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BackgroundLimited evidence informs on the prevalence of chronic kidney disease (CKD) in people living with HIV (PLWH) in South Africa. Thus, this study aimed to determine the prevalence of CKD and its associated risk factors among PLWH within the rural province of Limpopo, South Africa.MethodsWe conducted a cross-sectional study of 143 participants, subdivided into groups of PLWH (n = 103) and individuals without HIV (n = 43). Structured questionnaires were used to collect and capture sociodemographic information including age, sex, alcohol intake, smoking status, and educational status. Basic measurements taken included levels of cluster of differentiation 4 (CD4+) count, body mass index (BMI), blood pressure, plasma cystatin C, and fasting serum glucose levels. Plasma cystatin C-based estimated glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration (CKD-EPI) estimator to determine the prevalence of CKD.ResultsThe prevalence of CKD was approximately 7% in PLWH. Multivariate logistic regression analysis showed that it was only diabetes mellitus (odds ratio of 5.795, 95% confidence interval, p = 0.034) and age (odds ratio of 1.078, 95% confidence interval, p = 0.039) that were significantly associated with CKD in PLWH.ConclusionChronic kidney disease was prevalent in PLWH, and it was further associated with cardiovascular risk factors, diabetes, and ageing. As PLWH age, the burden of CKD may be increased with the increase in cardiovascular-related comorbidities such as diabetes.

During surveys, it is recommended that children immunization status should be based on immunization documents. It has been noted that in some communities, a number of children are claimed to be vaccinated but have no evidence of vaccination. This work is proposed to estimate routine immunization coverage in children based on both documented vaccination and the tracking of undocumented immunization. It was a community‑based survey targeting children aged 0‑59 months in which the immunization status of children was assessed based on vaccination documents and based on a questionnaire tracking immunization sites and period for children with undocumented vaccination. The vaccination coverage and completeness were estimated from data collected in immunization cards and re‑estimated after tracking the immunization status of children with no immunization cards. Of 1435 children reached in households, 1430 (99.7%) were included. Of 1072 children aged 12‑59 months, 194 (18.1%) received DPT‑Hi+Hb 3 with evidence and 399 (37.2%) with evidence and tracking. In the same age group, the dropout rate from DPT‑Hi+Hb 1 (157 doses administered) to DPT‑Hi+Hb 3 (127 doses administered) with evidence was 19.1% and 42.4% with evidence and tracking. The tracking of immunization status in children with no evidence of vaccination allows to determine their immunization status and to improve the reliability of the estimated vaccination coverage. This strategy could be adopted to be part of the planning and implementation of vaccination coverage surveys of EPI vaccines.

Abstract Background Body composition alterations, or lipodystrophy, can lead to serious health problems in people living with HIV/AIDS (PLWHA). The objectives of this study are to predict and validate sex-specific anthropometric predictive models for the diagnosis of lipodystrophy in PLWHA. Methods A cross-sectional design was employed to recruit 106 PLWHA (men = 65 and women = 41) in Brazil during 2013–2014. They were evaluated using dual-energy X-ray absorptiometry, and 19 regions of body perimeters and 6 skinfold thicknesses were taken. Sex-specific predictive models for lipodystrophy diagnosis were developed through stepwise linear regression analysis. Cross-validations using predicted residual error sum of squares was performed to validate each predictive model. Results Results support the use of anthropometry for the diagnosis of lipodystrophy in men and women living with HIV/AIDS. A high power of determination with a small degree of error was observed for lipodystrophy diagnosis for men in model six (r2 = 0.77, SEE = 0.14, r2 PRESS = 0.73, SEE PRESS = 0.15), that included ratio of skinfold thickness of subscapular to medial calf, skinfold thickness of thigh, body circumference of waist, formal education years, time of diagnosis to HIV months, and type of combined antiretroviral therapy (cART) (with protease inhibitor “WI/PI = 1” or without protease inhibitor “WO/PI = 0”); and model five for women (r2 = 0.78, SEE = 0.11, r2 PRESS = 0.71, SEE PRESS = 0.12), that included skinfold thickness of thigh, skinfold thickness of subscapular, time of exposure to cART months, body circumference of chest, and race (Asian) (“Yes” for Asian race = 1; “No” = 0). Conclusions The proposed anthropometric models advance the field of public health by facilitating early diagnosis and better management of lipodystrophy, a serious adverse health effect experienced by PLWHA.

