Relevance of the Health Extension Program to the current Health Needs and Evolving Demands of Rural Ethiopia: A Mixed-Method Analysis

Background

Ethiopia has been implementing a health extension program (HEP) to respond to the high maternal and child mortality in rural communities. HEP has brought tremendous contributions to improved access and coverage of primary healthcare in the last 15 years. Despite its attributions, attention to HEP has declined in recent years due to several reasons. This study is designed to explore HEP's relevance to the current healthcare needs of the rural communities.

Methods

This study is a nested cross-sectional mixed-method to the overall HEP's evaluation between March and May 2019. Descriptive statistics were used on qualitative and quantitative assessment. A literature review supplemented the assessment. A representative quantitative sample of 11,746 women, men, and young girls; a qualitative sample of 268 key informants from Kebele administrators, HEWs, program people in the health system and focus groups from community leaders, men and women from 185 Kebeles in 62 woredas were selected. A thematic approach was used for qualitative analysis.

Results

Rural communities and program managers asserted that HEP's service packages with the existing service delivery modalities were relevant. Eighty-two percent of men and women and 77% of young girls confirmed this relevance. Besides the existing packages, additional curative services for adults and children were recommended with emphasis on the pastoralist community. HEP's service uptake has declined as over 86% of targeted rural communities bypassed HPs due to unavailability of services and capacity problems of HEWs.

Conclusion

The current HEP packages with the existing service delivery modalities are still relevant to the rural communities' health needs. However, on-going changes to address the evolving demands of the targeted rural communities are crucial.

Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after total knee arthroplasty - a longitudinal study

OBJECTIVES

There are several known predictors of pain after total knee arthroplasty (TKA). However, it is unclear whether acute postoperative pain intensity and postoperative opioid intake are associated with pain 12 months after TKA. Thus, the aim of this study was to assess whether worst pain intensity and opioid intake during the early postoperative period are associated with moderate-severe pain 12 months after TKA.

METHODS

A total of 202 patients undergoing primary TKA between October 2012 and September 2014 were prospectively enrolled. Age, sex, contralateral knee pain, BMI, physical status and opioid intake were collected preoperatively. Ketamine and daily opioid intake were collected on postoperative days (POD) 0-3. Using the Brief Pain Inventory, patients' "worst pain intensity" was measured preoperatively, on POD 0-4, and 12 months after TKA. Two logistic regression models evaluated the independent association of early postoperative pain intensity (model 1) and postoperative opioid intake (model 2) with moderate-severe pain 12 months after TKA, adjusting for possible confounders.

RESULTS

In total, 187 patients with data at the 12 month postoperative follow-up were included in this analysis. Pain intensity on POD2 and POD3, as well as preoperative pain and BMI, were significantly associated with pain at 12 months in univariate models. However, in multivariable models adjusted for preoperative pain and BMI, neither pain intensity on POD 0-4 (model 1) nor opioid intake on POD 0-3 (model 2) were associated with pain at 12 months. Preoperative pain was still significant in both models, but BMI remained significant only in model 2.

CONCLUSIONS

Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after TKA when controlling for potential confounders. More research is needed to confirm these findings.

Global COVID-19 lockdown highlights humans as both threats and custodians of the environment

The global lockdown to mitigate COVID-19 pandemic health risks has altered human interactions with nature. Here, we report immediate impacts of changes in human activities on wildlife and environmental threats during the early lockdown months of 2020, based on 877 qualitative reports and 332 quantitative assessments from 89 different studies. Hundreds of reports of unusual species observations from around the world suggest that animals quickly responded to the reductions in human presence. However, negative effects of lockdown on conservation also emerged, as confinement resulted in some park officials being unable to perform conservation, restoration and enforcement tasks, resulting in local increases in illegal activities such as hunting. Overall, there is a complex mixture of positive and negative effects of the pandemic lockdown on nature, all of which have the potential to lead to cascading responses which in turn impact wildlife and nature conservation. While the net effect of the lockdown will need to be assessed over years as data becomes available and persistent effects emerge, immediate responses were detected across the world. Thus, initial qualitative and quantitative data arising from this serendipitous global quasi-experimental perturbation highlights the dual role that humans play in threatening and protecting species and ecosystems. Pathways to favorably tilt this delicate balance include reducing impacts and increasing conservation effectiveness.

