 38% of the NPCSs. The mean cataract surgery rate was 188/year, median 76 (range 0-1700). For 39 (31%) NPCSs their surgical rate was more than 200/year. Approximately 22% in Kenya and 25% in Tanzania had years where the cataract surgical rate was zero. About 11% of the surgeons had no support staff.Factors significantly associated with increased productivity were: 1) located at a regional or private/mission hospital compared to a district hospital (OR = 8.26; 95 % CI 2.89 – 23.81); 2) 3 or more nurses in the eye unit (OR = 8.69; 95% CI 3.27-23.15); 3) 3 or more cataract surgical sets (OR = 3.26; 95% CI 1.48-7.16); 4) a separate eye theatre (OR = 5.41; 95% CI 2.15-13.65); 5) a surgical outreach program (OR = 4.44; 95% CI 1.88-10.52); and 6) providing transport for patients to hospital (OR = 6.39; 95% CI 2.62-15.59). The associations were similar for baseline and follow-up assessments. Attrition during the 3 years occurred in 13 surgeons (10.3%) and was due to retirement or promotion to administration.

Conclusions

High quality training is necessary but not sufficient to result in cataract surgical activity that meets population needs and maintains surgical skill. Needed are supporting institutions and staff, functioning equipment and programs to recruit and transport patients.

     

Towards a molecular characterization of autism spectrum disorders: an exome sequencing and systems approach

The hypothetical ‘AXAS'' gene network model that profiles functional patterns of heterogeneous DNA variants overrepresented in autism spectrum disorder (ASD), X-linked intellectual disability, attention deficit and hyperactivity disorder and schizophrenia was used in this current study to analyze whole exome sequencing data from an Australian ASD cohort. An optimized DNA variant filtering pipeline was used to identify loss-of-function DNA variations. Inherited variants from parents with a broader autism phenotype and de novo variants were found to be significantly associated with ASD. Gene ontology analysis revealed that putative rare causal variants cluster in key neurobiological processes and are overrepresented in functions involving neuronal development, signal transduction and synapse development including the neurexin trans-synaptic complex. We also show how a complex gene network model can be used to fine map combinations of inherited and de novo variations in families with ASD that converge in the L1CAM pathway. Our results provide an important step forward in the molecular characterization of ASD with potential for developing a tool to analyze the pathogenesis of individual affected families.     

Seniors Road Safety Enhancement through Perceptual-Motor Competences Training Program Impact upon the Performance on the Useful Field of Vision (UFOV)

The purpose of this study was to verify the efficacy of a Perceptual-Motor Competences Training Program upon the performance on UFOV of an experimental active group of elderly drivers. Program tasks were conceived to force subjects to divide their attention for central and peripheral stimuli, using a visual strategy of gazing at an anchor-point and, from there, detect important clues on peripheral visual field. For this purpose, almost all tasks were performed on groups of two, being one responsible for testing the other and switching functions from time to time (for instance, dropping one of two juggling handkerchiefs hold apart, one in each tester hand, with the partner having to detect which was dropped and react as quick as possible, catching it before it felt to the floor). We found a significant improvement in the capacity of dividing attention for central and peripheral stimuli under a visual environment full of distractors (selective attention UFOV test) following the Program, as well as a significant reduction on the category of risk (component based upon the three UFOV subtests results), which evidence very clearly the benefits of this training program on the elderly experimental group and its potential to reduce their risk of being involved in car accidents, on their fault, due to perceptual reasons.     

High-Resolution Computed Tomographic Findings of Cocaine-Induced Pulmonary Disease: A State of the Art Review

Cocaine is the most commonly used illicit drug among patients presenting at hospital emergency departments and the most frequent cause of drug-related deaths reported by medical examiners. Various respiratory problems temporally associated with cocaine use have been reported. Acute and chronic uses also are responsible for lung complications, such as pulmonary edema, alveolar hemorrhage, pulmonary hypertension, organizing pneumonia, emphysema, barotrauma, infection, cancer, eosinophilic disease, and aspiration pneumonia. Although most imaging findings are nonspecific, they may raise suspicion of a cocaine-related etiology when considered together with patients’ profiles and medical histories. This literature review describes cocaine-induced diseases with pulmonary involvement, with an emphasis on high-resolution chest computed tomographic findings and patterns.     

