Performance-based financing in the heath sector in low- and middle-income countries: Is there anything whereof it may be said, see, this is new?

Whereas performance-based financing (PBF) is now developing fast in the health sector in low- and middle-income countries and is presented an innovative approach-concomitantly, subject to a separate research stream-it shares many features of the "managing for results" (MfR) and performance-based budgeting (PBB) currents that have existed for decades. In this paper, we first argue that PBF as currently developed in the health sector in low- and middle-income countries shares many features and thus can be viewed as an avatar of MfR and more precisely PBB. Secondly, we draw lessons from the literature on MfR and PBB so as to (1) better apprehend PBF conceptually and (2) avoid pitfalls and better design PBF schemes in practice. We argue that the lessons from the theoretical and empirical literature on MfR and PBB offer interesting insights to feed into a "theory of change" of PBF, enabling to analyse critical aspects and better design PBF schemes. Moreover, it is hoped that just like MfR processes have been demonstrated as having the potential to boost individual performance not only through links with financial incentives but also through acting on other sources of motivation, one can demonstrate more accurately by which mechanisms the various elements of the PBF package can help improve health sector results.

Female patients display poorer burn-specific quality of life 12 months after a burn injury

INTRODUCTION

Although gender differences in morbidity and mortality have been measured in patients with moderate to severe burn injury, little attention has been directed at gender effects on health-related quality of life (HRQoL) following burn injury. The current study was therefore conducted to prospectively measure changes in HRQoL for males and females in a sample of burn patients.

METHODS

A total of 114 adults who received treatment at a statewide burns service for a sustained burns injury participated in this study. Instruments measuring generic health status (Short Form 36 Medical Outcomes Survey version 2), burn-specific HRQoL (Burns Specific Health Scale-Brief), psychological distress (Kessler Psychological Distress Scale) and alcohol use (Alcohol Use Disorders Identification Tool) were prospectively measured at 3, 6 and 12 months post-burn.

RESULTS

In the 12 months post-injury, female patients showed overall poorer physical (p=0.01) and mental health status (p<0.001), greater psychological distress (p<0.001), and greater difficulty with aspects of burn-specific HRQoL: body image (p<0.001), affect (p<0.001), interpersonal functioning (p=0.005), heat sensitivity (p=0.01) and treatment regime (p=0.01). While significant interaction effects suggested that female patients had more improvement in difficulties with treatment regime (p=0.007), female patients continued to report greater difficulty with multiple aspects of physical and psychosocial health status 12 months post-injury.

CONCLUSION

Even though demographic variables, injury characteristics and burn care interventions were similar across genders, following burn injury female patients reported greater impairments in generic and burn-specific HRQoL along with psychological morbidity, when compared to male patients. Urgent clinical and research attention utilising an evidence-based research framework, which incorporates the use of larger sample sizes, the use of validated instruments to measure appropriate outcomes, and a commitment to monitoring long-term care, can only improve burn-care.

Systemic arterial stiffness in infants with bronchopulmonary dysplasia: potential cause of systemic hypertension

OBJECTIVE

Systemic hypertension is common among preterm infants with severe bronchopulmonary dysplasia (BPD); the exact cause is unknown. The objective of this preliminary hypothesis generating study was to examine systemic arterial structure and vasomotor function in a cohort of preterm infants with severe BPD, using a cohort of preterm infants without BPD and a cohort of term infants for comparison.

STUDY DESIGN

After obtaining informed consent, we measured aortic wall thickness and vasomotor function by ultrasonography in 20 infants with severe BPD, 7 infants with no BPD, and compared them with 20 healthy term infants.

RESULTS

Maximum aortic thickness was significantly higher in infants with BPD (827±163 μm) compared to those with no BPD (674±22 μm) and term infants (657±67 μm) (unadjusted P<0.0001). The input impedance was similarly elevated in the infants with BPD (574±127 dynes s( )cm(-5)) compared to those with no BPD (325±24 dynes s cm(-)(5)) or term infants (328±113 dynes s cm(-)(5)) (unadjusted P<0.0001). Stiffness index was significantly higher in the infants with BPD (3.4±0.6) compared to those with no BPD (2.6±0.3) or term infants (2.3±0.4) (unadjusted P<0.0001). Systemic vascular resistance was also significantly elevated in the infants with BPD. The results remained significant even after adjusting for gestational age and birth weight. Measures of vasomotor function significantly correlated with blood pressure.

CONCLUSION

The aortic wall thickness and vasomotor function are significantly altered in preterm infants with severe BPD. These findings may explain the higher incidence of systemic hypertension in this population.

Integrating smoking cessation into routine care in hospitals--a randomized controlled trial

AIMS

To evaluate the effectiveness of a pharmacist-led multi-component smoking cessation programme (GIVE UP FOR GOOD) compared with usual care in hospitalized smokers.

DESIGN

Randomized, assessor-blinded, parallel-group trial.

SETTING

Three tertiary public hospitals in Australia.

PARTICIPANTS

A total of 600 adult in-patient smokers [mean ± standard deviation (SD), age 51 ± 14 years; 64% male] available for 12 months follow-up.

INTERVENTIONS

Multi-component hospital pharmacist-led behavioural counselling and/or pharmacotherapy provided during hospital stay, on discharge and 1 month post-discharge, with further support involving community health professionals (n = 300). Usual care comprised routine care provided by hospitals (n = 300).

