Frontline health workers' experiences of providing care for people living with non-communicable diseases during the COVID-19 pandemic in Ghana: a qualitative study

BACKGROUND

The COVID-19 pandemic has significantly impacted frontline health workers. However, a neglected dimension of this discourse was the extent to which the pandemic impacted frontline healthcare workers providing non-communicable diseases (NCDs) care. This study aims to understand the experiences of healthcare workers with no prior exposure to pandemics who provided care to people living with NCDs (PLWNCDs).

METHODS

A qualitative study design was employed, using a face-to-face in-depth interviews. Interviews were conducted in primary healthcare facilities in three administrative regions of Ghana, representing the Northern, Southern and Middle Belts. Only frontline health workers with roles in providing care for PLWNCDs were included. Purposive snowballing and convenience sampling methods were employed to select frontline health workers. An open-ended interview guide was used to facilitate data collection, and thematic content analysis was used to analyse the data.

RESULTS

A total of 47 frontline health workers were interviewed. Overall, these workers experienced diverse patient-driven and organisational challenges. Patient-level challenges included a decline in healthcare utilisation, non-adherence to treatment, a lack of continuity, fear and stigma. At the organisational levels, there was a lack of medical logistics, increased infection of workers and absenteeism, increased workload and burnout, limited motivational packages and inadequate guidelines and protocols. Workers coped and responded to the pandemic by postponing reviews and consultations, reducing inpatient and outpatient visits, changing their prescription practices, using teleconsultation and moving to long-shift systems.

CONCLUSION

This study has brought to the fore the experiences that adversely affected frontline health workers and, in many ways, affected the care provided to PLWNCDs. Policymakers and health managers should take these experiences into account in plans to mitigate the impact of future pandemics.

The role of teams in shaping quality of obstetrical care: a cross-sectional study in Dire Dawa, Ethiopia

OBJECTIVES

To examine how characteristics of clinical colleagues influence quality of care.

DESIGN

We conducted a cross-sectional observational study examining the associations between quality of care and a provider's coworkers, controlling for individual provider's characteristics and contextual factors.

SETTING

Nine health facilities in Dire Dawa Administration, Ethiopia, from December 2020 to February 2021.

PARTICIPANTS

824 clients and 95 unique providers were observed across the 9 health facilities.

OUTCOME MEASURES

We examine the quality of processes of intrapartum and immediate postpartum care during five phases of the delivery (first examination, first stage of labour, third stage of labour, immediate newborn care and immediate maternal postpartum care).

RESULTS

For the average client, 50% of the recommended routine clinical actions were completed during the delivery overall, with immediate maternal postpartum care being the least well performed (17% of recommended actions). Multiple healthcare providers were involved in 55% of deliveries. The number of providers contributing to a delivery was unassociated with the quality of care, but a one standard deviation increase in the coworker's performance was associated with a 2% point increase in quality of care (p<0.01); this association was largest among providers in the middle quartiles of performance.

CONCLUSIONS

A provider's typical performance had a modest positive association with quality of delivery care given by their coworker. As delivery care is often provided by multiple healthcare providers, examining the dynamics of how they influence one another can provide important insights for quality improvement.

Identification of non-calcified coronary plaque characteristics using machine learning radiomic analysis of non-contrast high-resolution CT

Objective

To explore whether machine learning (ML) radiomic analysis of low-dose, high-resolution, non-contrast, ECG gated cardiac CT scan allows identification of non-calcified coronary plaque characteristics.

Background

Novel imaging and analysis techniques may provide the ability to detect non-calcified or high risk coronary plaques on a non-contrast CT scan, advancing cardiovascular diagnostics.

Methods

We prospectively enrolled 125 patients with a non-calcified plaque and an adverse plaque characteristic (APC), and 25 controls without visible atherosclerosis on coronary CT angiography (CCTA). All patients underwent the non-contrast CT exam prior to CCTA. 419 radiomic features were calculated to identify: presence of any CAD, obstructive CAD (stenosis&gt;50%), plaque with ≥2 APC, degree of calcification and specific APCs. ML models were trained on a training set (917 segmentations) and tested on a separate (validation) set (292 segmentations).

Results

Among the radiomic features 88.3% was associated with any plaque, 0.9% with obstructive CAD and 76.4% with presence of at least two APCs. Overall, 80.2%, 88.5% and 36.5%, of features were associated with calcified, partially calcified, and noncalcified plaques, respectively. Regarding APCs, 61.1%, 61.8%, 84.2%, and 61.3%, of features were associated with low attenuation (LAP), napkin-ring sign (NRS), spotty calcification (SC), and positive remodeling (PR), respectively. ML models outperformed conventional methods for the presence of plaque, obstructive stenosis, presence of 2 APC, as well as for noncalcified plaque and partially calcified plaque, but not for calcified plaque. ML models also significantly outperformed identification of LAP and PR, but neither NRS nor SC.

