Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites

INTRODUCTION

Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes.

METHODS

The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars.

RESULTS

Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted.

CONCLUSION

MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

Antioxidant and UV-blocking activity of PVA/tannin-based bioplastics in food packaging application

In this study, bioplastics with antioxidant and UV protection properties based on tannin and PVA were created for packaging uses. Using a hot water extraction method at various extraction temperatures (60-100 °C), tannins were removed from the bark of Acacia mangium. Tannins with the best antioxidant activity were extracted at 80 °C. In order to create bioplastic formulations (PVA/Tannins), the extract is then employed. The non-heating bioplastic method's preparation (M3) stage produced the highest levels of antioxidant activity. Therefore, subsequent tests were conducted using the non-heating method (M3). On the opacity, UV protective activity, antioxidant capacity, mechanical strength, thermal stability, and water vapor permeability of the resultant bioplastics, the impact of tannin concentration (0.1-0.5 g) was examined. The findings of the experiments demonstrate that PVA/Tannin bioplastics are less transparent than pure PVA. The PVA/tannin bioplastics that are formed, on the whole, show strong antioxidant and UV protection action. Comparing PVA/Tannin bioplastics to pure PVA also revealed a small improvement in thermal stability and tensile strength. In PVA bioplastics with resistant tannins, moisture content was marginally greater even at low tannin concentrations (0.1 g). Based on the findings, bioplastics made from PVA and the tannin A. mangium have the potential to be used to create packaging that is UV and active antioxidant resistant. It can be applied as the second (inner) layer of the primary packaging to protect food freshness and nutrition due to their antioxidant activity.

Exploring Pseudomonas syringae pv. tomato biofilm-like aggregate formation in susceptible and PTI-responding Arabidopsis thaliana

Bacterial biofilm-like aggregates have been observed in plants, but their role in pathogenicity is underinvestigated. In the present study, we observed that extracellular DNA and polysaccharides colocalized with green fluorescent protein (GFP)-expressing Pseudomonas syringae pv. tomato (Pst) aggregates in Arabidopsis leaves, suggesting that Pst aggregates are biofilms. GFP-expressing Pst, Pst ΔalgU ΔmucAB (Pst algU mutant), and Pst ΔalgD ΔalgU ΔmucAB (Pst algU algD mutant) were examined to explore the roles of (1) alginate, a potential biofilm component; (2) Pst AlgU, thought to regulate alginate biosynthesis and some type III secretion system effector genes; and (3) intercellular salicylic acid (SA) accumulation during pathogen-associated molecular pattern-triggered immunity (PTI). Pst formed extensive aggregates in susceptible plants, whereas aggregate numbers and size were reduced in Pst algU and Pst algD algU mutants, and both multiplied poorly in planta, suggesting that aggregate formation contributes to Pst success in planta. However, in SA-deficient sid2-2 plants, Pst algD algU mutant multiplication and aggregate formation were partially restored, suggesting plant-produced SA contributes to suppression of Pst aggregate formation. Pst algD algU mutants formed fewer and smaller aggregates than Pst algU mutants, suggesting both AlgU and AlgD contribute to Pst aggregate formation. Col-0 plants accumulated low levels of SA in response to Pst and both mutants (Pst algU and Pst algD algU), suggesting the regulatory functions of AlgU are not involved in suppressing SA-mediated plant defence. Plant PTI was associated with highly reduced Pst aggregate formation and accumulation of intercellular SA in flg22-induced PTI-responding wild-type Col-0, but not in PTI-incompetent fls2, suggesting intercellular SA accumulation by Arabidopsis contributes to suppression of Pst biofilm-like aggregate formation during PTI.

Performance of modified hollow fiber membrane silver nanoparticles-zeolites Na-Y/PVDF composite used in membrane bioreactor for industrial wastewater treatment

Membrane bioreactor (MBR) deteriorates due to fouling on the membrane pores, which can reduce the membrane performance. To reduce membrane fouling, the addition of inorganic filler can enhance the antifouling properties. This study investigates two different membrane preparation by thermally induced phase separation (TIPS) and dip coating methods to modify hollow fiber membrane with Silver Nanoparticles (AgNPs)-Zeolites used in MBR for industrial wastewater treatment. Performance was evaluated by analyzing the flux of water and wastewater, rejection, water content, and antifouling properties. Characterization result represented the synthesized silver nanoparticles had similar diffraction peak with commercial AgNPs, then the micrograph of AgNPs and zeolites addition membrane showed that the inorganic material had an octahedral shape representing zeolite crystal and irregular shape representing AgNPs. The addition of zeolites and AgNPs resulted in satisfying performance, increased flux, rejection, and antifouling properties.

Midwife-led birthing centres in four countries: a case study

BACKGROUND

Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC.

METHODS

A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff.

RESULTS

Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels.

CONCLUSION

The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

Advances and key considerations of liquid chromatography–mass spectrometry for porcine authentication in halal analysis

The halal food industries are rapidly expanding to fulfill global halal demands. Non-halal substances such as porcine proteins are often added intentionally or unintentionally to products. The development of highly selective and sensitive analytical tools is necessary, and liquid chromatography–mass spectrometry is a powerful tool that can cope with the challenge. The LC–MS method has great potential for halal authentication, because it has high sensitivity and low detection limit and detects several species markers and different tissue origins at once within one species. This article provides an understanding of recent advances in the application of LC–MS for the improvement of porcine authentication. Sample preparation, marker selection, separation and mass spectrometry conditions, quantitative assessment, and data processing for protein identification were all covered in detail to choose the most suitable method for the analytical needs.

