Dexmedetomidine an Adjuvant to Levobupivacaine in Supraclavicular Brachial Plexus Block: A Randomized Double Blind Prospective Study

Background

Apha-2 agonists are combined with local anesthetics to extend the duration of regional anesthesia. We evaluated the effect of combining dexmedetomidine with levobupivacine with respect to duration of motor and sensory block and duration of analgesia.

Methods

Sixty patients scheduled for elective forearm and hand surgery were divided into two equal groups in a randomized double blind fashion. The patients received brachial plexus block via supraclavicular route with the help of nerve stimulator. In group L (n=30) 35cc of levobupivacaine with 1ml of isotonic saline and in group LD (n=30) 35cc of levobupivacine with 1 ml of (100 microgram) of dexmedetomidine was given. Duration of motor and sensory block and time to first rescue analgesia were recorded. Data analysis was done by SPSS version 16.0 [SPSS Inc ILLINOIS, USA, 2008]. Categorical variables were analyzed using Pearson”s Chi-square test. Normally distributed numerical variables were analyzed using unpaired “t” test. Skewed numerical variables within the group were analyzed using Man-Whitney “U” test. All tests were two tailed. Statistical significance was defined as P<0.05.

Results

Sensory and motor block durations were longer in group LD as compared to L (P<0.01). Duration of analgesia was significantly longer in group LD as compared to group L (p<0.05).

Conclusion

Dexmedetomidine added to levobupivacaine in supraclavicular brachial plexus block prolongs the duration of block and the duration of postoperative analgesia.     

NHS Scotland reduces the postcode lottery for hip arthroplasty: an ecological study of the impact of waiting time initiatives

Objectives

Following the election of the Labour government in 1997, policies were developed in England to reduce waiting times for NHS treatment with commitments to reduce health inequalities. Similar policies were adopted in Scotland but with less emphasis on the use of the private sector to deliver NHS treatments than in England. This study uses routinely collected NHS Scotland data to analyse geographical and socioeconomic inequalities in elective hip arthroplasty treatment before and after the introduction of the waiting time initiatives in Scotland in 2003.

Design

Ecological study design.

Setting

Scotland.

Participants

NHS-funded patients receiving elective hip arthroplasty delivered by the NHS and private hospitals between 1 April 1998 and 31 March 2008.

Main outcome measures

Directly standardised treatment rates and incidence rate ratios calculated using Poisson regression.

Results

There was a 42% increase in NHS-funded hip arthroplasties carried out in Scotland from 4095 in 2002–2003 (1 April 2002–31 March 2003) to 5829 in 2007–2008. There is evidence of a statistically significant reduction in geographical inequality (likelihood ratio test p < 0.001) but no evidence of any statistically significant change in socioeconomic inequality (p = 0.108), comparing the 5 years after 1 April 2003 with the 5 years before 1 April 2003. The number of NHS-funded hip arthroplasties undertaken privately rose from 1.1% in 2002–2003 to 2.9% in 2007–2008, whereas the NHS Golden Jubilee National Hospital increased its share from 3.3% to 10.6% over the same period.

Conclusions

The reduction in geographical inequality, or ‘postcode lottery’, in hip arthroplasty treatment in Scotland may be due to increased NHS capacity, in particular the development of the NHS Golden Jubilee National Hospital in Clydebank, Greater Glasgow as a dedicated centre to reduce surgery waiting times.     

Effect of providing risk information on undergoing cervical cancer screening: a randomized controlled trial

Background

In Japan, the cervical cancer screening rate is extremely low. Towards improving the cervical cancer screening rate, encouraging eligible people to make an informed choice, which is a decision-making process that relies on beliefs informed by adequate information about the possible benefits and risks of screening, has attracted increased attention in the public health domain. However, there is concern that providing information on possible risks of screening might prevent deter from participating.

Methods

In total, 1,912 women aged 20–39 years who had not participated in screening in the fiscal year were selected from a Japanese urban community setting. Participants were randomly divided into 3 groups. Group A received a printed reminder with information about the possible benefits of screening, group B received a printed reminder with information about possible benefits and risks, and group C received a printed reminder with simple information only (control group).

