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A mobile colistin resistance gene mcr was first reported in 2016 in China and has since been found with increasing prevalence across South-East Asia. Here we survey the presence of mcr genes in 4907 rectal swabs from mothers and neonates from three hospital sites across Nigeria; a country with limited availability or history of colistin use clinically. Forty mother and seven neonatal swabs carried mcr genes in a range of bacterial species: 46 Enterobacter spp. and single isolates of; Shigella , E. coli and Klebsiella quasipneumoniae . Ninety percent of the genes were mcr-10 ( n  = 45) we also found mcr-1 ( n  = 3) and mcr - 9 ( n  = 1). While the prevalence during this collection (2015-2016) was low, the widespread diversity of mcr -gene type and range of bacterial species in this sentinel population sampling is concerning. It suggests that agricultural colistin use was likely encouraging sustainment of mcr -positive isolates in the community and implementation of medical colistin use will rapidly select and expand resistant isolates. Here, the authors report the results of a BARNARDS sub-study identifying a 1% mobile colistin resistance gene (mcr) carriage rate in around 5000 rectal swabs from mothers and neonates across Nigeria, of which 90% were mcr-10 (mostly Enterobacter spp.) and 10% were mcr-1 and mcr9.

Early development of the microbiome has been shown to affect general health and physical development of the infant and, although some studies have been undertaken in high-income countries, there are few studies from low- and middle-income countries. As part of the BARNARDS study, we examined the rectal microbiota of 2,931 neonates (term used up to 60 d) with clinical signs of sepsis and of 15,217 mothers screening for bla CTX-M-15 , bla NDM , bla KPC and bla OXA-48 -like genes, which were detected in 56.1%, 18.5%, 0% and 4.1% of neonates’ rectal swabs and 47.1%, 4.6%, 0% and 1.6% of mothers’ rectal swabs, respectively. Carbapenemase-positive bacteria were identified by MALDI-TOF MS and showed a high diversity of bacterial species (57 distinct species/genera) which exhibited resistance to most of the antibiotics tested. Escherichia coli , Klebsiella pneumoniae and Enterobacter cloacae / E. cloacae complex, the most commonly found isolates, were subjected to whole-genome sequencing analysis and revealed close relationships between isolates from different samples, suggesting transmission of bacteria between neonates, and between neonates and mothers. Associations between the carriage of antimicrobial resistance genes (ARGs) and healthcare/environmental factors were identified, and the presence of ARGs was a predictor of neonatal sepsis and adverse birth outcomes. Analysis of gut microbiota of mothers and its neonates—as part of the BARNARDS study—reveals associations between β-lactamase gene carriage and neonatal sepsis risk in low-income settings.

Background Expanding access to equitable health insurance is an important lever towards the overall strategy for achieving universal health coverage. In Nigeria, health insurance coverage is low with a renewed government action on increasing access to and coverage of high-quality healthcare services to citizens, particularly for the vulnerable and poor population. Therefore, our study co-creates the priorities for expanding health insurance in Nigeria, focusing on key policy reforms, public advocacy, and innovative financing strategies to ensure broader and more equitable coverage for the population. Methodology We employed a Delphi approach methodology through strategic health insurance meetings with a diverse multidisciplinary panel of 125 stakeholders including representatives of accredited Health Insurance Maintenance Organizations, Heads of States Social Health Insurance Agencies, Development Partners representatives, academics, government officials, national health insurance authority expanded management team and experts in health insurance across all the states of Nigeria to recommend specific actions towards health insurance expansion and universal health coverage in Nigeria. Results The participants/panels were able to come up with a consensus on 66 priorities for health insurance expansion in Nigeria working with stakeholders within the Nigerian health insurance ecosystem across the 36 states and Nigeria’s FCT. From these priorities, seven priority areas and 17 themes were derived that should be considered by the government, policymakers, regulators, and practitioners to deepen health insurance penetration in Nigeria. These seven priority areas that have been identified include enrolment, equity, organizational health and structure, data and technology, quality, market efficiency, and citizen engagement. Conclusion The priorities identified for health insurance expansion in Nigeria will go a long way in shaping health insurance. We hope that government, policymakers, regulators, and practitioners in the health ecosystem will use these social policy actions to set priorities for increasing health insurance coverage and address inadequacies to accelerate the drive towards the attainment of UHC by 2030.

In a large study in 17 countries, an estimated sodium intake that was either higher or lower than the average estimated sodium intake was associated with an increased risk of cardiovascular events. A higher-than-average potassium intake was associated with reduced risk. Most of the global population consumes between 3.0 and 6.0 g of sodium per day (7.5 to 15.0 g of salt per day). 1 , 2 Guidelines on cardiovascular disease prevention recommend a maximum sodium intake of 1.5 to 2.4 g per day, but achieving this target will require a substantial change in diet for most people. 3 – 5 Although clinical trials have shown a reduction in blood pressure with a reduced sodium intake, to our knowledge, no large randomized trial has been conducted to document reductions in the risk of cardiovascular disease with low sodium intake. 6 Prospective cohort studies have shown inconsistent . . .

