Applicability of the WHO Maternal Near Miss Criteria in a Low-Resource Setting

Background

Maternal near misses are increasingly used to study quality of obstetric care. Inclusion criteria for the identification of near misses are diverse and studies not comparable. WHO developed universal near miss inclusion criteria in 2009 and these criteria have been validated in Brazil and Canada.

Objectives

To validate and refine the WHO near miss criteria in a low-resource setting.

Methods

A prospective cross-sectional study was performed in a rural referral hospital in Tanzania. From November 2009 until November 2011, all cases of maternal death (MD) and maternal near miss (MNM) were included. For identification of MNM, a local modification of the WHO near miss criteria was used, because most laboratory-based and some management-based criteria could not be applied in this setting. Disease-based criteria were added as they reflect severe maternal morbidity. In the absence of a gold standard for identification of MNM, the clinical WHO criteria were validated for identification of MD.

Results

32 MD and 216 MNM were identified using the locally adapted near miss criteria; case fatality rate (CFR) was 12.9%. WHO near miss criteria identified only 60 MNM (CFR 35.6%). All clinical criteria, 25% of the laboratory-based criteria and 50% of the management-based criteria could be applied. The threshold of five units of blood for identification of MNM led to underreporting of MNM. Clinical criteria showed specificity of 99.5% (95%CI: 99.4%–99.7%) and sensitivity of 100% (95%CI: 91.1%–100%). Some inclusion criteria did not contribute to the identification of cases and therefore may be eligible for removal.

Conclusion

The applicability of the WHO near miss criteria depends on the local context, e.g. level of health care. The clinical criteria showed good validity. Lowering the threshold for blood transfusion from five to two units in settings without blood bank and addition of disease-based criteria in low-resource settings is recommended.     

Bioconversion of lignocellulosic waste from selected dumping sites in Dar es Salaam,Tanzania

The poor management of solid wastes in Tanzania urban centers is a chronic problem that has increasingly become a source of environmental pollution. Bioconversion offers a cheap and safe method of not only disposing these wastes, but also it has the potential to convert lignocellulosic wastes into usable forms such as reducing sugars that could be used as food. This paper reports a preliminary study on the physical characteristics, acid pretreatment, saccharification by cellulase from Trichoderma reesei and fermentation by Saccharomyces cerevisiae of the lignocellulosic component of the solid wastes collected from various dumping sites located in Kinondoni Municipality, Dar es Salaam city. The results showed that overall, the lignocellulosic component constitute about 50% of solid wastes dumped in the study areas. Maximum production of reducing sugars was obtained after 6 h of saccharification while highest concentrations of bioethanol were achieved after 48 h of fermentation. Microbial bioconversion of lignocellulose component yielded up to 21% bioethanol.     

Continuous production of lignin-degrading enzymes by Bjerkandera adusta immobilized on polyurethane foam

Continuous production of lignin-degrading enzymes by Bjerkandera adusta immobilized on polyurethane foam gave maximum activities of 220 U lignin peroxidase ml^–1, 150 U manganese peroxidase ml^–1, 50 U laccase ml^–1 and 6.2 U protease ml^–1 at the retention time of 24 h for 60 days. Protease secretion destabilized the produced lignin peroxidase, manganese peroxidase and laccase.     

Comparative genomics of Bifidobacterium species isolated from marmosets and humans

The genus Bifidobacterium is purported to have beneficial consequences for human health and is a major component of many gastrointestinal probiotics. Although species of Bifidobacterium are generally at low relative frequency in the adult human gastrointestinal tract, they can constitute high proportions of the gastrointestinal communities of adult marmosets. To identify genes that might be important for the maintenance of Bifidobacterium in adult marmosets, ten strains of Bifidobacterium were isolated from the feces of seven adult marmosets, and their genomes were sequenced. There were six B. reuteri strains, two B. callitrichos strains, one B. myosotis sp. nov. and one B. tissieri sp. nov. among our isolates. Phylogenetic analysis showed that three of the four species we isolated were most closely related to B. bifidum, B. breve and B. longum, which are species found in high abundance in human infants. There were 1357 genes that were shared by at least one strain of B. reuteri, B. callitrichos, B. breve, and B. longum, and 987 genes that were found in all strains of the four species. There were 106 genes found in B. reuteri and B. callitrichos but not in human bifidobacteria, and several of these genes were involved in nutrient uptake. These pathways for nutrient uptake appeared to be specific to Bifidobacterium from New World monkeys. Additionally, the distribution of Bifidobacterium in fecal samples from captive adult marmosets constituted as much as 80% of the gut microbiome, although this was variable between individuals and colonies. We suggest that nutrient transporters may be important for the maintenance of Bifidobacterium during adulthood in marmosets.     