Abstract Background Health education is important to empower patients and encourage their contribution towards tuberculosis (TB) control. In South Africa, health education activities are integrated into services provided at the primary health care (PHC) level. This study was conducted in a high TB burden metropolitan area in South Africa. The objective was to assess TB-related knowledge, attitudes and infection control practices of patients attending PHC facilities. Methods In September and October 2015, a cross-sectional survey using fieldworker-administered questionnaires was conducted among patients older than 17 years attending 40 PHC facilities in the Mangaung Metropolitan. Convenience sampling was used to select patients. Participation in the study was voluntary. Descriptive, inferential and multivariate logistic regression analyses were performed. Statistical significance was considered at alpha

Abstract Aim To assess the clinical utility of novel anthropometric indices and other traditional anthropometric indices in identifying the risk of type 2 diabetes mellitus (T2D) among South African adult females. Methods In the first South African National Health and Nutrition Examination Survey (SANHANES-1), traditional [body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR)] and novel [a-body shape index (ABSI), abdominal volume index (AVI), body adiposity index (BAI), body roundness index (BRI), conicity index (CI), and Clínica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE)] anthropometric indices were assessed. T2D was diagnosed using glycated haemoglobin (HbA1c) ≥ 6.5% among participants without known T2D. Basic statistics and multiple regression analyses were explored the association between anthropometric indices and newly diagnosed T2D. Receiver operating characteristic (ROC) curve analysis was used to measure the predictive ability of both traditional and novel indices. Results Among 2 623 participants, 384 (14.6%) had newly diagnosed T2D. All anthropometric indices mean values were significantly higher among participants with T2D (most p 0.80). The WC, WHtR, AVI, BRI, and CUN-BAE, however, performed acceptably (AUCs 0.70–0.79), while also exhibiting corresponding cutoff values of 86.65 cm, 0.57, 15.52, 3.83, and 38.35, respectively. Conclusions The data shows that traditional and novel anthropometric indices similarly identifying newly diagnosed T2D among adult South African females. We recommend the continuing the use of traditional indices, as they are affordable and easy to use in our setting.

Abstract Introduction Firefighters are required to perform physically strenuous tasks such as hose drags, victim rescues, forcible entries and stair climbs to complete their public safety mission. Occupational-specific tasks are often used to evaluate the ability of firefighters to adequately/safely perform their duties. Depending on the regions, occupational-specific tasks include six to eight individual tasks, which emphasize distinct aspects of their physical fitness, while also requiring different levels of cardiovascular (CVH) and musculoskeletal health (MSH). Therefore, the aim of this study was to evaluate the relationship between specific occupational task performance and measures of physical fitness, cardiovascular and musculoskeletal health. Methods Using a cross-sectional design, 282 full-time male and female firefighters were recruited. A researcher-generated questionnaire and physical measures were used to collect data on sociodemographic characteristics, CVH, MSH and weekly physical activity habits. Physical measures were used to collect data on physical fitness and occupational-specific task performance. Results Absolute cardiorespiratory fitness (abV̇O2max), grip strength, leg strength, push-ups, sit-ups and lean body mass (all p

Abstract Background The association of traumatic experiences with problematic alcohol use has been described, but data on possible mediation effects of mental distress are sparse. We examined whether mental ill-health mediated the association between trauma exposure across the lifespan and alcohol use. Method We analysed cross-sectional data from a sample of rape-exposed and non-rape-exposed women, living in KwaZulu-Natal, with self-reported data on alcohol misuse (AUDIT-C cut-off ≥ 3) and exposure to childhood maltreatment (CM), intimate partner violence (IPV), non-partner sexual violence (NPSV), other traumatic events, and mental ill-health. Logistic regression and multiple mediation models were used to test the mediation effects of symptoms of depression and PTSS on the association between abuse/trauma and alcohol misuse. Results Of 1615 women, 31% (n = 498) reported alcohol misuse. Exposure to any CM (adjusted odds ratio (aOR): 1.59, 95% confidence interval (CI): 1.27–1.99), as well as to sexual, physical and emotional CM, were independently associated with alcohol misuse. Lifetime exposure to any IPV (aOR:2.01, 95%CI:1.59–2.54), as well as to physical, emotional and economic IPV, NPSV (aOR: 1.75, 95%CI: 1.32–2.33), and other trauma (aOR:2.08, 95%CI:1.62–2.66), was associated with alcohol misuse. Exposure to an increasing number of abuse types, and other traumatic events, was independently associated with alcohol misuse. PTSS partially mediated the associations of CM, IPV, NPSV and other trauma exposures with alcohol misuse (ps ≤ 0.04 for indirect effects), but depression symptoms did not. Conclusions These findings highlight the need for trauma-informed interventions to address alcohol misuse that are tailored to the needs of women who have experienced violence.

