Flexible two-piece distributions for right censored survival data.

An important complexity in censored data is that only partial information on the variables of interest is observed. In recent years, a large family of asymmetric distributions and maximum likelihood estimation for the parameters in that family has been studied, in the complete data case. In this paper, we exploit the appealing family of quantile-based asymmetric distributions to obtain flexible distributions for modelling right censored survival data. The flexible distributions can be generated using a variety of symmetric distributions and monotonic link functions. The interesting feature of this family is that the location parameter coincides with an index-parameter quantile of the distribution. This family is also suitable to characterize different shapes of the hazard function (constant, increasing, decreasing, bathtub and upside-down bathtub or unimodal shapes). Statistical inference is done for the whole family of distributions. The parameter estimation is carried out by optimizing a non-differentiable likelihood function. The asymptotic properties of the estimators are established. The finite-sample performance of the proposed method and the impact of censorship are investigated via simulations. Finally, the methodology is illustrated on two real data examples (times to weaning in breast-fed data and German Breast Cancer data).

Mental health capacity building in refugee primary health care settings in Sub-Saharan Africa: impact, challenges and gaps.

BACKGROUND: In 2015, the United Nations High Commissioner for Refugees started a process of mental health capacity building in refugee primary health care settings in seven countries in Sub-Saharan Africa, ultimately aiming to decrease the treatment gap of mental, neurological and substance use (MNS) conditions in these operations. In 2015 and 2016, a specialized non-governmental organization, the War Trauma Foundation, trained 619 staff with the mental health gap action programme (mhGAP) Humanitarian Intervention Guide (HIG), a tool designed to guide clinical decision making in humanitarian settings. METHODS: This paper describes the results of a process evaluation of a real-life implementation project by an external consultant, one and a half years after starting the programme. RESULTS: The mhGAP-HIG capacity building efforts had various effects contributing to the integration of mental health in refugee primary health care. Facility-and community-based staff reported strengthened capacities to deliver mental health and psychosocial support interventions as well as changes in their attitude towards people suffering from MNS conditions. Service delivery and collaboration amongst different intervention levels improved. The scarcity of specialized staff in these settings was a major barrier, hindering the setting-up of supervision mechanisms. CONCLUSION: Mental health training of non-specialized staff in complex humanitarian settings is feasible and can lead to increased competency of providers. However, capacity building is a 'process' and not an 'event' and mhGAP trainings are only one element in a spectrum of activities aimed at integrating mental health into general health care. Regular supervision and continuing on-the-job training are in fact critical to ensure sustainability.

Adapting the Bayley Scales of infant and toddler development in Ethiopia: evaluation of reliability and validity.

BACKGROUND: There is a need for valid and reliable observational measures of early child development in low-income and middle-income country settings. METHODS: The aims of the study were to adapt the Bayley Scales of Infant Development (Bayley III) for a rural Ethiopian setting and evaluate reliability and validity. The study was carried out between January 2008 and January 2009 in the Butajira demographic surveillance site, south central Ethiopia. The Bayley III was adapted to be socioculturally appropriate for a rural Ethiopian context. Nurses and high school graduates were trained in administration of the measure for 10 days. Inter-rater reliability was evaluated (n = 60). Content, construct and convergent validity was then examined on a population-based cohort of children at the ages of 30 (n = 440) and 42 months (n = 456). Mokken scale analysis was used to determine the scalability of items in unidimensional, hierarchical sub-scales. The mean score was compared by age of child and by stunting status (less than -2 z scores below the standard height-for-age). RESULTS: The intra-class correlations between raters were above 0.90 for all sub-scales of the child development measure. Some scale items were not contextually relevant and showed poor scalability. However, the majority of items scaled onto the existing sub-scales of the international measure to form adequate-to-strong hierarchical scales with good internal consistency (Cronbach's α above 0.70 except for gross motor and expressive language sub-scales). Item-scale coefficients were good. The mean score of all sub-scales was significantly higher in the older group of children (33.02 higher total score; P < 0.001) and in the children who were stunted (total Bayley score 2.58 (95% confidence interval 0.07 to 5.10) points lower at 30 months and 3.87 (1.94 to 5.81) points lower at 42 months. CONCLUSIONS: An adapted version of an international, observational measure of child development was found to be reliable, valid and feasible in a rural Ethiopian setting.

The low birth weight infant in the Ethio-Swedish Children's Hospital, Addis Ababa.

All low birth weight infants admitted to the neonatal unit of the Ethio-Swedish Children's Hospital (ESCH), Addis Ababa from September 1995 to August 1996 were followed until discharge. There were 604 babies with birth weight of less than 2,500 grams and 198 of them died in the hospital making the low birth weight mortality rate of 32.8%. More than 90% of these babies were admitted to the unit with body temperature of less than 36.5 degrees C irrespective of their birth places. Gestational age, birth weight and presence of mother in the neonatal unit had significant role in determining survival of the low birth weight infants. Prematurity related conditions were the most common causes of death followed by infection of the unit. Recommendations are made to improve survival rates of the low birth weight infants in Addis Ababa.

Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings.

