Postpartum hemorrhage: new insights for definition and diagnosis.

The current definition of is inadequate for early recognition of this important cause of maternal death that is responsible for >80,000 deaths worldwide in 2015. A stronger definition of postpartum hemorrhage should include both blood loss and clinical signs of cardiovascular changes after delivery, which would help providers to identify postpartum hemorrhage more promptly and accurately. Along with the amount of blood loss, clinical signs, and specifically the shock index (heart rate divided by systolic blood pressure) appear to aid in more accurate diagnosis of postpartum hemorrhage.

Shock index: an effective predictor of outcome in postpartum haemorrhage?

OBJECTIVES: To compare the predictive value of the shock index (SI) with conventional vital signs in postpartum haemorrhage (PPH), and to establish 'alert' thresholds for use in low-resource settings. DESIGN: Retrospective cohort study. SETTING: UK tertiary centre. POPULATION: Women with PPH ≥ 1500 ml (n = 233). METHODS: Systolic blood pressure (BP), diastolic BP, mean arterial pressure, pulse pressure, heart rate (HR) and SI (HR/systolic BP) were measured within the first hour following PPH. Values measured at the time of highest SI were selected for analysis. The area under the receiver operating characteristic curve (AUROC) for each parameter, used to predict admission to an intensive care unit and other adverse outcomes, was calculated. Sensitivity, specificity and negative/positive predictive values determined thresholds of the best predictor. MAIN OUTCOME MEASURES: Intensive care unit (ICU) admission, blood transfusion ≥ 4 iu, haemoglobin level <7 g/dl, and invasive surgical procedures. RESULTS: Shock index has the highest AUROC to predict ICU admissions (0.75 for SI [95% CI 0.63-0.87] compared with 0.64 [95% CI 0.44-0.83] for systolic BP). SI compared favourably for other outcomes: SI ≥ 0.9 had 100% sensitivity (95% CI 73.5-100) and 43.4% specificity (95% CI 36.8-50.3), and SI ≥ 1.7 had 25.0% sensitivity (95% CI 5.5-57.2) and 97.7% specificity (CI 94.8-99.3), for predicting ICU admission. CONCLUSIONS: Shock index compared favourably with conventional vital signs in predicting ICU admission and other outcomes in PPH, even after adjusting for confounding; SI <0.9 provides reassurance, whereas SI ≥ 1.7 indicates a need for urgent attention. In low-resource settings this simple parameter could improve outcomes. It was not possible to adjust for resuscitative measures administered following vital sign measurement that may have influenced the outcome.

Home matters: work and household predictors of smoking and cessation among blue-collar workers.

OBJECTIVE: This study examined the joint influence of work- and household-related variables on smoking behavior among a population representative sample of blue-collar workers with live-in partners. METHODS: The study used data on 1389 blue-collar workers from the Tobacco Use Supplement to the United States Current Population Survey 2002 to 2003 longitudinal overlap sample. Unadjusted and adjusted logistical regression analyses, which employed sampling and replicate weights to account for sampling design, were run to estimate independent and joint effects of the predictors. RESULTS: In adjusted analyses, partner smoking (OR=4.97, 95%CI=3.02-8.18) and complete and partial home smoking policy (OR=0.16, 95%CI=0.09-0.29 and OR=0.39, 95%CI=0.23-0.68, respectively) were significant predictors of smoking status, but worksite smoking policies and presence of a young child under 5 in the household were not (p>0.05). Baseline complete home smoking ban was a significant predictor of subsequent cessation (OR=3.49, 95%CI=1.19-10.23), while partner smoking status, workplace smoking policy, and the presence of a young child in the home did not predict cessation (p>0.05). CONCLUSION: Household-related variables were significant predictors of smoking status and cessation among blue-collar workers. Current efforts to decrease smoking in this group, which are mostly focused on work-related risk factors, should consider how to incorporate household risk factors.

Influence of the 2014-2015 Ebola outbreak on the vaccination of children in a rural district of Guinea.

Setting: All health centres in Macenta District, rural Guinea. Objective: To compare stock-outs of vaccines, vaccine stock cards and the administration of various childhood vaccines across the pre-Ebola, Ebola and post-Ebola virus disease periods. Design: This was an ecological study. Results: Similar levels of stock-outs were observed for all vaccines (bacille Calmette-Guérin [BCG], pentavalent, polio, measles, yellow fever) in the pre-Ebola and Ebola periods (respectively 2760 and 2706 facility days of stock-outs), with some variation by vaccine. Post-Ebola, there was a 65-fold reduction in stock-outs compared to pre-Ebola. Overall, 24 facility-months of vaccine stock card stock-outs were observed during the pre-Ebola period, which increased to 65 facility-months of stock-outs during the Ebola outbreak period; no such stock-out occurred in the post-Ebola period. Apart from yellow fever and measles, vaccine administration declined universally during the peak outbreak period (August-November 2014). Complete cessation of vaccine administration for BCG and a prominent low for polio (86% decrease) were observed in April 2014, corresponding to vaccine stock-outs. Post-Ebola, overall vaccine administration did not recover to pre-Ebola levels, with the highest gaps seen in polio and pentavalent vaccines, which had shortages of respectively 40% and 38%. Conclusion: These findings highlight the need to sustain vaccination activities in Guinea so that they remain resilient and responsive, irrespective of disease outbreaks.

