Does adherence to evidence-based practices during childbirth prevent perinatal mortality? A post-hoc analysis of 3,274 births in Uttar Pradesh, India

BACKGROUND

Evidence-based practices that reduce childbirth-related morbidity and mortality are core processes to quality of care. In the BetterBirth trial, a matched-pair, cluster-randomised controlled trial of a coaching-based implementation of the WHO Safe Childbirth Checklist (SCC) in Uttar Pradesh, India, we observed a significant increase in adherence to practices, but no reduction in perinatal mortality.

METHODS

Within the BetterBirth trial, we observed birth attendants in a subset of study sites providing care to labouring women to assess the adherence to individual and groups of practices. We observed care from admission to the facility until 1 hour post partum. We followed observed women/newborns for 7-day perinatal health outcomes. Using this observational data, we conducted a post-hoc, exploratory analysis to understand the relationship of birth attendants' practice adherence to perinatal mortality.

FINDINGS

Across 30 primary health facilities, we observed 3274 deliveries and obtained 7-day health outcomes. Adherence to individual practices, containing supply preparation and direct provider care, varied widely (0·51 to 99·78%). We recorded 166 perinatal deaths (50·71 per 1000 births), including 56 (17·1 per 1000) stillbirths. Each additional practice performed was significantly associated with reduced odds of perinatal (OR: 0·82, 95% CI: 0·72, 0·93) and early neonatal mortality (OR: 0·78, 95% CI: 0·71, 0·85). Each additional practice as part of direct provider care was associated strongly with reduced odds of perinatal (OR: 0·73, 95% CI: 0·62, 0·86) and early neonatal mortality (OR: 0·67, 95% CI: 0·56, 0·80). No individual practice or single supply preparation was associated with perinatal mortality.

INTERPRETATION

Adherence to practices on the WHO SCC is associated with reduced mortality, indicating that adherence is a valid indicator of higher quality of care. However, the causal relationships between practices and outcomes are complex.

FUNDING

Bill & Melinda Gates Foundation.

TRIAL REGISTRATION DETAILS

ClinicalTrials.gov: NCT02148952; Universal Trial Number: U1111-1131-5647.

Implementing the WHO Safe Childbirth Checklist: lessons learnt on a quality improvement initiative to improve mother and newborn care at Gobabis District Hospital, Namibia

Background

Although there are many evidence-based practices that reduce the risk of maternal and neonatal mortality around the time of birth, there remains a gap between what is known and the care received. This know-do gap is a source of preventable maternal and perinatal deaths and is the focus of improvement efforts in many countries. Following an increase in perinatal and maternal deaths, Gobabis District Hospital initiated a quality improvement (QI) initiative to increase adherence to these WHO Safe Childbirth Checklist (SCC)-targeted essential birth practices (EBPs).

Methods

We implemented the SCC with support from leadership, coaching and organisational redesign. Implementation was led by a facility champion supported by a QI team and adapted through a series of three 8-week Plan–Do–Study–Act (PDSA) cycles.

Results

During the 6-month period, we observed an improvement of average EBPs delivered from 68% to 95%. We also found reductions in perinatal mortality rates from 22 deaths/1000 deliveries to 13.8/1000 deliveries largely due to a drop in fresh stillbirths.

Conclusion

We conclude that replicating the programme is feasible, acceptable and effective in areas where gaps exist, but it requires local leadership, ongoing coaching and adaptation through PDSA cycles.

Can we improve the quality of documented end-of-life conversations using a structured, multicomponent intervention?