Assessment of the Performance of selected Special Care Newborn Units (SCANUs) in Bangladesh.. [DOI: 10.21203/rs.3.rs-1595564/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: Government of Bangladesh initiated the Special Care Newborn Units (SCANU) in 2011 at selected district hospitals followed by its scale up in other districts with support from UNICEF and other partners. The objective of the study was to assess the performance of those SCANUs in Bangladesh.Methods: A cross-sectional study approach was applied for assessment of the performance of SCANU facilities compared to facilities without SCANU. Fifteen facilities with SCANUs and 5 facilities without SCANUs were selected from eight divisions of the country for the study. The selected SCANU and Non-SCANU facilities were of secondary level hospital with similar patient flow and workload. Quantitative data were collected from direct observation of the 20 facilities and interviews with 678 caregivers using a field-tested questionnaire. Caregivers were mothers of the infants (≤ 59 days old) who were admitted and stayed for at least one day in those hospitals. Analysis was done using Stata version 15.1 and presented in tabular, graphical and numerical measures of central tendency and dispersion.Result: The results of the assessment found that 60% of SCANU facilities had KMC care services and 27% of SCANU facilities had rooming in services and special sick baby ward services but no such services was available in non-SCANU facilities. Equipment in the SCANUs such as resuscitation bag and mask, radiant warmers, phototherapy machines and to a large extent CPAP machines and Oxygen blenders were mostly available and functioning optimally. More than half of the SCANUs still need to have oxygen blenders, CPAP machines and transcutaneous bilirubinometers since they were not found/functional during the assessment. Majority of SCANU facilities 60%-80% reported no stock-outs of critical medications like dexamethasone, ceftriaxone and gentamicin which are critical for management of preterm and sick babies. A web-based online ‘Individual Case Tracking’ system has been developed for online reporting from all SCANUs by the Health Management Information System (HMIS) of the DGHS. UNICEF is supporting its linkage to the district health information system (DHIS-2). There was a statistically significant difference between SCANUs and non-SCANUs with respect to the proportions of admissions. SCANUs are acting as referral destination for sick and small newborns as 41%-45% of the admitted newborns were either were born at home or in other facilities.Conclusions: The assessment findings will be helpful for country strategy for improving newborn care through expansion of SCANU expansion throughout the country.Trial registration: Not applicable in this study

Systematic Review on Loxapine: A Typical Antipsychotic Drug Used to Treat Agitation in Schizophrenic Patients

Loxapine is an antipsychotic drug used in neuroleptic disorders since 1980 with an entrenched drug profile. Drug possesses dibenzoxazepine tricyclic 7-membered heterocyclic ring available commercially as oral, intramuscular and inhalation dosage forms. This review comprises the various study designs of loxapine irrespective of its dose formulations. A comprehensive and systematic search was conducted on “Scopus”, “Web of science” and “Pub-med” data base and findings were critically analyzed. The data suggests that there is no significant difference in efficacy between typical and atypical antipsychotics.  Till now, oral and intramuscular route is widely in use. Oral dosage forms are available in the market for the treatment of agitation related to schizophrenia but it has limitation of delayed onset of action that results in increased risk. Intramuscular formulations reveal a significant difference compared to placebo with respect to agitation but time range could be in range of 15 to 60 minutes. Therefore, there is a need for a novel drug delivery system with rapid action, increased half life, better tolerance by the patient and sustained release to get enhanced patient compliance.

Perceptions and practices on newborn care and managing complications at rural communities in Bangladesh: a qualitative study

Background

Community misperception on newborn care and poor treatment of sick newborn attributes to neonatal death and illness severity. Misperceptions and malpractices regarding neonatal care and neonatal complications are the leading causes of neonatal deaths in Bangladesh. The study was conducted to explore neonatal care’s perceptions and practices and manage complications among Bangladesh’s rural communities.

Methods

A qualitative study was conducted in Netrakona district of Bangladesh from April to June 2015. Three sub-districts (Upazilas) including Purbadhala, Durgapur and Atpara of Netrakona district were selected purposively. Five focus group discussions (FGDs) and twenty in-depth interviews (IDIs) were conducted in the rural community. Themes were identified through reading and re-reading the qualitative data and thematic analysis was performed.

Results

Community people were far behind, regarding the knowledge of neonatal complications. Most of them felt that the complications occurred due to lack of care by the parents. Some believed that mothers did not follow the religious customs after delivery, which affected the newborns. Many of them followed the practice of bathing the newborns and cutting their hair immediately after birth. The community still preferred to receive traditional treatment from their community, usually from Kabiraj (traditional healer), village doctor, or traditional birth attendant. Families also refrained from seeking treatment from the health facilities during neonatal complications. Instead, they preferred to wait until the traditional healers or village doctors recommended transferring the newborn.

Conclusions

Poor knowledge, beliefs and practices are the key barriers to ensure the quality of care for the newborns during complications. The communities still depend on traditional practices and the level of demand for facility care is low. Appropriate interventions focusing on these issues might improve the overall neonatal mortality in Bangladesh.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02633-z.

Dakwah Advokasi Sosial dalam Al-Quran: Perspektif Hermeneutika Jeorge J.E. Gracia

This article discusses the verses of the Koran that explain the principles of da'wah social advocacy by using using hermeneutic approach of JE Jorge Gracia. This research has found that da'wah for social advocacy is an important part of Islamic teachings. The principles and scope of Islamic social advocacy are summarized in the spirit of Maqashid Shariah (the science of ushul fiqh), namely the defense of the basic rights of society in the framework of safeguarding religion, thought, soul, descent and property. In addition, this study also has found that da'wah acitivist for social advocacy purposes are required to have sensitivity and concern regarding the efforts to solve social problems as part of fulfilling people's basic rights. Therefore, the integrity and capability of Islamic preachers who are engaged in the field of social advocacy is required.

