WASH interventions and child diarrhea at the interface of climate and socioeconomic position in Bangladesh

Many diarrhea-causing pathogens are climate-sensitive, and populations with the lowest socioeconomic position (SEP) are often most vulnerable to climate-related transmission. Household Water, Sanitation, and Handwashing (WASH) interventions constitute one potential effective strategy to reduce child diarrhea, especially among low-income households. Capitalizing on a cluster randomized trial population (360 clusters, 4941 children with 8440 measurements) in rural Bangladesh, one of the world's most climate-sensitive regions, we show that improved WASH substantially reduces diarrhea risk with largest benefits among children with lowest SEP and during the monsoon season. We extrapolated trial results to rural Bangladesh regions using high-resolution geospatial layers to identify areas most likely to benefit. Scaling up a similar intervention could prevent an estimated 734 (95% CI 385, 1085) cases per 1000 children per month during the seasonal monsoon, with marked regional heterogeneities. Here, we show how to extend large-scale trials to inform WASH strategies among climate-sensitive and low-income populations.

Foliar application of triacontanol ameliorates heat stress through regulation of the antioxidant defense system and improves yield of eggplant

Abstract Transplanting time and genotype contribute to improving crop yield and quality of eggplant (Solanum melongena L.). A field experiment was conducted to investigate the impact of foliar applied of triacontanol (TRIA) and eggplant genotypes 25919, Nirala, 28389 and Pak-10927,transplanted on 1 March,15 March, and 1 April on exposure to high air temperature conditions. The experiment was performed according to Randomized Complete Block Design and the data was analyzed by using Tuckey,s test . The TRIA was applied at 10µM at flowering stage; distilled water was used as the control. Rate of photosynthesis and transpiration, stomatal conductance, water use efficiency, and effects on antioxidative enzymes (superoxide dismutase, catalase and peroxidase) were evaluated. The 10µM TRIA increased photosynthesis rate and water use efficiency and yield was improved in all genotypes transplanted at the different dates. Foliar application of 10µM TRIA increased antioxidative enzyme activities (SOD, POD & CAT) and improved physiological as well as biochemical attributes of eggplant genotypes exposed to high heat conditions. Highest activity of dismutase enzyme 5.41mg/1g FW was recorded in Nirala genotype in second transplantation. Whereas, lowest was noted in PAK-10927 (2.30mg/g FW). Maximum fruit yield was found in accession 25919 (1.725kg per plant) at 1st transplantation with Triacontanol, whereas accession PAK-10927 gave the lowest yield (0.285 kg per plant) at control treatment on 3rd transplantation. Genotype, transplanting date and application of TRIA improved growth, yield and quality attributes under of heat stress in eggplant.

Knowledge, Adherence, and Perception of Patients on Maintenance Hemodialysis to Treatment Regimens at a Tertiary Care Hospital in Pakistan

Background The management of end-stage renal disease (ESRD) demands meticulous adherence to treatment regimens, encompassing hemodialysis (HD) sessions, medication protocols, dietary guidelines, and fluid restrictions. The intricate interplay of factors impacting treatment adherence warrants comprehensive exploration, particularly within Pakistan. Objective To assess knowledge, adherence, and perception regarding the treatment regimens and their determinants among ESRD patients. Methodology Employing a nonprobability, consecutive sampling method, this prospective, cross-sectional study was conducted in July and August 2023 at Lahore General Hospital, Lahore, Pakistan. It exclusively enrolled adult patients with a minimum three-month history of hemodialysis. Thorough demographic data were collected, followed by the meticulous administration of a translated version of the End Stage Renal Disease-Adherence Questionnaire (ESRD-AQ) through face-to-face interviews in the native language. IBM SPSS Statistics for Windows, Version 26 (released 2019; IBM Corp., Armonk, New York, United States) was used to acquire descriptive statistics, as well as Pearson's and Spearman's correlations and univariate and multivariate regression analysis. Results The study encompassed 119 patients, with a mean age of 43.13 ± 14.99 years. Adherence scores revealed means of 921.83 ± 28.37 for males and 865.18 ± 28.81 for females, out of 1200. Notably, only 10.1% demonstrated good adherence, 31.9% displayed moderate adherence, and 58% exhibited poor adherence. A statistically significant association emerged between better adherence and access to personal transportation (β=-0.225; 95% CI -178.24 to -20.77, p=0.014), with no other demographic factors predicting adherence. Conclusion The study underscores the sobering reality of minimal optimal adherence. Chief impediments include anxiety, alongside challenges such as fistula complications, financial constraints, transportation barriers, and inadequate counseling and motivation. Evidently, robust patient education, sustained motivation, and unwavering support from healthcare providers and institutional entities are imperative to surmount the multifaceted barriers that compromise treatment adherence.

Unlocking the Role of Social Norms: How They Shape Women's Public Toilet Usage in India

Poor access to toilets has significant impacts on hygiene, health, safety, and well-being. Women in resource-poor areas may not use public toilets because of concerns about personal safety and the disapproval of others. This study examines social beliefs about women's use of public toilets in India, using data from 5,052 households in rural, semi-urban, and urban slum areas of Bihar and Tamil Nadu in 2018. We asked respondents about their beliefs regarding the prevalence of young women aged 16 to 30 years using public toilets alone and whether this behavior was approved of in their community. We also asked about their personal beliefs on this issue. We used hypothetical vignettes to assess perceptions of a young woman's behavior in different settings regarding public toilet usage by women. Our results show that people who believe many women in their community use public toilets alone and approve of it are more likely to have positive beliefs about this behavior. The experimental vignettes suggest a potential causal link between the prevalence and approval of public toilet usage among young women and their likelihood of using it. These findings are consistent across Bihar and Tamil Nadu and the three administrative regions, indicating that interventions aimed at changing social expectations about women's use of public toilets should focus on highlighting community members' usage and approval. Efforts to encourage woman's access to public toilets and services should target shifting beliefs about public toilet usage among women without disapproval from others.

Examining the avenues of sustainability in resources and digital blockchains backed currencies: evidence from energy metals and cryptocurrencies

The sustainability issues have been surmounted in the last decades. The digital disruption caused by blockchains and other digitally backed currencies has raised several serious concerns for policymakers, governmental agencies, environmentalists, and supply chain managers. Alternatively, sustainable resources are environmentally sustainable and naturally available resources which are employable by several regulation authorities to reduce the carbon footprint and attain energy transition mechanisms to support sustainable supply chains in the ecosystem. Using the asymmetric time-varying parameters vector auto-regressions approach, the current study examines the asymmetric spillovers between blockchain-backed currencies and environmentally supported resources. We find clusters between blockchain-based currencies and resource-efficient metals, highlighting similar-class dominance of spillovers. We portrayed several implications of our study for policymakers, supply chain managers, the blockchain industry, sustainable resources mechanisms, and regulatory bodies to emphasize that natural resources play a significant role in attaining sustainable supply chains servicing the benefits to society at large and to other stakeholders.

