Prevalence and correlates of knowledge and practices regarding infection prevention and control, and triage in primary healthcare settings: A cross-sectional study in Bangladesh.

Background: Despite the high prevalence of healthcare-acquired infection in resource-limited settings, healthcare workers' (HCWs') knowledge and practices of infection prevention and control (IPC) and triage are not well-researched. We examined thisin Bangladesh's primary healthcare facilities (HCFs) during the COVID-19 pandemic. Methods: We surveyed 312 HCWs in 94 community clinics (CCs) and 90 family welfare centres (FWCs) in six districts from February to April 2021. We assessed HCWs' self-reported knowledge and observed practices in four domains: personal hygiene, medical instrument processing, waste management, and triage. We constructed a weighted composite knowledge score and estimated the association between knowledge and background characteristics using a generalised linear mixed effects model. Practices were described through univariate analysis. Findings: On a scale of 100, the mean composite knowledge score was 38.3 (SD: 13.3) overall and 44.0 (SD: 13.1) and 33.8 (SD: 11.6) for FWCs and CCs, respectively. The HCWs of FWCs were more aged, experienced, and educated than those of CCs. Knowledge score was the highest in personal hygiene and the lowest in medical waste segregation. Knowledge was significantly associated with HCWs' designation and education. Concerning practices, not more than one-third of the HCWs or HCFs, on average, followed the recommended protocols, except for wearing face masks while on duty (87.1%) and referring potential COVID-19 patients to higher-level facilities (68.3%). Conclusions: HCWs' capacity in instrument processing, waste management, and triage needs to be improved through formal education and training initiatives. Our study can contribute to the under-researched IPC and triage domains in resource-limited settings.

Urban-rural and sex differentials in tuberculosis mortality in Bangladesh: results from a population-based survey.

OBJECTIVE: To assess tuberculosis mortality in Bangladesh through a population-based survey using a Verbal Autopsy tool. METHODS: Nationwide mortality survey employing the WHO-recommended Verbal Autopsy (VA) tool, and using InsilicoVA, a data-driven method, to assign the cause of death. Using a three-stage cluster sampling method, 3997 VA interviews were conducted in both urban and rural areas of Bangladesh. Cause-specific mortality fractions (CSMF) were estimated using Bayesian probabilistic models. RESULTS: 6.8% of total deaths in the population were due to TB [95% CI: (5.1, 8.9)], comprising 12.0% [95% CI: (11.1, 12.8)] and 6.42% [95% CI: (5.4, 7.3)] of total male and female deaths, respectively. This proportion was highest among adults age 15-49 years [12.2%, 95% CI: (9.4, 14.6)]. The urban population is more likely to die from TB, and urban males have highest CSMF [13.6%, 95% CI: (9.1, 16.9)]. CONCLUSION: Our survey results show that TB is the fifth major cause of death in the general population and that sex and place of residence (urban/rural) have a significant effect on TB mortality in Bangladesh. The underlying causes of higher rates of TB-related deaths in urban areas and particularly among urban males, who have better knowledge and higher enrollment in the DOTS Program, need to be explored.

Identifying novel phenotypes of acute heart failure using cluster analysis of clinical variables.

BACKGROUND: Acute heart failure (AHF) is a heterogeneous disease caused by various cardiovascular (CV) pathophysiology and multiple non-CV comorbidities. We aimed to identify clinically important subgroups to improve our understanding of the pathophysiology of AHF and inform clinical decision-making. METHODS: We evaluated detailed clinical data of 345 consecutive AHF patients using non-hierarchical cluster analysis of 77 variables, including age, sex, HF etiology, comorbidities, physical findings, laboratory data, electrocardiogram, echocardiogram and treatment during hospitalization. Cox proportional hazards regression analysis was performed to estimate the association between the clusters and clinical outcomes. RESULTS: Three clusters were identified. Cluster 1 (n=108) represented "vascular failure". This cluster had the highest average systolic blood pressure at admission and lung congestion with type 2 respiratory failure. Cluster 2 (n=89) represented "cardiac and renal failure". They had the lowest ejection fraction (EF) and worst renal function. Cluster 3 (n=148) comprised mostly older patients and had the highest prevalence of atrial fibrillation and preserved EF. Death or HF hospitalization within 12-month occurred in 23% of Cluster 1, 36% of Cluster 2 and 36% of Cluster 3 (p=0.034). Compared with Cluster 1, risk of death or HF hospitalization was 1.74 (95% CI, 1.03-2.95, p=0.037) for Cluster 2 and 1.82 (95% CI, 1.13-2.93, p=0.014) for Cluster 3. CONCLUSIONS: Cluster analysis may be effective in producing clinically relevant categories of AHF, and may suggest underlying pathophysiology and potential utility in predicting clinical outcomes.

