Antibiotic Usage in Relation to Resistant Bacterial Infections and Liver and Kidney Cancer Outcomes in South Carolina

Antibiotics are one of the most beneficial discoveries in medicine and public health. However, the use, overuse, and misuse of these drugs have led to increases in antibiotic resistant bacterial infections (ARI). Furthermore, previous epidemiological studies have linked antibiotic use to breast cancer, but these studies have not included effects on metabolic organs, such as the liver and kidneys. This dissertation investigates the role of antibiotic use in infections and liver and kidney cancers in the state of South Carolina. Using ecological study methods and Poisson regression to determine relative risk ratios, it was found that antibiotic use is a risk factor for the development of ARIs and kidney cancer, but not liver cancer. Census tracts with higher percentages of black populations were found to be more at risk for these outcomes, including liver cancer. Case-control methodology was used to investigate individual risk for liver and kidney cancer outcomes, and demographic and geographic variables were examined as confounders or effect modifiers between these relationships. Using conditional logistic regression to calculate odds ratios (OR), it was determined that antibiotic usage is not a risk factor for liver cancer, with ORs of 1.07 (0.77-1.49) for 5 to 36 total prescriptions, 1.33 (0.72-1.46) for 64 to 204 total prescriptions, and 1.39 (0.98-1.98) for 205 to 4374 total prescriptions per participant. No association was found between liver cancer and days of use of antibiotics, nor was their increased risk by specific antibiotic classes. Despite these findings, antibiotic usage was associated with higher odds of kidney cancer outcomes, with ORs of 1.50 (1.27-1.78) for 18 to 131 total prescriptions and 1.43 (1.20-1.69) for 132 to 12362 total prescriptions per participant. For days of use of antibiotics, ORs were 1.41 (1.20-1.67) for 116 to 950 total days of use, and 1.46 (1.23-1.73) for 951 to 123588 total days of use per participant. Also, increased kidney cancers risks were associated with certain classes of antibiotics for some or all levels of exposure by total prescription number and days of use. Overall, these findings suggest that antibiotics must be used in a more judicious manner in medical settings

HYPHENATED HINDUS: A Study of the Relationship between the Formation of a Indo-Caribbean Hindu Identity and the Development of the West Indian Temple in Trinidad and in the United States

In this thesis, I argue that West Indian temples are a material articulation of an Indo-Caribbean Hindu identity that no longer claims India as home. The hyphenated identity of Indo-Caribbeans does not allow them to be fully represented by either South Asian or Caribbean cultures. Hence Caribbean temples, like the Indo-Caribbean identity, attempts to combine two different worlds. By tracing the political and social events that led to the development of a separate Hindu identity from that of East Indians, I demonstrate the ways in which Hinduism in Caribbean combines Hindu nationalism with features from Christianity into a unique form of Hinduism. I argue that West Indian Hinduism is not simply borrowing from Christianity or merely articulating Hinduism in opposition to Christianity, but rather it unites the two which in turn alienates it from mainstream Christianity as well as from Hinduism as practiced in India. As a result, West Indian Hinduism exists in the tension created between Christianity and Hindu reform movements. I propose that this tension is especially evident in West Indian temples in the United States as demonstrated by temples in Orlando, Florida and Queens, New Yor

Organisational capacity of public sector ART provision in Gauteng Province and its impact on patient adherence : Case studies of two facilities

