Karsten Lunze

The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival

BackgroundTo provide evidence on the global epidemiological situation of neonatal hypothermia and to provide recommendations for future policy and research directions.MethodsUsing PubMed as our principal electronic reference library, we searched studies for prevalence and risk factor data on neonatal hypothermia in resource-limited environments globally. Studies specifying study location, setting (hospital or community based), sample size, case definition of body temperature for hypothermia, temperature measurement method, and point estimates for hypothermia prevalence were eligible for inclusion.ResultsHypothermia is common in infants born at hospitals (prevalence range, 32% to 85%) and homes (prevalence range, 11% to 92%), even in tropical environments. The lack of thermal protection is still an underappreciated major challenge for newborn survival in developing countries. Although hypothermia is rarely a direct cause of death, it contributes to a substantial proportion of neonatal mortality globally, mostly as a comorbidity of severe neonatal infections, preterm birth, and asphyxia. Thresholds for the definition of hypothermia vary, and data on its prevalence in neonates is scarce, particularly on a community level in Africa.ConclusionsA standardized approach to the collection and analysis of hypothermia data in existing newborn programs and studies is needed to inform policy and program planners on optimal thermal protection interventions. Thermoprotective behavior changes such as skin-to-skin care or the use of appropriate devices have not yet been scaled up globally. The introduction of simple hypothermia prevention messages and interventions into evidence-based, cost-effective packages for maternal and newborn care has promising potential to decrease the heavy global burden of newborn deaths attributable to severe infections, prematurity, and asphyxia. Because preventing and treating newborn hypothermia in health institutions and communities is relatively easy, addressing this widespread challenge might play a substantial role in reaching Millennium Development Goal 4, a reduction of child mortality.

Pulmonary Vascular Resistance, Collateral Flow and Ventricular Function in Fontan Patients at Rest and During Dobutamine Stress

Background—The role, interplay, and relative importance of the multifactorial hemodynamic and myocardial mechanisms causing dysfunction of the Fontan circulation remain incompletely understood. Methods and Results—Using an MRI catheterization technique, we performed a differential analysis of pulmonary vascular resistance and aortopulmonary collateral blood flow in conjunction with global ventricular pump function, myocontractility (end-systolic pressure-volume relation), and diastolic compliance (end-diastolic pressure-volume relation) in 10 patients with a Fontan circulation at rest and during dobutamine stress. Pulmonary and ventricular pressures were measured invasively and synchronized with velocity-encoded MRI-derived pulmonary and aortic blood flows and cine MRI-derived ventricular volumes. Pulmonary vascular resistance and end-systolic and end-diastolic pressure-volume relations were then determined. Aortopulmonary collateral flow was calculated as the difference between aortic and pulmonary flow. Compared to rest, dobutamine caused a small increase in mean pulmonary pressures (P<0.05). Collateral flow was significantly augmented (P<0.001) and contributed importantly to an increase in pulmonary flow (P<0.01). Pulmonary vascular resistance decreased significantly (P<0.01). Dobutamine did not increase stroke volumes significantly despite slightly enhanced contractility (end-systolic pressure-volume relation). Active early relaxation (&tgr;) was inconspicuous, but the end-diastolic pressure-volume relation shifted upward, indicating reduced compliance. Conclusions—In patients with a Fontan circulation, aortopulmonary collateral flow contributes substantially to enhanced pulmonary flow during stress. Our data indicate that pulmonary vascular response to augmented cardiac output was adequate, but decreased diastolic compliance was identified as an important component of ventricular dysfunction.

Financial Incentives for Healthy Behavior Ethical Safeguards for Behavioral Economics

Economic incentives to promote healthy behavior are becoming increasingly common and have been suggested as an approach to decreasing healthcare costs. Ethical concerns about programs with such incentives are that they may contribute to inequities, be coercive, interfere with therapeutic relationships, undermine personal responsibility for health, and decrease social solidarity. Additionally, they may be a source of stigma or discrimination, promote dependence, and be unfair for those already engaged in targeted health behaviors or those who cannot fulfill the incentivized behaviors. Incentive programs need to incorporate appropriate safeguards to monitor these risks and support fairness in offering economic incentives to promote healthy behavior.

