Health Advisory Services Research Articles

Prescribing Nirmatrelvir/Ritonavir for COVID-19 in Advanced CKD.

Prescribing Nirmatrelvir/Ritonavir for COVID-19 in Advanced CKD.

SPATIAL DECISION SUPPORT SYSTEM FOR LIVELIHOOD PROGRAMMES IN NORTHERN NIGERIA

The paper examines the relevance of geospatial maps and technics in execution of livelihood support projects among rural poor. Previous attempts towards driving the poor along prosperity pathways in Nigeria have failed because of incorrect deployment of interventions in time and space. Global positioning systems and Geographical information systems were employed in this study to provide insight to the challenges faced by previous livelihood support projects in the country while also providing a robust spatial decision support system for geographical targeting of interventions to vulnerable households. The study selected 1,459 households from the 42,000 households adopted for the Feed the Future Project in 3 northern States namely; Sokoto, Kebbi States and the Federal Capital Territory. Acquired survey data were converted into GIS maps so as to expose hidden trends in the characteristics of target population and to suggest the best options for interventions. The data were subjected to spatial analysis such as simple distance analysis. The outcomes revealed 86% of sampled households to be largely below the poverty line. This is mainly due to poor access to facilities like health care, markets, good roads, agricultural inputs, agricultural information and advisory services. 10 % of children’s absolute score of Mid Upper Arm Circumference (MUAC) revealed acute malnutrition. 42 % of the household however now have stronger safety nets as a result of the interventions. The study found Spatial Information technology highly useful in social intervention project as the one by the Feed the Future project

Landscape of Spinal Muscular Atrophy Newborn Screening in the United States: 2018-2021.

Newborn screening (NBS) programs identify newborns at increased risk for genetic disorders, linking these newborns to timely intervention and potentially life-saving treatment. In the United States, the Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) recommends the disorders for state NBS programs to screen. ACHDNC updated the Recommended Uniform Screening Panel to include Spinal Muscular Atrophy (SMA) in July 2018. As of June 2021, 34 state NBS programs had fully implemented SMA newborn screening, and at least 8 programs were pursuing implementation. This article will review current SMA screening processes, considerations, challenges, and status.

Gender-differentiated impacts of plant clinics on maize productivity and food security: Evidence from Zambia

The United Nation’s declaration of 2020 as the International Year of Plant Health underscores the crucial role of crop protection in achieving the sustainable development goals. In this article, we analyse the gendered impacts of plant clinics—an innovative extension approach that aims to help smallholder farmers to lose less of their crops to pests through the provision of plant health diagnostic and advisory services. In particular, we investigate whether male and female farmers accrue similar benefits, in terms of technology adoption, maize productivity and food security, from participating in plant clinics. We use gender-disaggregated plot-level data from maize producers in Zambia. Applying doubly robust estimators, we find that participation in plant clinics stimulates the adoption of multiple pest management strategies, which boost maize yield and income by 14% and 27% respectively, and ultimately help to stave off food insecurity. A disaggregated analysis shows that both male and female farmers achieve positive outcomes from using plant clinic services, but the effects are disproportionately greater for male farmers. We also observe heterogeneous impacts for female household heads and female spouses, reflecting differences in decision-making power within the household. The findings suggest that plant clinics can play a significant role in helping male and female farmers address crop health problems and reduce transitory food insecurity, but female participants (particularly female spouses) will need additional support if the goal is to bridge the gender gap in agricultural productivity.

Study of health information needs among adolescents in Croatia shows distinct gender differences in information seeking behaviour.

Understanding the health information needs of adolescents is the first step towards providing them with relevant information to aid them in their decision making regarding health issues. The goal of this study is to assess adolescents' needs, perceptions and sources of health information. Four hundred sixty-nine high school students in Osijek, Croatia, participated in this study by answering a questionnaire. The collected data were analysed using basic frequency and non-parametric statistical methods. The most popular health topics identified by adolescents in our study were nutrition, diseases, depression, relationships, sexual intercourse and alcohol. Adolescents consider their parents the most reliable personal source of health information (72.0%), while they perceive the Internet as the main non-personal source of health information (29.8%). Adolescents wish to get more education about health issues at school (54.4%). Significant gender differences were found in adolescents' needs, perceptions and sources of health information. It is important to provide adolescents with systematic institutional health education and improve health advisory services and library/information services to assist adolescents in locating health information and resolving their health related questions.