Conclusions

Radiomic analysis of non-contrast CT heart exams may allow identification of specific non-calcified coronary plaque characteristics which could aid cardiovascular risk stratification or pre-screening of individuals prior to contrast enhanced CCTA exam.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Science Center

Non-invasive characterization of pancoronary inflammation by computed tomography angiography in patients with recent spontaneous coronary dissection

Background

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction of unclear aethiology. Histopathological analyses have identified increased coronary inflammation in patients with SCAD [1]. Recently the peri-coronary adipose tissue attenuation (PCAT) derived from standard computed tomography angiography (CTA) has been established as a reproducible method for measuring vascular inflammation which enhances risk stratification in patients with coronary atherosclerosis [2].

Purpose

To characterize the pancoronary and vessel-specific inflammation by means of CTA-derived PCAT in patients with recent SCAD compared with individuals without prior SCAD.

Methods

Patients with confirmed SCAD referred to a tertiary center between 2017 and 2021 who underwent CTA as a routine cardiac evaluation were included in this retrospective study. Subjects were matched 1:1 with individuals with no prior SCAD who underwent CTA within the same timespan, using the same scanner and imaging protocol, with coronary arteries free of obstructive disease and similar clinical characteristics (Table 1). PCAT was analyzed on end-diastolic CTA reconstructions with a semi-automated software using standard methodology (Figure 1A) [3]. Proximal 40 mm of all major coronary vessels &gt;2 mm in diameter as well as the SCAD-related vessel were included. The primary outcome was pancoronary PCAT defined as mean PCAT in the right (RCA), left anterior descending (LAD) and circumflex (LCX) artery. Secondary outcome was vessel-specific PCAT defined as PCAT in RCA and averaged PCAT in LAD and LCX (PCAT LCA).

Results

The final cohort comprised 35 patients with recent SCAD (median 6.1 mo. [4.0–16.8] since SCAD, 94.3% female) and 35 patients in the non-SCAD group. Pancoronary PCAT was higher in patients with SCAD compared with non-SCAD group (−80.1 [IQR: −74.5, −84.6] vs. −83.4 HU [−78.7, −88.0], P=0.008) suggestive of increased coronary inflammation. Vessel-specific PCAT was higher for the RCA (−80.7 [−70.4, −86.9] vs. −85.3 [−80.4, −90.6] HU, P&lt;0.001) and borderline higher for the LCA (−79.2 [−73.9, −83.2] vs. −83.4 [−78.0, −88.3] HU, P=0.056) in patients with SCAD compared with non-SCAD respectively (Figure 1B). In patients with SCAD, PCAT in previously dissected vessel was not significantly different from averaged PCAT in unaffected vessels (−78.4 [−73.7, −89.0] vs. −80.9 [−74.9, −83.3], P=0.77; Figure 1C). While PCAT numerically decreased with time since SCAD, the association was not statistically significant when patients were stratified into tertiles according to time from SCAD (Figure 1D).

Conclusions

Patients with recent SCAD have higher pericoronary adipose tissue attenuation compared with non-SCAD patients suggesting increased perivascular inflammatory activity. This association is not restricted to the dissected vessel, nor reflected in routine serum inflammatory analysis and persists over time.

Funding Acknowledgement

Type of funding sources: None.

Service delivery reform for maternal and newborn health in Kakamega County, Kenya: study protocol for a prospective impact evaluation and implementation science study

Background

Maternal and neonatal mortality remain elevated in low and middle income countries, and progress is slower than needed to achieve the Sustainable Development Goals. Existing strategies appear to be insufficient. One proposed alternative strategy, Service Delivery Redesign for Maternal and Neonatal Health (SDR), centers on strengthening higher level health facilities to provide rapid, definitive care in case of delivery and post-natal complications, and then promoting delivery in these hospitals, rather than in primary care facilities. However to date, SDR has not been piloted or evaluated.

Methods

We will use a prospective, non-randomized stepped-wedge design to evaluate the effectiveness and implementation of Service Delivery Redesign for Maternal and Neonatal Health in Kakamega County, Kenya.

Discussion

This protocol describes a hybrid effectiveness/implementation evaluation study with an adaptive design. The impact evaluation (“effectiveness”) study focuses on maternal and newborn health outcomes, and will be accompanied by an implementation evaluation focused on program reach, adoption, and fidelity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13578-y.

Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.

Level of confidence in and endorsement of the health system among internet users in 12 low-income and middle-income countries

INTRODUCTION

People's confidence in and endorsement of the health system are key measures of system performance, yet are undermeasured in low-income and middle-income countries (LMICs). We explored the prevalence and predictors of these measures in 12 countries.

METHODS

We conducted an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal and South Africa collecting demographics, ratings of quality, and confidence in and endorsement of the health system. We used multivariable logistic regression to assess the association between confidence/endorsement and self-reported quality of recent healthcare.