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Background: Conversations about serious illness care goals are often inadequate and fail to address key elements of high-quality discussions. Methods: As part of a cluster-randomized trial of a multi-component communication intervention, we conducted a retrospective chart review of 147 deceased oncology patients to assess frequency and timing of documentation of end-of-life (EOL) conversations; charts of a subset of 20 intervention and 20 matched control patients underwent detailed review to assess quality. A systematically developed abstraction tool was used by two blinded researchers. The tool contained 25 elements reflecting four EOL conversation domains: goals/values, illness understanding/prognosis, EOL care planning, life-sustaining treatments. Results: Of 153 intervention patients, 44.4% died (n = 68); of 161 controls, 49.1% died (n = 79). Significantly more intervention patients than controls (92.7% vs 74.7%, p = 0.006) had at least 1 documented EOL discussion before death; intervention conversations occurred 3 months earlier (median 147 days vs 62 days, p = 0.003). 59.4% of intervention conversations were documented in a retrievable EHR location compared to 10.2% of controls (p = 0.001). In the detailed review, 85% (n = 17) of intervention and 40% (n = 8) of controls had at least 1 documented discussion about values/goals (p = 0.0001), with an average of 3.6 of 8 elements (0.7 of 8 for controls) (p = 0.0003). 85% percent (n = 17) of intervention and 30% (n = 6) of controls had at least 1 documented discussion about prognosis (p = 0.0014), with an average of 2.5 of 7 elements (0.5 of 7 for controls) (p = 0.001). 85% of intervention (n = 17) and 55% of controls (n = 11) had at least 1 documented discussion about EOL planning (p = 0.009). 55% of intervention and 30% of controls had at least 1 documented discussion about life-sustaining treatments (p = 0.20). Conclusions: The intervention resulted in more, earlier and better documentation of serious illness care goals. Across 3 of 4 domains of quality, intervention patients had more detailed information about their EOL care preferences, demonstrating that the intervention results in more patient-centered, comprehensive discussions. Clinical trial information: NCT01786811.

Bedside Availability of Prepared Oxytocin and Rapid Administration After Delivery to Prevent Postpartum Hemorrhage: An Observational Study in Karnataka, India

Postpartum hemorrhage is a leading cause of maternal death worldwide. Rapid provision of uterotonics after childbirth is recommended to reduce the incidence and severity of postpartum hemorrhage. Data obtained through direct observation of childbirth practices, collected in a study of the World Health Organization's Safe Childbirth Checklist in Karnataka, India, were used to measure if oxytocin prepared for administration and available at the bedside before birth was associated with decreased time to administration after birth. This was an observational study of provider behavior: data were obtained during a baseline assessment of health worker practices prior to introduction of the Safe Childbirth Checklist, representing behavior in the absence of any intervention. Analysis was based on 330 vaginal deliveries receiving oxytocin at any point postpartum. Oxytocin was prepared and available at bedside for approximately 39% of deliveries. We found that advance preparation and bedside availability of oxytocin was associated with increased likelihood of oxytocin administration within 1 minute after delivery (adjusted risk ratio = 4.89, 95% CI = 2.61, 9.16), as well as with decreased overall time to oxytocin administration after delivery (2.9 minutes sooner in adjusted models, 95% CI = -5.0, -0.9). Efforts to reduce postpartum hemorrhage should include recommendations and interventions to ensure advance preparation and bedside availability of oxytocin to facilitate prompt administration of the medicine after birth.

Understanding prolonged cessation from heroin use: findings from a community-based sample

BACKGROUND

There is abundant literature describing heroin initiation, co-morbidities, and treatment. Few studies focus on cessation, examining the factors that motivate and facilitate it.

METHODS

The CHANGE study utilized mixed methods to investigate heroin cessation among low-income New York City participants. This paper describes findings from qualitative interviews with 20 former and 11 current heroin users. Interviews focused on background and current activities, supports, drug history, cessation attempts, and motivators and facilitators to cessation.

RESULTS

Participants found motivation for cessation in improved quality of life, relationships, and fear of illness, incarceration and/or death. Sustained cessation required some combination of treatment, strategic avoidance of triggers, and engagement in alternative activities, including support groups, exercise, and faith-based practice. Several reported that progress toward goals served as motivators that increased confidence and facilitated cessation. Ultimatums were key motivators for some participants. Beyond that, they could not articulate factors that distinguished successful from unsuccessful cessation attempts, although data suggest that those who were successful could describe more individualized and concrete-rather than general-motivators and strategies.

CONCLUSIONS

Our findings indicate that cessation may be facilitated by multifaceted and individualized strategies, suggesting a need for personal and comprehensive approaches to treatment.

"Just like I'm saving money in the bank": client perspectives on care coordination services

Older adults face many challenges to community living. The literature has not sufficiently explored the roles of care coordination in the maintenance of housing and access to health care among older adults, particularly from their own perspectives. This qualitative study analyzes the findings from 25 interviews and 6 focus group discussions (48 participants) with a multiethnic sample of older adults in the New York City area. Care coordination services appear to assist older adults access health care, and to a lesser extent, maintain affordable housing. Disparities in access to care coordination appear to remain for immigrant, minority and suburban populations.