Forearm compartment syndrome: anatomical analysis of surgical approaches to the deep space

Forearm compartment syndrome is a surgical emergency that usually requires release of the superficial muscle compartments. In some clinical situations it is imperative to also explore the deep muscle compartments. There are no anatomical guides for surgical exploration of the deep compartments that would minimize collateral damage to surrounding vessels, nerves, and muscles. Surgical injury in the setting of ischemia, especially vascular injury, compounds the tissue damage that has already occurred. The authors evaluated four surgical approaches (three volar and one dorsal) to the deep forearm by performing detailed anatomical dissections on 10 embalmed and plastinated cadavers. They used a scoring system to rate the approaches for their ability to visualize the deep space without causing iatrogenic injury to superficial muscles, arteries, and nerves. In the volar forearm, an ulnar approach to the deep space is simple, causes the least iatrogenic surgical injury, and provides access to the deep volar forearm structures. The plane of dissection is between the flexor carpi ulnaris and the flexor digitorum superficialis. Dividing one or two distal segmental branches of the ulnar artery to the distal flexor digitorum superficialis exposes the pronator quadratus. Lifting the ulnar neurovascular bundle with the flexor digitorum superficialis in the middle third of the forearm exposes the flexor digitorum profundus and the flexor pollicis longus. This approach to the deep space requires no sharp dissection. In the dorsal forearm, a midline approach between the extensor digitorum communis and the extensor carpi radialis brevis is simple and safe.     

Impact of environment on mosquito response to pyrethroid insecticides: Facts,evidences and prospects

By transmitting major human diseases such as malaria, dengue fever and filariasis, mosquito species represent a serious threat worldwide in terms of public health, and pose a significant economic burden for the African continent and developing tropical regions. Most vector control programmes aiming at controlling life-threatening mosquitoes rely on the use of chemical insecticides, mainly belonging to the pyrethroid class. However, resistance of mosquito populations to pyrethroids is increasing at a dramatic rate, threatening the efficacy of control programmes throughout insecticide-treated areas, where mosquito-borne diseases are still prevalent. In the absence of new insecticides and efficient alternative vector control methods, resistance management strategies are therefore critical, but these require a deep understanding of adaptive mechanisms underlying resistance. Although insecticide resistance mechanisms are intensively studied in mosquitoes, such adaptation is often considered as the unique result of the selection pressure caused by insecticides used for vector control. Indeed, additional environmental parameters, such as insecticides/pesticides usage in agriculture, the presence of anthropogenic or natural xenobiotics, and biotic interactions between vectors and other organisms, may affect both the overall mosquito responses to pyrethroids and the selection of resistance mechanisms. In this context, the present work aims at updating current knowledge on pyrethroid resistance mechanisms in mosquitoes and compiling available data, often from different research fields, on the impact of the environment on mosquito response to pyrethroids. Key environmental factors, such as the presence of urban or agricultural pollutants and biotic interactions between mosquitoes and their microbiome are discussed, and research perspectives to fill in knowledge gaps are suggested.     

Anaerobic fermentation of woody biomass treated by various methods

Anaerobic fermentation was attempted to produce methane from the wood chip (Eucalyptus globulus). By the pretreatment of the wood chip using hot water with high temperature, NaOH, and steam explosion, the production of methane gas was enhanced. The pretreatment using steam explosion resulted in more amount of methane gas produced than the treatment using either hot water or 1% (w/w) NaOH with high temperature, and the steam explosion at a steam pressure of 25 atm and a steaming time of 3 min was the most effective for the methane production. The amount of methane gas produced depended on the ratio of weight of Klason lignin, a high molecular weight lignin, in the treated wood chip.     

Effect of scheduled antimicrobial and nicotinamide treatment on linear growth in children in rural Tanzania: A factorial randomized,double-blind,placebo-controlled trial