MEASUREMENTS

Two primary end-points were tested using intention-to-treat analysis: carbon monoxide (CO)-validated 1-month sustained abstinence at 6-month follow-up and verified 6-month sustained abstinence at 12-month follow-up. Smoking status and pharmacotherapy usage were assessed at baseline, discharge, 1, 6 and 12 months.

FINDINGS

Sustained abstinence rates for intervention and control groups were not significantly different at both 6 months [11.6% (34 of 294) versus 12.6% (37 of 294); odds ratio (OR) = 0.91, 95% confidence interval (CI) = 0.55-1.50] and 12 months [11.6% (34 of 292) versus 11.2% (33 of 294); OR = 1.04, 95% CI = 0.63-1.73]. Secondary end-points, self-reported continuous abstinence at 6 and 12 months, also agreed with the primary end-points. Use of pharmacotherapy was higher in the intervention group, both during hospital stay [52.3% (157 of 300) versus 42.7% (128 of 300); P = 0.016] and after discharge [59.6% (174 of 292) versus 43.5% (128 of 294); P < 0.001].

CONCLUSIONS

A pharmacist-led multi-component smoking cessation intervention provided during hospital stay did not improve sustained abstinence rates at either 6 or 12 months compared with routine hospital care.

Comparative responses of river biofilms at the community level to common organic solvent and herbicide exposure

Residual pesticides applied to crops migrate from agricultural lands to surface and ground waters. River biofilms are the first aquatic non-target organisms which interact with pesticides. Therefore, ecotoxicological experiments were performed at laboratory scale under controlled conditions to investigate the community-level responses of river biofilms to a chloroacetanilide herbicide (alachlor) and organic solvent (methanol) exposure through the development referenced to control. Triplicate rotating annular bioreactors, inoculated with river water, were used to cultivate river biofilms under the influence of 1 and 10 μg L(-1) of alachlor and 25 mg L(-1) of methanol. For this purpose, functional (thymidine incorporation and carbon utilization spectra) and structural responses of microbial communities were assessed after 5 weeks of development. Structural aspects included biomass (chlorophyll a, confocal laser scanning microscopy) and composition (fluor-conjugated lectin binding, molecular fingerprinting, and diatom species composition). The addition of alachlor resulted in a significant reduction of bacterial biomass at 1 μg L(-1), whereas at 10 μg L(-1), it induced a significant reduction of exopolymer lectin binding, algal, bacterial, and cyanobacterial biomass. However, there were no changes in biofilm thickness or thymidine incorporation. No significant difference between the bacterial community structures of control and alachlor-treated biofilms was revealed by terminal restriction fragment length polymorphism (T-RFLP) analyses. However, the methanol-treated bacterial communities appeared different from control and alachlor-treated communities. Moreover, methanol treatment resulted in an increase of bacterial biomass and thymidine incorporation as well. Changes in dominant lectin binding suggested changes in the exopolymeric substances and community composition. Chlorophyll a and cyanobacterial biomass were also altered by methanol. This study suggested that the concentration-dependent effect of alachlor mainly remains limited to biomass and growth inhibition without apparent changes of structural and functional characteristics measured. Our work also establishes the potential toxic effects of organic solvents on river biofilm in ecotoxicological experiments. For the ecotoxicological experiments, the alternative of dissolution in organic solvent followed by its evaporation, depositing the chemical on a glass surface prior to dissolution in river water used here, appears to allow exposure while minimizing the effect of organic solvent.

Modelling nitrogen and carbon interactions in composting of animal manure in naturally aerated piles

Composting animal manure with natural aeration is a low-cost and low-energy process that can improve nitrogen recycling in millions of farms world-wide. Modelling can decrease the cost of choosing the best options for solid manure management in order to decrease the risk of loss of fertilizer value and ammonia emission. Semi-empirical models are suitable, considering the scarce data available in farm situations. Eleven static piles of pig or poultry manure were monitored to identify the main processes governing nitrogen transformations and losses. A new model was implemented to represent these processes in a pile considered as homogeneous. The model is based on four modules: biodegradation, nitrogen transformations and volatilization, thermal exchanges, and free air space evolution. When necessary, the parameters were calibrated with the data set. The results showed that microbial growth could reduce ammonia volatilization. Greatest nitrogen conservation is achieved when microbial growth was limited by nitrogen availability.

Does arthroscopic subacromial decompression improve quality of life

INTRODUCTION

There has been a significant rise in the volume of subacromial decompression surgery performed in the UK. This study aimed to determine whether arthroscopic subacromial decompression improves health related quality of life in a cost effective manner.

METHODS

Patients undergoing arthroscopic subacromial decompression surgery for impingement were enrolled between 2012 and 2014. The Oxford shoulder score and the EQ-5D™ instruments were completed prior to and following surgery. A cost-utility analysis was performed.

RESULTS

Eighty-three patients were eligible for the study with a mean follow-up duration of 15 months (range: 4-27 months). The mean Oxford shoulder score improved by 13 points (95% confidence interval [CI]: 11-15 points). The mean health utility gain extrapolated from the EQ-5D™ questionnaire improved by 0.23 (95% CI: 0.16-0.30), translating to a minimum cost per QALY of £5,683.