Integrated Assessment of Diastolic and Systolic Ventricular Function Using Diagnostic Cardiac Magnetic Resonance Catheterization Validation in Pigs and Application in a Clinical Pilot Study

OBJECTIVES This study sought to develop and validate a method for the integrated analysis of systolic and diastolic ventricular function. BACKGROUND An integrated approach to assess ventricular pump function, myocontractility (end-systolic pressure-volume relationship [ESPVR]), and diastolic compliance (end-diastolic pressure-volume relation [EDPVR]) is of high clinical value. Cardiac magnetic resonance (CMR) is well established for measuring global pump function, and catheterization-combined CMR was previously shown to accurately measure ESPVR, but not yet the EDPVR. METHODS In 8 pigs, the CMR technique was compared with conductance catheter methods (gold standard) for measuring the EDPVR in the left and right ventricle. Measurements were performed at rest and during dobutamine administration. For CMR, the ESPVR was estimated with a single-beat approach by synchronizing invasive ventricular pressures with cine CMR-derived ventricular volumes. The EDPVR was determined during pre-load reduction from additional volume data that were obtained from real-time velocity-encoded CMR pulmonary/aortic blood flow measurements. Pre-load reduction was achieved by transient balloon occlusion of the inferior vena cava. The stiffness coefficient beta was calculated by an exponential fit from the EDPVR. After validation in the animal experiments, the EDPVR was assessed in a pilot study of 3 patients with a single ventricle using identical CMR and conductance catheter techniques. RESULTS Bland-Altman tests showed good agreement between conductance catheter-derived and CMR-derived EDPVR. In both ventricles of the pigs, dobutamine enhanced myocontractility (p < 0.01), increased stroke volume (p < 0.01), and improved diastolic function. The latter was evidenced by shorter early relaxation (p < 0.05), a downward shift of the EDPVR, and a decreased stiffness coefficient beta (p < 0.05). In contrast, in the patients, early relaxation was inconspicuous but the EDPVR shifted left-upward and the stiffness constant remained unchanged. The observed changes in diastolic function were not significantly different when measured with conductance catheter and CMR. CONCLUSIONS This novel CMR method provides differential information about diastolic function in conjunction with parameters of systolic contractility and global pump function.

Punitive policing and associated substance use risks among HIV-positive people in Russia who inject drugs

Drug law enforcement is part of the HIV risk environment among people who inject drugs (PWID). Punitive policing practices such as extrajudicial arrests for needle possession and police planting of drugs have been described anecdotally in Russia, but these experiences and their associations with risky drug behaviours have not been quantified. This study aims to quantify the burden of extrajudicial police arrests among a cohort of HIV‐positive PWID in Russia and to explore its links to drug‐related health outcomes.

Tobacco control in the Russian Federation- a policy analysis

BackgroundThe Russian Federation (Russia) has one of the highest smoking rates in the world. The purpose of this study is to analyze past and current trends of the tobacco epidemic in the Russian Federation, review current tobacco control policy responses, and identify areas of opportunity for policy priorities.MethodsWe used a policy triangle as analytical framework to examine content, context, and processes of Russian tobacco control policy. The analysis was based on secondary data on supply and demand sides of the Russian tobacco epidemic, tobacco-related economic and health effects during Russia’s economic transition, and compliance of Russian tobacco policy with international standards and regulations.ResultsTobacco-promoting strategies have specifically targeted women and youth. Russia’s approval of a “National Tobacco Control Concept” and draft for a comprehensive tobacco control bill increasingly align national legislature with the WHO Framework Convention on Tobacco Control (FCTC). However, several structural and cultural factors represent substantial barriers to the policy process. The influence of transnational tobacco companies on policy processes in Russia has so far impeded a full implementation of the FCTC mandates.ConclusionsSeveral strategies have been identified as having the potential to reduce the prevalence of tobacco use in Russia and decrease tobacco-related national health and economic burden: adjusting national tobacco policy by raising tobacco tax from the current lowest level in Europe to at least 70%; consequent enforcement of a complete smoking ban in public places; marketing restrictions; and smoking cessation interventions integrated into primary care. Russia’s tobacco control efforts need to target women and youths specifically to efficiently counter industry efforts.