Gestational Diabetes: Exploring the Perceptions, Practices and Barriers of the Community and Healthcare Providers in Rural Bangladesh: A Qualitative Study

BACKGROUND AND OBJECTIVE

Gestational Diabetes Mellitus (GDM) is a prevalent and important disease during pregnancy and has detrimental effects on both the mother and the baby. The current study explored the perception and attitude of the community people about GDM and describes the challenges and gaps in knowledge, availability and accessibility of services for GDM screening and management at a rural community in Bangladesh.

METHODS

We performed a qualitative study including seven Focus Group Discussions (FGDs) and eight Key Informant Interviews (KIIs) from November 2017 to January 2018 at randomly selected areas of Tangail district. A highly trained team including two anthropologists conducted the qualitative studies (FGDs and KIIs) under the guidance of experienced researchers. Thematic analysis was performed.

RESULTS

GDM is not a known term for pregnant women, their husbands, mothers, and mothers-in-law. Most of the participants (78.7%) did not even hear the term. Some of them (25.5%) perceived that GDM will persist for whole life and transmit from husband to wife and mother to baby. Some people (21.3%) thought that GDM entirely depends on the wish of the God. Most of the participants (68.1%) perceived that symptoms of other types of diabetes and GDM are almost the same. Some participants (19.1%) thought that GDM patients need to intake some medicines that might affect the fetus. The majority of the respondents (83%) had no idea when a pregnant woman should test her diabetes during pregnancy. If GDM diagnosed, pregnant women decided to follow the advice of the doctors. The results from KII with health managers found that they lack in-depth knowledge of GDM. There is no structured guideline or protocol at their facilities for GDM management.

CONCLUSION

The existing barriers at the communities for adequate detection and management of GDM are identified properly. The findings of this study will be helpful for the decision-makers in taking necessary actions to control the GDM.

Situation of Obstetric Fistula in a Marginalized Teagarden Community of Bangladesh: A Qualitative Study

Aims: This study aims to explore why and how difficult it is for obstetric fistula patients living in the underprivileged teagardens community of Bangladesh. Methods: It was a qualitative study conducted in 10 teagardens with approximately fifty thousand population. Five case studies followed by five Focus Group Discussions (FDG) were conducted in places where obstetric fistulas were identified. Results: The mean age of the women was 41 years and the mean duration of suffering was 19 years. All of them got married before the age of 15 and became pregnant in the following year. One woman was divorced, two were separated and two were living with their husband. Only one of them received treatment from a tertiary center but did not continue due to economic constraints; rest of them were never exposed to any treatment or care. They believed that it would be recovered over time. All of them were neglected in their society and were deprived from all social and religious activities in the community. FGDs findings represent that poverty, lack of knowledge and perception are the significant barriers. Conclusions: Underprivileged communities in the teagardens in Bangladesh are far behind in terms of access to quality health care services. Obstetric fistula is particularly still being under reported and undermined and focused intervention is required to eliminate fistula among them.

Social autopsy for maternal and perinatal deaths in Bangladesh: a tool for community dialog and decision making

Bangladesh has an established comprehensive death review system for tracking and reviewing maternal and perinatal deaths. This death review system, established in 2010, was initially known as the “Maternal and Perinatal Death Review (MPDR) System.” One of the key interventions of the MPDR system, social autopsy (SA), is generally undertaken following a maternal or perinatal death notification. Social autopsy is managed at the community level by government field health workers. The main purpose of SA is to enable community discussion and create awareness of the preventable causes of maternal or neonatal deaths. Through these conversations, it is hoped to reduce future maternal and neonatal deaths. During the scaling up of the system in Bangladesh in 2016, the Ministry of Health and Family Welfare (MoH&FW) included social autopsy as a useful intervention in reviewing death at the community level and named it “Maternal and Perinatal Death Surveillance and Response” (MPDSR). The new MPDSR tool is currently being administered for the the 2017 to 2021 period under the National Health and Nutrition Population Sector Program (HPNSP). This paper seeks to review the experiences of the social autopsy tool, from the initial MPDR system to the current MPDSR system and its role in reducing maternal and neonatal deaths in Bangladesh.

Stillbirth surveillance and review in rural districts in Bangladesh

BACKGROUND

An estimated 2.6 million stillbirths occur every year, with the majority occurring in low- and middle-income countries. Understanding the cause of and factors associated with stillbirth is important to help inform the design and implementation of interventions aimed at reducing preventable stillbirths.

METHODS

Population-based surveillance with identification of all stillbirths that occurred either at home or in a health facility was introduced in four districts in Bangladesh. Verbal autopsy was conducted for every fifth stillbirth using a structured questionnaire. A hierarchical model was used to assign likely cause of stillbirth.

RESULTS

Six thousand three hundred thirty-three stillbirths were identified for which 1327 verbal autopsies were conducted. 63.9% were intrapartum stillbirths. The population-based stillbirth rate obtained was 20.4 per 1000 births; 53.9% of all stillbirths occurred at home. 69.6% of mothers had accessed health care in the period leading up to the stillbirth. 48.1% had received care from a highly trained healthcare provider. The three most frequent causes of stillbirth were maternal hypertension or eclampsia (15.2%), antepartum haemorrhage (13.7%) and maternal infections (8.9%). Up to 11.3% of intrapartum stillbirths were caused by hypoxia. However, it was not possible to identify a cause of death with reasonable certainty using information obtained via verbal autopsy in 51.9% of stillbirths.

