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Background In recent years, there has been greater recognition of the important role of community health volunteers in many countries and their important role informs many health programs. This include health education, provision of services such as screening, monitoring and referral to health facilities. Their roles are better understood in the areas of communicable diseases like HIV infection, Tuberculosis and Malaria however little is known about their role in non-communicable diseases. This study seeks to explore perception of CHVs’ functions, tasks, and their fulfilment in identifying people with elevated blood pressure for diagnosis and monitoring of hypertension in Lilongwe, Malawi. Methods This was a qualitative naturalistic research design utilizing observation and semi-structured interviews with community health volunteers working in Lilongwe, Malawi. Interviews were carried out with the researcher. Participants were recruited from the ZaMaC project. An interview guide was developed with a category-guided deductive approach. The interviews were recorded through note taking. Data analysis was performed using content analysis approach. Results Community health volunteers have multiple roles in prevention and monitoring of hypertension. They act as health educators and provide lifestyle counselling. They screened for hypertension and monitored blood pressure and assisted community members to navigate the health system such as linkage to health facilities. These roles were shaped in response to community needs. Conclusion This study indicates the complexities of the roles of community health volunteer in identifying people with elevated BP for diagnosis and monitoring of hypertension. Understanding community health volunteers’ roles provides insight into their required competencies in provision of their daily activities as well as required training to fill in their knowledge gaps.

The objective of this study was to analyze the impact of a community-based physical activity program, the Health Academy Program (Academia da Saúde or PAS), on leisure-time physical activity (LTPA) among the population living at the Brazilian state capitals. We pooled individual data from the National Surveillance for Protective and Risk Factors for Chronic Diseases (VIGITEL) between 2006 and 2016 and estimated odds ratios according to levels of exposure by using a multilevel logistic regression. Total sample was composed of 572,437 individuals. In the initial model, chances of reaching sufficient LTPA was 1.20 (95%CI: 1.16-1.25) times higher among individuals exposed since 2011. In the analyses adjusted for year, sex, age and education, this probability was only 1.04 (95%CI: 1.00-1.08) times higher among exposed individuals. Odds of reaching recommended LTPA was 1.09 (95%CI: 1.04-1.15) times higher among women exposed since 2011 as compared to women in the control group with no exposure. No other statistically significant results were found. We conclude that the PAS cannot substantially affect whole populations. Yet it is possible to visualize a positive influence of the program on specific subgroups, pointing to its potential to reduce gender inequity in LTPA practice. We recommend more tailored interventions before indistinctively scaling up the program, as well as we suggest better monitoring for large scale evaluations.

Objective: The aim of this study is to assess factors that influence the uptake of short term contraceptives among married women aged between 15-49 years in Afghanistan.Method: The cross sectional Afghanistan 2015 Demographic and Health Survey provided the dataset for this analysis. We included 22,974 women and applied multivariable logistic regression to investigate the influencing factors for the uptake of short term contraceptives.Results: 95% of Afghan women knew at least one type of contraception but only 16% were using short term contraceptives. Short term contraceptive use was most prevalent among women in the age group between 30 and 40 who were educated, employed, and rich. Most of users were living in the western parts of Afghanistan and belong to Balooch and Pashtun ethnic groups. Media exposure and women empowerment were also positively associated with the use of short term contraceptives. However, we did not find an association with living in urban or rural settings.Conclusion: FP in Afghanistan requires multisectorial efforts, tailored to the needs of women stemming from low and middle socioeconomic status. Health promotion 5 activities, empowering women, strengthening education, and training of FP service providers on effective counseling are good options to address the issue.

ObjectiveThe aim of this study is to assess factors that influence the uptake of short term contraceptives among married women aged between 15-49 years in Afghanistan.MethodThe cross sectional Afghanistan 2015 Demographic and Health Survey provided the dataset for this analysis. We included 22,974 women and applied multivariable logistic regression to investigate the influencing factors for the uptake of short term contraceptives.Results95% of Afghan women knew at least one type of contraception but only 16% were using short term contraceptives. Short term contraceptive use was most prevalent among women in the age group between 30 and 40 who were educated, employed, and rich. Most of users were living in the western parts of Afghanistan and belong to Balooch and Pashtun ethnic groups. Media exposure and women empowerment were also positively associated with the use of short term contraceptives. However, we did not find an association with living in urban or rural settings.ConclusionFP in Afghanistan requires multisectoral efforts, tailored to the needs of women stemming from low and middle socioeconomic status. Health promotion activities, empowering women, strengthening education, and training of Family Planning service providers on effective counseling are good options to address the issue.

Resettlers are a large migrant group of more than 2 million people in Germany who migrated mainly from the former Soviet Union to Germany after 1989. We sought to compare the distribution of the major risk factors for cardiovascular disease (CVD) and to investigate the overall genetic differences in a study population which consisted of resettlers and native (autochthone) Germans. This was a joint analysis of two cohort studies which were performed in the region of Augsburg, Bavaria, Germany, with 3363 native Germans and 363 resettlers. Data from questionnaires and physical examinations were used to compare the risk factors for cardiovascular diseases between the resettlers and native Germans. A population-based genome-wide association analysis was performed in order to identify the genetic differences between the two groups. The distribution of the major risk factors for CVD differed between the two groups. The resettlers lead a less active lifestyle. While female resettlers smoked less than their German counterparts, the men showed similar smoking behavior. SNPs from three genes (BTNL2, DGKB, TGFBR3) indicated a difference in the two populations. In other studies, these genes have been shown to be associated with CVD, rheumatoid arthritis and osteoporosis, respectively.