Acetylcholinesterase inhibitory potential of scorpion venom in Aedes aegypti (Diptera: Culicidae)

Scorpion venom contains a variety of neurotoxins which interact with ion channels and affect their activities. The present study was designed to evaluate the potential of scorpion venom as acetylcholinesterase (AChE) inhibitor by using Aedes aegypti as model organism. Venoms of two species, Hottentota tamulus (Fabricus, 1798) and Androctonus finitimus (Pocock, 1897) were selected for this study. Two peptides (36 kDa from H. tamulus and 54 kDa from A. finitimus) were separated from scorpion venom by using HPLC. Selected peptides caused significantly higher mortality in larvae and adults of Aedes aegypti than control (no mortalities were observed in control groups). Significant acetylcholinesterase (AChE) inhibitory potential of both peptides was recorded by spectrophotometer. The peptide of A. finitimus caused significantly higher mortality (95±1.53% in larvae and 100% in adults) than the peptide of H. tamulus (84.33±2.33% in larvae and 95.37±1.45% in adults). While H. tamulus peptide was more efficient in reducing AChE activity (0.029±0.012 in larvae and 0.03±0.003 in adults) than the peptide of A. finitimus (0.049±0.005 in larvae and 0.047±0.001 in adults). It was concluded that H. tamulus venom peptide was more efficiently reducing AChE activity, thus it could be a potential bio-insecticide which can be synthesized at industrial scale for the control of harmful insects.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Preventive small-quantity lipid-based nutrient supplements reduce severe wasting and severe stunting among young children: an individual participant data meta-analysis of randomized controlled trials

BACKGROUND

Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNS) reduce child wasting and stunting. There is little information regarding effects on severe wasting or stunting.

OBJECTIVE

We aimed to identify the effect of SQ-LNS on prevalence of severe wasting (weight-for-length z-score < -3) and severe stunting (length-for-age z-score < -3).

METHODS

We conducted a two-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNS provided to children 6 to 24 mo of age. We generated study-specific and subgroup estimates of SQ-LNS vs. control and pooled the estimates using fixed-effects models. We used random effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.

RESULTS

SQ-LNS provision led to a relative reduction of 31% in severe wasting (Prevalence Ratio, PR 0.69 (0.55, 0.86), n=34,373) and 17% in severe stunting (PR 0.83 (95% CI: 0.78, 0.90), n=36,795) at endline. Results were similar in most of the sensitivity analyses but somewhat attenuated when comparisons using passive control arms were excluded: PR 0.74 (0.57, 0.96), n=26,327 for severe wasting and PR 0.88 (0.81, 0.95), n=28,742 for severe stunting. Study-level characteristics generally did not significantly modify the effects of SQ-LNS, but results suggested greater effects of SQ-LNS in sites with greater burdens of wasting or stunting, or with poorer water quality or sanitation.

CONCLUSIONS

Including SQ-LNS in preventive interventions to promote healthy child growth and development is likely to reduce rates of severe wasting and stunting. Registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Colchicine anti-inflammatory therapy for non-intensive care unit hospitalized COVID-19 patients: results from a pilot open-label, randomized controlled clinical trial

Systemic inflammation is a hallmark of severe coronavirus disease-19 (COVID-19). Anti-inflammatory therapy is considered crucial to modulate the hyperinflammatory response (cytokine storm) in hospitalized COVID-19 patients. There is currently no specific, conclusively proven, cost-efficient, and worldwide available anti-inflammatory therapy available to treat COVID-19 patients with cytokine storm. The present study aimed to investigate the treatment benefit of oral colchicine for hospitalized COVID-19 patients with suspected cytokine storm. Colchicine is an approved drug and possesses multiple anti-inflammatory mechanisms. This was a pilot, open-label randomized controlled clinical trial comparing standard of care (SOC) plus oral colchicine (colchicine arm) vs. SOC alone (control arm) in non-ICU hospitalized COVID-19 patients with suspected cytokine storm. Colchicine treatment was initiated within first 48 hours of admission delivered at 1.5 mg loading dose, followed by 0.5 mg b.i.d. for next 6 days and 0.5 mg q.d. for the second week. A total of 96 patients were randomly allocated to the colchicine (n=48) and control groups (n=48). Both colchicine and control group patients experienced similar clinical outcomes by day 14 of hospitalization. Treatment outcome by day 14 in colchicine vs control arm: recovered and discharged alive: 36 (75.0%) vs. 37 (77.1%), remain admitted after 14-days: 4 (8.3%) vs. 5 (10.4%), ICU transferred: 4 (8.3%) vs. 3 (6.3%), and mortality: 4 (8.3%) vs. 3 (6.3%). The speed of improvement of COVID-19 acute symptoms including shortness of breath, fever, cough, the need of supplementary oxygen, and oxygen saturation level, was almost identical in the two groups. Length of hospitalization was on average 1.5 day shorter in the colchicine group. There was no evidence for a difference between the two groups in the follow-up serum levels of inflammatory biomarkers including C-reactive protein (CRP), D-dimer, lactate dehydrogenase (LDH), ferritin, interleukin-6 (IL-6), high-sensitivity troponin T (hs-TnT) and N-terminal pro b-type natriuretic peptide (NT pro-BNP). According to the results of our study, oral colchicine does not appear to show clinical benefits in non-ICU hospitalized COVID-19 patients with suspected cytokine storm. It is possible that the anti-inflammatory pathways of colchicine are not crucially involved in the pathogenesis of COVID-19.

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials

BACKGROUND

Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design.

OBJECTIVES

We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes.

METHODS

We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.

RESULTS

SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation.

CONCLUSIONS

The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Studies on parasitic prevalence in pet birds from Punjab, Pakistan

During this one year study, blood and fecal samples of doves (Zenaida asiatica), ducks (Anas platyrhynchos), pigeons (Columba livia), partridges (Alectoris chukar), turkeys (Meleagris gallopavo) and goose (Chen caerulescens) were collected to assess the parasitic prevalence in these birds. The birds were kept at Avian Conservation and Research Center, Department of Wildlife and Ecology, University of Veterinary and Animal Sciences, Lahore. All these avian species were kept in separate cages and their entire body was inspected on regularly basis to record external parasites. For internal parasites, 100 blood and 100 fecal samples for each species were analyzed. During present study, two species of ectoparasites i.e. fowl ticks (Args persicus) and mite (Dermanyssus gallinae) while 17 species of endoparasites; three from blood and 14 from fecal samples were identified. Prevalence of blood parasites was Plasmodium juxtanucleare 29.3%, Aegyptinella pullorum 15% and Leucoctoyzoon simond 13%. Parasitic species recorded from fecal samples included 6 species of nematodes viz. Syngamus trachea with parasitic prevalence of 50%, Capillaria anatis 40%, Capillaria annulata 37.5%, Heterakis gallinarum 28.3%, Ascardia galli 24% and Allodpa suctoria 2%. Similarly, two species of trematodes viz. Prosthogonimus ovatus having parasitic prevalence of 12.1% and Prosthogonimus macrorchis 9.1% were also recorded from fecal samples of the birds. Single cestode species Raillietina echinobothrida having parasitic prevalence of 27% and 3 protozoan species i.e. Eimeria maxima having prevalence 20.1%, Histomonas meleagridis 8% and Giardia lamblia 5.3% were recorded. In our recommendation, proper medication and sanitation of the bird's houses and cages is recommended to avoid parasites.

Postoperative complications of colorectal cancer

Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.