Contexte: Tous les centres de santé de la Préfecture de Macenta, en Guinée rural.Objectif: Comparer la rupture en vaccins, en cartes de stock de vaccins et l'administration des différents vaccins d'enfance pendant les périodes pré-Ebola, Ebola et post-Ebola.Schéma: Une étude écologique.Résultats: Des niveaux similaires de rupture étaient observés pour tous les vaccins (bacille Calmette-Guérin [BCG], pentavalent, polio, rougeole, fièvre jaune) dans les périodes pré-Ebola et Ebola (respectivement 2760 et 2706 jours-structure de rupture), avec quelques variations par vaccin. Post-Ebola, il y avait 65 fois plus de réduction en rupture, comparé à la période pré-Ebola. Un total de 24 mois-structure de rupture en cartes de stock de vaccins était observé pendant la période pré-Ebola, qui a augmenté à 65 mois-structure de rupture pendant la période Ebola ; une telle rupture ne s'est pas produite dans la période post-Ebola. Excepté la fièvre jaune et la rougeole, l'administration de vaccin a diminué universellement pendant la période de pointe de l'épidémie (août­novembre 2014). L'arrêt complet de l'administration de vaccin pour le BCG et une baisse marquée pour la polio (diminution de 86%) étaient observés en avril 2014, correspondant à une rupture de vaccins. Post-Ebola, l'administration globale de vaccins n'a pas atteint les niveaux pré-Ebola, avec les plus grands écarts observés aux niveaux de la polio et du pentavalent (respectivement des baisses de 40% et 38%).Conclusion: Ces résultats soulignent le besoin de maintenir les activités de vaccination en Guinée afin qu'elles restent résilientes et réactives, indépendamment de l'épidémie d'une maladie.

Marco de referencia: Todos los centros de atención de salud del distrito de Macenta en una zona rural de Guinea.Objetivo: Comparar el desabastecimiento de vacunas, las tarjetas de existencias de vacunas y la administración de las diversas vacunas de la infancia durante diferentes períodos, en función de la epidemia de fiebre hemorrágica del Ébola, a saber: antes, durante el brote y después del mismo.Método: Un estudio ecológico.Resultados: Se observaron niveles equivalentes de desabastecimientos de todas las vacunas (BCG, pentavalente, antipoliomielítica, antisarampionosa y antiamarílica) antes de la epidemia del Ébola y durante la misma (2760 y 2706 días de desabastecimiento por establecimiento, respectivamente), con alguna variación en función de las vacunas. En el período posterior a la epidemia se presentó una tasa de desabastecimientos 65 veces menor, en comparación con el período anterior a la epidemia. En general, se observaron 24 meses-centro de desabastecimiento en las tarjetas de existencias vacunales durante el período pre-Ébola, que aumentaron a 65 meses-centro de desabastecimiento durante la epidemia; en el período posterior al brote no ocurrió este tipo de desabastecimiento. Con la excepción de la vacuna antiamarílica y la antisarampionosa, la administración de vacunas disminuyó globalmente durante el período de máxima actividad de la epidemia (de agosto a noviembre del 2014). Se observó una interrupción total de la administración de BCG y una tasa considerablemente baja de administración de vacuna antipoliomielítica (disminución de un 86%) en abril del 2014, que correspondió con el desabastecimiento de vacunas. Después de la epidemia del Ébola, la administración general de vacunas no recuperó el nivel anterior al brote y las mayores carencias se observaron con la vacuna antipoliomielítica y la pentavalente (40% y 38% de déficit, respectivamente).Conclusión: Los resultados del presente estudio destacan la necesidad de sostener las actividades de vacunación en Guinea, de manera que conserven su capacidad de recuperación y de respuesta, con independencia de los brotes epidémicos.

Interactions between neomycin and cerebral dopaminergic and serotoninergic transmission in rats.

The aim of this work was to investigate the effects of neomycin on monoamine contents of rat striatal tissue. The analysis was performed by HPLC with electrochemical detection. Rats were injected with neomycin (2 mg/kg; i.p.) and killed at different times over 24 h. The striatal homogenate was injected in a reversed-phase HPLC. Results showed a significant increase in dopamine tissue level (+35 per cent; 4 h after neomycin injection) and a decrease (-36 per cent) in the level of its metabolites. Striatal serotonin level showed a rapid and significant (p < 0.001) increase, +130 per cent, 2 h after neomycin injection. DOPAC/DA and 5HIAA/5HT ratios were reduced by 34 per cent and 46 per cent respectively. These results indicate an inhibitory effect of neomycin on striatal dopaminergic and serotoninergic systems. Several mechanisms could be involved in these effects of neomycin in the biosynthesis process through stimulation of tyrosine hydroxylase and tryptophane hydroxylase and/or MAO and COMT activities. The blockage of calcium channels was also suggested.