BackgroundStunting among children in low-resource settings is associated with enteric pathogen carriage and micronutrient deficiencies. Our goal was to test whether administration of scheduled antimicrobials and daily nicotinamide improved linear growth in a region with a high prevalence of stunting and enteric pathogen carriage.Methods and findingsWe performed a randomized, 2 × 2 factorial, double-blind, placebo-controlled trial in the area around Haydom, Tanzania. Mother–child dyads were enrolled by age 14 days and followed with monthly home visits and every 3-month anthropometry assessments through 18 months. Those randomized to the antimicrobial arm received 2 medications (versus corresponding placebos): azithromycin (single dose of 20 mg/kg) at months 6, 9, 12, and 15 and nitazoxanide (3-day course of 100 mg twice daily) at months 12 and 15. Those randomized to nicotinamide arm received daily nicotinamide to the mother (250 mg pills months 0 to 6) and to the child (100 mg sachets months 6 to 18). Primary outcome was length-for-age z-score (LAZ) at 18 months in the modified intention-to-treat group. Between September 5, 2017 and August 31, 2018, 1,188 children were randomized, of whom 1,084 (n = 277 placebo/placebo, 273 antimicrobial/placebo, 274 placebo/nicotinamide, and 260 antimicrobial/nicotinamide) were included in the modified intention-to-treat analysis. The study was suspended for a 3-month period by the Tanzanian National Institute for Medical Research (NIMR) because of concerns related to the timing of laboratory testing and the total number of serious adverse events (SAEs); this resulted in some participants receiving their final study assessment late. There was a high prevalence of stunting overall (533/1,084, 49.2%). Mean 18-month LAZ did not differ between groups for either intervention (mean LAZ with 95% confidence interval [CI]: antimicrobial: −2.05 CI −2.13, −1.96, placebo: −2.05 CI −2.14, −1.97; mean difference: 0.01 CI −0.13, 0.11, p = 0.91; nicotinamide: −2.06 CI −2.13, −1.95, placebo: −2.04 CI −2.14, −1.98, mean difference 0.03 CI −0.15, 0.09, p = 0.66). There was no difference in LAZ for either intervention after adjusting for possible confounders (baseline LAZ, age in days at 18-month measurement, ward, hospital birth, birth month, years of maternal education, socioeconomic status (SES) quartile category, sex, whether the mother was a member of the Datoga tribe, and mother’s height). Adverse events (AEs) and SAEs were overall similar between treatment groups for both the nicotinamide and antimicrobial interventions. Key limitations include the absence of laboratory measures of pathogen carriage and nicotinamide metabolism to provide context for the negative findings.ConclusionsIn this study, we observed that neither scheduled administration of azithromycin and nitazoxanide nor daily provision of nicotinamide was associated with improved growth in this resource-poor setting with a high force of enteric infections. Further research remains critical to identify interventions toward improved early childhood growth in challenging conditions.Trial registrationClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT03268902","term_id":"NCT03268902"}}NCT03268902.

In a randomized trial, Mark DeBoer and colleagues investigate the effect of antimicrobial and nicotinamide interventions on child growth.     

Predicting the Impact of Temperature Change on the Future Distribution of Maize Stem Borers and Their Natural Enemies along East African Mountain Gradients Using Phenology Models

Lepidopteran stem borers are among the most important pests of maize in East Africa. The objective of the present study was to predict the impact of temperature change on the distribution and abundance of the crambid Chilo partellus, the noctuid Busseola fusca, and their larval parasitoids Cotesia flavipes and Cotesia sesamiae at local scale along Kilimanjaro and Taita Hills gradients in Tanzania and Kenya, respectively. Temperature-dependent phenology models of pests and parasitoids were used in a geographic information system for mapping. The three risk indices namely establishment, generation, and activity indices were computed using current temperature data record from local weather stations and future (i.e., 2055) climatic condition based on downscaled climate change data from the AFRICLIM database. The calculations were carried out using index interpolator, a sub-module of the Insect Life Cycle Modeling (ILCYM) software. Thin plate algorithm was used for interpolation of the indices. Our study confirmed that temperature was a key factor explaining the distribution of stem borers and their natural enemies but other climatic factors and factors related to the top-down regulation of pests by parasitoids (host-parasitoid synchrony) also played a role. Results based on temperature only indicated a worsening of stem borer impact on maize production along the two East African mountain gradients studied. This was attributed to three main changes occurring simultaneously: (1) range expansion of the lowland species C. partellus in areas above 1200 m.a.s.l.; (2) increase of the number of pest generations across all altitudes, thus by 2055 damage by both pests will increase in the most productive maize zones of both transects; (3) disruption of the geographical distribution of pests and their larval parasitoids will cause an improvement of biological control at altitude below 1200 m.a.s.l. and a deterioration above 1200 m.a.s.l. The predicted increase in pest activity will significantly increase maize yield losses in all agro-ecological zones across both transects but to a much greater extent in lower areas.     

Sanje mangabey Cercocebus sanjei kills an African crowned eagle Stephanoaetus coronatus

We present the first ever reported observations of a hunting African crowned eagle Stephanoaetus coronatus being killed by a primate, in the Udzungwa Mountains of south-central Tanzania. An adult female eagle launched an attack on a young Sanje mangabey Cercocebus sanjei who was feeding in a tree, but was intercepted and bitten by an adult mangabey who was feeding nearby. The adult mangabey and the eagle then fell together 25 m to the forest floor below. The eagle subsequently died from her injuries, while the mangabey escaped and is thought to have survived. This rare event is briefly discussed in the context of previous accounts of primate-crowned eagle interactions.