Polymer-based diffractive optical elements for rear end automotive applications: design and fabrication process

Advances in illumination technology in the automotive industry are heading toward the use of coherent sources for adaptable and high-resolution head lamps as well as interior and rear-end lights. We present a cost-effective method to fabricate and design laser-based lighting systems for the rear end in automobiles and other vehicles. The design relies on using binary gratings to generate a desired intensity distribution. For cost-effective fabrication, an optical maskless UV lithography system that employs a spatial light modulator (SLM) for projection of the desired structure onto photoresist is introduced. To replicate the structures onto polymers like poly(methyl methacrylate) (PMMA), we use polydimethylsiloxane soft stamps and a hot embossing system. The experimental results show that the proposed design and fabrication process is promising for high-resolution rear-end lights that might be employed to project symbols or information to guide road users in future.

How do external donors influence national health policy processes? Experiences of domestic policy actors in Cambodia and Pakistan

Although concerns have historically been raised about the influence of external donors on health policy process in recipient countries, remarkably few studies have investigated perspectives and experiences of domestic policymakers and advisers. This study examines donor influence at different stages of the health policy process (priority setting, policy formulation, policy implementation and monitoring and evaluation) in two aid-dependent LMICs, Cambodia and Pakistan. It identifies mechanisms through which asymmetries in influence between donors and domestic policy actors emerge. We conducted 24 key informant interviews-14 in Pakistan and 10 in Cambodia-with high-level decision-makers who inform or authorize health priority setting, allocate resources and/or are responsible for policy implementation, identifying three routes of influence: financial resources, technical expertise and indirect financial and political incentives. We used both inductive and deductive approaches to analyse the data. Our findings indicate that different routes of influence emerged depending on the stage of the policy process. Control of financial resources was the most commonly identified route by which donors influenced priority setting and policy implementation. Greater (perceived) technical expertise played an important role in donor influence at the policy formulation stage. Donors' power in influencing decisions, particularly during the final (monitoring and evaluation) stage of the policy process, was mediated by their ability to control indirect financial and political incentives as well as direct control of financial resources. This study thus helps unpack the nuances of donor influence over health policymaking in these settings, and can potentially indicate areas that require attention to increase the ownership of domestic actors of their countries' health policy processes.

The growth and strategic functioning of One Health networks: a systematic analysis

BACKGROUND

The recent increase in attention to linkages between human health, animal health, and the state of the environment has resulted in the rapid growth of networks that facilitate collaboration between these sectors. This study ascertained whether duplication of efforts is occurring across networks, which stakeholders are being engaged, and how frequently monitoring and evaluation of investments is being reported.

METHODS

This study is a systematic analysis of One Health networks (OHNs) in Africa, Asia, and Europe. We defined an OHN as an engagement between two or more discrete organisations with at least two of the following sectors represented: animal health, human health, and the environment or ecosystem. Between June 5 and Sept 29, 2017, we systematically searched for OHNs in PubMed, Google, Google Scholar, and relevant conference websites. No language restrictions were applied, but we were only able to translate from English and French. Data about OHNs, including their year of initiation, sectors of engagement, regions of operation, activities conducted, and stakeholders involved, were extracted with a standardised template and analysed descriptively.

FINDINGS

After screening 2430 search results, we identified and analysed 100 unique OHNs, of which 86 were formed after 2005. 32 OHNs covered only human and animal health, without engaging with the role of the environment on health. 78 OHNs involved academic bodies and 78 involved government bodies, with for-profit organisations involved in only 23 and community groups involved in only ten. There were few collaborations exclusively between networks in the developing world (four OHNs) and only 15 OHNs reported monitoring and evaluation information. The majority of OHNs worked on supporting communication, collaboration, information sharing, and capacity building.

INTERPRETATION

Amid concerns about there being insufficient strategic direction and coordination in the growth of OHNs, our study provides empirical evidence about limitations in stakeholder representation, apparently absent or ambiguous monitoring and evaluation structures, and potential areas of duplication. The collective strategic functioning of OHNs might be improved by more transparent reporting of goals and outcomes of OHN activities, as well as more collaborations led by networks within the developing world and increased attention to environmental health.