CONCLUSIONS

Subacromial decompression leads to significant improvement in function and quality of life in a cost effective manner. This provides justification for its ongoing practice by appropriately trained shoulder surgeons in correctly selected patients.

Pet ownership is associated with increased risk of non-atopic asthma and reduced risk of atopy in childhood: findings from a UK birth cohort

BACKGROUND

Studies have shown an inverse association of pet ownership with allergy but inconclusive findings for asthma.

OBJECTIVE

To investigate whether pet ownership during pregnancy and childhood was associated with asthma and atopy at the age of 7 in a UK population-based birth cohort.

METHODS

Data from the Avon Longitudinal Study of Parents and Children (ALSPAC) were used to investigate associations of pet ownership at six time points from pregnancy to the age of 7 with asthma, atopy (grass, house dust mite, and cat skin prick test) and atopic vs. non-atopic asthma at the age of 7 using logistic regression models adjusted for child's sex, maternal history of asthma/atopy, maternal smoking during pregnancy, and family adversity.

RESULTS

A total of 3768 children had complete data on pet ownership, asthma, and atopy. Compared with non-ownership, continuous ownership of any pet (before and after the age of 3) was associated with 52% lower odds of atopic asthma [odds ratio (OR) 0.48, 95% CI 0.34-0.68]. Pet ownership tended to be associated with increased risk of non-atopic asthma, particularly rabbits (OR 1.61, 1.04-2.51) and rodents (OR 1.86, 1.15-3.01), comparing continuous vs. non-ownership. Pet ownership was consistently associated with lower odds of sensitization to grass, house dust mite, and cat allergens, but rodent ownership was associated with higher odds of sensitization to rodent allergen. Differential effects of pet ownership on atopic vs. non-atopic asthma were evident for all pet types.

CONCLUSIONS AND CLINICAL RELEVANCE

Pet ownership during pregnancy and childhood in this birth cohort was consistently associated with a reduced risk of aeroallergen sensitization and atopic asthma at the age of 7, but tended to be associated (particularly for rabbits and rodents) with an increased risk of non-atopic asthma. The opposing effects on atopy vs. non-atopic asthma might be considered by parents when they are deciding whether to acquire a pet.

Proximal Versus Distal Splenic Artery Embolisation for Blunt Splenic Trauma: What is the Impact on Splenic Immune Function?

PURPOSE

To compare the impact of proximal or distal splenic artery embolisation versus that of splenectomy on splenic immune function as measured by IgM memory B cell levels.

MATERIALS AND METHODS

Patients with splenic trauma who were treated by splenic artery embolisation (SAE) were enrolled. After 6 months splenic volume was assessed by CT, and IgM memory B cells in peripheral blood were measured and compared to a local normal reference population and to a post-splenectomy population.

RESULTS

Of the 71 patients who underwent embolisation, 38 underwent proximal embolisation, 11 underwent distal embolisation, 22 patients were excluded, 1 had both proximal and distal embolisation, 5 did not survive and 16 did not return for evaluation. There was a significant difference between splenectomy and proximal or distal embolisation and a trend towards greater preservation of IgM memory B cell number in those with distal embolisation-a difference that could not be attributed to differences in age, grade of injury or residual splenic volume.

CONCLUSION

IgM memory B cell levels are significantly higher in those treated with SAE compared to splenectomy. Our data provide evidence that splenic embolisation should reduce immunological complications of spleen trauma and suggest that distal embolisation may maintain better function.

Paediatric CT dose: a multicentre audit of subspecialty practice in Australia and New Zealand

OBJECTIVES

To evaluate paediatric CT dosimetry in Australia and New Zealand and calculate size-specific dose estimates (SSDEs) for chest and abdominal examinations.

METHODS

Eight hospitals provided data from 12 CT systems for 1462 CTs in children aged 0-15. Imaging data were recorded for eight examinations: head (trauma, shunt), temporal bone, paranasal sinuses, chest (mass) and chest HRCT (high-resolution CT), and abdomen/pelvis (mass/inflammation). Dose data for cranial examinations were categorised by age and SSDEs by lateral dimension. Diagnostic reference ranges (DRRs) were defined by the 25th and 75th percentiles. Centralised image quality assessment was not undertaken.

RESULTS

DRRs for 201 abdominopelvic SSDEs were: 2.8-4.7, 3.6-11.5, 8.5-15.0, 7.6-15, and 10.6-16.2 for the <15 cm, 15-19 cm, 20-24 cm, 25-29 cm and >30 cm groups, respectively. For 147 chest examinations using these body width categories, SSDE DRRs were 2.0-4.4, 3.3-7.9, 4.0-9.4, 4.5-12, and 6.5-12. Kilovoltage peak (kVp), but not AEC or IR, was associated with SSDE (parameter estimate [standard error]: 0.12 (0.03); p < 0.0001).

CONCLUSIONS

Australian and New Zealand paediatric CT DRRs and abdominal SSDEs are comparable to international data. SSDEs for chest examinations are proposed. Dose variations could be reduced by adjusting kVp.

KEY POINTS

• SSDEs can be calculated for all patients, CT systems, and practices • Kilovoltage peak (kVp) has the greatest association with dose in similar-sized patients • Paediatric DRRs for CT are now available for use internationally.