Despite positive NCD policies in recent years, majority of Sub-Saharan African (SSA) health systems are inadequately prepared to deliver comprehensive first-line care for NCDs. Primary health care (PHC) settings in countries like Malawi and Zambia could be a doorway to effectively manage NCDs by moving away from delivering only episodic care to providing an integrated approach over time. As part of a collaborative health system strengthening project, we assessed and compared the preparedness and operational capacity of two target networks of public PHC settings in Lilongwe (Malawi) and Lusaka (Zambia) to integrate NCD services within routine service delivery. Data was collected and analyzed using validated health facility survey tools. These baseline assessments conducted between August 2018 and March 2019, also included interviews with 20 on-site health personnel and focal persons, who described existing barriers in delivering NCD services. In both countries, policy directives to decentralize disease-specific NCD services to the primary care level were initiated to meet increased demand but lacked operational guidance. In general, the assessed PHC sites were inadequately prepared to integrate NCDs into various service delivery domains, thus requiring further support. In spite of existing multi-faceted limitations, there was motivation among healthcare staff to provide NCD services.

Background To achieve higher effectiveness in population-based SARS-CoV-2 surveillance and to reliably predict the course of an outbreak, screening, and monitoring of infected individuals without major symptoms (about 40% of the population) will be necessary. While current testing capacities are also used to identify such asymptomatic cases, this rather passive approach is not suitable in generating reliable population-based estimates of the prevalence of asymptomatic carriers to allow any dependable predictions on the course of the pandemic. Methods This trial implements a two-factorial, randomized, controlled, multi-arm, prospective, interventional, single-blinded design with cluster sampling and four study arms, each representing a different SARS-CoV-2 testing and surveillance strategy based on individuals’ self-collection of saliva samples which are then sent to and analyzed by a laboratory. The targeted sample size for the trial is 10,000 saliva samples equally allocated to the four study arms (2500 participants per arm). Strategies differ with respect to tested population groups (individuals vs. all household members) and testing approach (without vs. with pre-screening survey). The trial is complemented by an economic evaluation and qualitative assessment of user experiences. Primary outcomes include costs per completely screened person, costs per positive case, positive detection rate, and precision of positive detection rate. Discussion Systems for active surveillance of the general population will gain more importance in the context of pandemics and related disease prevention efforts. The pandemic parameters derived from such active surveillance with routine population monitoring therefore not only enable a prospective assessment of the short-term course of a pandemic, but also a more targeted and thus more effective use of local and short-term countermeasures. Trial registration ClinicalTrials.gov DRKS00023271. Registered November 30, 2020, with the German Clinical Trials Register (Deutsches Register Klinischer Studien)

Zika virus (ZIKV) emerged in Brazil during 2013–2014 causing an epidemic of previously unknown congenital abnormalities. The frequency of severe congenital abnormalities after maternal ZIKV infection revealed an unexplained geographic variability, especially between the Northeast and the rest of Brazil. Several reasons for this variability have been discussed. Prior immunity against Dengue virus (DENV) affecting ZIKV seems to be the most likely explanation. Here we summarise the current evidence regarding this prominent co-factor to potentially explain the geographic variability. This systematic review followed the PRISMA guidelines. The search was conducted up to May 15th, 2020, focussing on immunological interactions from Zika virus with previous Dengue virus infections as potential teratogenic effect for the foetus. Eight out of 339 screened studies reported on the association between ZIKV, prior DENV infection and microcephaly, mostly focusing on antibody-dependent enhancement (ADE) as potential pathomechanism. Prior DENV infection was associated with enhancement for ZIKV infection and increased neurovirulence in one included in vitro study only. Interestingly, the seven in vivo studies exhibited a heterogeneous picture with three studies showing a protective effect of prior DENV infections and others no effect at all. According to several studies, socio-economic factors are associated with increased risk for microcephaly. Very few studies addressed the question of unexplained variability of infection-related microcephaly. Many studies focussed on ADE as mechanism without measuring microcephaly as endpoint. Interestingly, three of the included studies reported a protective effect of prior DENV infection against microcephaly. This systematic review strengthens the hypothesis that immune priming after recent DENV infection is the crucial factor for determining protection or enhancement activity. It is of high importance that the currently ongoing prospective studies include a harmonised assessment of the potential candidate co-factors., Author summary Despite the large volume of Zika virus (ZIKV)-related research, the difference in the frequency of ZIKV-related severe congenital abnormalities between Northeastern Brazil in the rest of Brazil and other locations has not been adequately explained. This systematic review summarizes the existing evidence for the role of prior Dengue virus (DENV) infections as co-factor to explain the variability in the frequency of ZIKV-related severe congenital abnormalities. Results differed significantly according to study type (e.g. in vitro versus in vivo studies), and no clear picture emerged with regard to prior DENV infections causing ZIKV-related severe congenital abnormalities. However, evidence from additional studies not included in this systematic review that focus on immunological interactions between DENV and ZIKV infections imply the potential that severe ZIKV disease is more frequent in those with prior DENV infections. Therefore, an assessment of background immunity against closely related viruses (e.g. the flavivirus family) needs to be included in future and ongoing longitudinal studies on ZIKV-related congenital abnormalities.