FUNDING

None.

Large funding inflows, limited local capacity and emerging disease control priorities: a situational assessment of tuberculosis control in Myanmar

There are numerous challenges in planning and implementing effective disease control programmes in Myanmar, which is undergoing internal political and economic transformations whilst experiencing massive inflows of external funding. The objective of our study-involving key informant discussions, participant observations and linked literature reviews-was to analyse how tuberculosis (TB) control strategies in Myanmar are influenced by the broader political, economic, epidemiological and health systems context using the Systemic Rapid Assessment conceptual and analytical framework. Our findings indicate that the substantial influx of donor funding, in the order of one billion dollars over a 5-year period, may be too rapid for the country's infrastructure to effectively utilize. TB control strategies thus far have tended to favour medical or technological approaches rather than infrastructure development, and appear to be driven more by perceived urgency to 'do something' rather informed by evidence of cost-effectiveness and sustainable long-term impact. Progress has been made towards ambitious targets for scaling up treatment of drug-resistant TB, although there are concerns about ensuring quality of care. We also find substantial disparities in health and funding allocation between regions and ethnic groups, which are related to the political context and health system infrastructure. Our situational assessment of emerging TB control strategies in this transitioning health system indicates that large investments by international donors may be pushing Myanmar to scale up TB and drug-resistant TB services too quickly, without due consideration given to the health system (service delivery infrastructure, human resource capacity, quality of care, equity) and epidemiological (evidence of effectiveness of interventions, prevention of new cases) context.

A strong TB programme embedded in a developing primary healthcare system is a lose-lose situation: insights from patient and community perspectives in Cambodia

As exemplified by the situation in Cambodia, disease specific (vertical) health programmes are often favoured when the health system is fragile. The potential of such an approach to impede strengthening of primary healthcare services has been studied from a health systems perspective in terms of access and quality of care. In this bottom-up, qualitative study we investigate patient and community member experiences of health services when a strong tuberculosis (TB) programme is embedded into a relatively underutilized primary healthcare system. We conducted six gender-stratified community focus group discussions (n = 49) and seven mixed-gender focus group discussions with TB patients (n = 45) in three provinces located in urban, peri-urban and rural areas of Cambodia. Our analysis of health-seeking behaviour and experiences for TB and TB-like illness indicates that building a strong vertical TB control programme has had numerous benefits, including awareness of typical symptoms and need to seek care early; confidence in free TB services at public facilities; and willingness to complete treatment. However, there was a clear dichotomy in experiences and behaviour with respect to care-seeking for less severe illness at primary health services, which were generally avoided owing to access barriers and perceived poor quality. The tendency to delay seeking health care until the development of severe symptoms clearly indicative of TB is a major barrier to early diagnosis and treatment of TB. Our study indicates that an imbalance in the strength of vertical and primary health services could be a lose-lose situation as this impedes improvements in health system functioning and constrains progress of vertical disease control programmes.

Preventing emergence of drug resistant tuberculosis in Myanmar's transitioning health system