CONCLUSIONS

Introducing surveillance for stillbirths at community level is possible. However, verbal autopsy yields limited data, and the questionnaire used for this needs to be revised and/or combined with information obtained through case note review. Most women accessed and received care from a qualified healthcare provider. To reduce the number of preventable stillbirths, the quality of antenatal and intrapartum care needs to be improved.

Timely referral saves the lives of mothers and newborns: Midwifery led continuum of care in marginalized teagarden communities - A qualitative case study in Bangladesh

Background: Prompt and efficient identification, referral of pregnancy related complications and emergencies are key factors to the reduction of maternal and newborn morbidity and mortality. As a response to this critical need, a midwifery led continuum of reproductive health care was introduced in five teagardens in the Sylhet division, Bangladesh during 2016. Within this intervention, professional midwives provided reproductive healthcare to pregnant teagarden women in the community.  This study evaluates the effect of the referral of pregnancy related complications. Methods: A qualitative case study design by reviewing records retrospectively was used to explore the effect of deploying midwives on referrals of pregnancy related complications from the selected teagardens to the referral health facilities in Moulvibazar district of the Sylhet division during 2016.  In depth analyses was also performed on 15 randomly selected cases to understand the facts behind the referral. Results: Out of a total population of 450 pregnant women identified by the midwives, 72 complicated mothers were referred from the five teagardens to the facilities. 76.4% of mothers were referred to conduct delivery at facilities, and 31.1% of them were referred with the complication of prolonged labour. Other major complications were pre-eclampsia (17.8%), retention of the placenta with post-partum hemorrhage (11.1%) and premature rupture of the membrane (8.9%). About 60% of complicated mothers were referred to the primary health care centre, and among them 14% of mothers were delivered by caesarean section. 94% deliveries resulted in livebirths and only 6% were stillbirths. Conclusions: This study reveals that early detection of pregnancy complications by skilled professionals and timely referral to a facility is beneficial in saving the majority of baby's as well as mother's lives in resource-poor teagardens with a considerable access barrier to health facilities.

Comparative genomics of two jute species and insight into fibre biogenesis

Jute (Corchorus sp.) is one of the most important sources of natural fibre, covering ∼80% of global bast fibre production¹. Only Corchorus olitorius and Corchorus capsularis are commercially cultivated, though there are more than 100 Corchorus species² in the Malvaceae family. Here we describe high-quality draft genomes of these two species and their comparisons at the functional genomics level to support tailor-designed breeding. The assemblies cover 91.6% and 82.2% of the estimated genome sizes for C. olitorius and C. capsularis, respectively. In total, 37,031 C. olitorius and 30,096 C. capsularis genes are identified, and most of the genes are validated by cDNA and RNA-seq data. Analyses of clustered gene families and gene collinearity show that jute underwent shared whole-genome duplication ∼18.66 million years (Myr) ago prior to speciation. RNA expression analysis from isolated fibre cells reveals the key regulatory and structural genes involved in fibre formation. This work expands our understanding of the molecular basis of fibre formation laying the foundation for the genetic improvement of jute.

The Economic Cost of Implementing Maternal and Neonatal Death Review in a District of Bangladesh

Introduction

Maternal and neonatal death review (MNDR) introduced in Bangladesh and initially piloted in a district during 2010. MNDR is able to capture each of the maternal, neonatal deaths and stillbirths from the community and government facilities (hospitals). This study aimed to estimate the cost required to implement MNDR in a district of Bangladesh during 2010-2012.

Materials and methods

MNDR was implemented in Thakurgaon district in 2010 and later gradually extended until 2015. MNDR implementation framework, guidelines, tools and manual were developed at the national level with national level stakeholders including government health and family planning staff at different cadre for piloting at Thakurgaon. Programme implementation costs were calculated by year of costing and costing as per component of MNDR in 2013. The purchasing power parity conversion rate was 1 $INT = 24.46 BDT, as of 31^st Dec 2012.

Results

Overall programme implementation costs required to run MNDR were 109,02,754 BDT (445,738 $INT $INT) in the first year (2010). In the following years cost reduced to 8,208,995 BDT (335,609 $INT, during 2011) and 6,622,166 BDT (270,735 $INT, during 2012). The average cost per activity required was 3070 BDT in 2010, 1887 BDT and 2207 BDT required in 2011 and 2012 respectively. Each death notification cost 4.09 $INT, verbal autopsy cost 8.18 $INT, and social autopsy cost 16.35 $INT. Facility death notification cost 2.04 $INT and facility death review meetings cost 20.44 $INT. One death saved by MNDR costs 53,654 BDT (2193 $INT).

Conclusions

Programmatic implementation cost of conducting MPDR give an idea on how much cost will be required to run a death review system for a low income country settings using government health system.

Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance

OBJECTIVES

Social Autopsy (SA) is an innovative strategy where a trained facilitator leads community groups through a structured, standardised analysis of the physical, environmental, cultural and social factors contributing to a serious, non-fatal health event or death. The discussion stimulated by the formal process of SA determines the causes and suggests preventative measures that are appropriate and achievable in the community. Here we explored individual experiences of SA, including acceptance and participant learning, and its effect on rural communities in Bangladesh. The present study had explored the experiences gained while undertaking SA of maternal and neonatal deaths and stillbirths in rural Bangladesh.

DESIGN

Qualitative assessment of documents, observations, focus group discussions, group discussions and in-depth interviews by content and thematic analyses.

