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A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda

Background
To improve management of severely ill hospitalized patients in low-income settings, the World Health Organization (WHO) established a triage tool called “Quick Check” to provide clinicians with a rapid, standardized approach to identify patients with severe illness based on recognition of abnormal vital signs. Despite the availability of these guidelines, recognition of severe illness remains challenged in low-income settings, largely as a result of infrequent vital sign monitoring.

Methods
We conducted a staggered, pre-post quasi-experimental study at four inpatient health facilities in western Uganda to assess the impact of a multi-modal intervention for improving quality of care following formal training on WHO “Quick Check” guidelines for diagnosis of severe illness in low-income settings. Intervention components were developed using the COM-B (“capability,” “opportunity,” and “motivation” determine “behavior”) model and included clinical mentoring by an expert in severe illness care, collaborative improvement meetings with external support supervision, and continuous audits of clinical performance with structured feedback.

Results
There were 5759 patients hospitalized from August 2014 to May 2015: 1633 were admitted before and 4126 during the intervention period. Designed to occur twice monthly, collaborative improvement meetings occurred every 2–4 weeks at each site. Clinical mentoring sessions, designed to occur monthly, occurred every 4–6 months at each site. Audit and feedback reports were implemented weekly as designed. During the intervention period, there were significant increases in the site-adjusted likelihood of initial assessment of temperature, heart rate, blood pressure, respiratory rate, mental status, and pulse oximetry. Patients admitted during the intervention period were significantly more likely to be diagnosed with sepsis (4.3 vs. 0.4%, risk ratio 10.1, 95% CI 3.0–31.0, p < 0.001) and severe respiratory distress (3.9 vs. 0.9%, risk ratio 4.5, 95% CI 1.8–10.9, p = 0.001).

Conclusions
Theory-informed quality improvement programs can improve vital sign collection and diagnosis of severe illness in low-income settings. Further implementation, evaluation, and scale-up of such interventions are needed to enhance hospital-based triage and severe illness management in these settings.

Trial registration
Severe illness management system (SIMS) intervention development,
ISRCTN46976783

Publication type: 
Author: 
Matthew Cummings
Elijah Goldberg
Savio Mwaka
Olive Kabajaasi
Eric Vittinghoff
Adithya Cattamanchi
Achilles Katamba
Nathan Kenya-Mugisha
Shevin T. Jacob
Lucian J. Davis
Subjects: 
World health
Diagnosis
Health facilities
Medical care
World Health Organization
Title string: 
A complex intervention to improve implementation of World Health Organization guidelines for diagnosis of severe illness in low-income settings: a quasi-experimental study from Uganda
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:05qfttdz0p

Session III: Issues Concerning Enforcement and Dispute Resolution (Steven Tepp)

Undergirding really all the discussion that we’ve been having today is a fundamental truth that hasn’t actually been articulated. I wanted to just give that voice as I begin my remarks, and that is: foreign piracy of copyrighted works is widespread, pervasive, and persistent. It’s been going on for decades. You can go back and read the Special 301 reports that Probir and his predecessors, including Stan, have overseen and published, going back to the 1980s. And there is massive theft. The mode and methodology has changed over the years, but there’s a real problem out there. For a period of time, we were able to address that through norm setting, the WIPO, but the problem there is there was no real enforcement mechanism. It has this International Court of Justice adjudication, but there were really no teeth to that. So it was really left to a matter of bilateral political pressure, and even the trade sanctions. And back in that age, that era, the United States did impose trade sanctions on occasion, bilaterally, unilaterally. With the adoption of the TRIPS agreement as part of the WTO, we have both a more modern and extensive set of standards, including enforcement standards, which generally didn’t exist in WIPO documents. And we have a dispute resolution process that allowed a neutral third party adjudication of disputes, which were beneficial. Unfortunately, as was pointed out earlier, the TRIPS standards are now about a quarter century old. And as we’re undergoing continual innovation and development in marketplace practices, as well as piracy practices, it’s a fundamental necessity of global standards to keep pace. The reality is that the member states at WTO, and WIPO these days, are not willing to do that. Indeed, even a discussion of existing enforcement standards in a non-norm setting granulite TRIPS council is met with howls of protest.5 So it should be no surprise that countries whose industries are highly valued—like the United States—have sought other means to introduce modern norms.6 And that’s what we see. Thus, you have more regional and bilateral agreements. We can debate whether that’s good, bad or indifferent. But that’s why it’s happened.