Evolving practice: X-linked agammaglobulinemia and lung transplantation

X-linked agammaglobulinemia (XLA) is a rare primary humoral immunodeficiency syndrome characterized by agammaglobulinemia, recurrent infections and bronchiectasis. Despite the association with end-stage bronchiectasis, the literature on XLA and lung transplantation is extremely limited. We report a series of 6 XLA patients with bronchiectasis who underwent lung transplantation. Short-term outcomes were excellent however long-term outcomes were disappointing with a high incidence of pulmonary sepsis and chronic lung allograft dysfunction (CLAD).

Evidence-based development of a post-surgical lumbar discectomy leaflet intervention: a Delphi consensus study

OBJECTIVE

To produce free, expert-informed postoperative information for lumbar discectomy patients, satisfying UK National Health Service Information Standards.

DESIGN

A mixed methods approach utilising the Delphi technique and focus groups.

SETTING

Five spinal centres across the UK.

PARTICIPANTS

Panel members included 23 physiotherapists, 11 patients and 17 spinal surgeons.

INTERVENTION

Three rounds of questionnaires including open and closed questions and attendance at a clinician/patient focus group.

RESULTS

Response rates of 85%, 26% and 35% were achieved for the Delphi rounds. Ten clinicians and six patients participated in the focus groups. Consensus for leaflet sections was achieved in round 1 and content in round 3. The focus groups informed further revisions.

CONCLUSIONS

A consensually agreed, Information Standard compliant, patient lumbar discectomy leaflet was produced containing: (1) normal spine anatomy; (2) anatomy disc herniation and surgery; (3) back protection strategies and (4) frequently asked questions. Illustrations of exercises enable tailoring to the individual patient.

A Cohort and Database Study of Airway Management in Patients Undergoing Thyroidectomy for Retrosternal Goitre

Patients undergoing thyroid surgery with retrosternal goitre may raise concerns for the anaesthetist, especially airway management. We reviewed a multicentre prospective thyroid surgery database and extracted data for those patients with retrosternal goitre. Additionally, we reviewed the anaesthetic charts of patients with retrosternal goitre at our institution to identify the anaesthetic induction technique and airway management. Of 4572 patients in the database, 919 (20%) had a retrosternal goitre. Two cases of early postoperative tracheomalacia were reported, one in the retrosternal group. Despite some very large goitres, no patient required tracheostomy or cardiopulmonary bypass and there were no perioperative deaths. In the subset of 133 patients managed at our institution over six years, there were no major adverse anaesthetic outcomes and no patient had a failed airway or tracheomalacia. In the latter cohort, of 32 (24%) patients identified as having a potentially difficult airway, 17 underwent awake fibreoptic tracheal intubation, but two of these were abandoned and converted to intravenous induction and general anaesthesia. Eleven had inhalational induction; two of these were also abandoned and converted to intravenous induction and general anaesthesia. Of those suspected as having a difficult airway, 28 (87.5%) subsequently had direct laryngoscopy where the laryngeal inlet was clearly visible. We found no good evidence that thyroid surgery patients with retrosternal goitre, with or without symptoms and signs of tracheal compression, present the experienced anaesthetist with an airway that cannot be managed using conventional techniques. This does not preclude the need for multidisciplinary discussion and planning.

Local stakeholders' perceptions about the introduction of performance-based financing in Benin: a case study in two health districts

BACKGROUND

Performance-Based Financing (PBF) has been advanced as a solution to contribute to improving the performance of health systems in developing countries. This is the case in Benin. This study aims to analyse how two PBF approaches, piloted in Benin, behave during implementation and what effects they produce, through investigating how local stakeholders perceive the introduction of PBF, how they adapt the different approaches during implementation, and the behavioural interactions induced by PBF.

METHODS

The research rests on a socio-anthropological approach and qualitative methods. The design is a case study in two health districts selected on purpose. The selection of health facilities was also done on purpose, until we reached saturation of information. Information was collected through observation and semi-directive interviews supported by an interview guide. Data was analysed through contents and discourse analysis.

RESULTS

The Ministry of Health (MoH) strongly supports PBF, but it is not well integrated with other ongoing reforms and processes. Field actors welcome PBF but still do not have a sense of ownership about it. The two PBF approaches differ notably as for the organs in charge of verification. Performance premiums are granted according to a limited number of quantitative indicators plus an extensive qualitative checklist. PBF matrices and verification missions come in addition to routine monitoring. Local stakeholders accommodate theoretical approaches. Globally, staff is satisfied with PBF and welcomes additional supervision and training. Health providers reckon that PBF forces them to depart from routine, to be more professional and to respect national norms. A major issue is the perceived unfairness in premium distribution. Even if health staff often refer to financial premiums, actually the latter are probably too weak-and 'blurred'-to have a lasting inciting effect. It rather seems that PBF motivates health workers through other elements of its 'package', especially formative supervisions.

CONCLUSION

If the global picture is quite positive, several issues could jeopardise the success of PBF. It appears crucial to reduce the perceived unfairness in the system, notably through enhancing all facilities' capacities to ensure they are in line with national norms, as well as to ensure financial and institutional sustainability of the system.

No increase in colorectal cancer in patients under 50 years of age: a Victorian experience from the last decade

AIM

The study aimed to assess whether there has been an increase in the incidence of colorectal cancer (CRC) among young patients in Victoria and whether such cancers are more advanced at presentation.