Objective To explore the barriers to successful home-based human papillomavirus (HPV) self-sampling in North Gondar, Ethiopia. Methods The study participants were women who had previously participated in a community-wide home-based HPV self-sampling pilot study, community health workers, women’s development army leaders, and the sample collectors of the home-based HPV self-sampling pilot study. A community based qualitative descriptive study was conducted. We applied purposive and convenience sampling. In total, 47 women participated in the study (in-depth interviews n = 22, four focus group discussions n = 25, 6–7 participants each). The study employed thematic analysis for clustering the emerged themes. Results Husband disapproval was identified as the main barrier to the acceptance of home-based HPV self-sampling. Social influence, lack of knowledge about cervical cancer and screening, lack of health education on cervical cancer and HPV-based screening, feeling healthy, and religious influence were identified as additional barriers. Fear of using Evalyn brush® for self-sampling was found to be the main barrier to the provision of a quality sample. The inability of the sample collectors to check the proper utilization of Evalyn brush® and the difficulty in understanding the instructions did also contribute to the low-quality. Providing health education concerning cervical cancer and HPV self-sapling to women, male involvement in the screening program, and linking the screening service to existing local health facilities were suggested to guarantee the success of home-based HPV self-sampling. Conclusions Educating women regarding cervical cancer and HPV testing, providing clear instructions on how to collect self-sample, and male involvement in the screening program are prerequisites for a successful implementation of home-based HPV testing. Women empowerment should also be focused to overcome the identified sociocultural barriers. Furthermore, the screening program should guarantee the timely provision of the test results and offering women follow-up examinations and treatment for abnormal findings.

ObjectiveWe undertook a systematic review of the literature to explore the prevalence of post-traumatic stress disorder (PTSD) in Palestinian children and adolescents exposed to political violence. This is the first systematic review and meta-analysis of the prevalence of PTSD in this population.MethodsPubMed, Embase, PsycInfo, Google Scholar and Cochrane library were searched until June 2020. To estimate the prevalence of PTSD, sub-group and meta-analysis were conducted.ResultsThe search resulted in 2786 studies, of which 28 articles representing 32 samples with a total of 15,121 participants from Gaza Strip and West Bank met either the DSM-4 or DSM-5 criteria and were included. The pooled prevalence of PTSD was 36% (95% CI 30–41%;I298.6%) and ranged from 6% to 70%. Sub-group analysis showed that the PTSD prevalence did not differ according to region (West Bank, Gaza Strip) and tended to decrease after including only studies using a representative sample (ppConclusionWe identified high prevalence of PTSD among Palestinian children and adolescents exposed to political violence. However, the pooled results should be interpreted with caution, due to the high heterogeneity and risk of bias in the included studies. These limitations also reflect the challenge in conceptualizing and measuring PTSD in the Palestinian context with a background of continuous and cumulative trauma. Understanding the contextual factors and developing locally adapted survey measures are of relevance to future research, public health planning, and the provision of mental healthcare in Palestine.

Background There has been a significant reduction of abortion rates in high-income countries, while the rates remain unchanged in low- and middle-income countries. In Ethiopia, for example, the number of women of reproductive age seeking an induced abortion is increasing. However, there is limited information concerning the reasons why the occurrence of this procedure is increasing. Thus, this study aimed to identify factors associated with having induced abortion in Addis Ababa, Ethiopia. Methods An unmatched case-control study was conducted using a semi-structured, interviewer-administered questionnaire from October to December 2017. The cases were 147 women of reproductive age who underwent abortion in a health facility or presented with complications due to induced abortion conducted outside the health facility. The controls were 295 women who came for antenatal care and who reported never having had an induced abortion. The cases were selected by consecutive sampling from nine health facilities, whereas the controls were selected by systematic sampling from the same health facilities. Bivariate and multivariate logistic regression models were employed using STATA version 14 to identify factors associated with induced abortion. Results The mean age of cases was 26.5 ± 5.7 years, while for the controls it was 28.1 ± 4.8 years. Being unmarried (AOR = 9.6; 95% CI: 1.5–61.7), having primary (AOR = 5.3; 95% CI: 1.5–18.3) and tertiary (AOR = 5.7; 95% CI: 1.6–21.1) education, earning monthly income 100–300 USD (AOR = 0.2; 95% CI: 0.1–0.4) and > 300 USD (AOR = 0.1; 95% CI: 0.0–0.2), initiating first intercourse between ages of 15 and 19 (AOR = 4.7; 95% CI: 1.4–15.6), marrying before the age of 18 (AOR = 2.9; 95% CI: 1.3–6.7), and having two children (AOR = 4.7; 95% CI: 1.8–12.7) were independent predictors of induced abortion. Conclusion Family planning programs hoping to reduce the occurrence of induced abortion should specifically target unmarried women, low income, and those who have two children. The government should also work on preventing early marriage and providing sexual and reproductive health education to help adolescents delay age at first sexual experience.

