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Development Of An Interleukin-4-Inducing Principle From Schistosoma Mansoni Eggs (Ipse)-Specific Pcr Assay As A Quantitative Predictor Of Schistosomiasis-Associated Morbidity, Dannah Farah, Evaristis Mbanefo, Michael H. Hsieh

GW Research Days 2016 - 2020

Schistosomiasis is a neglected tropical disease affecting between 200-500 million people worldwide. The two species causing most human cases of schistosomiasis are Schistosoma mansoni and Schistosoma haematobium. The gold standard for diagnosis is parasitological detection of parasite eggs in stool using the Kato-Katz method. Counting eggs shed in stool is labor-intensive and inaccurate. Interleukin-4- inducing principle from Schistosoma mansoni eggs (IPSE) is the most abundant secreted protein from schistosome eggs. We hypothesized that the mRNA transcripts of the IPSE protein may be found in the liver tissue and stool of experimentally infected animals, and that these transcripts can be specifically …

Long-Term Outcomes After Autologous Hematopoietic Stem Cell Transplantation For Multiple Sclerosis., Paolo A Muraro, Marcelo Pasquini, Harold L Atkins, James D Bowen, Dominique Farge, Athanasios Fassas, Mark S Freedman, George E Georges, Francesca Gualandi, Nelson Hamerschlak, Eva Havrdova, Vassilios K Kimiskidis, Tomas Kozak, Giovanni L Mancardi, Luca Massacesi, Daniela A Moraes, Richard A Nash, Steven Pavletic, Jian Ouyang, Montserrat Rovira, Albert Saiz, Belinda Simoes, Marek Trnený, Lin Zhu, Manuela Badoglio, Xiaobo Zhong, Maria Pia Sormani, Riccardo Saccardi

Articles, Abstracts, and Reports

Importance: Autologous hematopoietic stem cell transplantation (AHSCT) may be effective in aggressive forms of multiple sclerosis (MS) that fail to respond to standard therapies.

Objective: To evaluate the long-term outcomes in patients who underwent AHSCT for the treatment of MS in a large multicenter cohort.

Design, Setting, and Participants: Data were obtained in a multicenter, observational, retrospective cohort study. Eligibility criteria were receipt of AHSCT for the treatment of MS between January 1995 and December 2006 and the availability of a prespecified minimum data set comprising the disease subtype at baseline; the Expanded Disability Status Scale (EDSS) score at baseline; …

Gene Expression Profiles Among Murine Strains Segregate With Distinct Differences In The Progression Of Radiation-Induced Lung Disease., Isabel L. Jackson, Fitsum Baye, Chirayu Pankaj Goswami, Barry P. Katz, Andrew Zodda, Radmila Pavlovic, Ganga Gurung, Don Winans, Zeljko Vujaskovic

Jefferson Hospital Staff Papers and Presentations

Molecular mechanisms underlying development of acute pneumonitis and/or late fibrosis following thoracic irradiation remain poorly understood. Here, we hypothesize that heterogeneity in disease progression and phenotypic expression of radiation-induced lung disease (RILD) across murine strains presents an opportunity to better elucidate mechanisms driving tissue response toward pneumonitis and/or fibrosis. Distinct differences in disease progression were observed in age- and sex-matched CBA/J, C57L/J and C57BL/6J mice over 1 year after graded doses of whole-thorax lung irradiation (WTLI). Separately, comparison of gene expression profiles in lung tissue 24 h post-exposure demonstrated >5000 genes to be differentially expressed (P<0.01; >twofold change) between strains …

Ventilator-Associated Pneumonia: New Definitions., M Chance Spalding, Michael W Cripps, Christian T Minshall

Trauma and Acute Care Articles

The National Healthcare Safety Network's new classification characterizes all adverse ventilator-associated events (VAE) into a tiered system designed to shift the focus away from ventilator-associated pneumonia as the only important cause or morbidity in ventilated patients. This new surveillance definition of VAE eliminates subjectivity by using clearly defined criteria and facilitates the automated collection of data. This allows for easier comparison and analysis of factors affecting rates of VAE. Numerous studies have been published that demonstrate its clinical application. This article presents the VAE criteria, contrasts the difference from the previous ventilator-associated pneumonia definition, and discusses its implementation over the …