Abstract Background Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations. Methods We conducted this scoping review to answer the question: “what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?” Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively. Results Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Conclusion Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined.

Abstract Background Convincing evidence supports the effectiveness of lifestyle interventions in preventing the occurrence of diabetes in high-income countries, however little is known about appropriate interventions for use in African countries, where there are higher relative increases in diabetes prevalence. The South African Diabetes Prevention Programme (SA-DPP) was initiated with the aim of preventing or delaying the occurrence of diabetes among South Africans (SAs), through interventions, targeting lifestyle changes related to diet and physical activity. The purpose of the current project is to implement and evaluate the suitability and applicability of the SA-DPP developed and tailored in urban populations in the Western Cape Province, in peri-urban populations in the Eastern Cape Province of SA. Methods The SA-DPP, which is an cluster randomized control trial, will be implemented in adults aged 30–65 years residing in the OR Tambo district, Eastern Cape, SA. Participants will be recruited using self-selected sampling techniques and 24 clusters across peri-urban communities will be randomly allocated to participate in the lifestyle intervention, facilitated by non-professional health workers (NPHW). The diabetes risk screening will follow a two-staged approach, including the community-based screening, using the African diabetes risk score (ADRS), followed by a clinic-based risk status assessment by an oral glucose tolerance test (OGTT) to exclude unknown diabetes. The lifestyle-change objectives of the current programme relate to, 1) 15 g of fibre/1000 kcal; 4) > 4 h/week moderate level of physical activity; and 5) > 2% body mass index (BMI) reduction. Discussion The SA-DPP could represent a successful model for the prevention of diabetes and potentially other lifestyle-related diseases in SA and other countries in the region that are confronted with similar challenges. Trial registration PACTR202205591282906.

Firefighters’ face life threatening situations and are frequently exposed to numerous physical, chemical, biological, ergonomic and psychosocial hazards. The purpose of this pilot study was to investigate the feasibility of conducting a large-scale study on cardiovascular and musculoskeletal health, physical fitness and occupational performance of firefighters. We conducted a cross-sectional pilot study by recruiting 36 firefighters. A researcher-generated questionnaire and physical measures were used to collect data on sociodemographic characteristics, cardiovascular and musculoskeletal health, physical fitness and occupational performance using a physical ability test (PAT). We documented a high equipment and intra-assessor reliability (r > 0.9). The potential logistic and/or administrative obstacles in the context of a larger study were discerned. Data were successfully retrieved using available equipment and survey instruments. Hypertension (30.6%) dyslipidaemia (33.3%), obesity (36.1%) and physical inactivity (66.7%) were the most prevalent cardiovascular disease risk factors. A significant difference between genders in total PAT completion time was also seen (p < 0.001). Cardiorespiratory fitness, lean body mass, grip strength and leg strength were significantly associated with occupational performance (p < 0.001). The pilot study supports the larger study feasibility and verified equipment and assessors’ reliability for research. Cardiovascular health, musculoskeletal health and physical fitness may be related to PAT performance.