Interspecific variations in external and internal egg quality among various captive avian species from Punjab, Pakistan

Present study was planned to determine variations in external and internal quality egg parameters of different avian species including ostrich Struthio camelus, ducks Anas platyrhynchos, chicken Gallus gallus, turkeys Meleagris gallopavo and grey francolin Francolinus pondicerinus. All the birds were kept under similar rearing conditions. A total of 150 eggs were collected for each species to record external features of these eggs. Statistically significant (p<0.05) variations were recorded in egg weight, egg length and egg width between ostrich, ducks, chicken, turkey and quail eggs. Significantly (p<0.05) higher egg weight, egg length and egg width was observed for ostrich eggs while the same was lowest for grey francolin eggs. Similarly, significantly (p<0.05) greater shape index and egg volume values were observed for ostrich eggs while lowest shape index values were recorded for turkey eggs and egg volume was lowest for grey francolin. Significantly, higher (p<0.05) values of egg density were noted for eggs of the quail and the same were lowest for ostrich eggs. Non-significant variations in egg density values were observed between eggs of the ducks, chicken, turkey and grey francolin. It has been concluded that the positive correlations between the internal and external egg quality traits indicated that the traits can be improved through selection.

937 Is the Dog Still Man's Best Friend?

Introduction

It is colloquially known that dogs are man’s best friend. However, animal attacks cause a large number of injuries and deaths worldwide, with 70% of injuries being caused by pets. This study highlights the impact of dog related injuries.

Method

Data was collected retrospectively over 1 year in a small district general hospital. The search term “dog” was used to find patients who had attended A&E or fracture clinic. This data was analysed for patient demographics, injury type and severity, management, and cost to the NHS.

Results

The majority (77%) of patients were female and elderly, with the modal age group being 70-79. Of the 38% of patients requiring admission, average length of stay was 6.7 days. Fractures made up the majority of injuries (56%) and 17% of patients required operative management. A further 2% suffered from post-operative complications. The average cost to the NHS was £1,695 per patient.

Conclusions

Dog related injuries disproportionately affected women and the elderly, with a large portion requiring operative management. Some patients developed further complications. As well as health burden there was also a financial burden associated with these injuries. These health and financial detriments are not often considered when deciding on pet ownership.

958 Pre-operative Pregnancy Testing in Paediatric Patients

Introduction

NICE emphasises the importance of pregnancy testing before surgical procedures as a patient safety precaution, especially in 13-16-year-olds. This is because, in the UK, a third of females will have been sexually active by the age of 16, meanwhile, in England there are 67,000 operations involving females aged 12-15 annually.

Method

Guidance from NICE and RCPCH was used to create standards to compare against current practice. Surgical admissions involving females aged 13-16 were retrospectively analysed over a one-year period and compared to these standards. Changes, including creation of a protocol, revision of the clerking proforma and staff education, were implemented to improve compliance and patient data was re-audited following this.

Results

Initially, 27% of patients did not have pregnancy testing before their procedure and consent for pregnancy testing was not documented. However, when pregnancy tests were performed, the result was documented 100% of the time. After implementing changes, 100% of patients had pregnancy testing before their procedure and documentation of consent had improved.

Conclusions

Initial practice showed poor compliance with NICE and RCPCH standards. Changes implemented have shown increased compliance to NICE and RCPCH standards and these changes could be used as a model to improve clinical compliance in further areas.

28 Shifting to Virtual MDT in the COVID-19 Era and Beyond

Aim

The COVID19 pandemic has accelerated the need for staff to work remotely. Our aim was to demonstrate how a next-generation digital platform could be used to create a virtual MDT ecosystem in order to manipulate holographic 2D and 3D images in real-time.

Method

This study involved setting up a mock virtual MDT using de-identified DICOM files from a patient who had been treated for colorectal cancer and then subsequently found to have a liver metastasis. The image file was segmented and converted into a 2D and 3D format for visualisation within Microsoft HoloLens 2 ® (smart glasses) using Holocare Solutions ® (Mixed Reality software).

Results

A seamless cross-border pipeline was developed that involved "clinician" training, DICOM segmentation and virtual connection. We successfully performed a virtual MDT with participants able to visualise and manipulate a virtual 3D organ in real-time. The digital network remotely connected sites in England and Norway. The streaming quality was stable and HIPAA compliant. Each participant could observe others as "avatars" interacting with images within the virtual ecosystem allowing image characteristics to be highlighted.

Conclusions

We successfully conducted a virtual MDT using novel hardware and software. Our intention is to conduct a large-scale study to assess the platform's effectiveness in “Real World" MDTs.

Norms and Social Network-Centric Behavior Change Intervention (Nam Nalavazhvu) for Improved Toilet Usage in Peri-Urban Communities of Tamil Nadu: Protocol for a Cluster-Randomized Controlled Trial

BACKGROUND

Inconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings.

OBJECTIVE

The objective of this paper is to detail the rationale and design of an ex ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norm-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India.

METHODS

Following formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for "our well-being"). The multilevel intervention aims to improve toilet usage by shifting empirical expectations or beliefs about other relevant people's sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to own, consistently use, and maintain their toilets. This trial includes 76 wards in the Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining served as counterfactuals.

RESULTS

We enrolled wards and conducted a baseline survey among randomly selected individuals in all 76 wards. The 1-year behavior change intervention is currently ongoing. At the endline, we will collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, and well-being outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We are also conducting a process evaluation to understand the extent to which the intervention was implemented as designed, given the special pandemic context.

CONCLUSIONS

Findings from this trial will inform norm-centric behavior change strategies to improve exclusive toilet usage.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04269824; https://www.clinicaltrials.gov/ct2/show/NCT04269824.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24407.

Evaluation of serum analytes in pregnant and non-pregnant dairy cows as indicators of pregnancy

This study was conducted to reveal the dynamics of haematological indicators in pregnant and non-pregnant dairy cows. Sixty multiparous healthy dairy cows were divided into four groups based on the length of time they had been pregnant, namely first, second and third trimesters, and non-pregnant (n=15 each). Blood was collected from each animal, and serum was harvested and stored at -20 °C for biochemical profiling. Concentrations of serum total oxidants (TOC), ceruloplasmin oxidase (CpO) and triiodothyronine (T3) were higher (P <0.05) during the third trimester compared with non-pregnant cows. Serum arylesterase (Ary) concentration was lower (P <0.05) during the second and the third trimesters compared with the non-pregnant cows. The concentration of serum total homocysteine (tHcy) was higher (P <0.05) the third trimester compared with the first and the second trimesters. The concentrations of serum total antioxidants (TAC), paraoxonase 1 (PON1), thyroxine (T4), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were not different in the pregnant and the non-pregnant cows. Thus, TOC, Ary, CpO, tHcy and T3 could be taken as biological markers to assess the progression of pregnancy and to develop management tools to improve health status during late gestation in dairy cows Keywords: ceruloplasmin, hepatic enzymes, late gestation, triiodothyronine

Could Alcohol-Based Hand Sanitizer Be an Option for Hand Hygiene for Households in Rural Bangladesh?

In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, installed handwashing stations (bucket with tap, stand, basin, and bottle for soapy water), and conducted household visits and community meetings. During Phase 1, promoters recommended handwashing with soap or soapy water, or hand sanitizer after defecation, after cleaning a child's anus/feces, and before food preparation. In Phase 2, they recommended separate key times for hand sanitizer: before touching a child ≤ 6 months and after returning home. Three to 4 months after each intervention phase, we conducted a survey, in-depth interviews, and group discussions with child caregivers and male household members. After Phase 1, 82/89 (92%) households reported handwashing with soap after defecation versus 38 (43%) reported hand sanitizer use. Participants thought soap and water removed dirt from their hands, whereas hand sanitizer killed germs. In Phase 2, 76/87 (87%) reported using hand sanitizer after returning home and 71/87 (82%) before touching a child ≤ 6 months. Qualitative study participants reported that Phase 2-recommended times for hand sanitizer use were acceptable, but handwashing with soap was preferred over hand sanitizer when there was uncertainty over choosing between the two. Hand sanitizer use was liked by household members and has potential for use in LMICs, including during the coronavirus pandemic.

