Associations between body mass index and all-cause mortality: A systematic review and meta-analysis.

Fasting insulin and c-reactive protein confound the association between mortality and body mass index. An increase in fat mass may mediate the associations between hyperinsulinemia, hyperinflammation, and mortality. The objective of this study was to describe the "average" associations between body mass index and the risk of mortality and to explore how adjusting for fasting insulin and markers of inflammation might modify the association of BMI with mortality. MEDLINE and EMBASE were searched for studies published in 2020. Studies with adult participants where BMI and vital status was assessed were included. BMI was required to be categorized into groups or parametrized as non-first order polynomials or splines. All-cause mortality was regressed against mean BMI squared within seven broad clinical populations. Study was modeled as a random intercept. ß coefficients and 95% confidence intervals are reported along with estimates of mortality risk by BMIs of 20, 30, and 40 kg/m2 . Bubble plots with regression lines are drawn, showing the associations between mortality and BMI. Splines results were summarized. There were 154 included studies with 6,685,979 participants. Only five (3.2%) studies adjusted for a marker of inflammation, and no studies adjusted for fasting insulin. There were significant associations between higher BMIs and lower mortality risk in cardiovascular (unadjusted ß -0.829 [95% CI -1.313, -0.345] and adjusted ß -0.746 [95% CI -1.471, -0.021]), Covid-19 (unadjusted ß -0.333 [95% CI -0.650, -0.015]), critically ill (adjusted ß -0.550 [95% CI -1.091, -0.010]), and surgical (unadjusted ß -0.415 [95% CI -0.824, -0.006]) populations. The associations for general, cancer, and non-communicable disease populations were not significant. Heterogeneity was very large (I2 ≥ 97%). The role of obesity as a driver of excess mortality should be critically re-examined, in parallel with increased efforts to determine the harms of hyperinsulinemia and chronic inflammation.

Assessment of the WHO non-communicable diseases kit for humanitarian emergencies in South Sudan: a retrospective, prospective, observational study.

BACKGROUND: The WHO Non-Communicable Diseases Kit (NCDK) was developed to support care for non-communicable diseases (NCDs) in humanitarian settings. Targeting primary healthcare, each kit contains medicines and supplies that are forecasted to meet the needs of 10,000 people for 3 months. This study aimed to evaluate the NCDK deployment process, contents, usage and limitations, and to explore its acceptability and effectiveness among healthcare workers (HCWs) in South Sudan. METHODS: This mixed-method observational study captured data from pre-and-post NCDK deployment. Six data collection tools included: (i) contextual analysis, (ii) semi-structured interviews, in addition to surveys measuring/assessing (iii) healthcare workers' knowledge about NCDs, and healthcare workers' perceptions of: (iv) health facility infrastructure, (v) pharmaceutical supply chain, and (vi) NCDK content. The pre- and post-deployment evaluations were conducted in four facilities (October-2019) and three facilities (April-2021), respectively. Descriptive statistics were used for quantitative data and content analysis for open-ended questions. A thematic analysis was applied on interviews findings and further categorized into four predetermined themes. RESULTS: Compared to baseline, two of the re-assessed facilities had improved service availability for NCDs. Respondents described NCDs as a growing problem that is not addressed at a national level. After deployment, the same struggles were intensified with the COVID-19 pandemic. The delivery process was slow and faced delays associated with several barriers. After deployment, poor communications and the "push system" of inventories were commonly perceived by stakeholders, leading to expiry/disposal of some contents. Despite being out-of-stock at baseline, at least 55% of medicines were found to be unused post-deployment and the knowledge surveys demonstrated a need for improving HCWs knowledge of NCDs. CONCLUSIONS: This assessment further confirmed the NCDK role in maintaining continuity of care on a short-term period. However, its effectiveness was dependent on the health system supply chain in place and the capacity of facilities to manage and treat NCDs. Availability of medicines from alternative sources made some of the NCDK medicines redundant or unnecessary for some health facilities. Several learnings were identified in this assessment, highlighting barriers that contributed to the kit underutilization.

The case for increased peritoneal dialysis utilization in low- and lower-middle-income countries.