Static and dynamic magnetic properties of Co nanoparticles

Co nanoparticles have been synthesized using wet-chemical methods. As-synthesized particles show a sharp low temperature peak in zero-field cooled (ZFC) magnetization well below the blocking transition temperature and this feature is associated with surface spin disorder. We have investigated the dynamic magnetic properties of Co using ac susceptibility and resonant RF transverse susceptibility (TS). We also studied the memory and relaxation effects in these nanoparticle systems. From these measurements we show a typical blocking behavior of an assembly of superparamagnetic nanoparticles with a wide distribution of blocking temperatures. The transverse susceptibility measurements on these particles show the presence of anisotropy even above the blocking temperature. The role of surface anisotropy and the size distribution of the particles on the observed memory and magnetic relaxation effects are discussed.

Study of a Swiss dopa-responsive dystonia family with a deletion in GCH1: redefining DYT14 as DYT5

OBJECTIVE

To report the study of a multigenerational Swiss family with dopa-responsive dystonia (DRD).

METHODS

Clinical investigation was made of available family members, including historical and chart reviews. Subject examinations were video recorded. Genetic analysis included a genome-wide linkage study with microsatellite markers (STR), GTP cyclohydrolase I (GCH1) gene sequencing, and dosage analysis.

RESULTS

We evaluated 32 individuals, of whom 6 were clinically diagnosed with DRD, with childhood-onset progressive foot dystonia, later generalizing, followed by parkinsonism in the two older patients. The response to levodopa was very good. Two additional patients had late onset dopa-responsive parkinsonism. Three other subjects had DRD symptoms on historical grounds. We found suggestive linkage to the previously reported DYT14 locus, which excluded GCH1. However, further study with more stringent criteria for disease status attribution showed linkage to a larger region, which included GCH1. No mutation was found in GCH1 by gene sequencing but dosage methods identified a novel heterozygous deletion of exons 3 to 6 of GCH1. The mutation was found in seven subjects. One of the patients with dystonia represented a phenocopy.

CONCLUSIONS

This study rules out the previously reported DYT14 locus as a cause of disease, as a novel multiexonic deletion was identified in GCH1. This work highlights the necessity of an accurate clinical diagnosis in linkage studies as well as the need for appropriate allele frequencies, penetrance, and phenocopy estimates. Comprehensive sequencing and dosage analysis of known genes is recommended prior to genome-wide linkage analysis.

Progranulin mutations and amyotrophic lateral sclerosis or amyotrophic lateral sclerosis-frontotemporal dementia phenotypes

OBJECTIVE

Mutations in the progranulin (PGRN) gene were recently described as the cause of ubiquitin positive frontotemporal dementia (FTD). Clinical and pathological overlap between amyotrophic lateral sclerosis (ALS) and FTD prompted us to screen PGRN in patients with ALS and ALS-FTD.

METHODS

The PGRN gene was sequenced in 272 cases of sporadic ALS, 40 cases of familial ALS and in 49 patients with ALS-FTD.

RESULTS

Missense changes were identified in an ALS-FTD patient (p.S120Y) and in a single case of limb onset sporadic ALS (p.T182M), although the pathogenicity of these variants remains unclear.

CONCLUSION

PGRN mutations are not a common cause of ALS phenotypes.

Prolyl endopeptidases

This review describes the structure and function of prolyl endopeptidase (PEP) enzymes and how they are being evaluated as drug targets and therapeutic agents. The most well studied PEP family has a two-domain structure whose unique seven-blade beta-propeller domain works with the catalytic domain to hydrolyze the peptide bond on the carboxyl side of internal proline residues of an oligopeptide substrate. Structural and functional studies on this protease family have elucidated the mechanism for peptide entry between the two domains. Other structurally unrelated PEPs have been identified, but have not been studied in detail. Human PEP has been evaluated as a pharmacological target for neurological diseases due to its high brain concentration and ability to cleave neuropeptides in vitro. Recently, microbial PEPs have been studied as potential therapeutics for celiac sprue, an inflammatory disease of the small intestine triggered by proline-rich gluten.