Multidrug-resistant tuberculosis (MDR-TB) is a particular threat to the populations of resource-limited countries. Although inadequate treatment of TB has been identified as a major underlying cause of drug resistance, essential information to inform changes in health service delivery and policy is missing. We investigate factors that may be driving the emergence of MDR-TB in Myanmar, a country where investment and health system reforms are ongoing to address the unexplained, high occurrence of MDR-TB. We conducted a multi-centre, retrospective case-control study in 10 townships across Yangon. Cases were 202 GeneXpert-confirmed MDR-TB patients with a history of prior first-line treatment for TB. Controls were 404 previously untreated smear-microscopy confirmed TB patients who had no evidence of resistance to anti-TB drugs. Information on patient and health service factors was collected through face-to-face patient interviews and hospital record reviews. Multivariable logistic regression analysis indicated that the following TB patient groups are at higher risk of developing MDR-TB after initial TB treatment: those who have diabetes (aOR 2.10; 95% CI 1.17-3.76), those who missed taking drugs during the initial treatment more than once weekly (aOR 2.35; 95% CI 1.18-4.65) and those with a higher socioeconomic (aOR 1.99; 95% CI 1.09-3.63) or educational status (aOR 1.78; 95% CI1.01-3.13). Coinciding with a surge in funding to improve health in Myanmar, this study identifies practices of patients and healthcare organizations that can be addressed, and high-risk TB patient groups that can be prioritized for treatment support. Specifically, the study shows that TB patients who experience frequent, short interruptions in treatment and those with diabetes may require enhanced treatment support and monitoring by health services in order to prevent further generation of drug resistance.

Are scientific research outputs aligned with national policy makers' priorities? A case study of tuberculosis in Cambodia

With funding for tuberculosis (TB) research decreasing, and the high global disease burden persisting, there are calls for increased investment in TB research. However, justification of such investments is questionable, when translation of research outputs into policy and health care improvements remains a challenge for TB and other diseases. Using TB in Cambodia as a case study, we investigate how evidence needs of national policy makers are addressed by topics covered in research publications. We first conducted a systematic review to compile all studies on TB in Cambodia published since 2000. We then identified priority areas in which evidence for policy and programme planning are required from the perspective of key national TB control stakeholders. Finally, results from the literature review were analysed in relation to the priority research areas for national policy makers to assess overlap and highlight gaps in evidence. Priority research areas were: TB-HIV co-infection; childhood TB; multidrug resistant TB (MDR-TB); and universal and equitable access to quality diagnosis and treatment. On screening 1687 unique papers retrieved from our literature search, 253 were eligible publications focusing on TB in Cambodia. Of these, only 73 (29%) addressed one of the four priority research areas. Overall, 30 (11%), five (2%), seven (2%) and 37 (14%) studies reported findings relevant to TB-HIV, childhood TB, MDR-TB and access to quality diagnosis and treatment respectively. Our analysis shows that a small proportion of the research outputs in Cambodia address priority areas for informing policy and programme planning. This case study illustrates that there is substantial room for improvement in alignment between research outputs and evidence gaps that national policy makers would like to see addressed; better coordination between researchers, funders and policy makers' on identifying priority research topics may increase the relevance of research findings to health policies and programmes.

Are global tuberculosis control targets overlooking an essential indicator? Prolonged delays to diagnosis despite high case detection rates in Yunnan, China

Delay in treating active tuberculosis (TB) impedes disease control by allowing ongoing transmission, and may explain the unexpectedly modest declines in global TB incidence. Even though China has achieved TB control targets under the global Directly Observed Treatment, Short course (DOTS) strategy, TB prevalence in western provinces, including Yunnan, is not decreasing. This cross-sectional study investigates whether prolonged delay in identifying and correctly treating TB patients, which is not routinely monitored, persists even when there is a well-functioning TB control programme and global targets are being met. Records of adult smear-positive pulmonary TB patients diagnosed with between 2006 and 2013 were extracted from the Yunnan Centre for Disease Control electronic database, which contains information on the entire population of TB patients managed across 129 diagnostic centres. Delay was investigated at three stages: delay to DOTS facility (period between symptom onset and first visit to at a CDC unit providing standardized treatment); delay to TB confirmation (period between reaching a CDC unit and confirmation of smear-positive TB) and delay to treatment (period between confirmation of TB and initiation of treatment). Data from 76 486 patients was analysed. Delay to reaching a DOTS facility was by far the largest contributor to total delay to treatment initiation. The median delay to reaching a DOTS facility, to TB confirmation and to treatment was 57 days (IQR 25-112), 2 days (IQR 1-6) and 1 day (IQR 0-1) respectively. Prolonged delays to reaching a facility providing standardized TB care occurred in a substantial subset of the population despite all TB control targets being met; overall, 32% (24 676) of patients experienced a delay of more than 90 days to reaching a DOTS facility. Policies that focus on reducing delays in accessing appropriate health services, rather than only on increasing overall case-detection rates, may result in greater progress towards reducing TB incidence.