METHOD

The Victorian Cancer registry database was searched for patients, 18-50 years of age, diagnosed with CRC [young colorectal cancer (YCRC)] between 2000 and 2010. Average annual percentage changes and incidence rate ratios (IRRs) were calculated to characterize trends in CRC rates over time and to make comparisons with patients over 50 years of age with CRC [late colorectal cancer (LCRC)].

RESULTS

Of 37432 CRCs registered during the study period, 2635 (7%) were in YCRC patients (annual increase in incidence = 1.7%; 95% CI: 0.5-2.9), compared with 34797 (93%) in LCRC patients (annual increase in incidence = 1.3%; 95% CI: 0.9-1.6). A small, nonsignificant increase in the incidence of YCRC over time was observed [IRR = 1.004 (95% CI: 0.992-1.016) for YCRC vs. 0.989 (95% CI: 0.986-0.992) for LCRC]. Rectal cancer was more common in YCRC patients than in LCRC patients (42% vs. 34%, respectively; P < 0.0001). The cancer would have been seen on flexible sigmoidoscopy in 63% of YCRC patients compared with 53.6% of LCRC patients (P < 0.0001). YCRC patients were more likely to have node-positive disease (49.3% YCRC patients vs. 40% LCRC patients; P < 0.0001), especially those with colonic cancer (52.7% YCRC patients vs. 41.2% LCRC patients; P < 0.0001).

CONCLUSION

There has been an increase in incident cases of YCRC. A small, nonsignificant increase in the incidence of YCRC over time was observed. Young patients are more likely to have rectal cancer and to be node positive.

The cost of photoselective vaporization of the prostate compared to transurethral resection of the prostate: Experience in a large public Australian teaching centre

Objective:

The purpose of this study was to compare the cost of photoselective vaporization of the prostate (PVP) with transurethral resection of the prostate (TURP) in the treatment of men with bladder outflow obstruction (BOO).

Patients and methods:

Men underwent PVP or TURP for clinical BOO or urinary retention. We developed a cost framework to calculate the costs of theatre, recovery and ward time in our publically funded institution and calculated a cost for each procedure including the initial stay and any associated admissions over the first 60 days. These costs were statistically analyzed.

Results:

A total of 99 men underwent PVP and 97 had TURP. Groups were well matched for age and operative indication. The American Society of Anesthesia (ASA) grade was higher for the PVP group with more taking anticoagulants (36% versus 3.1%). PVP was 74% more expensive (median AUD$4243 vs AUD$2439, p<0.001) than TURP, even in a sub-set analysis excluding the anticoagulated patients. This was because of longer operating time and unavoidable disposable costs.

Conclusions:

Previous cost studies have all had significant flaws. Using our “bottom up” cost framework suggests that the unavoidable costs of purchasing a laser, single use laser fibers and other paraphernalia will almost always exceed the costs associated with in-patient stay. We caution against establishing a PVP service in a public hospital setting.

Patterns of recovery over 12 months following a burn injury in Australia

OBJECTIVE

To describe patients' generic health status and health-related quality of life (HRQoL) 12-months following admission to a state-wide burns service.

METHODS

A total of 114 injured adults with >10% total body surface area burned (TBSA) or burns less than 10% TBSA to smaller anatomical areas such as the hands and feet participated in this study. Retrospective assessment of pre-burn injury status and prospective assessment of generic health and HRQoL were followed up at 3, 6 and 12-months after injury using the 36-item Short Form Health Survey (SF-36 v.2) and Burns Specific Health Scale-Brief (BSHS-B). The SF-36 v.2 was administered retrospectively during the initial hospital stay to assess pre-injury HRQoL. Changes in instruments scores were assessed using multilevel mixed effects regression models. Mean scores were compared over time and between severity groups as defined by <10%, 10-30% and >30% TBSA.

RESULTS

For the overall sample, the SF-36 v.2 physical component scale (PCS) score between 3 and 12-months post-burn injury were significantly lower than pre-injury scores (p<0.01), with no significant change over time for the mental component scale (MCS) (p=0.36). Significant %TBSA-burden by time interactions highlighted changes from pre-burn injury in overall PCS (p=0.02), physical functioning (p<0.001) and role-physical (p=0.03), with subscales worse for the TBSA >30% group. With respect to the BSHS-B, significant improvement from 3 to 12-months post-burn injury was seen for the entire sample in simple abilities (p<0.001), hand function (p=0.001), work (p=0.01), and treatment regime (p=0.004) subscales. The TBSA >30% group showed a greater rate of improvement in simple abilities (p=0.01) and hand function (p=0.005) between 3 and 12 months post-burn injury.

CONCLUSIONS

Whilst certain HRQoL measures improve over the 12-months, in most cases they do not reach pre-morbid levels. Patients face ongoing challenges regarding their physical and psychosocial recovery 12-months post-burn injury with respect to generic health and burn-specific health. These challenges vary at different time periods over the 12-month post-burn period, and may provide windows of opportunity in which to address ongoing issues.

