Care Seeking for Neonatal Illness in Low- and Middle-Income Countries: A Systematic Review

Background

Despite recent achievements to reduce child mortality, neonatal deaths continue to remain high, accounting for 41% of all deaths in children under five years of age worldwide, of which over 90% occur in low- and middle-income countries (LMICs). Infections are a leading cause of death and limitations in care seeking for ill neonates contribute to high mortality rates. As estimates for care-seeking behaviors in LMICs have not been studied, this review describes care seeking for neonatal illnesses in LMICs, with particular attention to type of care sought.

Methods and Findings

We conducted a systematic literature review of studies that reported the proportion of caregivers that sought care for ill or suspected ill neonates in LMICs. The initial search yielded 784 studies, of which 22 studies described relevant data from community household surveys, facility-based surveys, and intervention trials. The majority of studies were from South Asia (n = 17/22), set in rural areas (n = 17/22), and published within the last 4 years (n = 18/22). Of the 9,098 neonates who were ill or suspected to be ill, 4,320 caregivers sought some type of care, including care from a health facility (n = 370) or provider (n = 1,813). Care seeking ranged between 10% and 100% among caregivers with a median of 59%. Care seeking from a health care provider yielded a similar range and median, while care seeking at a health care facility ranged between 1% and 100%, with a median of 20%. Care-seeking estimates were limited by the few studies conducted in urban settings and regions other than South Asia. There was a lack of consistency regarding illness, care-seeking, and care provider definitions.

Conclusions

There is a paucity of data regarding newborn care-seeking behaviors; in South Asia, care seeking is low for newborn illness, especially in terms of care sought from health care facilities and medically trained providers. There is a need for representative data to describe care-seeking patterns in different geographic regions and better understand mechanisms to enhance care seeking during this vulnerable time period. Please see later in the article for the Editors'' Summary     

Heart Failure Care in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Background

Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.

Methods and Findings

Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%–64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%–41%) with beta-blockers, and 32% (95% CI: 25%–39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%–7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%–10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified.

Conclusions

The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors'' Summary     

注意缺损多动障碍关联于DXS7位点

用单细胞凝胶电泳法检测了稀土化合物氯化钇和氯化镨对人外周血淋巴细胞的DNA损伤效应。结果表明,与对照相比,3种不同浓度的氯化钇和氯化镨均可引起淋巴细胞DNA受损后DNA迁移率的显著升高,受损伤细胞的百分率与对照差异明显,提示氯化钇和氯化镨具有一定的遗传毒性。 Abstract:The effect of DNA damage in human lymphocytes induced by yttrium chloride and praseodymium chloride was detected using SCG assay.The results showed that a highly significant increase in DNA migration in DNA-damaged lymphocytes was induced by three different concentrations of yttrium and praseodymium compared with the control,The percentage of DNA-damaged have genetic toxicity.The relevant points to this study are discussed.     

Maternal and Perinatal Outcomes of Twin Pregnancy in 23 Low- and Middle-Income Countries

Background

Twin pregnancies in low- and middle-income countries (LMICs) pose a high risk to mothers and newborns due to inherent biological risks and scarcity of health resources. We conducted a secondary analysis of the WHO Global Survey dataset to analyze maternal and perinatal outcomes in twin pregnancies and factors associated with perinatal morbidity and mortality in twins.

Methods

We examined maternal and neonatal characteristics in twin deliveries in 23 LMICs and conducted multi-level logistic regression to determine the association between twins and adverse maternal and perinatal outcomes.

Results

279,425 mothers gave birth to 276,187 (98.8%) singletons and 6,476 (1.2%) twins. Odds of severe adverse maternal outcomes (death, blood transfusion, ICU admission or hysterectomy) (AOR 1.85, 95% CI 1.60–2.14) and perinatal mortality (AOR 2.46, 95% CI 1.40–4.35) in twin pregnancies were higher, however early neonatal death (AOR 2.50, 95% CI 0.95–6.62) and stillbirth (AOR 1.22, 95% CI 0.58–2.57) did not reach significance. Amongst twins alone, maternal age <18, poor education and antenatal care, nulliparity, vaginal bleeding, non-cephalic presentations, birth weight discordance >15%, born second, preterm birth and low birthweight were associated with perinatal mortality. Marriage and caesarean section were protective.

