Emerging research has identified sluggish cognitive tempo (SCT) as a construct separate from ADHD predominately inattentive presentation. The present study explores the longitudinal stability of SCT over a period of 7 years, specifically the independent effects of SCT on behavioural and academic outcomes concurrently over a 3-year period. A sample of 639 twins, aged 6–12 years, participating in the Western Reserve Reading and Math Project (WRRMP) were assessed at seven annual home visits. The WRRMP sample is an unselected sample of twins representative of the general population of typically developing school-age children. The current investigation will focus on parent and teacher reports which assess attention deficit hyperactive/impulsive disorder (ADHD) and standardized achievement measures which assess academic outcomes. Over periods longer than 1 or 2 years, SCT does not display good longitudinal stability ( r < .60). SCT also does not have consistent significant independent effects on academic outcomes once the effects of ADHD were controlled for. Over a 7-year period, SCT does not demonstrate consistent longitudinal stability. SCT significantly predicts social problems, internalizing behaviours, and anxious/depressive behaviours after the effects of ADHD are controlled for. SCT has no significant independent effects on cognitive or educational outcomes after the effects of inattentive ADHD are controlled for.

Background: Delivery of high-quality efficient health services is a cornerstone of the global agenda to achieve universal health coverage. According to the World Health Organization, health service delivery is considered good when equitable access to a comprehensive range of high-quality health services is ensured within an integrated and person-centered continuum of care. However, good health service delivery can be challenging in low-resource settings. In this review, we summarize and discuss key advances in health service delivery, particularly in the context of using digital health strategies for mitigating human resource constraints. Methods: The review updates the foundational systematic review conducted by Agarwal et al. in 2015. We used PubMed, EMBASE, and CINAHL to find relevant English-language peer-reviewed articles published 2018. Our search strategy for MEDLINE was based on MeSH (medical subject headings) terms and text words of key articles that we identified a priori. Our search identified 92 articles. After screening, we selected 24 articles for abstract review, of which only 6 met the eligibility criteria and were ultimately included in this review. Results: Despite encouraging advances in the evidence base on digital strategies for health service delivery, the current body of evidence is still quite limited in 3 main areas: the effectiveness of interventions on health outcomes, improvement in health system efficiencies for service delivery, and the human capacity required to implement and support digital health strategies at scale. Two particular areas, digital health-enhanced referral coordination and mobile clinical decision support systems, demonstrate considerable potential to improve the quality and comprehensiveness of care received by patients, but they require a greater level of standardization and an expanded scope of health worker engagement across the health system in order to scale them up effectively. Conclusions: Additional research is urgently needed to inform the effectiveness of interventions on health outcomes, improvement in health system efficiencies, and cost-effectiveness of service delivery. In particular, more documentation and research on ways to standardize and engage health workers in digital referral and clinical decision support systems can provide the foundation needed to scale these promising approaches in low- and middle-income settings.

Refugees and internally displaced persons who are affected by armed-conflict are at increased vulnerability to some forms of sexual violence or other types of gender-based violence. A validated, brief and easy-to-administer screening tool will help service providers identify GBV survivors and refer them to appropriate GBV services. To date, no such GBV screening tool exists. We developed the 7-item ASIST-GBV screening tool from qualitative research that included individual interviews and focus groups with GBV refugee and IDP survivors. This study presents the psychometric properties of the ASIST-GBV with female refugees living in Ethiopia and IDPs in Colombia.