ESTABLISHING LOCAL DIAGNOSTIC REFERENCE LEVELS FOR ROUTINE COMPUTED TOMOGRAPHY EXAMINATIONS IN JIMMA UNIVERSITY MEDICAL CENTER SOUTH WEST ETHIOPIA

The main purpose of this study was to determine local diagnostic reference level (LDRL) for Routine Computed Tomography (CT) examination in, Jimma University Medical Center (JUMC) South West Ethiopia. Retrospective study was conducted to determine LDRL for routine CT examination in JUMC. We have considered CTDIvol and DLP as dosimetric quantity based on the recommended guidelines to determine LDRLs by different international legal Authorities. The 75th percentile values of the calculated CTDIvol and DLP were proposed as LDRL. LDRL was obtained as CTDIvol, 42.97mGy, 7.76mGy, 14.32mGy, and 10.86mGy for routine brain CT, routine chest CT, routine thoraco-lumbar CT and routine abdomen CT examination respectively. Similarly the determined LDRL from DLP was 1364.15mGycm, 368.96mGycm, 853.18mGycm, and 1568.96mGycm for brain, chest, thoraco-lumbar and abdomen examination respectively. The LDRL obtained for DLP was higher compared with international DRLs; it can be reduced by coordinating effort between radiologists, technologists and medical physicist.

High levels of preoperative pain and fatigue are red flags for moderate-severe pain 12 months after total knee arthroplasty-A longitudinal cohort study

Background

Moderate/severe pain after total knee arthroplasty (TKA) is a poor surgical outcome. Many studies have identified preoperative risk factors of pain after TKA, but studies of the joint contributions of co‐occurring symptoms are lacking.

Methods

Patients undergoing primary TKA (n = 202) were enrolled in a longitudinal cohort study. Preoperatively, patients completed questionnaires measuring demographics and symptoms (pain, fatigue, sleep problems and depression). Pain was re‐assessed 12 months after TKA. Logistic regression analysis was used to compute the probabilities of moderate‐severe pain at 12 months based on preoperative symptom levels, and results were combined into a risk matrix.

Results

More than one‐third (40%) of patients (n = 187) reported moderate‐severe pain after TKA. Among preoperative risk factors included in the logistic regression analyses were age, sex, pain, fatigue, sleep problems and depression. Adjusting for possible confounders, fatigue (p = 0.02) and pain (p = 0.01) were significant risk factors for moderate‐severe pain at 12‐months follow‐up and were retained in the final risk matrix. The co‐occurrence of high‐preoperative fatigue and pain scores resulted in 57% estimated probability of moderate‐severe pain at 12 months. Similarly, the co‐occurrence of low‐preoperative fatigue and pain scores resulted in 14% estimated probability of moderate‐severe pain 12 months after TKA.

Conclusion

The combination of high fatigue and pain scores prior to surgery was a key risk factor for moderate‐severe pain 12 months after TKA. Mapping of these factors could be used preoperatively to identify patients who are at risk to experience a poor outcome of TKA.

Lipid-based nutrient supplements do not affect efavirenz but lower plasma nevirapine concentrations in Ethiopian adult HIV patients

OBJECTIVES

Lipid-based nutrient supplements (LNSs) are increasingly used in HIV programmes in resource-limited settings. However, the possible effects of LNSs on the plasma concentrations of antiretroviral drugs have not been assessed. Here, we aimed to assess the effects of LNSs on plasma efavirenz and nevirapine trough concentrations in Ethiopian adult HIV-infected patients.

METHODS

The effects of LNSs were studied in adults initiating antiretroviral therapy (ART) in a randomized trial. Patients with body mass index (BMI) > 17 kg/m(2) (n = 282) received daily supplementation of an LNS containing whey (LNS/w), an LNS containing soy (LNS/s) or no LNS. Trough plasma concentrations of efavirenz and nevirapine were measured at 1 and 2 months. Genotyping for 516 G>T and 983 T>C polymorphisms of the cytochrome P450 (CYP) 2B6 locus was performed. Multilevel linear mixed-effects models were used to assess the associations between LNS and plasma efavirenz and nevirapine concentrations.

