Evaluation of primary care in a community clinic by means of explicit process criteria.

This study reports an evaluation of care given at an urban multidisciplinary community family practice clinic. By means of an "indicator-condition" approach, the criteria and rating system developed for the Burlington Randomized Controlled Trial (BRCT) were applied to 103 randomly selected charts demonstrating 124 episodes of care given for seven specific "conditions": otitis media, hypertension, prenatal care, care of the newborn up to the age of 12 months, immunization up to the age of 24 months, depression and urinary tract infection. Overall, 83 (67%) of the episodes of care studied were rated adequate or superior. The proportion of such episodes varied from 33% for hypertension to 81% for care of the newborn. No statistically significant differences were found between these results and those of the BRCT. A total of 48 instances of inadequate care were noted, of which 21 (44%) were omissions in patient management. Inadequate preventive care and care of chronic diseases was more common than inadequate care of acute infectious diseases. The method of primary care assessment used was found to be both practical and inexpensive.     

Serologic evidence of Chlamydia trachomatis infection and risk of preterm birth.

OBJECTIVE: To determine whether serologic evidence of Chlamydia trachomatis during pregnancy is a risk factor for preterm delivery (before 37 weeks'' gestation). DESIGN: Chart review. SETTING: Antenatal clinics associated with a teaching hospital. PATIENTS: A group of 103 unselected consecutive patients presenting for routine prenatal care. OUTCOME MEASURES: Pregnancy outcome and C. trachomatis serologic status. RESULTS: A total of 21 women (20%) were found to be seropositive for IgG antibodies to C. trachomatis. They were similar to the seronegative women with respect to maternal age, parity, history of preterm birth, obstetric or medical problems, smoking status, history of drug abuse, educational status and psychosocial stressors. The seropositive women were significantly more likely than the seronegative women to have a preterm birth (24% [5/21] v. 7% [6/82]i p = 0.029, odds ratio 3.96, 95% confidence interval 1.08 to 14.57), an infant with a lower mean gestational age at birth (262 [standard deviation (SD) 19] days v. 273 [SD 15] days; p = 0.0052) and an infant with a lower mean birth weight (3125 [SD 692] g v. 3473 [SD 696] g; p = 0.0434). The positive predictive value of a seropositive result for preterm birth was 31% (5/16); the negative predictive value of a seronegative result for preterm birth was 8% (6/76). CONCLUSION: Women with serologic evidence of C. trachomatis may be at risk for preterm birth. Further study is required to determine whether serologic testing for C. trachomatis should be a routine part of prenatal care.     

Influence of serum on in situ proliferation and genotoxicity in A549 human lung cells exposed to nanomaterials

In this work in situ proliferation of A549 human lung epithelial carcinoma cells exposed to nanomaterials (NMs) was investigated in the presence or absence of 10% serum. NMs were selected based on chemical composition, size, charge and shape (Lys-SiO(2), TiO(2), ZnO, and multi walled carbon nanotubes, MWCNTs). Cells were treated with NMs and 4h later, cytochalasin-B was added. 36 h later, cell morphology was analyzed under a light microscope. Nuclearity was scored to determine the cytokinesis-block proliferation index (CBPI). CBPI, based on percentage of mono-, bi- and multi-nucleated cells, reflects cell toxicity and cell cycle delay. For some conditions depending on NM type (TiO(2) and MWCNT) and serum concentration (0%) scoring of CBPI was impossible due to overload of agglomerated NMs. Moreover, where heavy agglomeration occurs, micronuclei (MN) detection and scoring under microscope was prevented. A statistically significant decrease of CBPI was found for ZnO NM suspended in medium in the absence or presence of 10% serum at 25 μg/ml and 50 μg/ml, respectively and for Lys-SiO(2) NM at 3.5 μg/ml in 0% serum. Increase in MN frequency was observed in cells treated in 10% serum with 50 μg/ml ZnO. In 0% serum, the concentrations tested led to high toxicity. No genotoxic effects were induced by Lys-SiO(2) both in the absence or presence of serum up to 5 μg/ml. No toxicity was detected for TiO(2) and MWCNTs in both 10% and 0% serum, up to the dose of 250 μg/ml. Restoration of CBPI comparable to untreated control was shown for cells cultured without serum and treated with 5 μg/ml of Lys-SiO(2) NM pre-incubated in 100% serum. This observation confirms the protective effect of serum on Lys-SiO(2) NM cell toxicity. In conclusion in situ CBPI is proposed as a simple preliminary assay to assess both NMs induced cell toxicity and feasibility of MN scoring under microscope.     