RESULTS

Of 13 489 respondents, 62% reported a health visit in the past year. Applying population weights, 32% of these users were very confident that they could receive effective care if they were to 'become very sick tomorrow'; 30% endorsed the health system, that is, agreed that it 'works pretty well and only needs minor changes'. Reporting high quality in the last visit was associated with 4.48 and 2.69 greater odds of confidence (95% CI 3.64 to 5.52) and endorsement (95% CI 2.33 to 3.11). Having health insurance was positively associated with confidence and endorsement (adjusted odds ratio (AOR) 1.68, 95% CI 1.49 to 1.90 and AOR 1.34, 95% CI 1.22 to 1.48), while experiencing discrimination in healthcare was negatively associated (AOR 0.67, 95% CI 0.56 to 0.80 and AOR 0.63, 95% CI 0.53 to 0.76).

CONCLUSION

Confidence and endorsement of the health system were low across 12 LMICs. This may hinder efforts to gain support for universal health coverage. Positive patient experience was strongly associated with confidence in and endorsement of the health system.

High-risk plaque regression after intensive dietary intervention in patients with non-obstructive coronary artery disease: a randomised computed tomography angiography study (DISCO-CT)

Background

Lifestyle and diet modification are the forefront in the management of coronary artery disease (CAD), however, there is no data whether they may stop progression of atheroslcerosis. Some coronary plaque characteristics are known to increase the risk of future cardiovascular events independently of coronary stenosis severity. These plaques are characterized by the presence of lipids and necrotic elements, and can be identified with coronary computed tomography angiography (CTA).

Purpose

To study the effect of intensive dietary intervention on changes in atherosclerotic plaque volume and composition.

Methods

We enrolled 89 patients (41% women, mean age 60±7.7 years) with nonobstructive coronary lesions (&lt;70% stenosis) identified by CTA (2x192-multislice scanner, temporal resolution 66 ms), qualified to medical treatment. All participants were subjected to optimal medical therapy (OMT). Patients were randomised (1:1) to either A) OMT with regular follow-up (after 1, 3, 6, 9 and 12 months) by a dietitian to stick to Dietary Approaches to Stop Hypertension (DASH) model, or B) routine management, ie. OMT alone. CTA was repeated in all patients after the mean time of 66.9±13.7 weeks. An experienced observer blinded to the allocated treatment group and other clinical data evaluated all of the scans. The outcome was change in total plaque volume, percent plaque volume and plaque composition, assessed with a dedicated software system. Based on tissue attenuation ranges in Hounsfield units (HU), the following components of atheroma were distinguished: dense calcium (&gt;351 HU), fibrous plaque (151 to 350 HU), and fibrofatty plaque plus necrotic core (−100 to 150 HU), regarded as the vulnerable plaque component.

Results

Total plaque volume did not change significantly in any group (p=0.41; Figure 1A). Percent atheroma volume increased in the control arm vs. no significant change in the experimental arm, with no significant intergroup difference (p=0.79; Figure 1B). Vulnerable plaque component decreased in both subgroups, by 52.9±82.2 mm3 in the experimental vs. 20.8±58.5 mm3 in the control arm, and there was a significant difference in the reductions between the groups (p=0.04; Figure 1C). Fibrous plaque volume and dense calcium volume did not change significantly in any group (+9.5±117.8 mm3 in the experimental vs. +7.6±92.1 mm3 in the control arm, p=0.93, and +33±68.9 mm3 vs. +30.2±52.5 mm3, p=0.78, respectively).

Conclusions

Intensive diet intervention atop OMT can stop the progression of atherosclerosis and lead to a significant reduction in vulnerable plaque component compared to OMT alone.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Institute of Cardiology in Warsaw, Poland

Aortic invovement in fibromuscular dysplasia. 3-dimensional CT, case-control study. THE ARCADIA-POL BIS study

Background

Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease that manifests as the presence of beaded or focal lesions in medium or small-sized arteries and may also include arterial dissection, aneurysm, and tortuosity. FMD could be revealed in various manifestations, however limited data on the involvement of the thoracic aorta is reported.

Purpose

To measure and evaluate involvement of thoracic aorta in patients with FMD.

Methods

We analysed aortas of 144 consecutive patients (mean age 50.2±14.0, 116 women) with confirmed FMD in at least one vascular bed. The control group consisted of 144 (mean age 50.5±14.0, 116 women) age and sex matched individuals. All patients underwent detailed clinical evaluation including angio-CT scan including aortic valve, thoracic aorta and coronary arteries. We measured the aortic valve annulus, sinus of valsalva, sinotubular junction, the diameters of ascending and descending aorta, aortic unfolding, the height of ostium of RCA and LCA and diameter of right and left coronary artery ostia in patients with fibromuscular dysplasia and compared them to matched controls.

