Substantial progress has been made in the fight against tuberculosis (TB); however, new approaches are needed to achieve the current target set by the World Health Organization (WHO) to reduce TB incidence to 90% of 2016 levels by 2035  and Kilifi County Hospital (KCH) in Coast Province, Kenya. CPGH provides primary and secondary care to the city of Mombasa and tertiary services for Coast Province. KCH is nested within the Kilifi Health and Demographic Surveillance System (KHDSS)  according to clinical, radiologic, and microbiological findings, based closely on stringent published definitions  Table 2 http://ukneqas.org.uk).Acid-fast bacilli microscopy and mycobacterial culture using the BACTEC MGIT system  were performed according to standard protocols  divided by the total person-years of observation in each age stratum. We compared estimates generated using the study case definitions with incidence estimates derived by applying other published clinical definitions of childhood TB to our dataset .Crude incidence estimates assume all incident cases among KHDSS residents are captured by the study; however, hospital-based surveillance of childhood illnesses is known to be insensitive in this setting .We linked clinical data with National Tuberculosis Programme notification data and KHDSS census data. We estimated the CDR as 1) the proportion of KHDSS-resident smear-positive childhood TB cases reported to the National Tuberculosis Programme that were captured by passive case detection at KCH, and 2) the proportion of children’s household contacts of new smear-positive pulmonary TB cases captured by active contact tracing.We linked KHDSS vital status data with KCH admission data. We then calculated the proportion of all childhood deaths in the KHDSS area captured at KCH during the study period.By using disease-specific mortality data from a contemporaneous verbal autopsy study of all deaths within the KHDSS  cases among children nationally by multiplying the total number of adult cases reported in Kenya in 2010 (<0.1) and presented adjusted ORs and 95% CIs.We explored risk factors for childhood TB in a nested case–control analysis of children with CHPTB (cases) and children for whom TB was excluded (controls). To mitigate ascertainment bias in analysis of TB contact history, we excluded the small minority of children identified through active contact tracing. For each association, we derived crude odds ratios (ORs) and 95% CIs. We then included in a multivariable logistic regression model those variables with at least a weak association with TB in the univariable analysis  as the measure most likely to optimize sensitivity and specificity for estimation of childhood TB incidence.Compared with estimates based on published clinical definitions, our measure of CHPTB incidence is among the most conservative, similar to the estimate obtained by retrospectively applying more recent consensus definitions for research (Robust community incidence estimates depend on high-quality diagnosis to minimize misclassification as well as a high CDR. Broad screening criteria for all children admitted to hospital with any features of suspected TB, plus active case detection through contact tracing, ensured that case ascertainment at KCH was optimized. Nevertheless, the social, financial, and geographic barriers to obtaining hospital care in this setting mean that many ill KHDSS-resident children are not seen at KCH (Because we used the highest CDR estimate to generate conservative estimates of childhood TB incidence, the projected national incidence was 3 times higher than that reported. Nevertheless, the projected ratio of adult-to-child TB cases is still consistent with other studies in Africa (The strong association of childhood TB with a history of close TB contact has 2 important implications for clinical practice and public health policy. First, eliciting a history of TB contact should be a standard part of the assessment of every ill child in TB-endemic settings. Among inpatients in our study, 1 in 5 with a known close TB contact had CHPTB. Early identification and investigation of this high-risk group might improve clinical outcomes through earlier diagnosis and treatment.Second, and most important, our finding that 49% TB cases among children <5 years of age were attributable to a known household TB contact suggests that half the CHPTB cases in young children might have been prevented by chemoprophylaxis. Estimating the population attributable fraction of contact with a person with confirmed TB provides a novel approach for assessing the potential impact of TB chemoprophylaxis at the population level that might be applied to other settings. Our results from Kenya support recent global estimates of TB burden among child TB contacts (Extrapolation of results from a single district must be interpreted with caution. Childhood TB incidence and the contribution of childhood TB cases to the total TB burden are likely to be affected by factors that vary geographically, including community TB prevalence; social and demographic factors, such as urbanization, that affect the annual risk for TB infection; prevalence of host factors, such as BCG vaccination, HIV infection, and malnutrition; and local population structures. Therefore, we did not attempt simply to age-standardize the Kilifi incidence rates to the national population of children in Kenya.We reasoned instead that the proportion of the total TB caseload accounted for by children is probably less prone to geographic variation, and estimated the national burden of childhood TB by assuming that the CDR among adults and the ratio of adult-to-child cases is the same in the KHDSS and nationally. Importantly, the age structures of the KHDSS and Kenya are very similar (In conclusion, by using a combination of clinical, laboratory, and epidemiologic resources not usually available for routine surveillance, we have estimated the incidence of childhood TB in Kenya. Although this study is very resource-intensive, the wide range of incidence estimates based on existing clinical definitions highlights the difficulty in interpreting routine notification data and reinforces the need for similar studies in a range of different epidemiologic settings. In a setting where routine facilities for childhood TB diagnosis are typical of most countries with a high TB burden, our results also provide important empirical data on the TB CDR among children. The results support recently improved WHO estimates of global childhood TB incidence based on modeling approaches, which assume a very similar CDR (Description of methods and supplementary results of the Kilifi Health and Demographic Surveillance Survey, Kenya, August 2009–July 2011.


Background: Meeting demand for family planning can facilitate progress towards all major themes of the United Nations Sustainable Development Goals (SDGs): people, planet, prosperity, peace, and partnership. Many policymakers have embraced a benchmark goal that at least 75% of the demand for family planning in all countries be satisfied with modern contraceptive methods by the year 2030.Objective: This study examines the demographic impact (and development implications) of achieving the 75% benchmark in 13 developing countries that are expected to be the furthest from achieving that benchmark.Methods: Estimation of the demographic impact of achieving the 75% benchmark requires three steps in each country: 1) translate contraceptive prevalence assumptions (with and without intervention) into future fertility levels based on biometric models, 2) incorporate each pair of fertility assumptions into separate population projections, and 3) compare the demographic differences between the two population projections. Data are drawn from the United Nations, the US Census Bureau, and Demographic and Health Surveys.Results: The demographic impact of meeting the 75% benchmark is examined via projected differences in fertility rates (average expected births per woman’s reproductive lifetime), total population, growth rates, age structure, and youth dependency. On average, meeting the benchmark would imply a 16 percentage point increase in modern contraceptive prevalence by 2030 and a 20% decline in youth dependency, which portends a potential demographic dividend to spur economic growth.Conclusions: Improvements in meeting the demand for family planning with modern contraceptive methods can bring substantial benefits to developing countries. To our knowledge, this is the first study to show formally how such improvements can alter population size and age structure. Declines in youth dependency portend a demographic dividend, an added bonus to the already well-known benefits of meeting existing demands for family planning. In 2015, member states of the United Nations endorsed a set of Sustainable Development Goals (SDGs), organized around five themes: people, planet, prosperity, peace, and partnership –5 as welFamily planning facilitates many of these goals by reducing unwanted fertility and altering population dynamics. The pace of population growth has a major influence on the environment, food security, poverty elimination, and sustainable development . ChanginThis study estimates the demographic impact of achieving the benchmark for 13 countries that seem furthest from meeting that benchmark. Specifically, we present a set of demographic indicators for each country – total fertility rate (TFR), population size, growth rate, proportions of population by age group, and child dependency ratios – in 2030 and 2050 based in part on two projections of modern contraceptive prevalence rates (MCPRs): the current projections by the United Nations and projections which assume that each country instead met the 75% benchmark . Falling child dependency ratios provide an especially valuable window into the potential economic benefits (demographic dividend) [The 13 countries expected to be furthest from reaching the benchmark were determined based on United Nations’ projections . They weFor each country, we began with the United Nation’s median estimates of MCPR, traditional contraceptive prevalence rate (TCPR), and total demand for family planning among married women through 2030 . United Method-specific contraceptive prevalence rates were drawn from either the United Nations wallchart on contraceptive patterns  or the lFor each country, three steps are required to assess the demographic impact of achieving the benchmark of meeting 75% of the demand for family planning with modern contraception by 2030. First, future expected contraceptive prevalence in both reference and benchmark projections are translated into levels of fertility. Second, these levels of fertility are incorporated into a pair of population projections. Third, the resulting reference and benchmark projections are compared.Contraception is one factor among several that influences fertility. The key ‘proximate determinants’ of fertility also include marital patterns, post-partum sterility, and other factors ,18. A fuwhere:m is an index of marriage (proportion of women ages 15–49 in union)Cc is the index of contraceptionCi is the index of postpartum insusceptibilityCa is the index of abortionCp is an index of infecundity or pathological sterilityCTFR is the total fertility rate (average expected births per woman)TF is total fecundity The above biometric identity holds at different points in time. Thus, the ratio of the TFR to the proximate determinant indexes in 2014 and 2030, for example (below), can be expressed as:where :2014 is an estimate of the TFR in 2014 drawn from the Census Bureau’s International Data Base (IDB)TFR2030 is the biometric model estimate of the TFR in 2030 from TFRC indexes (for 2014 and 2030) are included where availableUpon rearranging the equation (below), the TFR in 2030 can be derived from current fertility estimates as well as current and future expected values of the proximate determinant indexes.a) or pathological sterility (Cp). Thus, for most countries, we used the following abridged biometric