Results

Out of 1,912 participants, 169 (8.8%) participated in cervical cancer screening. In the intervention groups, 137 (10.9%) participated in cervical cancer screening, compared to only 32 (4.9%) of the control group (p < 0.001). In addition, logistic regression analysis revealed that there was no significant difference in screening rate between group A and group B (p = 0.372).

Conclusions

Providing information on the possible risks of screening may not prevent people from taking part in cervical cancer screening among a Japanese non-adherent population.     

Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality

Objectives

To compare risks of hypernatraemia on admission to hospital in persons who were with those who were not identified as care home residents and evaluate the association of hypernatraemia with in-hospital mortality.

Design

Retrospective observational study.

Setting

A National Health Service Trust in London.

Participants

A total of 21,610 patients aged over 65 years whose first admission to the Trust was between 1 January 2011 and 31 December 2013.

Main outcome measures

Hypernatraemia on admission (plasma Na > 145 mmol/L) and in-hospital death.

Results

Patients admitted from care homes had 10-fold higher prevalence of hypernatraemia than those from their own homes (12.0% versus 1.3%, respectively; odds ratio [OR]: 10.5, 95% confidence interval [CI]: 8.43–13.0). Of those with hypernatraemia, nine in 10 cases were associated with nursing home ECOHOST residency (attributable fraction exposure: 90.5%), and the population attributable fraction of hypernatraemia on admission associated with care homes was 36.0%. After correcting for age, gender, mode of admission and dementia, care home residents were significantly more likely to be admitted with hypernatraemia than were own-home residents (adjusted odds ratio [AOR]: 5.32, 95% CI: 3.85–7.37). Compared with own-home residents, care home residents were also at about a two-fold higher risk of in-hospital mortality compared with non-care home residents (AOR: 1.97, 95% CI: 1.59–2.45). Consistent with evidence that hypernatraemia is implicated in higher mortality, the association of nursing homes with in-hospital mortality was attenuated after adjustment for it (AOR: 1.61, 95% CI: 1.26–2.06).

Conclusions

Patients admitted to hospital from care homes are commonly dehydrated on admission and, as a result, appear to experience significantly greater risks of in-hospital mortality.     

Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: national cohort study in Denmark

Objective

Based on converging observations in animal, clinical and ecological studies, we hypothesised a possible impact of ritual circumcision on the subsequent risk of autism spectrum disorder (ASD) in young boys.

Design

National, register-based cohort study.

Setting

Denmark.

Participants

A total of 342,877 boys born between 1994 and 2003 and followed in the age span 0–9 years between 1994 and 2013.

Main outcome measures

Information about cohort members’ ritual circumcisions, confounders and ASD outcomes, as well as two supplementary outcomes, hyperkinetic disorder and asthma, was obtained from national registers. Hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status were obtained using Cox proportional hazards regression analyses.

Results

With a total of 4986 ASD cases, our study showed that regardless of cultural background circumcised boys were more likely than intact boys to develop ASD before age 10 years (HR = 1.46; 95% CI: 1.11–1.93). Risk was particularly high for infantile autism before age five years (HR = 2.06; 95% CI: 1.36–3.13). Circumcised boys in non-Muslim families were also more likely to develop hyperkinetic disorder (HR = 1.81; 95% CI: 1.11–2.96). Associations with asthma were consistently inconspicuous (HR = 0.96; 95% CI: 0.84–1.10).

Conclusions

We confirmed our hypothesis that boys who undergo ritual circumcision may run a greater risk of developing ASD. This finding, and the unexpected observation of an increased risk of hyperactivity disorder among circumcised boys in non-Muslim families, need attention, particularly because data limitations most likely rendered our HR estimates conservative. Considering the widespread practice of non-therapeutic circumcision in infancy and childhood around the world, confirmatory studies should be given priority.     

Dicing with chance,life and death in systematic reviews and meta-analyses: D.I.C.E. 3, a simulation study

Objectives

To show the effects of chance on meta-analyses, and the potential dangers of being prompted to do a meta-analysis by one favourable trial.