The role of cognitive training in endourology: a randomised controlled trial

INTRODUCTION

Cognitive training is an important training modality which allows the user to rehearse a procedure without physically carrying it out. This has led to recent interests to incorporate cognitive training within surgical education but research is currently limited. The use of cognitive training in surgery is not clear-cut and so this study aimed to determine whether, relative to a control condition, the use of cognitive training improves technical surgical skills on a ureteroscopy simulator, and if so whether one cognitive training method is superior.

METHODS

This prospective, comparative study recruited 59 medical students and randomised them to one of three groups: control- simulation training only (n=20), flashcards cognitive training group (n=20) or mental imagery cognitive training group (n=19). All participants completed three tasks at baseline on the URO Mentor simulator followed by the cognitive intervention if randomised to receive it. Participants then returned to perform an assessment task on the simulator. Outcome measures from the URO Mentor performance report was used for analysis and a quantitative survey was given to all participants to assess usefulness of training received.

RESULTS

This study showed cognitive training to have minimal effects on technical skills of participants. The mental imagery group had fewer laser misfires in the assessment task when compared to both control and flashcards group (P=.017, P=.036, respectively). The flashcards group rated their preparation to be most useful when compared to control (P=.0125). Other parameters analysed between the groups did not reach statistical significance. Cognitive training was found to be feasible and cost effective when carried out in addition to simulation training.

CONCLUSION

This study has shown that the role of cognitive training within acquisition of surgical skills is minimal and that no form of cognitive training was superior to another. Further research needs to be done to evaluate other ways of performing cognitive training.

Prevalence of Degnala disease in bovine along with screening of toxigenic fungi isolated from contaminated rice straw

Toxigenic potential of different candidate fungi, isolated from rice straw feed of Degnala disease affected bovines was analyzed along with species, age, gender and seasonal prevalence. Of 1,536 cases, 104 (6.77%) showed positive signs with a significant association (p less than 0.05) between this disease and rice straw feeding, in buffaloes, and bovine aged over 1 year in the winter season. Complete blood count showed a marked increase in erythrocyte sedimentation rate and all white blood cells numbers, except lymphocytes in positive cases. There was a significant increase (p less than 0.05) in alanine amino transferase, aspirate amino transferase and alkaline phosphatase in the liver function test. At the same time, an increased value of creatinine was noted in the renal function test. For isolation and screening of toxigenic fungi, rice straw samples (n=40) being fed to the positive cases were processed further, and 85 fungal isolates were found, mainly of Aspergillus (57), Penicillium (10), Fusarium (04), Zygomycetes (03), Curvularia (01) and unidentified (10). All isolated fungi were subjected for mycotoxin production and only 11 showed mycotoxin-producing capability (including Aspergillus, Penicillium and Fusarium isolates) analyzed by thin layer chromatography and quantified through high performance liquid chromatography. It is concluded that all the fungi contaminating rice straw feed of Degnala affected animals were not toxigenic. This work will help in establishing major mycotoxin-producing fungi leading to the probable cause of Degnala disease in bovine.

Risk factors that may be driving the emergence of drug resistance in tuberculosis patients treated in Yangon, Myanmar

Background

The majority of new tuberculosis cases emerging every year occur in low and middle-income countries where public health systems are often characterised by weak infrastructure and inadequate resources. This study investigates healthcare seeking behaviour, knowledge and treatment of tuberculosis patients in Myanmar—which is facing an acute drug-resistant tuberculosis epidemic—and identifies factors that may increase the risk of emergence of drug-resistant tuberculosis.