model:For the countries of interest, not enough information was available to estimate and project indexes for abortion (Cc) is calculated based on MCPR, TCPR, relative mix of modern methods, and effectiveness of each method to prevent pregnancy [The contraceptive index  in 2030 were estimated based on the trajectory of such indexes as indicated by consecutive sources at two points in time, typically from Demographic and Health Surveys (DHSs). Because such data were not available in some countries , a further abridgement was required to the biometric equation in these countries (see simplified model below). The abridged The other indexes . The key TFR estimates for each country and each scenario in 2014, 2030, and 2050 are shown on The fertility levels projected in Step 1 were incorporated into standard cohort component population projections using the Census Bureau’s Rural/Urban Projection (RUP) program. This method begins with the population of each country in 2014 (disaggregated by sex and single-year age groups) and projects it into the future based on the three components of population change – fertility, mortality, and net migration. For each country in 2014, we relied on population, fertility, and other demographic change estimates  from the Census Bureau’s International Data Base. That source was also used to project demographic change into the future .Two separate population projections were developed for each of the 13 countries: reference projections (based on United Nations’ projections of MCPR and TCPR) and benchmark projections (which assume that 75% of the United Nations’ projected demand for family planning would be met with modern methods by 2030). Differences between the projections of the reference and benchmark models in each country indicate the potential impact of achieving the family planning benchmark on the overall population as well as age structure.Given that each pair of projections begins in 2014, the expected reduction in the population under the benchmark scenario affects only those born after 2014. Aforementioned results demonstrate how meeting the 75% benchmark by 2030 would affect population size, growth, and age structure in 13 developing countries. What are the broader implications of such demographic changes? In regard to lowering population size and growth, meeting the benchmark could reduce pressures on natural resources and facilitate SDGs related to environmental sustainability and food security [In addition, the lower projected proportions of youth provide an opportunity for more rapid economic development as a greater share of the population advances into economically productive ages – an opportunity known as the demographic dividend. In the East Asian context, this dividend has accounted for 10–20% of economic growth ,21. LoweSome qualifications and limitations regarding these estimates deserve mention. Updated estimates and projections from the United Nations  and the US Census Bureau (fertility rates and cohort component projections) would alter the estimates herein. For instance, if demand for family planning increases faster/slower than expected, meeting the 75% benchmark should have a correspondingly larger/smaller affect. Moreover, our biometric models estimated fertility by assuming a constant relative mix among modern methods and incorporate factors other than contraception (marriage and postpartum insusceptibility) based on extrapolations from the two most recent DHS studies – future studies may suggest trends other than the ones we used. All in all, however, in the absence of major changes in such parameters, our primary substantive conclusions are unlikely to change dramatically. Further details about the sources we used, the methods through which they were derived, as well as statistical and other limitations, are available ,15,23.The indicator examined in this study – met demand for family planning – is an appealing one. Rather than specify a pre-set target of contraceptive use or an ideal family size, this indicator measures success by satisfying individual’s and couple’s own expressed desires for family planning through voluntarism and informed choice . To our We quantified that impact by assembling demographic evidence, developing biometric models and performing population projections (reference and benchmark) for 13 countries expected to be furthest from meeting the benchmark. Although there is uncertainty as to whether the benchmark can be achieved in most developing countries , as well


Previous research indicated that dietary diversity had favorable association with metabolic syndrome (MetS), and it has not been investigated in China.n=4308). Dietary diversity was measured by modified Dietary Diversity Score (DDS). MetS was defined by the harmonized criteria. The association between DDS and MetS was investigated by multivariable adjusted logistic regression.Adults (aged 18+) with complete dietary and biochemical data were collected from 2009 China Health and Nutrition Survey (P<0.05). However, this association reversed for old female (>60) and male adults (>45&≤60). Greater DDS was associated with higher serum TGs, and lower HDL-C level for male adults, higher blood pressure for old men, but lower blood pressure and fasting blood glucose in young men .An inverse-U shape relationship between MetS risk and age was detected for both genders, and female were more vulnerable than male at old times. More diversified diet decreased the risk of MetS for young female (≥18 & ≤45), similar trends were detected in serum TGs, abdominal adiposity, blood pressure, and fasting blood glucose (all Male adults and old female had the highest risk of getting MetS. More diversified diet decreased MetS risk for young female, but increased the risk for male adults and old female. Metabolic syndrome (MetS) is a complex of anthropometric and biochemical marker aberrations including abdominal obesity, insulin resistance, dyslipidemia and high blood pressure  . MetS wDiet is a key melleable risk factor for multiple chronic diseases . GloballPrevious studies found a negative association between dietary diversity and MetS in Iran, Korea, and Brazil -23. SimiTable Table No significant association was detected between DDS tertiles and MetS when the analysis was done with the multivariable logistic regression in both male and female , adult (45∼60), and old (>60). Age was treated as categorical variables and the interaction term between age and DDS tertiles was used to replace age and age square in the former model . However, individual oil consumption is not available in our dataset, which restricted our further analysis. Additionally, the inter-relations among individual components of MetS may attenuate the association between DDS and MetS. Finally, MetS is the result of jointly work of genetic and environmental factors. Ignoring these factors might bias our estimation of the association between DDS and MetS. Therefore, interventional or longitudinal study should be carried out to reinforce our analysis.In spite of the limitations of our research, this study still has a number of strengths which could contribute to the current literature. First, we predicted the risk of having MetS for men and women at different ages, and found that women have lower risk of being MetS in comparison with men at young age, but the risk overpasses men when they get older. Moreover, middle-aged men and old women are more vulnerable to MetS, and the susceptible age of MetS for men and women are around 50 years old and 70 years old respectively. Thus, further intervention strategy should be design for men and women individually. Second, we exclude patients with hypertension, stork, diabetes and myocardial infarction, so the dietary of the remaining participants can better reflect the real food consumption in association analysis. Third, using a population based, represented sample of Chinese adults, our finding could be extrapolated to generalize Chinese adults.MetS is considered as a substantial predictor of CVD and all-cause mortality. China is undergoing ageing and nutrition transition simultaneously and inevitably. MetS can be well controlled via health promotion and health education strategy, which can be designed specifically for each subpopulation. Regarding the ageing and shrinking population in China, improving the health status of ageing people is a long-term strategy for the labor force market , and we CHNS was implemented by the University of North Carolina at Chapel Hill (UNC-CH) and the Chinese Institute of Nutrition and Food Safety (INFS), and China Center for Disease Control and Prevention (CCDC). This survey was approved by the Institutional Review Board of aforementioned institutions. All participants provided the written informed consent. Detailed information about this survey and laboratory examinations has been described elsewhere . This stIndividual daily food consumption data were collected through face-to-face interviews for 3 consecutive days which are randomly distributed within one week. Trained field interviewers helped each participants recall the food that they consumed at home and outside in a 24-h period and recorded the codes (listed in the Food Composition Table of China), types, amounts, and locations of consumption for each food item by using food models and pictures. More detailed information about the dietary data in CHNS has been previously reported .In line with previous studies, we combine the original 12 major food categories in Chinese Food Composition Table into 6 broad groups  based on similarities in nutrient composition and dietary function. Detailed information about DDS has been depicted in previous studies , 46, 47.Waist circumference, height and weight were measured by trained health worker using regularly calibrated equipments under the instructions of manufacturers. Blood pressure was measured after thrice rest in a seated position, each rest lasts for 5 minutes. It was utilized to calculate the average value of systolic blood pressure (SBP) and diastolic blood pressure (DBP). Blood sample was collected after 12-14h overnight fasting from all participants, and was stored in vacationer tubes. All blood samples were analyzed in the central laboratories of China-Japan Friendship Hospital. Fasting plasma glucose was measured by GOD-PAP, using the kit produced by Randox, UK. Serum high-density lipoprotein cholesterol (HDL-C) concentration was measured by enzymatic method; serum triglyceride levels was measured by CHOD-PAP; these two testing reagent were produced by the Kyowa, Japan. The last three indices were measured by the Hitachi 7600 machine.MetS was defined according to the harmonized definition of the International Diabetes Federation and other organizations , that thSocio-economic characteristics such as sex, age, income per capita, educational level , total energy intake, smoking status  and drinking status , and residential area  were collected as co-variables. Physical activity was defined according to occupation , and adjusted in the model as well. Adults were categorized into three age groups according to the WHO standards .The descriptive statistical were presented at each tertiles of DDS for each sex. Continuous variates are presented as means ± SEs and categorical variables are presented as percentages.The association between DDS and MetS and its individual components was detected by multivariable-adjusted logistic regression, both the OR values and 95% CI were presented. Aformentioned socio-economic variables were adjusted in the multivariable regression model. Income and total energy intake were measured in logarithm. The association between predicted probability of MetS and age was mapped using kernel weighted local polynomial smoothing; both the fitted probability and 95% confidence interval were presented. The linear trend of odds ratio for DDS was tested by taking DDS as continuous variable in the multivariable logistic regression.All analyses were performed with Stata MP 13.0  and P<0.05 was considered as statistical significance.