Results

The FMD group had significantly smaller dimensions of aortic valve annulus and sinus of Valsalva than control group (2.3 [2.1–2.6] vs 2.9 [2.7–3.1] p&lt;0,0001; 2.9 [2.7–3.2] vs 3.1 [2.8–3.3] p=0,0011 respectively). In addition the FMD group had a significantly greater mean diameter of the ascending and the descending aorta than the control group (3.1 [2.7–3.3] vs 3 [2.9–3] p=0,0436; 2.4 [2.2–2.7] vs 2.3 [1.8–2.5] p&lt;0,0001 respectively). The height of the ostium of the left and of the right coronary artery was smaller in FMD than in the control group (1.2 [1.1–1.4] vs 1.3 [1.2–1.4] p=0,0001; 1.1 [1–1.3] vs 1.3 [1.1–1.4] p&lt;0,0001 respectively). There was no difference in the diameter of sinotubular junction and the right and the left coronary artery ostias between the FMD and control groups (2.7 [2.5–2.9] vs 2.7 [2.5–2.9]; 0.3 [0.2–0.3] vs 0.3 [0.2–0.3]; 0.3 [0.3–0.3] vs 0.3 [0.3–0.4] respectively).

Conclusions

Patients with fibromuscular dysplasia display smaller dimensions of aortic valve and larger diameter of ascending and descending aorta as compared to control subjects. Despite the predominant clinical significance of focal pathologies in FMD patients, the disease may display a specific, pan-vascular phenotype.

Funding Acknowledgement

Type of funding source: None

The role of health system context in the design and implementation of performance-based financing: evidence from Cote d'Ivoire

Low quality of care is a significant problem for health systems in low-income and middle-income countries (LMICs). Policymakers are increasingly interested in using performance-based financing (PBF), a system-wide provider payment reform, conditioned on both quantity and quality of performance, to improve quality of care. The health system context influences both the design and the implementation of these programmes and thus their effectiveness. This study analyses how context has influenced the design and implementation of PBF in improving the quality of primary care in one particular setting, Cote d'Ivoire, a lower-middle income country with some of the poorest health outcomes in the world. Based on literature, an analytical framework was developed identifying five pathways through which financial incentives can influence the quality of primary care: earmarking, conditioning, provider behaviour, community involvement and management. Guided by this framework, semistructured interviews were conducted with policymakers and providers to diagnose the context and to assess the links between financing and quality of care at the primary care level. PBF in Cote d'Ivoire was found to have increased data availability and quality, facility-wide and disease-specific inputs, provider motivation and management practices in contracted facilities, but had limited success in improving process and outcome measures of quality, as well as community involvement and the provision of non-incentivised services. These limitations were attributable to a centralised health system structure constraining the decision space of health providers; financing and governance challenges across the health sector; and shortcomings with regard to the design of the PBF quality checklist and incentive structures in Cote d'Ivoire. In order to improve the quality of primary care, health sector reforms such as PBF should incorporate the organisational and service delivery context more broadly into their design and implementation, as is the case in other countries.

P3415Will less developed countries be capable of giving high-quality universal coverage to cardiovascular disease survivors? Results from a national health survey, Chile ENS 2016–2017

Background

Chilean Health System has fully implemented Universal Health Coverage (UHC) for acute cardiovascular events since 2005. Age-adjusted cardiovascular mortality has decreased, but there is limited information about coverage and quality of chronic health care given to cardiovascular disease (CVD) survivors at the national level.

Purpose

To assess the prevalence and quality of care in Chilean adult CVD survivors.

Methods

Chilean National Health Survey 2016–2017 (ENS 2016–2017) is a random stratified multistage sample of non-institutionalized population over 14 years (n=6240). Age, education, gender, rural/urban and geographical area weighted prevalence of CVD survivors (self-reported medical diagnosis of myocardial infarction or cerebrovascular attack) were calculated. High quality of care was defined as meeting six criteria simultaneously: under 70mg% LDL- C level, statin use, aspirin use, blood pressure under 130/80 mmHg, HgA1C<7 or 8 (>74-year-old) and non-smoking. Quality of care was explored using multivariate linear and logistic regression adjusting by age, gender, education and year of diagnosis (before or after UHC).

Results

Weighted national prevalence of CVD survivors in over 20-year-old population was 6.1%. The sample size for the CVD survivor analyses was n=455. 28.7% of CVS had their first event before the year 2005 (n=141). Overall 27.9% had LDL-C under 70mg%, 37.8% used statins, 41.4% used aspirin, 37.8% had controlled blood pressure, 78.3% were non-smokers and 84.3% had good glycemic control. National “high quality of care” prevalence in CVD survivors was 0.3%, 0.4% and 0.1% for men and women respectively. LDL and Blood pressure control prevalence (meet both criteria simultaneously) was 4,4%. In the adjusted multivariate model age was associated to a higher number of quality criteria achievement.