Topic: 
Publication type: 
Author: 
Steven Tepp
Subjects: 
Law enforcement--International cooperation
Copyright
International
Dispute resolution (Law)
Law
Title string: 
Session III: Issues Concerning Enforcement and Dispute Resolution (Steven Tepp)
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:bvq83bk3kk

Session II: Rigidity in Global Intellectual Property Norms

These remarks are a transcript of a talk that was given on October 14, 2016, at the Kernochan Center Annual Symposium at Columbia Law School.

Session II addressed how international copyright treaties and FTAs affect national IP laws in the U.S. and elsewhere.

Session Panelists:

Krista Cox, Director of Public Policy Initiatives, Association of Research Libraries (ARL)

Ysolde Gendreau, Professor, Université de Montréal

Eric J. Schwartz, Partner, Mitchell, Silberberg & Knupp LLP and Counsel to the International Intellectual Property Alliance

Karyn Temple Claggett, Associate Register of Copyrights and Director of Policy & International Affairs, U.S. Copyright Office

Topic: 
Publication type: 
Author: 
Krista L. Cox
Subjects: 
Free trade
Copyright
International
Intellectual property (International law)
Treaties
Title string: 
Session II: Rigidity in Global Intellectual Property Norms
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:4xgxd25485

The rise and fall of income inequality in Chile

This paper presents evidence on a rise and fall in income inequality in Chile during the past two decades. We show that income inequality rises from 1990 to 2000 and then falls from 2000 to 2011. We perform simple but informative decompositions to figure out the contributing factors behind that dissimilarity in the behavior of inequality across those two subperiods. Our results are consistent with a story in which economic growth increases the demand for more educated workers, initially increasing inequality. However, those higher returns to education encourage agents to invest in higher education, producing a subsequent human capital deepening that reduces inequality at later stages of the development process.

Topic: 
Publication type: 
Author: 
Francisco Parro
Loreto Reyes
Subjects: 
Income distribution
Labor economics
Labor market
Title string: 
The rise and fall of income inequality in Chile
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:dbrv15dv5b

Towards a Healthier 2020: Advancing Mental Health as a Global Health Priority

Mental and behavioral disorders account for approximately 7.4 percent of the global burden of disease and represent the leading cause of disability worldwide. Intricately connected to educational achievement, overall health outcomes, and economic prosperity, mental and behavioral disorders have nonetheless largely been disregarded within the global health agenda. Recent efforts that more fully quantify the burden of mental and behavioral disorders, coupled with accumulating data of evidence-based approaches that successfully treat these disorders, even in low resource communities, serve as a cornerstone for envisioning a new era that prioritizes and integrates mental health in global health and development. A healthier 2020 depends on global collaboration, improved classification systems, expanded research networks that inform policy and practice globally, and innovative strategies to build capacity in terms of workforce and health care delivery systems. This work will require vigilance to combat ongoing stigma and vision to anticipate global demographic trends of an increasingly urban and ageing population. Such efforts have the potential to transform the lives of hundreds of millions of people around the globe.

Topic: 
Publication type: 
Author: 
Kathleen M. Pike
Ezra S. Susser
Sandro Galea
Harold A. Pincus
Subjects: 
Public health
Mental health
World health
Mental health policy
International cooperation
Epidemiology
Title string: 
Towards a Healthier 2020: Advancing Mental Health as a Global Health Priority
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:qnk98sf7p1

Modification of the association between recreational physical activity and survival after breast cancer by promoter methylation in breast cancer-related genes

Background:
Mechanisms underlying the inverse association between physical activity and survival after breast cancer are unresolved, but DNA methylation may play a role. We hypothesized that promoter methylation of breast cancer-related genes, as well as global methylation, may modify the association between prediagnostic recreational physical activity (RPA) and breast cancer mortality.

Methods:
Using a population-based sample of 1254 women diagnosed with first primary breast cancer, we examined modification of the RPA-mortality association by gene-specific promoter methylation and global methylation. Average lifetime RPA was assessed from menarche to diagnosis through structured in-home interviews. Promoter methylation of 13 breast cancer-related genes was evaluated in archived tumor by methylation-specific polymerase chain reaction and MethyLight assay. Global methylation in white blood cell DNA was determined at long interspersed nucleotide element 1 and by the luminometric methylation assay. After approximately 15 years of follow-up, 486 patients had died, and 186 of the deaths were breast cancer-related. We used Cox proportional hazards regression to estimate HRs and 95% CIs as well as likelihood ratio tests to assess multiplicative interactions.