Suicide is the second cause one of the leading causes of death in young individuals. Timely and adequate identification of individuals with suicidal ideation could prevent from suicidal behavior. Psychotic experiences (PE) have been shown to increase levels of suicidal ideation (SI) in the general population. Therefore, detailed investigation of the relationship of PE and SI is relevant. However, the exact nature of the relationship between these two phenomena remains unclear, which is intensely debated nowadays. Given both the high complexity of SI and behavior and the fact that its expression has a trans-diagnostic nature, a fruitful approach to gain new insights about its relationships with psychiatric symptoms might be the application of network analysis, which could be helpful to elucidate specific associations existing between PE and SI.A specific type of network analysis, the Ising model, was used to examine connections between dichotomized questions on psychotic experiences and suicidal ideation in a cross-sectional study with 1685 adolescents from the general population aged 13–18 years. To assess psychotic experiences, we used an item generation deductive method  of two pre-existing scales that we adapted in previous studies: the Brief Self-report Questionnaire for Screening Putative Pre-psychotic States , and the Community Assessment of Psychic Experiences—Positive scale . The questionnaire encompassed 15 items addressing the following dimensions: perceptual anomalies ; bizarre experiences ; social anxiety ; and negative symptoms . Suicidal ideation (SI) was assessed by six items of the Columbia–Suicide Severity Rating Scale , adapted for being used as a self-report questionnaire. Severity of SI was rated on a 6-point ordinal scale in which 1 = wish to be dead, 2 = nonspecific active suicidal thoughts, 3 = thoughts about how to commit suicide, 4 = suicidal thoughts and intentions, 5 = suicidal thought with detailed plan, and 6 = intentions to conduct plan.SI was mostly connected to the PE domains perceptual anomalies (PA) and bizarre experiences (BE), which have higher strength values in the network. Central nodes within these domains, as indexed by higher centrality measures (strength and betweenness) were: auditory experiences , persecutory ideation , and social anxiety (SA) (SA1: I cannot get close to people).Through a network analytic approach, our results add new insights to previous findings concerning the associations between psychotic experiences and suicidal ideation, suggesting that perceptual anomalies (mainly auditory experiences), social anxiety (being distant to people), and bizarre experiences (paranoid beliefs) are connected in a meaningful way to suicidal ideation in a network of symptoms in a sample of non-help-seeking adolescents. Given the potential advantages of the network analysis to study psychopathology and suicidal behavior, its usage can contribute to a better understanding of the nature of the complex relationships between these phenomena. Future network analysis studies should include additional symptom domains to analyze whether the associations between PE and suicidal behavior are undifferentiated; are specifically and independently associated, regardless of antecedents of mental disorders; or if the associations are not specific, but merely reflect a higher underlying risk of suicidal behavior as a function of psychiatric symptoms or mental distress.


Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern.To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples’ preferences, needs, opportunities and barriers to palliative care.A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly’s hierarchy of evidence-for-practice in qualitative research.Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples’ experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements.The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas.The online version of this article (10.1186/s12904-018-0325-1) contains supplementary material, which is available to authorized users. Palliative care services aim to improve quality of life (QoL) among patients with life-threatening illnesses and their families . These sIn developed countries, palliative care now warrants attention as a priority for Indigenous people , given their disproportionate burden from chronic diseases and higher mortality rates compared with non-Indigenous people . HoweverThe objective of this review was to learn from experiences and inform ways to improve palliative care service delivery for the Indigenous peoples of Australia, Canada, NZ, and the USA, recognising that the Indigenous peoples of these four developed countries share similar histories of colonisation and marginalisation. We aimed to highlight what is known of the needs and preferences of Indigenous patients at the EOL, any barriers to quality care at this time, but primarily the focus was to identify the key features of specific models of care and innovative strategies developed to address these needs, preferences and barriers. We adopted the Agency for Clinical Innovation’s definition of Model of Care (MOC) which is broadly defined as ‘the way health services are delivered. It outlines best practice care and services for a person or population group or patient cohort as they progress through the stages of a condition, injury or event. It aims to ensure people get the right care, at the right time, by the right team and in the right place’  p.3. InnThe review of studies was conducted in accordance with the principles of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement , with thThe search was from the year 2000 and was conducted in November 2016 across the following databases: PubMed, CINAHL, Embase, PsycInfo, InfoRMIT, Global Health, ScienceDirect, Web of Science and Scopus. The key concepts of ‘palliative care’ and ‘Indigenous’ were searched using a combination of prescribed subject headings and free text keywords.  independently reviewed the full text of articles, and conferred in pairs to confirm whether articles met the selection criteria. Any remaining uncertainties were discussed and resolved by the entire team. A publication was excluded following full text examination if it: (i) included no findings on the provision of palliative care to Indigenous patients ; (ii) included findings only on advance care planning and EOL care within aged-care services; (iii) had a primary focus on cultural or ceremonial EOL practices; iv) focused on pre and post bereavements rather than on the patients care ; (v) described palliative care education programs, or (vi) was an opinion or reflection piece without research findings.Multiple papers from the same authors reporting on the same study population were included only if different findings were reported.The methodological quality of the selected publications was assessed using Daly’s hierarchy of evidence-for-practice in qualitative research  . Only 17A data extraction pro-forma was developed in Microsoft Excel to assist identifying the details of the study design, aims, sample, study context, analytical framework and key findings, including needs, preferences, barriers, opportunities, and also critical elements of approaches/ initiatives/ models of palliative care service delivery to Indigenous peoples. Data extraction was performed by the authors , initially individually, then working in pairs to confirm the themes. Thematic synthesis  was usedn = 660) had been discarded, 515 potentially relevant articles were identified through our search, and an additional 7 through citation snowballing. Of the 522 publications, 408 were excluded during title and abstract screening. Full text review of the remaining 114 publications eliminated a further 75 that did not meet the inclusion criteria, leaving 39 articles to be included in the systematic review.Once duplicates , New Zealand (10), Canada (8), and the USA (12). In 11 studies, the study population consisted of both Indigenous peoples and clinical staff (both Indigenous and non-Indigenous), 17 studies included Indigenous peoples only and three comprised service providers only (both Indigenous and non-Indigenous). Four studies comprised diverse ethnic groups including Indigenous peoples, and five studies did not specifically mention the study population as two of them were literature reviews, and three described specific models for Indigenous populations. The Indigenous populations studied included Aboriginal and Torres Strait Islander Australians, Māori and Samoans, Canadian First Nations , Métis, Alaska Natives , Native Americans , and Native Hawaiians.n = 33 [85%]) focused on the provision of general palliative care with no terminal condition specified, three focused on palliative care for cancer patients, and one on palliative care for patients with a chronic disease other than cancer. Most studies (29) used qualitative methods only, five were based on mixed methods, two were quantitative, two were literature reviews and one described a palliative care model.Most articles (The majority of the articles (30) contributed to findings about the palliative care needs and preferences of Indigenous people and the barriers they face in this context. Only 17 papers described actual approaches  were identified as key barriers to access palliative care services , 42, 45.Differences between Western medical models and Indigenous cultures in understandings of and priorities for EOL care pose a major issue within the health care setting. Disrespectful and racist treatment by HSPs, and difficulty in regards to communicating EOL care issues to Indigenous patients and families, were also identified as barriers , 46, 47.A range of models and innovative service delivery strategies, for delivering EOL care for Indigenous communities across the four countries, were identified from the literature Table . The mosHands-on, practical, and innovative service delivery models were identified as having adopted diverse strategies to deliver palliative care into communities. The service models included: Patient Navigators Model , OutreacIn most cases, evaluations of these service models have been included in the published literature, with the following positive short-term outcomes reported Table : symptomThe contexts for implementing these innovations varied: some were in-patient hospital or hospice settings whereas others were in community-based care settings. Common themes and critical elements that have facilitated EOL service delivery to Indigenous populations are discussed below Table .Table 5CEffective service models implemented in rural or remote settings demonstrated strong community connection and involvement from the outset , 33, 49.Providing continuing education and training to upskill HSPs and community stakeholders and family members is an integral part of all community-based program models , 23, 48.Various service delivery strategies have been identified. Attributes of individual staff were identified as particularly crucial for service delivery models like the Navigator Model, whereas the IHSD Model  adopted A report on innovative palliative care programs noted that they tended to be more successful when implemented in stable institutions, i.e., those not experiencing severe financial stress or undergoing structural changes . SuccessOrganisational level changes were reported in Outreach Care, a non-residential, community-based hospice organisation in New Zealand, when the organisation was required “to move beyond Eurocentric individualism to a more collectivist approach to care” . OutreacPalliative care service providers sometimes underwent infrastructure refurbishments to make their service more comfortable and accessible to Indigenous patients and their families , 53, 54.Patient-centred care that is “respectful of and responsive to the preferences, needs and values of patients and consumers” was prioritised in all these service models. The dimensions of patient-centred care are “respect, emotional support, physical comfort, information and communication, continuity and transition, care coordination, involvement of family and carers, and access to care”  p.13.