Methods

We randomly selected adult smear-positive pulmonary tuberculosis patients diagnosed between September 2014 and March 2015 at ten public township health centres in Yangon, the largest city in Myanmar. Data on patients’ healthcare seeking behaviour, treatment at the township health centres, co-morbidities and knowledge was collected through patient interviews and extraction from hospital records. A retrospective descriptive cross-sectional analysis was conducted.

Results

Of 404 TB patients selected to participate in the study, 11 had died since diagnosis, resulting in 393 patients being included in the final analysis. Results indicate that a high proportion of patients (16%; 95% CI = 13–20) did not have a treatment supporter assigned to improve adherence to medication, with men being more likely to have no treatment supporter assigned. Use of private healthcare providers was very common; 59% (54–64) and 30.3% (25.9–35.0) of patients reported first seeking care at private clinics and pharmacies respectively. We found that 8% (6–11) of tuberculosis patients had confirmed diabetes. Most patients had some knowledge about tuberculosis transmission and the consequences of missing treatment. However, 5% (3–8) stated that they miss taking tuberculosis medicines at least weekly, and patients with no knowledge of consequences of missing treatment were more likely to miss doses.

Conclusions

This study analysed healthcare seeking behaviour and treatment related practices of tuberculosis patients being managed under operational conditions in a fragile health system. Findings indicate that ensuring that treatment adherence support is arranged for all patients, monitoring of response to treatment among the high proportion of tuberculosis patients with diabetes and engagement with private healthcare providers could be strategies addressed to reduce the risk of emergence of drug-resistant tuberculosis.

Development of a programmable standard of ultra-low capacitance values

A set of ultra-low value capacitance standards together with a programmable coaxial multiplexer (mux) have been developed. The mux allows the connection of these capacitances in parallel configuration and they together form the programmable capacitance standard. It is capable of producing decadic standard capacitances from 10 aF to at least 0.1 pF, which are later used to calibrate commercial precision capacitance bridges. This paper describes the realization and the characterization of this standard together with results obtained during the calibration of Andeen-Hagerling AH2700A bridges with a maximum uncertainty of 0.8 aF for all the capacitances generated ranging from 10 aF to 0.1 pF, at 1 kHz. These latter could be then integrated to functionalized AFMs or probe stations for quantitative capacitance measurements. Sources of uncertainties of the programmable capacitance standard, such as parasitic effects due to stray impedances, are evaluated and a method to overcome these hindrances is also discussed.

Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China

BACKGROUND

Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden.

METHODS

Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding.

RESULTS

Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable.

CONCLUSIONS

Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.

Comparative Efficacy of Silymarin and Choline Chloride (Liver Tonics) in Preventing the Effects of Aflatoxin B1 in Bovine Calves

Aflatoxins are secondary metabolites produced by Aspergillus spp. which are injurious to animals and humans The aim of this study was to determine the effects of aflatoxin B1 (AFB1) on Average Daily Feed Intake (ADFI), Average Daily Weight Gain (ADWG), haematological and serum biochemical responses of Bovine Calves and to determine the comparative efficacy of two different liver tonics against AFB1. Twenty seven calves were selected from herd and divided into 3 groups. All calves were fed with 1.0 mg/kg AFB1 for a period of 10 days. After that they were fed with liver tonics: Silymarin fed at a rate of 600 mg/kg and Choline chloride 500 mg/kg for 7 days. The results indicate that the ADFI and ADWG of AFB1 treated calves decreased significantly. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN) and creatinine significantly increased due to AFB1. In haematology the total erythrocyte count (TEC), total leukocyte count (TLC), haemoglobin concentration (HGB), haematocrit levels (HCT), mean corpuscular haemoglobin (MCH), mean corpuscular volume (MCV) and mean corpuscular haemoglobin concentration (MCHC), lymphocyte %, neutrophil % and monocyte % significantly decreased in AFB1 treated calves after 10 days of feeding. Both liver tonics significantly (p<0.05) improved all the parameters, including ADFI, ADWG, hematologial and serum biochemical test. However, Silymarin comparatively more efficiently ameliorate the effects induced by AFB1 than choline chloride.