In November 2003, the Department of Health launched the Operational Plan for Comprehensive Care, Management and Treatment (CCMT) for South Africa. This policy has as its central goal universal access to antiretroviral therapy to 1 million people living with HIV by the end of 2007. National implementation of the operational plan began in April 2004 and as at the end of October 2006, South Africa had initiated 213 828 people onto ART through the Plan, making it the biggest programme in the world. Of these, 55 580 people had been placed on treatment in Gauteng Province. Despite these early achievements, there are concerns as to whether the South African public health sector can rise to the challenge of universal access while achieving good clinical outcomes and programme performance. As Venter (2006: 298) states, “the health sector is buckling under the current load, and currently does not have the capacity to do anymore than dent the numbers needed to treat, unless a radical restructuring of health services occurs.” A crucial factor in providing a comprehensive approach to HIV/AIDS is the reorientation of service delivery from acute to chronic disease care. In addition to the shift in focus to chronic disease management of HIV/AIDS, health system constraints need to be addressed. These include inadequate health system infrastructure and human resources. This study aimed to comprehensively assess organisational capacity to provide antiretroviral therapy (ART) in two public sector CCMT sites in Gauteng Province and the influence of these organisational factors on follow-up and adherence to ART, with the view to understanding whether public sector CCMT sites are able to deal with new challenges posed by the Plan. The objectives were to assess: (1) levels of follow-up and adherence in patients registered at the CCMT site, (2) dimensions of organisational capacity, drawing on internationally recognised chronic disease care frameworks, namely the Wagner Chronic Care Model (CCM) and Innovative Care for Chronic Conditions (ICCC). These dimensions were: presence of motivated and adequately staffed teams; delivery systems design; the quality of support systems; and facility information systems. 3) the similarities and differences between the two sites with respect to organisational capacity, follow-up and adherence. The two sites were selected through a stratified (CHC and hospital) random sample of CCMT sites in Region A of the province, excluding the long–standing and well-established academic hospital CCMT sites in the sampling frame. The two sites, located in a District Hospital in the West Rand and a Community Health Centre (CHC) in Central Witwatersrand, were visited between May and July 2006. They had initiated 540 and 1001 patients on ART respectively since October 2004. A multi-method health service evaluation of capacity in the HIV related services (ART/Wellness, VCT, PMTCT, and TB) was conducted. This consisted of 11 semi-structured interviews with facility and programme managers; review of registers and routine facility data; an observation checklist and mapping to assess the physical infrastructure of the facility, presence of management and health information systems; 35 self administered questionnaires to assess the levels of motivation of nursing staff at each site. Data on self-reported adherence and viral loads were obtained from a separate study involving exit interviews with 356 patients who had been attending the services for at least four months in the two sites.1 Of the 540 and 1001 patients enrolled in the two services, 69.8% and 69.3% were still in the service after 18 months at the hospital and CHC, respectively. The monthly drop-out rate at the hospital had risen fairly sharply towards the end of the 18 month period, attributed by the staff to growing difficulties in access to the site by new enrolments. Nevertheless, based on self-reports (3- day recall period), viral load measures, and loss to follow-up, adherence levels at both sites appeared to be in line with national and international best practice. The percentage of patients with undetectable virus was 76.2% and 74.4% at the hospital and CHC, respectively. Staffing of the CCMT sites matched the pre-requisites outlined by the National Department of Health for a ‘core’ health care team treating 500 patients. The CHC CCMT site, however, had more than 500 patients on ART and moreover was providing two services within one unit, i.e. ART/Wellness and VCT thus increasing the patient load. Sites were reaching saturation and this was due to the lack of sufficient space coupled with the high volumes of patients, shortage of certain scarce skills (in particular pharmacy staff), and the multiple responsibilities of nursing staff. In general, the staffing situation at the hospital appeared better. More staff had joined than left the hospital over the year prior to March 2006, and clinical workloads both in the ambulatory services and the CCMT site were less than at the CHC. Vacancy rates were low, at 13.8% and 4.8% for the hospital and CHC, respectively. Strong leadership of CCMT sites by motivated ART programme managers was displayed; site managers were highly respected and revered by staff. Based on ratings in a self-administered questionnaire, overall levels of motivation and organisational commitment at both sites appeared good, although, worryingly, a sizeable proportion of respondents in both sites agreed with statement “I intend to leave this hospital/clinic.” Lack of external support (from the HIV/AIDS, STI, TB Programme) and debriefing systems for programme managers and nursing staff was identified as weaknesses. With some exceptions, both sites showed evidence of strong ‘horizontal’ mechanisms of referral and coordination between HIV and AIDS related services within sites; however the PMTCT programme at the hospital was less co-ordinated and networked with other services. In addition, ART and PMTCT programme managers at the hospital indicated that the relationship between hospital services and surrounding clinics was poor. Apart from the lack of space at the CHC CCMT site, support systems were adequate. There were no reported drug stock outs and supply of drugs and general supplies was good at both sites. Both sites were able to offer a range of routine and HIV specific tests. A combination of paper and electronic based information systems were used at both sites, however, the hospital CCMT site used a mixture of standard and locally designed data collection forms compared to the CHC which mainly used standard Department of Health forms. The information systems were adequate in monitoring and evaluating patients and programme performance; however, the study highlighted the absence of a clear patient register for individual and programme monitoring and only cross sectional patient data was reported. There was also considerable duplication at the hospital in collecting and compiling patient information. The findings of the study suggest that the two sites, located in the ‘routine’ public sector environment of Gauteng Province have demonstrated ability to build organisational capacity for ART provision, through a degree of systems integration and design, decision support systems, generation and local use of information and motivated local champions. Through these elements of organisational capacity, both sites have achieved good adherence rates. The key factors to achieving this good programme performance were motivated local champions who drove programmes forward and good working relationships between the CCMT and other players. In light of the weaknesses identified, the following key recommendations are proposed: Review sites to identify the reasons for the high-drop out rate and address these issues Due to evidence of early saturation at the CHC, it is suggested that additional roll-out sites be established, or alternatively increase staffing and space at the CHC to meet the needs of the high patient load. In addition, well patients should be decanted to lower level services e.g. community based care organisations, thus reducing the burden on the site Pay attention to the physical infrastructure needs of clinic based sites, especially as they become saturated Foremost, the current Employee Assistance Programme (EAP) implemented in Gauteng Province should be strengthened and marketed so that staff members are more aware of the service and make use of it accordingly. Alternatively, a culture of “caring for the caregivers” should be cultivated, through for example, specialist assistance, debriefing sessions, and better external programme support from HIV/AIDS, STI, TB (HAST) managers Improve support and supervision of ART programmes by facilitating greater communication and feedback between sites and district, national and provincial levels of government. Adopt a strategy of “task shifting”, through better use of lay workers, counsellors, and mid level workers such as pharmacy assistants. Facilitate greater integration and coordination between the PMTCT programmes and other services, including the provision of VCT and training of staff. In addition, it is imperative that there is good integration between services provided by local and provincial Departments of Health Simplify and standardise information systems, particularly the development of clear patient registers to allow for cohort analysis