RESULTS

Each community's maternal and neonatal death was a unique, sad story. SA undertaken by government field-level health workers were well accepted by rural communities. SA had the capability to explore the social reasons behind the medical cause of the death without apportioning blame to any individual or group. SA was a useful instrument to raise awareness and encourage community responses to errors within the society that contributed to the death. People participating in SA showed commitment to future preventative measures and devised their own solutions for the future prevention of maternal and neonatal deaths.

CONCLUSIONS

SA highlights societal errors and promotes discussion around maternal or newborn death. SA is an effective means to deliver important preventative messages and to sensitise the community to death issues. Importantly, the community itself is enabled to devise future strategies to avert future maternal and neonatal deaths in Bangladesh.

When, Where, and Why Are Babies Dying? Neonatal Death Surveillance and Review in Bangladesh

BACKGROUND

Better data on cause of, and factors contributing to, neonatal deaths are needed to improve interventions aimed at reducing neonatal mortality in low- and middle-income countries.

METHODS

Community surveillance to identify all neonatal deaths across four districts in Bangladesh. Verbal autopsy for every fifth case and InterVA-4 used to assign likely cause of death.

FINDINGS

6748 neonatal deaths identified, giving a neonatal mortality rate of 24.4 per 1000 live births. Of these, 51.3% occurred in the community and 48.7% at or on the way to a health facility. Almost half (46.1%) occurred within 24 hours of birth with 83.6% of all deaths occurring in the first seven days of life. Birth asphyxia was the leading cause of death (43%), followed by infections (29.3%), and prematurity (22.2%). In 68.3% of cases, care had been provided at a health facility before death occurred. Care-seeking was significantly higher among mothers who were educated (RR 1.18, 95% CI: 1.04-1.35) or who delivered at a health facility (RR 1.48, 95% CI 1.37-1.60) and lower among mothers who had 2-4 previous births (RR 0.89, 95% CI 0.82-0.96), for baby girls (RR 0.87, 95% CI 0.80-0.93), and for low birth weight babies (RR 0.89, 95% CI 0.82-0.96).

INTERPRETATION

Most parents of neonates who died had accessed and received care from a qualified healthcare provider. To further reduce neonatal mortality, it is important that the quality of care provided, particularly skilled birth attendance, emergency obstetric care, and neonatal care during the first month of life is improved, such that it is timely, safe, and effective.

Facility Death Review of Maternal and Neonatal Deaths in Bangladesh

Objectives

To explore the experiences, acceptance, and effects of conducting facility death review (FDR) of maternal and neonatal deaths and stillbirths at or below the district level in Bangladesh.

Methods

This was a qualitative study with healthcare providers involved in FDRs. Two districts were studied: Thakurgaon district (a pilot district) and Jamalpur district (randomly selected from three follow-on study districts). Data were collected between January and November 2011. Data were collected from focus group discussions, in-depth interviews, and document review. Hospital administrators, obstetrics and gynecology consultants, and pediatric consultants and nurses employed in the same departments of the respective facilities participated in the study. Content and thematic analyses were performed.

Results

FDR for maternal and neonatal deaths and stillbirths can be performed in upazila health complexes at sub-district and district hospital levels. Senior staff nurses took responsibility for notifying each death and conducting death reviews with the support of doctors. Doctors reviewed the FDRs to assign causes of death. Review meetings with doctors, nurses, and health managers at the upazila and district levels supported the preparation of remedial action plans based on FDR findings, and interventions were planned accordingly. There were excellent examples of improved quality of care at facilities as a result of FDR. FDR also identified gaps and challenges to overcome in the near future to improve maternal and newborn health.

Discussion

FDR of maternal and neonatal deaths is feasible in district and upazila health facilities. FDR not only identifies the medical causes of a maternal or neonatal death but also explores remediable gaps and challenges in the facility. FDR creates an enabled environment in the facility to explore medical causes of deaths, including the gaps and challenges that influence mortality. FDRs mobilize health managers at upazila and district levels to forward plan and improve healthcare delivery.

Perceptions of health care providers and patients on quality of care in maternal and neonatal health in fourteen Bangladesh government healthcare facilities: a mixed-method study

Background

Bangladesh has achieved remarkable progress in healthcare with a steady decline in maternal and under-5 child mortality rates in efforts to achieve Millennium Development Goals 4 and 5. However, the mortality rates are still very high compared with high-income countries. The quality of healthcare needs improve to reduce mortality rates further. It is essential to investigate the current quality of healthcare before implementing any interventions. The study was conducted to explore the perception of healthcare providers about the quality of maternal and neonatal health (MNH) care. The study also investigated patient satisfaction with the MNH care received from district and sub-district hospitals.

Methodology

Both qualitative and quantitative methods were used in the study. Two district and 12 sub-district hospitals in Thakurgaon and Jamalpur in Bangladesh were the study settings. Fourteen group discussions and 56 in-depth interviews were conducted among the healthcare providers. Client exit interviews were conducted with 112 patients and their attendants from maternity, labor, and neonatal wards before being discharged from the hospitals. Eight physicians and four anthropologists collected data between November and December 2011 using pretested guidelines.

Results

The hospital staff identified several key factors that affected the quality of patient care: shortage of staff and logistics; lack of laboratory support; under use of patient-management protocols; a lack of training; and insufficient supervision. Doctors were unable to provide optimal care because of the high volume of patients. The exit interviews revealed that 85 % of respondents were satisfied with the hospital services received. Seven out of 14 respondents were satisfied with the cleanliness of the hospital facilities. More than half of the respondents were satisfied with the drugs they received. In half of the facilities, patients did not get an opportunity to ask the healthcare providers questions about their health conditions and treatments.