Conclusion

The number of CVD survivors in Chile is a huge challenge for the health care system. Universal coverage does not guarantee the quality of chronic life long care. Specific surveillance in high-risk population is needed to assess the system's effectiveness and accountability.

Acknowledgement/Funding

ENS 2016-2017 was funded by the chilean Ministry of Health (MINSAL)

P2680Changes in body fat distribution after intensive dietary intervention in patients with stable coronary artery disease

Introduction

Contradictory reports are available on the role of adipose tissue in the pathophysiology and progression of coronary artery disease (CAD). It seems accepted that local fat distribution is more relevant than the general amount of body fat. As in the case of visceral fat, pericardial adipose tissue (PEAT) has been postulated an important mediator of metabolic risk, with a special role attributed to epicardial adipose tissue (EAT).

Purpose

To study the effect of intensive dietary and lifestyle modification on the distribution of body fat in patients diagnosed with stable CAD qualified to conservative treatment.

Methods

Total body fat mass (TBF), visceral fat area (VFA), PEAT volume, and EAT volume were measured in 67 participants (43% women) of the DISCO-CT trial (Dietary Intervention to Stop COronary Atherosclerosis in Computed Tomography, NCT02571803) who completed the study by the end of 2018. All patients, randomly assigned to either experimental or control arm in a 1:1 fashion, were regularly followed-up at our site, with those in the experimental arm being strictly supervised by a dietitian to stick to Dietary Approaches to Stop Hypertension (DASH) diet and encouraged to lifestyle changes atop optimal medical therapy. Contrast-enhanced coronary computed tomography was performed at baseline and after the median time of 59 weeks (2x192-multislice scanner, temporal resolution 66 ms, Somatom Force, Siemens).

PEAT and EAT volumes, expressed in mm3, were measured with a dedicated offline workstation (syngo.via Frontier, Siemens Healthcare) using a semiautomatic segmentation technique (window width range −195 to −45 Hounsfield units). TBF, expressed in kg, and VFA, expressed in cm2, were measured using the InBody S10 Body Water Analyser at baseline and completion of the study.

57% of subjects included into the analysis represented the experimental arm.

Results

There were no significant between-arm differences in baseline TBF, VFA, PEAT, and EAT volumes.

A significant reduction by 3.7±5.0 kg in TBF (p<0.001; 95% CI 2.1, 5.3) and by 19.7±30.1 cm2 in VFA (p<0.001; 95% CI 9.8, 29.6) was observed in the experimental arm, while in the control group both TBF and VFA irrelevantly increased, by 0.6±4.7 kg (p=0.53; 95% CI −2.4, 1.3) and 2.2±27.0 cm2 (p=0.67; 95% CI −12.7, 8.2), respectively. A significant decrease in PEAT volume, by 19.9±43.0 mm3 (p=0.007; 95% CI 5.8, 34.1), was observed in the experimental group, compared to a non-significant PEAT volume reduction by 5.8±3.5.0 mm3 (p=0.38, 95% CI −7.5; 19.2) in the control group.

Contrarily, no significant changes in EAT volumes were observed in either experimental (reduction by 3.8±15.2 mm3; p=0.13, 95% CI −1.2, 8.8) or control arm (reduction by 5.1±17.2 mm3; p=0.13, 95% CI −1.5, 11.6).

Conclusion

Intensive dietary intervention in patients with stable CAD can lead to a significant reduction in total body fat, visceral fat and pericardial fat, this effect, however, may not apply to epicardial fat.

Acknowledgement/Funding

This study was founded by a grant (2.15/III/15) from the Institute of Cardiology in Warsaw, Poland

P2719The impact of “diseased only coronary artery” invasive diagnostics strategy on contrast and radiation dose in patients with coronary artery disease following coronary computed tomography angiography

Background

Coronary computed tomography angiography (CTA) has high diagnostic accuracy in ruling out significant stenosis of coronary arteries in patients with intermediate probability of coronary artery disease. Based on CTA result, some patients are scheduled for invasive coronary angiography (ICA). As no specyfic guidelines exist for such situations, during ICA contrast media is routinely injected into both coronary arteries, irrespectively of CTA result. Conceivably, patients scheduled for ICA with one vessel disease may benefit from invasive interrogation limited to the diseased vessel only, presumably resulting in less contrast, lower radiation dose and less complications related to catheterization.

Purpose

The aim of this study was to analyse the potential trade-off between the benefits and costs of a “diseased-vessel-only” (>50% DS in CTA) invasive diagnostic approach in patients undergoing ICA following coronary CTA, as compared to the traditional “total ICA” (including both arteries regardless of CTA result) approach. The potential benefits were defined as contrast and radiation doses reduction during ICA and the costs were defined as missing significant coronary stenosis.