“when a client is terminal, we work hard to take a neutral position relative to cancer treatment. We provide information and allow them to make their own decisions about continuing chemotherapy and other treatments. If a client starts saying he/she is ‘tired of treatment and pain’ and ‘it’s time to return to God’, we discuss what the client and family want of the future, and provide information about advance directives, palliative care, and hospice.” [ospice.” The availability of navigators’ support during EOL phases was successful in ensuring that patients found cancer care understandable, available, accessible, affordable, appropriate, and accountable. Navigators work as cultural brokers and interpreters for their clients, and ensure that the clients are participating fully and actively in care . One navAs part of the IHSD Model, implemented through the Promoting Excellence in EOL Care program in the USA, different communities adopted different locally suitable strategies to promote EOL care. The IHSD model introduced new standards and protocols to ensure delivery of core palliative care services: pain and symptom management, psychosocial care, spiritual counselling and support, QoL improvement and continuity of care, value-based care, and life-review . Twenty Most of the projects, especially those under the Promoting Excellence in Palliative Care program in the USA , used esThis comprehensive review of the literature has identified a variety of key innovative strategies for delivering palliative care to Indigenous communities in Australia, NZ, Canada, and the USA. Preferences, barriers and needs that can influence quality of palliative care for Indigenous patients and their families have also been examined. Despite diversity amongst the included Indigenous communities, similarities in terms of the needs and preferences were observed in the literature. Many of the issues identified are not likely to be very different from those of other people at the EOL; however, HSPs drawing on those that were more unique to Indigenous people might make a big difference to the care for Indigenous people globally. Overwhelmingly the included publications focused on community-based palliative care services. There were very few examples in the literature of culturally safe palliative care delivery within hospital inpatient settings or specifically designed ‘stand-alone’ inpatient palliative care facilities . This could be because of the preference of Indigenous people to be cared for at home


Imaging is critical in the diagnosis and treatment of dementia, particularly in vascular cognitive impairment, due to the visualization of ischemic and hemorrhagic injury of gray and white matter. Magnetic resonance imaging (MRI) and positron emission tomography (PET) provide structural and functional information. Clinical MRI is both generally available and versatile – T2-weighted images show infarcts, FLAIR shows white matter changes and lacunar infarcts, and susceptibility-weighted images reveal microbleeds. Diffusion MRI adds another dimension by showing graded damage to white matter, making it more sensitive to white matter injury than FLAIR. Regions of neuroinflammatory disruption of the blood–brain barrier with increased permeability can be quantified and visualized with dynamic contrast-enhanced MRI. PET shows metabolism of glucose and accumulation of amyloid and tau, which is useful in showing abnormal metabolism in Alzheimer’s disease. Combining MRI and PET allows identification of patients with mixed dementia, with MRI showing white matter injury and PET demonstrating regional impairment of glucose metabolism and deposition of amyloid. Excellent anatomical detail can be observed with 7.0-Tesla MRI. Imaging is the optimal method to follow the effect of treatments since changes in MRI scans are seen prior to those in cognition. This review describes the role of various imaging modalities in the diagnosis and treatment of vascular cognitive impairment. Vascular etiologies are among the most common causes of dementia, but the numbers vary considerably according to the different criteria used for vascular cognitive impairment (VCI) , 2. AccoFurthermore, it is evident from autopsy studies that many patients with mixed dementia have both vascular and degenerative causes , 5. The For this review, based on the lectures presented at the International Congress of Vascular Dementia in Ljubljana 2015, additional literature was searched in PubMed and relevant publications were selected with special prioritization to publications published over the last 10 years. Due to limitations in space, a complete coverage of the extensive literature on this widespread topic was not possible.Neuroimaging provides important information on the neuroanatomical substrate of the disorder, plays an important role in the diagnosis, and adds to the prediction of VCI. Most acute stroke patients undergo brain imaging by computed tomography (CT); thus, studies using CT are representative of the whole clinical population. In clinical practice, CT is performed primarily to exclude hemorrhage and stroke mimics (such as brain tumors), and can often demonstrate early signs of ischemia  and old stroke lesions. Furthermore, the presence and severity of WMHs and brain atrophy can also be readily determined from CT brain scans, which may predict subsequent cognitive impairment and dementia. There is good agreement between brain atrophy and moderate to severe white matter lesions on CT and MRI measurements , 13.2 -PK11195 and others) have been developed to measure the activity of microglia (the most important cellular marker of neuroinflammation) in the ischemic brain in vivo and can be used to address these questions [11C-PiB) and microglia activation (11C-[R]-PK11195). Cognitive performance 5–7 months after the stroke was negatively correlated with gray matter amyloid deposition and this relationship remained significant even when initial cognitive performance and age were entered as covariates into the analysis. Similarly, microglia activation in the stroke-affected hemisphere white matter was highly correlated with cognitive performance [Several PET tracers (such as uestions . While auestions , 83, it uestions  and in vuestions , that isuestions  and thusformance . The res1H-MRS, diffusion tensor imaging, and DCEMRI augment clinical MRI studies by showing ischemic damage to white matter and disruption of the BBB, a major factor in neuroinflammation. It is important to separate patients with mainly AD from those with mainly VCI; however, in reality, the majority of patients appear to have combinations of both. Planning clinical trials of patients with VCI is a critical need, and the ability to more clearly delineate between AD, VCI, and mixed pathology will be crucial to reduce the number of patients needed for a trial. A longitudinal study comparing the development of clinical symptoms with changes in imaging, including various MRI parameters and eventually quantitative data from PET followed by validation through neuropathological confirmation, would be the ideal basis for long-term treatment studies.Neuroimaging will continue to play a leading role in the diagnosis of patients with dementia. While MRI is the most widely used modality and is available in most centers, PET offers the ability to distinguish between the vascular and neurodegenerative causes of dementia. Further,


Clinical quality registries (CQRs) are playing an increasingly important role in improving health outcomes and reducing health care costs. CQRs are established with the purpose of monitoring quality of care, providing feedback, benchmarking performance, describing pattern of treatment, reducing variation and as a tool for conducting research.To synthesise the impact of clinical quality registries (CQRs) as an ‘intervention’ on (I) mortality/survival; (II) measures of outcome that reflect a process or outcome of health care; (III) health care utilisation; and (IV) healthcare-related costs.The following electronic databases were searched: MEDLINE, EMBASE, CENTRAL, CINAHL and Google Scholar. In addition, a review of the grey literature and a reference check of citations and reference lists within articles was undertaken to identify relevant studies in English covering the period January 1980 to December 2016. The PRISMA-P methodology, checklist and standard search strategy using pre-defined inclusion and exclusion criteria and structured data extraction tools were used. Data on study design and methods, participant characteristics attributes of included registries and impact of the registry on outcome measures and/or processes of care were extracted.We identified 30102 abstracts from which 75 full text articles were assessed and finally 17 articles were selected for synthesis. Out of 17 studies, six focused on diabetes care, two on cardiac diseases, two on lung diseases and others on organ transplantations, rheumatoid arthritis, ulcer healing, surgical complications and kidney disease. The majority of studies were “before after” design (#11) followed by cohort design (#2), randomised controlled trial (#2), experimental non randomised study and one cross sectional comparison. The measures of impact of registries were multifarious and included change in processes of care, quality of care, treatment outcomes, adherence to guidelines and survival. Sixteen of 17 studies demonstrated positive findings in their outcomes after implementation of the registry.Despite the large number of published articles using data derived from CQRs, few have rigorously evaluated the impact of the registry as an intervention on improving health outcomes. Those that have evaluated this impact have mostly found a positive impact on healthcare processes and outcomes.CRD42015017319PROSPERO  Clinical registries play an important role in monitoring disease and healthcare delivery patterns and generating real world evidence of the impact of treatment and service delivery models on health outcomes –3. IncreRegistries play an important role in medical research. Data within registries provide an ideal platform for randomized clinical trials, reducing both time and cost of prospective data collection . The colGitt et al.  identifiHealth care systems costs in developed countries are rising, in part due to the introduction of advanced medical technology, pharmaceutical expenditure, hospital care and services as well as the high prevalence of chronic diseases and their financial consequence , 38. OneExamples of clinical quality registries can be found across most clinical specialities, monitoring both chronic and acute stages of illness. Acute stroke registries have been established in Sweden, Germany, Canada, Australia, the US, Argentina and many other countries –46. The Emilsson et al  recentlyIt is