Therapeutic Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Although selective or whole body cooling combined with optimal intensive care improves outcomes following neonatal encephalopathy in high-income countries, the safety and efficacy of cooling in low-and middle-income countries is not known.

Objective

We performed a systematic review and meta-analysis of all published randomised or quasi-randomised controlled trials of cooling therapy for neonatal encephalopathy in low-and middle-income countries.

Results

Seven trials, comprising a total of 567 infants were included in the meta-analysis. Most study infants had mild (15%) or moderate encephalopathy (48%) and did not receive invasive ventilation (88%). Cooling devices included water-circulating cooling caps, frozen gel packs, ice, water bottles, and phase-changing material. No statistically significant reduction in neonatal mortality was seen with cooling (risk ratio: 0.74, 95% confidence intervals: 0.44 to 1.25). Data on other neonatal morbidities and long-term neurological outcomes were insufficient.

Conclusion

Cooling therapy was not associated with a statistically significant reduction in neonatal mortality in low-and middle-income countries although the confidence intervals were wide and not incompatible with results seen in high-income countries. The apparent lack of treatment effect may be due to the heterogeneity and poor quality of the included studies, inefficiency of the low technology cooling devices, lack of optimal neonatal intensive care, sedation and ventilatory support, overuse of oxygen, or may be due to the intrinsic difference in the population, for example higher rates of perinatal infection, obstructed labor, intrauterine growth retardation and maternal malnutrition. Evaluation of the safety and efficacy of cooling in adequately powered randomised controlled trials is required before cooling is offered in routine clinical practice in low-and middle-income countries.     

Integrating HIV Care into Primary Care Services: Quantifying Progress of an Intervention in South Africa

Background

Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated.

Methods

A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach''s alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial.

Results

Cronbach''s alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score.

Conclusion

The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.     

Geographic distribution of genetic diversity in populations of Rio Grande Chub <Emphasis Type="Italic">Gila pandora</Emphasis>

In the southwestern United States (US), the Rio Grande chub (Gila pandora) is state-listed as a fish species of greatest conservation need and federally listed as sensitive due to habitat alterations and competition with non-native fishes. Characterizing genetic diversity, genetic population structure, and effective number of breeders will assist with conservation efforts by providing a baseline of genetic metrics. Genetic relatedness within and among G. pandora populations throughout New Mexico was characterized using 11 microsatellite loci among 15 populations in three drainage basins (Rio Grande, Pecos, Canadian). Observed heterozygosity (H_O) ranged from 0.71–0.87 and was similar to expected heterozygosity (0.75–0.87). Rio Ojo Caliente (Rio Grande) had the highest allelic richness (A_R = 15.09), while Upper Rio Bonito (Pecos) had the lowest allelic richness (A_R = 6.75). Genetic differentiation existed among all populations with the lowest genetic variation occurring within the Pecos drainage. STRUCTURE analysis revealed seven genetic clusters. Populations of G. pandora within the upper Rio Grande drainage (Rio Ojo Caliente, Rio Vallecitos, Rio Pueblo de Taos) had high levels of admixture with Q-values ranging from 0.30–0.50. In contrast, populations within the Pecos drainage (Pecos River and Upper Rio Bonito) had low levels of admixture (Q = 0.94 and 0.87, respectively). Estimates of effective number of breeders (N _b ) varied from 6.1 (Pecos: Upper Rio Bonito) to 109.7 (Rio Grande: Rio Peñasco) indicating that populations in the Pecos drainage are at risk of extirpation. In the event that management actions are deemed necessary to preserve or increase genetic diversity of G. pandora, consideration must be given as to which populations are selected for translocation.     

The BCL2 -938C>A Promoter Polymorphism Is Associated with Risk for and Time to Aseptic Loosening of Total Hip Arthroplasty

Aseptic loosening is a major cause of revision surgery of total hip arthroplasty (THA). Only few host factors affecting aseptic loosening have been identified until now, although they are urgently needed to identify and possibly treat those patients at higher risk for aseptic loosening. To determine whether the functional single nucleotide polymorphism (SNP) c.-938C>A (rs2279115), located in the promoter region of the BCL2 gene has an impact on aseptic loosening of THA we genotyped and analyzed 234 patients suffering from aseptic loosening and 231 patients after primary THA. The polymorphism is associated with risk for aseptic loosening with the CC genotype at highest risk for aseptic loosening, Odds Ratio CC vs. AA 1.93, 95%CI 1.15–3.25, p = 0.013. In contrast, low risk AA genotype carriers that still developed aseptic loosening showed a significantly shorter time to aseptic loosening than patients carrying the C allele (p = 0.004). These results indicate that the BCL2 -938C>A polymorphism influences the occurrence and course of aseptic loosening and suggests this polymorphism as an interesting candidate for prospective studies and analyses in THA registers.     

Opposing the veil in the name of liberalism: popular attitudes to liberalism and Muslim veiling in the Netherlands

Is popular antagonism towards Muslim veils in Europe rooted in an exclusionary ‘enlightenment liberalism’? By examining different conceptions of liberalism and readings of veiling in a Dutch survey from 2014, we present the first study that investigates this question empirically. We thus bring together two hitherto largely unconnected literatures. The first is the work on immigration and ethnicity, which has shown the centrality of enlightenment liberalism in anti-Muslim media and policy discourses. The second is the literature on anti-Muslim attitudes in public opinion, which explains support for veil bans as the result of perceiving veils as threatening the respondent's own, supposedly liberal, values – but has failed to distinguish between different conceptions of liberalism and thus reached inconclusive results. This, we show, can be remedied by distinguishing between ‘enlightenment liberals’, who hold negative attitudes, and ‘reformation liberals’, who hold positive attitudes towards Muslim veils.     

Molecular-assisted alpha taxonomy of the genus Rhodymenia (Rhodymeniaceae,Rhodymeniales) from Australia reveals overlooked species diversity

A previously published DNA barcode survey of red macroalgae in Australia revealed significant cryptic and overlooked diversity for the genus Rhodymenia with recognition of R. novahollandica, R. prolificans, R. stenoglossa, R. wilsonis and an additional four uncharacterized genetic species groups. Since that study, increased sampling effort in Australia has warranted reassessment and reinvestigation of the number of genetic species groups attributed to Rhodymenia and their respective taxonomic affiliations. Using molecular-assisted alpha taxonomy employing the DNA barcode (COI-5P), the present study resolved 188 Australian specimens in 12 genetic species groups assignable to the genus Rhodymenia. Four of these groups were attributed to the previously recognized species (above), whereas some collections from Lord Howe Island were attributed to the New Zealand species R. novazelandica, expanding its biogeographic range. The following seven genetic groups were inconsistent with existing species of Rhodymenia and established as novel taxa: R. compressa sp. nov., R. contortuplicata sp. nov., R. gladiata sp. nov., R. insularis sp. nov., R. lociperonica sp. nov., R. norfolkensis sp. nov. and R. womersleyi sp. nov. Although morphological and biogeographic features were adequate for distinguishing some species of Rhodymenia from Australia, DNA sequencing in combination with morphology and biogeography provided the most reliable means of identification.