IntroductionTo perform their work efficiently and safely, firefighters should maintain all aspects of physical fitness. Cardiac-related incidents are the leading cause of duty-related deaths in firefighters, and many firefighters have poor musculoskeletal health (MSH) that hinder their occupational performance (OP). Establishing the relationship between physical fitness, cardiovascular health (CVH), MSH and OP may add new insight on the most significant factors influencing OP in firefighters, specifically in the City of Cape Town Fire and Rescue Service (CoCTFS), which had not been studied before. Therefore, the purpose of this study was to investigate whether physical fitness, CVH and MSH were associated with OP in firefighters, in the COCTFRS.MethodsThis cross-sectional study included 283 full-time firefighters aged 20–65 years from Cape Town, South Africa. A researcher-generated questionnaire was used to collect data on sociodemographic characteristics, lifestyle factors and MSH. Physical measures were used to collect information on physical fitness, CVH, and OP [using a physical ability test (PAT)]. Linear and binary logistic regressions, adjusted for age, sex, height and weekly metabolic equivalent minutes (WMETM), multivariate analysis of covariance (MANCOVA), adjusted for age, sex, height and body mass index (BMI) and backward stepwise regressions were used to investigate the associations between the various constructs.ResultsFrom multivariable analyses, age, lean body mass, body fat percentage (BF%), estimated absolute oxygen consumption (abV̇O2max), grip strength, leg strength, push-ups, sit-ups, WMETM and heart rate variability were associated with PAT completion times (all p

Abstract Background Studies have investigated dietary attributes associated with cardiovascular disease (CVD) risk in Africa. However, there has been no effort to critically assess the existing evidence. This systematic review examined available evidence on the association between plant-based dietary exposures and CVD risk profile in Africa. PROSPERO registration number: CRD42020159862. Methods We conducted a literature search for observational studies reporting on plant-based dietary exposures in relation to CVD risk profile in African populations. PubMed-Medline, Scopus, EBSCOhost, and African Journals Online platforms were searched up to 19 March 2021. Titles and abstracts of the identified records were screened independently by two investigators. The quality of the studies was also assessed independently. Results Of 458 entries identified, 15 studies published between 2002 and 2020 were included in this review. These studies originated from 12 sub-Saharan Africa (SSA) countries. Sample sizes ranged from 110 to 2362, age from 18 to 80 years; and majority of participants were females (66.0%). In all, four plant-based dietary exposures were identified across SSA. Sixty percent of the studies reported a significant association between a plant-based dietary exposure with at least one CVD risk factor such as hypertension, diabetes mellitus, dyslipidaemia, overweight/obesity, and metabolic syndrome. Conclusions The few available studies suggest that there may be a protective effect of plant-based dietary exposures on CVD risk profile in the African setting. Nonetheless, more elaborated studies are still needed to address plant-based diet (PBD) adherence in relation with CVD risk in African populations.

Abstract Background Evidence concerning the relationship between objectively-measured attributes of the built environment with cardio-metabolic risk in populations from lower- and middle-income countries is lacking. In this paper, we describe the association between the objectively-measured built environment with body mass index, blood pressure and physical activity in adult South Africans. Methods This cross-sectional study included 341 adults aged ≥35 years drawn from the Cape Town arm of the Prospective Urban Rural Epidemiology (PURE) cohort study. All Cape Town PURE participants were invited to take part in the study. Actigraph GT3X accelerometer and Geographic Information Systems were used to measure physical activity and built environment attributes (community center, shopping center and taxi rank). Results In age and sex adjusted models (reference 500 m), access to community centers (1000 m) was positively related to body mass index [beta 4.70 (95%CI: 2.06 to 7.34)] and diastolic blood pressure [4.97 (0.00 to 9.95)]. Distance from a community center (1600 m) was positively related to diastolic blood pressure [6.58 (1.57 to 11.58)] and inversely with moderate-to-vigorous physical activity [− 69.30 (− 134.92 to − 3.70)]. Distance to a shopping center (1600 m) was positively related to body mass index [4.78 (1.11 to 8.45)] and shopping center (1000 m) was positively related to systolic blood pressure respectively [76.99 (0.03 to 83.95)]. Conclusion Distance to community and shopping centers were significantly associated with BMI, systolic, diastolic blood pressure and moderate-to-vigorous physical activity. Future research should include multiple aspects of built environment variables in order to provide for a broader understanding of their effect on cardiovascular risk profile of African populations.

