Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi-experimental pre-post study (The PartoMa study)

OBJECTIVE

To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia.

DESIGN

Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice.

SETTING

Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital.

POPULATION

Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2015 until 31 January 2016) [corrected].

METHODS

Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively).

MAIN OUTCOME MEASURES

Stillbirths and neonates with 5-minute Apgar score ≤5.

RESULTS

Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved.

CONCLUSION

Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.

Synthesis and characterization of protic ionic liquids as thermoelectrochemical materials

PILs have been designed and synthesized for energy harvesting applications. The module exhibited a maximum S_e value of 420 μV K⁻¹ which is the highest reported for PILs with the I⁻/I₃⁻ redox couple.

Ionic liquid entrapment by an electrospun polymer nanofiber matrix as a high conductivity polymer electrolyte

Through external doping, novel conductive polymer nanofibers were successfully fabricated using ionic liquids.

Impact of aluminium addition on the corrosion behaviour of Sn–1.0Ag–0.5Cu lead-free solder

(a) Al provides an enhanced passivation capability over SAC105 solder alloy. (b) Corrosion products on the surface consist of Al₂CuO₄, Al₂O₃, SnO and SnO₂. (c) Al-added SAC105 is less susceptible to corrosion.

Correction: Impact of aluminium addition on the corrosion behaviour of Sn–1.0Ag–0.5Cu lead-free solder

Correction for ‘Impact of aluminium addition on the corrosion behaviour of Sn–1.0Ag–0.5Cu lead-free solder’ by N. I. M. Nordin et al., RSC Adv., 2015, 5, 99058–99064.

Surgical stabilization of flail chest: the impact on postoperative pulmonary function

OBJECTIVES

Flail chest results in significant morbidity. Controversies continue regarding the optimal management of flail chest. No clear guidelines exist for surgical stabilization. Our aim was to examine the association of bedside spirometry values with operative stabilization of flail chest.

METHODS

IRB approval was obtained to identify patients with flail chest who underwent surgical stabilization between August 2009 and May 2011. At our institution, all rib fracture patients underwent routine measurement of their forced vital capacity (FVC) using bedside spirometry. Formal pulmonary function tests were also obtained postoperatively and at three months in patients undergoing stabilization. Both the Synthes and Acute Innovations plating systems were utilized. Data is presented as median (range) or (percentage).

RESULTS

Twenty patients (13 male: 65 %) with median age of 60 years (30-83) had a median of four ribs (2-9) in the flail segment. The median Injury Severity Score was 17 (9-41) and the median Trauma and Injury Severity Score was 0.96 (0.04-0.99). Preoperative pneumonia was identified in four patients (20 %) and intubation was required in seven (35 %). Median time from injury to stabilization was four days (1-33). The median number of plates inserted was five (3-11). Postoperative median FVC (1.8 L, range 1.3-4 L) improved significantly as compared to preoperative median value (1 L, range 0.5-2.1 L) (p = 0.003). This improvement continued during the follow-up period at three months (0.9 L, range 0.1-3.0) (p = 0.006). There were three deaths (15 %), none of which were related to the procedure. Subsequent tracheostomy was required in three patients (15 %). The mean hospital stay and ventilator days after stabilization were nine days and three days, respectively. Mean follow-up was 5.6 ± 4.6 months.

CONCLUSION

Operative stabilization of flail chest improved pulmonary function compared with preoperative results. This improvement was sustained at three months follow-up.

Ultrasound guided thrombin injection of pseudoaneurysm of the radial artery after percutaneous coronary intervention

Thrombin injection is frequently used to occlude iatrogenic pseudoaneurysms in larger vessels, but has never successfully been used in the radial artery location. Here we report the use of this treatment in a patient with radial artery pseudoaneurysm following coronary intervention. After Doppler sonographic visualization of the pseudoaneurysm cavity and its neck, an ultrasound-guided transcutaneous injection of thrombin was carried out. Immediately after the injection, the pseudoaneurysm was completely clotted and Doppler measurement confirmed the stop of blood flow. The result suggests that ultrasound-guided injection of thrombin into a radial artery pseudoaneurysm following coronary intervention is a feasible alternative to surgical intervention.

[Thrombocytopenia in a patient with coronary artery disease after percutaneous coronary intervention]

Thrombocytopenia in patients with percutanous coronary intervention is a known complication of glycoprotein IIb/IIIa inhibitors. This can limit the application of these agents. Platelet count monitoring 2, 6, 12 and 24 hours after starting the treatment reveals most cases of acute thrombocytopenia. Side effects can be avoided by the early discontinuation of the glycoprotein IIb/IIIa antagonist treatment. A selective diagnostic approach by laboratory measures should exclude any confusion with heparin-induced thrombocytopenia and pseudo thrombocytopenia.

Wie zuverlässig sind unsere Krebsstatistiken?

BACKGROUND

Among the causes of death, cancer ranks second after cardiovascular diseases. If a cancer patient dies before the tumor is diagnosed the malignancy may be unreported among post-mortem findings and thus is often not included in cancer and cause of death statistics.

