Introducing the hormonal Intrauterine Device in Madagascar, Nigeria, and Zambia: results from a pilot study

BACKGROUND

The hormonal Intrauterine Device (IUD) is a highly effective contraceptive option growing in popularity and availability in many countries. The hormonal IUD has been shown to have high rates of satisfaction and continuation among users in high-income countries. The study aims to understand the profiles of clients who choose the hormonal IUD in low- and middle-income countries (LMICs) and describe their continuation and satisfaction with the method after 12 months of use.

METHODS

A prospective longitudinal study of hormonal IUD acceptors was conducted across three countries-Madagascar, Nigeria, and Zambia-where the hormonal IUD had been introduced in a pilot setting within the of a broad mix of available methods. Women were interviewed at baseline immediately following their voluntary hormonal IUD insertion, and again 3 and 12 months following provision of the method. A descriptive analysis of user characteristics and satisfaction with the method was conducted on an analytic sample of women who completed baseline, 3-month, and 12-month follow-up questionnaires. Kaplan-Meier time-to-event models were used to estimate the cumulative probability of method continuation rates up to 12 months post-insertion.

RESULTS

Each country had a unique demographic profile of hormonal IUD users with different method-use histories. Across all three countries, women reported high rates of satisfaction with the hormonal IUD (67-100%) and high rates of continuation at the 12-month mark (82-90%).

CONCLUSIONS

Rates of satisfaction and continuation among hormonal IUD users in the study suggest that expanding method choice with the hormonal IUD would provide a highly effective, long-acting method desirable to many different population segments, including those with high unmet need.

Sexual and reproductive health self-care in humanitarian and fragile settings: where should we start?

Recent crises have accelerated global interest in self-care interventions. This debate paper aims to raise the issue of sexual and reproductive health (SRH) self-care and invites members of the global community operating in crisis-affected settings to look at potential avenues in mainstreaming SRH self-care interventions. We start by exploring self-care interventions that could align with well-established humanitarian standards, such as the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Crises, point to the potential of digital health support for SRH self-care in crisis-affected settings, and discuss related policy, programmatic, and research considerations. These considerations underscore the importance of self-care as part of the care continuum and within a whole-system approach. Equally critical is the need for self-care in crisis-affected settings to complement other live-saving SRH interventions-it does not eliminate the need for provider-led services in health facilities. Further research on SRH self-care interventions focusing distinctively on humanitarian and fragile settings is needed to inform context-specific policies and practice guidance.

Helping Postpartum Women in Mali Achieve Their Fertility Intentions: Perspectives From Introduction of the Dedicated Postpartum IUD Inserter

In this pilot introduction setting, trained providers reported higher acceptance and preference for the dedicated inserter compared with the conventional postpartum insertion with forceps, suggesting potential for the dedicated inserter to expand access to postpartum IUDs.

Background:

Mali has one of the highest maternal mortality ratios in the world coupled with one of the lowest modern contraceptive use rates. Nearly a quarter of the country's 750,000 annual births occur within 24 months of a previous birth, increasing the risks for mothers and babies. Nearly 70% of postpartum women have an unmet need for family planning. In 2016, Population Services International Mali (PSI-Mali) introduced a dedicated postpartum intrauterine device (PPIUD) inserter to replace the technique of using forceps for PPIUD insertion, with the aim of helping to address this substantial family planning gap.

Methods:

A mixed-methods approach was used to assess program results and the experiences of PSI-trained providers using the dedicated PPIUD inserter in 5 health facilities in Bamako. We conducted 10 key informant interviews with providers and 4 key informant interviews with operational and clinical staff involved in training and supporting providers. Further data were collected from district health surveys and facility registers. Secondary data encompassed documentation from 2011 through 2017, with the service delivery figures of PPIUD using the dedicated inserter focused on the pilot period of March 2016 through December 2017. Primary data were collected in Mali in July 2017.