Background: Organizations working in conflict-affected areas have a need to monitor and evaluate their programs, however this is often difficult due to the logistical challenges of conflict areas. Lot quality assurance sampling may be a suitable method of assessing programs in these situations.Methods: We conducted a secondary data analysis of information collected during Medair's routine program management functions. Medair's service area in West Darfur, Sudan was divided into seven supervisory areas. Using the available population information, a sampling frame was developed and interviews were conducted from randomly selected caretakers of children in each supervisory area every six months over 19 months. A survey instrument with questions related to key indicators for immunizations and maternal, newborn, and child health was used for the interviews. Based on Medair's goals for each indicator, decision rules were calculated for the indicators; these decision rules determined which supervisory areas and indicators performed adequately in each assessment period. Pearson's chi-squared tests, adjusted for the survey design using STATA "svy: tab" commands, were used to detect overall differences in coverage in this analysis.Results: The coverage of tetanus toxoid vaccination among pregnant women increased from 47.2 to 69.7 % (p value = 0.046), and births attended by a skilled health professional increased from 35.7 to 52.7 % (p value = 0.025) from the first to last assessment periods. Measles vaccinations declined from 72.0 to 54.1 % (p value = 0.046). The estimated coverage for the proportion of women receiving a postpartum dose of vitamin A (54.7 to 61.3 %, p value = 0.44); pregnant women receiving a clean delivery kit (54.6 to 47.1 %, p value = 0.49); and pentavalent vaccinations (49.7 to 42.1 %, p value = 0.28) did not significantly change.Conclusions: Lot quality assurance sampling was a feasible method for Medair staff to evaluate and optimize primary health programs in a conflict-affected area. Medair managers were able to collect, analyze, and disseminate data to staff alongside the routine work of the organization. These results suggest LQAS may be used in other complex humanitarian emergencies in which there are logistical challenges and limited resources.

Medically underserved populations in the United States continue to experience higher cancer burdens of incidence, mortality, and other cancer-related outcomes. It is imperative to understand how health inequities experienced by diverse population groups may contribute to our increasing unequal cancer burdens and disparate outcomes. The National Cancer Institute convened a diverse group of scientists to discuss research challenges and opportunities for cancer epidemiology in medically underserved and understudied populations. This report summarizes salient issues and discusses five recommendations from the group, including the next steps required to better examine and address cancer burden in the United States among our rapidly increasing diverse and understudied populations. Cancer Epidemiol Biomarkers Prev; 25(4); 573–80. ©2016 AACR. See all articles in this CEBP Focus section, “Multilevel Approaches to Addressing Cancer Health Disparities.”

Background Kabul has over 12,000 people who inject drugs (PWID), most of them heroin users, and opioid substitution therapy has recently been introduced as an effective method to reduce opioid use. We aimed to evaluate a pilot Opioid Substitution Therapy Pilot Program (OSTPP) in Kabul, Afghanistan, particularly to (1) describe characteristics of the participants enrolled in the program and (2) identify factors associated with client retention in the OSTPP. Findings Two cross-sectional surveys evaluated participants attending the OSTPP at baseline ( n = 83) and 18 months after ( n = 57). Questionnaires assessed socio-demographic, drug use behavior, and general and mental health factors. After 18 months, 57 participants remained in the OSTPP. Participants lost to follow-up were younger ( p < 0.01) and married ( p < 0.01) and had no family contact ( p < 0.01). Participants at 18 months reported no criminal activity in the last month and only two (3.5 %) reported heroin use in the last month, constituting significant decreases from baseline. Conclusions While preliminary results are promising, further evaluation is needed to determine the feasibility of implementing OSTPP in this setting and effectiveness in reducing injection risk behaviors in Afghanistan.

Gender-based violence (GBV) is prevalent among, though not specific to, conflict affected populations and related to multifarious levels of vulnerability of conflict and displacement. Colombia has been marked with decades of conflict, with an estimated 5.2 million internally displaced persons (IDPs) and ongoing violence. We conducted qualitative research to understand the contexts of conflict, displacement and dynamics with GBV. This as part of a multi-phase, mixed method study, in collaboration with UNHCR, to develop a screening tool to confidentially identify cases of GBV for referral among IDP women who were survivors of GBV.