Background Already, Dengue affects 400 million individuals every year. Its main drivers, urbanization, globalization, and climate change, however, will spread the disease even further and potentially threaten billions. In Dengue, bleeding occurs frequently. Severe bleeding strongly increases mortality and immediate medical response is crucial for survival. Predicting the occurrence and course of bleeding in advance would improve clinical outcome, reduce unnecessary hospitalization, and improve economic efficiency. Methods Following the PRISMA-guidelines, we conducted a systematic review of the literature to identify predictors of bleeding in acute confirmed Dengue. We searched Pubmed, Web of Science, IRIS, LILACS, and the Cochrane Archives and included all prospective longitudinal studies restricting neither language nor study sample characteristics. Results We included 19 studies but found that most data suffered from high risk of bias because of poor reporting and not accounting for confounding. Only five studies were more reliable, and they unanimously reported that age-, and platelet count predicted bleeding severity. The body of evidence was too weak to draw conclusions for the other 23 markers investigated. Crucially, the researchers had defined central concepts in fundamentally different ways and thus prevented the comparison of their findings. Conclusions Our systematic review of the literature showed that more research is needed to create a reliable prediction model for bleeding in Dengue. We have moderate certainty that platelet count- and age predict bleeding severity. Our study exposed the urgent need to improve the quality of research in Dengue epidemiology. Most importantly, our findings illustrate the necessity to harmonize central concepts within the Dengue research community. To tackle the challenge that Dengue is bound to become, we need dialogue across research groups and collaboration that overcomes the limited impact of individual studies. Key messages We know too little about predictors of bleeding in Dengue. Reliable data is needed to identify new markers and to confirm existing markers that are carried by a weak body of evidence. We urge investigators to collaborate. To overcome the limitations of individual studies, we need better comparability and a scientific dialogue based on common definitions of core concepts in Dengue.

OBJECTIVE The prevalence of type 2 diabetes is rising rapidly in low-income and middle-income countries (LMICs), but the factors driving this rapid increase are not well understood. Adult height, in particular shorter height, has been suggested to contribute to the pathophysiology and epidemiology of diabetes and may inform how adverse environmental conditions in early life affect diabetes risk. We therefore systematically analyzed the association of adult height and diabetes across LMICs, where such conditions are prominent. RESEARCH DESIGN AND METHODS We pooled individual-level data from nationally representative surveys in LMICs that included anthropometric measurements and diabetes biomarkers. We calculated odds ratios (ORs) for the relationship between attained adult height and diabetes using multilevel mixed-effects logistic regression models. We estimated ORs for the pooled sample, major world regions, and individual countries, in addition to stratifying all analyses by sex. We examined heterogeneity by individual-level characteristics. RESULTS Our sample included 554,122 individuals across 25 population-based surveys. Average height was 161.7 cm (95% CI 161.2–162.3), and the crude prevalence of diabetes was 7.5% (95% CI 6.9–8.2). We found no relationship between adult height and diabetes across LMICs globally or in most world regions. When stratifying our sample by country and sex, we found an inverse association between adult height and diabetes in 5% of analyses (2 out of 50). Results were robust to alternative model specifications. CONCLUSIONS Adult height is not associated with diabetes across LMICs. Environmental factors in early life reflected in attained adult height likely differ from those predisposing individuals for diabetes.

Surveillance of HIV/AIDS mortality is crucial to evaluate a country’s response to the disease. With a modified estimation approach, this study aimed to provide more accurate estimates on deaths due to HIV/AIDS in Iran from 1990 to 2015 at national and sub-national levels. Using a comprehensive data set, death registration incompleteness and misclassification were addressed by demographical and statistical methods. Trends of mortality due to HIV/AIDS at national and sub-national levels were estimated by applying a set of models. A total of 474 men (95% uncertainty interval [UI]: 175–1332) and 256 women (95% UI: 36–1871) died due to HIV/AIDS in 2015 in Iran. Peaked in 1995, HIV/AIDS-related mortality has steadily declined among both genders. Mortality rates were remarkably higher among men than women during the period studied. At the sub-national level, the highest and the lowest annual percent change were found at 10.97 and −1.36% for women, and 4.04 and −3.47% for men, respectively. The findings of our study (731 deaths) were remarkably lower than the Joint United Nations Programme on HIV and AIDS (4000) but higher than Global Burden of Disease (339) estimates in 2015. The overall decrease in mortality due to HIV/AIDS may be attributed to the increasing burden of noncommunicable diseases; however, the role of the national and international organizations to fight HIV/AIDS should not be overlooked. To decrease HIV/AIDS mortality and to achieve international goals, evidence-based action is required. To fast-track targets, the priority must be to prevent infection, promote early diagnosis, provide access to treatment, and to ensure treatment adherence among patients.

ObjectivesTo examine the knowledge, attitudes and practices (KAP) of COVID-19 of rural and urban residents in Liberia to inform the development of local social and behaviour change communication strategies.DesignCross-sectional, mixed-mode (online and telephone) survey using non-probability sampling.SettingAll 15 counties in Liberia with a focus on Maryland County.ParticipantsFrom 28 May to 28 June 2020, data were collected from a total of 431 adults aged 18 years and older (telephone 288 (66.8%); online 143 (33.2%)) out of a total of 741 contacts.Main outcome measuresKAP scores. Frequencies and proportions were calculated, followed by univariate and multivariable analyses to examine the association between KAP scores and the sociodemographic variables.ResultsAround 69% of the online survey respondents were younger than 35 years of age, compared with 56% in the telephone interviews. The majority (87%) of online respondents had completed tertiary education, compared with 77% of the telephone respondents. Male participants, on average, achieved higher knowledge (52%) and attitude scores (72%), in contrast to females (49% and 67%, respectively). Radio (71%) was the most cited source for COVID-19 information, followed by social media (63%). After controlling for sociodemographic variables, adaptive regression modelling revealed that survey mode achieved 100% importance for predicting knowledge and practice levels with regard to COVID-19.ConclusionsThe survey population demonstrated moderate COVID-19 knowledge, with significant differences between survey mode and educational level. Correct knowledge of COVID-19 was associated with appropriate practices in Maryland County. Generalisation of survey findings must be drawn carefully owing to the limitations of the sampling methods. Yet, given the differences in knowledge gaps between survey modes, sex, education, occupation and place of residence, it is recommended that information is tailored to different audiences.