Gene Therapy with Endogenous Inhibitors of Angiogenesis for Neovascular Age-Related Macular Degeneration: Beyond Anti-VEGF Therapy

Age-related macular degeneration (AMD) is the leading cause of substantial and irreversible vision loss amongst elderly populations in industrialized countries. The advanced neovascular (or “wet”) form of the disease is responsible for severe and aggressive loss of central vision. Current treatments aim to seal off leaky blood vessels via laser therapy or to suppress vessel leakage and neovascular growth through intraocular injections of antibodies that target vascular endothelial growth factor (VEGF). However, the long-term success of anti-VEGF therapy can be hampered by limitations such as low or variable efficacy, high frequency of administration (usually monthly), potentially serious side effects, and, most importantly, loss of efficacy with prolonged treatment. Gene transfer of endogenous antiangiogenic proteins is an alternative approach that has the potential to provide long-term suppression of neovascularization and/or excessive vascular leakage in the eye. Preclinical studies of gene transfer in a large animal model have provided impressive preliminary results with a number of transgenes. In addition, a clinical trial in patients suffering from advanced neovascular AMD has provided proof-of-concept for successful gene transfer. In this mini review, we summarize current theories pertaining to the application of gene therapy for neovascular AMD and the potential benefits when used in conjunction with endogenous antiangiogenic proteins

Using an open-source tablet perimeter (Eyecatcher) as a rapid triage measure in a glaucoma clinic waiting area

Background: Glaucoma services are under unprecedented pressure. The UK Healthcare Safety Investigation Branch recently called for new ways to identify glaucoma patients most at risk of developing sight loss, and of filtering-out false-positive referrals. Here we evaluate the feasibility of one such technology, “Eyecatcher”: a free, tablet-based ‘triage’ perimeter, designed to be used unsupervised directly within clinic waiting areas. It does not require a button or headrest: patients are simply required to look at fixed-luminance dots as they appear. Methods: Seventy-seven people were tested twice using Eyecatcher (one eye only) while waiting for a routine appointment in a UK glaucoma clinic. The sample included individuals with an established diagnosis of glaucoma, and false-positive new referrals (no visual field or optic nerve abnormalities). No attempts were made to control the testing environment. Patients wore their own glasses and received minimal task instructions. Results: Eyecatcher was fast (median: 2.5 mins), produced results in good agreement with standard automated perimetry (SAP), and was rated as more enjoyable, less tiring, and easier to perform than SAP (P -2 dB). And it was able to flag two thirds of false-positive referrals as functionally normal. However, eight people (10%) failed to complete the test twice, and reasons for this limitation are also discussed. Conclusions: Tablet-based eye-movement perimetry could potentially provide a pragmatic way of triaging busy glaucoma clinics (flagging high-risk patients and possible false-referrals)