Abstract Background To investigate the association between perceived environmental attributes and leisure-time and transport-related physical activity. Methods This was a cross-sectional survey involving 671 South Africans aged ≥35 years from urban and rural settings. International Physical Activity Questionnaire and Neighbourhood Walkability Scale were used to collect data. Multivariable logistic regressions were used to investigate the associations. Results Significant urban vs. rural differences were apparent in the distribution of most attributes of neighborhood environment. After adjusting for gender, age, setting and relevant interaction terms, proximity to local stores was significantly associated with leisure-time physical activity (OR: 4.26; 95% CI, 1.00–18.08); while proximity to transit stops (2.44; 1.48–4.02), pleasant scenery (1.93; 1.07–3.46), sidewalks (2.36; 1.25–4.44), shade from trees (2.14; 1.19–3.85), traffic (2.17; 91.21–3.91) and well-lit streets (2.01; 1.04–3.89) were significantly associated with walking for leisure. Four-way intersections (4.54; 1.54–13.43), pleasant scenery (3.84; 1.35–10.99), traffic (0.28; 0.09–0.89), sidewalks (3.75; 1.06-13.27) and crosswalks were associated with transport related physical activity. Proximity to transit stops (2.12; 1.17–3.84) and well maintained sidewalks (2.69; 2.20–10.02) were significantly associated with total physical activity. Significant interactions by setting were apparent in some of the associations. Conclusion Some, but not all attributes of a neighborhood environment were significantly associated in expected directions with the three physical activity domains in this mixed urban and rural population. This study highlights the need for policy strategies aimed at improving or maintaining these perceived environmental attributes to promote physical activity.

Background: The World Health Organization (WHO) algorithm for the diagnosis of tuberculosis in seriously ill HIV-infected patients recommends that treatment for Pneumocystis jiroveciipneumonia (PJP) should be considered without giving clear guidance on selecting patients for empiric PJP therapy. PJP is a common cause of hospitalisation in HIV-infected patients in resource-poor settings where diagnostic facilities are limited. Methods: We developed clinical prediction rules for PJP in a prospective cohort of HIV-infected inpatients with WHO danger signs and cough of any duration. The reference standard for PJP was > 1000 copies/mL of P. jirovecii DNA on real-time sputum polymerase chain reaction (PCR). Four potentially predictive variables were selected for regression models: dyspnoea, chest X-ray, haemoglobin and oxygen saturation. Respiratory rate was explored as a replacement for oxygen saturation as pulse oximetry is not always available in resource-poor settings. Results: We enrolled 500 participants. After imputation for missing values, there were 56 PJP outcome events. Dyspnoea was not independently associated with PJP. Oxygen saturation and respiratory rate were inversely correlated. Two clinical prediction rules were developed: chest X-ray possible/likely PJP, haemoglobin ≥ 9 g/dL and either oxygen saturation < 94% or respiratory rate. The area under the receiver operating characteristic curve of the clinical prediction rule models was 0.761 (95% CI 0.683–0.840) for the respiratory rate model and 0.797 (95% CI 0.725–0.868) for the oxygen saturation model. Both models had zero probability for PJP for scores of zero, and positive likelihood ratios exceeded 10 for high scores. Conclusion: We developed simple clinical prediction rules for PJP, which, if externally validated, could assist decision-making in the WHO seriously ill algorithm.

Background: Tuberculosis (TB) prevention, including infection control, is a key element in the strategy to end the global TB epidemic. While effective infection control requires all health system components to function well, this is an area that has not received sufficient attention in South Africa despite the availability of policy and guidelines. Aim: To describe the state of implementation of TB infection control measures in a high-burden metro in South Africa. Setting: The research was undertaken in a high TB- and HIV-burdened metropolitan area of South Africa. More specifically, the study sites were primary health care facilities (PHC), thatamong other services also diagnosed TB. Methods: A cross-sectional survey, focusing on the World Health Organization levels of infection control, which included structured interviews with nurses providing TB diagnosis and treatment services as well as observations, at all 41 PHC facilities in a high TB-burdened and HIV-burdened metro of South Africa. Results: Tuberculosis infection control was poorly implemented, with few facilities scoring 80% and above on compliance with infection control measures. Facility controls: 26 facilities (63.4%) had an infection control committee and 12 (29.3%) had a written infection control plan. Administrative controls: 26 facilities (63.4%) reported separating coughing and noncoughing patients, while observations revealed that only 11 facilities (26.8%) had separate waiting areas for (presumptive) TB patients. Environmental controls: most facilities used open windows for ventilation (n = 30; 73.2%); however, on the day of the visit, only 12 facilities (30.3%) had open windows in consulting rooms. Personal protective equipment: 9 facilities (22%) did not have any disposable respirators in stock and only 9 respondents (22%) had undergone fit testing. The most frequently reported barrier to implementing good TB infection control practices was lack of equipment (n = 22; 40%) such as masks and disposable respirators, as well as the structure or layout of the PHC facilities. The main recommendation to improve TB infection control was education for patients and health care workers (n = 18; 33.3%). Conclusion: All levels of the health care system should be engaged to address TB prevention and infection control in PHC facilities. Improved infection control will address the nosocomial spread of TB in health facilities and keep health care workers and patients safe from infection.