Zika Virus From A Neonatologist’S Perspective, A Zylak, Sergio Golombek

NYMC Faculty Publications

Zika virus has been known for more than half a century. Its clinical significance was just recently discovered, after the epidemic of Zika virus emerged in South and Central America. A task force established in 2015 by the Brazil Ministry of Health investigated the possible association between congenital Zika infection and microcephaly in fetuses and newborns. Since then more and more evidence emerged, supporting this hypothesis. The objective of this article is to review and summarize the currently available literature regarding Zika virus from a neonatologist’s standpoint and provide some guidance to medical providers who may have to care for …

Autoimmune Hemolytic Anemia Associated With Babesiosis, Roshni Narurkar, Aleksandra Mamorska-Dyga, John Nelson, Delong Liu

NYMC Faculty Publications

BACKGROUND: Babesiosis is endemic in selected areas in North America. Babesia infection is commonly associated with anemia, thrombocytopenia, hyponatremia and elevated liver enzymes. Autoimmune hemolytic anemia (AIHA) is known to be caused by parasitic and viral infections but has not been well characterized. CASE PRESENTATION: We describe two cases diagnosed with babesiosis triggering severe AIHA. One case had history of splenectomy, and the other was an elderly patient. Older, immunocompromised and asplenic patients may be particularly at risk for post-babesiosis AIHA (PB-AIHA). CONCLUSIONS: The pathogenesis for conventional AIHA and PB-AIHA appears to be different, since splenectomy is a treatment for …

Unmet Need For Surgery In South Asia, Sanjay Nagral, Maharra Hussain, Sarder A Nayeem, Ranjan Dias, S. Ather Enam

Department of Surgery Docs

No abstract provided.

Appendicular Mass – A Rare Form Of Tuberculosis, Petrisor Banu, Vlad D. Constantin, Florian Popa, Mircea Bratucu, Teodora Vladescu, Cristian Balalau

Journal of Mind and Medical Sciences

Tuberculosis is in the top 10 causes of death worldwide, being one of the most deadly infectious diseases. It is estimated that one of three people from the entire earth population has a latent infection with M tuberculosis. This aerobic bacterium possesses the ability to persist in host tissues for years and to begin replication once immunity declines.

The lungs are most frequent site of infection as the Mycobacterium tuberculosis is carried by aerosol droplets and is commonly transmitted by respiratory route. The second way of transmission is by contaminated food.

Intestinal contamination coexists with pulmonary tuberculosis and only 10% …

Forensic And Clinical Diagnosis In "Shaken Baby Syndrome", Between Child Abuse And Iatrogenic Abuse, Roxana M. Duncea, Irina Apostol, Relu G. Calota, Vladimir Belis

Journal of Mind and Medical Sciences

“Shaken baby syndrome” in child abuse cases is a challenge for pediatrician and forensic experts, often a diagnosis of exclusion, with overwhelming moral and legal implications. Diagnosis is based on: subdural bleeding, rupture of retinal vessels, traumatic diffuse axonal injury with diffuse brain encephalopathy in the absence of external traumatic injuries and anamnesis data of an accidentally head injury.

Microscopic findings in diffuse axonal injuries were initially considered as a specific traumatic effect due to unrestricted movement and accelerated rotation of the head. Immunohistochemistry of beta amyloid protein precursor is gold standard method for identifying pathological diffuse axonal lesions, which …

Adverse Reactions Of Biological Therapies In Patients With Psoriasis, Maria I. Sârbu, Mircea Tampa, Mădălina I. Mitran, Cristina I. Mitran, Alexandra M. Limbău, Simona R. Georgescu

Journal of Mind and Medical Sciences

Psoriasis is a chronic, immune-mediated disorder characterized by well demarcated, erythematous plaques covered by thick, silvery-white scales, most often located on the knees, elbows, sacral area and scalp. It has a significant impact on the patient's quality of life.

Biological therapies revolutionized the treatment of psoriasis vulgaris but there has been concern regarding the use of those agents due to severe adverse reactions reported in patients receiving TNF-α inhibitors for various inflammatory diseases.