Results:

Between March 2016 and December 2017, PSI-Mali trained 134 providers on the dedicated PPIUD inserter and provided more than 3,500 voluntary PPIUDs. Of the 1,840 voluntary PPIUDs provided in 2017 alone, 67% were provided by facilities trained to use the dedicated PPIUD inserter. Providers stated a preference for the inserter (compared with the use of forceps) due to its ease, speed, and perceived lower associated risks of infection. Service data from the 5 facilities visited showed an overall average PPIUD uptake of 7.3% of deliveries in 2017. Although private facilities had considerably fewer deliveries than public facilities (600–900 compared with 20–30, respectively), a much higher proportion of women delivering in the private facilities chose a PPIUD.

Conclusion:

The acceptance of the dedicated PPIUD inserter by providers may help reduce some of the supply-side barriers that inhibit women's access to postpartum family planning methods. With continued support to providers, coupled with ongoing efforts to address differences in service trends between sectors and demand-side barriers to the PPIUD and family planning more broadly, the dedicated PPIUD inserter could play an important role in responding to the high unmet need among postpartum women in Mali.

Establishing and Scaling-Up Clinical Social Franchise Networks: Lessons Learned From Marie Stopes International and Population Services International

Family planning social franchising has succeeded in countries with an active private sector serving low- and middle-income clients, with services provided mostly by mid-level providers, such as nurses and midwives. Key support for social franchising includes: clinical training and supportive supervision, help building sustainable businesses, marketing and demand creation, and mechanisms to make services affordable for clients. The forward agenda includes selectively introducing other priority health services, improving cost-effectiveness of the model, and promoting sustainability and health system integration.

In many low- and middle-income countries, a majority of people seek health care from the private sector. However, fragmentation, poor economies of scale, inadequate financing, political opposition, a bias toward curative services, and weak regulatory and quality control systems pose serious challenges for the private sector. Social franchising addresses a number of these challenges by organizing small, independent health care businesses into quality-assured networks. Global franchisors Marie Stopes International (MSI) and Population Services International (PSI) have rapidly scaled their family planning social franchising programs in recent years, jointly delivering over 10.8 million couple-years of protection (CYPs) in 2014—up 26% from 8.6 million CYPs just 1 year prior. Drawing on experience across MSI’s 17 and PSI’s 25 social franchise networks across Africa, Asia, and Latin America and the Caribbean, this article documents the organizations’ operational approaches, challenges faced, and solutions implemented. The organizations provide intensive capacity building and support for private-sector providers, including clinical training, branding, monitoring quality of franchised services, and commodity support. In addition, franchising programs engage providers and clients through behavior change communication (BCC) and demand generation activities to raise awareness and to attract clients, and they implement initiatives to ensure services are affordable for the lowest-income clients. Social franchise programs offer the private sector a collective platform to better engage government in health policy advocacy and for integrating into new public health care financing and procurement mechanisms. The future of social franchising will require developing approaches to scale-up and sustain the model cost-effectively, selectively integrating other health services into the franchise package, and being responsive to evolving health care financing approaches with the potential to contribute to universal health coverage.

Fractal images induce fractal pupil dilations and constrictions

Fractals are self-similar structures or patterns that repeat at increasingly fine magnifications. Research has revealed fractal patterns in many natural and physiological processes. This article investigates pupillary size over time to determine if their oscillations demonstrate a fractal pattern. We predict that pupil size over time will fluctuate in a fractal manner and this may be due to either the fractal neuronal structure or fractal properties of the image viewed. We present evidence that low complexity fractal patterns underlie pupillary oscillations as subjects view spatial fractal patterns. We also present evidence implicating the autonomic nervous system's importance in these patterns. Using the variational method of the box-counting procedure we demonstrate that low complexity fractal patterns are found in changes within pupil size over time in millimeters (mm) and our data suggest that these pupillary oscillation patterns do not depend on the fractal properties of the image viewed.

Massive Dirac fermions and Hofstadter butterfly in a van der Waals heterostructure

van der Waals heterostructures constitute a new class of artificial materials formed by stacking atomically thin planar crystals. We demonstrated band structure engineering in a van der Waals heterostructure composed of a monolayer graphene flake coupled to a rotationally aligned hexagonal boron nitride substrate. The spatially varying interlayer atomic registry results in both a local breaking of the carbon sublattice symmetry and a long-range moiré superlattice potential in the graphene. In our samples, this interplay between short- and long-wavelength effects resulted in a band structure described by isolated superlattice minibands and an unexpectedly large band gap at charge neutrality. This picture is confirmed by our observation of fractional quantum Hall states at ± 5/3 filling and features associated with the Hofstadter butterfly at ultrahigh magnetic fields.

