Prevalence, diagnostic delay and economic burden of endometriosis and its impact on quality of life: results from an Eastern Mediterranean population.

BACKGROUND: There are limited data on endometriosis from the Eastern Mediterranean region. This study for the first time estimates the prevalence and impact of endometriosis on women in Northern Cyprus, an under-represented region in Europe. METHODS: Cyprus Women's Health Research Initiative, a cross-sectional study recruited 7646 women aged 18-55 in Northern Cyprus between January 2018 and February 2020. Cases were identified using self-reported and ultrasound data and two control groups were defined, with (n = 2922) and without (n = 4314) pain. Standardized tools, including the 11-point Numerical Rating Scale and the Short Form 36 Health Survey version 2, were used to assess pain and quality of life, respectively. RESULTS: Prevalence and median diagnostic delay of endometriosis were 5.4% [95% confidence interval (CI): 4.9-5.9%, n = 410] and 7 (interquartile range 15.5) years. Endometriosis cases experienced a higher prevalence of bladder pain compared with asymptomatic pain controls (6.3% vs. 1.0%, P < 0.001) and irritable bowel syndrome relating to pelvic pain compared with symptomatic (4.6% vs. 2.6%, P = 0.027) and asymptomatic (0.3%, P < 0.001) controls. The odds of endometriosis cases reporting an anxiety diagnosis was 1.56 (95% CI: 1.03-2.38) higher than the symptomatic and 1.95 (95% CI: 1.30-2.92) times higher than the asymptomatic controls. The physical component score of the health-related quality-of-life instrument suggested a significant difference between the endometriosis cases and the symptomatic controls (46.8 vs. 48.5, P = 0.034). Average annual economic cost of endometriosis cases was Int$9864 (95% CI: $8811-$10 917) including healthcare, costs relating to absence and loss of productivity at work. CONCLUSION: Prevalence was lower than the global 10% estimate, and substantial proportion of women without endometriosis reported moderate/severe pelvic pain hinting at many undiagnosed cases within this population. Coupled with lower quality of life, significant economic burden and underutilized pain management options, the study highlights multiple opportunities to improve care for endometriosis patients and women with pelvic pain.

Predictors and trends of Caesarean section and breastfeeding in the Eastern Mediterranean region: Data from the cross-sectional Cyprus Women's Health Research (COHERE) Initiative.

INTRODUCTION: Caesarean section (C-section) is a life-saving procedure when medically indicated but unmet need and overuse can add to avoidable morbidity and mortality. It is not clear whether C-section has a negative impact on breastfeeding and there is limited data available on rates of C-section or breastfeeding from Northern Cyprus, an emerging region in Europe. This study aimed to investigate prevalence, trends and associations of C-section and breastfeeding in this population. METHODS: Using self-reported data from the representative Cyprus Women's Health Research (COHERE) Initiative, we used 2,836 first pregnancies to describe trends in C-section and breastfeeding between 1981 and 2017. Using modified Poisson regression, we examined the relationship between year of pregnancy and C-section and breastfeeding, as well as the association between C-section and breastfeeding prevalence and duration. RESULTS: C-section prevalence in first pregnancies increased from 11.1% in 1981 to 72.5% in 2017 with a relative risk of 2.60 (95%CI; 2.14-2.15) of babies being delivered by C-section after 2005 compared to before 1995, after full adjustment for demographic and maternal medical and pregnancy related factors. Prevalence of ever breastfeeding remained steady throughout the years at 88.7% and there was no significant association between breastfeeding initiation and the year of pregnancy, or demographic and maternal medical and pregnancy related variables. After full adjustment, women who gave birth after 2005 were 1.24 (95%CI; 1.06-1.45) times more likely to breastfeed for >12 weeks compared to women who gave birth before 1995. There was no association between C-section and breastfeeding prevalence or length. CONCLUSION: Prevalence of C-section in this population is much higher than WHO recommendations. Public awareness campaigns surrounding choice during pregnancy and change in legal framework to allow for midwife-led continuity models of birthing care should be implemented. Further research is required to understand the reasons and drivers behind this high rate.

COVID-19 in the homeless population: a scoping review and meta-analysis examining differences in prevalence, presentation, vaccine hesitancy and government response in the first year of the pandemic.

AIMS: People experiencing homelessness (PEH) have been identified as being increasingly susceptible to Coronavirus disease (COVID-19), with policies enacted to test, isolate, increase hygiene practices and prioritise vaccines among this population. Here, we conduct a scoping review of the current evidence-base pertaining to the prevalence and presentation of COVID-19 in PEH, COVID-vaccine hesitancy rates and government interventions enacted within the first year of the pandemic for PEH. MATERIALS AND METHODS: A systematic search was conducted on Pubmed, Cochrane, Embase and MedRxiv databases for studies reporting primary data on COVID-19 prevalence and clinical characteristics in PEH, vaccine uptake for PEH and policies enacted targeting PEH. Study qualities were assessed with The National Heart, Lung and Blood Institute's set of Study Quality. RESULTS: Eighty-three studies were included in our final analysis. The overall prevalence of symptomatic COVID-19 infection in PEH is estimated at 35%. The most common symptoms found were cough and shortness of breath, followed by fever. Concerns regarding vaccine hesitancy amongst PEH related to thoroughness of COVID-19 vaccine clinical trials, side effects and mistrust of the government. The main strategies implemented by governments were mass testing, adaption of healthcare service provision, provision of alternative housing, encouraging personal hygiene (hand sanitation and mask wearing), and inter-organisational communication. DISCUSSION: In our meta-analysis, 35% of PEH with a COVID-19 infection presented symptomatically; the low prevalence of symptomatic COVID-19 infection suggests widespread testing following outbreaks would be beneficial for this group of individuals. Temporary recuperation units and measures for housing stability in the pandemic, namely provision of alternative housing and stopping evictions, were found to be highly effective. High rates of vaccine hesitancy means that education and encouragement towards vaccination would be beneficial for this vulnerable population, where comorbidities are common. Finally increased focus in research should be placed on the mental health burden of COVID-19 and the pandemic on PEH moving forwards.