[The effectiveness of health aid to West Africa: now more uncertain than ever]

La préoccupation d’améliorer l’efficacité de l’aide au développement dans le secteur de la santé est plus que jamais d’actualité. L’approche sectorielle permet d’obtenir des améliorations importantes à ce niveau et connaît un renouveau à travers le Partenariat International pour la Santé et initiatives liées (IHP+). Dans ce commentaire, nous montrons comment l’IHP+ a été mis en œuvre dans trois pays ouest-africains francophones : le Bénin, le Burkina Faso et le Mali. La dynamique existant dans le secteur de la santé dans chacun des pays a influencé la façon dont l’IHP+ s’y est traduit. Au-delà de ces dynamiques différentes, l’IHP+ a permis de renforcer la place des plans et dispositifs nationaux de coordination comme plateforme de suivi-évaluation et de redevabilité du secteur santé. Toutefois, certaines pratiques contraires aux principes de l’efficacité de l’aide perdurent encore, en particulier le manque d’alignement sur les systèmes de gestion nationaux et le manque de prévisibilité de l’aide.

Changes in tolerance to herbicide toxicity throughout development stages of phototrophic biofilms

Ecotoxicological experiments have been performed in laboratory-scale microcosms to investigate the sensitivity of phototrophic biofilm communities to the alachlor herbicide, in relation to the stages of phototrophic biofilm maturation (age of the phototrophic biofilms) and physical structure (intact biofilm versus recolonization). The phototrophic biofilms were initially cultivated on artificial supports in a prototype rotating annular bioreactor (RAB) with Taylor-Couette type flow under constant operating conditions. Biofilms were collected after 1.6 and 4.4 weeks of culture providing biofilms with different maturation levels, and then exposed to nominal initial alachlor concentration of 10 μg L(-1) in either intact or recolonized biofilms for 15 days in microcosms (mean time-weighted average concentration - TWAC of 5.52 ± 0.74 μg L(-1)). At the end of the exposure period, alachlor effects were monitored by a combination of biomass descriptors (ash-free dry mass - AFDM, chlorophyll a), structural molecular fingerprinting (T-RFLP), carbon utilization spectra (Biolog) and diatom species composition. We found significant effects that in terms of AFDM, alachlor inhibited growth of the intact phototrophic biofilms. No effect of alachlor was observed on diatom composition or functional and structural properties of the bacterial community regardless of whether they were intact or recolonized. The intact three-dimensional structure of the biofilm did not appear to confer protection from the effects of alachlor. Bacterial community structure and biomass level of 4.4 weeks - intact phototrophic biofilms were significantly influenced by the biofilm maturation processes rather than alachlor exposure. The diatom communities which were largely composed of mobile and colonizer life-form populations were not affected by alachlor. This study showed that the effect of alachlor (at initial concentration of 10 μg L(-1) or mean TWAC of 5.52 ± 0.74 μg L(-1)) is mainly limited to biomass reduction without apparent changes in the ecological succession trajectories of bacterial and diatom communities and suggested that carbon utilization spectra of the biofilm are not damaged resulting. These results confirmed the importance of considering the influence of maturation processes or community age when investigating herbicide effects. This is particularly important with regard to the use of phototrophic biofilms as bio-indicators.

Early MRI in term infants with perinatal hypoxic-ischaemic brain injury: interobserver agreement and MRI predictors of outcome at 2 years

AIM

To compare diffusion-weighted imaging (DWI) and non-DWI magnetic resonance imaging (MRI), proton MR spectroscopy (1H-MRS), and clinical biomarkers for prediction of 2 year developmental outcome in term infants with perinatal hypoxic-ischaemic encephalopathy (HIE).

MATERIALS AND METHODS

Nineteen infants ≥36 weeks gestation with HIE were recruited and MRI performed day 3-7 (mean = 5). MRI was scored independently by three radiologists using a standardized scoring system. Lactate-to-N-acetylaspartate ratio (Lac:NAA) in the lentiform nucleus was calculated. Developmental assessment was performed at 2 years using the Bayley Scales of Infant and Toddler Development (BSID-III). Interobserver agreement about abnormality in 10 brain regions was measured. Univariate analysis was performed to determine variables associated with adverse outcome (i.e., death or Bayley score for any domain <70).

RESULTS

Good interobserver agreement (kappa = 0.61-0.69) on scores for DWI was obtained for the cortex, putamen, and brainstem, but not for any region on non-DWI. A significant association was found between outcome and Lac:NAA (p < 0.003) and DWI scores for lentiform nucleus, thalamus, cortex, posterior limb of the internal capsule (PLIC), and paracentral white matter (p = 0.001-0.013), but for non-DWI score only in the vermis or brainstem. A combination of Lac:NAA ≥0.25 or DWI/apparent diffusion coefficient (ADC) signal abnormality in the PLIC had 100% specificity and sensitivity for poor outcome.

CONCLUSION

Interobserver agreement for non-DWI performed during the first week is poor. Agreement by three radiologists about the presence of abnormal signal within the PLIC on ADC/DWI images or elevation of Lac:NAA above 0.25 improved sensitivity without reducing the prognostic specificity of MRS in the 19 patients, but this requires validation in a larger group of infants with HIE who have been treated with hypothermia.

Age-related reference intervals for bone turnover markers from an Australian reference population

BACKGROUND

This study was performed to establish age-related serum reference intervals for procollagen type I N-propeptide (P1NP) and type I collagen C-telopeptide (CTx) in the Australian population.

METHODS

Fasting sera from 1143 males (mean age 60 years; range 20-97 years) and 1246 females (mean age 53 years; range 20-93 years) who participated in the Geelong Osteoporosis Study were analysed for CTx and P1NP using the automated Roche Modular Analytics E170 analyser.