Can plant clinics enhance judicious use of pesticides? Evidence from Rwanda and Zambia

Recent outbreaks of crop pests such as fall armyworm and desert locusts are threatening food security and have spurred increased use of pesticides in sub-Saharan Africa. While pesticides can prevent crop losses, they can also have adverse effects on human health and the environment, if not used judiciously. In this article, we examine whether plant clinics―an innovative extension approach of providing plant health diagnostic and advisory services to smallholder farmers―can enhance judicious use of pesticides, measured by intensity of pesticide use, adoption of alternative and more environmentally friendly pest management practices, safe pesticide use practices, and incidence of pesticide-related illness. We use data from a sample of 1474 farm households in Rwanda and Zambia. Propensity score matching estimates suggest that although plant clinic participants exhibit a higher probability of opting for pesticides for pest control, they do not use pesticides intensively and are more likely to adopt alternatives to chemical pest control. On the other hand, plant clinic users and non-users are equally likely to use restricted pesticides and inappropriate methods of disposing of pesticide wastes, which can lead to pesticide poisoning. Overall, our results imply that the plant clinic extension approach can promote sustainable pest management in smallholder agriculture, but additional training of plant clinic staff and clients on pesticide safety would be necessary.

Big-ECG: Cardiographic Predictive Cyber-Physical System for Stroke Management

Electrocardiogram (ECG) is sensitive to autonomic dysfunction and cardiac complications derived from ischemic or hemorrhage stroke and is supposed to be a potential prognostic tool in stroke identification and post-stroke treatment. ECG data generated cannot be real-time accumulated, processed, and used for enterprise-level healthcare and wellness services with the existing cardiovascular monitoring system used in hospitals. This study aims to assess the feasibility of a cyber-physical cardiac monitoring system to classify stroke patients with altered cardiac activity and healthy adults. Here, we propose Big-ECG, a cyber-physical cardiac monitoring system for stroke management, consisting of a wearable ECG sensor, data storage and data analysis in a big data platform, and health advisory services using data analytics and medical ontology. We investigated our proposed ECG-based patient monitoring system with 45 stroke patients (average age 70.8 years old, 68% men) admitted to the rehabilitation center of the hospital and 40 healthy elderly volunteers (average age 75.4 years old, 38% men). We recorded ECG at resting state using a single-channel ECG patch within three months of diagnosis of ischemic stroke (clinically confirmed). In statistical results, ECG fiducial features, RR-I, QRS, QT, ST, and heart rate variability (HRV) features, SDSD, LF/HF, LF/(LF + HF), and HF/(LF + HF) are observed as significantly distinctive biomarkers for the stroke group relative to the healthy control group. The Random Trees model presented the best classification performance (overall accuracy: 95.6%) utilizing ECG fiducial variables. This system may assist healthcare enterprises in prognosis and rehabilitation management during post-stroke treatment.

Impact of Krishi Vigyan Kendra on transferring knowledge to tribal farmers on improved animal husbandry practices

A study was conducted on the impact of KVK interventions on transferring knowledge to tribal farmers on improved animal husbandry practices in Panchmahal district of central Gujarat, to creating awareness regarding the efficient technologies through various efficient extension tools under the banner of ICAR- KVK, Panchmahal. A random sampling technique was applied to draw the samples of 120 farmers from eight villages of Kalol and Jambughoda Tehsil of Panchmahal district. Accordingly, strategies of technological intervention were made regularly during the period of study. In adopted villages, KVK, Panchmahal organized several activities like animal health camps, training programs, advisory services, and FLDs on different aspects of animal husbandry. The results of the study revealed that the means knowledge index and mean adoption index were recorded 39.24 and 93.81 and 77.24 and 25.43 percent, respectively for pre and after interventions. The impact of KVK interventions was found to be 53.19 percent over the existing knowledge and adoption by the trained farmers which were found to be substantial over the non-benefited tribal farmers on various aspects of animal husbandry after the intervention of Krishi Vigyan Kendra, Panchmahal. Based on the study it may be concluded that the overall improvement in the knowledge of the tribal farmers with respect to the adoption of animal husbandry technologies would be possible through the demonstration of efficient technologies needed for healthy livestock rearing which had not only created awareness but also improved the knowledge and attitude of tribal farmers in relation to scientific animal husbandry practices.