A novel DNase like compound that inhibits virus propagation from Asian Green Mussel, Perna viridis (Linn.)

Viral diseases are not only responsible for health related issues but also exert pressure on the State economy. Tropical and subtropical countries have more prevalence of virus associated pathological conditions such as chickenpox, adenovirus related infections, dengue, chickengunya, infectious mononucleosis, etc. Treatment options with effective antiviral drugs are limited and are unfortunately not free from undesirable effects. The Asian Green Mussel, Perna viridis (Linn.) (Mytilidae) are not only important for their evolutionary significance, high caloric index, ecological role in the sequestration of environmental pollutants especially heavy metals, but also are potential source for extraction of therapeutic and bioactive compounds. On the other hand, generally in bivalves, virus mediated mortality is not uncommon. In this study, we made a maiden attempt of exploring DNAse like bioactivity for natural non-protenacious compound(s) extracted from P. viridis. Crude Methanol Extract (CME) of soft tissue of P. viridis and subsequently its partially purified component (PPC) possess exceptional ability to degrade indiscriminately both low and high molecular weight DNAs. In vitro digestions for1, 2 and 3 h with CME and PPC were found to be comparable to commercial (Sigma-Aldrich) enzyme, DNase I. Bioactive assays conducted to evaluate antimicrobial property, have shown that CME and PPC exclusively inhibit viral propagation. Nonetheless, CME & PPC have no effect on the propagation of bacteria (0 mm ZOI). These results indicate the possibility of a source of potential antiviral drug against DNA Group I viruses. Although our study does not provide any data to correlate to any physiological functions of these substances but provides a clue towards an important role in the biology of mussels. Any conclusion at this stage is premature. However, taking into consideration the significantly high virus mediated mortality in bivalves and the antiviral bioactivity of these substances, it appears that mussels have evolved some mechanisms to counteract some viruses.

Changes in R-R and Q-T Intervals Following Cardiac Vagotomy in Neonatal Swine

Asymmetric innervation of the myocardium, especially a predominance of sympathetic innervation, may establish conditions whereby electrical instability could result. Using a swine animal model, we studied the effect of right cardiac vagal denervation on the variability of R-R and Q-T intervals. Newborn pigs were assigned randomly to two groups: sham-operated controls (C), or denervation of the right cardiac vagus nerve (RCVX). EKGs were recorded weekly until the two groups exhibited significant heart rate differences. Analysis of the EKG included measurements of R-R and Q-T intervals and corrected Q-T intervals (QTc). Poincaré plots were used to display age-related differences in R-R and Q-T intervals. For RCVX animals, decreased QTc and R-R intervals were noted at 6 and 7 weeks after denervation, respectively. Unexpectedly, one RCVX animal exhibited marked sudden pauses in sinus rhythm. These data indicated that reduced vagal cardiac modulation during development might alter cardiac electrical stability in conscious swine.

Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis

Involuntary migration is a crucially important global challenge from an economic, social, and public health perspective. The number of displaced people reached an unprecedented level in 2015, at a total of 60 million worldwide, with more than 1 million crossing into Europe in the past year alone. Migrants and refugees are often perceived to carry a higher load of infectious diseases, despite no systematic association. We propose three important contributions that the global health community can make to help address infectious disease risks and global health inequalities worldwide, with a particular focus on the refugee crisis in Europe. First, policy decisions should be based on a sound evidence base regarding health risks and burdens to health systems, rather than prejudice or unfounded fears. Second, for incoming refugees, we must focus on building inclusive, cost-effective health services to promote collective health security. Finally, alongside protracted conflicts, widening of health and socioeconomic inequalities between high-income and lower-income countries should be acknowledged as major drivers for the global refugee crisis, and fully considered in planning long-term solutions.

Comparison of preoperative CT-based imaging parameters to predict postoperative pancreatic fistula

AIM

To review all reported methods of preoperative computed tomography (CT) in one patient cohort and to identify which were the strongest to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy.