The aim of this paper is to review the most important adverse reactions reported in patients receiving biological treatments. The most common and severe side effects associated …

Approach To Diagnosis And Treatment Of Drug Allergy, Roy Akur Pandapotan, Iris Rengganis

Jurnal Penyakit Dalam Indonesia

Drug allergy is a serious medical problem. Drug allergy can be defined as an adverse drug reaction involving immunological mechanism. However, it is not easy to decide whether an adverse drug reaction is an allergic reaction, and it requires a systematically diagnostic approach. Beside a thorough history taking and physical examination, there are general and specific laboratory examination to investigate drug allergy which can be done in vivo, in vitro, or biopsy. The management of drug allergy include the avoidance of the precipitating event, and specific methods to reduce the drug reaction which include threating through, dosing test, desensitization, and …

Factors Related To 30 Day Mortality In Critically Ill Patients Withinvasive Candidiasis In Cipto Mangunkusumo Hospital, Ardi Ardian, Ceva W. Pitoyo, Dita Adhitianingsih, Widayat Djoko Santoso, Siti Setiati

Jurnal Penyakit Dalam Indonesia

Introduction. Mortality rate of invasive candidiasis is still high, approximately 30-70%. Every study has a variety mortality rate depend on study design and sample. There is no data in Indonesia about profile and mortality factors analysis in critically ill patients with invasive candidiasis. Methods. The Study design was cross sectional. We studied 102 hospitalized critically ill patients with invasive candidiasis. The demographic, clinical and laboratory data, the risk factors for invasive candidiasis and the outcome of each patient in 30 days were recorded. An analysis bivariate with chi square or Fisher’s test was carried out to analyse some factors such …

Maternal Characteristics And Obstetrical Complications Impact Neonatal Outcomes In Indonesia: A Prospective Study., Trisari Anggondowati, Ayman A E El-Mohandes, S Nurul Qomariyah, Michele Kiely, Judith J Ryon, Reginald F Gipson, Benjamin Zinner, Anhari Achadi, Linda L Wright

Medicine Faculty Publications

BACKGROUND: We investigated associations between maternal characteristics, access to care, and obstetrical complications including near miss status on admission or during hospitalization on perinatal outcomes among Indonesian singletons.

METHODS: We prospectively collected data on inborn singletons at two hospitals in East Java. Data included socio-demographics, reproductive, obstetric and neonatal variables. Reduced multivariable models were constructed. Outcomes of interest included low and very low birthweight (LBW/VLBW), asphyxia and death.

RESULTS: Referral from a care facility was associated with a reduced risk of LBW and VLBW [AOR = 0.28, 95% CI = 0.11-0.69, AOR = 0.18, 95% CI = 0.04-0.75, respectively], stillbirth …

Clostridium Septicum Aortitis With Synchronous Ascending Colon And Rectal Adenocarcinoma., Deepanshu Jain, Andrew C. Kistler, Patricia L. Kozuch

Division of Gastroenterology and Hepatology Faculty Papers

Clostridium septicum (C. septicum) aortitis is a rare condition frequently associated with colon adenocarcinoma and carries a poor prognosis. We report the case of a 66-year-old man who presented with abdominal pain, blood in the stool, fever and chills. Laboratory tests were significant for leukocytosis and microcytic anemia. Abdominal imaging revealed a right colon mass and aortitis. Colonoscopy confirmed the right colon mass and also discovered a rectal mass, both adenocarcinomas. Treatment consisted of antibiotics, aortic repair, right hemi-colectomy and later trans-anal excision of the rectal mass. Blood cultures and the aortic specimen grew C. septicum. The patient improved and …

Broadly Neutralizing Antibodies As Treatment: Effects On Virus And Immune System., Jinal N Bhiman, Rebecca M Lynch

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Purpose of Review

The purpose of this study is to summarize recent advances in the use of broadly neutralizing antibodies (bNAbs) as therapeutics in human clinical trials and in non-human primate (NHP) models. We seek to highlight lessons from these studies with an emphasis on consequences to the virus and immune system.