Hofstadter's butterfly and the fractal quantum Hall effect in moiré superlattices

Electrons moving through a spatially periodic lattice potential develop a quantized energy spectrum consisting of discrete Bloch bands. In two dimensions, electrons moving through a magnetic field also develop a quantized energy spectrum, consisting of highly degenerate Landau energy levels. When subject to both a magnetic field and a periodic electrostatic potential, two-dimensional systems of electrons exhibit a self-similar recursive energy spectrum. Known as Hofstadter's butterfly, this complex spectrum results from an interplay between the characteristic lengths associated with the two quantizing fields, and is one of the first quantum fractals discovered in physics. In the decades since its prediction, experimental attempts to study this effect have been limited by difficulties in reconciling the two length scales. Typical atomic lattices (with periodicities of less than one nanometre) require unfeasibly large magnetic fields to reach the commensurability condition, and in artificially engineered structures (with periodicities greater than about 100 nanometres) the corresponding fields are too small to overcome disorder completely. Here we demonstrate that moiré superlattices arising in bilayer graphene coupled to hexagonal boron nitride provide a periodic modulation with ideal length scales of the order of ten nanometres, enabling unprecedented experimental access to the fractal spectrum. We confirm that quantum Hall features associated with the fractal gaps are described by two integer topological quantum numbers, and report evidence of their recursive structure. Observation of a Hofstadter spectrum in bilayer graphene means that it is possible to investigate emergent behaviour within a fractal energy landscape in a system with tunable internal degrees of freedom.

In vitro comparison of the fracture resistance and failure mode of fiber, ceramic, and conventional post systems at various stages of restoration

PURPOSE

This in vitro study evaluated 6 post systems over 4 simulated clinical stages of tooth restoration to (1) determine quantitatively the fracture resistance strength at each stage when a static loading force is applied to cause failure; (2) determine the failure mode for each post system at each simulated clinical stage; and (3) determine the feasibility of removing failed post systems.

MATERIALS AND METHODS

Ten post systems made with various materials and designs were tested at the following 4 stages of simulated clinical treatment: stage #1: posts only, loaded using a 3-point loading model to failure, to determine transverse strengths and failure modes for each post system; stage #2: posts alone, bonded into teeth; stage #3: posts bonded into teeth with core build up; stage #4: post and core build up and full veneer restoration. For stages #2 through #4, the coronal portion of 60 mandibular premolars was amputated at the cemento-enamel junction, the canals were treated endodontically, and the specimens were mounted in acrylic blocks. A testing force was applied to the posts at 90 degrees to the long axis of the tooth, 4 mm from the cemento-enamel junction. The O'Brien test for constant variance was performed over the treatment groups. For nonconstant variance, the Welsh analysis of variance was used to test for equalities of treatment means. The Tukey Kramer procedure determined which treatment procedures differed.

RESULTS

The failure thresholds for each post system were significantly different at each stage of testing, but the order of test results by post type remained generally consistent from one stage to the next. ParaPosts (Coltene, Whaledent Int, New York, NY) and core build up resulted in significantly higher failure thresholds through all 4 stages of testing. This post system also consistently displayed a high number of nonfavorable tooth fractures. FibreKor post and cores (Jeneric Pentron Inc, Wallingford, CT) resulted in significantly lower failure threshold values in stages #2 through #4. This post system displayed no tooth fractures in stages #2 and #3 and a similar number of nonfavorable tooth fractures in stage #4 when compared with the other systems. C-Post (Bisco Dental Products, Schaumburg, IL), CosmoPost (Ivoclar Vivadent North America Inc, Amherst, NY), and AesthetiPost (Bisco Dental Products) grouped in descending order through stages #2 to #4. These systems displayed intermediate fracture resistance strengths, as well as a moderate number of nonfavorable tooth fractures. CosmoPost exhibited a significant number of brittle post fractures with fragments left in the root canal at all stages. The fracture resistance of the cast metal post varied from stage to stage. No teeth fractured at stage #2. At stage #3, 9 of 10 teeth fractured nonfavorably, and all teeth fractured nonfavorably in stage #4.