Results:
All-cause mortality was lower only among physically active women with methylated promoter of APC (HR 0.60, 95% CI 0.40–0.80), CCND2 (HR 0.56, 95% CI 0.32–0.99), HIN (HR 0.55, 95% CI 0.38–0.80), and TWIST1 (HR 0.28, 95% CI 0.14–0.56) in tumors, but not among those with unmethylated tumors (significant interaction p < 0.05). We found no interaction between RPA and global methylation.

Conclusions:
The improved survival after breast cancer that is associated with RPA may be more pronounced in women with promoter tumor methylation in biologically plausible genes.

Topic: 
UNI: 
Publication type: 
Author: 
Lauren E. McCullough
Jia Chen
Yoon H. Cho
Nikhil K. Khankari
Patrick T. Bradshaw
Alexandra J. White
Susan L. Teitelbaum
Mary Beth Terry
Alfred I. Neugut
Hanina Hibshoosh
Regina M. Santella
Marilie D. Gammon
Subjects: 
Methylation
Epigenetics
Breast--Cancer--Patients
Exercise
Oncology
Title string: 
Modification of the association between recreational physical activity and survival after breast cancer by promoter methylation in breast cancer-related genes
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:p5hqbzkh39

Association between genome-wide copy number variation and arsenic-induced skin lesions: a prospective study

Background:
Exposure to arsenic in drinking water is a global health problem and arsenic-induced skin lesions are hallmark of chronic arsenic toxicity. We and others have reported germline genetic variations as risk factors for such skin lesions. The role of copy number variation (CNV) in the germline DNA in this regard is unknown.

Methods:
From a large prospectively followed-up cohort, exposed to arsenic, we randomly selected 2171 subjects without arsenic-induced skin lesions at enrollment and genotyped their whole blood DNA samples on Illumina Cyto12v2.1 SNP chips to generate DNA copy number. Participants were followed up every 2 years for a total of 8 years, especially for the development of skin lesions. In Cox regression models, each CNV segment was used as a predictor, accounting for other potential covariates, for incidence of skin lesions.

Result:
The presence of genomic deletion(s) in a number of genes (OR5J2, GOLGA6L7P, APBA2, GALNTL5, VN1R31P, PHKG1P2, SGCZ, ZNF658) and lincRNA genes (RP11-76I14.1, CTC-535 M15.2, RP11-73B2.2) were associated with higher risk [HR between 1.67 (CI 1.3-2.1) and 2.15 (CI 1.5-2.9) for different CNVs] for development of skin lesions independent of gender, age, and arsenic exposure. Some deletions had stronger effect in a specific gender (ZNF658 in males, SGCZ in females) and some had stronger effect in higher arsenic exposure (lincRNA CTD-3179P9.1) suggesting a possible gene-environment interaction.

Conclusion:
This first genome-wide CNV study in a prospectively followed-up large cohort, exposed to arsenic, suggests that DNA deletion in several genes and lincRNA genes may predispose an individual to a higher risk of development of arsenic-induced skin lesions.

Topic: 
UNI: 
Publication type: 
Author: 
Muhammad G. Kibriya
Farzana Jasmine
Faruque Parvez
Maria Argos
Shantanu Roy
Rachelle Paul-Brutus
Tariqul Islam
Alauddin Ahmed
Muhammad Rakibuz-Zaman
Justin Shinkle
Vesna N. Slavkovich
Joseph Graziano
Habibul Ahsan
Subjects: 
Human genome--Research
Environmental health
Arsenic--Toxicology
Genotype-environment interaction
Title string: 
Association between genome-wide copy number variation and arsenic-induced skin lesions: a prospective study
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:fttdz08krc

Pregnant and breastfeeding women: A priority population for HIV viral load monitoring

With more than 18 million HIV-infected individuals having initiated antiretroviral therapy (ART) in low- and middle-income countries (LMICs) by the end of 2016, ensuring effective HIV care and treatment services is a global public health priority [1]. Viral load (VL) quantification provides a direct measure of the effectiveness of ART, with a consistently elevated VL suggesting poor adherence or treatment failure and the need for intervention. In turn, HIV VL monitoring is now recognised as a key component of ART services in LMICs in World Health Organization (WHO) guidelines, with an emphasis on scaling up access to VL testing for ART programmes [2].