The Role of Prenatal Care and Social Risk Factors in the Relationship between Immigrant Status and Neonatal Morbidity: A Retrospective Cohort Study

Background and Aim

Literature evaluating association between neonatal morbidity and immigrant status presents contradictory results. Poorer compliance with prenatal care and greater social risk factors among immigrants could play roles as major confounding variables, thus explaining contradictions. We examined whether prenatal care and social risk factors are confounding variables in the relationship between immigrant status and neonatal morbidity.

Methods

Retrospective cohort study: 231 pregnant African immigrant women were recruited from 2007–2010 in northern Spain. A Spanish population sample was obtained by simple random sampling at 1:3 ratio. Immigrant status (Spanish, Sub-Saharan and Northern African), prenatal care (Kessner Index adequate, intermediate or inadequate), and social risk factors were treated as independent variables. Low birth weight (LBW < 2500 grams) and preterm birth (< 37 weeks) were collected as neonatal morbidity variables. Crude and adjusted odds ratios (OR) were estimated by unconditional logistic regression with 95% confidence intervals (95% CI).

Results

Positive associations between immigrant women and higher risk of neonatal morbidity were obtained. Crude OR for preterm births in Northern Africans with respect to nonimmigrants was 2.28 (95% CI: 1.04–5.00), and crude OR for LBW was 1.77 (95% CI: 0.74–4.22). However, after adjusting for prenatal care and social risk factors, associations became protective: adjusted OR for preterm birth = 0.42 (95% CI: 0.14–1.32); LBW = 0.48 (95% CI: 0.15–1.52). Poor compliance with prenatal care was the main independent risk factor associated with both preterm birth (adjusted OR inadequate care = 17.05; 95% CI: 3.92–74.24) and LBW (adjusted OR inadequate care = 6.25; 95% CI: 1.28–30.46). Social risk was an important independent risk factor associated with LBW (adjusted OR = 5.42; 95% CI: 1.58–18.62).

Conclusions

Prenatal care and social risk factors were major confounding variables in the relationship between immigrant status and neonatal morbidity.     

Adequate Prenatal Care Reduces the Risk of Adverse Pregnancy Outcomes in Women with History of Infertility: A Nationwide Population-Based Study

Objectives

To investigate the effects of various measures of prenatal care on adverse pregnancy outcomes in women with a history of infertility.

Study Design

A retrospective cohort study.

Methods

Data were derived by linking 2 large nationwide population-based datasets, the National Health Insurance Research Database and Taiwan Birth Certificate Registry. The study sample included 15,056 women with an infertility diagnosis and 60,224 randomly selected women without infertility matched to the study sample by maternal age. A conditional logistic regression analysis was performed for the analysis.

Results

Women diagnosed with infertility respectively had 1.39 (95% CI, 1.06~1.83), 1.15 (95% CI, 1.08~1.24), 1.13 (95% CI, 1.08~1.18), and 1.08 (95% CI, 1.05~1.12) higher odds of having very low birth weight (VLBW) babies, preterm births, labor complications, and cesarean sections (CSs) compared to women without infertility. Inadequate numbers of total and major prenatal visits and late initiation of prenatal care increased the risks of adverse pregnancy outcomes in women with infertility, especially the risk of a VLBW baby. However, no significant associations were found for the risks of adverse birth outcomes in infertile women with adequate prenatal care compared to fertile women with adequate care.

Conclusions

Study findings suggest that adequate prenatal care can reduce the risk of adverse pregnancy outcomes in women with infertility.     