Tele-Neuro-Ophthalmology: Vision for 20/20 and Beyond

Background: Telehealth provides health care to a patient from a provider at a distant location. Prior to the COVID-19 pandemic adoption of telehealth modalities was increasing slowly but steadily. During the public health emergency rapid widespread telehealth implementation has been encouraged to promote patient and provider safety and preserve access to health care. Evidence acquisition: Evidence was acquired from English language Internet-searches of medical and business literature and following breaking news on the COVID-19 pandemic and responses from health care stakeholders including policy makers, payers, physicians and health care organizations, and patients. We also had extensive discussions with colleagues who are developing telehealth techniques relevant to neuro-ophthalmology. Results: Regulatory, legal, reimbursement and cultural barriers impeded the widespread adoption of telehealth prior to the COVID-19 pandemic. With the increased use of telehealth in response to the public health emergency, we are rapidly accumulating experience and an evidence base identifying opportunities and challenges related to the widespread adoption of tele-neuro-ophthalmology. One of the major challenges is the current inability to adequately perform funduscopy remotely. Conclusions: Telehealth is an increasingly recognized means of healthcare delivery. Tele-neuro-ophthalmology adoption is necessary for the sake of our patients, the survival of our subspecialty, and the education of our trainees and students. Telehealth does not supplant but supplements and complements in-person neuro-ophthalmologic care. Innovations in digital optical fundus photography, mobile vision testing applications, artificial intelligence and principles of channel management will facilitate further adoption of tele-neuro-ophthalmology and bring the specialty to the leading edge of healthcare delivery

Six-month Longitudinal Comparison of a Portable Tablet Perimeter With the Humphrey Field Analyzer.

PURPOSE: To establish the medium-term repeatability of the iPad perimetry app Melbourne Rapid Fields (MRF) compared to Humphrey Field Analyzer (HFA) 24-2 SITA-standard and SITA-fast programs. DESIGN: Multicenter longitudinal observational clinical study. METHODS: Sixty patients (stable glaucoma/ocular hypertension/glaucoma suspects) were recruited into a 6-month longitudinal clinical study with visits planned at baseline and at 2, 4, and 6 months. At each visit patients undertook visual field assessment using the MRF perimetry application and either HFA SITA-fast (n = 21) or SITA-standard (n = 39). The primary outcome measure was the association and repeatability of mean deviation (MD) for the MRF and HFA tests. Secondary measures were the point-wise threshold and repeatability for each test, as well as test time. RESULTS: MRF was similar to SITA-fast in speed and significantly faster than SITA-standard (MRF 4.6 ± 0.1 minutes vs SITA-fast 4.3 ± 0.2 minutes vs SITA-standard 6.2 ± 0.1 minutes, P < .001). Intraclass correlation coefficients (ICC) between MRF and SITA-fast for MD at the 4 visits ranged from 0.71 to 0.88. ICC values between MRF and SITA-standard for MD ranged from 0.81 to 0.90. Repeatability of MRF MD outcomes was excellent, with ICC for baseline and the 6-month visit being 0.98 (95% confidence interval: 0.96-0.99). In comparison, ICC at 6-month retest for SITA-fast was 0.95 and SITA-standard 0.93. Fewer points changed with the MRF, although for those that did, the MRF gave greater point-wise variability than did the SITA tests. CONCLUSIONS: MRF correlated strongly with HFA across 4 visits over a 6-month period, and has good test-retest reliability. MRF is suitable for monitoring visual fields in settings where conventional perimetry is not readily accessible.Funding/Support: Cambridge Eye Trust Jukes Glaucoma Research Fund Glance Optical Pty. Ltd

Multi-centre comparison between device-independent web-browser perimetry (Melbourne Rapid Fields-web) and SITA-Faster for glaucoma

PurposeVisual field testing is important for glaucoma diagnosis and management, but access to standard automated perimetry can be limited in some areas due to cost or access. Melbourne Rapid Fields-web (MRF-web) perimeter is designed to address these limitations by allowing perimetry testing on the flat screen of your personal computer.MethodsThis study is a retrospective, cross-sectional study involving two locations in Australia, one in metropolitan Melbourne and one in rural Dubbo NSW. 232 patients with stable glaucoma, glaucoma suspect or normal eyes were tested with MRF-web and outcomes were compared to the most recent Humphrey Field Analyzer (HFA) 24-2 SITA Faster test. Outcomes were compared by Deming regressions, Intraclass Correlation Coefficients (ICC) and Bland-Altman methods.ResultsPatient age ranged from 21 to 92 (average 66.3, SD 16.1). Bland-Altman found a bias of -0.50dB for Mean Deviation (MD) between the two tests, with 95% Limits of Agreement (LoA) of -6.80dB to 5.80dB. Pattern Deviation (PD) had a bias of -0.58dB with 95% LoA of -5.60dB to 4.40dB. High concordance was found for MD and PD, with ICCs of 0.87 and 0.73. No significant differences were found in false positive and fixation loss rates. Test time was approximately one minute longer for MRF-web compared to SITA-Faster. Area Under the Curve of MRF and HFA are similar indicating comparable diagnostic capacity.ConclusionMRF-web produces outcomes comparable to HFA SITA-Faster. Its portability and cost-effectiveness suggest suitability as an alternative method for visual field testing where a standard perimeter is not easily accessible