Methods

In 85 patients who underwent CTA and subsequently ICA we precisely measured contrast volume and radiation dose used to visualise each vessel during ICA. Then we proposed excluding a vessel (either left or right coronary artery) without >50% diameter stenosis in CTA from ICA, and studied how it would affect ICA contrast and radiation values. DS in CTA and ICA were assessed quantitatively.

Results

CTA sensitivity, specificity, positive predictive value and negative predictive value in diagnosing >50%DS as assessed by ICA were 95.2%, 96.2%, 91.6% and 97.9%, respectively. Applying <50% DS in CTA as a threshold not to visualise the artery during ICA would reduce contrast volume by 47% (27ml, Fig. 1) and radiation dose by 51% (3.14mSv, Fig.2, both p<0.0001). No significant (>50%DS in ICA) stenosis would be missed by CTA.

Figures 1 and 2

Conclusion

These real-world data support the concept that vessels with <50%DS in CTA do not need to be visualised during ICA. Such approach would result in significant reduction in contrast media volume and patient's exposure to radiation during ICA, without underdiagnosing any of the patients.

Encouraging junior doctors to work in rural Sudan: a discrete choice experiment

Background

Out-migration of physicians and urban-rural maldistribution are two of the most serious challenges facing the health sector.

Aims

To determine the preference of junior doctors for rural postings in Sudan, and estimate how much junior doctors are willing to trade off from their salaries for nonmonetary incentives.

Methods

The study targeted junior doctors who had completed their internship training and were taking their Medical Licensing Examination at the Sudan Medical Council for permanent registration. Focus group discussions were conducted to identify potentially valued incentives. A computer-based discrete choice experiment and accompanying questionnaire were administered between September and October 2012 at the two licence examination centres in Sudan.

Results

Four hundred and fifty-five doctors completed the survey. More than one third of the respondents intended to emigrate from Sudan immediately and another 30% within the next two years. The findings showed that providing scholarships to train abroad, improving the standard of health facilities to an advanced level, and providing on-site supervision were the attributes most preferred by the respondents and they were willing to trade off SDG 3650 (US$ 608), SDG 1997 (US$ 333) and SDG 1948 (US$ 325) of their salaries for these, respectively. Less-preferred attributes were availability of supervision by telephone, followed by a scholarship in family medicine and a 2-year commitment, post-training.

Conclusions

Authorities may consider the above preferences to enhance human resources for attraction strategies in rural areas. Addressing the supervision issue may be more feasible for policy-makers in the short term, when compared to improving salaries and infrastructure.

On the benefits of living in clumps: a case study on Polytrichastrum formosum

The study concerns the mechanics and water relationships of clumps of a species of endohydric moss, Polytrichastrum formosum. Anatomical and morphological studies were done using optical and scanning electron microscopy. Experiments on waterdrop capture and their distribution to adjacent shoots within a moss clump were performed with the experimental set-up for the droplet collision phenomena and ultra-high speed camera. The mechanical strength of the moss clump was tested on an electromechanical testing machine. During the process of moss clump wetting, the falling water drops were captured by the apical stem part or leaves, then flowed down while adhering to the gametophore and never lost their surface continuity. In places of contact with another leaf, the water drop stops there and joins the leaves, enabling their hydration. Mathematical analysis of anatomical images showed that moss stems have different zones with varying cell lumen and cell wall/cell radius ratios, suggesting the occurrence of a periodic component structure. Our study provides evidence that the reaction of mosses to mechanical forces depends on the size of the clump, and that small groups are clearly stronger than larger groups. The clump structure of mosses acts as a net for falling rain droplets. Clumps of Polytrichastrum having overlapping leaves, at the time of loading formed a structure similar to a lattice. The observed reaction of mosses to mechanical forces indicates that this phenomenon appears to be analogous to the 'size effect on structural strength' that is of great importance for various fields of engineering.

Financial hardship on the path to Universal Health Coverage in the Gulf States

BACKGROUND

Countries globally are pursuing universal health coverage to ensure better healthcare for their populations and prevent households from catastrophic expenditure. The countries of the Gulf Cooperation Council (GCC) have and continue to implement reforms to strengthen their health systems. A common theme between the countries is their pursuit of universal health coverage to provide access to necessary health care without exposing people to financial hardship.

METHODS

Using nationally representative data from the Global Findex study, we sought to analyze the hardship faced by individuals from four high-income countries in the GCC. We estimated the weighted proportion of individuals borrowing for medical reasons and those who are not able to obtain emergency funds. We further examined variations in these outcomes by key socioeconomic factors.

RESULTS

We found up to 11% of respondents borrowed money for medical purposes, double of that reported in other high-income countries. In contrast to affluent respondents, we found that respondents from deprived background were more likely to borrow money for medical purposes (adjusted odds ratio: 1.81, P<0.001) and expected to fail in obtaining emergency funds (adjusted odds ratio: 4.03, P<0.001).