RESULTS

Optimal age-related reference intervals were based on the central 90% of the distribution. The male CTx reference interval was divided into three age groups. For men aged 25 to 40 years, the interval was 170-600 ng/L; 40 to 60 years, the interval was 130-600 ng/L; and for men aged greater 60 years the interval was 100-600 ng/L. For P1NP the male reference interval was 15-80 μg/L for men aged between 25 to 70 years. In men greater than 70 years of age values were higher possibly due to increased bone turnover. High values are frequently seen for both CTx and P1NP in males aged younger than 25 years. This is probably due to bone growth that is not completely finalised. The female CTx reference interval was divided into four age groups. For women aged less than 30 years, the interval was 150-800 ng/L; 30-39 years, the interval was 100-700 ng/L; 40-49 years, the interval was 100-600 ng/L; and for women aged 50 years or more the interval was 100-700 ng/L. The female P1NP reference interval was divided into four age groups. For women aged less than 30 years, the interval was 25-90 μg/L; 30-39 years, the interval was 15-80 μg/L; 40-49 years, the interval was 15-60 μg/L; and for women aged 50-69 years the interval was 15-75 μg/L. In women greater than 70 years of age values were higher possibly due to increased bone turnover.

CONCLUSION

Values obtained from this large study provide sound age-related reference intervals for serum P1NP and CTx values in the Australian population.

Performance of APACHE III over time in Australia and New Zealand: a retrospective cohort study

The Acute Physiology and Chronic Health Evaluation (APACHE) III-j model has been used for benchmarking intensive care unit (ICU) outcomes in Australia and New Zealand for over a decade. This study assessed performance of the APACHE III-j model in adult patients admitted to Australasian ICUs during a ten-year period. Data were extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database. Performance of APACHE III-j at different time points and within different age strata was evaluated by dividing the whole cohort into five 'two-year' groups. Calibration and discrimination were assessed by the Brier score, Hosmer-Lemeshow C and H statistics, Standardised Mortality Ratio (SMR), Cox calibration regression, calibration curves and area under the receiver operating characteristic curve (AUROC). Model performance within diagnostic categories was evaluated. Between 1 January 2000 and 31 December 2009, 558,585 ICU admissions which met inclusion criteria were included in the analysis. The mean (standard deviation) age was 60.8 (18.4) years and 58.3% were male. Overall observed mortality was 12.6%. The mean (standard deviation) APACHE III-j predicted mortality was 14.5% (21.8). Although discrimination (as measured by AUROC) was preserved over time, all other markers of model performance showed deterioration. There was a significant decrease in SMR in eight of ten most common diagnoses examined. This study demonstrates that performance of APACHE III-j model has deteriorated in Australasian hospitals and there is now a clear need for an updated modelling approach to improve mortality prediction, performance monitoring and quality of research undertaken in Australian and New Zealand ICUs.

Modeling organic matter stabilization during windrow composting of livestock effluents

Composting is a complex bioprocess, requiring a lot of empirical experiments to optimize the process. A dynamical mathematical model for the biodegradation of the organic matter during the composting process has been developed. The initial organic matter expressed by chemical oxygen demand (COD) is decomposed into rapidly and slowly degraded compartments and an inert one. The biodegradable COD is hydrolysed and consumed by microorganisms and produces metabolic water and carbon dioxide. This model links a biochemical characterization of the organic matter by Van Soest fractionating with COD. The comparison of experimental and simulation results for carbon dioxide emission, dry matter and carbon content balance showed good correlation. The initial sizes of the biodegradable COD compartments are explained by the soluble, hemicellulose-like and lignin fraction. Their sizes influence the amplitude of the carbon dioxide emission peak. The initial biomass is a sensitive variable too, influencing the time at which the emission peak occurs.

Motivation of human resources for health: a case study at rural district level in Tanzania

An increasing number of studies explore the association between financial and non-financial incentives and the retention of health workers in developing countries. This study aims to contribute to empirical evidence on human resource for health motivation factors to assist policy makers in promoting effective and realistic interventions. A cross-sectional survey was conducted in four rural Tanzanian districts to explore staff stability and health workers' motivation. Data were collected using qualitative and quantitative techniques, covering all levels and types of health facilities. Stability of staff was found to be quite high. Public institutions remained very attractive with better job security, salary and retirement benefits. Satisfaction over working conditions was very low owing to inadequate working equipment, work overload, lack of services, difficult environment, favouritism and 'empty promotions'. Positive incentives mentioned were support for career development and supportive supervision. Attracting new staff in rural areas appeared to be more difficult than retaining staff in place. The study concluded that strategies to better motivate health personnel should focus on adequate remuneration, positive working and living environment and supportive management. However, by multiplying health facilities, the latest Tanzanian human resource for health plan could jeopardize current positive results.