Pregnant and postpartum women are an important population within ART programmes. In many countries, the majority of identified HIV-infected adults are women, and many women of reproductive age are diagnosed with HIV infection during pregnancy through prevention of mother-to-child transmission of HIV (PMTCT) services in antenatal care (ANC) [3]. With universal eligibility for ART for all HIV-infected pregnant and postpartum women (based on the WHO’s 2013 ‘Option B+’ policy [4]), many women of reproductive age initiating ART do so during pregnancy. PMTCT services extend through early infant diagnosis around 6–10 weeks postpartum until the cessation of breastfeeding and documentation of the infant’s final HIV testing status, which may extend well beyond 1 year postpartum based on the recently updated infant feeding recommendations [5]. With ongoing risk of HIV transmission throughout breastfeeding, maintaining ART adherence and viral suppression is especially crucial during this period.

Although the importance of routine VL monitoring for HIV-infected individuals on ART is widely recognised [6], there has been minimal attention to VL monitoring in pregnancy and the postpartum period. Here we discuss key considerations for VL monitoring in pregnant and breastfeeding women in the context of expanding access to VL monitoring (summarised in Box 1).

Topic: 
UNI: 
Publication type: 
Author: 
Landon Myer
Shaffiq Essajee
Laura N. Broyles
D. Heather Watts
Maia Lesosky
Wafaa Mahmoud El-Sadr
Elaine J. Abrams
Subjects: 
HIV infections
Pregnancy
Breastfeeding
Medicine
Antiretroviral agents
Title string: 
Pregnant and breastfeeding women: A priority population for HIV viral load monitoring
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:hdr7sqv9tv

Inhibition of NF-κB improves the stress resistance and myogenic differentiation of MDSPCs isolated from naturally aged mice

A decline in the regenerative capacity of adult stem cells with aging is well documented. As a result of this decline, the efficacy of autologous stem cell therapies is likely to decline with increasing donor age. In these cases, strategies to restore the function of aged stem cells would have clinical utility. Globally, the transcription factor NF-κB is up-regulated in aged tissues. Given the negative role that NF-κB plays in myogenesis, we investigated whether the age-related decline in the function of muscle-derived stem/progenitor cells (MDSPCs) could be improved by inhibition of NF-κB. Herein, we demonstrate that pharmacologic or genetic inhibition of NF-κB activation increases myogenic differentiation and improves resistance to oxidative stress. Our results suggest that MDSPC “aging” may be reversible, and that pharmacologic targeting of pathways such as NF-κB may enhance the efficacy of cell-based therapies.

Publication type: 
Author: 
Jonathan D. Proto
Aiping Lu
Akaitz Dorronsoro
Alex Scibetta
Paul Robbins
Laura J. Niedernhofer
Johnny Huard
Subjects: 
Stem cells
Transcription factors
Medicine
Aging
Biology
Title string: 
Inhibition of NF-κB improves the stress resistance and myogenic differentiation of MDSPCs isolated from naturally aged mice
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:j0zpc866vr

Parenting and Adjustment in Schizophrenia

Objective: Patients with schizophrenia who became parents and those who remained childless were compared on premorbid characteristics and current clinical and social adjustment.

Methods: Subjects were 400 men and women with a DSM-III-R diagnosis of chronic schizophrenia based on the Structured Clinical Interview for DSM-III-R (SCID). Assessments
measured concurrent substance abuse and antisocial behavior, positive and negative symptoms using the Positive and Negative Syndrome Scale, functional status using the Global Assessment of Functioning scale, family support, and treatment compliance. A total of 158 patients were parents (47 men and 111 women), and 242 were childless (153 men and 89 women).

Results: Compared with childless subjects, parents were more likely to have had better premorbid social adjustment, to have ever been married or involved in a conjugal relationship, and to have become ill at a later age. More than two-thirds of parents entered parenthood before the onset of schizophrenia. More women than men were parents, and parents were more likely to be members of ethnic minority groups. No differences were found in current clinical and social adjustment of parents and childless subjects.

Conclusions: Parenthood was associated with better premorbid social adjustment, but it conferred no advantage in the long-term course of schizophrenia. Patients who experience a later onset of schizophrenia or have better premorbid social skills may be more likely to undertake marriage and parenthood, but they will then also be more likely to need special support for the parenting role once the illness begins and takes its typical course.

Topic: 
UNI: 
Publication type: 
Author: 
Carol L. M. Caton
Francine Cournos
Boanerges Dominguez
Subjects: 
Children of schizophrenics
Mentally ill parents
Psychiatry
Social adjustment
Title string: 
Parenting and Adjustment in Schizophrenia
GUID update: 
https://academiccommons.columbia.edu/catalog/ac:stqjq2bvsh

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