Background: Injecting drug use is the primary mode of HIV transmission and acquisition in Afghanistan. People who inject drugs (PWID) in the country have been characterized by high risk injecting behavior and a high burden of HCV infection. We aimed to estimate the burden of HIV, HCV, and other infectious diseases and to identify the correlates of HIV and HCV infection among PWID living in three major Afghan cities in 2009.Methods: Epidemiologic data was collected among PWID for the integrated biological and behavioral surveillance (IBBS) survey between May and August, 2009 in three Afghan cities. Data were collected using a structured questionnaire and biologic specimens to screen for HIV, HBV, HCV, syphilis, and HSV-2 using rapid testing kits. Multiple logistic regression models were constructed to identify correlates of infection.Results: Among 548 participants, pooled HIV prevalence was 7.1% (Mazar-i-Sharif: 1.0%, Kabul: 3.1%, Herat: 18.4%) and HCV prevalence was 40.3%. Almost all participants with HIV infection were co-infected with HCV (94.9%). Pooled prevalence estimates for other diseases included 7.1% for HBV, 5.5% for syphilis; and 9.3% for HSV-2. Living in Herat, ever in prison and time injecting were independently associated with HIV infection. Living in Kabul, Herat and time injecting were independently associated with HCV infection.Conclusions: There is a high and heterogeneous burden of HIV and HCV among PWID in Afghan cities. Provision of comprehensive harm reduction services to PWID in Afghanistan is warranted to reduce exposures associated with HIV and HCV infection, especially in the city of Herat. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

IMPORTANCE:Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain.OBJECTIVE:Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies.DATA SOURCE:We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources.STUDY SELECTION:Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. After a review of 1175 citations 19 unique studies were selected.DATA EXTRACTION:Two reviewers worked independently to identify final selection and a third reviewer adjudicated any differences. Descriptive and quantitative information was extracted; prevalence estimates were synthesized. Heterogeneity was assessed using I2.MAIN OUTCOMES:The main outcome of interest was sexual violence among female refugees and internally displaced persons in complex humanitarian settings.RESULTS:The prevalence of sexual violence was estimated at 21.4% (95% CI, 14.9-28.7; I2=98.3%), using a random effects model. Statistical heterogeneity was noted with studies using probability sampling designs reporting lower prevalence of sexual violence (21.0%, 95% CI, 13.2-30.1; I2=98.6%), compared to lower quality studies (21.7%, 95% CI, 11.5-34.2; I2=97.4%). We could not rule out the presence of publication bias.CONCLUSIONS:The findings suggest that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence. However, this is likely an underestimation of the true prevalence given the multiple existing barriers associated with disclosure. The long-term health and social consequences of sexual violence for women and their families necessitate strategies to improve identification of survivors of sexual violence and increase prevention and response interventions in these complex settings.

Objective: It is in order to examine associations between social desirability (SD) and self-reports of abstinence among youths in rural Ethiopia. Methods: Youths of ages 15 - 24 (114 participants) were administered questionnaire to assess HIV knowledge and primary abstinence and a modified Marlowe-Crowne Social Desirability Scale to assess SD bias. The relationships between SD groups (dichotomized into high and low) and abstinence by various characteristics were assessed by using Fisher’s exact p-values. Results: The odds of individuals reporting abstinence were 13.2 times greater in the high SD group compared to the low SD group (p-value 0.002) when adjusted for education, gender, age group, and HIV knowledge. The differences in abstinence between the high and low SD score groups were also examined for selected variables. Conclusions: Individuals who exhibited more SD bias were more likely to report primary abstinence. SD bias should be considered when conducting self-reported surveys to measure the effectiveness of HIV prevention programs.