Design

In total, 100,000 trials were simulated and combined into 10,000 meta-analyses, using data from the control group of a cancer trial. Each participant record was randomly coded to simulate allocation to ‘treatment’ or ‘control’.

Setting

Simulated study.

Participants

De-identified records for 578 patients from the control group of a cancer trial, of whom 147 had died.

Main outcome measure

Time to death from any cause.

Results

Of the 100,000 trials, 4897 (4.9%) were statistically significant at 2p < 0.05 and 123 (1.2%) of the 10,000 meta-analyses were significant at 2p < 0.01. The most extreme result was a 20% reduction (99% CI: 0.70–0.91; 2p = 0.00002) in the annual odds of dying in the ‘treatment’ group. If a meta-analysis contained at least one trial with a statistically significant result (at 2p < 0.05), the likelihood of the meta-analysis being significant (at 2p < 0.01) increased strikingly. For example, among the 473 meta-analyses in which the first trial in a batch of 10 was statistically significant (at 2p < 0.05), 18 (3.8%) favoured treatment at 2p < 0.01.

Conclusions

Chance can influence the results of meta-analyses regardless of how well they are conducted. Researchers should not ignore this when they plan a meta-analysis and when they report their results. People reading their reports should also be wary. Caution is particularly important when the results of one or more included studies influenced the decision to do the meta-analysis.     

Developing regional weight-for-age growth references for malaria-endemic countries to optimize age-based dosing of antimalarials

Objective

To derive regional weight-for-age growth references to help optimize age-based dosing of antimalarials in Africa, the Americas, South-East Asia and the Western Pacific.

Methods

A weight-for-age database was constructed from pre-existing population-based anthropometric data obtained from household surveys and research groups. It contained data collected between 1995 and 2012 on 1 263 119 individuals (909 368 female, 353 751 male) older than 14 days and younger than 50 years in 64 malaria-endemic countries. Regional growth references were generated using a generalized additive model for location, scale and shape by combining data with varying distributions from a range of sources. Countries were weighted by their population at risk of malaria to enable references to be used in optimizing the dosing of antimalarials.

Findings

Large differences in weight-for-age distributions existed between the regions and between the regions and global growth standards. For example, the average adult male from the Americas weighed 68.1 kg – 6.0 kg more than males in South-East Asia and the Western Pacific (average: 62.1 kg). For adult women, the difference was over 10.4 kg: the average was 60.4 kg in the Americas and 50.0 kg in South-East Asia and the Western Pacific.

Conclusion

There were substantial variations in weight-for-age growth curves between malaria-endemic areas. The growth reference charts derived here can be used to guide the evidence-based optimization of aged-based dosing regimens for antimalarials and other drugs often prescribed by age.     

Interventions for physical activity promotion applied to the primary healthcare settings for people living in regions of low socioeconomic level: study protocol for a non-randomized controlled trial

Background

Regular physical activity practice has been widely recommended for promoting health, but the physical activity levels remain low in the population. Therefore, the study of interventions to promote physical activity is essential. Objective: To present the methodology of two physical activity interventions from the “Ambiente Ativo” (“Active Environment”) project.

Methods

12-month non-randomized controlled intervention trial. 157 healthy and physically inactive individuals were selected: health education (n = 54) supervised exercise (n = 54) and control (n = 49). Intervention based on health education: a multidisciplinary team of health professionals organized the intervention in group discussions, phone calls, SMS and educational material. Intervention based on supervised exercise program: consisted of offering an exercise program in groups supervised by physical education professionals involving strength, endurance and flexibility exercises. The physical activity level was assessed by the International Physical Activity Questionnaire (long version), physical activities recalls, pedometers and accelerometers over a seven-day period.

Result

This study described two different proposals for promoting physical activity that were applied to adults attended through the public healthcare settings. The participants were living in a region of low socioeconomic level, while respecting the characteristics and organization of the system and its professionals, and also adapting the interventions to the realities of the individuals attended.