BackgroundDecision support systems (DSSs) for suggesting optimal treatments for individual patients with low back pain (LBP) are currently insufficiently accurate for clinical application. Most of the input provided to train these systems is based on patient-reported outcome measures. However, with the appearance of electronic health records (EHRs), additional qualitative data on reasons for referrals and patients’ goals become available for DSSs. Currently, no decision support tools cover a wide range of biopsychosocial factors, including referral letter information to help clinicians triage patients to the optimal LBP treatment. ObjectiveThe objective of this study was to investigate the added value of including qualitative data from EHRs and referral letters to the accuracy of a quantitative DSS for patients with LBP. MethodsA retrospective study was conducted in a clinical cohort of Dutch patients with LBP. Patients filled out a baseline questionnaire about demographics, pain, disability, work status, quality of life, medication, psychosocial functioning, comorbidity, history, and duration of pain. Referral reasons and patient requests for help (patient goals) were extracted via natural language processing (NLP) and enriched in the data set. For decision support, these data were considered independent factors for triage to neurosurgery, anesthesiology, rehabilitation, or minimal intervention. Support vector machine, k-nearest neighbor, and multilayer perceptron models were trained for 2 conditions: with and without consideration of the referral letter content. The models’ accuracies were evaluated via F1-scores, and confusion matrices were used to predict the treatment path (out of 4 paths) with and without additional referral parameters. ResultsData from 1608 patients were evaluated. The evaluation indicated that 2 referral reasons from the referral letters (for anesthesiology and rehabilitation intervention) increased the F1-score accuracy by up to 19.5% for triaging. The confusion matrices confirmed the results. ConclusionsThis study indicates that data enriching by adding NLP-based extraction of the content of referral letters increases the model accuracy of DSSs in suggesting optimal treatments for individual patients with LBP. Overall model accuracies were considered low and insufficient for clinical application.

BackgroundIn addition to their direct pathogenic effects, arthropod-borne (arboviruses) have been hypothesized to indirectly contribute to hospitalizations and death through decompensation of pre-existing comorbidities. Using nationwide data routinely collected from 1 January 2014 to 31 December 2019 in Brazil, we investigated whether local increases in arbovirus notifications were associated with excess hospitalization.MethodsWe estimated the relative risks for the association between municipality- and state-level increases in arboviral case notifications and age-standardized hospitalization rates (i.e., classified as direct or indirect based on ICD-10 codes) using Bayesian multilevel models with random effects accounting for temporal and geographic correlations. For municipality-level analyses, we excluded municipalities with ResultsFrom 2014 to 2019, Brazil registered 7,566,330 confirmed dengue cases, 159,029 confirmed ZIKV cases, and 433,887 confirmed CHIKV cases. Dengue notifications have an endemic and seasonal pattern, with cases present in 5334 of the 5570 (95.8%) Brazilian municipalities and most (69.5%) registered between February and May. Chikungunya notifications followed a similar seasonal pattern to DENV but with a smaller incidence and were restricted to 4390 (78.8%) municipalities. ZIKV was only notified in 2581 (46.3%) municipalities. Increases in dengue and chikungunya notifications were associated with small increases in age-standardized arbovirus-related hospitalizations, but no consistent association was found with all-cause or other specific indirect causes of hospitalization. Zika was associated to increases in hospitalizations by neurological diseases.ConclusionsAlthough we found no clear association between increased incidence of the three arboviruses and excess risks of all-cause or indirect hospitalizations at the municipality- and state-levels, follow-up investigations at the individual-level are warranted to define any potential role of acute arbovirus infection in exacerbating risks of hospitalization from underlying conditions.