CONCLUSIONS

The fiber posts evaluated provided an advantage over a conventional post that showed a higher number of irretrievable post and unrestorable root fractures. At the stage of final restoration insertion, there was no difference in force to failure for all but the FibreKor material, which continued to be weaker than all other tested materials. The fiber posts were readily retrievable after failure, whereas the remaining post systems tested were nonretrievable. J Prosthodont 2001;10:26-36.

Unilateral thalamic stroke does not decrease ipsilateral sleep spindles

STUDY OBJECTIVES

To measure the sleep spindle characteristics in patients with unilateral thalamic stroke.

DESIGN

A prospective study of patients with thalamic stroke and age-matched healthy controls.

SETTING

Department of Neurology of a University Hospital.

PARTICIPANTS

Thirteen patients (mean age: 67 years, SD: 13,44) with an isolated, unilateral acute thalamic stroke and 18 healthy age-matched volunteers.

INTERVENTIONS

A polysomnogram recording from 14 scalp EEG electrodes performed during 2 consecutive nights, the second or third week after the stroke. Only the sleep of the second night was analyzed.

MEASUREMENTS AND RESULTS

Sleep spindles were counted during two separate 10-minute epochs of stage II. Spindles appearing synchronously in both sides with similar amplitude were called "bilateral." Spindles with twice the amplitude in one side than the other were "right" or "left-side predominant". There were 8 patients with posterolateral, 3 with global and 2 with anterior lesions. Eight were right and 5 left-sided. The number of spindles was similar in patients (39.8 +/- 23.4 in 20 minutes) than controls (26.07 +/- 29.07; p=0.173). Spindles with a centroparietal (34%) and centroparieto-occipital localization (22%) were the most frequent. In controls approximately 66% of the spindles had a bilateral and symmetric distribution over the scalp, 23% of the spindles were predominantly left-sided and 5% were predominantly right-sided. In patients, bilateral spindles decreased (p<0.0001) but asymmetric spindles did not change.

CONCLUSION

Unilateral acute thalamic stroke does not decrease sleep spindles ipsilaterally; rather, it seems to produce a bilateral diminution in their number.

Use of a handheld device for analysis of blood electrolyte concentrations and blood gas partial pressures in dogs and horses

OBJECTIVE

To compare, for blood samples from dogs and horses, blood electrolyte concentrations, blood gas partial pressures, and Hct obtained using a handheld analyzer with those obtained using a standard chemistry analyzer and to compare results obtained with the handheld analyzer using warm versus cold test cartridges.

DESIGN

Case series with analysis of split samples.

SAMPLE POPULATION

Blood samples from 22 dogs and 17 horses.

PROCEDURE

Sodium, potassium, ionized calcium, bicarbonate, and total CO2 concentrations, pH, PO2, PCO2, base excess, and Hct were determined by use of a handheld analyzer and test cartridges that had been allowed to warm to ambient temperature or had been recently removed from a refrigerator. Results were compared with those from a standard chemistry analyzer by use of linear regression.

RESULTS

For canine samples, values obtained with the handheld analyzer and warm cartridges were highly correlated (r2 > or = 0.83) with values obtained with the standard chemistry analyzer, except for sodium concentration (r2 = 0.6). For equine samples, values obtained with the handheld analyzer and warm cartridges were highly correlated (r2 > or = 0.79) with values obtained with the standard chemistry analyzer, except for Hct (r2 = 0.38). For all samples, results obtained with cold and warm cartridges were moderately correlated (r2 > or = 0.69).

CLINICAL IMPLICATIONS

Results obtained with the handheld analyzer were similar to those obtained from the standard chemistry analyzer, with the exception of sodium concentration for canine samples and Hct for equine samples. Results were not substantially affected by use of cold, rather than warm, test cartridges.

