Disfunção sistólica ventricular esquerda detetada por speckle tracking em hipertensos com fração de ejeção preservada

Introduction The spectrum of hypertensive heart disease is wide, and can include left ventricular dysfunction. The development of echocardiographic parameters to improve patient stratification and to identify early adverse changes could be clinically useful.Aim To identify subclinical left ventricular dysfunction in hypertensive subjects with preserved ejection fraction (>55%), identified by global parameters of myocardial strain on speckle tracking imaging.Methods This was a comparative observational study of two groups of individuals: normotensive (n=20, age 59±7 years, 55% male) and hypertensive (n=229, age 62±12 years, 57% male). Left ventricular function was assessed by various conventional clinical and echocardiographic parameters and global longitudinal and circumferential myocardial strain. Cut-off values to detect subclinical left ventricular dysfunction were established and applied in the hypertensive group. The Student's t test, Mann-Whitney test and chi-square test were used for the comparative statistical analysis.Results Most hypertensive subjects (53.7%) had grade I hypertension; blood pressure was controlled in 64.9%, and 54.8% showed left ventricular structural changes. Comparison between the normotensive and hypertensive groups showed no significant differences in parameters of global longitudinal or circumferential systolic strain. Application of the cut-offs to the hypertensive group identified 35 individuals (15.3%) as having subclinical left ventricular systolic dysfunction as assessed by global longitudinal myocardial strain parameters.Conclusions In this group of hypertensive patients, global myocardial strain parameters identified a group of individuals with subclinical left ventricular systolic dysfunction despite preserved ejection fraction. The clinical relevance of these findings needs to be assessed in long-term follow-up studies.     

Characterization of Adverse Events Detected in a Large Health Care Delivery System Using an Enhanced Global Trigger Tool over a Five‐Year Interval

Objective

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

Study Setting

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

Study Design

We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

Data Collection

Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).

Principal Findings

Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were “preventable/possibly preventable.” Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were “preventable/possibly preventable”; the most common category was “surgical/procedural” (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.

Conclusions

AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.     

Appraisal of guidelines developed by the World Health Organization

Objective

To appraise the quality of guidelines developed by the World Health Organization (WHO) that were approved by its Guidelines Review Committee (GRC) and identify strengths and weaknesses in the guideline development process.

Study design

Cross-sectional.

Methods

Three individuals independently assessed GRC-approved WHO guidelines using the Appraisal of Guidelines for Research and Evaluation II instrument (AGREE II). Scores were standardized across domains and overall quality was determined through consensus.

Results

124 guidelines met inclusion criteria and were assessed. 58 guidelines were recommended for use, 58 were recommended with modifications and eight were not recommended. The highest scoring domains across guidelines were scope and purpose, and clarity of presentation. The recommended guidelines had higher rigor of development and applicability domain scores in comparison to other guidelines. 77% of the guidelines referenced an underlying evidence review and 49% used GRADE to assess the body of evidence or the strength of the recommendation. The domains in need of improvement included stakeholder engagement, editorial independence, and applicability. Guidelines not recommended for use were generally insufficient in their rigor of development.

Conclusions

WHO guidelines need further improvement, most importantly in the rigor of their development (i.e., use of evidence reviews). Other areas for improvement include increased stakeholder engagement, a more explicit process for recommendation formulation and disclosure of interests, discussion of the facilitators, barriers, resource implications, and criteria for monitoring the outcomes of guideline implementation. WHO guidelines can improve through increased transparency, adherence to the WHO Handbook for Guideline Development, and better oversight by the GRC.     

Leveraging non-binding instruments for global health governance: reflections from the Global AIDS Reporting Mechanism for WHO reform

As countries contend with an increasingly complex global environment with direct implications for population health, the international community is seeking novel mechanisms to incentivize coordinated national and international action towards shared health goals. Binding legal instruments have garnered increasing attention since the World Health Organization adopted its first convention in 2003.     

Global exponential almost periodicity of a delayed memristor-based neural networks

In this paper, the existence, uniqueness and stability of almost periodic solution for a class of delayed memristor-based neural networks are studied. By using a new Lyapunov function method, the neural network that has a unique almost periodic solution, which is globally exponentially stable is proved. Moreover, the obtained conclusion on the almost periodic solution is applied to prove the existence and stability of periodic solution (or equilibrium point) for delayed memristor-based neural networks with periodic coefficients (or constant coefficients). The obtained results are helpful to design the global exponential stability of almost periodic oscillatory memristor-based neural networks. Three numerical examples and simulations are also given to show the feasibility of our results.     