Conclusions

Twin pregnancy is a significant risk factor for maternal and perinatal morbidity and mortality in low-resource settings; maternal risk and access to safe caesarean section may determine safest mode of delivery in LMICs. Improving obstetric care in twin pregnancies, particularly timely access to safe caesarean section, is required to reduce risk to mother and baby.     

Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder

Historically, pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) have been considered to be the only type of interventions effective for reducing the core symptoms of this condition. However, during the past three decades, a series of case and controlled group studies examining the effects of EEG biofeedback have reported improved attention and behavioral control, increased cortical activation on quantitative electroencephalographic examination, and gains on tests of intelligence and academic achievement in response to this type of treatment. This review paper critically examines the empirical evidence, applying the efficacy guidelines jointly established by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR). On the basis of these scientific principles, EEG biofeedback was determined to be “probably efficacious” for the treatment of ADHD. Although significant clinical improvement was reported in approximately 75% of the patients in each of the published research studies, additional randomized, controlled group studies are needed in order to provide a better estimate of the percentage of patients with ADHD who will demonstrate such gains in clinical practice.     

注意缺损多动障碍和儿茶酚-O-甲基转移酶基因无关联性

以往研究表明,儿茶酚胺系统可能参于注意缺损多动障碍（attention—deficit hyperactivityity disorder,ADHD）的发生,而儿茶酚胺-O-甲基转移酶（catechel—O—methyltransferase,COMT）是一种降解多巴胺和去甲肾上腺素系统的儿茶酚胺神经递质的酶。因此,采用两种以家系为基础的分析方法,即传递不平衡实验（transmission disequilibrium test,TDT）和单倍型为基础的单倍型相对风险率（haplotype—based haplotype relative risk,HHRR）去探讨COMT和中国人群中79个ADHD核心家系的关联性,ADHD诊断符合DSM—IV的诊断标准。TDT（X^2=1．03,df=1,P〉0．05）和HHRR（X^2=1．08,df=1,P〉0．05）两种方法的分析结果表明,COMT等位基因不能优先传递给ADHD儿童,提示在中国人群中ADHD与COMT基因无关联性。     

Imaging Functional and Structural Brain Connectomics in Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopment disorders in childhood. Clinically, the core symptoms of this disorder include inattention, hyperactivity, and impulsivity. Previous studies have documented that these behavior deficits in ADHD children are associated with not only regional brain abnormalities but also changes in functional and structural connectivity among regions. In the past several years, our understanding of how ADHD affects the brain’s connectivity has been greatly advanced by mapping topological alterations of large-scale brain networks (i.e., connectomes) using noninvasive neurophysiological and neuroimaging techniques (e.g., electroencephalograph, functional MRI, and diffusion MRI) in combination with graph theoretical approaches. In this review, we summarize the recent progresses of functional and structural brain connectomics in ADHD, focusing on graphic analysis of large-scale brain systems. Convergent evidence suggests that children with ADHD had abnormal small-world properties in both functional and structural brain networks characterized by higher local clustering and lower global integrity, suggesting a disorder-related shift of network topology toward regular configurations. Moreover, ADHD children showed the redistribution of regional nodes and connectivity involving the default-mode, attention, and sensorimotor systems. Importantly, these ADHD-associated alterations significantly correlated with behavior disturbances (e.g., inattention and hyperactivity/impulsivity symptoms) and exhibited differential patterns between clinical subtypes. Together, these connectome-based studies highlight brain network dysfunction in ADHD, thus opening up a new window into our understanding of the pathophysiological mechanisms of this disorder. These works might also have important implications on the development of imaging-based biomarkers for clinical diagnosis and treatment evaluation in ADHD.     

A Framework for the Monitoring and Evaluation of International Surgical Initiatives in Low- and Middle-Income Countries

Background

An estimated two billion people worldwide lack adequate access to surgical care. To address this humanitarian emergency, an increasing number of international surgical partnerships are emerging between developed and low- and middle-income countries (LMICs). At present, there are no clear indicators that may be used to assess the effectiveness of such initiatives.

