Evaluation of a Cluster-Randomized Controlled Trial of a Package of Community-Based Maternal and Newborn Interventions in Mirzapur,Bangladesh

Background

To evaluate a delivery strategy for newborn interventions in rural Bangladesh.

Methods

A cluster-randomized controlled trial was conducted in Mirzapur, Bangladesh. Twelve unions were randomized to intervention or comparison arm. All women of reproductive age were eligible to participate. In the intervention arm, community health workers identified pregnant women; made two antenatal home visits to promote birth and newborn care preparedness; made four postnatal home visits to negotiate preventive care practices and to assess newborns for illness; and referred sick neonates to a hospital and facilitated compliance. Primary outcome measures were antenatal and immediate newborn care behaviours, knowledge of danger signs, care seeking for neonatal complications, and neonatal mortality.

Findings

A total of 4616 and 5241 live births were recorded from 9987 and 11153 participants in the intervention and comparison arm, respectively. High coverage of antenatal (91% visited twice) and postnatal (69% visited on days 0 or 1) home visitations was achieved. Indicators of care practices and knowledge of maternal and neonatal danger signs improved. Adjusted mortality hazard ratio in the intervention arm, compared to the comparison arm, was 1.02 (95% CI: 0.80–1.30) at baseline and 0.87 (95% CI: 0.68–1.12) at endline. Primary causes of death were birth asphyxia (49%) and prematurity (26%). No adverse events associated with interventions were reported.

Conclusion

Lack of evidence for mortality impact despite high program coverage and quality assurance of implementation, and improvements in targeted newborn care practices suggests the intervention did not adequately address risk factors for mortality. The level and cause-structure of neonatal mortality in the local population must be considered in developing interventions. Programs must ensure skilled care during childbirth, including management of birth asphyxia and prematurity, and curative postnatal care during the first two days of life, in addition to essential newborn care and infection prevention and management.

Trial Registration

Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00198627","term_id":"NCT00198627"}}NCT00198627     

Human Microglia Transplanted in Rat Focal Ischemia Brain Induce Neuroprotection and Behavioral Improvement

Background and Purpose

Microglia are resident immunocompenent and phagocytic cells of central nervous system (CNS), which produce various cytokines and growth factors in response to injury and thereby regulate disease pathology. The purpose of this study is to investigate the effects of microglial transplantation on focal cerebral ischemia model in rat.

Methods

Transient middle cerebral artery occlusion (MCAO) in rats was induced by the intraluminal filament technique. HMO6 cells, human microglial cell line, were transplanted intravenously at 48 hours after MCAO. Functional tests were performed and the infarct volume was measured at 7 and 14 days after MCAO. Migration and cell survival of transplanted microglial cells and host glial reaction in the brain were studied by immunohistochemistry. Gene expression of neurotrophic factors, cytokines and chemokines in transplanted cells and host rat glial cells was determined by laser capture microdissection (LCM) and quantitative real time-PCR.

Results

HMO6 human microglial cells transplantion group demonstrated significant functional recovery compared with control group. At 7 and 14 days after MCAO, infarct volume was significantly reduced in the HMO group. In the HMO6 group, number of apoptotic cells was time-dependently reduced in the infarct core and penumbra. In addition, number of host rat microglia/macrophages and reactive astrocytes was significantly decreased at 7 and 14 days after MCAO in the penumbra. Gene expression of various neurotrophic factors (GDNF, BDNF, VEGF and BMP7) and anti-inflammatory cytokines (IL4 and IL5) was up-regulated in transplanted HMO6 cells of brain tissue compared with those in culture. The expression of GDNF and VEGF in astrocytes in penumbra was significantly up-regulated in the HMO6 group.

Conclusions

Our results indicate that transplantation of HMO6 human microglial cells reduces ischemic deficits and apoptotic events in stroke animals. The results were mediated by modulation of gliosis and neuroinflammation, and neuroprotection provided by neurotrophic factors of endogenous and transplanted cells-origin.     

Depression comorbidity among patients with tuberculosis in a university teaching hospital outpatient clinic in Nigeria

Background Tuberculosis (TB) remains a leading infectious cause of morbidity and mortality throughout the world. Medication non-compliance has been recognised as one of the drawbacks in the successful management of this disease. Hence, different approaches for ensuring medication compliance have been adopted; these include the Directly Observed Therapy Short course (DOTS). TB is associated with psychiatric morbidity, particularly depressive disorder, and this has been recognised as a cause of poor compliance and a cause of increased morbidity and mortality from the disease. Despite this recognition, little attention is paid to the identification of depression among TB patients, particularly in the DOTS clinics that most of these patients attend. This study was designed to determine the prevalence of depression in patients with TB attending the DOTS outpatient clinic in a university teaching hospital in Nigeria, and to find out the factors that may be associated with this.Method All consenting TB patients attending the clinic completed a socio-demographic questionnaire and nine-item Patient Health Questionnaire (PHQ-9) designed to screen for depression, especially in outpatient and primary care settings.Results Sixty-five patients participated in the study of whom 41 (63.1%) were males. The mean age of the respondents was 35.1 ± 14.4 (range 15-70 years). Eighteen (27.7%) of the patients had depression, comprising 14 (21.5%) with mild depression and four (6.2%) with moderate depression. Socio-demographic factors (age groups, P=0.024; and financial status, P=0.02) and a clinical factor (persistent cough, P=0.04) were significantly associated with depression.Conclusion Measures to reduce depression among patients with TB should include effective symptom control, particularly of coughing, and measures to improve the financial status of this group of patients. Financial empowerment of patients may reduce depression in them, improve the compliance rate to anti-TB medication, and could furthermore bring an improvement to their quality of life.     