Elevated International Normalized Ratio (INR) Did Not Prevent Against Thrombosis in Patients with Chronic Liver Disease (CLD): A Population Based Study

Background: Elevated INR values are common among patients with chronic liver disease (CLD), and signify a decrease in the synthesis of clotting factors II, V, VII, IX and X. Preclinical evidence suggests that the decrease in these factors is balanced by a decrease in anticoagulant factors (e.g. antithrombin, protein C) and an increase in factor VIII {Tripodi 2009, Tipodi 2010}, establishing a rebalanced hemostasis in CLD {Tripodi 2011}. The proposed rebalanced hemostasis has been observed in vitro by rate of thrombin generation being similar to that of individuals with normal hepatic function {Tripodi 2005, Tripodi 2006}. There is however, a lack of in vivo data supporting rebalanced hemostasis in CLD patients. Whether an elevated INR protects against thrombosis among these patients is therefore controversial. We studied the INR-specific rate of non-portal venous thromboembolism (VTE) in a large cohort of United States Veterans with CLD. Methods: Study Population: We identified patients diagnosed with CLD in the Veterans Health Administration database between January 2001 and December 2016 using International Classification of Diseases (ICD) 9/10 codes. To improve the positive predictive value of CLD diagnosis, we followed a previously validated algorithm where patients were required to have an additional ICD9/10 code for one of the common clinical presentations of CLD (e.g., esophageal varices). We identified a control cohort of patients with atrial fibrillation using ICD9/10 codes that had a prescription for warfarin for at least 30 days. Patients with artificial valves, history of VTE within 5 years prior to diagnosis and malignancy were excluded from both cohorts. Patients on warfarin were excluded from the CLD cohort, and those on other anticoagulants were excluded from the control cohort unless anticoagulation was started after a thrombotic event. Patients were followed retrospectively until December 2016. Measurement of Outcomes: Non-portal VTE was identified using ICD9/10 codes plus the presence of a current procedural terminology code for relevant diagnostic imaging (e.g. Doppler ultrasound or computerized tomography scan). Statistical Analysis: To account for the competing risk of non-VTE related death, we analyzed the association between INR and non-portal VTE in a competing risk analysis by the methods of Fine and Gray. For atrial fibrillation patients with newly prescribed warfarin, time 0 started 15-days after their 1st warfarin prescription. For patients with CLD, time 0 was the time of first INR measurement, at least 15 days after CLD diagnosis. We used the natural logarithm of INR as a time-dependent continuous variable in the analysis, and adjusted for the following confounders: age, gender, race, body mass index (BMI), concomitant antiplatelet therapy, surgery, fracture, trauma, presence of central venous line, estimated glomerular filtration rate (GFR), and Charlson comorbidity index (excluding liver disease and chronic kidney disease). The primary test of our hypothesis (that INR values had a different risk among patients with CLD than warfarin users) was an interaction term between CLD (Yes/No) and INR. Results: A total of 15,930 patients with CLD, and 81,415 atrial fibrillation patients on warfarin were included in the study. During the 12-month follow-up, 164 CLD patients and 1,347 warfarin users developed VTE. African American race, low serum albumin, low eGFR, central-line placement, surgery, fracture and trauma increased the risk of VTE. The interaction between INR and CLD was significant (p < 0.01) i.e., the effect of INR values on the incidence of VTE differed between CLD patients and warfarin users. Each unit-increase in INR decreased the risk of VTE in warfarin users by 33% [adjusted hazards ratio (aHR)= 0.67 , 95% Confidence Interval (CI)=0.56 to 0.80]); it however, did not affect the risk of VTE in CLD patients (aHR=1.45, 95% CI=0.82 to 2.59) Conclusion: In this study of 97,345 Veterans, elevated INR values did not decrease the risk of VTE in CLD patients. Thus, healthcare providers should not rely solely on INR values to inform decisions regarding primary and secondary thromboprophylaxis in this patient population. Disclosures Sanfilippo: Bayer HealthCare Pharamceuticals: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Other: Travel Support for Investigator Meeting; Pfizer: Membership on an entity's Board of Directors or advisory committees; Covington & Burling LLP: Consultancy; Luther & Associates: Consultancy; Health Services Advisory Group: Consultancy; Amgen: Other: Trasfer of Value (food) during discussion of research.