Hemodialysis as long term treatment: Patients satisfaction and its impact on quality of life

Objective:

To determine the level of satisfaction as hemodialysis a long term treatment and quality of life in patients off End Stage Kidney Disease ESKD on hemodialysis.

Methods:

A cross-sectional study was carried out from January to April 2019 in hemodialysis unit of Lahore General Hospital on 141 ESKD patients by using self-designed questionnaire after informed consent.

Results:

Majority (82.56%) of the participants were satisfied with the care provided at the dialysis center. except with the time spent with doctor and 36.9% were not satisfied with their cannulation technique for dialysis. About 89.9% were satisfied with the knowledge provided to them about self-care. Satisfaction is subjective well-being in different aspects of life, including mental health and behavior of people experiencing serious health concerns. Quality of Life (QOL) is defined as “perception of one’s position in life, in the light of his culture and customs, consisting someone’s goals, standards or expectations. Financial problems to the patient was limited to the transportation as dialysis session and erythropoietin were free, but 54.1% of the patients were unable to earn due to their disease even those who were working ,80% of them had to take the day off for dialysis. The financial burden and debilitating illness didn’t cause separation/divorce from spouse but led to increased frequency of scuffles. Among the unmarried population, 40% of it does not want to start a relationship and 40% is facing difficulties in finding a partners while 97.9% of the population is satisfied with the psychological and emotional support of family.

Conclusion:

Most patients were satisfied with their decision of opting hemodialysis as treatment and care provided at dialysis centre, although Quality of Life was badly affected in terms of financial and psycho-social aspects. Employed, married with good income have good quality of life. Loopholes of unit environment and health education were also exposed. Despite the medical advancement and emerging techniques to make dialysis better, the outcome of hemodialysis has yet to reach a safe level and more work should be done to improve patient’s outcome.

Achieving equitable uptake of handwashing and sanitation by addressing both supply and demand-based constraints: findings from a randomized controlled trial in rural Bangladesh

Background

Supply driven programs that are not closely connected to community demand and demand-driven programs that fail to ensure supply both risk worsening inequity. Understanding patterns of uptake of behaviors among the poorest under ideal experimental conditions, such as those of an efficacy trial, can help identify strategies that could be strengthened in routine programmatic conditions for more equitable uptake. WASH Benefits Bangladesh was a randomized controlled efficacy trial that provided free-of cost WASH hardware along with behavior change promotion. The current paper aimed to determine the impact of the removal of supply and demand constraints on the uptake of handwashing and sanitation behaviors across wealth and education levels.

Methods

The current analysis selected 4 indicators from the WASH Benefits trial— presence of water and soap in household handwashing stations, observed mother’s hand cleanliness, observed visible feces on latrine slab or floor and reported last child defecation in potty or toilet. A baseline assessment was conducted immediately after enrolment and endline assessment was conducted approximately 2 years later. We compared change in uptake of these indicators including wealth quintiles (Q) between intervention and control groups from baseline to endline.

Results

For hand cleanliness, the poorest mothers improved more [Q1 difference in difference, DID: 16% (7, 25%)] than the wealthiest mothers [Q5 DID: 7% (− 4, 17%)]. The poorest households had largest improvements for observed presence of water and soap in handwashing station [Q1 DID: 82% (75, 90%)] compared to the wealthiest households [Q5 DID: 39% (30, 50%)]. Similarly, poorer household demonstrated greater reductions in visible feces on latrine slab or floor [Q1DID, − 25% (− 35, − 15) Q2: − 34% (− 44, − 23%)] than the wealthiest household [Q5 DID: − 1% (− 11, 8%). For reported last child defecation in potty or toilet, the poorest mothers showed greater improvement [Q1–4 DID: 50–54% (44, 60%)] than the wealthier mothers [Q5 DID: 39% (31, 46%).

Conclusion

By simultaneously addressing supply and demand-constraints among the poorest, we observed substantial overall improvements in equity. Within scaled-up programs, a separate targeted strategy that relaxes constraints for the poorest can improve the equity of a program.

Trial registration

WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095. Date of registration: April 30, 2012 ‘Retrospectively registered’.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01353-7.

Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Environmental Enteric Dysfunction in Young Children: A Cluster-randomized, Controlled Trial in Rural Bangladesh

BACKGROUND

We hypothesized that drinking water, sanitation, handwashing (WSH), and nutritional interventions would improve environmental enteric dysfunction (EED), a potential contributor to stunting.

METHODS

Within a subsample of a cluster-randomized, controlled trial in rural Bangladesh, we enrolled pregnant women in 4 arms: control, WSH, child nutrition counseling plus lipid-based nutrient supplements (N), and nutrition plus WSH (N+WSH). Among the birth cohort, we measured biomarkers of gut inflammation (myeloperoxidase, neopterin), permeability (alpha-1-antitrypsin, lactulose, mannitol), and repair (regenerating gene 1β) at median ages 3, 14, and 28 months. Analysis was intention-to-treat.

RESULTS

We assessed 1512 children. At age 3 months, compared to controls, neopterin was reduced by nutrition (-0.21 log nmol/L; 95% confidence interval [CI], -.37, -.05) and N+WSH (-0.20 log nmol/L; 95% CI, -.34, -.06) interventions; similar reductions were observed at 14 months. At 3 months, all interventions reduced lactulose and mannitol (-0.60 to -0.69 log mmol/L). At 28 months, myeloperoxidase was elevated in the WSH and nutrition arms (0.23-0.27 log ng/mL) and lactulose was higher in the WSH arm (0.30 log mmol/L; 95% CI, .07, .53).

CONCLUSIONS

Reductions in permeability and inflammation at ages 3 and 14 months suggest that the interventions promoted healthy intestinal maturation; however, by 28 months, the WSH and nutrition arms showed elevated EED biomarkers. These results underscore the importance of developing a better understanding of EED pathophysiology and targeting interventions early in childhood, when they are likely to have the largest benefit to intestinal health.

CLINICAL TRIALS REGISTRATION

NCT01590095.

ASSOCIATION OF THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI) RISK SCORE WITH EXTENT OF CORONARY ARTERY DISEASE IN PATIENTS WITH UNSTABLE ANGINA AND NSTEMI

Objective: To evaluate the correlation between thrombolytic in Myocardial Infarction risk score with the severity of coronary lesions found by coronary angiography during hospitalization in patients with non-ST elevation Acute coronary syndrome. Study Design: Cross sectional study. Place and Duration of Study: Adult Cardiology department, Armed Forces Institute of Cardiology & National Institute of Heart Diseases, Rawalpindi from Jul to Dec 2018.Methodology: Patients who had chest pain suggestive of angina or anginal equivalent symptoms and diagnosis of Acute Coronary Syndrome (ACS) were included in the study. Patients with Acute Coronary Syndrome were risk stratified with Thrombolysis In Myocardial Infarction risk scores and were further evaluated with coronary angiograms to assess the extent of coronary artery disease. Results: Total 115 patients were recruited in the study with mean age 57.08 ± 10.2 years. There were 87 (75.7%) male patients while 28 (24.3%) female patients. The most common co-morbidity was hypertension 66 (57.4%) followed by diabetes mellitus 39 (33.9%) and smoking 25 (21.7%). 71 (61.7%) patients had one angina episode in the last 2 hours while 34 patients had two angina episodes in the last 2 hours. Cardiac biomarkers were raised in 36 (31.3%) patients. 60 (52.2%) used aspirin in the last 7 days. Chi-square test was applied between Thrombolysis In Myocardial Infarction Score and Coronaries lesions, which showed statistically significant results (p<0.001). Conclusion: Our study demonstrates that among patients presenting with Non-STE Acute coronary syndrome i.e. unstable angina /NSTEMI who are referred for coronary angiography, clinical risk stratification according......