BACKGROUND:Children are a special population, particularly susceptible to injury. Registries for various injury types in the pediatric population are important, not only for epidemiological purposes but also for their implications on intervention programs. Although injury registries already exist, there is no uniform injury classification system for traumatic mass casualty events such as earthquakes.OBJECTIVE:To systematically review peer-reviewed literature on the patterns of earthquake-related injuries in the pediatric population.METHODS:On May 14, 2012, the authors performed a systematic review of literature from 1950 to 2012 indexed in Pubmed, EMBASE, Scopus, Web of Science, and Cochrane Library. Articles written in English, providing a quantitative description of pediatric injuries were included. Articles focusing on other types of disasters, geological, surgical, conceptual, psychological, indirect injuries, injury complications such as wound infections and acute kidney injury, case reports, reviews, and non-English articles were excluded.RESULTS:A total of 2037 articles were retrieved, of which only 10 contained quantitative earthquake-related pediatric injury data. All studies were retrospective, had different age categorization, and reported injuries heterogeneously. Only 2 studies reported patterns of injury for all pediatric patients, including patients admitted and discharged. Seven articles described injuries by anatomic location, 5 articles described injuries by type, and 2 articles described injuries using both systems.CONCLUSIONS:Differences in age categorization of pediatric patients, and in the injury classification system make quantifying the burden of earthquake-related injuries in the pediatric population difficult. A uniform age categorization and injury classification system are paramount for drawing broader conclusions, enhancing disaster preparation for future disasters, and decreasing morbidity and mortality.

Background. There are currently 34 International Emergency Medicine (IEM) fellowship programs. Applicants and programs are increasing in number and diversity. Without a standardized application, applicants have a difficulty approaching programs in an informed and an organized method; a streamlined application system is necessary. Objectives. To measure fellows' knowledge of their programs' curricula prior to starting fellowship and to determine what percent of fellows and program directors would support a universal application system. Methods. A focus group of program directors, recent, and current fellows convened to determine the most important features of an IEM fellowship application process. A survey was administered electronically to a convenience sample of 78 participants from 34 programs. Respondents included fellowship directors, fellows, and recent graduates. Results. Most fellows (70%) did not know their program's curriculum prior to starting fellowship. The majority of program directors and fellows support a uniform application service (81% and 67%, resp.) and deadline (85% for both). A minority of program directors (35%) and fellows (30%) support a formal match. Conclusions. Program directors and fellows support a uniform application service and deadline, but not a formalized match. Forums for disseminating IEM fellowship information and for administering a uniform application service and deadline are currently in development to improve the process.

Over the past few decades there has been a steady growth in funding for global health, yet generally little is known about funding for global health research. As part of the 2013 Academic Emergency Medicine consensus conference, a session was convened to discuss emergency care research funding in the global health context. Overall, the authors found a lack of evidence available to determine funding priorities or quantify current funding for acute care research in global health. This article summarizes the initial preparatory research and reports on the results of the consensus conference focused on identifying challenges and strategies to improve funding for global emergency care research. The consensus conference meeting led to the creation of near- and long-term goals to strengthen global emergency care research funding and the development of important research questions. The research questions represent a consensus view of important outstanding questions that will assist emergency care researchers to better understand the current funding landscape and bring evidence to the debate on funding priorities of global health and emergency care. The four key areas of focus for researchers are: 1) quantifying funding for global health and emergency care research, 2) understanding current research funding priorities, 3) identifying barriers to emergency care research funding, and 4) using existing data to quantify the need for emergency services and acute care research. This research agenda will enable emergency health care scientists to use evidence when advocating for more funding for emergency care research.