Does one person provide it all? Defining the social support of women with cancer

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Background: Medical care encourages the appointment of a health care proxy in the event the patient cannot make decisions and it is assumed that this same person will serve other critical roles for the patient. Yet, this assumption that a patient truly relies on the same person for various supportive roles has never been formally evaluated. We hypothesized that there may be a large proportion of women with cancer who do not rely on the same person to be their primary support (PS), to participate in health care decision making as proxy (HCP), and serve as an emergency contact (EC). In order to evaluate this we conducted a questionnaire over a six-month period for women treated in the Program in Women’s Oncology (PWO). Methods: Patients seen at the PWO for a cancer diagnosis were invited to participate in a four part survey on social supports. Demographic data including age, race, cancer diagnosis, date of diagnosis, and current status were collected by chart review. Categorical variables were analyzed using Fisher’s Exact Test or Chi-square analysis. Results: Over 6 months, 224/228 women (98%) agreed to participate. The median age was 58 (range, 30–85). 138 (62%) had breast cancer, 78 (35%) had a gynecologic cancer, and 8 (3.5%) had a non-gyn/non-breast tumor (6/8 colorectal). 66% were married, 8% had a partner, and 26% did not identify a partner. In this sample, 43% did not name the same person as EC, PS, and HCP. 75% named the EC as HCP, 68% EC as PS, and 62% PS as HCP (p<0.05). Of married women (n=147) only 60% named their spouse to all three roles. Divorced women were not as likely to name a partner to one of these roles as were single women with partners. When asked to define primary support, women had diverse perspectives spanning the emotional, physical, intimate, and spiritual dimensions. Age did not appear to be a significant predictor of how these questions were answered. Conclusions: This study demonstrates the complex social support structures of women with cancer. Understanding these relationships may help to enable more effective patient-centered interventions designed to improve quality of care and ultimately the quality of life of cancer survivors.

No significant financial relationships to disclose.

Phase imaging without 2pi ambiguity by multiwavelength digital holography

We present a phase-imaging method with an axial range that can in principle be arbitrarily large compared to the wavelength and does not involve the usual phase unwrapping by detection of phase discontinuity. The method consists of the generation and combination of two phase maps in a digital holography system by use of two separate wavelengths. For example, we reconstructed the surface of a spherical mirror with approximately 10-nm axial resolution and an axial range of approximately 3 microm.

Similarities not differences: an exploration of the impact of change upon a group of nursing lecturers within a university setting

The concepts of collaboration and partnership currently have extensive impact upon health care providers and higher education institutions. One of the challenges is to develop networks which will foster partnerships able to react, and contribute, to an ever-evolving educational culture. These themes are illustrated by using the example of one school of nursing and midwifery, and the collective experience of a number of its academic staff. By focusing on distinct features of collaboration (strategic planning, origins of change, group dynamics and building a community), the authors seek to explore the impact of an educational culture in an attempt to provide meaning to their recent experiences. In so doing, group identity is explored and the prospect for creating partnerships across disciplines ('similarities rather than differences') is considered.

Interviewing in phenomenology and grounded theory: is there a difference?

This paper explores the differences and similarities that may exist in respect of using the interview method in phenomenological and grounded theory methodologies. Baker et al. set out to differentiate between method in grounded theory and phenomenology and concluded that it was essential to ensure that the method matches the research question being asked. However, the paper, whilst clear in intent to differentiate between the methodologies of phenomenology and grounded theory, does little to help the researcher in the differences that may exist in carrying out such research using the same method, that is, interviewing. Interviewing has become synonymous with qualitative research and may become the accepted method of data collection irrespective of methodology. We postulate that the interview as a method of data collection may be inconsistent with the underlying principles of the methodology (phenomenology or grounded theory). Should this be the case then the interview as a means of collecting data may be viewed as generic and lack a clear connection to the methodological framework. Such a position could be consistent with a critique of qualitative nursing research on the grounds of rigour.