Retention of esthetic veneers on primary stainless steel crowns

The purpose of this study was to ascertain the amount of shearing force necessary to fracture, dislodge or deform the esthetic veneer facings of four commercially available veneered primary incisor stainless steel crowns. The four types tested were: Cheng Crowns, [Peter Cheng Orthodontic Laboratory]; Whiter Biter Crown II, [White Bite Inc.]; Kinder Krowns, [Mayclin Dental Studio, Inc]; and NuSmile Primary Crowns, [Orthodontic Technologies, Inc]. The crowns (#4 right central incisor) from each manufacturer were obtained with the facings attached. The crowns were soaked for ninety days and thermocycled at 4 degrees C and 55 degrees C for 500 45-second cycles. The crowns were cemented to standardized chromium cobalt metal dies. Each die was placed in to a custom holder on the Instron Universal testing machine. A force was applied at the incisal edge of the veneer at 148 degrees, (the primary interincisal angle), with a crosshead speed of 0.05 inches/minute until the veneer either fractured, dislodged or deformed. The mean force (Ibs) required +/- SD to produce failure, in descending order, was as follows: Cheng (107.8 +/- 17.3); NuSmile (100.2 +/- 18.2); KinderKrown (91.3 +/- 27.4)d Whiter Biter (81.5 +/- 21.7). To test the hypothesis of no difference among the four manufacturers, an analysis of variance was performed using PROC GLM. The resultant F statistic was 2.79 (p < 0.0543), indicating a marginally statistically significant difference in the response variable "pressure" among the four groups. A posthoc test was then performed to ascertain where these differences occurred. These results, using Turkey's studentized range test for pairwise comparisons, suggested that the only difference was between the Cheng and Whiter Biter manufacturers.

Investigation of a new light imaging technique to detect incipient caries in teeth

At the present time dental X-rays are the best method to locate carious lesions, however, small lesions can be detected only with difficulty. Even though investigations in the past have shown that light imaging systems are more sensitive to small lesions than X-rays it is difficult to determine the characteristics of these lesions with any of these systems. We developed a new light imaging technique that makes it much easier to determine the size and depth of these lesions on most areas of the teeth even though modifications on the present setup will still be necessary to detect them as easily on occlusal surfaces. This technique is based on raster scans of the teeth with narrow collimated light beams. The results of this investigation show that the areas ( greater than 0.1 mm 2) of small incipient lesions can be measured and their depths estimated.

Development of monoclonal antibodies that identify Vibrio species commonly isolated from infections of humans, fish, and shellfish

Monoclonal antibodies (MAbs) against Vibrio species that infect humans, fish, and shellfish were developed for application in rapid identifications. The pathogens included Vibrio alginolyticus, V. anguillarum, V. carchariae, V. cholerae, V. damsela, V. furnissii, V. harveyi, V. ordalii, V. parahaemolyticus, and V. vulnificus. Three types of MAbs were selected. The first important group included MAbs that reacted with only a single species. A second group comprised a number of MAbs that reacted with two, taxonomically closely related Vibrio species. For example, of 22 MAbs raised against V. alginolyticus, 6 recognized a 52-kDa flagellar H antigen common to both V. alginolyticus and V. parahaemolyticus; V. anguillarum and V. ordalii also shared antigens. A third group included three genus-specific MAbs that reacted with almost all Vibrio species but did not react with other members of the family Vibrionaceae (e.g., members of the Aeromonas, Photobacterium, and Plesiomonas genera) or a wide range of gram-negative bacteria representing many genera. This last group indicated the possible existence of an antigenic determinant common to Vibrio species. Two of these three genus-specific MAbs reacted with heat-stable antigenic determinants of Vibrio species as well as lipopolysaccharide extracted from Vibrio species. The use of the MAbs in blind tests and diagnosis of clinical isolates indicated that three different types of bacteria, viz., live, formalin-fixed, and sodium azide-killed bacteria, were detected consistently. Overall, it was found that the genus-specific MAbs were very useful for rapidly identifying vibrios in the screening of acute infections, while the species-specific MAbs and others were useful for completing the diagnosis.