Conclusion

Both interventions are applicable in regions of low socioeconomic level, while respecting the social and economic characteristics of each region.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01852981","term_id":"NCT01852981"}}NCT01852981     

Changes in government spending on healthcare and population mortality in the European union, 1995–2010: a cross-sectional ecological study

Objective

Economic measures such as unemployment and gross domestic product are correlated with changes in health outcomes. We aimed to examine the effects of changes in government healthcare spending, an increasingly important measure given constrained government budgets in several European Union countries.

Design

Multivariate regression analysis was used to assess the effect of changes in healthcare spending as a proportion of total government expenditure, government healthcare spending as a proportion of gross domestic product and government healthcare spending measured in purchasing power parity per capita, on five mortality indicators. Additional variables were controlled for to ensure robustness of data. One to five year lag analyses were conducted.

Setting and Participants

European Union countries 1995–2010.

Main outcome measures

Neonatal mortality, postneonatal mortality, one to five years of age mortality, under five years of age mortality, adult male mortality, adult female mortality.

Results

A 1% decrease in government healthcare spending was associated with significant increase in all mortality metrics: neonatal mortality (coefficient −0.1217, p = 0.0001), postneonatal mortality (coefficient −0.0499, p = 0.0018), one to five years of age mortality (coefficient −0.0185, p = 0.0002), under five years of age mortality (coefficient −0.1897, p = 0.0003), adult male mortality (coefficient −2.5398, p = 0.0000) and adult female mortality (coefficient −1.4492, p = 0.0000). One per cent decrease in healthcare spending, measured as a proportion of gross domestic product and in purchasing power parity, was both associated with significant increases (p < 0.05) in all metrics. Five years after the 1% decrease in healthcare spending, significant increases (p < 0.05) continued to be observed in all mortality metrics.

Conclusions

Decreased government healthcare spending is associated with increased population mortality in the short and long term. Policy interventions implemented in response to the financial crisis may be associated with worsening population health.     

Implications of late complications from adhesions for preoperative informed consent

Summary

The process of informed consent is a critical aspect of the doctor–patient relationship. Doctors have a professional duty to provide patients with sufficient information if a treatment is associated with a significant risk. NHS guidelines advise doctors to mention risks that occur more frequently than 1–2% or risks that are serious even if the likelihood is very small. In the case of abdominal and pelvic surgery, risks can broadly be divided into early and late complications. Early complications, such as bleeding and infection, have a close temporal relationship with the operation. Such complications are routinely mentioned during the consent process. In contrast, postoperative adhesions cause changes in the normal anatomy that can adversely affect function many years and even decades after the original operation, leaving patients at lifelong risk for late complications. These late adhesive complications, namely bowel obstruction, mechanical female infertility and chronic pain, are often neglected during the consent process. However, the risks to patients from late adhesive complications are serious and well in excess of the accepted threshold where it could be considered a breach in the duty of care not to inform patients. This is reflected by a number of claims against the NHS based on consent issues regarding late adhesive complications of surgery. Therefore, late complications of surgery from adhesions should be included in the pre-operative consent process. This would decrease litigation costs but more importantly also underpins the doctor–patient relationship.     

Health risk assessment of zinc,chromium, and nickel from cow meat consumption in an urban Nigerian population

Background:

Meat consumption is increasingly becoming a larger part of diets worldwide. However, the bioaccumulation of toxic metals from anthropogenic pollution is a potential health risk to human health.

Objective:

To measure the daily intake of zinc, chromium, and nickel from cow meat consumption and assess the possible health risks in an urban population in Nigeria.

Methods:

Dried meat samples were digested with 3 : 2HNO3 : HClO4 v/v. Zinc, chromium, and nickel concentrations were determined with atomic absorption spectrophotometer. Daily intakes of meat were obtained using a food frequency questionnaire (FFQ).

Results:

The estimated daily intakes (EDI) (μg/person/day) ranges were: zinc (10 496–13 459), chromium (310.90–393.73), and nickel (26.72–34.87). Estimated daily intake for zinc was 15–30% of provisional maximum tolerable daily intake (PMTDI) and for nickel it was 8–15% of tolerable daily intake (TDI).