RESULTS

In patients with BMI > 17 kg/m(2), nevirapine concentrations were lower in the LNS/w and LNS/s groups by a median of -2.3 μg/mL [interquartile range (IQR) -3.9; -0.9 μg/mL; P = 0.002] and -2.1 μg/mL (IQR -3.9; -0.9 μg/mL; P = 0.01), respectively, compared with the group not receiving supplements. There were no differences between groups with respect to efavirenz plasma concentrations. The CYP2B6 516 G>T polymorphism was associated with a 5 μg/mL higher plasma efavirenz concentration compared with the wild type (P < 0.0001), while it was not associated with plasma nevirapine concentrations.

CONCLUSIONS

Intake of an LNS was associated with lower plasma nevirapine trough concentrations, indicating possible drug-LNS interactions. The clinical relevance of such reductions in nevirapine exposure is not clear. Plasma efavirenz concentration was not affected by the LNS.

Maternal and fetal outcome of pregnancy related hypertension in Mettu Karl Referral Hospital, Ethiopia

BACKGROUND

Hypertensive disorders of pregnancy are the most common causes of adverse maternal & perinatal outcomes. Such investigations in resource limited settings would help to have great design strategies in preventing maternal and perinatal morbidity and mortality.

AIM

To determine management outcome and factor associated with pregnancy related hypertensive disorder in Mettu Karl Referral Hospital, Mettu, Ethiopia.

METHOD

A retrospective study deign was conducted at Mettu Karl Referral Hospital from 1st January 2010 to December 1st 2013 by reviewing medical records and logbooks. Descriptive, binary and multiple logistic regression analysis were used. A 95% CI and P- value of < 0.05 were considered statistically significant.

RESULT

The magnitude of pregnancy related hypertensive disorder was 2.4%. Majority 82.6% of the mothers were in the age range between 18 to 34 year with a mean age and standard deviation (SD) of 24.4 (SD ± 5.12). Sever preeclampsia was the most prevalent diagnosis made to 35.5% of the mother, followed by 19% cases of eclampsia and 12.4% of HELLP. Fetal management outcomes indicates 120.37 perinatal mortality per 1000 deliveries and a stillbirth rate of 10.2%, low birth weight of 30.5%, and low APGAR score of 18.5%, abortion 10.7% and preterm delivery 31.4%.

CONCLUSION

In this study severe preeclampsia is the most common of all pregnancy related hypertension disorders followed by Eclampsia. Fetal complications like low Apgar score and preterm deliveries were statistically significant and associated with fetal management outcomes.

The epidemiological profile of pediatric patients admitted to the general intensive care unit in an Ethiopian university hospital

BACKGROUND

In least developing countries, there are few data on children's critical care. This makes the provision of aid and improvement of outcome difficult.

OBJECTIVES

To describe admission and outcome patterns of children managed in a general intensive care unit at Jimma University Specialized Hospital (JUSH), Ethiopia, over a 5-year period.

METHODS

A retrospective cross-sectional study design was used. All children from birth to 14 years of age who were admitted to the general ICU of the hospital from 2009-2013 were included. Patient charts and ICU documentation log were reviewed.

RESULTS

A total of 170 children were admitted to the ICU of JUSH over the study period. The greater share was taken by males (54.7%), with a male-to-female ratio of 1.2:1. The overall mortality rate was 40%. The majority of the children were in the age range of 10-14 years (38.8%). Of the total number of patients admitted, 34.7% were trauma cases, 45.8% of whom died. The highest percentage, 69.5%, of trauma patients were admitted for head injuries. Among the trauma cases, burn and polytrauma were the second and third leading causes (15.3%) of admission. Postoperative patients and medical patients accounted for the rest of the admitted cases (28.2% and 27.6% of the cases respectively).

CONCLUSION

The leading cause of admission and death was trauma. Postoperative and medical causes of admission were also significant. The mortality rate in the ICU was very high, and this could be due to various factors. Further research benchmarking and interventions are highly recommended.