Escore de Cálcio Coronário e Estratificação do Risco de Doença Arterial Coronariana em Pacientes com Acidente Vascular Encefálico Isquêmico Aterosclerótico e não-Aterosclerótico

BackgroundIschemic Stroke (IS) and Coronary Artery Disease (CAD) frequently coexist and share atherosclerotic disease risk factors. According to the American Heart Association, IS subtypes may be considered CAD risk equivalents, but the evidence for non-atherosclerotic IS is uncertain. Additionally, the Coronary Calcium Score (CCS) is an accurate marker to address CAD risk; however, CCS distribution between IS subtypes is not well characterized.ObjectivesTo compare the CCS between atherosclerotic and non-atherosclerotic IS groups; and to determine which covariates were associated with high CCS in IS.MethodsThis cross-sectional design included all patients with IS, 45 to 70 years of age at the time of the stroke, consecutively admitted to a rehabilitation hospital between August 2014 and December 2016, without prevalent CAD. All patients underwent CT scanning for CCS measurement. CCS≥100 was considered a high risk for CAD, with a significance level of p<0.05.ResultsFrom the 244 studied patients (mean age 58.4±6.8 years; 49% female), 164 (67%) had non-atherosclerotic etiology. The proportions of CCS≥100 were similar between the atherosclerotic and the non-atherosclerotic groups (33% [n=26] x 29% [n=47]; p= 0.54). Among all IS patients, only age ≥60 years was independently associated with CCS≥100 (OR 3.5; 95%CI 1.7-7.1), accounting for hypertension, dyslipidemia, diabetes, sedentarism, and family history of CAD.ConclusionAtherosclerotic IS did not present a greater risk of CAD when compared to non-atherosclerotic IS according to CCS. Only age ≥60 years, but not etiology, was independently associated with CCS≥100.     

Cumulative mortality of Aedes aegypti larvae treated with compounds

OBJECTIVE

To evaluate the larvicidal activity of Azadirachta indica, Melaleuca alternifolia, carapa guianensis essential oils and fermented extract of Carica papaya against Aedes aegypti (Linnaeus, 1762) (Diptera: Culicidae).

METHODS

The larvicide test was performed in triplicate with 300 larvae for each experimental group using the third larval stage, which were exposed for 24h. The groups were: positive control with industrial larvicide (BTI) in concentrations of 0.37 ppm (PC1) and 0.06 ppm (PC2); treated with compounds of essential oils and fermented extract, 50.0% concentration (G1); treated with compounds of essential oils and fermented extract, 25.0% concentration (G2); treated with compounds of essential oils and fermented extract, 12.5% concentration (G3); and negative control group using water (NC1) and using dimethyl (NC2). The larvae were monitored every 60 min using direct visualization.

RESULTS

No mortality occurred in experimental groups NC1 and NC2 in the 24h exposure period, whereas there was 100% mortality in the PC1 and PC2 groups compared to NC1 and NC2. Mortality rates of 65.0%, 50.0% and 78.0% were observed in the groups G1, G2 and G3 respectively, compared with NC1 and NC2.

CONCLUSIONS

The association between three essential oils from Azadirachta indica, Melaleuca alternifolia, Carapa guianensis and fermented extract of Carica papaya was efficient at all concentrations. Therefore, it can be used in Aedes aegypti Liverpool third larvae stage control programs.     

Discrimination and Substance Use Disorders Among Latinos: The Role of Gender,Nativity, and Ethnicity