An in-depth review of the UNICEF NutriDash platform, lessons learnt and future perspectives: a mixed-methods study.

OBJECTIVES: Robust data on nutrition are essential to realise the right to nutrition for every child. Created in 2009, UNICEF's Nutrition Dashboard (NutriDash) collects nutrition programme information from 125 countries. An in-depth review of NutriDash was conducted to understand its strengths and identify key actions to increase its effectiveness and efficiency. METHODS: Adapting the Centres for Disease Control and Prevention updated guidelines for evaluating public health surveillance systems, a mixed-methods approach was used. A questionnaire was designed to capture information on key attributes of NutriDash and disseminated to UNICEF country offices for quantitative feedback on user experiences. Structured key informant interviews were held with internal and external stakeholders to gain qualitative perceptions on data generated from NutriDash. Analysis involved producing frequency distributions for the questionnaire data and performing thematic analyses on interview data. RESULTS: A total of 53 respondents completed the questionnaire (42% response rate), representing 48 countries and good regional geographic representation. Most respondents (96%) worked in UNICEF country offices. The percentages of participants who agreed or strongly agreed with each attribute of the NutriDash system were as follows: acceptability: 71%, stability: 68%, simplicity; 63%, data quality: 60%, flexibility: 58% and usefulness: 43%. Internal and external stakeholders commented on the value of NutriDash; its use ranging from nutrition global trend monitoring for programme planning to producing reports and dashboards. Key themes derived from this review as areas for improvement included communication, access to data and data quality. CONCLUSIONS: This review has identified key themes that will inform improvements to NutriDash and form a baseline for future periodic reviews to continuously enhance the system to improve availability of timely quality nutrition programme data. UNICEF will continue to engage with countries, key partners and governments to improve the NutriDash data value chain and ensure the right to nutrition for every child.

Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners' reports during the COVID-19 pandemic.

OBJECTIVES: To examine coroners' Prevention of Future Deaths (PFDs) reports to identify deaths involving SARS-CoV-2 that coroners deemed preventable. DESIGN: Consecutive case series. SETTING: England and Wales. PARTICIPANTS: Patients reported in 510 PFDs dated between 01 January 2020 and 28 June 2021, collected from the UK's Courts and Tribunals Judiciary website using web scraping to create an openly available database: https://preventabledeathstrackernet/. MAIN OUTCOME MEASURES: Concerns reported by coroners. RESULTS: SARS-CoV-2 was involved in 23 deaths reported by coroners in PFDs. Twelve deaths were indirectly related to the COVID-19 pandemic, defined as those that were not medically caused by SARS-CoV-2, but were associated with mitigation measures. In 11 cases, the coroner explicitly reported that COVID-19 had directly caused death. There was geographical variation in the reporting of PFDs; most (39%) were written by coroners in the North West of England. The coroners raised 56 concerns, problems in communication being the most common (30%), followed by failure to follow protocols (23%). Organisations in the National Health Service were sent the most PFDs (51%), followed by the government (26%), but responses to PFDs by these organisations were poor. CONCLUSIONS: PFDs contain a rich source of information on preventable deaths that has previously been difficult to examine systematically. Our openly available tool (https://preventabledeathstracker.net/) streamlines this process and has identified many concerns raised by coroners that should be addressed during the government's inquiry into the handling of the COVID-19 pandemic, so that mistakes made are less likely to be repeated. STUDY PROTOCOL PREREGISTRATION: https://osf.io/bfypc/.

Protocol for the Cultural Translation and Adaptation of the World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project Endometriosis Participant Questionnaire (EPHect).

Endometriosis affects 10% of women worldwide and is one of the most common causes of chronic pelvic pain and infertility. However, causal mechanisms of this disease remain unknown due to its heterogeneous presentation. In order to successfully study its phenotypic variation, large sample sizes are needed. Pooling of data across sites is not always feasible given the large variation in the complexity and quality of the data collected. The World Endometriosis Research Foundation (WERF) Endometriosis Phenome and Biobanking Harmonization Project (EPHect) have developed an endometriosis participant questionnaire (EPQ) to harmonize non-surgical clinical participant characteristic data relevant to endometriosis research, allowing for large-scale collaborations in English-speaking populations. Although the WERF EPHect EPQs have been translated into different languages, no study has examined the cross-cultural translation and adaptation for content and face validity. In order to investigate this, we followed the standard guidelines for cross-cultural adaptation and translation of the minimum version of the EPQ (EPQ-M) using 40 patients who underwent laparoscopic surgery in Turkey and 40 women in Northern Cyprus, aged between 18 and 55. We assessed the consistency by using cognitive testing and found the EPHect EPQ-M to be comprehensive, informative, and feasible in these two Turkish-speaking populations. The translated and adapted questionnaire was found to be epidemiologically robust, taking around 30-60 min to complete; furthermore, participants reported a similar understanding of the questions, showing that common perspectives were explored. Results from the cognitive testing process led to minor additions to some items such as further descriptive and/or visuals in order to clarify medical terminology. This paper illustrates the first successful cross-cultural translation and adaptation of the EPHect EPQ-M and should act as a tool to allow for further studies that wish to use this questionnaire in different languages. Standardized tools like this should be adopted by researchers worldwide to facilitate collaboration and aid in the design and conduction of global studies to ultimately help those affected by endometriosis and its associated symptoms.