This paper addresses coverage loss and rapid energy depletion issues for wireless livestock sensor networks by proposing a UAV-based energy-efficient reconfigurable routing (UBER) scheme for smart wireless livestock sensor networking applications. This routing scheme relies on a dynamic residual energy thresholding strategy, robust cluster-to-UAV link formation, and UAV-assisted network coverage and recovery mechanism. The performance of UBER was evaluated using low, normal and high UAV altitude scenarios. Performance metrics employed for this analysis are network stability (NST), load balancing ratio (LBR), and topology fluctuation effect ratio (TFER). Obtained results demonstrated that operating with a UAV altitude of 230 m yields gains of 31.58%, 61.67%, and 75.57% for NST, LBR, and TFER, respectively. A comparative performance evaluation of UBER was carried out with respect to hybrid heterogeneous routing (HYBRID) and mobile sink using directional virtual coordinate routing (MS-DVCR). The performance indicators employed for this comparative analysis are energy consumption (ENC), network coverage (COV), received packets (RPK), SN failures detected (SNFD), route failures detected (RFD), routing overhead (ROH), and end-to-end delay (ETE). With regard to the best-obtained results, UBER recorded performance gains of 46.48%, 47.33%, 15.68%, 19.78%, 46.44%, 29.38%, and 58.56% over HYBRID and MS-DVCR in terms of ENC, COV, RPK, SNFD, RFD, ROH, and ETE, respectively. The results obtained demonstrated that the UBER scheme is highly efficient with competitive performance against the benchmarked CBR schemes.

The benefit of oral anticoagulation in atrial fibrillation is based on a balance between reduction in ischaemic stroke and increase in major bleeding. We aimed to develop and validate a new biomarker-based risk score to improve the prognostication of major bleeding in patients with atrial fibrillation. We developed and internally validated a new biomarker-based risk score for major bleeding in 14 537 patients with atrial fibrillation randomised to apixaban versus warfarin in the ARISTOTLE trial and externally validated it in 8468 patients with atrial fibrillation randomised to dabigatran versus warfarin in the RE-LY trial. Plasma samples for determination of candidate biomarker concentrations were obtained at randomisation. Major bleeding events were centrally adjudicated. The predictive values of biomarkers and clinical variables were assessed with Cox regression models. The most important variables were included in the score with weights proportional to the model coefficients. The ARISTOTLE and RE-LY trials are registered with ClinicalTrials.gov, numbers NCT00412984 and NCT00262600, respectively. The most important predictors for major bleeding were the concentrations of the biomarkers growth differentiation factor-15 (GDF-15), high-sensitivity cardiac troponin T (cTnT-hs) and haemoglobin, age, and previous bleeding. The ABC-bleeding score (age, biomarkers [GDF-15, cTnT-hs, and haemoglobin], and clinical history [previous bleeding]) score yielded a higher c-index than the conventional HAS-BLED and the newer ORBIT scores for major bleeding in both the derivation cohort (0·68 [95% CI 0·66–0·70] vs 0·61 [0·59–0·63] vs 0·65 [0·62–0·67], respectively; ABC-bleeding vs HAS-BLED p<0·0001 and ABC-bleeding vs ORBIT p=0·0008). ABC-bleeding score also yielded a higher c-index score in the the external validation cohort (0·71 [95% CI 0·68–0·73] vs 0·62 [0·59–0·64] for HAS-BLED vs 0·68 [0·65–0·70] for ORBIT; ABC-bleeding vs HAS-BLED p<0·0001 and ABC-bleeding vs ORBIT p=0·0016). A modified ABC-bleeding score using alternative biomarkers (haematocrit, cTnI-hs, cystatin C, or creatinine clearance) also outperformed the HAS-BLED and ORBIT scores. The ABC-bleeding score, using age, history of bleeding, and three biomarkers (haemoglobin, cTn-hs, and GDF-15 or cystatin C/CKD-EPI) was internally and externally validated and calibrated in large cohorts of patients with atrial fibrillation receiving anticoagulation therapy. The ABC-bleeding score performed better than HAS-BLED and ORBIT scores and should be useful as decision support on anticoagulation treatment in patients with atrial fibrillation. BMS, Pfizer, Boehringer Ingelheim, Roche Diagnostics.