D-Dimer Improves Risk Prediction of Venous Thromboembolism in Patients with Multiple Myeloma

Introduction: Venous thromboembolism (VTE) is a common cause of morbidity and mortality among patients with multiple myeloma (MM). Thromboprophylaxis is a safe and effective way to decrease VTE in other high-risk populations. Recently, a clinical prediction model was developed to identify patients with newly diagnosed MM starting chemotherapy at highest risk of VTE. The model, IMPEDE VTE, found the following clinical risk factors for VTE: immunomodulatory drugs, body mass index, recent pathologic fracture of the femur or hip, erythropoietin stimulating drugs, dexamethasone, doxorubicin, Asian ethnicity/race, history of VTE, tunneled line or central venous catheter, and existing use of aspirin or anticoagulation. External validation of the model has yielded a c-statistic for VTE risk prediction of 0.64 to 0.65. Laboratory parameters can predict VTE in some patients with cancer. Accordingly so, the addition of laboratory parameters to IMPEDE VTE has the ability to improve model performance. Thus, we sought to determine the association between soluble P-selectin and D-dimer with the development of VTE in patients with newly diagnosed MM starting chemotherapy. Methods: We identified 545 patients from the Washington University in St. Louis MM banking protocol, with available plasma from time of diagnosis (2007-2019). Thirty-eight cases of VTE were identified within 6 months following treatment initiation. An additional 137 patients were randomly selected as controls. D-dimer and soluble P-selectin ELISA assays were performed on the banked plasma by Eve Technologies, who was blinded to case vs. control status. Both assays were performed in duplicate and results averaged. All additional variables were collected through manual chart abstraction. IMPEDE VTE scores were calculated as we previously described (Sanfilippo et al.). The association of D-dimer and soluble P-selectin with VTE risk was assessed using Cox regression, adjusting for IMPEDE VTE score. Results: The median age of all 545 patients was 65 (range 32-79), 54% were male, and 85% were white. All patients received novel chemotherapy agents for first-line MM therapy and 66% underwent autologous stem cell transplant. Of the 38 cases with VTE, 20 patients had deep vein thrombosis, 17 had pulmonary emboli, and 1 patient had concurrent events. The median time from chemotherapy initiation to VTE was 51 days (range 4-193). The median IMPEDE VTE score was 5 (range -1 to 12). Each unit increase in IMPEDE VTE score was associated with a 21% increase in risk for VTE (HR 1.21; 95% CI 1.04-1.40; p = 0.01). Median D-dimer was 11,795 ng/mL (range 280-144,832). Each 1000 ng/mL unit increase in D-dimer was associated with a 2% increase risk for VTE after controlling for IMPEDE VTE score (aHR 1.02; 95% CI 1.01-1.04; p < 0.001). Patients in the highest quartile of D-dimer levels, above the 75th percentile, had a 2-fold increase in risk of VTE after adjusting for IMPEDE VTE score (aHR 2.04; 95% CI 1.03-4.02; p = 0.04). Median soluble P-selectin was 189 ng/ml (range 23-638). There was no association between soluble P-selectin level and VTE risk in patients with MM. Conclusions and Relevance: D-dimer is predictive of VTE in patients with MM starting chemotherapy. The combination of D-dimer and the IMPEDE VTE score can improve identification of patients at high risk of VTE and therefore allow for selection of primary thromboprophylaxis among patients with MM. Disclosures Sanfilippo: Bayer HealthCare Pharamceuticals: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Other: Travel Support for Investigator Meeting; Pfizer: Membership on an entity's Board of Directors or advisory committees; Covington & Burling LLP: Consultancy; Luther & Associates: Consultancy; Health Services Advisory Group: Consultancy; Amgen: Other: Trasfer of Value (food) during discussion of research.

Do Plant Clinics Improve Household Food Security? Evidence from Rwanda

AbstractOne of the main drivers of food insecurity is pests, which are estimated to cause around 40% of crop losses worldwide. We examine the food security effects of plant clinics, a novel agricultural extension model that aims to reduce crop losses due to pests through the provision of demand‐driven plant health diagnostic and advisory services to smallholder farmers. The study is based on survey data from maize‐growing households in Rwanda, where 66 plant clinics have been established. Using switching regression and matching techniques as well as various food security metrics, including the food insecurity experience scale, we find evidence that participation in plant clinics is significantly associated with a reduction in household food insecurity. For instance, among the participating households, plant clinics contribute to a decrease in the period of food shortage by one month and a reduction in the severity of food insecurity by 22 percentage points. We also show that these effects are more pronounced for female‐headed households. Overall, our findings suggest that plant clinics can play an important role in achieving the Sustainable Development Goal 2 of zero hunger.