evident that the clinical registries, including CQRs, are being established as a tool to monitor and improve quality of care and as a platform for epidemiological research . Yet, deA clinical registry is described as a system which collects a defined minimum data set from patients undergoing a particular procedure or therapy, diagnosed with a disease or using a health care resource .In this systematic review we define CQR as a sub-group of clinical registries which systematically collect health-related information on the quality, safety and outcomes of care provided to individuals who are treated with a particular surgical procedure, device or drug; diagnosed with a particular illness; or managed via a specific healthcare resource . CQRs arBased on a pilot search it was evident that there were likely to be insufficient randomised controlled trial (RCT) studies assessing registries as an intervention to enable a meta-analysis to be undertaken. Therefore, a decision was made to include before-after, case control, cohort and controlled clinical trial study designs in addition to RCT studies.A description of the population, intervention, comparison and outcome (PICO)  of the sStudies with and without comparators were eligible for inclusion. Comparators were considered contemporaneous data sources such as hospital administrative databases, insurance databases and clinical information systems measuring mortality/survival; processes of care; outcomes other than mortality/survival; healthcare utilisation and costs.Studies conducted in clinical environments which were considered acute care (inpatient and outpatient), sub-acute care (rehabilitation centre) and community  were included.The primary outcome measure was impact of clinical registries, including CQRs, on survival or mortality. Secondary outcome measures were those reflecting a process or outcome of health care , health care utilization and costs. Quality of care measures included those assessing impact of the registry on patient safety (complications), timeliness (reduce waits and harmful delays), effectiveness , efficiency (avoid waste), equitable access to the services , and patient centeredness  .Before finalizing the search strategy, a pilot search strategy was developed, tested and amended as necessary across the different databases. Once the search strategy was finalized and agreed upon among the team, it was then refined by a senior medical librarian (LR). A database record was maintained at each stage of the review process including the detailing of how the search was undertaken and results of the search strategy.The following electronic databases were searched: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL and Google Scholar to identify studies in English covering the period January 1980 to December 2016. The search strategy included keywords describing studies involving established registries as the intervention. The MeSH terms relating to registry or registries combined with the MeSH terms referring to mortality, morbidity, patient reported outcome, health care utilization, cost/economic evaluation and clinical competence were included in the search.Additional searches were conducted of grey literature resources such as conference websites and government websites, searching without limiting by outcome, searching informal sources such as conference abstracts and PhD theses. Hand-searching and reference checking of citations and reference lists were also undertaken.Titles and/or abstracts of studies identified using the search strategy and those from additional sources were distributed among four review authors. Two review team members independently retrieved and assessed the eligibility of the full text articles of potentially suitable studies. Any disagreement between the two reviewers was resolved through discussion with the third review author of the study team.A standardised data extraction form was developed and piloted, based on the template of the Cochrane data abstraction form . Data exThe first author (DEH) extracted the data; and inconsistencies were discussed with the second review author (VK) and if necessary with the third author (SE).Our study protocol has been registered on PROSPERO: the international prospective register of systematic reviews (ID: CRD42015017319) and the study protocol has been described elsewhere .We followed the guideline for narrative synthesis for systematic reviews proposed by Popay J et al  as approNarrative synthesis of the selected articles was undertaken. It was not possible to conduct a meta-analysis because of heterogeneity among the study populations; coverage, duration and outcomes of interest, made it not possible to pool results. There was also variation among registries in follow-up, reporting mechanism, data management, quality assurance, audit mechanisms and processes; and feedback to stakeholders. Moreover, only two studies were RCT.The results of our search strategy and selection process are presented in “Through primary database screening, we identified 30102 articles. In addition, through hand searching, and reference searching of citations we identified an additional eight documents. After removal of duplications the numbers of abstracts reduced to 27856. Initially, 393 articles were screened after reviewing titles and abstracts. After reviewing 75 full text articles, a total of 17 articles were selected for final synthesis. All the selected journals were published between 2003 and 2015.Details of the included studies and their Key characteristics are described in Four studies measured the registries association with either mortality or survival as the primary outcome , 71, 72;P < 0.01) than the control arm. Those patients visiting registry clinics reported accessing counselling programs significantly more often (P < 0.001) than patients receiving care in the control condition [With regard to the impact of the registry on process of care measures such as compliance with evidence-based guidelines, the findings were principally positive. The RCT by Thomas et al  assessinondition . Jakobseondition  demonstrOf six registries monitoring diabetes care assessed by HbA1c and lipid test results showed a positive benefit –66, 74 oOne study reported that use of a diabetic registry was associated with a higher average number of patients and attendances by patients with diabetes per GP compared to those not using a registry . Öien etÖien et al found that there was a significant reduction of healing time for hard-to-heal ulcers when the registry was used 21 weeks in 2009 to 9 weeks in 2012. Geubbels et al , reporteNone of the 17 studies included in this review rigorously evaluated the cost effectiveness of the clinical registry.One registry has demonstrated significantly reduced regional difference of improving clinical practice and core results .In this review our primary objective was to establish the impact of registries, including CQRs, on mortality or survival. We identified four articles which reported on survival, of which two demonstrated a positive impact. Our secondary objectives were to assess impact on processes or outcome of health care other than survival or mortality, health care utilization, clinical outcome and cost. We identified 17 articles which assessed the impact of clinical registries on secondary outcomes of which all articles reported a positive impact except one  and few Our finding that few studies have rigorously evaluated the impact of clinical registries as interventions on improved health outcomes may be explained by a number of factors. Firstly, we found it difficult to disentangle registries as interventions from larger quality improvement projects which use registries to store data. For example, the Get with the Guidelines (GWTG) Stroke, Coronary Artery disease and Heart failure programs collect data on patients with these diseases and report performance measures back to hospitals as part of a quality improvement cycle , 78. TheAnother reason for the limited number of studies evaluating registries as interventions may be that researchers have not established them with quality improvement as an outcome in mind. Registries are often established to describe patterns of care, to understand variation in treatment and outcomes and predictors of prognosis and quality of life. Yet, many have not been set up to report quality of care data back to health services. Often population-based registries store data for reporting to government and for research purposes but fail to collect data which is meaningful to health services to assess their performance or, if they, do not make it available to the health services, so that they can see how they compare with others and with themselves over time.Finally, it may be that there were few studies evaluating the impact of registries because researchers and sites investing heavily in the development of registries have been reluctant to formally assess their impact through rigorous trial design. Establishing a registry requires substantial resources, infrastructure and sustained funding .While we found no studies during our study period of investigation to December 2016 comparing the cost effectiveness of registries, two articles have provided supportive evidence of cost-effectiveness of investing in the registry  and a reThis is the first review which has rigorously evaluated the impact of registries as interventions on quality of care. We found that registries play an important role in care management processes through generating performance feedback reports to physicians , 66, helOur review has several limitations. These include the quality of the studies and the heterogeneity of the study populations, coverage, duration and outcomes of interest, making it impossible to pool results. We found variation in follow-up, reporting mechanism, data management and quality assurance, and audit of data within the registry. Reporting and feedback mechanisms of the registries to stakeholder were also diverse; an issue similar to other review findings .Only two , 60 of tWhile effort was made to minimise publication bias by including a broad search strategy including both the academic and grey literature, it may be that further evidence exists on the impact of registries on health outcomes, care utilization and costs but is not yet published. As we limited our search by English language, we may have missed relevant article which published in other languages. However, the major shift towards publication of studies in English, the extent and effects of language bias may have recently been reduced.As registries continue to proliferate, there is a need to more rigorously evaluate their impact within and across disease conditions. This includes identifying what attributes of registries are most effective and which have little or no impact. Registries should consider using progressive study designs such as stepped wedge RCTS. This provides the advantage of allocating all sites the intervention at some point in time . BecauseDespite the large number of published articles using data derived from clinical registries, few have rigorously evaluated the impact of the registry as an intervention on improving health outcomes; those that have evaluated this impact have mostly found that registries have improved healthcare processes and outcomes. No studies have evaluated the economic impact of registries as an intervention.S1 Table(DOCX)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.