Conclusion:

Chromium intakes were above recommended daily intake (RDI). Target hazard quotient (THQ) for nickel and zinc were within WHO/FAO limit. There was no evidence of possible health risk to consumers with regard to zinc and nickel. However, chromium intake should be of utmost concern, while disposal of tanning waste should be checked.     

Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6?months to 5?years

Background

Mid-upper arm circumference (MUAC) was recently endorsed and recommended for screening for acute malnutrition in the community. The objective of this study was to determine whether a colour-banded MUAC strap would allow minimally trained mothers to screen their own children for malnutrition, without locating the mid-point of the left upper arm by measurement, as currently recommended.

Methods

A non-randomised non-blinded evaluation of mothers’ performance when measuring MUAC after minimal training, compared with trained Community Health Workers (CHW) following current MUAC protocols. The study was conducted in 2 villages in Mirriah, Zinder region, Niger where mothers classified one of their children (n = 103) aged 6–59 months (the current age range for admission into community malnutrition programs) using the MUAC tape.

Results

Mothers’ had a sensitivity and specificity for classification of their child’s nutritional status of > 90% and > 80% respectively for global acute malnutrition (GAM, defined by a MUAC < 125 mm) and > 73% and > 98% for severe acute malnutrition (SAM, defined by a MUAC < 115 mm). The few children misclassified as not having SAM, were classified as having moderate acute malnutrition (MAM). The choice of arm did not influence the classification results; weighted Kappa of 0.88 for mothers and 0.91 for CHW represent almost perfect agreement. Errors occurred at the class boundaries and no gross errors were made.

Conclusions

Advanced SAM is associated with severe complications, which often require hospital admission or cause death. Mothers (with MUAC tapes costing $0.06) can screen their children frequently allowing early diagnosis and treatment thereby becoming the focal point in scaling-up community management of acute malnutrition.

Trial registration

The trial is registered with clinicaltrials.gov (Trial number {"type":"clinical-trial","attrs":{"text":"NCT01790815","term_id":"NCT01790815"}}NCT01790815)     

Psychological distress and the perception of radiation risks: the Fukushima health management survey

Objective

To assess relationships between the perception of radiation risks and psychological distress among evacuees from the Fukushima nuclear power plant disaster.

Methods

We analysed cross-sectional data from a survey of evacuees conducted in 2012. Psychological distress was classified as present or absent based on the K6 scale. Respondents recorded their views about the health risks of exposure to ionizing radiation, including immediate, delayed and genetic (inherited) health effects, on a four-point Likert scale. We examined associations between psychological distress and risk perception in logistic regression models. Age, gender, educational attainment, history of mental illness and the consequences of the disaster for employment and living conditions were potential confounders.

Findings

Out of the 180 604 people who received the questionnaire, we included 59 807 responses in our sample. There were 8717 respondents reporting psychological distress. Respondents who believed that radiation exposure was very likely to cause health effects were significantly more likely to be psychologically distressed than other respondents: odds ratio (OR) 1.64 (99.9% confidence interval, CI: 1.42–1.89) for immediate effects; OR: 1.48 (99.9% CI: 1.32–1.67) for delayed effects and OR: 2.17 (99.9% CI: 1.94–2.42) for genetic (inherited) effects. Similar results were obtained after controlling for individual characteristics and disaster-related stressors.

Conclusion

Among evacuees of the Fukushima nuclear disaster, concern about radiation risks was associated with psychological distress.     

A cluster of lead poisoning among consumers of Ayurvedic medicine

Background

Use of alternative medications and herbal remedies is widespread in the United States and across the globe. These traditional medications can be contaminated with toxic metals. Despite several case reports of poisoning from such contamination, the epidemiological data are still limited.

Objectives

To report on a cluster of lead and mercury toxicity cases in 2011 among a community of adherents of traditional medical practice of Ayurveda.

Methods

Adherents of Ayurveda were offered heavy metals screening following the identification of the index case.

Results

Forty-six of 115 participants (40%) had elevated blood lead levels (BLLs) of 10 μg/dl or above, with 9.6% of BLLs at or above 50 μg/dl.