Expanding Newborn Screening for Pompe Disease in the United States: The NewSTEPs New Disorders Implementation Project, a Resource for New Disorder Implementation.

Public health programs in the United States screen more than four million babies each year for at least 30 genetic disorders. The Health and Human Services (HHS) Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) recommends the disorders for state newborn screening (NBS) programs to screen. ACHDNC updated the Recommended Uniform Screening Panel (RUSP) to include Pompe disease in March 2015. To support the expansion of screening for Pompe disease, the Association of Public Health Laboratories (APHL) proposed the Newborn Screening Technical assistance and Evaluation Program (NewSTEPs) New Disorders Implementation Project, funded by the HHS’ Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB). Through this project, APHL provided financial support to 15 state NBS programs to enable full implementation of screening for Pompe disease. As of April 27, 2020, nine of the 15 programs had fully implemented Pompe disease newborn screening and six programs are currently pursuing implementation. This article will discuss how states advanced to statewide implementation of screening for Pompe disease, the challenges associated with implementing screening for this condition, the lessons learned during the project, and recommendations for implementing screening for Pompe disease.

1249-P: Development and Validation of a Measure for Appropriateness of Glucose-Lowering Therapy

Current diabetes quality indicators do not reflect considerations of clinical complexity, hypoglycemia risk, and treatment burden in identifying optimal therapeutic regimens and targets. Based on existing evidence and input from patients and clinician, payer, and quality measurement experts, we developed a metric that incorporates HbA1c level, comorbidity burden, and number/type of glucose lowering medications (Table) to classify patients as potentially overtreated, undertreated, or appropriately treated. Measure was tested in a national cohort of commercial and Medicare Advantage enrollees with diabetes using the OptumLabs® Data Warehouse. Among 215,429 adults ≥18 years (mean 65 years, 49.6% female, 59.4% white, 4.2% type 1 diabetes, 12.1% clinically complex, 52.7% with HbA1c <7%), 71.0% were treated appropriately, 21.3% undertreated, and 7.7% overtreated in 2015. Compared with current measures (HbA1c <8% for all), 4.4% low complexity and 12.6% high complexity patients were reclassified as no longer appropriately treated. Rates of hypoglycemia-related ED/hospitalization visits in 2016 were 7.0, 12.4, and 22.9 per 1000 persons/year for those appropriately, under-, and over-treated in 2015. Rates of hyperglycemia-related visits were 2.5, 12.2, and 4.6. Implementation of this measure to minimize over- and under-treatment through a patient-centered approach to glucose lowering therapy is planned. Disclosure R.G. McCoy: None. K.J. Lipska: Consultant; Self; Health Services Advisory Group (HSAG). Research Support; Self; National Institute on Aging. Other Relationship; Self; Centers for Medicare and Medicaid Services. H. Van Houten: None. N. Shah: None. Funding American Association of Retired Persons; OptumLabs; National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)

1607-P: Prevalence and Correlates of Potential Glycemic Overtreatment and Undertreatment among U.S. Adults with Diabetes

Poor glycemic control increases the risk of long-term complications, while overtreatment exposes patients to hypoglycemia. In this study, we examined the rates and correlates of potential overtreatment and undertreatment among adults (≥18 years) with diabetes using OptumLabs® Data Warehouse, an administrative claims dataset of commercial and Medicare Advantage enrollees across the U.S. Patient comorbidities were ascertained in 2014. Demographics, HbA1c, glucose-lowering medications, and attributed provider (internal medicine [IM], family medicine [FM], endocrinology) were ascertained in 2015. Patients were classified as potentially over- or undertreated based on their HbA1c, treatment regimen, and clinical complexity. The study cohort was comprised of 215,429 adults with diabetes; mean age 65.0 years, 59.4% white, 4.2% with type 1 diabetes, 23.1% ≥75 years, and 12.1% clinically complex. Overall, 21.3% were undertreated (22.7% low complexity, 10.9% high complexity) and 7.7% overtreated (5.4% low complexity, 23.8% high complexity). Younger age, male sex, black/Hispanic race/ethnicity, type 1 diabetes, FM management, and low clinical complexity were associated with glycemic undertreatment (Table). Younger age, male sex, white/Asian race/ethnicity, type 1 diabetes, endocrine management, and high clinical complexity were associated with glycemic overtreatment. Disclosure R.G. McCoy: None. K.J. Lipska: Consultant; Self; Health Services Advisory Group (HSAG). Research Support; Self; National Institute on Aging. Other Relationship; Self; Centers for Medicare and Medicaid Services. H. Van Houten: None. N. Shah: None. Funding American Association of Retired Persons; OptumLabs; National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)