Sanitation Practices during Early Phases of COVID-19 Lockdown in Peri-Urban Communities in Tamil Nadu, India

In countries without adequate access to improved sanitation, government-imposed restrictions during the COVID-19 pandemic can impact toilet usage. In India, where millions have recently transitioned to using a toilet, pandemic-related barriers to use might increase open defecation practices. We assessed changes in reported defecation practices in peri-urban communities in Tamil Nadu. Field assistants conducted phone surveys in 26 communities in two districts from May 20, 2020 to May 25, 2020. They asked respondents about their access to a toilet, whether they or a family member left their house to defecate in the past week, and whether specific practices had changed since the lockdown. Among 2,044 respondents, 60% had access to a private toilet, 11% to a public or community toilet, whereas 29% lacked access to any toilet facility. In our study, 92% of the respondents did not change their defecation behaviors in the 2 months following the pandemic-related lockdown. About a third (27%) reported that they or a family member left their house daily to defecate amid lockdown measures. A majority of those with private toilets (91%) or with public toilets (69%) continued using them. Respondents with private toilet access were more likely to report an increased frequency of handwashing with soap (prevalence ratio [PR]: 1.78, 95% CI: 1.04–3.05) since the lockdown. The lack of private toilets contributes to the need to leave the house amid a lockdown. Maintaining shared toilets require disinfection protocols and behavioral precautions to limit the risk of fomite transmission. Robust urban COVID-19 control strategies should include enhanced sanitation facility management and safe usage messaging.

Women are more likely to expect social sanctions for open defecation: Evidence from Tamil Nadu India

Social sanctions can be effective for sustaining beneficial norms by harnessing the power of social pressure and peer monitoring. Yet, field evidence regarding how norms might be linked to perceived risk of sanction is limited. In this study, we focused on communities located in peri-urban areas of Tamil Nadu, India, and examined how people’s perceived prevalence of a socially desirable behavior (i.e., toilet use) relates to the perceived risk of sanctions for deviating from this behavior (i.e., open defecation) in the sanitation domain. Cross-sectional data from 2427 participants in 75 communities revealed that the majority (77%, n = 1861) perceived the risk of informal sanctions related to open defecation. Among those, verbal reprimand was the most common (60%), followed by advice (30%) and gossip (7%). Results from multilevel logistic regression indicated that those who believed toilet use was prevalent in their community were more likely to perceive the risk of social sanctions for open defecation. Moderation analysis revealed that this relationship was robust among women, but attenuated among men. Our findings suggest that women are more likely to expect social sanctions if they deviate from what is perceived as the prevalent sanitation behavior (e.g., toilet use) in their community. Open defecation practices are known to cause psychosocial stress among women due to their experiences with sanitation insecurity, which may include fear of disapproval from community members. Our results highlight the need for gendered intervention strategies when sanitation programs leverage social influence for behavior change.

Awareness, Risk Perception, and Stress during the COVID-19 Pandemic in Communities of Tamil Nadu, India

The health and economic consequences of the COVID-19 pandemic is expected to disproportionately impact residents of lower-middle income countries. Understanding the psychological impact of the pandemic is important to guide outreach interventions. In this study, we examined people's awareness of COVID-19 symptoms, risk perception, and changes in behaviors and stress levels during the lockdown in peri-urban Tamil Nadu India. Field workers conducted phone call surveys (included n = 2044) in 26 communities from 20-25 May 2020. The majority perceived no (60%) or low (23%) level of risk of personally contracting coronavirus. Common fears were related to health and economic concerns, including loss of income (62%), inability to travel freely (46%), and becoming sick (46%). Residents were well aware of the common symptoms of COVID-19, such as fever (66%) and dry cough (57%), but not the asymptomatic transmission (24%). The majority experienced increased stress about finance (79%) and the lockdown (51%). Our findings emphasize the need to develop context-adequate education and communication programs to raise vigilance about asymptomatic transmission and to sustain preventative behaviors. The evidence on fear and changes in stress levels could inform designing coping strategies and programs focused on mental well-being.

Bias in the perceived prevalence of open defecation: Evidence from Bihar, India

People often form perceptions about how prevalent a behavior is in a social group. However, these perceptions can be inaccurate and biased. While persistent undesirable practices in low-income countries have drawn global attention, evidence regarding people’s perception of how prevalent these practices are is scarce. Among those harmful practices, open defecation in India remains a significant public health concern, where it perpetuates the vicious cycle of disease and poverty. In this study, we focus on measuring the perceived prevalence of open defecation among respondents in Bihar, India. We examined the bias in perceived prevalence, which is defined as a pattern of deviation from the actual prevalence of open defecation. Results showed that respondents who defecate in the open overestimate the prevalence of open defecation, whereas those who consistently use toilets underestimate it. This finding suggests a false consensus bias in the perceived prevalence of open defecation. Scholars, policymakers, and program implementers who seek to correct misperceptions about open defecation by broadcasting real prevalence should be aware of biases in the perceived prevalence and address them in behavior change interventions.

Effect of maternal yeast feeding on dam performance and serum health biomarkers of Beetal goat kids

Supplementation with dietary yeast has improved digestibility and productive performance in ruminants. In this research the primary objective was to appraise the effects of dietary yeast supplementation of female goats during the transition period on milk composition and yield and on production and serum health biomarkers of their kids. Twenty-four Beetal goats (4 ± 1.2 years) were randomly assigned to three groups, which received 0, 5, and 10 grams/animal/day of live dried yeast Saccharomyces cerevisiae for 60 days (30 days pre- and post-partum). All goats were fed 500 grams of concentrate with water and green fodder ad libitum. Milk samples were collected at 7, 14, 21, and 28 days post kidding. Kids were weighed on days 0, 7, 15, 22, and 30, and blood samples were collected on days 15 and 30 for serum metabolites (glucose, urea, cholesterol, non-esterified fatty acids (NEFA), serum total proteins, albumin, globulin, albumin to globulin ratio, serum oxidant and antioxidant activity (malondialdehyde) (MDA) and catalase), and liver enzymes aspartate aminotransferase (AST) and alanine transaminase (ALT) assessment. Milk yield was significantly (P =0.02) higher during the post-partum period in yeast-fed goats. Yeast-fed goats also produced milk containing more fat (P <0.001) and protein (P <0.001) compared with control goats. Birth weight, average daily gain, and serum health biomarkers of the kids were not influenced by the treatments. In conclusion, dietary yeast supplementation resulted in increased production performance of the dams without significant impact on their offspring.Keywords: average daily gain, catalase activity, hepatic enzymes, milk production, Saccharomyces cerevisiae, transition period

Effect of Improved Water Quality, Sanitation, Hygiene and Nutrition Interventions on Respiratory Illness in Young Children in Rural Bangladesh: A Multi-Arm Cluster-Randomized Controlled Trial