Conclusions

This is the largest cluster of lead and mercury toxicity following use of Ayurvedic supplements described in the literature in the US. Contamination of herbal products is a public health issue of global significance. There are few regulations addressing contamination of “natural” products or supplements.     

Introducing rapid diagnostic tests for malaria to drug shops in Uganda: a cluster-randomized controlled trial

Objective

To evaluate the impact – on diagnosis and treatment of malaria – of introducing rapid diagnostic tests to drug shops in eastern Uganda.

Methods

Overall, 2193 households in 79 study villages with at least one licensed drug shop were enrolled and monitored for 12 months. After 3 months of monitoring, drug shop vendors in 67 villages randomly selected for the intervention were offered training in the use of malaria rapid diagnostic tests and – if trained – offered access to such tests at a subsidized price. The remaining 12 study villages served as controls. A difference-in-differences regression model was used to estimate the impact of the intervention.

Findings

Vendors from 92 drug shops successfully completed training and 50 actively stocked and performed the rapid tests. Over 9 months, trained vendors did an average of 146 tests per shop. Households reported 22 697 episodes of febrile illness. The availability of rapid tests at local drug shops significantly increased the probability of any febrile illness being tested for malaria by 23.15% (P = 0.015) and being treated with an antimalarial drug by 8.84% (P = 0.056). The probability that artemisinin combination therapy was bought increased by a statistically insignificant 5.48% (P = 0.574).

Conclusion

In our study area, testing for malaria was increased by training drug shop vendors in the use of rapid tests and providing them access to such tests at a subsidized price. Additional interventions may be needed to achieve a higher coverage of testing and a higher rate of appropriate responses to test results.     

Cognitive function,body mass index and mortality in a rural elderly Chinese cohort

Background

Previous studies have shown that poor cognition and low body mass index were associated with increased mortality. But few studies have investigated the association between cognition and mortality across the entire cognitive spectrum while adjusting for BMI. The objective of this study is to examine the associations between cognitive function, BMI and 7-year mortality in a rural elderly Chinese cohort.

Methods

A prospective cohort of 2,000 Chinese age 65 and over from four rural counties in China were followed for 7-years. Cognitive function, BMI and other covariate information were obtained at baseline. Cox’s proportional hazard models were used to determine the effects of cognitive function and BMI on mortality risk.

Results

Of participants enrolled, 473 (23.7%) died during follow-up. Both lower cognitive function (HR = 1.48, p = 0.0049) and lower BMI (HR = 1.6, p < 0.0001) were independently associated with increased mortality risk compared to individuals with average cognitive function and normal weight. Higher cognitive function was associated with lower mortality risk (HR = 0.69, p = 0.0312). We found no significant difference in mortality risk between overweight/obese participants and those with normal weight.

Conclusions

Cognitive function and BMI were independent predictors of mortality risk. Intervention strategies for increasing cognitive function and maintaining adequate BMI may be important in reducing morality risk in the elderly population.     

Occupational and non-occupational factors associated with work-related injuries among construction workers in the USA

Background:

Many factors contribute to occupational injuries. However, these factors have been compartmentalized and isolated in most studies.

Objective:

To examine the relationship between work-related injuries and multiple occupational and non-occupational factors among construction workers in the USA.

Methods:

Data from the 1988–2000 National Longitudinal Survey of Youth, 1979 cohort (N = 12,686) were analyzed. Job exposures and health behaviors were examined and used as independent variables in four multivariate logistic regression models to identify associations with occupational injuries.

Results:

After controlling for demographic variables, occupational injuries were 18% (95% CI: 1.04–1.34) more likely in construction than in non-construction. Blue-collar occupations, job physical efforts, multiple jobs, and long working hours accounted for the escalated risk in construction. Smoking, obesity/overweight, and cocaine use significantly increased the risk of work-related injury when demographics and occupational factors were held constant.

Conclusions:

Workplace injuries are better explained by simultaneously examining occupational and non-occupational characteristics.     

Reaching the poor with adequately iodized salt through the Supplementary Nutrition Programme and Midday Meal Scheme in Madhya Pradesh,India

Problem

In India, adequately iodized salt needs to be made accessible to the most marginalized.