Overexpression of malate dehydrogenase in transgenic alfalfa enhances organic acid synthesis and confers tolerance to aluminum

Al toxicity is a severe impediment to production of many crops in acid soil. Toxicity can be reduced through lime application to raise soil pH, however this amendment does not remedy subsoil acidity, and liming may not always be practical or cost-effective. Addition of organic acids to plant nutrient solutions alleviates phytotoxic Al effects, presumably by chelating Al and rendering it less toxic. In an effort to increase organic acid secretion and thereby enhance Al tolerance in alfalfa (Medicago sativa), we produced transgenic plants using nodule-enhanced forms of malate dehydrogenase and phosphoenolpyruvate carboxylase cDNAs under the control of the constitutive cauliflower mosaic virus 35S promoter. We report that a 1.6-fold increase in malate dehydrogenase enzyme specific activity in root tips of selected transgenic alfalfa led to a 4.2-fold increase in root concentration as well as a 7.1-fold increase in root exudation of citrate, oxalate, malate, succinate, and acetate compared with untransformed control alfalfa plants. Overexpression of phosphoenolpyruvate carboxylase enzyme specific activity in transgenic alfalfa did not result in increased root exudation of organic acids. The degree of Al tolerance by transformed plants in hydroponic solutions and in naturally acid soil corresponded with their patterns of organic acid exudation and supports the concept that enhancing organic acid synthesis in plants may be an effective strategy to cope with soil acidity and Al toxicity.

Overexpression of malate dehydrogenase in transgenic alfalfa enhances organic acid synthesis and confers tolerance to aluminum

Al toxicity is a severe impediment to production of many crops in acid soil. Toxicity can be reduced through lime application to raise soil pH, however this amendment does not remedy subsoil acidity, and liming may not always be practical or cost-effective. Addition of organic acids to plant nutrient solutions alleviates phytotoxic Al effects, presumably by chelating Al and rendering it less toxic. In an effort to increase organic acid secretion and thereby enhance Al tolerance in alfalfa (Medicago sativa), we produced transgenic plants using nodule-enhanced forms of malate dehydrogenase and phosphoenolpyruvate carboxylase cDNAs under the control of the constitutive cauliflower mosaic virus 35S promoter. We report that a 1.6-fold increase in malate dehydrogenase enzyme specific activity in root tips of selected transgenic alfalfa led to a 4.2-fold increase in root concentration as well as a 7.1-fold increase in root exudation of citrate, oxalate, malate, succinate, and acetate compared with untransformed control alfalfa plants. Overexpression of phosphoenolpyruvate carboxylase enzyme specific activity in transgenic alfalfa did not result in increased root exudation of organic acids. The degree of Al tolerance by transformed plants in hydroponic solutions and in naturally acid soil corresponded with their patterns of organic acid exudation and supports the concept that enhancing organic acid synthesis in plants may be an effective strategy to cope with soil acidity and Al toxicity.

Group-specific differentiation of Rhizobium from clover species by PCR amplification of 23S rDNA sequences

Two 20-bp primers that provide group-specific detection of Rhizobium spp. by polymerase chain reaction (PCR) have been used to differentiate strains that belong to different effectiveness groups within the Rhizobium-Trifolium cross-inoculation group. The target for DNA amplification was a 370-bp fragment of the 23S rDNA region. Analysis of additional root-nodule forming, as well as root-associated bacterial species by PCR-primer assay revealed that variability within this 20-bp segment of the 23S rDNA region may be widespread and provide an effective identification tool. Our data suggest that strains of Rhizobium isolated from the perennial clover Trifolium semipilosum may be phylogenetically more closely related to Rhizobium etli.

Comparison of partial 23S rDNA sequences from Rhizobium species

A hypervariable region of Rhizobium 23S rDNA was amplified by polymerase chain reaction and phylogenetic relationships of several strains were determined by comparing nucleotide sequences of the amplified product. Variation in the 23S rDNA nucleotide sequences was consistent with phylogenetic relationships determined by host nodulation specificity and (or) 16S rDNA sequence analysis. Six strains representing three Rhizobium species (R. leguminosarum bv. trifolii, R. meliloti, and R. etli), and two strains each of Bradyrhizobium and Agrobacterium were clustered into five rDNA groups. Unique features identified by secondary structure analysis of the 23S rRNA sequenced region were consistent with the hypothesis that 23S rDNA could be used to design species- or strain-specific Rhizobium probes.