CONCLUSION

In moving forward with their reforms, GCC countries should adopt a financing strategy that addresses the health needs of poorer groups in their pursuit of universal health coverage.

Key factors leading to reduced recruitment and retention of health professionals in remote areas of Ghana: a qualitative study and proposed policy solutions

BACKGROUND

The ability of many countries to achieve national health goals such as the Millennium Development Goals remains hindered by inadequate and poorly distributed health personnel, including doctors. The distribution of doctors in Ghana is highly skewed, with a majority serving in two major metropolitan areas (Accra and Kumasi), and inadequate numbers in remote and rural districts. Recent policies increasing health worker salaries have reduced migration of doctors out of Ghana, but made little difference to distribution within the country. This qualitative study was undertaken to understand how practicing doctors and medical leaders in Ghana describe the key factors reducing recruitment and retention of health professionals into remote areas, and to document their proposed policy solutions.

METHODS

In-depth interviews were carried out with 84 doctors and medical leaders, including 17 regional medical directors and deputy directors from across Ghana, and 67 doctors currently practicing in 3 regions (Greater Accra, Brong Ahafo, and Upper West); these 3 regions were chosen to represent progressively more remote distances from the capital of Accra.

RESULTS AND DISCUSSION

All participants felt that rural postings must have special career or monetary incentives given the loss of locum (i.e. moonlighting income), the higher workload, and professional isolation of remote assignments. Career 'death' and prolonged rural appointments were a common fear, and proposed policy solutions focused considerably on career incentives, such as guaranteed promotion or a study opportunity after some fixed term of service in a remote or hardship area. There was considerable stress placed on the need for rural doctors to have periodic contact with mentors through rural rotation of specialists, or remote learning centers, and reliable terms of appointment with fixed end-points. Also raised, but given less emphasis, were concerns about the adequacy of clinical equipment in remote facilities, and remote accommodations.

CONCLUSIONS

In-depth discussions with doctors suggest that while salary is important, it is career development priorities that are keeping doctors in urban centers. Short-term service in rural areas would be more appealing if it were linked to special mentoring and/or training, and led to career advancement.

Effects of the cannabinoid receptor ligands on anxiety-related effects of d-amphetamine and nicotine in the mouse elevated plus maze test

The purpose of the experiments was to examine the anxiety-related effects of d-amphetamine and nicotine, and the possible involvement of the endocannabinoid system. D-amphetamine (2 mg/kg, ip) was administered acutely or daily for 8 days. On the 9th day, mice were challenged with d-amphetamine (2 mg/kg, ip) or nicotine (0.1 mg/kg, sc), and were tested in the elevated plus maze. Additionally, a distinct group of mice was pretreated with an acute (0.1 mg/kg,sc) or subchronic nicotine (6 days), and subjected to nicotine (0.1 mg/kg, sc) or d-amphetamine (2 mg/kg, ip) challenge on the 7th day. The cannabinoid receptor ligands, WIN 55,212-2, a non-selective cannabinoid receptor agonist (0.25; 0.5 and 1 mg/kg, ip) and rimonabant, a CB1 cannabinoid receptor antagonist (0.25; 0.5; 1 and 2 mg/kg, ip) were injected prior to each injection of saline or acute and subchronic d-amphetamine or nicotine. We observed that acute anxiogenic and subchronic anxiolytic effects of both psychostimulants as well as the development of full cross-tolerance to their anxiogenic effects were dose-dependently blunted by ineffective doses of WIN 55,212-2 (0.25 and 0.5 mg/kg) and rimonabant (0.5 and 1 mg/kg). These results provide evidence that the endogenous cannabinoid system is involved in the anxiety-related responses to d-amphetamine and/or nicotine.

Presence of Chlamydia pneumoniae in patients with and without atherosclerosis

Data published over the past decade show that Chlamydia pneumoniae is likely associated with the development of atherosclerosis. The aim of this study was to ascertain whether C. pneumoniae infections occur more frequently in patients with atherosclerosis than in healthy subjects. A total of 517 persons were studied. Serum samples, leukocytes, and tissue samples were assayed for the presence of C. pneumoniae-specific IgG and IgA antibodies and C. pneumoniae DNA. C. pneumoniae DNA was found in renal, iliac, and brachial vessels, but it was not detected in radial arteries. C. pneumoniae DNA was found most often in directional coronary atherectomy tissue specimens (11/41, 26.8%), but it was also found in the leukocytes of 14.9% (28/188) of patients with atherosclerosis and 24.6% (28/114) of patients without atheroma changes in vessels. Specific IgG and IgA antibodies were present in 63.8 and 49.9% of atheroma patients, respectively. The prevalence of C. pneumoniae antibodies differs significantly in patients with and without atherosclerosis (for IgG, p=0.002, and for IgA, p=0.006). The identification of persons with chlamydial infection of atherosclerotic arteries necessitates the examination of vascular tissues obtained during revascularization procedures. Serological investigation alone cannot identify individuals with vascular chlamydial infections. Detection of C. pneumoniae DNA in peripheral blood mononuclear cells does not seem to be the exclusive marker of persistent vascular infection. A more easily accessible parameter that allows prediction of chlamydial vascular infection is required.