Causes of Early Childhood Deaths in Urban Dhaka,Bangladesh

Data on causes of early childhood death from low-income urban areas are limited. The nationally representative Bangladesh Demographic and Health Survey 2007 estimates 65 children died per 1,000 live births. We investigated rates and causes of under-five deaths in an urban community near two large pediatric hospitals in Dhaka, Bangladesh and evaluated the impact of different recall periods. We conducted a survey in 2006 for 6971 households and a follow up survey in 2007 among eligible remaining households or replacement households. The initial survey collected information for all children under five years old who died in the previous year; the follow up survey on child deaths in the preceding five years. We compared mortality rates based on 1-year recall to the 4 years preceding the most recent 1 year. The initial survey identified 58 deaths among children <5 years in the preceding year. The follow up survey identified a mean 53 deaths per year in the preceding five years (SD±7.3). Under-five mortality rate was 34 and neonatal mortality was 15 per thousand live births during 2006–2007. The leading cause of under-five death was respiratory infections (22%). The mortality rates among children under 4 years old for the two time periods (most recent 1-year recall and the 4 years preceding the most recent 1 year) were similar (36 versus 32). The child mortality in urban Dhaka was substantially lower than the national rate. Mortality rates were not affected by recall periods between 1 and 5 years.     

Changes induces by haloperidol (antidepressant drug) on the developing retina of the chick embryo

Morphological and histological studies were done on the retina of chick embryos of 6th, 10th and 16th days of incubation by a single dose of haloperidol (0.25 mg/egg), injected on day zero and 5 of incubation. To get an idea about the extent of the teratogenic effect of this drug on the development retina. Sign of malformation in the chick embryo after administration of haloperidol were seen as absent of the ear vesicles, eyes or decreased size of them. Retardation of growth of the retina at 6th, 10th and 16th days treated chick embryo were observed as evidenced of reduction of the size of the retina, associated with sign of degeneration of the retina cells.

Conclusion

The injection of haloperidol drug give rise to several side effects as retardation of growth and degeneration of the cells. The decrease of the thickness of the layers and less density of the cells was related to direct effect of the drug on the cells of this organ. Also on the DNA formation and on the retardation of cellular mitotic activates, therefore the retina appeared decrease in thickness and less cell density with degeneration its cells.     

Cadmium and mercury levels in saudi women and its possible relationship with hypertension

The association between elevated blood pressure and blood cadmium and mercury levels was examined (2001–2002) in 185 Saudi women previously selected for a case-control study of lead and hypertension risk. Blood pressure was measured twice according to the World Health Organization recommendations. Cadmium and mercury were determined with graphite furnace and hydride system-atomic absorption spectrometry, respectively. Mean blood cadmium concentrations were 0.874±0.995 μg/L in hypertensive and 0.785±0.665 μg/L in controls. While blood mercury concentrations for hypertensives and controls were 3.506±3.617 μg/L and 3.687±3.186 μg/L, respectively. Participants were classified according to the median of blood cadmium and mercury levels. After adjustment for potentially confounding variables, the final logistic regression analyses revealed that women with blood cadmium ≥0.627 μg/L were 3.934 times were more likely to be hypertensive than those with blood cadmium levels <0.627 μg/L, although this was marginally significant (p=0.098). This was likely the result of the small number of subjects, resulting in the weak power to detect a strong significant difference between hypertensives and control cases. On the other hand, the final regression model showed no association between hypertension and mercury. However, this finding should not be conclusive because of the inappropriate choice of the biomarker indicator. Nevertheless, our study supports the hypothesis that exposure to cadmium might increase the risk of hypertension.     

Was Rodney Ledward a statistical outlier? Retrospective analysis using routine hospital data to identify gynaecologists' performance

Objectives To investigate whether routinely collected data from hospital episode statistics could be used to identify the gynaecologist Rodney Ledward, who was suspended in 1966 and was the subject of the Ritchie inquiry into quality and practice within the NHS.Design A mixed scanning approach was used to identify seven variables from hospital episode statistics that were likely to be associated with potentially poor performance. A blinded multivariate analysis was undertaken to determine the distance (known as the Mahalanobis distance) in the seven indicator multidimensional space that each consultant was from the average consultant in each year. The change in Mahalanobis distance over time was also investigated by using a mixed effects model.Setting NHS hospital trusts in two English regions, in the five years from 1991-2 to 1995-6.Population Gynaecology consultants (n = 143) and their hospital episode statistics data.Main outcome measure Whether Ledward was a statistical outlier at the 95% level.Results The proportion of consultants who were outliers in any one year (at the 95% significance level) ranged from 9% to 20%. Ledward appeared as an outlier in three of the five years. Our mixed effects (multi-year) model identified nine high outlier consultants, including Ledward.Conclusion It was possible to identify Ledward as an outlier by using hospital episode statistics data. Although our method found other outlier consultants, we strongly caution that these outliers should not be overinterpreted as indicative of “poor” performance. Instead, a scientific search for a credible explanation should be undertaken, but this was outside the remit of our study. The set of indicators used means that cancer specialists, for example, are likely to have high values for several indicators, and the approach needs to be refined to deal with case mix variation. Even after allowing for that, the interpretation of outlier status is still as yet unclear. Further prospective evaluation of our method is warranted, but our overall approach may be potentially useful in other settings, especially where performance entails several indicator variables.