Recent Findings

In the past 10 years, advances in HIV-1 trimer structure and B cell isolation methods have precipitated the identification of “new-generation” anti-HIV antibodies with broad and potent neutralization. In the past 2 years, the concept of using these bNAbs as therapeutic tools has moved from NHP …

A New Class Of Inhibitors Of The Arac Family Virulence Regulator Vibrio Cholerae Toxt, Anne K. Woodbrey, Evans O. Onyango, Maria Pellegrini, Gabriela Kovacikova, Ronald Taylor, Gordon Gribble, F. Jon Kull

Dartmouth Scholarship

Vibrio cholerae is responsible for the diarrheal disease cholera that infects millions of people worldwide. While vaccines protecting against cholera exist, and oral rehydration therapy is an effective treatment method, the disease will remain a global health threat until long-term solutions such as improved sanitation and access to clean water become widely available. Because of this, there is a pressing need for potent therapeutics that can either mitigate cholera symptoms, or act prophylactically to prevent the virulent effects of a cholera infection. Here we report the design, synthesis, and characterization of a set of compounds that bind and inhibit ToxT, …

Functional Studies Of Ccaat/Enhancer Binding Protein Site Located Downstream Of The Transcriptional Start Site., Yujie Liu, Michael R. Nonnemacher, Aikaterini Alexaki, Vanessa Pirrone, Anupam Banerjee, Luna Li, Evelyn Kilareski, Brian Wigdahl

Kimmel Cancer Center Papers, Presentations, and Grand Rounds

Previous studies have identified a CCAAT/enhancer binding protein (C/EBP) site located downstream of the transcriptional start site (DS3). The role of the DS3 element with respect to HIV-1 transactivation by Tat and viral replication has not been characterized. We have demonstrated that DS3 was a functional C/EBPβ binding site and mutation of this site to the C/EBP knockout DS3-9C variant showed lower HIV-1 long terminal repeat (LTR) transactivation by C/EBPβ. However, it was able to exhibit similar or even higher transcription levels by Tat compared to the parental LTR. C/EBPβ and Tat together further enhanced the transcription level of the …

Outcomes In Necrotizing Enterocolitis (Nec) Treated With Granulocyte Colony Stimulating Factor (Gcsf) And Intravenous Immunoglobulin (Ivig) Vs Standard Of Care Alone: Rct Interim Safety Analysis, Sanjeet Panda, Courtney Briggs-Steinberg, Brian Debenedictis, Sri Narayana, Edmund F. La Gamma

NYMC Faculty Posters

No abstract provided.

Coccolithoviruses: A Review Of Cross-Kingdom Genomic Thievery And Metabolic Thuggery, Jozef I. Nissimov, António Pagarete, Fangrui Ma, Sean Cody, David D. Dunigan, Susan A. Kimmance, Michael J. Allen

Nebraska Center for Virology: Faculty Publications

Coccolithoviruses (Phycodnaviridae) infect and lyse the most ubiquitous and successful coccolithophorid in modern oceans, Emiliania huxleyi. So far, the genomes of 13 of these giant lytic viruses (i.e., Emiliania huxleyi viruses—EhVs) have been sequenced, assembled, and annotated. Here, we performed an in-depth comparison of their genomes to try and contextualize the ecological and evolutionary traits of these viruses. The genomes of these EhVs have from 444 to 548 coding sequences (CDSs). Presence/absence analysis of CDSs identified putative genes with particular ecological significance, namely sialidase, phosphate permease, and sphingolipid biosynthesis. The viruses clustered into distinct clades, based on their DNA polymerase …

Dynamic Transcriptomes Identify Biogenic Amines And Insect-Like Hormonal Regulation For Mediating Reproduction In Schistosoma Japonicum., Jipeng Wang, Ying Yu, Haimo Shen, Tao Qing, Yuanting Zheng, Qing Li, Xiaojin Mo, Shuqi Wang, Nana Li, Riyi Chai, Bin Xu, Mu Liu, Paul J Brindley, Donald P Mcmanus, Zheng Feng, Leming Shi, Wei Hu

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Eggs produced by the mature female parasite are responsible for the pathogenesis and transmission of schistosomiasis. Female schistosomes rely on a unique male-induced strategy to accomplish reproductive development, a process that is incompletely understood. Here we map detailed transcriptomic profiles of male and female Schistosoma japonicum across eight time points throughout the sexual developmental process from pairing to maturation. The dynamic gene expression pattern data reveal clear sex-related characteristics, indicative of an unambiguous functional division between males and females during their interplay. Cluster analysis, in situ hybridization and RNAi assays indicate that males likely use biogenic amine neurotransmitters through the …