Synthesis of allyl O-[sodium(alpha-D-glycero-D-talo-2- octulopyranosyl)onate]-(2-->6)-2-acetamido-2-deoxy-beta-D-glucopyranosi de, a core constituent of the lipopolysaccharide from Acinetobacter calcoaceticus NCTC 10305

Reaction of methyl 2,6-anhydro-2,3-dideoxy-D-manno-2-octenoate 1 with 3-chloroperoxybenzoic acid gave the 2,3-anhydro derivative 2, which was converted into the per-O-acetylated anomeric methyl glycosides of D-glycero-D-galacto-2-octulopyranosylonic acid in good yield. Subsequent inversion of the configuration at C-3 and deprotection afforded sodium (methyl beta-D-glycero-D-talo-2-octulopyranosid)onate. Alternatively, 2 was transformed into methyl (alpha-D-glycero-D-talo-2- octulopyranosyl bromide(onate derivatives. Reaction with methanol or allyl 2-acetamido-2-deoxy- 3,4-O-(1,1,3,3-tetraisopropyldisiloxan-1,3-diyl)-beta-D-g lycopyranoside, promoted by silver triflate, gave good yields of the corresponding orthoester derivatives. Me3Si triflate-catalyzed orthoester rearrangement and removal of the protecting groups afforded sodium O-(methyl alpha-D-glycero- D-talo-2-octulopyranosid)onate and the disacchanide, allyl O-[sodium(alpha-D-glycero-D-talo-2- octulopyranosyl)onate]-(2-->6)-2-acetamido-2-deoxy-beta-D-gl ucopyranoside in high yield.

Penetrating cardiac wounds: prospective study of factors influencing initial resuscitation

A prospective study of 66 consecutive patients with cardiac wounds seen over a 27-month period is reported. No patient was excluded. Patients were stratified by injury mechanism and by physiologic scoring at admission using the cardiovascular-respiratory elements of the Trauma Score (CVRS). Admission cardiac rhythm was obtained in patients with a CVRS of 0 and a Glasgow Coma Scale (GCS) score of 3. Information concerning the anatomic extent of the cardiac wound, the presence or absence of tamponade, and the degree of injury to other structures was also collected prospectively. Seventy percent of the cardiac wounds were caused by gunshots. The probability of successful resuscitation was significantly related to mechanism of injury and physiologic condition on arrival. Among patients arriving with a CVRS of 0 and a GCS score of 3, survival correlated with cardiac rhythm. Pericardial tamponade did not prove to be an independent predictor of early survival. The presence of tamponade was statistically linked to the mechanism of injury. Transport by non-official conveyance was associated with a higher CVRS on arrival. Intoxication with alcohol or cocaine had no evident effect on resuscitation probability.

Preparation of the calcified tibial artery for bypass grafting

This method of preparation of calcified tibial arteries for bypass grafting produces softening of the arterial wall to permit vascular control and the construction of a technically precise anastomosis. The presence of the inflated intraluminal balloon during compression of the arterial wall inhibits violent cracking of the calcific skeleton and displacement of calcium plates into the lumen. This results in fewer intimal flaps and the preservation of an undisrupted outflow tract.

Artificial antigens. Synthesis of polyacrylamide copolymers containing 3-deoxy-D-manno-2-octulopyranosylonic acid (KDO) residues

Starting from an anomeric mixture of methyl (allyl 4,5,7,8-tetra-O-acetyl-3-deoxy-alpha- and -beta-D-manno-2-octulopyranosid)onates, the glycosides sodium (allyl 3-deoxy-alpha- and -beta-D-manno-2-octulopyranosid)onate, sodium O-(sodium 3-deoxy-alpha-D-manno-2-octulopyranosylonate)-(2----4)-[allyl 3-deoxy-alpha-D-manno-2-octulopyranosid]onate and sodium (allyl 3-deoxy-7-O-beta-D-ribofuranosyl-beta-D-manno-2-octulopyranosid)++ +onate were prepared in several steps. Radical copolymerization of the allyl glycosides with acrylamide afforded linear macromolecular antigens containing mono- and di-saccharide residues corresponding to the KDO-region of Salmonella minnesota rough-form lipopolysaccharide and to partial structures of the capsular polysaccharide from Escherichia coli K 23, respectively. The copolymers were substituted by KDO-residues in a ratio of 1:18 +/- 2 (based on acrylamide) and had molecular masses of 60-100 kdaltons.