Breach of confidentiality or invasion of privacy from the collection and use of medical records, particularly those of patients with HIV/AIDS or other diseases sensitive to stigmatization, should be prevented by all related stakeholders in healthcare settings. The main focus of this study was to assess practices regarding security and confidentiality of HIV-related information among staff at HIV outpatient clinics (HIV-OPCs) in Vietnam.A descriptive cross-sectional study was conducted at all 312 HIV-OPCs across the country using an online survey technique.In general, the staff practices for securing and protecting patient information were at acceptable levels. Most staff had proper measures and practices for maintaining data security; however, the protection of patient confidentiality, particularly for data access, sharing, and transfer still required improvement. Most HIV-OPC staff had good or moderate knowledge and positive perceptions towards security and confidentiality issues. Staff who were not trained in the practice of security measures differed significantly from those who were trained ; staff needing improved knowledge levels differed significantly from those with good  and moderate knowledge levels ; and staff needing improved perception levels differed significantly from those with good  and moderate perception levels . Staff who were not trained in the protection of data confidentiality differed significantly from those who were trained .Training is an important factor to help raise the levels of proper practices regarding confidentiality and security, to improve knowledge and raise awareness about change among staff. The operation and management of HIV treatment and care in Vietnam are currently transitioning from separate healthcare clinics (HIV-OPC) into units integrated into general hospitals/healthcare facilities. The findings of this study highlight topics that could be used for improving management and operation of information system and revising guidelines and regulations on protection measures/strategies for data security and confidentiality of HIV/AIDS patients by Vietnam health authorities or other countries facing similar situations. Secure infrastructure and secure measures for data access and use are very important, worthwhile investments. The provision of continuous training and active enforcement and monitoring of the practices of healthcare personnel might lead to an improved understanding and acknowledegement of the importance of national policies/guidelines regarding HIV-related patient information. In Vession)” . Vietnamession)” . At the ession)” . Howeveression)” . Confideession)” –12.The use of patient-identifiable data must strike a balance between maximizing the benefits of data usage and minimizing potential harm owing to inadvertent or malicious release of sensitive data . VietnamConfidentiality and security measures are valuable because they reflect autonomy and control over personal information and free patients from the burdens of stigma, inequality, and discrimination . ConfideIn Vietnam, an HIV/AIDS care and ART program was established in 2000 by creating 312 HIV outpatient clinics (HIV-OPCs) nationwide. These clinics provide services exclusively for HIV patients, and patients at these clinics must provide personal identifiable-information to clinic staff. While Vietnam has escaped poverty and become increasingly prosperous, funding for HIV/AIDS programs has decreased rapidly with clearly reduced donor-sponsor support. This changing situation has obliged the Vietnam HIV/AIDS prevention system to be more streamlined . The HIVA balance is needed between the collection and sharing of individual-level data with the protection and safeguarding of such data, to optimize clinical care and to monitor and evaluate HIV services. The Joint United Nations Programme on HIV/AIDS (UNAIDS) investigated 98 mid- and low-income countries; reports varied substantially on issues of information governance and privacy, data storage and availability, data access, and data transfer , 22. SevThe target population for this study comprised staff working at HIV-OPCs. With respect to sample size, we required at least 384 participants for a confidence interval of 95%, with a 50% planned proportion estimate and absolute precision of 5%. The study was conducted at all 312 HIV-OPCs in Vietnam, with the expectation of about two staff members at each HIV-OPC participating in the study.A descriptive cross-sectional study design was applied using an online survey, during March-June 2016. A structured questionnaire was used , with thAn e-mail containing a link to an online questionnaire was sent to the heads of the 312 HIV-OPCs, who then forwarded the link to their HIV-OPC staff. Staff members were asked to participate voluntarily in the study by completing the online form, which was automatically submitted to a database.For the portion of the survey addressing knowledge (10 items), 1 point was given for each correct answer. Mean scores for knowledge were classified into three subgroups: Good (8–10 points), Moderate (6–7 points), and Needs Improvement (≤ 5 points). For the portion querying perception , a positive perception was established as responses of “Agree” and “Strongly Agree” with positive items, or “Disagree” and “Strongly Disagree” with negative items. Three subgroups for perception were also established: Good (8–9 points), Moderate (6–7 points), and Needs Improvement (≤ 5 points). To measure practice levels, the four-point Likert scale options were Always (≥ 80%), Often (≥ 50%), Rarely (< 50%), and Never (0%). Scoring of practice statements ranged from 1 to 4 for positive items and the reverse for negative items, respectively. The average scores were calculated for two sets of practices; i.e., security measures (4 items) and protection of data confidentiality (3 items). The average scores for the two types of practice were then classified into two subgroups representing staff with “proper practices” at an acceptable level (mean score ≤ 2) and “need improvement” practices (means score > 2).Descriptive statistics were used to describe the characteristics, knowledge, perception, and practices of the respondents. Chi-square tests were used to compare the proportions between subgroups. Logistic regression was used to assess the strength of associations between respondent characteristics and their knowledge and perception levels with the levels of practices for security measures and protection of data confidentiality.The study was approved by the Vietnam Authority of HIV/AIDS Control, Ministry of Health of Vietnam, and the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University, Thailand. For the first part on the online questionnaire, study participants who followed a link on the questionnaire were clearly informed of the study’s purpose, risks and benefits, and their voluntary involvement. Respondents were informed that they could stop at any time while completing the survey, that all data were kept confidential and secure and with no respondent identities, and that their answers to the survey would not affect their job.From all 312 HIV-OPCs in 63 provinces, 400 staff from 238 (76%) in 56 (89%) provinces responded to the online survey . RespondRegarding security measures , about 9The practices on protection of confidential data of the HIV patients were not fully compliant with the national policy and regulation . For datThe associations of staff characteristics with their practices on security measures and protection of patient data confidentiality were analysed separately Tables  and 4. FFrom the average scores of their practice rating on 3-items regarding protection of patient data confidentiality, the HIV-OPC staff were classified into two subgroups: 264 (66%) had proper practice and 136 (34%) needs improvement in their practices . Again, The results of this study suggested that security and confidentiality practices among HIV-OPC staff potentially increase the risk of revealing patient information. There has been a question whether separate HIV clinical settings, as compared with general hospital settings, would result in a greater or lower risk of breaching confidentiality. With the new approach when the treatment of ARV is conducted at a public health facility and ARV drugs are administered by a commune health station, HIV/AIDS patients are exposed to several different levels of healthcare personnel and other people, including non-HIV-infected patients. Therefore, the risk of exposing confidential information is higher, and ensuring security and confidentiality is more difficult. Before the changes in policy and management in 2017, all HIV-OPCs operated as separate units; the HIV information management software was a specific system and different from the information management system used at the public hospital and general healthcare facilities. From 2017 onwards, when the integration of HIV-OPCs into public hospital settings is implemented, a good management information system is essential to ensure the security and confidentiality of HIV/AIDS patients data that become part of the large information systems normally used in general hospitals. In the literature, an exit survey demonstrated that some integrated sites had raised concerns about patient confidentiality . A studyThe majority of HIV-OPC staff had good or moderate levels of knowledge (88%) and positive perceptions (72%) regarding issues about security measures and disclosing/ensuring patient confidentiality. It should be noted that their knowledge and perception levels on such issues did not differ across profession categories, which may have different roles and responsibilities for accessing and using patient information. The professionals also did not differ in terms of training in security and confidentiality issues; however, only about a quarter of all professionals had been trained.As a general rule in data security measures, personal information should be collected, stored, and disseminated in accordance with applicable national regulations . SeveralRegarding protection of confidentiality of patient information in practice, about 39% of HIV-OPC staff always or often obtained patient consent before sharing personal information. However, for staff who reported never obtaining consent, this might be partially because these personnel had no role in using such information. In other studies in Vietnam , 39, 38%In examining the associations of HIV-OPC staff characteristics with their security and confidentiality practices, differences were observed among those who had been trained and those who had not. Those who had been trained on the concepts of data security and safeguarding patient data by the Vietnam Ministry of Health had better practices for both security measures and protection of personal health information. A systematic literature review reported that the implementation of legal requirements in dealing with security and confidentiality of sensitive data was mostly due to non-technical measures, including education/training program and raising awareness of such issues . In anotKnowledge and perceptions regarding the security and confidentiality of patient information were found to affect the proper practices of HIV-OPC staff, particularly regarding to security measures. Although there were no statistically significant differences for practices of protection of personal health information, the trends appeared to be similar—staff with moderate/good knowledge and perceptions had better practices for safeguarding patient data. Compared with 58% of the general population in a semi-urban setting in another study , 88% of The findings of this study reflect the classic theories of associations between knowledge and perception with awareness and behavior. Behavioral theories have also suggested that training is important as it would have positive associations with knowledge, beliefs, perceptions, and behaviors , 57; theVietnam has regulations for the prevention and control of disclosure of HIV-identifiable information, and penalties for violations of the law , but theSeveral limitations should be acknowledged in this study. First, we used an observational survey design, and could only assess associations, not causation, between practices and potential factors, such as knowledge and perceptions. Second, several other organizational and structural factors might influence staff practices. As suggested in one guideline, the privacy and security of electronic health information might depend on the following: administrative safeguards, physical safeguards, organizational standards, and policies and procedures . It shouIn general, the practices among HIV-OPC staff for securing and protecting patient information were at acceptable levels. Most staff had proper practices for maintaining data security; however, protection of patient confidentiality, particularly for data access, sharing, and transfer, still needed improvement. Most HIV-OPC staff had good or moderate knowledge and positive perceptions towards security and confidentiality issues. Staff with good and moderate knowledge and perception tended to engage in proper practices more often than those needing improvement. Training in data security and confidentiality is an important factor for better practices, as it would also improve knowledge and raise awareness about the need to change the perceptions/attitudes of those needing improvement.As the operation and management of HIV treatment and care in Vietnam is in transition from separate healthcare clinics (HIV-OPCs) into units integrated into general hospitals/healthcare facilities, the findings of this study suggest issues that might be useful for revising guidelines and regulations by Vietnam health authorities or other countries in similar situations. In planning for development and implementation of the computerized system and case-management procedures during this transition period, one should take into consideration, and have clear strategies to ensure, information confidentiality/safety/security and the benefits for HIV patients. Although there are many advantages to this transition approach, concerns involve the confidentiality of data that might engender patient stigma and discrimination. One of the critical questions of concern in the plan is how to ensure the security and confidentiality of HIV patients’ information when this information will be shared with third parties, especially health insurance officers and other health workers at general hospitals and commune health stations where HIV patients are administered ARV drugs. Secured infrastructure and data access and use measures are a very important and worthwhile investment. The provision of continuous training and active enforcement and monitoring of the practices of healthcare personnel, in either HIV-OPC settings or HIV/AIDS units integrating into general hospitals should improve understanding and acknowledegement of the importance of national policies and guidelines regarding HIV-related patient information.S1 Appendix(DOCX)Click here for additional data file.