Approach

In an effort to provide adequately iodized salt to the most vulnerable, in 2009 Madhya Pradesh launched a state-wide initiative through two national flagship nutrition programmes: the Supplementary Nutrition Programme of the Integrated Child Development Services and the Midday Meal Scheme. Programme staff members were taught how to correctly store salt and monitor its iodine content. Field monitors assessed the iodine content of the salt in the common kitchens of participating schools and anganwadi centres monthly.

Local setting

Madhya Pradesh, a state in central India, is home to a substantial proportion of India’s poor. In 2009, household coverage of adequately iodized salt in the state was nearly 90% among the richest but only about 50% among the poorest.

Relevant changes

Two hot meals prepared with adequately iodized salt were served daily for more than 21 days per month to approximately 89% of the 12 113 584 children aged 3 to 6 years enrolled in anganwadi centres (June 2011 to March 2012). One meal on school days was served to 78% of 5 751 979 primary-school children and to 79% of 2 704 692 secondary-school children (April 2011 to March 2012). Most of the kitchens visited in 2010 (79%) and 2011 (83%) were consistently using adequately iodized salt to prepare hot meals.

Lessons learnt

India has large-scale social safety net programmes for the poorest. Both national and state policies should mainstream the use of adequately iodized salt in these programmes.     

Self-reported illness and household strategies for coping with health-care payments in Bangladesh

Objective

To investigate self-reported illness and household strategies for coping with payments for health care in a city in Bangladesh.

Methods

A cluster-sampled probability survey of 1593 households in the city of Rajshahi, Bangladesh, was conducted in 2011. Multilevel logistic regression – with adjustment for any clustering within households – was used to examine the risk of self-reported illness in the previous 30 days. A multilevel Poisson regression model, with adjustment for clustering within households and individuals, was used to explore factors potentially associated with the risk of health-care-related “distress” financing (e.g. paying for health care by borrowing, selling, reducing food expenditure, removing children from school or performing additional paid work).

Findings

According to the interviewees, about 45% of the surveyed individuals had suffered at least one episode of illness in the previous 30 days. The most frequently reported illnesses among children younger than 5 years and adults were common tropical infections and noncommunicable diseases, respectively. The risks of self-reported illness in the previous 30 days were relatively high for adults older than 44 years, women and members of households in the poorest quintile. Distress financing, which had been implemented to cover health-care payments associated with 13% of the reported episodes, was significantly associated with heart and liver disease, asthma, typhoid, inpatient care, the use of public outpatient facilities, and poverty at the household level.

Conclusion

Despite the subsidization of public health services in Bangladesh, high prevalences of distress financing – and illness – were detected in the surveyed, urban households.     

Systematic review of statistics on causes of deaths in hospitals: strengthening the evidence for policy-makers

Objective

To systematically review the reliability of hospital data on cause of death and encourage periodic reviews of these data using a standard method.

Methods

We searched Google Scholar, Pubmed and Biblioteca Virtual de la Salud for articles in English, Spanish and Portuguese that reported validation studies of data on cause of death. We analysed the results of 199 studies that had used medical record reviews to validate the cause of death reported on death certificates or by the vital registration system.

Findings

The screened studies had been published between 1983 and 2013 and their results had been reported in English (n = 124), Portuguese (n = 25) or Spanish (n = 50). Only 29 of the studies met our inclusion criteria. Of these, 13 had examined cause of death patterns at the population level – with a view to correcting cause-specific mortality fractions – while the other 16 had been undertaken to identify discrepancies in the diagnosis for specific diseases before and after medical record review. Most of the selected studies reported substantial misdiagnosis of causes of death in hospitals. There was wide variation in study methodologies. Many studies did not describe the methods used in sufficient detail to be able to assess the reproducibility or comparability of their results.

Conclusion

The assumption that causes of death are being accurately reported in hospitals is unfounded. To improve the reliability and usefulness of reported causes of death, national governments should do periodic medical record reviews to validate the quality of their hospital cause of death data, using a standard.