Impact of fortified biscuits on micronutrient deficiencies among primary school children in Bangladesh.

BACKGROUND: Micronutrient deficiencies can compromise the development potential of school-aged children, and their later health and productivity as adults. School feeding and school-based fortification approaches have been utilized globally to redress nutritional deficiencies in this age group. OBJECTIVE: We explored the acceptability and micronutrient impact of a Bangladesh Government supported school-based micronutrient fortification program for children attending rural primary schools in 10 disadvantaged sub-districts. METHODS: We applied a mixed methods approach. The quantitative component assessed the impact of micronutrient fortification on 351 children aged 6-11 years using a cohort pre-post research design with a control group. The qualitative component explored the acceptability of the intervention using focus group discussions, body mapping and semi-structured interviews with teachers, school-going children and school authorities. RESULTS: Daily consumption of fortified biscuits by primary school children had a significant positive impact on mean levels of iron, folic acid, vitamin B12, retinol and vitamin D controlling for sex, baseline deficiency status, CRP, and H. pylori. Levels of anemia and vitamin D deficiency were also significantly reduced. Qualitative findings indicated the widespread acceptability of the daily biscuit. Teachers perceived students to be more attentive in class, less tired, and some attributed better school performance to biscuit consumption. Children reported similar improvements in concentration and energy levels. CONCLUSIONS: This study is among the first in Bangladesh to comprehensively assess a school-based fortification program in terms of its acceptability and impact on micronutrient status of children aged 6-11 years of age. While results strongly support this modality of school feeding, research on the cognitive impacts of micronutrient fortified biscuits will help clarify the case for scaled-up investments in school- based feeding program in Bangladesh and other low and middle income countries.

Double Trouble: Prevalence and Factors Associated with Tuberculosis and Diabetes Comorbidity in Bangladesh.

BACKGROUND: Diabetes among tuberculosis patients increases the risk of tuberculosis treatment failure, death, and development of multidrug-resistant tuberculosis. Yet, there is no data is available in Bangladesh on the prevalence of diabetes among tuberculosis patients. The objective of the current study was to estimate prevalence and identify factors associated with tuberculosis-diabetes co-morbidity among TB patients enrolled in the Directly Observed Treatment, Short course program. METHODS: A community based cross-sectional quantitative study was conducted among 1910 tuberculosis patients living in six urban and eleven rural areas among whom Oral Glucose Tolerance Test (those who fasted) and Random Blood Sugar test (those who did not fast) were performed. Besides glucose levels, data on socio-demographic information, family history of diabetes and anthropometric measurements (height and weight) were also collected. RESULT: Among the 1910 TB patients who participated in screening for diabetes, 245 (12.8%) were found to have diabetes and 296 (15.5%) to have pre-diabetes. Out of those who had diabetes, 34.7% were newly diagnosed through the current study and 65.3% already knew their status. Among those who were found to have prediabetes, 27 (9.1%) had impaired Fasting Blood Glucose (FBG), 230 (77.7%) had Impaired Glucose Tolerance (IGT), and 39 (13.2%) had both Impaired FBG and IGT. Older age, higher BMI, higher education (secondary level and above), being married, participation in less active work, and family history of diabetes are associated with higher prevalence of diabetes. CONCLUSION: We observed a higher prevalence of diabetes and pre-diabetes in TB patients than reported previously in Bangladesh among the general population which may challenge TB and diabetes control in Bangladesh. Diabetes diagnosis, treatment and care should be integrated in the National TB Program.

Trend of determinants of birth interval dynamics in Bangladesh.