Evaluating the competence of venous valves preserved with denaturation in cold ischaemia

AIM OF STUDY

The aim of this study was to evaluate the competence of venous valves preserved with denaturation in cold ischaemia.

MATERIAL AND METHOD

Eight segments of saphenous veins with 20 competent valves were analysed in the study. The material was collected during multiorgan retrievals. After harvesting, 15 cm long venous fragments were assessed with respect to valve presence. A 4-cm fragment with a valve was used for the analysis. Valve competence was assessed twice: after sampling and after 21 days of preservation. The valves were subjected to 136 cm water column pressure test. Denaturation in cold ischaemia consists of preservation of vessels at 4_C in a preservation medium containing antibiotics. Bacteriological and morphological examinations by light microscopy were performed.

RESULTS

After the preservation period, all the valves retained their mechanical properties. Well-preserved elastic elements of vascular wall were maintained in all vessels. Minor fragmentation of elastic fibres was observed and the structure of vascular wall was usually regular.

CONCLUSIONS

Our study indicates that denaturation in cold ischaemia allows for the maintenance of the properties and physiological functions of the valves after preservation. This effect is related to the good condition of elastic fibres, venous wall structure and the valve itself.

Relationship between CMV infection and coronary heart disease

Conflicting evidence implicating CMV infection in coronary heart disease (CHD) exists. In this work using serological methods (IgM-CMV by Western blot and IgG-CMV by ELISA) correlation between CMV infection and CHD was not found. On the other hand presence of CMV DNA in atherosclerotic plaques with absence in unchanged vessel indicates possible role of CMV infection in progression of this process.

[Prevalence of chlamydia pneumoniae antibodies in patients with coronary heart disease]

A possible role of infectious agents in the pathogenesis and progression of cardiovascular system diseases has been postulated by many scientists. The purpose of our study was to evaluate the correlation between Chlamydia pneumoniae infections and coronary heart disease. A group of 211 patients including: 120 patients with coronary heart disease (CHD) [63 patients enrolled for precutaneous coronary interventions (PTCA), 14 with proven restenosis after PTCA and 43 after coronary artery bypass grafting with recurrence of CHD symptoms], 17 patients suffering from congenital heart diseases or mitral valve stenosis with normal coronary angiograms and 74 healthy volunteers were tested. The levels of serum IgM, IgG and IgA antibodies for Chlamydia pneumoniae were measured with indirect microimmunofluorescence test (MRL Diagnostic, USA). C. pneumoniae specific IgG antibodies were detected in both, patients as well as healthy volunteers. They were seropositive with similar frequency (28.3% and 28.6% respectively). Among CHD patients, however, in PTCA/rest patients, specific C. pneumoniae antibodies have been detected more often (42.9%). Prevalence of C. pneumoniae specific antibodies correlated with patients' age, sex. There was no relation between behavioral habits (smoking) and presence C. pneumoniae antibodies.

Novel bifunctional periodic mesoporous organosilicas, BPMOs: synthesis, characterization, properties and in-situ selective hydroboration-alcoholysis reactions of functional groups

A new class of bifunctional periodic mesoporous organosilicas (BPMOs) containing two differently bonded organic moieties in a mesoporous host has been synthesized and characterized. By incorporating bridge-bonded ethylene groups into the walls and terminally bonded vinyl groups protruding into the channel space, both the chemistry and physical properties of the resulting BPMO could be modified. The materials have periodic mesoporous structures in which the bridging ethylene plays a structural and mechanical role and the vinyl groups are readily accessible for chemical transformations. The vinyl groups in the material underwent hydroboration with BH(3).THF and the resulting organoborane in the BPMO was quantitatively transformed into an alcohol using either H(2)O(2)/NaOH or NaBO(3).4H(2)O. The materials retained ordered structures after subsequent in situ reactions with largely unchanged pore volumes, specific surface areas and pore size distributions. Other organic functionalized BPMO materials may be synthesized in a similar manner or by further functionalizing the resulting borylated or alcohol functionalized BPMO materials. The thermal properties of the BPMO materials have also been investigated and are compared to those of the periodic mesoporous organosilica (PMO) materials. Noteworthy thermal events concern intrachannel reactions between residual silanols or atmospheric oxygen and organics in BPMOs. They begin around 300 degrees C and smoothly interconvert bridging ethylene to terminal vinyl groups and terminal vinyl to gaseous ethene and ethane, ultimately producing periodic mesoporous silica at 900 degrees C that exhibits good structural order and a unit-cell size decreased relative to that of the parent BPMO.