Differences in intrapartum obstetric care provided to women at low risk by family physicians and obstetricians.

To determine differences in practice style and to examine maternal and neonatal outcomes, we reviewed the hospital charts of 1115 women admitted by family physicians and 1250 women admitted by obstetricians who gave birth at one of three teaching hospitals in Toronto between April 1985 and March 1986. All the women in the two groups were categorized retrospectively as being at low risk at the onset of labour on the basis of their prenatal records and their admission histories and physical examination results. There were higher proportions of younger women and women of lower socioeconomic status in the family physician group than in the obstetrician group (p less than 0.001). The rates of interventions, including artificial rupture of the membranes, induction, augmentation, low forceps plus vacuum extraction, episiotomy and epidural anesthesia, were all higher in the obstetrician group. The mean birth weight and the cesarean section rate were the same in the two groups. Differences in labour and delivery outcomes between the two groups, including a higher rate of spontaneous vaginal delivery for the family physicians, reflected a more "expectant" practice style by family doctors. However, there were no significant differences in the rates of maternal or neonatal complications. A practice style characterized by a higher rate of interventions was not associated with improved maternal or newborn outcome in this low-risk setting.     

Comparative Hazard Identification by a Single Dose Lung Exposure of Zinc Oxide and Silver Nanomaterials in Mice

Comparative hazard identification of nanomaterials (NMs) can aid in the prioritisation for further toxicity testing. Here, we assessed the acute lung, systemic and liver responses in C57BL/6N mice for three NMs to provide a hazard ranking. A silver (Ag), non-functionalised zinc oxide (ZnO) and a triethoxycaprylylsilane functionalised ZnO NM suspended in water with 2% mouse serum were examined 24 hours following a single intratracheal instillation (I.T.). An acute pulmonary inflammation was noted (marked by a polymorphonuclear neutrophil influx) with cell damage (LDH and total protein) in broncho-alveolar lavage fluid (BALF) after administration of both non-functionalised and functionalised ZnO. The latter also induced systemic inflammation measured as an increase in blood neutrophils and a decrease in blood lymphocytes. Exposure to Ag NM was not accompanied by pulmonary inflammation or cytotoxicity, or by systemic inflammation. A decrease in glutathione levels was demonstrated in the liver following exposure to high doses of all three nanomaterials irrespective of any noticeable inflammatory or cytotoxic effects in the lung. By applying benchmark dose (BMD) modeling statistics to compare potencies of the NMs, we rank functionalised ZnO ranked the highest based on the largest number of affected endpoints, as well as the strongest responses observed after 24 hours. The non-functionalised ZnO NM gave an almost similar response, whereas Ag NM did not cause an acute response at similar doses.     

Electron microscopy of nuclear matrices prepared in situ under oxidizing conditions

Nuclear matrices (NM) were prepared from mouse 3T3 fibroblasts attached to growth support film in the continuous presence of the disulfide cross-linking reagent, sodium tetrathionate. Intact cells and samples at each stage of NM preparation were fixed, embedded in Epon-Araldite, sectioned and stained conventionally with uranyl-lead. Nuclear size and shape changed little during extraction, but nuclei showed a gradual reduction in internal fibrogranular elements up to 1M NaCl, after which larger spaces were visible in the nucleoplasm. In contrast to similar samples prepared under reducing conditions in other studies, final NMs contained a highly ramified internal network of fibers and granular aggregates.     

Care in a birth room versus a conventional setting: a controlled trial.

A controlled clinical trial was carried out to assess whether a birth room setting would influence the care of mothers and newborns. Of the 163 low-risk women enrolled, 49 (30%) manifested some prenatal risk and were excluded. The remaining 114 were allocated by strict alternation to a birth room or a conventional setting. Of the 56 women allocated to the birth room, 63% of the primiparas and 19% of the multiparas were later transferred. The numbers in the two settings who had oxytocin stimulation, epidural anesthesia, forceps delivery or cesarean section did not show statistically significant differences. The episiotomy rates were slightly lower in the birth room than in the conventional setting, and the rates of an intact perineum were higher in the birth room. Neither the Apgar scores nor the morbidity rates of the infants showed statistically significant differences related to the setting to which the mother had been allocated, although more infants from the conventional setting were admitted to a special care unit. Both "experimental" groups of women less often received routine perineal shaving, enemas or intravenous infusions than did an obstetrically similar nonexperimental comparison group. Despite the apparent inability in this setting for the birth room to influence the rate of major obstetric procedures (except for episiotomy) and outcomes, the authors believe that a birth room is desirable in tertiary care centres as well as in community hospitals.     