Conclusion

The quality of healthcare is poor in district and sub-district hospitals in Bangladesh because of the lack of healthcare personnel and logistic support. An integrated quality improvement approach is needed to improve MNH care service in district and sub-district hospitals in Bangladesh.

Cause of and contributing factors to maternal deaths; a cross-sectional study using verbal autopsy in four districts in Bangladesh

Verbal autopsy used at community level is an accepted method to identify cause of death and factors contributing to death. Maternal deaths occurring in four districts in Bangladesh over a period of 24 months were identified and community health workers were trained to conduct a verbal autopsy. Of 571 maternal deaths identified almost half (273, 47.8%) occurred at facility level, 97 (17.0%) died en route to a healthcare facility and 201 (35.2%) maternal deaths occurred at home. The majority of maternal deaths occurred in the postpartum period (78.8%) in the first 6 hours after giving birth (41.6% of all postpartum deaths). Women who had accessed care at a healthcare facility were less likely to die in the first 6 hours when compared with women who died at home (relative risk 0.70; 95% confidence interval 0.56-0.88) 70.4% (402) of deaths were classified as direct maternal deaths, 12.4% (71) as indirect and 13.8% (79) as unspecified. The most common cause of death was haemorrhage (38%), followed by eclampsia (20%) and sepsis (8.1%). Almost three out of four women who died had sought care for complications during the index pregnancy. Most mothers who died in Bangladesh had accessed care. It is now crucial that the quality of care received at health facility level is improved. This includes a refocus on strengthening healthcare providers' knowledge and skills to recognise and manage complications and provide emergency obstetric care. The enabling environment must be in place as well as ensuring a fully functional referral pathway between healthcare facilities.

Report of a rare case of carcinosarcoma of the maxillary sinus with sternal metastasis

Carcinosarcoma is a highly aggressive and infiltrative tumor. A finding of this tumor in a paranasal sinus is exceedingly rare. We describe the case of a 61-year-old man who presented with a mass on the left side of his face. The mass was excised via a total maxillectomy with a modified radical neck dissection. Histologic analysis identified a mixture of carcinomatous and sarcomatous components. Within 1 month of surgery, the patient developed a sternal metastasis, and he died within a short period of time. The aggressive nature of this tumor and its metastases demand early diagnosis and prompt treatment.

Laparoscopic cholecystectomy: experience at a tertiary level hospital

BACKGROUND

Cholecystectomy is the most frequently performed abdominal operation and currently laparoscopic cholecystectomy (LC) is considered gold standard being performed in 90% cases of symptomatic gallstones in USA since 1992. The aim of the study was to determine results obtained with LC at our setup.

METHODS

This observational case series study was conducted in department of General Surgery, Combined Military Hospital, Rawalpindi, from August 2009 to August 2011. The study participants were patients of both gender aged 14-75 years undergoing LC. Surgery was performed by consultant as well as resident surgeon. Demographic variables, intraoperative findings, mean operation time, hospital stay, conversion rate, morbidity and mortality were evaluated. Factors influencing rate of conversion were also studied.

RESULTS

A total of 504 patients were included. Mean age was 42.64 years (range 14-75 years) with a female: male ratio of 3.9:1.2. Comorbidities were found in 36.7% patients. Main indication of surgery was symptomatic cholelithiasis (78.57%). Mean operative time was 40.1 ± 6.9 minutes which increased to 75.12 ± 8.9 minutes in converted cases (p-value .000). Mean hospital stay was 1.89 ± 1.1 days that significantly increased in converted cases (5.7 ± 1.6 days) (p-value .000). Major surgical complications occurred in 3.17% patients. Common bile duct injury (CBDI) was found in 04 cases (0.79%). Conversion to laparotomy was required in 3.97% cases. Factors that influenced the rate of conversion included: age > 60 years, acute cholecystitis, coexisting diseases, ASA grade III/IV and inexperienced surgeon (p-value .000). Total complication rate was 3.56%, morbidity being 3.17% and mortality 0.39%.

CONCLUSION

Laparoscopic cholecystectomy offers shorter hospital stay and low morbidity/mortality. The operative time is short and procedure is standard, safe and effective method both for uncomplicated and complicated cholelithiasis.

Tools to kill: genome of one of the most destructive plant pathogenic fungi Macrophomina phaseolina

BACKGROUND

Macrophomina phaseolina is one of the most destructive necrotrophic fungal pathogens that infect more than 500 plant species throughout the world. It can grow rapidly in infected plants and subsequently produces a large amount of sclerotia that plugs the vessels, resulting in wilting of the plant.

RESULTS

We sequenced and assembled ~49 Mb into 15 super-scaffolds covering 92.83% of the M. phaseolina genome. We predict 14,249 open reading frames (ORFs) of which 9,934 are validated by the transcriptome. This phytopathogen has an abundance of secreted oxidases, peroxidases, and hydrolytic enzymes for degrading cell wall polysaccharides and lignocelluloses to penetrate into the host tissue. To overcome the host plant defense response, M. phaseolina encodes a significant number of P450s, MFS type membrane transporters, glycosidases, transposases, and secondary metabolites in comparison to all sequenced ascomycete species. A strikingly distinct set of carbohydrate esterases (CE) are present in M. phaseolina, with the CE9 and CE10 families remarkably higher than any other fungi. The phenotypic microarray data indicates that M. phaseolina can adapt to a wide range of osmotic and pH environments. As a broad host range pathogen, M. phaseolina possesses a large number of pathogen-host interaction genes including those for adhesion, signal transduction, cell wall breakdown, purine biosynthesis, and potent mycotoxin patulin.