“It is easier for me to shoot up”: stigma, abandonment, and why HIV-positive drug users in Russia fail to link to HIV care

ABSTRACT Many HIV-positive people who inject drugs (PWID) globally are not receiving HIV care. This represents a major challenge among key populations to end the global HIV epidemic. This qualitative study explored the process and associated barriers of linking HIV-positive PWID who are in addiction treatment to HIV care in St. Petersburg, Russia. We conducted three focus groups and seven semi-structured interviews with participants in the LINC (“Linking Infectious and Narcology Care”) project at addiction and HIV hospitals in St. Petersburg. The sample consisted of 25 HIV-infected patients with opioid dependence and seven health-care providers, including addiction and infectious disease physicians and case managers. A variety of intertwining factors influence effective engagement of PWID with HIV treatment. Stigma, problematic patient–provider relationships, and fragmented health care were the main challenges for HIV care initiation by PWID, which were further exacerbated by injection drug use. Effective linkage of PWID to HIV care requires acknowledging and addressing stigma’s role and different perspectives of patients and providers.

Limited Literacy and Poor Health: The Role of Social Mobility in Germany and the United States

The Organization for Economic Cooperation and Development (OECD) implemented the Program for the International Assessment of Adult Competencies (PIAAC) to provide policymakers with nationally representative profiles of knowledge, skills, and competencies. Results among participating countries indicate that the United States and Germany stand out as having the strongest relationship between literacy skills and self-reported health. Our analysis addresses factors that could mediate the particularly strong link between low literacy and poor health in these two countries and possible remedies for the problem. In particular, PIACC results also reveal that the United States and Germany share the most entrenched multigenerational literacy problem among the countries in the PIAAC survey. In spite of the many social differences that currently distinguish Germany and the United States, these countries share the lowest level of social mobility for education. Promoting social mobility by making higher education more accessible for those whose parents did not have the chance to access it might thus not only promote literacy and social capital, but indirectly also promote public health. Given the PIACC findings, the concept of social mobility and opportunities to dissolve the educational stratification merit more attention in public health research.

Heterogeneity of Regional Function and Relation to Ventricular Morphology in Patients With Fontan Circulation

The relation between underlying ventricular morphology and regional function in patients with Fontan circulation remains unclear. The aim of this study was to compare regional function and its heterogeneity in patients with tricuspid atresia (TA), biventricular apex-forming morphology (BiV), and controls. Nineteen patients (median age 12 years) with Fontan circulation who presented consecutively were prospectively enrolled and compared with age- and heart rate-matched controls. Most patients were in New York Heart Association class I (63%). Longitudinal systolic strain (S), systolic strain rate (SRsys), and early diastolic strain rate (SRdia) peaks were obtained from 6 ventricular segments, and a coefficient of variation by segment was calculated as a measure of regional heterogeneity. Systolic S, SRsys and SRdia peaks were decreased at the right and left lateral walls in both patient groups compared with controls (p ≤0.001 for all). Patients with TA had higher systolic S and SRsys in the middle of the right lateral wall than those with BiV morphology (p = 0.009 and p = 0.001, respectively). The mean coefficients of variation assessed by S and SRsys were similar in controls and patients with TA but lower in those with BiV than in controls and patients with TA (p <0.001 and p = 0.01, respectively). The mean coefficient of variation assessed by SRdia was greater only in patients with BiV than in controls (p = 0.001). In conclusion, patients with Fontan circulation have more heterogeneous systolic and early diastolic regional function than healthy control subjects, and patients with TA have better systolic regional function in the middle of the right lateral wall and less systolic heterogeneity than patients with BiV morphology.

Sexual violence from police and HIV risk behaviours among HIV-positive women who inject drugs in St. Petersburg, Russia - a mixed methods study

Police violence against people who inject drugs (PWID) is common in Russia and associated with HIV risk behaviours. Sexual violence from police against women who use drugs has been reported anecdotally in Russia. This mixed‐methods study aimed to evaluate sexual violence from police against women who inject drugs via quantitative assessment of its prevalence and HIV risk correlates, and through qualitative interviews with police, substance users and their providers in St. Petersburg, Russia.