One major aspect of the epidemiological transition happening in India is the increased diabetes prevalence. Poor environmental conditions in early childhood potentially can increase the risk of developing diabetes in adulthood. Adults' height as an indirect indicator might reflect such conditions. In this paper, we investigate the relationship between adult height as a proxy for early childhood conditions and the risk of developing diabetes in India.This cross-sectional study used national representative data of the latest National Family Health Survey (2015-2016), comprising 512 616 women aged 20 to 49 and 87 281 men aged 20 to 54. We applied the multivariable fractional polynomials approach in logistic regression models to allow for nonlinear relationships between height and diabetes, separated by sex. Additionally, we fitted logistic regression models with height categories. Fixed effects linear probability models were used to control for potential confounding.The study revealed a linear relationship between increasing height and increasing diabetes risk among men. Among women, the shortest were at the highest risk (not significant).Among Indian men, being taller increases the risk of developing diabetes, which contradicts findings from other countries. In contrast, the shortest women seem to be at the greatest risk. Hence, public health interventions in India might be well advised to focus more on the nutrition status of young girls.背景: 印度流行病学转变的一个主要方面是糖尿病患病率的增加。儿童早期处于恶劣的环境中可能会增加成年后发生糖尿病的风险。成年人的身高作为一个间接指标, 可能反映了这种情况。在本文中, 我们将印度成人身高作为代表儿童早期所处环境的指标, 调查了成人身高与糖尿病发病风险之间的关系。 方法: 这项横断面研究使用了最新全国家庭健康调查(2015-2016)研究的数据, 这些数据具有全国代表性, 其中包括512 616名20-49岁女性和87 281名20-54岁男性。我们在logistic回归模型中应用了多变量分数多项式方法, 来评估身高与糖尿病之间的非线性关系, 并按照性别分组。此外, 我们将身高分类以拟合逻辑回归模型。使用固定效应线性概率模型校正潜在的混杂因素。 结果: 这项研究揭示了男性身高与糖尿病风险之间存在正性线性关系。在女性中, 最矮女性的风险最高(无显著意义)。 结论: 在印度男性中, 身高会增加糖尿病的风险, 这与其他国家的研究结果相矛盾。相比之下, 身材矮小的女性似乎风险最大。因此, 建议印度公共卫生干预机构最好更多地关注年轻女孩的营养状况。.

RationaleGuidelines recommend pre-/post-bronchodilator spirometry for diagnosing COPD, but resource constraints limit the availability of spirometry in primary care in low- and middle-income countries. Although spirometry is the diagnostic gold standard, we shall assess alternative tools for settings without spirometry.MethodsA systematic literature review and meta-analysis was conducted, utilising Cochrane, CINAHL, Google Scholar, PubMed and Web of Science (search cut-off was May 01, 2020). Published studies comparing the accuracy of diagnostic tools for COPD with post-bronchodilator spirometry were considered. Studies without sensitivity/specificity data, without a separate validation sample and outside of primary care were excluded. Sensitivity, specificity and area under the curve (AUC) were assessed.ResultsOf 7578 studies, 24 were included (14 635 participants). Hand devices yielded a larger AUC than questionnaires. The meta-analysis included 17 studies and the overall AUC of micro-spirometers (0.84, 95% CI 0.80–0.89) was larger when compared to the COPD population screener (COPD-PS) questionnaire (0.77, 95% CI 0.63–0.85) and the COPD diagnostic questionnaire (CDQ) (0.72, 95% CI 0.64–0.78). However, only the difference between micro-spirometers and the CDQ was significant.ConclusionsThe CDQ and the COPD-PS questionnaire were approximately equally accurate tools. Questionnaires ensured testing of symptomatic patients, but micro-spirometers were more accurate. A combination could increase accuracy but was not evaluated in the meta-analysis.

Introduction Data on renal impairment in sub-Saharan Africa (SSA) remains scarce, determination of renal function is not part of routine assessments. We evaluated renal function and blood pressure in a cohort of people living with HIV (PLWH) on antiretroviral treatment (ART) in the Renal Care Zambia project (ReCaZa). Methods Using routine data from an HIV outpatient clinic from 2011–2013, we retrospectively estimated the glomerular filtration rate (eGFR, CKD-Epi formula) of PLWH on ART in Lusaka, Zambia. Data were included if adults had had at least one serum creatinine recorded and had been on ART for a minimum of three months. We investigated the differences in eGFR between ART subgroups with and without tenofovir disproxil fumarate (TDF), and applied multivariable linear models to associate ART and eGFR, adjusted for eGFR before ART initiation. Results and discussion Among 1118 PLWH (63,3% female, mean age 41.8 years, 83% ever on TDF; median duration 1461 [range 98 to 4342] days) on ART, 28.3% had an eGFR

Resettlers (in German: (Spat-)Aussiedler) form one of the biggest migrant groups in Germany. It is known that migrants have different mortality patterns compared to the autochthon population. In this paper, we combined data from three resettler cohorts and examined differences in mortality from non-communicable diseases among resettlers in Germany and the German population. Furthermore, we investigated time trends of cause-specific mortality for 20 years of follow-up and compared it with the German mortality rates. To assess differences in cause-specific mortality between resettlers and the general German population, we calculated standardized mortality ratios (SMRs). To ascertain mortality trends, cause-specific age-standardized mortality rates were calculated and modeled with Poisson regression and fractional polynomials. During the observation period, the study population accumulated almost 800,000 person-years and 5572 deaths were observed. All-cause mortality among resettlers was lower (SMR = 0.91, 95% CI = 0.89–0.94) compared to the general German population, as well as cardiovascular diseases (CVD) mortality (SMR = 0.82, 95% CI = 0.79–0.86). Results for cancer mortality varied considerably by cancer site. Analyses of time trends showed that all-cause and CVD mortality were decreasing over time in resettlers, as well as in the general German population. Lower all-cause mortality among resettlers is mainly explained by lower CVD mortality. Cancer-site specific mortality showed different results. Converging mortality rates may indicate an adaption of lifestyle behavior. However, there are no data on individual risk factors in this study.