Peritoneal dialysis (PD) has several advantages compared to haemodialysis (HD), but there is evidence showing underutilization globally, especially in low-income and lower-middle-income countries (LLMICs) where kidney replacement therapies (KRT) are often unavailable, inaccessible, and unaffordable. Only 11% of all dialysis patients worldwide use PD, more than 50% of whom live in China, the United States of America, Mexico, or Thailand. Various barriers to increased PD utilization have been reported worldwide including patient preference, low levels of education, and lower provider reimbursement. However, unique but surmountable barriers are applicable to LLMICs including the excessively high cost of providing PD (related to PD fluids in particular), excessive cost of treatment borne by patients (relative to HD), lack of adequate PD training opportunities for doctors and nurses, low workforce availability for kidney care, and challenges related to some PD outcomes (catheter-related infections, hospitalizations, mortality, etc.). This review discusses some known barriers to PD use in LLMICs and leverages data that show a global trend in reducing rates of PD-related infections, reducing rates of modality switches from HD, and improving patient survival in PD to discuss how PD use can be increased in LLMICs. We therefore, challenge the idea that low PD use in LLMICs is unavoidable due to these barriers and instead present opportunities to improve PD utilization in LLMICs.

The impact of vaccination status on importation of COVID-19 among international travellers.

Governments worldwide are looking for ways to safely enable international travel while mitigating the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the associated coronavirus disease 2019 (COVID-19). However, few data describe the impact of vaccination on importation of COVID-19. We took advantage of the sequential introduction of two government policies in Canada to evaluate the real-world evidence of vaccine effectiveness among 30,361 international travellers arriving by air in Alberta, Canada. The proportion of COVID-19-positive results for travellers who were either fully vaccinated or partially vaccinated was 0.02% (95% CI: 0.00-0.10) (i.e. one positive case among 5,817 travellers). In contrast, 1.42% (95% CI: 1.27-1.58) of unvaccinated travellers tested positive for SARS-CoV-2 (341 cases among 24,034 travellers). These findings suggest that COVID-19 vaccinations approved in Canada, substantially reduced the risk of travel-related importation of COVID-19 when combined with other public health measures. The low absolute rate of infection among fully vaccinated or partially vaccinated international travellers may inform quarantine requirements in this population.

COVID-19 infection among international travellers: a prospective analysis.

OBJECTIVES: This report estimates the risk of COVID-19 importation and secondary transmission associated with a modified quarantine programme in Canada. DESIGN AND PARTICIPANTS: Prospective analysis of international asymptomatic travellers entering Alberta, Canada. INTERVENTIONS: All participants were required to receive a PCR COVID-19 test on arrival. If negative, participants could leave quarantine but were required to have a second test 6 or 7 days after arrival. If the arrival test was positive, participants were required to remain in quarantine for 14 days. MAIN OUTCOME MEASURES: Proportion and rate of participants testing positive for COVID-19; number of cases of secondary transmission. RESULTS: The analysis included 9535 international travellers entering Alberta by air (N=8398) or land (N=1137) that voluntarily enrolled in the Alberta Border Testing Pilot Programme (a subset of all travellers); most (83.1%) were Canadian citizens. Among the 9310 participants who received at least one test, 200 (21.5 per 1000, 95% CI 18.6 to 24.6) tested positive. Sixty-nine per cent (138/200) of positive tests were detected on arrival (14.8 per 1000 travellers, 95% CI 12.5 to 17.5). 62 cases (6.7 per 1000 travellers, 95% CI 5.1 to 8.5; 31.0% of positive cases) were identified among participants that had been released from quarantine following a negative test result on arrival. Of 192 participants who developed symptoms, 51 (26.6%) tested positive after arrival. Among participants with positive tests, four (2.0%) were hospitalised for COVID-19; none required critical care or died. Contact tracing among participants who tested positive identified 200 contacts; of 88 contacts tested, 22 were cases of secondary transmission (14 from those testing positive on arrival and 8 from those testing positive thereafter). SARS-CoV-2 B.1.1.7 lineage was not detected in any of the 200 positive cases. CONCLUSIONS: 21.5 per 1000 international travellers tested positive for COVID-19. Most (69%) tested positive on arrival and 31% tested positive during follow-up. These findings suggest the need for ongoing vigilance in travellers testing negative on arrival and highlight the value of follow-up testing and contact tracing to monitor and limit secondary transmission where possible.

Video Visits Using the Zoom for Healthcare Platform for People Receiving Maintenance Hemodialysis and Nephrologists: A Feasibility Study in Alberta, Canada.