BACKGROUND: The distribution of birth intervals can be used to draw attention to important characteristics of dynamics of fertility process. The main objective of this paper is to examine the effects of socioeconomic, demographic and proximate determinants on the length of birth intervals of women of Bangladesh and also to see whether the effects are changed over the years. METHODS: Birth intervals can be considered as correlated time-to-event data because two or more birth intervals could correspond to a single mother. Moreover, women from the same neighborhood usually share certain unobserved characteristics, which may also lead to correlated time-to-event data (birth interval). A parametric random effect (frailty) model is used to analyze correlated birth interval data obtained from three Bangladesh Demographic and Health Surveys (BDHS 2004, 2007, and 2011). RESULTS: The results show that alongside different socioeconomic, demographic determinants, unobserved community and mother effects have considerable impact on birth interval in Bangladesh. However, the effects of different factors on birth interval changes in a small scale over the duration of 2004-2011. CONCLUSIONS: Efficient policy is a priority for promoting longer birth spacing and achieving a decline in fertility.

Transform-both-sides nonlinear models for in vitro pharmacokinetic experiments.

Transform-both-sides nonlinear models have proved useful in many experimental applications including those in pharmaceutical sciences and biochemistry. The maximum likelihood method is commonly used to fit transform-both-sides nonlinear models, where the regression and transformation parameters are estimated simultaneously. In this paper, an analysis of variance-based method is described in detail for estimating transform-both-sides nonlinear models from randomized experiments. It estimates the transformation parameter from the full treatment model and then the regression parameters are estimated conditionally on this estimate of the transformation parameter. The analysis of variance method is computationally simpler compared with the maximum likelihood method of estimation and allows a more natural separation of different sources of lack of fit. Simulation studies show that the analysis of variance method can provide unbiased estimators of complex transform-both-sides nonlinear models, such as transform-both-sides random coefficient nonlinear regression models and transform-both-sides fixed coefficient nonlinear regression models with random block effects.

Relative bioavailability and pharmacokinetic study of two trimetazidine modified release formulations in healthy Bangladeshi male volunteers.

Trimetazidine (CAS 5011-34-7) is an effective and well-tolerated antianginal drug that possesses protective properties against ischemia-induced heart injury. The relative bioavailability and pharmacokinetic characteristics of two modified release formulations of 35 mg trimetazidine, one as the test product (Metacard MR) and one as the reference product, were compared in healthy Bangladeshi male volunteers. The randomized, two-way crossover study was conducted in 24 healthy male volunteers after administration of a single 35 mg dose of each modified release formulation after 12-h overnight fasting, with a washout period of two weeks. Blood samples were collected at various time intervals following oral administration and analyzed for trimetazidine concentrations using a validated HPLC method. The pharmacokinetic parameters were determined by a non-compartmental method. After administering a single dose of 35 mg of each trimetazidine formulation, the obtained mean (SD) values for the test and reference products were 104.78 (29.3) and 98.57 (28.7) ng/ml for Cmax; 4.00 (1.1) and 3.54 (1.32) h for t(max); 423.81 (173.9) and 410.01 (195.87) ng x h/ml for AUC0-12; and 472.51 (195.2) and 462.78 (225.13) ng x h/ml for AUC0-infinity respectively. The mean t1/2 was found 3.69 (1.1) h and 3.45 (0.72) h for test and reference products respectively. From paired t-test, no significant differences were observed (p > 0.05) for any pharmacokinetic parameters. The 90% confidence intervals of the test/reference mean ratios of the In-transformed AUC0-12, AUC0-infinity, and Cmax mean values were 106.19% (97.16%-116.06%), 104.74% (95.04%-115.42%) and 106.30% (95.23%-118.66%), respectively. The two formulations demonstrated similar bioavailability with respect to both the rate and extent of trimetazidine absorption.

Relative bioavailability and pharmacokinetic properties of two different enteric formulations of esomeprazole in healthy Bangladeshi male volunteers: An open-label, single-dose, randomized-sequence, two-way crossover study.