Neuromelanins of Human Brain Have Soluble and Insoluble Components with Dolichols Attached to the Melanic Structure

Neuromelanins (NMs) are neuronal pigments of melanic-lipidic type which accumulate during aging. They are involved in protective and degenerative mechanisms depending on the cellular context, however their structures are still poorly understood. NMs from nine human brain areas were analyzed in detail. Elemental analysis led to identification of three types of NM, while infrared spectroscopy showed that NMs from neurons of substantia nigra and locus coeruleus, which selectively degenerate in Parkinson’s disease, have similar structure but different from NMs from brain regions not targeted by the disease. Synthetic melanins containing Fe and bovine serum albumin were prepared to model the natural product and help clarifying the structure of NMs. Extensive nuclear magnetic resonance spectroscopy studies showed the presence of dolichols both in the soluble and insoluble parts of NM. Diffusion measurements demonstrated that the dimethyl sulfoxide soluble components consist of oligomeric precursors with MWs in the range 1.4–52 kDa, while the insoluble part contains polymers of larger size but with a similar composition. These data suggest that the selective vulnerability of neurons of substantia nigra and locus coeruleus in Parkinson’s disease might depend on the structure of the pigment. Moreover, they allow to propose a pathway for NM biosynthesis in human brain.     

Effects of social support during parturition on maternal and infant morbidity.

Because continuous social support during labour is a component of care in many societies but inconsistent in our own, the clinical effect of support during labour on maternal and neonatal morbidity were studied. Social support was provided by female companions. Four hundred and sixty five healthy primigravidous women were enrolled using a randomised design. Compared with 249 women undergoing labour alone 168 women who had supportive female companions throughout labour had significantly fewer perinatal complications (p less than 0.001), including caesarean sections (7% v 17%, p less than 0.01) and oxytocin augmentation (2% v 13%, p less than 0.001), and fewer infants admitted to neonatal intensive care (p less than 0.10). Of the women who had an uncomplicated labour and delivery requiring no interventions, those with a companion had a significantly shorter duration of labour (7.7 hours v 15.5 hours, p less than 0.001). This study suggests that constant human support may be of great benefit to women during labour.     

Variables that explain variation in prenatal care in Turkey; social class, education and ethnicity re-visited

The extent and quality of prenatal care are important for the health of women and their babies. Recent studies suggest that women lack adequate prenatal care in contemporary Turkey. This paper uses regression models to examine the major factors impacting on the access of women to prenatal care through the 1993 Turkish Demographic and Health Survey. The findings suggest that after controlling for class, ethnicity does not explain the likelihood of a woman's access to prenatal care, partly because the predominant patriarchal ideology in Turkey determines women's access to education, which in turn determines their access to prenatal care. It can be argued that unless women's socioeconomic status in the family improves, their access to health care in general and prenatal care in particular will not increase significantly.     

MPSQ: a web tool for protein-state searching

MPSQ (multi-protein-states query) is a web-based tool for the discovery of protein states (e.g. biological interactions, covalent modifications, cellular localizations). In particular, large sets of genes can be used to search for enriched state transition network maps (NMs) and features facilitating the interpretation of genomic-scale experiments such as microarrays. One NM collects all the catalogued states of a protein as well as the mutual transitions between the states. For the returned NM, graph visualization is provided for easy understanding and to guide further analysis.     