Background Mortality statistics are used to compare health status of populations; optimally, they base on individual death certificates. However, determining cause of death is error-prone. E.g. cardiovascular disease (CVD) death determination is characterized by sensitivity (SE) and specificity (SP) lower than 85 %. Furthermore, differential misclassification may be present in case of homogenous target populations. We investigate the bias of standardized mortality ratios (SMR), based on real-world data. Methods CVD mortality of 6378 ethnic German repatriates was assessed and the SMR calculated. Non-differential age-dependent misclassification was introduced into data by scenarios of equal SE and SP in a range of 0.7 to 0.85. The bias between originally reported and actual SMR was calculated for each pair of values. Additionally, four differential misclassification scenarios were simulated, reflecting two extreme scenarios of both quality criteria varied in the cohort but fixed to either higher or lower in the reference, and two scenarios of crossed criteria values. Results In case of non-differential misclassification the bias is always towards the null-hypothesis. The lowest bias was 13.5 % (SE, SP = 0.85 constantly), the maximum bias was 40 % (SP = 0.7). However, in case of differential misclassification the observed SMR can be on the wrong track. If SP is high but SE low in the cohort, negative bias up to −10 % can occur. In case SE is low but SP is high in the reference, the bias remains always positive. In the opposite case plus SP is high in the cohort, the bias can reach −30 %. Conclusion SMR values are always biased due to the diagnostic test character of death determination. In majority of epidemiological studies the bias should be towards the null-hypothesis (non-differential misclassification). However, caution is needed in case of differential misclassification, possibly experienced in studies on homogenous subgroups, and in large prospective cohorts with specifically trained personnel.

Objective: There are 2 main types of access for patients requiring major open, elective abdominal surgery: the midline or the transverse approach. The aim of this study is to compare both approaches by focusing on postoperative pain, complications, and frequency of incisional hernias. Summary Background Data: A recent Cochrane review suggested that transverse incisions may be less painful but incisional hernia rates do not differ. Methods: Randomized, patient- and observer-blinded, monocentric, equivalence clinical trial. Patients were scheduled for elective primary abdominal incisions. Composite primary end point measured 48 hours after surgery was the total amount of analgesics (piritramide) required in the last 24 hours and pain (Visual Analogue Scale). Secondary end points were early-onset and late complications. This study is registered in the ISRCTN registry and has the ID number ISRCTN60734227. Results: Two hundred patients (101 midline and 99 transverse) were randomized. Both incision types resulted in similar amounts of required analgesics (95% confidence interval [―0.38; ―0.33] was included in the equivalence level). For the Visual Analogue Scale, both the 95% and 90% CI (0―10) were neither within the equivalence levels nor were their differences significant at the 5% level. No relevant differences between midline and transverse incisions were observed for 30-day mortality (2 vs. 2, P = 0.99), mortality after one year (15 vs. 23, P = 0.15), pulmonary complications (13 vs. 17, P = 0.43), median length of hospital stay (11 vs. 12 days, P = 0.08), median time to tolerance of solid food (12 vs. 14 days, P = 0.30), and incisional hernias after one year (13 vs. 8, P = 0.48). More wound infections occurred in the transverse group (15 vs. 5, P = 0.02). Conclusion: The decision about the incision should be driven by surgeon preference with respect to the patient's disease and anatomy.

Background Mental health consequences of migration are manifold. Where some migrants experience migration as liberation from life threatening conditions, others suffer from hostility and social descent in the target country. This study investigates deaths due to external causes, suicides, and events of undetermined intent in German repatriates from the Former Soviet Union. The relation between age at migration and suicide mortality is also explored. Methods A cohort of German repatriates who migrated between 1990 and 1999 was followed-up until 2010. Each individual accumulated time at risk, expressed in person years (PY). Standardized mortality ratios (SMR) were calculated, supplemented by subgroup analyses for age and calendar year strata, and immigration period. Multivariate Poisson models were used to investigate the influence of age, sex, calendar year, number of moves, and final move distance. Results A total of 6378 German repatriates (3031 men, 3347 women) accumulated 92 149 PY. Median age at immigration was 30 years in women and 27 years in men. Women's all-cause mortality was significantly lower (SMR = 0.85 [0.75; 0.97]). Men more often died from external causes (SMR = 1.58 [1.09; 2.23]), intentional self-harm (SMR = 1.68 [0.90; 2.88]), and events of undetermined intent such as poisoning by drugs (SMR = 8.07 [4.02; 14.44]). External cause mortality was significantly increased after 1995 (SMR = 1.87). In particular, men who migrated when they were 11–20 years old were at strongly increased risk of committing suicide (SMR = 3.84) or dying due to events of undetermined intent (SMR = 14.75). Conclusion The most endangered subgroup is men who migrated at teenage age. Protective factors such as strong family bounds formerly present in the FSU failed in Germany, the higher population density caused intense friction. The changes in the families' ethnical composition from mostly ethnic German members in the early 90s' towards predominantly Russian members around the turn of the millennium complicated integration. Setting-oriented prevention measures should consider the families' migration history, their link to culture and religion, and the different concepts of mental health.