BACKGROUND: In Bangladesh, a number of generic oral formulations of esomeprazole are marketed. Study of the relative bioavailability of these generic formulations has yet to be conducted in a Bangladeshi population. OBJECTIVES: The aims of this study were to assess the relative bioavailability and pharmacokinetic properties of 2 formulations (test and reference) of esomeprazole 40 mg. METHODS: This open-label, randomized, 2-way crossover study was conducted in healthy Bangladeshi male subjects in compliance with the Declaration of Helsinki and International Conference on Harmonisation guidelines. Subjects were randomly assigned to receive the test formulation followed by the reference formulation or vice versa, as a single dose of esomeprazole 40 mg after a 12-hour overnight fast. A washout period of 1 week was maintained between treatments. Following oral administration, blood samples were collected at 0, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.5, 4, 5, 7, 9, and 12 hour(s) after dosing and analyzed for esomeprazole concentrations using a validated HPLC method. Pharmacokinetic parameters, including C(max), AUC(0-12), and AUC(0-infinity), were determined with a non-compartmental method. The formulations were to be considered bioequivalent if the natural log (ln)-transformed ratios of the pharmacokinetic parameters were within the predetermined bioequivalence range of 80% to 125%, according to the US Food and Drug Administration (FDA) requirement. The within- and between-group differences were examined using ANOVA. Tolerability was assessed by monitoring vital signs and conducting subject interviews regarding adverse events. Interviewers were not blinded to study design. RESULTS: A total of 24 nonsmoking, healthy, Bangladeshi male subjects (mean [SD] age, 22.8 [2.22] years [range, 20-29 years]; weight, 64.7 [6.9] kg [range, 55-79 kg]; height, 1.69 [0.05] m [range, 1.63-1.82 m]; and body mass index, 22.39 [2.16] kg/m(2) [range, 18.99-27.34 kg/m(2)]) were enrolled. From serum data, the mean (SD) values for the test and reference products were as follows: 5.26 (1.57) and 5.54 (2.94) micromol/L for C(max); 2.53 (0.67) and 2.07 (0.65) hours for T(max); 15.74 (6.50) and 16.68 (6.77) micromol/L/h for AUC(0-12); and 17.15 (7.58) and 18.26 (7.31) micromol/L/h for AUC(0-infinity), respectively. The mean T(max) was found to be significantly different between the test and reference formulations (2.53 [0.67] vs 2.07 [0.65] hours, respectively; P < 0.05). The point estimates (90% CI) for the test/reference ratios of the In-transformed AUC(0-infinity) and C(max) were 92.92% (84.02%-102.76%) and 102.36% (85.96%-121.90%), respectively, which were within the FDA-accepted limits for assuming bioequivalence. No adverse events were reported by the volunteers during the study. CONCLUSION: This single-dose study found that the test and reference formulations of esomeprazole 40 mg met the FDA regulatory criteria for assuming bioequivalence in these healthy, fasting Bangladeshi male volunteers. A significant difference was found in T(max) between the 2 formulations. Both formulations were well tolerated in the studied population.

The outcome of induction therapy with monoclonal antibodies in kidney transplantation among Iranian patients: a prospective study.

INTRODUCTION: The administration of interlukin-2 receptor antagonists for induction therapy has reduced the incidence of acute rejection episodes in kidney transplantation. Although some studies have investigated the efficacy of these monoclonal antibodies, there is little experience among Iranian kidney transplant recipients. MATERIALS AND METHODS: Forty-three patients randomly divided into 2 groups were prospectively followed for 3.4 years. Eighteen patients received 2 doses of basiliximab (group I) and another 25 patients received 5 doses of daclizumab (group II). The posttransplantation complications, last serum creatinine level, as well as graft and patient survival rates were compared to investigate the efficacy of these therapies. RESULTS: Among 43 patients, 11.6% experienced acute rejection episodes: 22.2% in group I and 4% in group II (P > .05). In this study, 4.6% of recipients underwent graft nephrectomy: 11.1% in group I and 4% in group II (P > .05). The mortality rate was 4.6%: 5.5% in group I and 4% in group II (P > .05). The mean serum creatinine level was 1.47 +/- 0.7 mg/dL. Although it was lower in group I, the difference was not significant. The 1-year graft and patient survival rates were 90.6% and 95.3%, respectively, with no significant differences between the groups. DISCUSSION: Although induction therapy with monoclonal antibodies may reduce the incidence of acute rejection episodes, graft and patient survival rates were unchanged compared with conventional therapies. Also, there were no significant differences between the results of induction therapy with basiliximab and daclizumab.

Living or deceased donor kidney transplantation: a comparison of results and survival rates among Iranian patients.