CONCLUSIONS

The M. phaseolina genome provides a framework of the infection process at the cytological and molecular level which uses a diverse arsenal of enzymatic and toxin tools to destroy the host plants. Further understanding of the M. phaseolina genome-based plant-pathogen interactions will be instrumental in designing rational strategies for disease control, essential to ensuring global agricultural crop production and security.

Pharmacological characterization of rat amylin receptors: implications for the identification of amylin receptor subtypes

BACKGROUND AND PURPOSE

Amylin (Amy) is an important glucoregulatory peptide and AMY receptors are clinical targets for diabetes and obesity. Human (h) AMY receptor subtypes are complexes of the calcitonin (CT) receptor with receptor activity-modifying proteins (RAMPs); their rodent counterparts have not been characterized. To allow identification of the most clinically relevant receptor subtype, the elucidation of rat (r) AMY receptor pharmacology is necessary.

EXPERIMENTAL APPROACH

Receptors were transiently transfected into COS-7 cells and cAMP responses measured in response to different agonists, with or without antagonists. Competition binding experiments were performed to determine rAmy affinity.

KEY RESULTS

rCT was the most potent agonist of rCT((a)) receptors, whereas rAmy was most potent at rAMY(1(a)) and rAMY(3(a)) receptors. rAmy bound to these receptors with high affinity. Rat α-calcitonin gene-related peptide (CGRP) was equipotent to rAmy at both AMY receptors. Rat adrenomedullin (AM) and rAM2/intermedin activated all three receptors but were most effective at rAMY(3(a)) . AC187, AC413 and sCT(8-32) were potent antagonists at all three receptors. rαCGRP(8-37) displayed selectivity for rAMY receptors over rCT((a)) receptors. rAMY(8-37) was a weak antagonist but was more effective at rAMY(1(a)) than rAMY(3(a)) .

CONCLUSIONS AND IMPLICATIONS

AMY receptors were generated by co-expression of rCT((a)) with rRAMP1 or 3, forming rAMY(1(a)) and rAMY(3(a)) receptors, respectively. CGRP was more potent at rAMY than at hAMY receptors. No antagonist tested was able to differentiate the rAMY receptor subtypes. The data emphasize the need for and provide a useful resource for developing new CT or AMY receptor ligands as pharmacological tools or potential clinical candidates.

Cisplatin-ifosfamide combination chemotherapy in metastatic triple-negative, anthracycline- and taxane-pretreated breast cancer patients; a phase II study

PURPOSE

The purpose of this study was to prospectively evaluate the efficacy and toxicity of cisplatin and ifosfamide combination chemotherapy in metastatic triple negative breast cancer (TNBC) previously treated with anthracyclines and taxanes.

METHODS

Patients were treated with cisplatin 20 mg/ m2 iv, days 1-5, over 30 min and ifosfamide 1200 mg/m(2) iv, days 1-5 over 2 h with mesna uroprotection. Therapy was repeated every 3 weeks. Responding patients received a maximum of 6 cycles of chemotherapy. Treatment was delayed in the event of grade 3 or higher hematologic or non hematologic toxicity until resolution to grade 2 or less. Treatment then proceeded as scheduled but with 20% dose reduction of both drugs.

RESULTS

40 TNBC patients were enrolled. Median age was 43 years (range 37-49). Thirty (75%) patients had visceral involvement. Fourteen (35%) patients achieved objective response, disease stabilization occurred in 2 (5%) patients, while disease progression occurred in 24 (60%) patients. Grade 3/4 neutropenia occurred in 11 (27.5%) patients, while grade 3/4 thrombocytopenia was registered in 9 (22.5%) patients. Neurosensory toxicity was the commonest non hematologic acute severe toxicity (10%). With a median follow up of 14 months the median time to progression was 6 months and the median overall survival 12 months. Survival of responding patients was significantly better compared with non responders (p=0.000).

CONCLUSION

Our outpatient cisplatin / ifosfamide regimen displayed reasonable efficacy and toxicity in TNBC. However, the outcome did not differ from relevant studies in the literature. Further molecular studies and phase III trials are still needed to further improve treatment strategies in TNBC.

Extragonadal germ cell tumor presenting in a woman with systemic lupus erythematosus: a case report

INTRODUCTION

Germ cell tumor of the pituitary gland is a very rare occurrence.

CASE PRESENTATION

We describe the case of a 28-year-old Malaysian Malay woman with lupus nephritis who complained of a three month headache and blurring of vision. She was found to have a pituitary mass, which was later proven to be a germ cell tumor. As of writing this case report, her disease is in remission.

CONCLUSION

The disruption of the pituitary gonad axis could affect the disease activity by reducing immunoregulatory control.

Assessment of quality of care in maternal and newborn health services available in public health care facilities in Bangladesh

The study was conducted using the exit interview with patients (n=120), in depth interview with health care providers (n=87) and focus group discussion (n=16) with stakeholders to assess the perceived level of quality of care in maternal and newborn health at public facilities in Bangladesh. Both clients and providers expressed dissatisfaction for inadequate quality of care represented by poor cleanliness, long waiting time with less consultation time, poor compassion by providers, inadequate supply of drugs and unnoticed cost for services varied by level of facilities. Inadequacy in human resource and absenteeism and poor laboratory service were reported to worsen the condition especially at lower level of service delivery. Thus this study explored some important factors like poor quality of care, inadequate technical competencies, information exchange and follow-up services. A deficit in supplies and logistics are strong barrier in regards to quality of care at various levels which needs to be addressed immediately.