OBJECTIVE:Experts have proposed core curriculum components for international emergency medicine (IEM) fellowships. This study examined perceptions of program directors (PDs) and fellows on whether IEM fellowships cover these components, whether their perspectives differ and the barriers preventing fellowships from covering them.METHODS:From 1 November 2011 to 30 November 2011, a survey was administered to PDs, current fellows and recent graduates of the 34 US IEM fellowships. Respondents quantified their fellowship experience in six proposed core curriculum areas: emergency medicine (EM) systems development, EM education, humanitarian assistance, public health, emergency medical services and disaster medicine. Analysis was performed regarding what per cent of programmes fulfil the six curriculum areas. A paired t test determined the difference between PDs' and fellows' responses. Agreement between PDs and fellows within the same programme was determined using a κ statistic.RESULTS:Only 1/18 (6%) (according to fellows) to 2/24 (8%) (according to PDs) of programmes expose fellows to all six components. PDs consistently reported higher exposure than fellows. The difference in mean score between PDs and fellows was statistically significant (p<0.05) in three of the 6 (50%) core curriculum elements: humanitarian aid, public health and disaster medicine. Per cent agreement between PDs and fellows within each programmes ranged from poor to fair.CONCLUSIONS:While IEM fellowships have varying structure, this study highlights the importance of further discussion between PDs and fellows regarding delineation and objectives of core curriculum components. Transparent curricula and open communication between PDs and fellows may reduce differences in reported experiences.

BACKGROUND:High levels of gender-based violence (GBV) persist among conflict-affected populations and within humanitarian settings and are paralleled by under-reporting and low service utilization. Novel and evidence-based approaches are necessary to change the current state of GBV amongst these populations. We present the findings of qualitative research, which were used to inform the development of a screening tool as one potential strategy to identify and respond to GBV for females in humanitarian settings.METHODS:Qualitative research methods were conducted from January-February 2011 to explore the range of experiences of GBV and barriers to reporting GBV among female refugees. Individual interview participants (n=37) included female refugees (≥15 years), who were survivors of GBV, living in urban or one of three camps settings in Ethiopia, and originating from six conflict countries. Focus group discussion participants (11 groups; 77 participants) included health, protection and community service staff working in the urban or camp settings. Interviews and discussions were conducted in the language of preference, with assistance by interpreters when needed, and transcribed for analysis by grounded-theory technique.RESULTS:Single and multiple counts of GBV were reported and ranged from psychological and social violence; rape, gang rape, sexual coercion, and other sexual violence; abduction; and physical violence. Domestic violence was predominantly reported to occur when participants were living in the host country. Opportunistic violence, often manifested by rape, occurred during transit when women depended on others to reach their destination. Abduction within the host country, and often across borders, highlighted the constant state of vulnerability of refugees. Barriers to reporting included perceived and experienced stigma in health settings and in the wider community, lack of awareness of services, and inability to protect children while mothers sought services.CONCLUSIONS:Findings demonstrate that GBV persists across the span of the refugee experience, though there is a transition in the range of perpetrators and types of GBV that are experienced. Further, survivors experience significant individual and system barriers to disclosure and service utilization. The findings suggest that routine GBV screening by skilled service providers offers a strategy to confidentially identify and refer survivors to needed services within refugee settings, potentially enabling survivors to overcome existing barriers.

[Ann Emerg Med. 2011;57:520-525.] In replyAnnals of Emergency MedicineVol. 58Issue 6PreviewDr. Hauswald provides an excellent perspective about clinical practice in resource-limited settings. Although American physicians are trained in a technologically advanced environment with unlimited access to specialized services, the appeal of global health and international emergency medicine fellowships is that they do offer opportunities for American physicians to learn how to work and improve their diagnostic skills in resource-limited environments. Most (if not all) opportunities offered by international emergency medicine and global health fellowships cover aspects of local accreditation and licensing; in regard to more independent endeavors, providers should indeed be mindful of ensuring accreditation in the local environment. Full-Text PDF International Emergency Medicine and Global Health: Training and Career Paths for Emergency Medicine ResidentsAnnals of Emergency MedicineVol. 58Issue 6PreviewI share the enthusiasm of Morton and Vu1 for global medicine but wish to add a few cautionary notes. American physicians are trained in an environment that is uniquely technologic in focus and resistant to economic limitations. We train and practice, at least in urban areas, with essentially unlimited access to tests, consultants, and specialists. Access to a modern laboratory and radiology suite, the availability of orthopedic and other specialty surgeons, and the ability to triage pregnant patients directly to labor and delivery is certainly good for patients. Full-Text PDF