OBJECTIVE: Kidney transplantation is the selective treatment of end-stage renal disease. Although most previous studies have concluded that living kidney donation achieves better graft survival, some factors may limit this type of donation. This study investigated the survival rates of living and deceased donor kidney transplantations among Iranian patients. MATERIALS AND METHODS: The records of kidney transplantations up to year 2005 were used to compare 50 deceased (group I) with 50 living donor transplants (group II). The recipients were matched by transplantation time. We used SPSS version 15 software to analyze the data. RESULTS: Group I patients included 28 males and 22 females of mean age of 38 +/- 13 years, while 26 males and 24 females in group II had a mean age of 34.6 +/- 14 years. The rejection and graft nephrectomy rates were significantly higher among group I than group II (P = .01, P = .02). The first-year graft survival was higher in group II (P = .001). The graft survival was significantly lower in recipients who needed a biopsy or dialysis (P = .006 and P = .02, respectively) and higher among those who had a urine volume >4200 mL within the first 24 hours after transplantation (P = .003). Patient survivals were not significantly different between the groups. CONCLUSION: Living donor kidney transplantations showed higher graft survival and lower acute rejection rates compared with those from deceased donors.

Robustness considerations in selecting efficient two-color microarray designs.

The main goal of microarray experiments is to select a small subset of genes that are differentially expressed among competing mRNA samples. For a given set of such mRNA samples, it is possible to consider a number of two-color cDNA microarray designs with a fixed number of arrays. Appropriate criteria can be used to select an efficient design from such a set of alternative experimental designs. In practice, however, microarray expression data often contain missing observations and the most efficient design (with complete observations) for a specific setup may not be efficient in the presence of missing observations. In this article, we propose two criteria to address the robustness of microarray designs against missing observations. We demonstrate the simultaneous use of efficiency and robustness criteria to select good microarray designs for both one-factor and multi-factor experiments.

Relative bioavailability and pharmacokinetic study of omeprazole 20 mg enteric-coated tablet in healthy Bangladeshi volunteers.

OBJECTIVE: Introduction of omeprazole constituted a break through in the management of acid-related gastric disorders. Omeprazole effectively suppresses the gastric acid secretion in the parietal cells of the stomach. It is a widely prescribed proton pump inhibitor in Bangladesh. The increasing number of omeprazole containing products available in the market raises questions of therapeutic equivalence and/or generic substitution which are yet to be conducted on the Bangladeshi population. The aim of the study is to assess the relative bioavailability and pharmacokinetic properties of two oral formulations of 20 mg omeprazole tablet, namely LOSEC(R) as reference product and Losectil DR as test product using serum data. MATERIALS AND METHODS: The randomized, two-way crossover study was conducted on 24 healthy male subjects in compliance with the Declaration of Helsinki and ICH Guidelines. Subjects were assigned to receive Losectil DR (Test) and LOSEC (Reference) as a single dose of 20 mg tablet under fasting conditions, following a washout period of 1 week. After oral administration, blood samples were collected at various time intervals and analyzed for omeprazole concentrations using a validated HPLC method. The pharmacokinetic parameters were determined by a non-compartmental method. RESULTS: From serum data, the obtained values for test and reference products were 593.05 +/- 84.85 and 607.92 +/- 67.07 ng/ ml for Cmax; 1756.71 +/- 287.29 and 1786.90 +/- 280.17 ng-h/ml for AUC0-24; 1889.26 +/- 286.46 and 1929.18 +/- 284.33 ng-h/ml for AUC0- yen, respectively. No statistically significant differences were observed between two formulations by analyzing different pharmacokinetic parameters in terms of period, sequence and formulation. From the paired t-test, no significant differences between two formulations were observed (p > 0.05). The 90% CIs of Cmax, AUC0-24 and AUC0- yen were found to be 91.59 - 122.60%, 101.86 - 116.78% and 102.77 - 116.68%, respectively, which are within the FDA accepted limits for bioequivalence (80 - 125%). CONCLUSION: Finally it can be concluded that both products are bioequivalent in terms of rate and extent of drug absorption and therefore interchangeable.

CD137 ligand reverse signaling has multiple functions in human dendritic cells during an adaptive immune response.

T cell activation via dendritic cells (DC) is an important step in the adaptive immune response, which requires DC maturation, migration to lymph nodes and presentation of antigen to T cells. CD137 receptor expressed on activated T cells is a potent costimulatory molecule. Here, we investigated the functions of CD137 ligand (CD137L) in human monocyte-derived DC during an immune response. Cross-linking of CD137L on DC leads to cell maturation in an autocrine fashion, mostly via release of TNF-alpha. Reverse signaling of CD137L also mediates migration of DC via up-regulation of the CCR7 chemokine receptor, demonstrated by an in vivo MIP-3beta-dependent SCID mouse migration model. Finally, CD137L-activated DC induce differentiation of human T cells into potent Th1 effectors. Cocultivation of autologous T cells and CD137L-activated DC in an antigen-specific reaction leads to T cell proliferation and the release of IL-12p70 and IFN-gamma. These findings deliver new insights into the multiple effects of reverse signaling of CD137L in human DC during the initiation of an adaptive immune response, including the key features of DC maturation, migration and, ultimately, antigen-specific T cell differentiation.