Expression of hypoxia-inducible factor-1alpha (HIF-1alpha) related to oxidative stress in liver of rat-induced by systemic chronic normobaric hypoxia

AIM

To observe the expression of hypoxia-inducible factor-1alpha (HIF-1alpha) and its relation with oxidative stress in liver of rats induced by systemic chronic normobaric hypoxia.

METHODS

Twenty five male, 6-8 weeks old rats were induced by systemic hypoxia. Rats were divided randomly into 5 groups (n = 5 per group). The control group was exposed to normal environment while the hypoxic groups were kept in hypoxic chamber (10% O(2)) for 1, 3, 7, and 14 days. Animals were sacrificed, the liver isolated and homogenized. Total RNA was extracted and isolated and expression of HIF-1alpha mRNA was measured by real-time RT PCR using Pffafl method. Malondialdehyde (MDA), product of lipid peroxidation was measured by tBARS assay. Glutathione (GSH), an abundant endogenous antioxidant in the liver tissue was measured using Ellman method.

RESULTS

Study showed that expression of HIF-1alpha mRNA was increased in group treated for 1 day of hypoxic condition, and then decreased in group treated for 3, 7 and 14 days of hypoxic condition related with duration of hypoxic condition. The MDA level in liver tissue increased, but not significant in all groups of hypoxic condition and persisted along duration time of hypoxic condition. The GSH level was decreased significantly (p<0.005) in all groups of hypoxic condition.

CONCLUSION

Expression of HIF-1alpha mRNA was higher at the early phase of hypoxia and decreased as hypoxia continued. Systemic hypoxia induction caused increased ROS formation during hypoxia, and depleted the GSH concentration in the liver. Oxidative stress present in liver of rat was induced by systemic hypoxia.

Kerosene lamp "Kupi": lights the house, but may bring darkness to life

In terms of mortality and morbidity, childhood burn comprises a significant public health problem in Bangladesh, especially in rural poor families who use kerosene-lamp "Kupi" for lighting and traditional mud-made open oven for cooking. They lack optimum safety measures. A total of 100 patients in the age group of 01 to 15 years who got admitted into the burn unit of Dhaka Medical College Hospital during the first half of 2005 were enrolled in the study. Data on socio-demographic variables and information on events and consequences of burn were extracted and analyzed. The results identified flame burn from kerosene lamp "Kupi" as the major cause and source of burn in affected children. Both electrical burn and burn by ash were seen to happen in older male and toddler boys respectively. There were 02 deaths in the series; both were females and were the victims of massive flame burn-one from Kupi and other form oven fire during cooking. Pediatric burn imposes stress on the physique, psyche and socio-economic status of the affected personnel and families. Effective measures are needed to prevent this unfortunate injury in children which is preventable to a large extent.

Severe post-dialysis hypokalaemia leading to quadriparesis

A 36-year-old male developed acute renal failure and severe metabolic acidosis following acute severe gastroenteritis. Two hours following haemodialysis he developed generalized muscle weakness, which progressed to quadriplegia over the next 4 hours. Electrocardiography (ECG) revealed classic signs of hypokalaemia. Serum potassium (K+) levels were 0.98 mmol/L. He was immediately started on intravenous (i/v) and oral potassium supplementation. He gradually improved and his ECG changes also reverted as potassium levels normalized. Postdialysis hypokalaemia can be a serious complication in patients who are already in total body potassium deficit. Dialysis fluid potassium levels should be kept higher in such patients.

Assessment of lipid dysfunction in patients on maintenance haemodialysis

BACKGROUND

Dyslipidaemia is a major risk factor of cardiovascular disease in patients on maintenance haemodialysis. Both increased and decreased levels of cholesterol are associated with increased cardiovascular mortality in haemodialysis patients.

OBJECTIVE

To assess the lipid dysfunction among patients on maintenance haemodialysis in a nephrology unit at Rawalpindi as compared with healthy individuals.

METHODS

A descriptive comparative study was carried out in a nephrology unit at Rawalpindi, Pakistan. A total of 140 subjects were included consisting of 70 patients on maintenance haemodialysis (MHD) and 70 healthy controls. Body mass index (BMI) was measured according to WHO guidelines. Serum total cholesterol (TC), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C) were assayed on chemistry analyser. Low-density lipoprotein cholesterol (LDL-C) was calculated by Friedwald equation.

RESULT

MHD patients had significantly lower BMI, mean (SD) 20.07 (3.66) as compared with the controls 22.88 (3.97) kg/m2 (p < 0.001). The lipid profile among MHD patients and controls are given as mean (SD): (a) Total Cholesterol 3.84 (1.06) vs 4.65 (0.97) (p < 0.001), (b) LDL-C 2.21(0.77) vs 2.93 (0.71) (p < 0.001), (c) HDL-C 0.95 (0.166) vs 0.97 (0.138) (p = NS), (d) Non HDL 2.88 (0.95) vs 3.67 (0.88) (p < 0.0001), (e) Triglycerides 1.68 (1.09) vs 1.69 (0.86) (p = NS). The most common abnormality observed in haemodialysis patients was low HDL-C (81%) followed by increased Non-HDL-C (23%) and increased serum triglycerides (19%).

CONCLUSION

It is concluded that our patients on maintenance haemodialysis have significantly low BMI, total Cholesterol, LDL-C and Non-HDL-C depicting malnutrition leading to inflammation, accelerated atherosclerosis process and cardiovascular complications.