Optimization of an agent-based simulation (ABS) bears specific challenges. It is demonstrated in this paper that mainstream simulation-based optimization (SBO) approaches often do not perform well in such a setting, sometimes hardly outperforming a mere random search. Two new algorithms for SBO which combine superior solution quality with high resource efficiency and reliability for such problems are presented: an evolutionary algorithm called "neighbourhood elite selection" (NELS) with a specific selection mechanism which prevents premature clustering, and a hybrid algorithm which combines NELS with the popular best-in-class algorithm Simultaneous Perturbation Stochastic Approximation (SPSA). Those two algorithms are designed to perform well for problems which show typical properties of an agent-based simulation, a field that has largely been neglected so far, but should structurally also be universally applicable for other simulation-based optimization problems as well. In contrast to present literature, specific emphasis lies on the dynamic control of how many replications of the simulation are required for each solution brought up during the optimization run in order to make efficient use of the scarce simulation resources. The algorithms are benchmarked against the academic best-in-class optimization algorithm SPSA. A sketch of practical case studies is provided, showing how the optimization of an ABS can be used to help solve business decision problems like price optimization for a mobile phone operator.

Background: The burden of cardiovascular diseases (CVDs) is much more pronounced in Eastern Europe, a spatial gradient within Europe still exists. However, former studies showed a significantly lower CVD mortality of German repatriates from the Former Soviet Union compared with the German population. Methods: All-cause, CVD and ischemic heart disease (IHD) standardized mortality ratio (SMR), IHD standardized incidence ratio and annual age-standardized mortality and acute myocardial infarction (AMI) incidence rates were calculated in a retrospective cohort. Time trends were investigated by loess regression. Results: A total of 6378 German repatriates were observed from 1990 to 2010, accumulating 92 149 person-years. We observed a lower all-cause mortality [SMR = 0.86 (0.75, 0.98)] in females and CVD mortality [International Statistical Classification of Diseases and Related Health Problems, version 10 (ICD) 10: I00–I99; SMR = 0.82 (0.65, 1.03)] and IHD mortality (I20–I25) [SMR = 0.84 (0.60, 1.15)] in males. In contrast, AMI incidence was significantly higher in male repatriates [standardized incidence ratio = 1.30 (1.02, 1.65)]. Whereas in the general population, mortality rates of CVD, IHD and AMI incidence have continuously decreased over time, the pattern in the repatriates was not as clear. In male repatriates, mortality rates seemed to be lower after immigration and remained rather constant. Incidence rates possibly exceed Germans rates by now. Conclusions: A possible historical repatriates’ IHD advantage shown in former studies has disappeared. The increasing AMI incidence in (male) repatriates might demonstrate the delaying onset of the impact of changes in the CVD risk profile due to migration. Health politics and the health system should be sensitized and take care of the development of IHD mortality and AMI incidence among the repatriates.

Surgical trials focus mainly on mortality and morbidity rates, which may be not the most important endpoints from the patient's perspective. Evaluation of expectations and needs of patients enrolled in clinical trials can be analyzed using a procedure called ranking. Within the Postsurgical Pain Outcome of Vertical and Transverse Abdominal Incision randomized trial (POVATI), the perspectives of participating patients and surgeons were assessed as well as the influence of the surgical intervention on patients' needs. All included patients of the POVATI trial were asked preoperatively and postoperatively to rank predetermined outcome variables concerning the upcoming surgical procedure (e.g., pain, complication, cosmetic result) hierarchically according to their importance. Preoperatively, the surgeons were asked to do the same. One hundred eighty two out of 200 randomized patients (71 females, 111 males; mean age 59 years) returned the ranking questionnaire preoperatively and 152 patients (67 females, 85 males; mean age 60 years) on the day of discharge. There were no differences between the two groups with respect to the distribution of ranking variables (p > 0.05). Thirty-five surgeons (7 residents, 6 fellows, and 22 consultants) completed the same ranking questionnaire. The order of the four most important ranking variables for both patients and surgeons were death, avoiding of postoperative complications, avoiding of intraoperative complications, and pain. Surgeons ranked the variable “cosmetic result” significantly as more important compared to patients (p = 0.034, Fisher's exact test). Patients and surgeons did not differ in ranking predetermined outcomes in the POVATI trial. Only the variable “cosmetic result” is significantly more important from the surgeon's than from the patient's perspective. Ranking of outcomes might be a beneficial tool and can be a proper addition to RCTs.

Background Cardiovascular disease (CVD) is the leading cause of death in the industrialized world. Large variations in CVD mortality between countries and also between population subgroups within countries have been observed. Previous studies showed significantly lower risks in German repatriates and Jews emigrating from Russia than in the general Russian population. We examined to what degree the migration of large subgroups influenced national CVD mortality rates. Methods We used WHO data to map the CVD mortality distribution in Europe in 2005. Supplemented by data of the Statistisches Bundesamt, the mortality trends in three major CVD groups between 1980 and 2007 in Russia and Germany are displayed, as well as demographic information. The effects of migration on demography were estimated and percentage changes in CVD mortality trends were calculated under the assumption that migration had not occurred. Results Cardiovascular disease mortality patterns within Europe showed a strong west-east gradient with ratios up to sixfold. In Germany, the CVD mortality levels were low and steadily decreasing, whereas in Russia they fluctuated at high levels with substantial differences between the sexes and strong correlations with political changes and health campaigns. The trends in both Russia and Germany were affected by the migration that occurred in both countries over recent decades. However, our restricted focus in only adjusting for the migration of German repatriates and Jews had moderate effects on the national CVD mortality statistics in Germany (+1.0%) and Russia (-0.6%). Conclusions The effects on CVD mortality rates due to migration in Germany and Russia were smaller than those due to secular economical changes. However, migration should still be considered as a factor influencing national mortality trends.