METHOD

All 8844 autopsies carried out at the Institute of Forensic Medicine for the City of Hamburg from 1994 to 2001 were analysed and those cases with malignant tumor identified. The cases were then included in the cancer registry if this had not been done previously. The postmortem diagnosis of malignancy was made histologically on formalin-fixed tissue. In these cases attempts were made to find out if the initial diagnosis of malignancy had been made before death.

RESULTS

A malignancy was found in 519 autopsies (5.9 %). In 67.3 % of these (349/519) the patients had been aware of the disease. 27.2 % of all malignant tumors (141/519) were discovered during the post-mortem examination. In 5.6 % of cases (29/519) the question of whether the tumor had been diagnosed before death could not be answered because of lack of data or an incomplete case history. In 52.2 % (271/519) of the autopsies the tumor had definitely been the cause of death. Of these 271 tumors 17 % (46/271) were discovered only during the forensic post-mortem examination. The Hamburg Cancer Registry had been notified of only 58 cases of the 519. As a result of this study 451 new cancer cases (86.9 %) were notified to the Hamburg cancer registry.

CONCLUSIONS

The registration of cancer deaths in Hamburg is incomplete and the notification of cancer to the Cancer Registry is inadequate. The estimated number of unreported cases is probably greater and cancer as the cause of death is higher than reported in the statistics.

Glycoprotein IIb/IIIa inhibitor-induced thrombocytopenia

Thrombocyte glycoprotein IIb/IIIa inhibitors prevent fibrinogen binding and thereby thrombocyte aggregation. The inhibition of thrombocyte activation at the damaged coronary plaque is the target of the new therapeutic strategies in treating acute coronary syndrome. This reduces the ischemic complications associated with the non-STelevation myocardial infarction (NSTEMI) and percutaneous coronary intervention (PCI). Thrombocytopenia is a known complication of glycoprotein (GP) IIb/IIIa inhibitors. Although, in general, GP IIb/IIIa inhibitor-induced thrombocytopenia is a harmless side effect which responds readily to thrombocyte transfusion, it can occasionally be a very serious complication associated with serious bleeding. In addition patients developing thrombocytopenia have unfavorable outcome (e.g., death, myocardial infarction, bypass surgery or additional PCI) in comparison to patients without thrombocytopenia. Advanced age (> 65 years), low BMI and a low initial thrombocyte count (<180,000/microl) are independent risk factors of thrombocytopenia. The risk of bleeding is higher with this form of thrombocytopenia not only due to the low thrombocyte count but also to the impaired function of the remaining thrombocytes. It is important to closely monitor platelet count during GP IIb/IIIa antagonist treatment. Platelet count monitoring two, six, twelve and 24 hour after starting the treatment reveals most cases of acute thrombocytopenia. Side effects can be avoided by the early discontinuation of the GP IIb/IIIa antagonist treatment. This article reviews the diagnosis and treatment of glycoprotein IIb/IIIa inhibitor-induced thrombocytopenia and summarizes the differential diagnosis from heparin-induced thrombocytopenia and laboratory-related pseudothrombocytopenia.

MRI morphometric analysis and neuropsychological function in patients with neurofibromatosis

Volumes of cerebral gray and white matter were measured in 22 children with neurofibromatosis type 1 (NF1) and in 20 controls. Judgment of Line Orientation (JLO) and the Developmental Test of Visual-Motor Integration (DTVMI) were administered to 16 of the NF1 patients. General linear models analysis of covariance revealed significantly larger brain volumes in NF1 children than in controls, particularly in white matter, and particularly in girls. JLO and DTVMI performance were positively related to right-hemisphere gray-matter volume. The results implicate a failure of growth control in NF1, leading to aberrant neurodevelopment. Our findings also suggest a basis for refined understanding of learning disabilities, which are a prominent feature of NF1.

Hypertension in Jordanian children: a retrospective analysis of 70 cases

Seventy patients, aged 1-20 years, were seen at Jordan University Hospital with high blood pressure (BP) over a 3-year period. BP values ranged from 140 to 230 mmHg for systolic pressure and from 90 to 130 mmHg for diastolic pressure. Essential hypertension was seen in only 6 patients (8.6%); secondary hypertension (n = 64 or 91.4%) was due to renal parenchymal diseases (RPD) in 46 patients (65.7%), reno-vascular lesions in 8 (11.4%), renal transplantation in 5 (7.2%), teenage pregnancy in 4 (5.7%), and phaeochromocytoma in 1 patient (1.4%). The aetiologies of RPD were as follows: end-stage renal disease requiring dialysis in 14 patients, acute glomerulonephritis in 14, idiopathic nephrotic syndrome in 10, chronic renal insufficiency in 5, and polycystic kidney in 3 patients. Surgical cure of hypertension was achieved in 5 of the children with reno-vascular lesions and in the patient with phaeochromocytoma.