Study Design

We conducted an international qualitative study of 31 surgeons from developed and LMICs involved in international partnerships across a variety of subspecialties. Thematic analysis and grounded theory were applied in order to develop a practical framework that may be applied to monitor and evaluate global surgical initiatives.

Results

Several themes emerged from the study: (i) there is a large unmet need to establish and maintain prospective databases in LMICs to inform the monitoring and evaluation of international surgical partnerships; (ii) assessment of initiatives must occur longitudinally over the span of several years; (ii) the domains of assessment are contextual and encompass cultural, institutional and regional factors; and (iv) evaluation strategies should explore broader impact within the community and country. Based on thematic analysis within the domains of inputs, outputs and outcomes, a framework for the monitoring and evaluation of international surgical initiatives, the Framework for the Assessment of InteRNational Surgical Success (FAIRNeSS) is proposed.

Conclusions

In response to the increasing number of surgical partnerships between developed and LMICs, we propose a framework to monitor and evaluate international surgical initiatives.     

Infant Feeding and School Attainment in Five Cohorts from Low- and Middle-Income Countries

Background

Performance in intelligence tests tends to be higher among individuals breastfed as infants, but little is known about the association between breastfeeding and achieved schooling. We assessed the association of infant feeding with school achievement in five cohorts from low- and middle-income countries. Unlike high-income country settings where most previous studies come from, breastfeeding is not positively associated with socioeconomic position in our cohorts, thus reducing the likelihood of a spurious positive association.

Methodology and Principal Findings

Participants included 10,082 young adults from five birth cohorts (Brazil, India, Guatemala, the Philippines, and South Africa). The exposures variables were whether the subject was ever breastfed, total duration of breastfeeding, and age at introduction of complementary foods. We adjusted the estimates for age at follow up, sex, maternal age, smoking during pregnancy, birthweight and socioeconomic position at birth. The key outcome was the highest grade achieved at school. In unadjusted analyses, the association between ever breastfeeding and schooling was positive in Brazil, inverse in the Philippines, and null in South Africa; in adjusted analyses, these associations were attenuated. In Brazil, schooling was highest among individuals breastfed for 3–12 months whereas in the Philippines duration of breastfeeding was inversely associated with schooling; and null associations were observed in South Africa and Guatemala. These associations were attenuated in adjusted models. Late introduction of solid foods was associated with lower schooling achievement in Brazil and South Africa.

Conclusion

Measures of breastfeeding are not consistently related to schooling achievement in contemporary cohorts of young adults in lower and middle-income countries.     

Resource Needs for Adolescent Friendly Health Services: Estimates for 74 Low- and Middle-Income Countries

Background

In order to achieve Millennium Development Goals 4, 5 and 6, it is essential to address adolescents’ health.

Objective

To estimate the additional resources required to scale up adolescent friendly health service interventions with the objective to reduce mortality and morbidity among individuals aged 10 to 19 years in 74 low- and middle- income countries.

Methods

A costing model was developed to estimate the financial resources needed to scale-up delivery of a set of interventions including contraception, maternity care, management of sexually transmitted infections, HIV testing and counseling, safe abortion services, HIV harm reduction, HIV care and treatment and care of injuries due to intimate partner physical and sexual violence. Financial costs were estimated for each intervention, country and year using a bottom-up ingredients approach, defining costs at different levels of delivery (i.e., community, health centre, and hospital level). Programme activity costs to improve quality of care were also estimated, including activities undertaken at national-, district- and facility level in order to improve adolescents’ use of health services (i.e., to render health services adolescent friendly).

Results

Costs of achieving universal coverage are estimated at an additional US$ 15.41 billion for the period 2011–2015, increasing from US$ 1.86 billion in 2011 to US$ 4,31 billion in 2015. This corresponds to approximately US$ 1.02 per adolescent in 2011, increasing to 4.70 in 2015. On average, for all 74 countries, an annual additional expenditure per capita ranging from of US$ 0.38 in 2011 to US$ 0.82 in 2015, would be required to support the scale-up of key adolescent friendly health services.

Conclusion

The estimated costs show a substantial investment gap and are indicative of the additional investments required to scale up health service delivery to adolescents towards universal coverage by 2015.