379-P: Changes in Diabetes Management after a Hospital Visit for Severe Hypoglycemia

Clinical guidelines recommend reevaluation of glucose-lowering medications and relaxation of HbA1c targets in patients with diabetes after a severe hypoglycemic event. We compared diabetes management before and after hypoglycemia requiring emergency department (ED) visit or hospital admission. Using data from OptumLabs® Data Warehouse, we identified privately insured and Medicare Advantage enrollees 18+ years with pharmacologically-treated type 2 diabetes and an ED visit or hospitalization for hypoglycemia between July 1, 2013 and June 30, 2014. We assessed the differences in the number of physician office visits, glucometer test strips filled, continuous glucose monitor (CGM) use, diabetes medication fills, and HbA1c levels (available for 1582 [27.7%]), within 6 months prior to and 6 months after hypoglycemia. Among 5721 patients with type 2 diabetes and severe hypoglycemia, mean age was 67.8 (SD 12.3), 51% women, 63% white, and 68% used insulin. Changes in management are summarized in Table 1. After an event, the proportion of patients filling insulin increased, but the proportion filling sulfonylureas declined. Less than one third of patients with a baseline HbA1c <7% had a substantially higher post-event HbA1c. Few of the recommended changes in diabetes management occur after a severe hypoglycemic event. These findings suggest the need for better post-event care to improve the safety of glucose-lowering therapy. Disclosure P. Vijayakumar: None. S. Liu: None. P.A. Kahn: None. R.G. McCoy: None. A.J. Karter: None. K.J. Lipska: Consultant; Self; Health Services Advisory Group (HSAG). Research Support; Self; National Institute on Aging. Other Relationship; Self; Centers for Medicare and Medicaid Services. Funding National Institute of Diabetes and Digestive and Kidney Diseases (T35DK104689); National Institute on Aging; American Federation for Aging Research; National Institutes of Health (K23AG048359)

Large-scale cross-sectional study of relationships between somatic cell count and milking-time test results in different milking systems

Milking-time testing (MTT) is a method for evaluating the vacuum conditions in the teatcup during milking. The purpose is to evaluate the possible impact of the milking and milking equipment on udder health and milk quality. The method is commonly implemented by herd health advisory services, but results are interpreted empirically due to lack of scientific documentation on relationships between MTT result variables and objective measures of udder health.The current study was conducted to increase our understanding of associations between cow-level differences in composite milk somatic cell count (CMSCC) and MTT results in dairy cows milked in 3 different milking systems; automatic milking systems (AMS), milking parlors, and pipeline milking systems. Data from 7069 cows (predominantly Norwegian Red breed) in 1009 herds were used in a cross-sectional study. Multilevel linear regression models with a random intercept at herd level were used to describe relationships between CMSCC (on logarithmic scale) and the following MTT explanatory variables: average vacuum level in the short milk tube and mouthpiece chamber in the main milking and overmilking periods, the duration of these two periods, and vacuum stability, measured by sudden vacuum drops in the short milk tube. The models were corrected for the herd effect, mastitis history and differences in milk yield, lactation stage and parity between cows. Separate models were run for AMS, milking parlors, and pipeline milking systems, because this approach allowed for comparison between systems and for evaluation of the herd effect independently of milking system.The models described 8–10 % of the variation in CMSCC, indicating that MTT could only explain a relatively small proportion of a large total variation in CMSCC. In most observations, vacuum levels in the short milk tube during main milking were within the range recommended by the International Organization for Standardization. The results from our multivariable models showed decreasing CMSCC with increasing vacuum level in the short milk tube during the main milking period in AMS and milking parlors. Similarly, decreasing CMSCC was also associated with increasing duration of the main milking period in all 3 systems. These relationships are important for the interpretation of MTT results under practical conditions; finding high vacuum levels and long milking durations in a MTT is not associated with elevated CMSCC. In AMS herds, we also found indications that the relationships were different for cows where a case of mastitis had been treated before the MTT.

Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study

IntroductionSupervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form...

Farm characteristics and management routines related to cow longevity: a survey among Swedish dairy farmers

BackgroundLongevity is an important trait for increasing the profitability of dairy production. Long cow longevity is also essential to reduce the environmental impact of milk production, and to maintain positive consumer attitude. Genetic selection for increased longevity has been effective, but the phenotypic trend of longevity in Swedish dairy cows has not been improved. The objective of this study was to identify herd characteristics and management routines that are associated with the average cow longevity in a herd. To obtain this information, a questionnaire was developed and sent out to 661 Swedish dairy farmers.ResultsThe response rate was 35%. Seventeen of the 62 characteristics investigated had either a univariable association with the outcome (days from birth to culling) at P < 0.15, or were identified as confounders in the causal diagram and were therefore considered as candidates for the multivariable analysis. Multiple imputation was used to fill in the missing data from the questionnaires, and this increased the number of usable observations in the multivariable modeling from 156 to 228. Only a few of the investigated herd characteristics and management routines were associated with average cow longevity. The results demonstrated that using herd health advisory services shortened the average longevity, while using breeding advisory services prolonged the average longevity in the herd. Furthermore, having a greater interest in animal breeding (i.e. genetic selection) decreased the longevity, and calling the veterinarian when discovering an unhealthy cow increased the average longevity. Higher age of the farmer was also associated with longer average herd longevity.ConclusionsThe herd average cow longevity was only associated with some of the farm characteristics and management routines studied. The results demonstrate that the use of advisory services and farmers’ attitudes could be targeted for increasing the herd longevity. Further, the results indicate that other e.g. qualitative factors influencing farmers’ decisions play an important role.

Newborn Screening: Beyond the Spot.

The newborn screening paradigm of testing all newborns in the United States for treatable conditions within the first few hours of birth has proven to be a remarkable success story in the realm of public health by reducing neonatal and childhood morbidity and mortality. The Newborn Screening Saves Lives Act of 2007 and its successor, the Reauthorization Act of 2014, legislated the establishment of a Department of Health and Human Services Advisory Committee to make recommendations around newborn screening and a methodology to establish and add new conditions to a Recommended Uniform Screening Panel (RUSP) which currently includes 34 core conditions. In spite of the absence of a federal mandate that requires each of the states in the U.S. to screen for the disorders on the RUSP, most state public health laboratories have adopted the conditions on this panel. Moreover, the evolution of the evidence-based review process for adding new conditions to the RUSP has led to improvements in incorporating the public health impact and feasibility and implementation considerations. The cooperation between the federal partners who support implementation and rollout of state-based screening programs, develop technical standards and proficiency materials for laboratories, review and approve new technology platforms, and promote research to develop new assays and treatments for screenable disorders, points to the success of the newborn screening enterprise nationwide. As new technologic advances are made in the realm of genomic sequencing, the potential for incorporating these technologies holds great promise for newborn screening, but the ethical ramifications must be carefully considered to avoid harming the existing trust in the program.

Critical Review of "Family Health Advisory Services" Assessment in MBBS Training Program in Community Medicine.

Context:Family Health Advisory Services (FHAS) posting as well as its assessment is resource demanding but fails to enjoy priority. Study focuses on a holistic overview of the assessment process to understand need for change.Aims:The aim of this study is to identify perceived gaps in current assessment practices related to FHAS posting.Settings and Design:A cross-sectional mixed method study among all the V semester students currently undergoing assessment for the posting, past students (selected VII semester students and interns), preceptors (supervising residents – postgraduate students in department and senior resident, health assistants, medical social service officer), and involved faculty.Subject and Methods:Self-administered questionnaire, in-depth interview, focus group discussions (two) as well as observations using checklist were used for data collection and triangulation.Statistical Analysis Used:Quantitative data used in this study were statistical measures of central tendency and dispersion. Qualitative data transcript repeatedly read to identify underlying common themes, compared to draw inference.Results:There was a lack of guidelines and communication regarding assessment. Formative assessment was not performed and replaced by one time end assessment. All components of learning were not assessed. End-posting assessment was not standardized and unrelated to learning objectives. Award of scores was skewed toward right for intervention and toward left for analysis and community diagnosis.Conclusions:There is a need to focus on proper implementation of programme to strengthen formative assessment. Assessment should be relevant to learning objectives of posting. Faculty has to lead by example.