Spotlight On Blisibimod And Its Potential In The Treatment Of Systemic Lupus Erythematosus: Evidence To Date, Aleksander Lenert, Timothy B. Niewold, Petar Lenert

Internal Medicine Faculty Publications

B cells in general and BAFF (B cell activating factor of the tumor necrosis factor [TNF] family) in particular have been primary targets of recent clinical trials in systemic lupus erythematosus (SLE). In 2011, belimumab, a monoclonal antibody against BAFF, became the first biologic agent approved for the treatment of SLE. Follow-up studies have shown excellent long-term safety and tolerability of belimumab. In this review, we critically analyze blisibimod, a novel BAFF-neutralizing agent. In contrast to belimumab that only blocks soluble BAFF trimer but not soluble 60-mer or membrane BAFF, blisibimod blocks with high affinity all three forms of BAFF. …

Pulmonary Surfactant Fortified With Cath-2 As A Novel Therapy For Bacterial Pneumonia, Brandon J. Baer

Western Research Forum

Background: Bacterial pneumonia is a leading cause of death worldwide, with high mortality rates persisting even after antibiotic treatment. Current treatments for pneumonia involve administration of antibiotics, however after the bacteria are killed they release toxic substances that induce inflammation and lung dysfunction. Host defense peptides represent a potential solution to this problem through their ability to down regulate inflammation. However, effective delivery to the lung is difficult because of the complex branching structure of the airways. My study addresses this delivery problem by using exogenous surfactant, a pulmonary delivery vehicle capable of improving spreading of these peptides throughout the …

Camp Signaling Enhances Hiv-1 Long Terminal Repeat (Ltr)-Directed Transcription And Viral Replication In Bone Marrow Progenitor Cells., Anupam Banerjee, Luna Li, Vanessa Pirrone, Fred C. Krebs, Brian Wigdahl, Michael R. Nonnemacher

Kimmel Cancer Center Papers, Presentations, and Grand Rounds

CD34⁺ hematopoietic progenitor cells have been shown to be susceptible to HIV-1 infection, possibly due to a low-level expression of CXCR4, a coreceptor for HIV-1 entry. Given these observations, we have explored the impact of forskolin on cell surface expression of CXCR4 in a cell line model (TF-1). The elevation of intracellular cyclic adenosine monophosphate (cAMP) by forskolin through adenylyl cyclase (AC) resulted in transcriptional upregulation of CXCR4 with a concomitant increase in replication of the CXCR4-utilizing HIV-1 strain IIIB. Transient expression analyses also demonstrated an increase in CXCR4-, CCR5-, and CXCR4-/CCR5-utilizing HIV-1 (LAI, YU2, and 89.6, respectively) promoter …

Impact Of A National Guideline On Antibiotic Selection For Hospitalized Pneumonia., Derek J Williams, Matthew Hall, Jeffrey S Gerber, Mark I Neuman, Adam L Hersh, Thomas V Brogan, Kavita Parikh, Sanjay Mahant, Anne J Blaschke, Samir S Shah, Carlos G Grijalva

Pediatrics Faculty Publications

BACKGROUND: We evaluated the impact of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline and hospital-level implementation efforts on antibiotic prescribing for children hospitalized with pneumonia.

METHODS: We assessed inpatient antibiotic prescribing for pneumonia at 28 children's hospitals between August 2009 and March 2015. Each hospital was also surveyed regarding local implementation efforts targeting antibiotic prescribing and organizational readiness to adopt guideline recommendations. To estimate guideline impact, we used segmented linear regression to compare the proportion of children receiving penicillins in March 2015 with the expected proportion at this same time point had the guideline not …

A Murine Model To Study Epilepsy And Sudep Induced By Malaria Infection., Paddy Ssentongo, Anna E Robuccio, Godfrey Thuku, Derek G Sim, Ali Nabi, Fatemeh Bahari, Balaji Shanmugasundaram, Myles W Billard, Andrew Geronimo, Kurt W Short, Patrick J Drew, Jennifer Baccon, Steven L Weinstein, Frank G Gilliam, José A Stoute, Vernon M Chinchilli, Andrew F Read, Bruce J Gluckman, Steven J Schiff