MATERIALS AND METHODS

Consecutive patients undergoing pancreatoduodenectomy were included if they had unenhanced CT images for review. Eighteen variables and two scores were tested. Receiver operator characteristics (ROC) were explored.

RESULTS

POPF affected 26 of 107 patients (24.3%). Nine variables were significantly related to POPF with pancreatic duct width having the largest area under the ROC curve (AUROC; 0.808, p<0.001). An obese body habitus was associated with POPF with six of nine related variables using data from CT images associated with POPF; of these intra-abdominal wall thickness yielded the largest AUROC (0.713, p=0.001). This corresponded to the finding that body mass index (BMI) was related to POPF (AUROC 0.705, p=0.002). The largest AUROC of all was associated with one of the predictive scores (0.828, p<0.001). Substituting BMI for intra-abdominal wall thickness in this score yielded a non-significant increase to predict POPF (AUROC 0.840, p=0.676). None of the assessments of organ density (in Hounsfield Units) were associated with POPF.

CONCLUSION

Data from preoperative CT imaging provides valuable information regarding a patient's risk of POPF. Obesity as assessed by CT images strongly relates to POPF, but the largest single risk factor for POPF is a narrow pancreatic duct.

Economic interventions to improve population health: a scoping study of systematic reviews

BACKGROUND

Recognizing the close relationship between poverty and health, national program managers, policy-makers and donors are increasingly including economic interventions as part of their core strategies to improve population health. However, there is often confusion among stakeholders about the definitions and operational differences between distinct types of economic interventions and financial instruments, which can lead to important differences in interpretation and expectations.

METHODS

We conducted a scoping study to define and clarify concepts underlying key economic interventions - price interventions (taxes and subsidies), income transfer programs, incentive programs, livelihood support programs and health-related financial services - and map the evidence currently available from systematic reviews.

RESULTS

We identified 195 systematic reviews on economic interventions published between 2005 and July 2015. Overall, there was an increase in the number of reviews published after 2010. The majority of reviews focused on price interventions, income transfer programs and incentive programs, with much less evidence available from systematic reviews on livelihood support programs and health-related financial services. We also identified a lack of evidence on: health outcomes in low income countries; unintended or perverse outcomes; implementation challenges; scalability and cost-effectiveness of economic interventions.

CONCLUSIONS

We conclude that while more research is clearly needed to assess suitability and effectiveness of economic interventions in different contexts, before interventions are tested and further systematic reviews conducted, a consistent and accurate understanding of the fundamental differences in terminology and approaches is essential among researchers, public health policy makers and program planners.

Evidence to inform resource allocation for tuberculosis control in Myanmar: a systematic review based on the SYSRA framework

Myanmar represents an extreme example of the difficulties in optimally allocating resources for maximum public health benefit, on the basis of limited information. At the recent Myanmar Health Forum 'Investing in Health' much of the discussion revolved around what to invest in, how health systems could be strengthened, and what research and capacity building areas the international donor community should prioritise for support. Funding for infectious disease control, particularly HIV and tuberculosis, is being channelled to the country at an unprecedented rate, but very little research has been conducted in recent years, and existing information has not yet been synthesised. This paper presents findings of the first systematic literature review on tuberculosis control and the health system in Myanmar, with the aim of informing the development of optimal research priorities and strategies. Medline and grey literature were searched for relevant papers. Inclusion criteria and analyses were structured to capture data on the Myanmar health system, healthcare delivery, financing, tuberculosis control indicators and information systems. A total of 77 papers were included in the analysis. The results indicate that there has been a large increase in the number of peer-reviewed articles published on tuberculosis in Myanmar over the past decade, although the absolute number of studies remains small. We identified several areas in which evidence to inform policy and resource allocation decisions is lacking, including research focused on rural and/or vulnerable populations, analyses of risk factors for TB and drug resistance that can inform prevention strategies and economic analyses for optimising resource allocation. The gaps in research to inform policy identified through this study may be relevant to other low resource settings with extremely limited research capacity.