Pre-service midwifery education in sub-Saharan Africa: A scoping review

BackgroundIn response to a global call for more midwives, maternal health stakeholders have called for increased investment in midwifery pre-service education. Given the already long list of challenges and the increasing burden on health care systems due to the COVID-19 pandemic, the need to prioritize investment is acute, particularly in sub-Saharan Africa. An important first step is to examine the current evidence.MethodsWe conducted a scoping review of the peer-reviewed literature about pre-service midwifery education in sub-Saharan Africa. A search of studies published between 2015 and 2021 in French or English was conducted using six databases (PubMed, CINAHL, Embase, Scopus, Web of Science and African Index Medicus).ResultsThe search yielded 3061 citations, of which 72 were included. Most were a mix of qualitative and quantitative cross-sectional, country-specific studies. Organized by pre-service educational domain, the literature reflected a misalignment between international standards for midwifery education and what schools and clinical sites and the larger administrative systems where they operate, reliably provide. Inadequate infrastructure, teaching capacity in school and clinical settings and clinical site environment were factors that commonly impede learning. Literature related to faculty development and deployment were limited.ConclusionSchools, faculty and clinical sites are overwhelmed yet recommendations by key stakeholders for change are substantive and complex. Efforts are needed to help schools map their current status by pre-service education domain and prioritize where scarce resources should be directed. These results can inform research and investments in pre-service midwifery education in sub-Saharan Africa.     

Motor impairment,depression, dementia: Which forms the impression of disease severity in Parkinson's disease?

IntroductionClinical Global Impression of Severity (CGIS) is a common measure in clinical research on Parkinson's disease (PD). However, patient features that contribute to the impression of the physician remain unclear. In particular, the impact of cognitive impairment and depression is understudied.MethodsIn a nationwide study on 1449 outpatients with PD, examined by 315 office-based neurologists, PD severity was documented with the Unified Parkinson's Disease Rating Scale (UPDRS-I, II, and IV). All patients were screened with the Montgomery-Asberg Depression Rating Scale (MADRS) for depression. The diagnosis of dementia was based on Diagnostic and Statistical Manual of Mental Disorders IV Text Revision criteria. Each patient was rated on the CGIS.ResultsCGIS ratings were available for 1438 patients, of which 50.8% were rated as “borderline” to “moderately ill” and 49.2% as “markedly” to “extremely ill.” Worse ratings were associated with higher age (p < 0.001), longer PD duration (p < 0.001), and female sex (p < 0.001). The impact of patient and physician variables on CGIS rating was calculated with three regression models (A: single bivariate regression; B: multivariate regression; and C: multivariate, multilevel regression, including physician variables). In all models, higher UPDRS-II scores and longer disease duration of PD were the strongest predictors for a worse CGIS rating. In the multivariate models (B and C), neuropsychiatric symptoms were unrelated to the CGIS rating.ConclusionThe additional burden of dementia and depression was underestimated in the CGIS rating, suggesting that they are possibly relativized against the motor impairment.     

Whole-fat dairy food intake is inversely associated with obesity prevalence: findings from the Observation of Cardiovascular Risk Factors in Luxembourg study

Because research focusing on dairy food consumption and the risk for obesity is inconsistent and only a few studies have even examined specific dairy products, in regard to type of food and fat content, in relation to obesity risk, this cross-sectional study investigated whether dairy food consumption is associated with the prevalence of global and abdominal obesity. Data were analyzed from 1352 participants in the Observation of Cardiovascular Risk Factors in Luxembourg survey. We hypothesized that higher total dairy food consumption would be independently associated with reduced prevalence of obesity. A validated food frequency questionnaire was used to measure intakes of dairy foods. Odds for global obesity (body mass index ≥30 kg/m²) and abdominal obesity (waist circumference >102 cm for men and >88 cm for women) were determined based on total dairy food intake as well as intakes of individual low- and whole-fat dairy products (milk, yogurt, and cheese). Total dairy food intake was inversely associated with the likelihood of global obesity (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.30-0.89; P < .05) and abdominal obesity (OR, 0.51; 95% CI, 0.32-0.83; P < .01). Participants in the highest tertile of whole-fat dairy intakes (milk, cheese, yogurt) had significantly lower odds for being obese (global obesity: OR, 0.45; 95% CI, 0.29-0.72; P < .01; abdominal obesity: OR, 0.35; 95% CI, 0.23-0.54; P < .001), compared with those in the lowest intake tertile, after full adjustment for demographic, lifestyle, dietary, and cardiovascular risk factor variables. Increasing consumption of dairy foods may have the potential to lower the prevalence of global and abdominal obesity.     

Implementation of Community Health Fund in Tanzania: why do some districts perform better than others?

In early 1990s, Tanzania, like other African countries, introduced user fees in public health systems. Although user fees were considered important in promoting health, they appear to reduce people's access to health services. To counteract the detrimental effects of the user fees, various types of health insurances were introduced, including the Community Health Fund (CHF). Drawing from the review of minutes, health facility visits and key informant interviews, this study explored why implementation of the CHF in Tanzania has been more successful in some districts than in others. The findings indicate that in Lindi district, the enrolment rate for the CHF was very low. This was attributed to high premium rates, frequent drug stock‐out, lack of trust by the community members to the health providers, low incentives and local politics. In contrast, in Iramba district, the performance was better. Availability of drugs in the health facilities, effective supervision, commitment of the top district‐level officials and incentives to the health facility committees were the main factors that facilitated good performance of the fund in Iramba district. The focus of the implementation needs to be placed on the active engagement of the local‐level leaders and politicians who are responsible for the implementation of the policy. Equally important is the availability of quality health services in the health facilities. Copyright © 2013 John Wiley & Sons, Ltd.