Acute respiratory infections cause mortality in young children. We assessed the effects of water, sanitation, hygiene (WASH) and nutritional interventions on childhood ARI. Geographic clusters of pregnant women from rural Bangladesh were randomly assigned to receive 1) chlorinated drinking water and safe storage (W); 2) upgraded sanitation (S); 3) handwashing promotion (H); 4) combined water, sanitation, and handwashing (WSH); 5) nutrition intervention including lipid-based nutrient supplements; 6) combined WSH plus nutrition (WSHN); or 7) no intervention (control). Masking of participants was not possible. Acute respiratory illness was defined as caregiver-reported persistent cough, panting, wheezing, or difficulty breathing in the past 7 days among index children, those born to enrolled women. We assessed outcomes at 12 and 24 months of intervention using intention to treat. Compared with children in the control group (ARI prevalence, P: 8.9%), caregivers of index children reported significantly lower ARI in the water (P: 6.3%, prevalence ratio (PR): 0.71; 95% CI: 0.53, 0.96), sanitation (P: 6.4%, PR: 0.75, 95% CI: 0.58, 0.96), handwashing (P: 6.4%, PR: 0.68, 95% CI: 0.50, 0.93), and the combined WSH+N arms (P: 5.9%, PR: 0.67, 95% CI: 0.50, 0.90). Those in the nutrition (P: 7.4%, PR: 0.84, 95% CI: 0.63, 1.10) or the WSH arm (P: 8.9%, PR: 0.99, 95% CI: 0.76, 1.28) reported similar ARI prevalence compared with control children. Single targeted water, sanitation, and hygiene interventions reduced reported respiratory illness in young children. There was no apparent respiratory health benefit from combining WASH interventions.

Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Child Enteric Protozoan Infections in Rural Bangladesh: A Cluster-Randomized Controlled Trial

Background

We evaluated effects of individual and combined water, sanitation, handwashing (WSH), and nutritional interventions on protozoan infections in children.

Methods

We randomized geographical clusters of pregnant women in rural Bangladesh into chlorinated drinking water, hygienic sanitation, handwashing, nutrition, combined WSH, nutrition plus WSH (N+WSH), or control arms. Participants were not masked. After approximately 2.5 years of intervention, we measured Giardia, Cryptosporidium, and Entamoeba histolytica prevalence and infection intensity by multiplex real-time polymerase chain reaction of child stool. Analysis was intention-to-treat.

Results

Between May 2012 and July 2013, we randomized 5551 pregnant women. At follow-up, among 4102 available women, we enrolled 6694 children into the protozoan assessment. We analyzed stool from 5933 children (aged ~31 months) for protozoan infections. Compared with 35.5% prevalence among controls, Giardia infection prevalence was lower in the sanitation (26.5%; prevalence ratio [PR], 0.75 [95% confidence interval {CI}, .64-.88]), handwashing (28.2%; PR, 0.80 [95% CI, .66-.96]), WSH (29.7%; PR, 0.83 [95% CI, .72-.96]), and N+WSH (26.7%; PR, 0.75 [95% CI, .64-.88]) arms. Water and nutrition interventions had no effect. Low prevalence of E. histolytica and Cryptosporidium (<2%) resulted in imprecise effect estimates.

Conclusions

Individual handwashing and hygienic sanitation interventions significantly reduced childhood Giardia infections, and there were no effects of chlorinated drinking water and nutrition improvements in this context. Combined WSH interventions provided no additional benefit. To reduce Giardia infection, individual WSH interventions may be more feasible and cost-effective than combined interventions in similar rural, low-income settings.

Clinical Trials Registration

NCT01590095.

RHEB gene therapy maintains the chondrogenic characteristics and protects cartilage tissue from degenerative damage during experimental murine osteoarthritis

OBJECTIVE

Osteoarthritis (OA) is characterized by cartilage degeneration resulting from hypertrophic changes in chondrocytes caused by altered gene expression. The involvement of Ras homolog enriched in brain (RHEB) in OA regulation is unclear.

METHODS

Human knee articular cartilage samples - were analyzed for structural and biological changes by histology, immunohistochemistry, real time PCR and western blotting. OA-mouse model developed by surgical destabilization of the medial meniscus (DMM) were treated with adenovirus harboring Rheb gene to analyze onset and progression of OA. Histological scoring, immunohistochemistry, and TUNEL assay was performed to assess cartilage damage across the entire joint.

RESULTS

Human and mouse OA cartilage is degenerated and has markedly reduced levels of RHEB. Human OA-degenerated chondrocytes (DC) exhibited a fibroblastic phenotype and 80 % of degenerative cartilage were senescent, with higher levels of reactive oxygen species (ROS). Gene expression analysis of DC revealed almost no COL2A1 expression and reduced SOX9 and RHEB expression. Transient transfection of RHEB rescued the DC phenotype and reduced senescence and ROS levels markedly. RHEB overexpression also increased COL2A1 and SOX9 expression. In an OA-mouse model, the Rheb protein level decreased as the severity of OA increased. Ectopic expression of Rheb using adenovirus in mouse-OA cartilage suppressed surgically-induced OA pathogenesis accompanied by modulation of Adamts5, Mmp 13, Col 10, and Col2a1 expression. Rheb induction significantly reduced apoptosis in OA-cartilage.

CONCLUSION

RHEB plays an important role in maintaining the chondrogenic characteristics of chondrocytes, and has potential in preventing progression of OA in the destabilize the medial meniscus (DMM) mouse model of OA.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Effects of carrageenan induced synovitis on joint damage and pain in a rat model of knee osteoarthritis

OBJECTIVE

Knee osteoarthritis (OA) is associated with ongoing pain and joint damage that can be punctuated by acute flares of pain and inflammation. Synovitis in normal knees might resolve without long-term detriment to joint function. We hypothesised that osteoarthritis is associated with impaired resilience to inflammatory flares.

DESIGN

We induced synovitis by injecting carrageenan into rat knees with or without meniscal transection (MNX)-induced OA, and measured synovitis, weightbearing asymmetry (pain behaviour), and joint damage up to 35 days after OA induction (23 days after carrageenan-injection).

RESULTS

Carrageenan injection induced weightbearing asymmetry for 1 week, transient increase in knee diameter for 2 days, and a sustained increase in synovial macrophages, endothelial cell proliferation and vascular density compared with naive vehicle-injected controls. MNX surgery induced weightbearing asymmetry and histological evidence of OA. Carrageenan-injection in MNX-operated knees was followed for 2 days by increased weightbearing asymmetry compared either to MNX+vehicle or to sham+carrageenan groups. OA structural damage and synovitis at day 35 were greater in MNX+carrageenan compared to MNX+vehicle and sham+carrageenan groups. Carrageenan injection did not induce OA in Sham-operated knees.

CONCLUSION

Intra-articular injection of the pro-inflammatory compound carrageenan in OA and sham-operated control knees induced a short term increase in joint pain. Even though pain flares resolved in both groups and damage was not induced in sham-operated knees, carrageen injection exacerbated long-term joint damage in OA knees. OA knees display less resilience to inflammatory episodes. Preventing inflammatory flares may be particularly important in preventing symptoms and long term joint damage in OA.

WASH Benefits Bangladesh trial: management structure for achieving high coverage in an efficacy trial

BACKGROUND

Water, sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. A systematic and intensive approach to intervention delivery is required to achieve the high-level uptake necessary to measure efficacy. We describe the intervention delivery system adopted in the WASH Benefits Bangladesh study, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance.