Little has been published comparing the graduate medical education training structure and requirements across multiple countries. The goal of this study was to summarize and compare the characteristics of anesthesiology training programs in the USA, UK, Canada, Japan, Brazil, Denmark, and Switzerland as a way to better understand efforts to train anesthesiologists in different countries.Two physicians trained in each of the seven countries (convenience sample) were interviewed using a semi-structured approach. The interview was facilitated by use of a predetermined questionnaire that included, for example, the duration of post-medical school training and national requirements for certain rotations, a number of cases, faculty supervision, national in-training written exams, and duty hour limits. These data were augmented by review of each country’s publicly available residency training documents as available on the internet.Post-medical school anesthesia residency duration varied: three years (Brazil), four years (USA), five years (Canada and Switzerland), six years (Japan and Denmark) to nine years (UK), as did the number of explicitly required clinical rotations of a defined duration: zero (Denmark), one (Switzerland and UK), four (Brazil), six (Canada), and 12 (USA). Minimum case requirements exist in the USA, Japan, and Brazil, but not in the other countries. National written exams taken during training exist for all countries studied except Japan and Denmark. The countries studied increasingly aim to have competency-based education with milestone assessments. Training duty hour limits also varied including for example 37 hours/week averaged over a one month with limitations on night duties (Denmark), a weekly average of 48 hours taken over a 17 week period (UK), 50 hours/week maximum (Switzerland), 60 hours/week maximum (Brazil), and 80 hours/week averaged over four weeks (USA).Some countries have highly structured training programs with multiple national requirements with training principally carried out at a home institution. Other countries have a more decentralized and unregulated approach with fewer (if any) specific case or rotation requirements, where the trainee creates his/her own customized training to meet broad objectives and goals. The countries studied have different national training requirements, unique duty hour rules and are at varying stages in transitioning to an outcome based model of residency. Although some descriptions of the methodology of training in anesthesia in individual countries have been published , few if This is at a time when regulatory bodies in different countries are changing training requirements. For example, the Next Accreditation System was launched in the USA by the Accreditation Council for Graduate Medical Education (ACGME) in 2012 as a shift towards competency-based medical education where educational outcomes are emphasized instead of the traditional structure and process based approach of graduate medical education . New traThe goal of this study was to summarize and compare the characteristics of anesthesiology training programs in the USA, UK, Canada, Japan, Brazil, Denmark, and Switzerland as a way to better understand efforts to train anesthesiologists in different countries.After human subjects approval, two physicians trained in each of seven countries (convenience sample) were interviewed by the first author using a semi-structured approach facilitated by the use of a predetermined questionnaire about national requirements of anesthesia training programs in each respondent’s home country.Specific items of interest included: duration of post-medical school training, minimum case number or rotation requirements, use of competency-based curriculum, faculty supervision, duty hour limits and national in-training written exams.Questionnaire data were augmented by review of each country’s publicly available residency training documents as available on the Web and by visiting the official website of the governing anesthesia body in each country.Selection of applicants for anesthesia training differs between the countries studied. A mathematical computer algorithm is used to match an applicant to the program most preferred on that applicant’s rank order list in the USA and Canada. Other countries have candidates directly apply to a particular region or facility for training Table .Years of training after medical school ranged from three (Brazil), four (USA), five (Canada and Switzerland), six (Japan and Denmark) to nine (UK).Direct faculty supervision of residents was required in all countries at all times except under some circumstances in the UK and Denmark Table .Requirements for a minimum number of certain case types exist in the USA, Japan, and Denmark but not in the other countries Table  and 4.Training duty hour limits also varied for example 37 hours/week averaged over a one month with limitations on night duties (Denmark) to 80 hrs per week (USA) Table .   Some countries offer highly structured training programs with multiple national requirements and training principally provided at one primary facility, whereas other countries have a more decentralized and unregulated approach with fewer if any, case or rotation requirements.Different countries are at various stages in reaching an outcome based model of residency. In Canada the competence by design initiative will transition graduate medical education from a traditional time-based model to a hybrid form of competency-based medical education . DenmarkJapan implemented major revisions to residency requirements and anesthesia board qualification system in 2015. Historically in Japan, to address the need for anesthetists an “anesthesia provider “qualification existed requiring a minimum of 300 cases or two years of anesthesia training. However, since 2015, all Japanese medical practitioners are now required to graduate a two year primary residency with rotations for many departments including surgical, internal and ambulatory medicine. After this two-year primary training, residents are eligible to apply for the four-year anesthesia residency, and when completed can then apply for board certification.The varied structure of training programs and board certification processes between countries may create challenges for national medical boards to assure quality of training among anesthesiologists that wish to practice in countries outside the one they trained. Many European countries have adopted written and oral board exams administered by the European Society of Anesthesia .The design and components of the optimal training method of anesthesiologists are unknown. The differences in training among residency programs even within the same continent may be in part due to different functions that anesthesiologists are expected to serve in each country. For example, compared to the USA the scope of practice for anesthesiologists in Western Europe may include prehospital emergency medicine that encompasses more complex front-line decision-making and requires specific residency training . SimilarA barrier in creating international minimum training standards, is that differences exist in taxonomy of current competencies. For example, the ACGME in the USA outlines six core competencies  whereas the Canadian Medical Education Directives for Specialists utilizes different terms . Switzerland, as an example of how European countries differ from North America, specifies its own set of ten core competencies [i].Work hours also vary between different countries. As a result of the European working time directive 2003/88/EC, many European countries were legally mandated to decrease their weekly working hours to 58 hours in 1998, then 56 hours in 2007, and to a maximum of 48 a week in 2009 -11. OtheDuty hours restrictions have also been the subject of scrutiny in the USA. In 2011, the ACGME first limited trainee work hours to no more than 80 hours per week. The impact of this change on education and practical training still remains to be elucidated. Some studies suggest that work hours restrictions may have had the unintended consequence of adversely impacting patient care thought to be due to a lack of continuity of care and increased the frequency of handoffs -14.Only the USA, Canada, and Brazil specify that certain rotations be a required minimum duration. Trainees in the UK, in contrast, for example, spend three to six months at a time rotating at different hospitals in the geographical region (of the deanery) and during that time the trainee is expected to have their clinical experience units and knowledge and competencies be signed off. At annual review, overall progression is assessed by deanery-appointed consultants, but at each hospital, there is one consultant who is designated as the ‘college tutor’ for residents to consult, with regards to their progression.With regard to clinical training, case logs may be utilized as a surrogate for clinical competency. Specified national requirements for a minimum number of cases in various subspecialties currently exist in the USA. Other countries such as Brazil  have overall case minimums but do not break it down further into actual subspecialty case numbers. Although Brazil has no specific minimum number of certain subspecialty case types, there are minimum annual workload percentages for the following domains: pre and postoperative care , ICU and emergency department (minimum of 15%), elective anesthesia  and obstetrics (minimum of 10%)  Disease management, patient assessment and preoperative preparation, intraoperative care, postoperative patient care and pain management, resuscitation and emergency management, practical anesthetic procedures/skills, quality management and health economics, anesthesia non-technical skills, professionalism and ethics, and education, self-directed learning and research.Although apprenticeship remains the primary way of teaching overall, each country has unique training structure and characteristics. Many countries have different national training requirements, unique duty hour rules and are at varying stages in transitioning to an outcome based model of residency. Some countries have a structured education within a dedicated network of training hospitals in which the resident completes all necessary training. Other countries have a less structured approach, where the trainee creates customized training rotations that meet broad objectives and goals. These differences in training requirements, program design and board-certification processes between countries remain of unclear significance with regard to how they affect clinical care and whether countries can improve their training programs based on what is being done in other countries.


