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The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal.
To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP.
A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers.
The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors.
Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.
Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings.
To describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME).
ToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13–22) stakeholders per workshop; and (c) review and refinement of the cross-country ToC by 18 PRIME consortium members.
One cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts.
ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation.
The prevalence of depression in rural Ugandan communities is high and yet detection and treatment of depression in the primary care setting is suboptimal. Short valid depression screening measures may improve detection of depression. We describe the validation of the Luganda translated nine- and two-item Patient Health Questionnaires (PHQ-9 and PHQ-2) as screening tools for depression in two rural primary care facilities in Eastern Uganda.
A total of 1407 adult respondents were screened consecutively using the nine-item Luganda PHQ. Of these 212 were randomly selected to respond to the Mini International Neuropsychiatric Interview diagnostic questionnaire. Descriptive statistics for respondents’ demographic characteristics and PHQ scores were generated. The sensitivity, specificity and positive predictive values (PPVs), and area under the ROC curve were determined for both the PHQ-9 and PHQ-2.
The optimum trade-off between sensitivity and PPV was at a cut-off of ≧5. The weighted area under the receiver Operating Characteristic curve was 0.74 (95% CI 0.60–0.89) and 0.68 (95% CI 0.54–0.82) for PHQ-9 and PHQ-2, respectively.
The Luganda translation of the PHQ-9 was found to be modestly useful in detecting depression. The PHQ-9 performed only slightly better than the PHQ-2 in this rural Ugandan Primary care setting. Future research could improve on diagnostic accuracy by considering the idioms of distress among Luganda speakers, and revising the PHQ-9 accordingly. The usefulness of the PHQ-2 in this rural population should be viewed with caution.
Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings.
To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda.
Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change.
The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation.
To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings.
We introduce, in spherical geometry, experiments on electro-hydrodynamic driven Rayleigh–Bénard convection that have been performed for both temperature-independent (‘GeoFlow I’) and temperature-dependent fluid viscosity properties (‘GeoFlow II’) with a measured viscosity contrast up to 1.5. To set up a self-gravitating force field, we use a high-voltage potential between the inner and outer boundaries and a dielectric insulating liquid; the experiments were performed under microgravity conditions on the International Space Station. We further run numerical simulations in three-dimensional spherical geometry to reproduce the results obtained in the ‘GeoFlow’ experiments. We use Wollaston prism shearing interferometry for flow visualization – an optical method producing fringe pattern images. The flow patterns differ between our two experiments. In ‘GeoFlow I’, we see a sheet-like thermal flow. In this case convection patterns have been successfully reproduced by three-dimensional numerical simulations using two different and independently developed codes. In contrast, in ‘GeoFlow II’, we obtain plume-like structures. Interestingly, numerical simulations do not yield this type of solution for the low viscosity contrast realized in the experiment. However, using a viscosity contrast of two orders of magnitude or higher, we can reproduce the patterns obtained in the ‘GeoFlow II’ experiment, from which we conclude that nonlinear effects shift the effective viscosity ratio.
Recent information on epidemiology and management of herpes zoster (HZ) and post-herpetic neuralgia (PHN), a painful complication of HZ, is scarce. The objective of this study was to document the burden of HZ and PHN in the United Kingdom. This retrospective analysis of the UK General Practice Research Database aimed to estimate HZ incidence and proportion of HZ patients developing PHN and to assess management costs in immunocompetent individuals aged ⩾50 years. A cohort of 27 225 HZ patients was selected, corresponding to an incidence of 5·23/1000 person-years. Respectively 19·5% and 13·7% of patients developed PHN at least 1 and 3 months after HZ diagnosis. Mean direct cost was £103 per HZ patient and £341 and £397 per PHN episode (1- and 3-month definition respectively). Both HZ and PHN costs increased markedly with pain severity. This study confirms that HZ and PHN are frequent and costly diseases in the United Kingdom.
The immediate postweaning period in pigs is often characterised by a reduced and variable food intake, digestive disorders and poor growth and development. Historically such effects were reduced by the use of in-feed antibiotic growth promoters (AGPs), copper sulphate and zinc oxide to enhance the efficiency of feed conversion and hence maximise nutrient capture. However from January 2006 the routine use of in-feed AGPs was banned and, due to concern over environmental pollution, levels of inclusion of heavy metals are limited by regulation and likely to be further reduced in the future. Weaning pigs at a later age has been suggested as an approach to reduce the potentially negative effects of the AGP ban on the national herd. The objective of the AGEWEAN programme of research was to investigate the effects of weaning age (4, 6 and 8 weeks) in both an indoor and outdoor lactation environment on the biological and economic efficiency of production where diets contain no AGPs and lower levels of copper (<25ppm added) and zinc (<100ppm added).