Neurology Faculty Publications

One of the largest single sources of epilepsy in the world is produced as a neurological sequela in survivors of cerebral malaria. Nevertheless, the pathophysiological mechanisms of such epileptogenesis remain unknown and no adjunctive therapy during cerebral malaria has been shown to reduce the rate of subsequent epilepsy. There is no existing animal model of postmalarial epilepsy. In this technical report we demonstrate the first such animal models. These models were created from multiple mouse and parasite strain combinations, so that the epilepsy observed retained universality with respect to genetic background. We also discovered spontaneous sudden unexpected death in epilepsy …

Arrhythmias In Hospitalized Heart Transplanted Patients: A United States National Study, Srikanth Yandrapalli, Prakash Harikrishnan, Zeeshan Solangi, Wilbert S. Aronow, Sachin Sule, Alan L. Gass, Chhaya Aggarwal, William H. Frishman, Sei Iwai, Howard A. Cooper, Julio A. Panza, Gregg M. Lanier

NYMC Faculty Posters

No abstract provided.

The Role Of Estradiol Metabolism In Urogenital Schistosomiasis-Induced Bladder Cancer, Nuno Vale, Maria Gouveia, Gabriel Rinaldi, Julio Santos, Lucio Lara Santos, Paul J. Brindley, Jose Correia Da Costa

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Urogenital schistosomiasis is a neglected tropical disease that can lead to bladder cancer. How urogenital schistosomiasis induces carcinogenesis remains unclear, although there is evidence that the human blood fluke Schistosoma haematobium, the infectious agent of urogenital schistosomiasis, releases estradiol-like metabolites. These kind of compounds have been implicated in other cancers. Aiming for enhanced understanding of the pathogenesis of the urogenital schistosomiasisinduced bladder cancer, here we review, interpret, and discuss findings of estradiol-like metabolites detected in both the parasite and in the human urine during urogenital schistosomiasis. Moreover, we predict pathways and enzymes that are involved in the production of these …

Assessing Decision Of Inpatient Or Outpatient Care In Community Acquired Pneumonia: Apt Care Study, Saleem Ullah, Javaid Khan, Amanullah Khan, Irfan Hashemy

Section of Pulmonary & Critical Care

Objective: To estimate the proportion of community-acquired pneumonia patients with disagreement between Confusion, Uraemia, Respiratory rate, Blood pressure, age > 65 years recommendation and physician\\\'s decision to hospitalise or not.
Methods: This cross-sectional nation-wide, non-interventional, cross-sectional study was carried out across 10 cities of Pakistan from December 2011 to May 2012, and recruited consenting adult patients with confirmatory diagnosis of community-acquired pneumonia on chest X-ray. Confusion, Uraemia, Respiratory rate, Blood pressure, age > 65 years recommendation for each patient was determined at the time of analysis. This recommendation was compared with treatment decision made by the physician. Disagreement was considered when the …

Labrad : Vol 43, Issue 1 - March 2017, Aga Khan University Hospital, Karachi

LABRAD - Departments of Pathology & Laboratory Medicine and Radiology Archives

• Chikungunya
• Rapid Molecular Diagnosis of Chlamydia Trachomatis (CT) and Neisseria Gonorrhoeae (NG) Urethritis
• Overview of Rubella Testing
• Most Common Bone and Soft Tissue Infections Seen in our Practice
• Diagnosis of Helicobacter Pylori Infection in Developing Countries- Pros & Cons
• Screening for Neonatal Infections with TORCH Profile
• Blood and Bone Marrow Changes in Viral Infections
• Malaria
• World Rare Disease Day
• Radiology Pathology Correlation

Determinants Of Neonatal Mortality In Rural And Urban Nigeria: Evidence From A Population-Based National Survey, Emmanuel O. Adewuyi, Yun Zhao

Research outputs 2014 to 2021

Background: Significant reduction in the global burden of neonatal mortality was achieved through the millennium development goals. In Nigeria, however, only a marginal reduction was realized. This study assesses the rural–urban differences in neonatal mortality rate (NMR) and the associated risk factors in Nigeria.

Methods: The dataset from the 2013 Nigeria demographic and health survey (NDHS), disaggregated by rural–urban residence (n = 20 449 and 9935, respectively), was explored using univariate, bivariate, and multivariable analysis. Complex samples analysis was applied to adjust for the unequal selection probabilities due to the multi-stage cluster sampling method used in the 2013 NDHS. The …