Hepatic manifestations of tuberous sclerosis complex: a genotypic and phenotypic analysis

Hepatic manifestations of tuberous sclerosis complex: a genotypic and phenotypic analysis. A retrospective review of the clinical records and radiological images of 205 patients with tuberous sclerosis complex (TSC) was performed to evaluate the prevalence and progression of hepatic lesions; examine the association of hepatic phenotype with genotype, age, and gender; and investigate the relationships between hepatic, renal, and pulmonary involvement. Hepatic angiomyolipomas (AML), cysts, and other benign lesions were identified in 30% of the cohort, and some lesions grew significantly over time. However, no patient had clinical symptoms or complications from hepatic lesions. TSC2 patients exhibited a higher frequency of AML compared to TSC1 patients (p = 0.037), and patients with no mutation identified exhibited a higher frequency of cysts compared to TSC2 patients (p = 0.023). Age was positively correlated with frequency of hepatic involvement (p < 0.001), whereas hepatic phenotype was independent of gender. Presence of hepatic AML was associated with presence of renal AML (p = 0.001). These findings confirm a high rate of asymptomatic hepatic lesions in TSC and further characterize the TSC phenotype.

Can performance-based financing be used to reform health systems in developing countries?

Over the past 15 years, performance-based financing has been implemented in an increasing number of developing countries, particularly in Africa, as a means of improving health worker performance. Scaling up to national implementation in Burundi and Rwanda has encouraged proponents of performance-based financing to view it as more than a financing mechanism, but increasingly as a strategic tool to reform the health sector. We resist such a notion on the grounds that results-based and economically driven interventions do not, on their own, adequately respond to patient and community needs, upon which health system reform should be based. We also think the debate surrounding performance-based financing is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the performance-based financing package.

Removal of microbial multi-species biofilms from the paper industry by enzymatic treatments

This study aimed to characterize biofilms from the paper industry and evaluate the effectiveness of enzymatic treatments in reducing them. The extracellular polymeric substances (EPS) extracted from six industrial biofilms were studied. EPS were mainly proteins, the protein to polysaccharide ratio ranging from 1.3 to 8.6 depending on where the sampling point was situated in the paper making process. Eight hydrolytic enzymes were screened on a 24-h multi-species biofilm. The enzymes were tested at various concentrations and contact durations. Glycosidases and lipases were inefficient or only slightly efficient for biofilm reduction, while proteases were more efficient: after treatment for 24 h with pepsin, Alcalase® or Savinase®, the removal exceeded 80%. Savinase® appeared to be the most adequate for industrial conditions and was tested on an industrial biofilm sample. This enzyme led to a significant release of proteins from the EPS matrix, indicating its potential efficiency on an industrial scale.

A photosynthetic rotating annular bioreactor (Taylor-Couette type flow) for phototrophic biofilm cultures

In their natural environment, the structure and functioning of microbial communities from river phototrophic biofilms are driven by biotic and abiotic factors. An understanding of the mechanisms that mediate the community structure, its dynamics and the biological succession processes during phototrophic biofilm development can be gained using laboratory-scale systems operating with controlled parameters. For this purpose, we present the design and description of a new prototype of a rotating annular bioreactor (RAB) (Taylor-Couette type flow, liquid working volume of 5.04 L) specifically adapted for the cultivation and investigation of phototrophic biofilms. The innovation lies in the presence of a modular source of light inside of the system, with the biofilm colonization and development taking place on the stationary outer cylinder (onto 32 removable polyethylene plates). The biofilm cultures were investigated under controlled turbulent flowing conditions and nutrients were provided using a synthetic medium (tap water supplemented with nitrate, phosphate and silica) to favour the biofilm growth. The hydrodynamic features of the water flow were characterized using a tracer method, showing behaviour corresponding to a completely mixed reactor. Shear stress forces on the surface of plates were also quantified by computer simulations and correlated with the rotational speed of the inner cylinder. Two phototrophic biofilm development experiments were performed for periods of 6.7 and 7 weeks with different inoculation procedures and illumination intensities. For both experiments, biofilm biomasses exhibited linear growth kinetics and produced 4.2 and 2.4 mg cm(-)² of ash-free dry matter. Algal and bacterial community structures were assessed by microscopy and T-RFLP, respectively, and the two experiments were different but revealed similar temporal dynamics. Our study confirmed the performance and multipurpose nature of such an innovative photosynthetic bioreactor for phototrophic biofilm investigations.

Variability in total testosterone levels in ageing men with symptoms of androgen deficiency

The aim of this study was to determine the variability in total testosterone (TT) levels in healthy, non-obese ageing men with symptoms of androgen deficiency. Men aged ≥55 years were recruited from the community. Morning TT levels were measured on four occasions in a 12-month period. In all, 96 men aged 62.7 ± 6.8 years were studied. Geometric mean values (95% confidence interval) of TT levels for the cohort at each time point were 14.5 (13.4-15.7), 14.6 (13.5-15.8), 15.5 (14.4-16.8) and 15.0 (13.9-16.2) nmol/L. The maximum intra-individual difference in TT between the four samples was 4.1 nmol/L (interquartile range: 2.9-6.4). Using the average of two baseline TT values reduces the maximum difference to 2.3 nmol/L (1.0-3.8). Only 1 of 25 men with a documented TT <10 nmol/L at baseline had TT levels <10 nmol/L at all subsequent time points. A single TT level is a reliable predictor of repeat measures taken within a 12-month period for a cohort of healthy ageing men with symptoms of androgen deficiency. However, given that the diagnostic criteria for androgen deficiency are, in part, predicated upon serum TT, there is sufficient intra-subject variability to warrant repeat sampling to confirm an initial low TT level. Using an average of two baseline TT values reduces this variability.