AbstractObjectiveTo evaluate the association between intakes of refined grains, whole grains, and white rice with cardiovascular disease, total mortality, blood lipids, and blood pressure in the Prospective Urban and Rural Epidemiology (PURE) study.DesignProspective cohort study.SettingPURE study in 21 countries.Participants148 858 participants with median follow-up of 9.5 years.ExposuresCountry specific validated food frequency questionnaires were used to assess intakes of refined grains, whole grains, and white rice.Main outcome measureComposite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios were estimated for associations of grain intakes with mortality, major cardiovascular events, and their composite by using multivariable Cox frailty models with random intercepts to account for clustering by centre.ResultsAnalyses were based on 137 130 participants after exclusion of those with baseline cardiovascular disease. During follow-up, 9.2% (n=12 668) of these participants had a composite outcome event. The highest category of intake of refined grains (≥350 g/day or about 7 servings/day) was associated with higher risk of total mortality (hazard ratio 1.27, 95% confidence interval 1.11 to 1.46; P for trend=0.004), major cardiovascular disease events (1.33, 1.16 to 1.52; P for trend<0.001), and their composite (1.28, 1.15 to 1.42; P for trend<0.001) compared with the lowest category of intake (<50 g/day). Higher intakes of refined grains were associated with higher systolic blood pressure. No significant associations were found between intakes of whole grains or white rice and health outcomes.ConclusionHigh intake of refined grains was associated with higher risk of mortality and major cardiovascular disease events. Globally, lower consumption of refined grains should be considered.

In a large study in 18 countries, sodium and potassium intake were estimated from urine samples and correlated with blood pressure. The correlations were nonlinear and were most pronounced among people with high sodium intake, those with hypertension, and older persons. Hypertension affects 1 billion people and is considered to be a leading cause of death, stroke, myocardial infarction, congestive heart failure, and chronic renal impairment. 1 – 4 Sodium intake is reported to be a modifiable determinant of hypertension. 5 , 6 The International Study of Salt and Blood Pressure (INTERSALT), 7 but not another large study, 8 showed a modest association between higher levels of sodium intake and higher blood pressure. However, INTERSALT was not large enough to determine whether the association varied according to region, participant characteristics, or levels of sodium or potassium intake. Substantially larger studies are needed to assess the shape of . . .

Cardiopulmonary bypass initiates a systemic inflammatory response syndrome that is associated with postoperative morbidity and mortality. Steroids suppress inflammatory responses and might improve outcomes in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. We aimed to assess the effects of steroids in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. The Steroids In caRdiac Surgery (SIRS) study is a double-blind, randomised, controlled trial. We used a central computerised phone or interactive web system to randomly assign (1:1) patients at high risk of morbidity and mortality from 80 hospital or cardiac surgery centres in 18 countries undergoing cardiac surgery with the use of cardiopulmonary bypass to receive either methylprednisolone (250 mg at anaesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients were assigned with block randomisation with random block sizes of 2, 4, or 6 and stratified by centre. Patients aged 18 years or older were eligible if they had a European System for Cardiac Operative Risk Evaluation of at least 6. Patients were excluded if they were taking or expected to receive systemic steroids in the immediate postoperative period or had a history of bacterial or fungal infection in the preceding 30 days. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcomes were 30-day mortality and a composite of death and major morbidity (ie, myocardial injury, stroke, renal failure, or respiratory failure) within 30 days, both analysed by intention to treat. Safety outcomes were also analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00427388. Patients were recruited between June 21, 2007, and Dec 19, 2013. Complete 30-day data was available for all 7507 patients randomly assigned to methylprednisolone (n=3755) and to placebo (n=3752). Methylprednisolone, compared with placebo, did not reduce the risk of death at 30 days (154 [4%] vs 177 [5%] patients; relative risk [RR] 0·87, 95% CI 0·70–1·07, p=0·19) or the risk of death or major morbidity (909 [24%] vs 885 [24%]; RR 1·03, 95% CI 0·95–1·11, p=0·52). The most common safety outcomes in the methylprednisolone and placebo group were infection (465 [12%] vs 493 [13%]), surgical site infection (151 [4%] vs 151 [4%]), and delirium (295 [8%] vs 289 [8%]). Methylprednisolone did not have a significant effect on mortality or major morbidity after cardiac surgery with cardiopulmonary bypass. The SIRS trial does not support the routine use of methylprednisolone for patients undergoing cardiopulmonary bypass. Canadian Institutes of Health Research.

Pelvic inflammatory disease (PID) is a common reproductive health disorder among women of reproductive age. The treatment of PID has slowly evolved, reflecting changing antibiotic susceptibility and advancements in therapeutics and research; however, it has been largely unchanged over the last several decades. The most recent treatment recommendations consider the severity of infection, clinical presentation, and the polymicrobial nature of the disease. In addition, the role of novel organisms like in PID is of emerging significance. PID treatment guidance offers oral and parenteral treatment options based on the patient's clinical status; however, deviations from the published guidelines are a general concern. Point of care (POC) testing for precision care, provision of adherence support, optimizing self-management and prevention strategies, and other alternative or synergistic approaches that maximize treatment outcomes will be instrumental for addressing the current challenges in PID diagnosis and management.