The goal of this in vitro study was to identify the most suitable dye for endodontic dye leakage studies, which could be a further step towards standardisation. The root canals of 70 extracted, single-rooted human adult teeth were enlarged to apical size 50 using hand instruments. The teeth were divided into seven groups (n = 10 each), and all root canals were completely filled by injection with one of the following dyes: methylene blue 0.5% and 5%, blue ink, black ink, eosin 5%, basic fuchsine 0.5% and drawing ink. Transverse root sections from the coronal, middle and apical part of the roots were examined, and the percentage of the dentine penetrated by dye was evaluated by software-supported light microscopy. In addition, the range of particle size of drawing ink particles was evaluated. There were conspicuous differences in the relative dye penetration into the root dentine and the penetration behaviour in the different root sections (two-way ANOVA, both p

Background: Transverse incisions in open abdominal surgery may cause less pain than the midline approach according to the results of a recent Systematic Review and Meta-Analysis of the Cochrane Collaboration. Relevant clinical and methodological bias was detected in the underlying studies in addition. Therefore we investigated both incision types in a randomized patient and observer blinded trial. Methods: 200 patients with primary elective laparotomy for major abdominal procedures were randomized either to a midline or transverse incision in this single centre equivalence designed trial. After a standardized wound closure both groups received wound dressings covering the whole abdomen and a similar pain management through a patient controlled pump. Composite primary end point measured 48 hours after surgery was total amount of analgesics (piritramide) required in last 24 hours and pain (Visual Analogue Scale). Secondary end points were early-onset and late complications. Results: 101 patients in the midline and 99 patients in the transverse group were comparable after randomization at baseline for demographic and clinical characteristics. Blinding was successful. The pain medication used was similar in both groups (95 % CI -0.38–0.33). For the VAS the results were neither within the equivalence level (9 % CI 0–10) nor were a significant difference detected between the two incision types at a 5 % level. Only wound infections occurred more often in the transverse group (15 versus 5, p = 0.02) whereas frequencies of all other secondary endpoints (mortality, pulmonary complications, incisional hernias after one year) were not different between the groups. Conclusion: Incisions should be carried out according to the decision of the responsible surgeon focusing on the anatomy and planned intervention.

Background Fundus autofluorescence (AF) imaging using confocal scanning laser ophthalmoscopy (cSLO) provides an accurate delineation of areas of geographic atrophy (GA). Automated computer-assisted methods for detecting and removing interfering vessels are needed to support the GA quantification process in longitudinal studies and in reading centres. Methods A test tool was implemented that uses region-growing techniques to segment GA areas. An algorithm for illuminating shadows can be used to process low-quality images. Agreement between observers and between three different methods was evaluated by two independent readers in a pilot study. Agreement and objectivity were assessed using the Bland-Altman approach. Results The new method (C) identifies vascular structures that interfere with the delineation of GA. Results are comparable to those of two commonly used procedures (A, B), with a mean difference between C and A of -0.67 mm2 (95% CI [-0.99, -0.36]), between B and A of -0.81 mm2, (95% CI [-1.08, -0.53]), and between C and B of 0.15 mm2 (95% CI [-0.12, 0.41]). Objectivity of a method is quantified by the mean difference between observers: A 0.30 mm2 (95% CI [0.02, 0.57]), B -0.11 mm2 (95% CI [-0.28, 0.10]), and C 0.12 mm2 (95% CI [0.02, 0.22]). Conclusion The novel procedure is comparable with regard to objectivity and inter-reader agreement to established methods of quantifying GA. It considerably speeds up the lengthy measurement process in AF with well defined GA zones.

Background Annually, more than 90000 surgical procedures of the thyroid gland are performed in Germany. Strategies aimed at reducing the duration of the surgical procedure are relevant to patients and the health care system especially in the context of reducing costs. However, new techniques for quick and safe hemostasis have to be tested in clinically relevance randomized controlled trials before a general recommendation can be given. The current standard for occlusion of blood vessels in thyroid surgery is ligatures. Vascular clips may be a safe alternative but have not been investigated in a large RCT. Methods/design CLIVIT (Clips versus Ligatures in Thyroid Surgery) is an investigator initiated, multicenter, patient-blinded, two-group parallel relevance randomized controlled trial designed by the Study Center of the German Surgical Society. Patients scheduled for elective resection of at least two third of the gland for benign thyroid disease are eligible for participation. After surgical exploration patients are randomized intraoperatively into either the conventional ligature group, or into the clip group. The primary objective is to test for a relevant reduction in operating time (at least 15 min) when using the clip technique. Since April 2004, 121 of the totally required 420 patients were randomized in five centers. Discussion As in all trials the different forms of bias have to be considered, and as in this case, a surgical trial, the role of surgical expertise plays a key role, and will be documented and analyzed separately. This is the first randomized controlled multicenter relevance trial to compare different vessel occlusion techniques in thyroid surgery with adequate power and other detailed information about the design as well as framework. If significant, the results might be generalized and may change the current surgical practice.