Elaboración de Instrumentos de Evaluación para la asignatura de matemáticas en nivel 4° y 5° básico.

La asignatura de matemática es una de las fundamentales en el currículo nacional y de aquellas más difíciles de apropiarse por los estudiantes, logrando bajos resultados a nivel nacional si se comparan con los resultados de países de la OCDE, sin embargo a nivel Latinoamericano somos uno de los países que hemos ido superando estos resultados producto de la focalización con medidas ministeriales y a niveles internos en los establecimientos educacionales. Es debido a esta realidad que se hace necesario el monitoreo temprano de las conductas de entrada y seguimiento en todos los niveles de enseñanza en el área de matemáticas, por cuanto se ha seleccionado esta asignatura para diseñar, validar por expertos y luego aplicar dos evaluaciones diagnósticas a los cursos de 4° y 5° básico de manera de obtener datos duros que nos demuestren el nivel de desarrollo de las habilidades y competencias con que cuentan nuestros estudiantes para enfrentar la asignatura y en un futuro cercano afrontar evaluaciones externas que son de importancia para la clasificación del establecimiento educacional como también lograr los propósitos de la asignatura en la vida de los estudiantes. Se aplicó una metodología mixta, cuantitativa y cualitativa, cuantitativa en relación a la aplicación de los instrumentos de evaluación diagnóstica y recolección de datos que fueron analizados, presentados en pptt y sistematizados con los docentes del establecimiento que tienen los cursos a cargo, a través de una reunión reflexiva. Cualitativa en aspectos de validación de los instrumentos por expertos a través del método Delphi, método que es conocido y aplicado por los docentes del establecimiento como una práctica consolidada en el trabajo técnico del establecimiento. Con este método se elaboró una pauta de evaluación que fue aplicada por los docentes al instrumento creado y una de apreciación de sus competencias profesionales que validaran su trabajo. Del mismo modo se crearon notas de campo obtenidas de la reunión de análisis con docentes. Objetivos: - Elaborar dos instrumentos de evaluación diagnóstica en la asignatura de matemática para alumnos de enseñanza básica de la escuela Guillermo cereceda Rojas. - Validar los instrumentos de evaluación diagnóstica a través del apoyo de expertos. - Aplicar las evaluaciones a los cursos focalizados. - Analizar los resultados de las evaluaciones diagnósticas. - Diseñar un Plan remedial que permita subsanar los resultados deficitarios del diagnóstico. Las evaluaciones diagnósticas fueron creadas a partir de los aprendizajes claves de 3° y 4° básico respectivamente, por ser las conductas de entrada necesarias para el año escolar 2020, con ítems de selección múltiple, completación y desarrollo que abarcaron los objetivos y habilidades trabajadas en la asignatura. Los instrumentos fueron evaluados por docentes expertos en la materia, modificados en aspectos menores, y aplicadas al 100% de los estudiantes durante la segunda semana de clases, para aquellos estudiantes ausentes al momento de la evaluación, se les aplicó en forma individual con apoyo de la Unidad Técnico Pedagógica y el Programa PIE. Una vez revisados y obtenidos los resultados se tabularon en una planilla excell se realizaron análisis en relación a preguntas correctas, errores comunes , niveles de logro de los estudiantes, objetivos y habilidades con mayor éxito y más descendidas, se graficaron resultados y se realizó una reunión de presentación y reflexión de los mismos con los docentes de la asignatura de matemática con el fin de indagar posibles factores que explicaran los resultados e intencionar un trabajo mancomunado al poner en práctica el Plan de mejora para la asignatura en los dos cursos, de manera que se puedan intervenir tempranamente los aspectos deficitarios presentado en las evaluaciones con foco en las habilidades y estudiantes más descendidos