Effects of voltage-sensitive calcium channel blockers on extracellular dopamine levels in rat striatum.

Various subtypes of voltage-sensitive calcium channels (VSCCs) support the release of dopamine (DA) in the central nervous system. Using in vivo microdialysis, we investigate the influence of these subtypes of calcium channels on dopaminergic terminals in the rat striatum. L-type (nifedipine-sensitive), N-type (omega-conotoxin GVIA-sensitive), or N- and P/Q-type (omega-conotoxin MVIIC-sensitive) Ca2+ channels were blocked using selective antagonists injected locally, and K+-evoked DA release was measured in freely moving animals. K+ (100 mM) induced a massive increase of basal DA extracellular levels (930%) and was without significant effect on extracellular levels of DA metabolites DOPAC and HVA, and on the serotonin metabolite 5HIAA. Omega-conotoxin GVIA (1 microM) and omega-conotoxin MVIIC (1 microM) significantly reduced the K+-evoked DA release by 55 and 62%, respectively. The simultaneous application of the two conotoxins at the same concentration reduced K+-evoked DA release by 66%. Nifedipine (10 microM) had no significant effect on K-evoked DA release, while neomycin, a nonspecific VSCC blocker, produced a highly significant decrease when applied at 250 and 500 microM (56 and 75%, respectively). The compounds. however, had no effect on basal DA release and on the levels of extracellular DOPAC, HVA, and 5HIAA. These results suggest that under high and persistent conditions of membrane depolarization (15 min, 10 mM K+), striatal DA release is mainly mediated by N-type VSCCs.

Effectiveness of clinical guidelines for the presumptive treatment of streptococcal pharyngitis in Egyptian children.

BACKGROUND: Primary prevention of acute rheumatic fever requires antibiotic treatment of acute streptococcal pharyngitis. In developing countries, clinicians must rely on clinical guidelines for presumptive treatment of streptococcal pharyngitis since bacterial culture and rapid diagnostic tests are not feasible. We evaluated the WHO Acute Respiratory Infection guideline in a large urban paediatric clinic in Egypt. METHODS: Children between 2 and 13 years of age who had a sore throat and pharyngeal erythema were enrolled in the study. Clinical, historical, and demographic information was recorded and a throat culture for group A beta-haemolytic streptococci was done. Sensitivity (% of true-positive throat cultures) and specificity (% of true-negative throat cultures) were calculated for each clinical feature. The effect of various guidelines on correct presumptive treatment for throat-culture status was calculated. FINDINGS: Of 451 children with pharyngitis, 107 (24%) had group A beta-haemolytic streptococci on throat culture. A purulent exudate was seen in 22% (99/450) of these children and this sign was 31% sensitive and 81% specific for a positive culture. The WHO Acute Respiratory Infections (ARI) guidelines, which suggest treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific; 13/107 children with a positive throat culture would correctly receive antibiotics and 323/344 with a negative throat culture would, correctly, not receive antibiotics. Based on our data we propose a modified guideline whereby exudate or large cervical nodes would indicate antibiotic treatment, and this guideline would be 84% sensitive and 40% specific; 90/107 children with a positive throat culture would correctly receive antibiotics and 138/344 with a negative throat culture would, correctly, not receive antibiotics. INTERPRETATION: The WHO ARI clinical guideline has a high specificity but low sensitivity that limits the unnecessary use of antibiotics, but does not treat 88% of children with a positive streptococcal throat culture who are at risk of acute rheumatic fever. A modified guideline may be more useful in this population. Prospective studies of treatment guidelines from many regions are needed to assess their use since the frequency of pharyngitis varies.

PIP: In developing country settings without access to bacterial culture and rapid diagnostic tests, the prevention of acute rheumatic fever depends on clinicians' presumptive treatment of streptococcal pharyngitis. This study evaluated the effectiveness of World Health Organization (WHO) acute respiratory infection guidelines in a large pediatric clinic (Abu Reesh Children's Hospital) in Cairo, Egypt. 451 children 2-13 years of age with sore throat and pharyngeal erythema were enrolled, 107 (24%) of whom had group A beta-hemolytic streptococci on throat culture. Purulent exudate, present in 99 (22%) of these children, was 31% sensitive and 81% specific for a positive culture. The WHO guidelines, which recommend treatment for pharyngeal exudate plus enlarged and tender cervical node, were 12% sensitive and 94% specific. Based on these guidelines, 13 of 107 children with a positive throat culture would correctly receive antibiotics and 323 of 344 with a negative culture would not receive antibiotics. A modified guideline in which exudate or large cervical nodes would indicate antibiotic treatment would be 84% sensitive and 40% specific. With this modification, 90 of 107 children with a positive throat culture would correctly receive antibiotics and 138 out of 344 with a negative culture would not receive treatment. However, additional prospective studies from other regions of Egypt are necessary before modified guidelines are implemented.