Risk factors for gastroschisis

The prevalence at birth of gastroschisis, a rare abnormality of the abdominal wall, appears to have increased over the past decade. To characterize risk factors that might explain this increase, birth certificates for Washington State residents were compared for 62 infants born with gastroschisis during the years 1984 to 1987 and 617 randomly selected unaffected infants matched for birth year. After simultaneously adjusting for 14 potential risk factors, 4 factors stood out. Infants born during January, February, or March were at greater risk than infants born in any other months (odds ratio 2.2, 95% confidence interval 1.1, 4.1). Mothers less than 25 years old were at greater risk than mothers 25 years and older, with the highest risk to mothers less than 20 years old (odds ratio 4.1, 95% confidence interval 1.4, 12.0). Women who smoked during pregnancy were at greater risk than women who did not smoke (odds ratio 2.0, 95% confidence interval 1.03, 3.8). Finally, mothers receiving inadequate prenatal care were at greater risk than mothers receiving adequate prenatal care (odds ratio 2.1, 95% confidence interval 0.99, 4.6). Unidentified behavioral and environmental exposures may explain the associations with month of birth, maternal age, and prenatal care. However, smoking during pregnancy is a plausible risk factor that should be examined further as an explanation of the apparently increasing prevalence at birth of gastroschisis in developed nations.     

Underlying and proximate determinants of diarrhoea-specific infant mortality rates among municipalities in the state of Céara, north-east Brazil: an ecological study

This ecological study examines the variations in diarrhoea-specific infant mortality rates among municipalities in the State of Ceará, north-east Brazil, using data from a community health workers' programme. Diarrhoea is the main cause of postneonatal deaths in Ceará, and diarrhoea mortality rates vary substantially among municipalities, from 7 to 50 per thousand live births. To determine the inter-relationships between potential predictors of diarrhoea-specific infant mortality, eleven variables were classified into proximate determinants (i.e. adequate weight gain and exclusive breast-feeding in first 4 months) and underlying determinants (i.e. health services and socioeconomic variables). The health services variables included percentage with prenatal care up-to-date, participation in growth monitoring and immunization up-to-date, while the socioeconomic factors included female illiteracy rate, per capita gross municipality product and percentage of households with low income, percentage of households with inadequate water supply and inadequate sanitation, and urbanization. Using linear regression analysis variables were included from each group to build regression models. The significant determinants of variability in diarrhoea-specific infant mortality between municipalities were prevalence of infants exclusively breast-feeding, percentage of infants with adequate weight gain, percentage of pregnant women with prenatal care up-to-date, female illiteracy rate and inadequate water supply. These findings suggest that community-based promotion of exclusive breast-feeding in the first 4 months and care-giving behaviours that prevent weight faltering, including weaning practices and feeding during and following diarrhoea episodes, may further reduce municipality-level diarrhoea-specific mortality. Primary heath care strategies addressing these two proximate determinants provide only a partial solution to reducing diarrhoeal disease mortality. Improvements in municipal health services (prenatal care) and socioeconomic status variables, including water supply and maternal education, can also contribute to reduction of infant mortality due to diarrhoea. These results may be used by government health officials to set priorities by considering not only the strength of the association between selected risk factors and diarrhoea mortality rates, but also the prevalence of the risk factors being considered at the municipality level. Finally, the methods used are applicable to other settings with community-based primary health care decentralized to the state or municipal level.     

Comparative study of nano and bulk Fe3O4 induced oxidative stress in Wistar rats

Context: Magnetic nanomaterials (Fe₃O₄ NMs) have become novel tools with multiple biological and medical applications because of their biocompatibility. However, adverse health effects of these NMs are of great interest to learn.

Objective: This study was designed to assess the size and dose-dependent effects of Fe₃O₄ NMs and its bulk on oxidative stress biomarkers after post–subacute treatment in female Wistar rats.

Methods: Rats were daily administered with 30, 300 and 1000?mg/kg b.w. doses for 28?d of Fe₃O₄ NMs and its bulk for biodistribution and histopathological studies.

Results: Fe₃O₄ NMs treatment caused significant increase in lipid peroxidation levels of treated rats. It was also observed that the NM treatment elicited significant changes in enzyme activities of superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase and glutathione-S-transferase in treated rat organs with major reduction in glutathione content. Metal content analysis revealed that tissue deposition of NM in the organs was higher when compared to bulk and caused histological changes in liver.