BACKGROUND: Demand for virtual visits (an online synchronous medical appointment between a health care provider and patient) is increasing due to the COVID-19 pandemic. There may be additional benefits of virtual visits as they appear to be convenient and potentially cost-saving to patients. People receiving maintenance hemodialysis require ongoing care from their nephrologist and may benefit from virtual visits; however, the optimal model for a virtual kidney clinic is unknown. OBJECTIVE: To codesign and assess the feasibility of a virtual (video) kidney clinic model with clinic staff, nephrologists, and patients receiving maintenance hemodialysis, to be used for routine follow-up visits. DESIGN: Mixed-methods study. SETTING: Two main kidney clinics in central Calgary, Alberta. PARTICIPANTS: Adults with kidney failure receiving maintenance hemodialysis, nephrologists, and clinic staff. METHODS: First, we individually interviewed clinic staff and nephrologists to assess the needs of the clinic to deliver virtual visits. Then, we used participant observation with patients and nephrologists to codesign the virtual visit model. Finally, we used structured surveys to evaluate the patients' and nephrologists' experiences when using the virtual model. RESULTS: Eight video visits (8 patients; 6 nephrologists) were scheduled between October 2019 and February 2020 and 7 were successfully completed. Among completed visits, all participants reported high satisfaction with the service, were willing to use it again, and would recommend it to others. Three main themes were identified with respect to factors influencing visit success: IT infrastructure, administration, and process. LIMITATIONS: Patients received training on how to use the videoconference platform by the PhD student, whom also set up the technical components of the visit for the nephrologist. This may have overestimated the feasibility of virtual visits if this level of support is not available in future. Second, interviews were not audio-recorded and thematic analysis relied on field notes. CONCLUSIONS: Video visits for routine follow-up care between people receiving hemodialysis and nephrologists were acceptable to patients and nephrologists. Video visits appear to be feasible if clinics are equipped with appropriate equipment and IT infrastructure, physicians are remunerated appropriately, and patients receive training on how to use software as needed.

CONTEXTE: La demande pour des consultations virtuelles (rendez-vous médical par vidéoconférence entre un patient et son fournisseur de soins) augmente en raison de la pandémie de COVID-19. Ces consultations pourraient présenter des avantages pour les patients, notamment en raison de leur côté pratique et des économies qui en résultent. Les patients recevant des traitements d'entretien par hémodialyse nécessitent un suivi continu de la part de leur néphrologue et pourraient tirer profit de ce type de consultation. On ignore toutefois quel modèle de clinique de néphrologie virtuelle serait optimal. OBJECTIF: Concevoir, conjointement avec le personnel des cliniques, les néphrologues et les patients recevant des traitements d'hémodialyse, un modèle de consultation virtuelle (vidéoconférence) pour les visites de suivi de routine, et en évaluer la faisabilité. TYPE D'ÉTUDE: Étude à méthodes mixtes. CADRE: Les deux principales cliniques de néphrologie du centre de Calgary (Alberta). SUJETS: Des adultes atteints d'insuffisance rénale et recevant des traitements d'hémodialyse, des néphrologues et le personnel des cliniques concernées. MÉTHODOLOGIE: En premier lieu, le personnel de la clinique et les néphrologues ont été interrogés individuellement afin d'évaluer les besoins de la clinique en matière de consultations virtuelles. Les observations des participants ont ensuite servi à la conception conjointe du modèle de consultation virtuelle avec les patients et les néphrologues. Enfin, des questionnaires structurés ont servi à évaluer les expériences des patients et des néphrologues lors de l'utilisation du modèle. RÉSULTATS: Huit consultations virtuelles (8 patients; 6 néphrologues) étaient prévues entre octobre 2019 et février 2020, dont sept ont été réalisées avec succès. Tous les participants aux séances complétées se sont dits très satisfaits du modèle et ont mentionné qu'ils seraient prêts à l'utiliser à nouveau et qu'ils le recommanderaient à d'autres. Trois principaux thèmes ont été dégagés quant aux facteurs influençant le succès de la consultation ont été dégagés: l'infrastructure, l'administration et le processus informatiques. LIMITES: Les patients avaient reçu une formation sur l'utilisation de la plateforme de vidéoconférence de la part d'un étudiant au doctorat, lequel a également mis en place les composantes techniques de la consultation pour le néphrologue. La faisabilité des consultations virtuelles pourrait être surestimée si ce niveau de soutien n'est pas offert à l'avenir. Deuxièmement, les entrevues n'étaient pas enregistrées sur des fichiers audio, l'analyse thématique reposait donc sur des notes d'observation. CONCLUSION: Les patients hémodialysés et les néphrologues ont jugé acceptable ce modèle de consultations virtuelles pour les suivis de routine. Les consultations par vidéoconférence sont réalisables si les cliniques sont dotées de l'équipement et de l'infrastructure informatiques appropriés, si les médecins sont rémunérés adéquatement et si les patients reçoivent une formation sur l'utilisation du logiciel, au besoin.