METHODS

Community Health Workers (CHWs) delivered individual and combined WASH and nutrition interventions to 4169 enrolled households in geographically matched clusters. Households were provided with free enabling technologies and supplies, integrated with parallel behaviour-change promotion. Behavioural objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviours (birth to 24 months). The intervention delivery system built on lessons learned from prior WASH intervention effectiveness, implementation, and formative research studies. We recruited local CHWs, residents of the study villages, through transparent merit-based selection methods, and consultation with community leaders. CHW supervisors received training on direct intervention delivery, then trained their assigned CHWs. CHWs in turn used the technologies in their own homes. Each CHW counseled six to eight intervention households spread across a 0.2-2.2-km radius, with a 1:12 supervisor-to-CHW ratio. CHWs met monthly with supervisor-trainers to exchange experiences and adapt technology and behaviour-change approaches to evolving conditions. Intervention uptake was tracked through fidelity measures, with a priori benchmarks necessary for an efficacy study.

RESULTS

Sufficient levels of uptake were attained by the fourth intervention assessment month and sustained throughout the intervention period. Periodic internal CHW monitoring resulted in discontinuation of a small number of low performers.

CONCLUSIONS

The intensive intervention delivery system required for an efficacy trial differs in many respects from the system for a routine program. To implement a routine program at scale requires further research on how to optimize the supervisor-to-CHW-to-intervention household ratios, as well as other program costs without compromising program effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCC01590095 . Registered on 2 May 2012.

WASH Benefits Bangladesh trial: system for monitoring coverage and quality in an efficacy trial

BACKGROUND

Researchers typically report more on the impact of public health interventions and less on the degree to which interventions were followed implementation fidelity. We developed and measured fidelity indicators for the WASH Benefits Bangladesh study, a large-scale efficacy trial, in order to identify gaps between intended and actual implementation.

METHODS

Community health workers (CHWs) delivered individual and combined water, sanitation, handwashing (WSH) and child nutrition interventions to 4169 enrolled households in geographically matched clusters. Households received free enabling technologies (insulated water storage container; sani-scoop, potty, double-pit, pour-flush latrine; handwashing station, soapy-water storage bottle), and supplies (chlorine tablets, lipid-based nutrient supplements, laundry detergent sachets) integrated with parallel behavior-change promotion. Behavioral objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviors. We administered monthly surveys and spot-checks to households from randomly selected clusters for 6 months early in the trial. If any fidelity measures fell below set benchmarks, a rapid response mechanism was triggered.

RESULTS

In the first 3 months, functional water seals were detected in 33% (14/42) of latrines in the sanitation only arm; 35% (14/40) for the combined WSH arm; and 60% (34/57) for the combined WSH and Nutrition arm, all falling below the pre-set benchmark of 80%. Other fidelity indicators met the 65 to 80% uptake benchmarks. Rapid qualitative investigations determined that households concurrently used their own latrines with broken water seals in parallel with those provided by the trial. In consultation with the households, we closed pre-existing latrines without water seals, increased the CHWs' visit frequency to encourage correct maintenance of latrines with water seals, and discouraged water-seal removal or breakage. At the sixth assessment, 86% (51/59) of households were in sanitation only; 92% (72/78) in the combined WSH; and 93% (71/76) in the combined WSH and Nutrition arms had latrines with functional water seals.

CONCLUSIONS

An intensive implementation fidelity monitoring and rapid response system proved beneficial for this efficacy trial. To implement a routine program at scale requires further research into an adaptation of fidelity monitoring that supports program effectiveness.

TRIAL REGISTRATION

WASH Benefits Bangladesh: ClinicalTrials.gov, ID: NCT01590095 . Registered on 30 April 2012.

Unsafe disposal of feces of children <3 years among households with latrine access in rural Bangladesh: Association with household characteristics, fly presence and child diarrhea

BACKGROUND

Young children frequently defecate in the living environment in low-income countries. Unsafe child feces disposal has been associated with risk of diarrhea. Additionally, reported practices can underestimate socially undesirable unhygienic behaviors. This analysis aimed to assess (1) the sensitivity of reported child feces disposal practices as an indicator for observed presence of human feces in the domestic environment, (2) household characteristics associated with reported unsafe feces disposal and (3) whether unsafe feces disposal is associated with fly presence and diarrhea among children <3 years.

METHODS

We recorded caregiver-reported feces disposal practices for children <3 years; unsafe disposal was defined as feces put/rinsed into a drain, ditch, bush or garbage heap or left on the ground and safe disposal as feces put/rinsed into latrine or specific pit or buried. We conducted spot checks for human feces, counted flies in the compound and recorded caregiver-reported child diarrhea prevalence among 803 rural Bangladeshi households. We assessed associations using generalized estimating equations (GEE) and generalized linear models (GLM) with robust standard errors.

RESULTS

Unsafe disposal of child feces was reported by 80% of households. Reported disposal practices had high sensitivity (91%) but low positive predictive value (15%) as an indicator of observed feces in the compound. Unsafe disposal was more common among households that reported daily adult open defecation (PR: 1.13, 1.02-1.24) and had children defecating in a nappy or on the ground versus in a potty (PR: 2.92, 1.98-4.32), and less common in households where adults reported always defecating in latrines (PR: 0.91, 0.84-0.98). The presence of observed human feces was similarly associated with these household characteristics. Reported unsafe feces disposal or observed human feces were not associated with fly detection or child diarrhea.

CONCLUSION

Despite access to on-site sanitation, unsafe child feces disposal was reported by the majority of households. However, this practices was not associated with diarrhea; suggesting that child feces may not be the most important fecal exposure. Before resources are invested to improve child feces management practices, studies should explore whether these contribute meaningfully to risk of enteric disease.

Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh): a cluster-randomised controlled trial

Background

Poor nutrition and hygiene make children vulnerable to delays in growth and development. We aimed to assess the effects of water quality, sanitation, handwashing, and nutritional interventions individually or in combination on the cognitive, motor, and language development of children in rural Bangladesh.

Methods

In this cluster-randomised controlled trial, we enrolled pregnant women in their first or second trimester from rural villages of Gazipur, Kishoreganj, Mymensingh, and Tangail districts of central Bangladesh, with an average of eight women per cluster. Groups of eight geographically adjacent clusters were block-randomised, using a random number generator, into six intervention groups (all of which received weekly visits from a community health promoter for the first 6 months and every 2 weeks for the next 18 months) and a double-sized control group (no intervention or health promoter visit). The six intervention groups were: chlorinated drinking water; improved sanitation; handwashing with soap; combined water, sanitation, and handwashing; improved nutrition through counselling and provision of lipid-based nutrient supplements; and combined water, sanitation, handwashing, and nutrition. Here, we report on the prespecified secondary child development outcomes: gross motor milestone achievement assessed with the WHO module at age 1 year, and communication, gross motor, personal social, and combined scores measured by the Extended Ages and Stages Questionnaire (EASQ) at age 2 years. Masking of participants was not possible. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01590095.

Findings

Between May 31, 2012, and July 7, 2013, 5551 pregnant women residing in 720 clusters were enrolled. Index children of 928 (17%) enrolled women were lost to follow-up in year 1 and an additional 201 (3%) in year 2. 4757 children were assessed at 1 year and 4403 at 2 years. At year 1, compared with the control group, the combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the standing alone milestone (hazard ratio 1·19, 95% CI 1·01–1 ·40), and the nutrition group had a higher rate of attaining the walking alone milestone (1·32, 95% CI 1·07–1·62). The combined water, sanitation, handwashing, and nutrition group had a higher rate of attaining the walking alone milestone than those in the water, sanitation, and handwashing group (1·29, 1·01–1·65). At 2 years, we noted beneficial effects in the combined EASQ score in all intervention groups, with effect sizes smallest in the water treatment group (difference 0·15, 95% CI 0·04 to 0·26 vs control) and largest in the combined water, sanitation, handwashing, and nutrition treatment group (0·37, 0·27–0·46).