Diagnostic trends in autistic spectrum disorders in the South Wales valleys.

This study provides an analysis of the diagnostic trends in autistic spectrum disorder (ASD) for children aged under 17 years in the Rhondda and Taff Ely districts of South Wales. In the period 1988-2004, 336 children received a diagnosis of ASD and represent the case registry data of one community paediatric team. For the period 1994-2003, the caseload of 267 comprised Asperger (58%), Kanner (20%) and ;other forms' of autism (22%). In comparison to the previous 5 year period, diagnosis of ASD in 1999-2003 increased for Asperger (2.9 fold) and ;other forms' (4.4) but decreased for Kanner autism (0.69). Male:female gender ratios and age at diagnosis fell for all subcategories of ASD. Prevalences per 10,000 children born in Rhondda Taff Ely are ASD 61.2, Asperger 35.4, Kanner autism 12.7, and 'other forms' 13.0. Detected prevalences and trends for ASD are in line with national standards and do not show an increase for Kanner autism.

A new storage solution for porcine aortic valves.

The aim of this study was to assess the calcification tendency of two biovalves manufactured by different fixation techniques and compare their biocompatibility when implanted subcutaneously in rats. Two biological valve types (Intact) and Mosaic, stored in either glutaraldehyde or in a solution recently developed in our department, were investigated ultrastructurally and their calcium content was measured following 12 weeks subcutaneous implantation in rats. All valves tested in this study showed a considerable loss of the endothelial cover, as judged by scanning electron microscopy. Independent of fixation conditions, the bioprostheses demonstrated a partial destruction of collagen fibers and a rearrangement of the extracellular matrix. The calcium content of Intact valves was significantly higher than that of Mosaic valves (66+/-2.6 versus 3.6+/-0.6 mg/g dry tissue, p<0.0001). Low calcium content of the bioprostheses is considered to result from effective anti-calcification treatment. Ultrastructural changes of prosthetic tissue seem to promote degenerative calcification. The valves stored in the new storage solution exhibited a calcium content which was reduced by approximately 50% compared to those stored in glutaraldehyde. The percentage of reduction in calcification of the valves stored in our newly developed solution is independent of the fixation conditions (p=0.886). The advantage of the new storage solution is based on the fact that rinsing is unnecessary before implantation and, most importantly, a clear reduction in the calcification tendency is achieved.

Hyperopia and educational attainment in a primary school cohort.

BACKGROUND: Vision screening addresses the visual impairments that impact on child development. Tests of long-sightedness are not found in most school screening programmes. The evidence linking mild-moderate hyperopia and lack of progress in school is insufficient, although strengthened by recent findings of developmental problems in infants. AIMS: To report on the relation between hyperopia and education test results in a cohort of primary school children. METHODS: A total of 1298 children, aged 8 years, were screened for hyperopia on the basis of fogging test results. School test results (NFER and SATs) were compared between groups categorised by referral status and refractive error. RESULTS: A total of 166 (12.8%) fogging test failures were referred for ophthalmic assessment. Ophthalmic tests on 105 children provided an accurate diagnosis of vision defects, for reference to their education scores. Fifty per cent of the children examined by optometrists required an intervention (prescription change, glasses prescribed, or referral). Mean (95% CI) NFER scores of children with refractive errors (summed for both eyes) >+3D (98.4, 93.0-103.8, n = 32) or >+1.25D (best eye) (99.3, 93.0-105.6, n = 26) were lower than the respective scores of children with a less positive refractive state (104.8, 100.7-108.9, n = 43) (103.6, 99.7-107.4, n = 49), the non-referred group, and total sample. The SATs results followed a similar trend. A high proportion of the fogging test failures (16%) and confirmed hyperopes (29%) had been referred to an educational psychologist, and the latter group contributed substantially to the poor education scores. CONCLUSIONS: The results of this study provide further evidence for a link between hyperopia and impaired literacy standards in children.