A randomized controlled trial was carried out for 1 y in three tertiary and teaching hospitals, in Addis Ababa (Ethiopia), Yogyakarta (Indonesia) and Merida (Mexico), to study the effectiveness, feasibility, acceptability and cost of kangaroo mother care (KMC) when compared to conventional methods of care (CMC). About 29% of 649 low birthweight infants (LBWI; 1000-1999 g) died before eligibility. Of the survivors, 38% were excluded for various reasons, 149 were randomly assigned to KMC (almost exclusive skin-to-skin care after stabilization), and 136 to CMC (warm room or incubator care). There were three deaths in each group and no difference in the incidence of severe disease. Hypothermia was significantly less common in KMC infants in Merida (13.5 vs 31.5 episodes/100 infants/d) and overall (10.8 vs 14.6). Exclusive breastfeeding at discharge was more common in KMC infants in Merida (80% vs 16%) and overall (88% vs 70%). KMC infants had a higher mean daily weight gain (21.3 g vs 17.7 g) and were discharged earlier (13.4 vs 16.3 d after enrolment). KMC was considered feasible and presented advantages over CMC in terms of maintenance of equipment. Mothers expressed a clear preference for KMC and health workers found it safe and convenient. KMC was cheaper than CMC in terms of salaries (US$ 11,788 vs US$ 29,888) and other running costs (US$ 7501 vs US$ 9876). This study confirms that hospital KMC for stabilized LBWI 1000-1999 g is at least as effective and safe as CMC, and shows that it is feasible in different settings, acceptable to mothers of different cultures, and less expensive. Where exclusive breastfeeding is uncommon among LBWI, KMC may bring about an increase in its prevalence and duration, with consequent benefits for health and growth. For hospitals in low-income countries KMC may represent an appropriate use of scarce resources.

Comparison of nasal prongs with nasal catheters in the delivery of oxygen to children with hypoxia.

Efficient, inexpensive, and safe methods of oxygen delivery are needed for children with severe pneumonia in developing countries. The objective of this study was to estimate the frequency of complications when nasal catheters or nasal prongs are used to delivery oxygen. Ninety-nine children between 2 weeks and 5 years of age with hypoxia were randomized to receive oxygen via nasal catheter (49 children) or nasal prongs (50 children). There was no difference in the incidence of hypoxaemic episodes or in the oxygen flow rates between the two groups. Mucus production was more of a problem in the catheter group. Nasal blockage, intolerance to the method of administration, and nursing effort were generally higher amongst the catheter group, but these differences were not significant, except for nursing effort, when all age groups were analysed together.

Blepharophimosis syndrome (the syndrome of blepharophimosis, blepharoptosis and epicanthus inversus).

The syndrome of blepharophemosis, blepharoptosis and epicanthus inversus is described in a female neonate who was admitted to the Ethio-Swedish Children's Hospital (ESCH) in Jan 1996 at birth. The clinical features and mode of transmission of the syndrome is discussed.

Klebsiella oxytoca outbreak at the Ethio-Swedish Children's Hospital (ESCH).

Klebsiella oxytoca outbreak at the Ethio-Swedish Children's Hospital, is described. The organism was isolated for the first time on Oct. 1992 at the emergency room and subsequently spread to all wards including the neonatal unit of the hospital. The isolates were resistant to Ampicillin, Amoxicillin, Chloramphenicol, Co-trimoxazole and Gentamicin, but sensitive to Amikacin and ceftriaxone. Eighty six percent (182) of the isolates were from blood specimen. Nine out of ten suspected intravenous infusion bags were positive for Klebsiella oxytoca. The source of this nosocomial infection and possible control measures are discussed.

Oxygen administration to hypoxic children in Ethiopia: a randomized controlled study comparing complications in the use of nasal prongs with nasopharyngeal catheters.

Oxygen administration is one of the most important therapeutic interventions for a child with severe acute lower respiratory tract infection (ALRI). Inexpensive and efficient methods of oxygen administration are highly desirable in hospitals in developing countries. The objectives of this study were to compare the frequency and nature of complications when nasopharyngeal catheters or nasal prongs are used to deliver oxygen. One hundred and twenty-one children between the ages of 2 weeks and 5 years with hypoxia due to ALRI were randomized to receive oxygen via a catheter (61 children) or via nasal prongs (60 children). The two groups were similar in terms of diagnoses, clinical severity, oxygen saturation on admission and case fatality rates. There was no difference in the incidence of hypoxaemic episodes between the two groups. The oxygen flow rates required on the day of admission for adequate oxygenation (SaO2 > 90%) ranged from 0.8 litres per minute to 1.2 litres per minute. The required oxygen flow rate decreased during the course of treatment. Mucus production was more of a problem in the catheter group, and nasal blockage, intolerance of the method of oxygen administration and nursing effort were generally higher amongst the catheter group, but none of these differences was significant. Ulceration or bleeding of the nose was significantly more common in the catheter group (19.7% vs 6.7%, p < 0.05). Abdominal distension and nasal perforation were not seen in either group. This study suggests that nasal prongs are safer, more comfortable and require less nursing expertise than nasopharyngeal catheters for administration of oxygen to children.