Interpretation

Improvements in water quality, handwashing, sanitation, or nutrition supported by intensive interpersonal communication, when delivered either individually or in combination, contributed to improvements in child development. A crucial next step is to establish whether similar effects can be achieved with reduced intensity of promoter contacts that could be supported in large-scale interventions.

Funding

Bill & Melinda Gates Foundation.

Psychiatric Morbidity, Perceived Stress and Ways of Coping Among Parents of Children With Intellectual Disability in Lahore, Pakistan

Background This study assessed anxiety and depression levels among parents of children with intellectual disability (ID) and analyzed their coping strategies. Methods One hundred parents of children with ID were recruited through child psychiatry outpatient services in a tertiary care setting in Lahore, Pakistan. A structured questionnaire including sociodemographic details, the Agha Khan University Anxiety Depression Scale, the Family Stress and Coping Questionnaire, Brief COPE questionnaire, and Support questionnaire were used for data collection. Results The mean age of parents was 35 years, and the majority of parents (86%) in the study were females. Seventy percent of the parents had significant levels of anxiety and depression. Parents mostly used emotion-based coping to deal with their anxiety and depression; self-distraction, behavioral disengagement, and venting were the main coping strategies used. Conclusions The study showed family stressors, various coping strategies, and support sources in depressed parents who are taking care of their intellectually disabled children. Based on these results, effective culturally sensitive intervention programs can be designed to educate parents and help them effectively cope with stress.

Effect of Groundwater Iron on Residual Chlorine in Water Treated with Sodium Dichloroisocyanurate Tablets in Rural Bangladesh

We assessed the ability of sodium dichloroisocyanurate (NaDCC) to provide adequate chlorine residual when used to treat groundwater with variable iron concentration. We randomly selected 654 tube wells from nine subdistricts in central Bangladesh to measure groundwater iron concentration and corresponding residual-free chlorine after treating 10 L of groundwater with a 33-mg-NaDCC tablet. We assessed geographical variations of iron concentration using the Kruskal–Wallis test and examined the relationships between the iron concentrations and chlorine residual by quantile regression. We also assessed whether user-reported iron taste in water and staining of storage vessels can capture the presence of iron greater than 3 mg/L (the World Health Organization threshold). The median iron concentration among measured wells was 0.91 (interquartile range [IQR]: 0.36–2.01) mg/L and free residual chlorine was 1.3 (IQR: 0.6–1.7) mg/L. The groundwater iron content varied even within small geographical regions. The median free residual chlorine decreased by 0.29 mg/L (95% confidence interval: 0.27, 0.33, P < 0.001) for every 1 mg/L increase in iron concentration. Owner-reported iron staining of the storage vessel had a sensitivity of 92%, specificity of 75%, positive predictive value of 41%, and negative predictive value of 98% for detecting > 3 mg/L iron in water. Similar findings were observed for user-reported iron taste in water. Our findings reconfirm that chlorination of groundwater that contains iron may result in low-level or no residual. User reports of no iron taste or no staining of storage containers can be used to identify low-iron tube wells suitable for chlorination. Furthermore, research is needed to develop a color-graded visual scale for iron staining that corresponds to different iron concentrations in water.

Prevalence and Association of Escherichia coli and Diarrheagenic Escherichia coli in Stored Foods for Young Children and Flies Caught in the Same Households in Rural Bangladesh

Consumption of contaminated stored food can cause childhood diarrhea. Flies carry enteropathogens, although their contribution to food contamination remains unclear. We investigated the role of flies in contaminating stored food by collecting food and flies from the same households in rural Bangladesh. We selected 182 households with children ≤ 24 months old that had stored foods for later feeding at room temperature for ≥ 3 hours. We collected food samples and captured flies with fly tapes hung by the kitchen. We used the IDEXX Quanti-Tray System (Colilert-18 media; IDEXX Laboratories, Inc., Westbrook, ME) to enumerate Escherichia coli with the most probable number (MPN) method. Escherichia coli–positive IDEXX wells were analyzed by polymerase chain reaction for pathogenic E. coli genes (eae, ial, bfp, ipaH, st, lt, aat, aaiC, stx₁, and stx₂). Escherichia coli was detected in 61% (111/182) of food samples, with a mean of 1.1 log₁₀ MPN/dry g. Fifteen samples (8%) contained pathogenic E. coli; seven (4%) had enteropathogenic E. coli (EPEC) genes (eae and/or bfp); and 10 (5%) had enteroaggregative E. coli genes (aat and/or aaiC). Of flies captured in 68 (37%) households, E. coli was detected in 41 (60%, mean 2.9 log₁₀ MPN/fly), and one fly (1%) had an EPEC gene (eae). For paired fly-food samples, each log₁₀ MPN E. coli increase in flies was associated with a 0.31 log₁₀ MPN E. coli increase in stored food (95% confidence interval: 0.07, 0.55). In rural Bangladesh, flies possibly a likely route for fecal contamination of stored food. Controlling fly populations may reduce contamination of food stored for young children.

Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial

Background

Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering.

Methods

The WASH Benefits Bangladesh cluster-randomised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up. Pregnant women in geographically adjacent clusters were block-randomised to one of seven clusters: chlorinated drinking water (water); upgraded sanitation (sanitation); promotion of handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate child nutrition plus lipid-based nutrient supplements (nutrition); combined water, sanitation, handwashing, and nutrition; and control (data collection only). Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCC01590095.

Findings

Between May 31, 2012, and July 7, 2013, 5551 pregnant women in 720 clusters were randomly allocated to one of seven groups. 1382 women were assigned to the control group; 698 to water; 696 to sanitation; 688 to handwashing; 702 to water, sanitation, and handwashing; 699 to nutrition; and 686 to water, sanitation, handwashing, and nutrition. 331 (6%) women were lost to follow-up. Data on diarrhoea at year 1 or year 2 (combined) were available for 14 425 children (7331 in year 1, 7094 in year 2) and data on length-for-age Z score in year 2 were available for 4584 children (92% of living children were measured at year 2). All interventions had high adherence. Compared with a prevalence of 5·7% (200 of 3517 child weeks) in the control group, 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation (61 [3·5%] of 1760; prevalence ratio 0·61, 95% CI 0·46–0·81), handwashing (62 [3·5%] of 1795; 0·60, 0·45–0·80), combined water, sanitation, and handwashing (74 [3·9%] of 1902; 0·69, 0·53–0·90), nutrition (62 [3·5%] of 1766; 0·64, 0·49–0·85), and combined water, sanitation, handwashing, and nutrition (66 [3·5%] of 1861; 0·62, 0·47–0·81); diarrhoea prevalence was not significantly lower in children receiving water treatment (90 [4·9%] of 1824; 0·89, 0·70–1·13). Compared with control (mean length-for-age Z score −1·79), children were taller by year 2 in the nutrition group (mean difference 0·25 [95% CI 0·15–0·36]) and in the combined water, sanitation, handwashing, and nutrition group (0·13 [0·02–0·24]). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth.

Interpretation

Nutrient supplementation and counselling modestly improved linear growth, but there was no benefit to the integration of water, sanitation, and handwashing with nutrition. Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment. Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions.

Funding

Bill & Melinda Gates Foundation.