Objectives. We examined the relationship between discrimination and substance use disorders among a diverse sample of Latinos. We also investigated whether the relationship between discrimination and substance use disorders varied by gender, nativity, and ethnicity.Methods. Our analyses focused on 6294 Latinos who participated in the National Epidemiologic Survey on Alcohol and Related Conditions from 2004 to 2005. We used multinomial logistic regression to examine the association between discrimination and substance use disorders.Results. Discrimination was significantly associated with increased odds of alcohol and drug use disorders among Latinos. However, the relationship between discrimination and substance use disorders varied by gender, nativity, and ethnicity. Discrimination was associated with increased odds of alcohol and drug use disorders for certain groups, such as women, US-born Latinos, and Mexicans, but this relationship did not follow the same pattern for other subgroups.Conclusions. It is important to determine which subgroups among Latinos may be particularly vulnerable to the negative effects of discrimination to address their needs.Latinos are the largest ethnic or racial minority group in the United States1 and the fastest growing group entering substance abuse treatment programs.2 Although Latinos are disproportionately affected by substance abuse,3 they have been understudied.4 Previous research shows that high levels of poverty, minority status, and residential concentration in areas with widespread drug and alcohol distribution have been considered to be factors that may put Latinos at risk for substance use disorders.5 More recently, discrimination has also been considered to be a risk factor.6,7 As studies aim toward filling the gap in the literature, the heterogeneity of Latinos must also be considered.Discrimination has been associated with alcohol and drug use8–13 and substance use disorders among Latinos.6,7 Stress-coping frameworks and the minority stress model have been applied to hypothesize that individuals belonging to various marginalized groups respond to experiences of discrimination with unhealthy coping behaviors, such as substance use.14,15 Moreover, discrimination may lead to underemployment, lower wages, and limited access to health services and other resources that can affect health outcomes.16 In this way, discrimination operates at both the interpersonal and institutional levels simultaneously to situate individuals on different health trajectories, fostering and reinforcing poor health behaviors and outcomes.16,17The association between discrimination and substance use has been previously documented for Latinos and other groups. However, reviews of the literature have called for more granular analysis of specific risk patterns. One specific area needing analysis is whether some subgroups of Latinos are at higher risk of substance use related to discrimination than others. The identification of subgroups is an important first step toward the development of targeted population-level approaches and tailored interventions.In the present study, we focused on subgroups based on gender, nativity, and ethnicity (country of origin or heritage country). These subgroups were based on ascribed characteristics that refer to immutable characteristics (vs achieved characteristics, such as education) that are given status value.18,19 The status value placed on these characteristics can drive discrimination; for example, when men are considered more valuable than women and when US-born individuals are considered more valuable than immigrants.18,19 At the same time, these characteristics (gender, nativity, and ethnicity) are also associated with substance use disorders.Gender differences in substance use disorders are not unique to Latinos. Across racial/ethnic groups, men consistently have higher prevalence of substance use disorders. Using data from the National Latino and Asian American Study, the lifetime prevalence of alcohol use disorders was 16.7% for Latino men and 4.3% for Latina women.20 Research also shows that Latino men generally reported higher levels of discrimination compared with Latina women.13,21 Data from the National Latino and Asian American Study showed that 39% of Latino men, compared with 29% of Latina women, reported discrimination.22 These authors suggested that these patterns might be the result of minority men being more exposed and vulnerable to racial bias from social institutions. These higher rates of substance use and discrimination among men also appeared to be jointly related. A recent study found that discrimination was associated with increased risk of drug abuse among Latino men, but not Latina women.6 This interaction might occur because of greater cultural acceptability among men overall to use substances to cope with stress compared with women. In contrast, women were found to rely on social support and to turn to food to cope with stress.23–25 Other specific factors, such as abuse history,26 were found to be more central in predicting risk of substance use disorders among Latina women. Thus, we expected that discrimination would have a stronger relationship with substance use disorders among Latino men than Latina women.Similar to health differences by gender, differences by nativity are not unique to Latinos. Overall, foreign-born individuals tend to be healthier than their US-born counterparts. Lifetime rates of substance use disorders were higher among US-born than foreign-born Latinos (19.6% vs 5.5%, respectively).20 Previous studies also found greater reporting of discrimination among US-born Latinos; 47% of US-born compared with 25% of foreign-born Latinos reported discrimination.22 However, discrimination might be more harmful to foreign-born Latinos because they are less likely to enjoy citizenship rights (e.g., voting privileges, access to educational scholarships) that might help temper some of the stressful effects of discrimination. From this perspective, we expected that discrimination would have a stronger relationship with substance use disorders among foreign-born than US-born Latinos.Finally, it is also important to consider ethnicity. There is some indication of variation in rates of substance use across these groups. Cubans were found to have lower odds of substance use disorders compared with Puerto Ricans.27 In addition, there was good evidence for variation in reporting of discrimination.28 For example, 40% of Puerto Ricans reported discrimination compared with 34% of Mexicans and 16% of Cubans.22 This variation might be attributed to gradations based on socioeconomic resources that differ by Latino ethnicity.29 Gradations based on socioeconomic resources could dictate the risks and resources individuals have exposure and access to, affecting coping mechanisms. Thus, we expected the relationship between discrimination and substance use disorders to vary by ethnicity as well.In sum, based on this literature, we hypothesized that discrimination would be associated with increased risk of substance use disorders among Latinos overall, and that the relationship between discrimination and substance use disorders would vary by ascribed characteristics. Specifically, we theorized that the relationship between discrimination and substance use disorders would be stronger among men compared with women, among foreign-born Latinos compared with US-born Latinos, and among Mexicans and Puerto Ricans compared with Cubans.