We investigated the comparative seroepidemiology of varicella zoster virus (VZV) in pregnant women of two ethnic groups, white British and Bangladeshi, living in an inner city area of London, United Kingdom. Women aged 16–45 years were recruited from antenatal clinics of the Royal London Hospital in the Borough of Tower Hamlets. Complete data were obtained from 275 white British and 765 Bangladeshi women. VZV antibody prevalence was 93·1% (95% CI 89·4–95·8) and 86·0% (95% CI 83·3–88·4) respectively. Women who were born in Bangladesh and lived there at least until the age of 15 years had the lowest odds of being immune (OR 0·37, 95% CI 0·22–0·63). This implies they will have an increased risk of varicella during pregnancy. Women arriving in the United Kingdom in adulthood should be screened routinely during pregnancy and vaccination offered postpartum if they are susceptible.
The relationship between stockperson behaviour, measured as verbal and physical interactions with the dairy cows (no.=210), during milking and the subsequent milk yield obtained was examined. The numbers of steps and kicks made by the cows during milking was recorded. The behaviour of two stockteams, each consisting of two stockmen, were recorded over 10 weekend sessions. The two teams varied in the types of interactions and when the stockteam that performed more positive interactions worked with the cows (team A), the cows had a significantly higher milk yield (P<0·05) although this difference was small (17·54 v. 17·44 kg). When team A was milking the cows also stepped and kicked on the platform significantly more (P<0·05) compared with team B. The results also indicated that while each stockteam tended to interact with the same cows each session, different stockpersons interacted with different cows. These findings highlight the importance of the rôle of the stockperson in milk output and dairy cow behaviour in a commercial setting.
The immediate postweaning period in pigs is often characterised by a reduced and variable food intake and poor growth and development, reducing lifetime performance. At present the effects of the postweaning growth check are reduced by the use of antibiotic growth promoters (AGPs), copper sulphate and zinc oxide to enhance the efficiency of feed conversion and hence maximise nutrient capture. However from January 2006 the routine use of in feed AGPs is to be banned and, due to concern over environmental pollution, levels of inclusion of heavy metals are likely to be further reduced. Weaning pigs from the sow at an older age, when their digestive systems are more mature, has been suggested as an approach to reduce the potential negative effect of the AGP ban on the national herd. The objective of the AGEWEAN programme of research is to investigate the effects of weaning age (4, 6 and 8 weeks) in both an indoor and outdoor lactation environment on biological and economic efficiency of a production system where diets contain no AGPs and lower levels of copper (<25ppm added) and zinc (<100ppm added).
Hans Jacob Christoffel von Grimmelshausen (ca. 1621-1676) is the most significant (and still readable) author of seventeenth-century German novels. His Abenteuerlicher Simplicius Simplicissimusremains the one German novel of its time that has attained the stature of "world literature": its unique mix of violent action and solitary reflection, its superlative humor, its realistic portrayalof a peasant turned soldier turned hermit has made it the longest-running bestseller in German literature. Read by students and scholars in comparative literature, history, and German, and by those interested in the development of the picaresque novel in Europe, the work and its "Continuations" have increasingly occupied scholars around the world, who have in recent years shown it to be a work ofsubtle structure and characterization, bearing the imprint of the most advanced political thinking of the time, and showing the influences of some of the most significant works of world literature, including Cervantes' Don Quixote and Barclay's Argenis. This volume of essays by leading Grimmelshausen scholars from Germany, the United States, and England provides analyses of significant topics in his life and works, including questions of genre, structure, satire, allegory, narratology, political thought, religion, morality, humor, realism, and mortality. Contributors: Christoph E. Schweitzer, Italo Michele Battafarano, Klaus Haberkamm, Rosmarie Zeller, Andreas Solbach, Dieter Breuer, Lynne Tatlock, Peter Hess, Shannon Keenan Greene, and Alan Menhennet.
KarlF. Otto is Professor of German at the University of Pennsylvania and has written extensively on German Baroque literature.