Capacity to receive, verify, analyze, assess, and investigate public health events is essential for epidemic intelligence. Public health Emergency Operations Centers (PHEOCs) can be epidemic intelligence hubs by 1) having the capacity to receive, analyze, and visualize multiple data streams, including surveillance and 2) maintaining a trained workforce that can analyze and interpret data from real-time emerging events. Such PHEOCs could be physically located within a ministry of health epidemiology, surveillance, or equivalent department rather than exist as a stand-alone space and serve as operational hubs during nonoutbreak times but in emergencies can scale up according to the traditional Incident Command System structure. Every country needs a system for responding to emergencies and managing emergency response. Emergency Operation Centers (EOCs) are increasingly viewed as necessary components of emergency preparedness and are used for multiagency coordination and response to a variety of hazards, including natural disasters, chemical spills, radionuclear incidents, humanitarian emergencies, and disease outbreaks. Public health EOCs (PHEOCs) are physical spaces with the ability to monitor events using various sources of data, improve communication between public health and emergency management personnel, facilitate coordination with multiple response partners, and provide space for members of the incident command team to gather and work  has a 24,000-square-foot PHEOC staffed by trained personnel 24 hours per day, 365 days per year, on CDC’s main campus in Atlanta, Georgia  influenza pandemic; the Haiti cholera outbreak; and the outbreaks of Middle East respiratory syndrome, Ebola virus infection, and Zika virus infection  fragmented data streams that do not enable easy access to raw data for timely analyses and data use, 2) a small workforce that is responsible for most surveillance and response-related activities, 3) poor coordination during outbreaks resulting in slow response, and 4) limited resources dedicated to public health , officially launched in 2014, was developed to strengthen countries’ capacity to prevent, detect, and respond to human and animal biologic threats  in Hanoi and the Pasteur Institute of Ho Chi Minh City (PI-HCMC) lead the surveillance and outbreak response for the North and South regions, respectively, and collaborate with GDPM. NIHE has completed the establishment of a PHEOC, and PI-HCMC is in the process of doing the same. Vietnam plans to develop 2 additional PHEOCs in the remaining regional institutes in 2017. Both PHEOCs (NIHE and PI-HCMC) are situated physically and administratively in departments of epidemiology or disease control at the regional institutes and are staffed by epidemiologists within those departments, the same epidemiologists responsible for routine surveillance. A small number of support staff, including full-time PHEOC managers and information technology staff, are being recruited. During nonoutbreak times, the PHEOCs will be surveillance hubs where data from notifiable disease reporting from healthcare facilities, sentinel surveillance sites, and public health laboratory systems are all available through the data warehouse and displayed on data dashboards that automate routine analyses. Epidemiologists in each PHEOC will monitor and interpret the various streams of surveillance data to define usual patterns of disease transmission and monitor for aberrations. Data also are summarized for weekly distribution to policy makers in the MOH. The PHEOCs also will receive and incorporate event reports from the media, community, healthcare facilities, and event-based surveillance systems enabling more timely detection of emerging or small outbreaks. Separate real-time data dashboards are in place for priority diseases, such as Zika virus infection  Figure.After WHO declared Zika virus infection as a Public Health Emergency of International Concern, the national PHEOC at GDPM began operating as a nerve center for Zika virus preparedness and response  system is the framework for Cameroon’s disease surveillance and response. Public health policies, supervision and management of the health system, and IDSR at the central level are the responsibility of Ministère de la Santé Publique (MINSANTE), the Cameroon Ministry of Health. Cameroon has 10 regions with regional health delegations, and each is responsible for public health surveillance and response. Each region is further divided into districts, and the districts are additionally divided into health center catchment areas. These health center catchment areas are the outmost peripheral health units and may have community health volunteer networks. Aggregated reports of IDSR notifiable diseases are sent weekly from the districts to MINSANTE, and the process is completed by manual data entry shared by email.In 2014, Cameroon began developing a PHEOC, and MINSANTE prioritized its establishment to improve outbreak coordination, management, and response. The PHEOC was developed in the capital city, Yaoundé. It was created after several trainings of MINSANTE personnel, including training on the Incident Management System, participation in CDC’s Public Health Emergency Management Fellowship training program, and the execution of several tabletop exercises and simulations. This knowledge was shared within the country, through a course taught by the newly hired PHEOC manager, with support from CDC subject matter experts.The PHEOC was activated in May 2016 in response to an avian influenza virus A(H5N1) outbreak on a poultry farm in Yaoundé to enable the early detection of human cases, respond rapidly to interrupt human transmission, and oversee case management. A veterinary FETP fellow served as the liaison between the PHEOC and MINEPIA, Cameroon’s Ministry of Livestock, Fisheries, and Animal Industries, coordinating seamless communication between the National Veterinary Laboratory and the PHEOC. When the PHEOC was deactivated in June 2016, none of the human contacts had tested positive  , an antiviral medication used to treat persons with symptoms caused by influenza. Early in the PHEOC’s activation, all existing national stocks of Tamiflu were recognized to have expired, leaving the country unprepared for human cases. Working with WHO, the PHEOC obtained Tamiflu.When GHSA was launched in Cameroon, MINSANTE understood that Cameroon could not wait for another outbreak and needed to begin operating the national PHEOC immediately. MINSANTE positioned the PHEOC as a hub to coordinate resources, information, and communication for data receipt, integration, analyses and interpretation, and coordination, with less focus on the physical infrastructure. Thus, the PHEOC runs out of a small multipurpose room within the MINSANTE facility, and a new facility is being built nearby. The lack of a dedicated physical place has not hindered the PHEOC’s operation. In 2016 alone, the PHEOC responded to a cholera outbreak; prepared for a Lassa fever outbreak when it broke out in neighboring Nigeria; responded to measles, monkeypox, and avian influenza virus A(H5N1) outbreaks; elaborated on contingency plans for Zika virus; fine-tuned monkeypox plans when human cases and fatalities were registered in neighboring Central African Republic; and preventively activated for wild poliovirus detected in Nigeria. Most recently, the PHEOC responded to a train derailment in the Ezeka district, demonstrating all-hazards response capability. All of these opportunities helped Cameroon improve its preparedness, reducing its response time from 8 weeks to 24 hours during the recent H5N1 influenza outbreak .Engaging Cameroon’s FETP within the newly created PHEOC was a critical component of the design of the country’s PHEOC. The FETP trainees are forming the critical workforce that regularly analyze IDSR data from the district, interpret results, and present the results to stakeholders each week. These epidemiologic meetings are led by FETP trainees at the PHEOC and include stakeholders from WHO, UNICEF, the National Public Health Laboratory, Centre Pasteur of Cameroon, International Medical Corps, Metabiota, MaSanté, CDC, various officers from concerned directorates, and surveillance teams from MINSANTE, among others. This ethos of cooperation and stakeholder engagement was crucial for coordination meetings later, during the H5N1 influenza activation.As the concept of incident command started to take shape, it became apparent that 2 major gaps in the Cameroon health system had been secondarily bridged: more accountability and better coordination. The lack of these 2 attributes previously were the major cause of poor initial response to the wild poliovirus outbreak (2013–2015) (Cameroon’s PHEOC faces many challenges, including a time lag in data availability from districts because of manual collection and reporting of data and limited information systems capacity to collect and analyze information from diverse data sources. To address this challenge, MINSANTE is investing in a data warehouse and an automated software platform at the district, regional, and national levels to make data available in near real time to decision makers at each level and to enable information flow into the PHEOC. Work is also under way to build capacity for automated data analysis and visualization at the PHEOC.Developing PHEOCs to facilitate appropriate coordination, response, and management of public health events is essential for building countries’ emergency response capacity. Experience gained from developing PHEOC capacity in Vietnam and Cameroon demonstrated the following as a recommended sustainable path for PHEOC development:PHEOCs benefit from being housed physically and administratively in close proximity to or within the epidemiology or surveillance departments of the ministry of health. This closeness establishes the PHEOC as a working hub readily accessible by epidemiologic staff.PHEOCs should be epidemic intelligence hubs to receive, interpret, and visualize surveillance data from multiple sources. These hubs make information systems development a critical part of PHEOC operations. Mechanisms should be created that integrate data streams and develop data dashboards, automate routine analyses to improve the value and utility of surveillance data, and establish the continuous operations of the PHEOC.Rotating FETP trainees through the PHEOCs provides the epidemiologic workforce needed for analysis and interpretation of surveillance data. This rotation can augment epidemiology workforce capacity, especially in ministries of health where epidemiology staffing is limited. It also provides a valuable training experience for FETP fellows.PHEOCs should function during nonoutbreak periods, and surveillance data should routinely be interpreted by an epidemiologic workforce. Such an “always on” PHEOC facilitates the rapid transition to response mode during outbreaks and improves the cost-effectiveness of the infrastructure investment. Routine use of PHEOCs during outbreaks and during nonoutbreak periods helps ensure sustained technical capacity for data analyses, interpretation, and visualization tools and equipment, as well as the knowledge to analyze and interpret incoming health information.Each PHEOC must be tailored to the legislative context in which it is situated. The result is a PHEOC that fits within local legislation and more fully meets the needs of the ministries of health.,The 2015 WHO Framework for a Public Health Emergency Operations Centre provides valuable information about the role, function, and construction of PHEOCs (The approach described here could enable rapid establishment of a PHEOC with minimal infrastructure and available workforce. Such a PHEOC will serve well in resource-limited settings as a continuously operational hub for surveillance, yet ready for activation during emergencies. As additional resources become available, this PHEOC model can expand to fit international standards and be capable of addressing all emergency hazards.Data dashboard in national public health emergency operation center for Zika virus, Vietnam.