Conclusion: This study demonstrated that for same dose, NM showed higher bioaccumulation, oxidative stress and tissue damage than its bulk. The difference in toxic effect of Fe₃O₄ nano and bulk could be related to their altered physicochemical properties.     

Antenatal Care Utilisation and Content between Low-Risk and High-Risk Pregnant Women

Background

The purpose of antenatal care is to monitor and improve the wellbeing of the mother and foetus. The World Health Organization recommends risk-oriented strategy that includes: (i) routine care to all women, (ii) additional care for women with moderately severe diseases and complications, (iii) specialised obstetrical and neonatal care for women with severe diseases and complications. Antenatal care is concerned with adequate care in order to be effective. Measurement for adequacy of antenatal care often applies indexes that assess initiation of care and number of visits. In addition, adequacy of care content should also be assessed. Results of studies in developed settings demonstrate that women without risk factors use antenatal services more frequently than recommended. Such over-utilisation is problematic for low-resourced settings. Moreover, studies show that a substantial proportion of high-risk women had utilisation or content of care below the recommended standard. Yet studies in developing countries have seldom included a comparison between low-risk and high-risk women. The purpose of the study was therefore to assess adequacy of care and pregnancy outcomes for the different risk groups.

Methods

A retrospective study using a multistage sampling technique, at public-funded primary health care clinics was conducted. Antenatal utilisation level was assessed using a modified Adequacy of Prenatal Care Utilisation index that measures the timing for initiation of care and observed-to-expected visits ratio. Adequacy of antenatal care content assessed compliance to routine care based on the local guidelines.

Results

Intensive or “adequate-plus” antenatal care utilisation as defined by the modified index was noted in over half of the low-risk women. On the other hand, there were 26% of the high-risk women without the expected intensive utilisation. Primary- or non-educated high-risk women were less likely to have a higher antenatal care utilisation level compared with tertiary educated ones (OR = 0.20, P = 0.003). Half of all women had <80% of the recommended antenatal care content. A higher proportion of high-risk than low-risk women scored <80% of the routine care content (p<0.015). The majority of the additional laboratory tests were performed on high-risk women. Provision of antenatal education showed comparatively poor compliance to guidelines, more than half of the antenatal advice topics assessed were rarely provided to the women. High-risk women were associated with a higher prevalence of adverse pregnancy outcome.

Conclusions

Disproportionate utilisation of antenatal care according to risk level of pregnancy indicates the need for better scheduling of care. The risk-oriented approach often results in a tendency to focus on the risk conditions of the women. Training interventions are recommended to improve communication and to help healthcare professionals understand the priorities of the women. Further studies are required to assess the reason for disproportionate utilisation of antenatal care according to risk level and how delivery of antenatal advice can be improved, reviewing both user and provider perspectives.     

Barriers to prenatal care for low-income women.

Inadequate prenatal care is associated with poor birth outcomes. Recognizing barriers to care is necessary to improve results. Postpartum in-hospital interviews were conducted with women admitted through emergency departments with no physician of record (n = 69) in 8 Sacramento hospitals during April and May 1991. A focus group of local obstetrician-gynecologists was used to determine physicians'' attitudes about caring for low-income women. We undertook the study in response to an increased number of "no doc" births. The inability to find a physician willing to accept them was reported by the women as the single largest barrier to obtaining care, cited by 64% of women overall and 96% of those who tried but were unable to obtain care. Transportation difficulties were a problem regardless of women''s success in obtaining care and were ranked as the top barrier by women who never tried to obtain care. Physicians cited administrative difficulties and reimbursement levels of Medi-Cal plus extra care requirements and resource dependency of low-income patients as barriers to caring for this population. The value ascribed to prenatal care by women and physicians'' perceptions of women''s attitudes about care contrasted sharply. The link between poor women and physicians providing obstetric services can be fragile. The difficulty finding physicians willing to take them indicates that these women need special support services to ensure adequate care during pregnancy.