Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya.

BACKGROUND: Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability. METHODS: We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD). RESULTS: At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD. CONCLUSION: Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

The effect of pre-calving injection of trace mineral supplements on periparturient disease incidence in pasture based dairy cows.

Trace minerals, have a role in immune function and a trace mineral supplement (TMS) can improve animal health in dairy herds. This prospective randomised clinical study assessed whether subcutaneous injection of 5.5 mL of TMS (40 mg zinc, 10 mg manganese, 5 mg selenium, 15 mg copper per mL), 14-28 days before planned start of calving (PSC) reduced clinical mastitis (CM), subclinical mastitis (SCM) and purulent vaginal discharge (PVD). From four farms, half of 1700 cows stratified on somatic cell count, age and breed were randomly allocated to treatment or no treatment. Occurrence of CM from - 7 to PSC + 100 days, SCM at PSC + 60 days and PVD at PSC + 24 days was analysed using survival analysis and Bayesian generalised mixed multivariable models. From -7 to PSC +30 days, TMS reduced the adjusted hazard ratio (HR) for CM at quarter and cow level (P < 0.001), with no evidence for an effect beyond 30 days. The adjusted OR (and 95% highest density interval, HDI) for the effect of TMS on CM from -7 to PSC +30 days was 0.40 (95% HDI, 0.26-0.63) at quarter level, 0.51 (95% HDI, 0.38-0.69) at cow level and for SCM, 0.72 (95% HDI, 0.54-0.95). The difference in CM incidence from TMS at the cow level was -2.0% (95% HDI, -3.4 to -1.1%) and -1.2% (95% HDI, -3.2 to - 0.6%) at quarter level. No clear effect was identified of TMS on cumulative incidence of PVD.

Implementing an internet-based capacity building program for interdisciplinary midwifery-lead teams in Ethiopia, Kenya Malawi and Somalia.

The Swedish care model MIDWIZE defined as midwife-led interdisciplinary care and zero separation between mother and newborn, was implemented in 2020-21 in Ethiopia, Kenya, Malawi, and Somalia in a capacity building programme funded by the Swedish Institute. OBJECTIVE: To determine the feasibility of using an internet-based capacity building programme contributing to effective midwifery practices in the labour rooms through implementation of dynamic birthing positions, delayed umbilical cord clamping and skin-to-skin care of newborns in the immediate postnatal period. METHODS: The design is inspired by process evaluation. Focus group discussions with policy leaders, academicians, and clinicians who participated in the capacity building programme were carried out. Before and after the intervention, the numbers for dynamic birthing positions, delayed umbilical cord clamping and skin-to-skin care of the newborn in the immediate postnatal period were detected. RESULTS: Participants believed the internet-based programme was appropriate for their countries' contexts based on their need for improved leadership and collaboration, the need for strengthened human resources, and the vast need for improved outcomes of maternal and newborn health. CONCLUSION: The findings provide insight into the feasibility to expand similar online capacity building programmes in collaboration with onsite policy leaders, academicians, and clinicians in sub-Saharan African countries with an agenda for improvements in maternal and child health.

Distress, concerns and unmet needs in survivors of head and neck cancer: a cross-sectional survey.

The aim of this study was to identify the distress, unmet needs and concerns of head and neck cancer (HNC) survivors in the first 5 years after treatment. Two hundred and eighty HNC survivors from three Scottish health boards responded to a cross-sectional postal survey in 2011. Questionnaires included the Distress Thermometer, Patient Concerns Inventory (PCI) and an adapted version of the PCI to measure unmet needs. One-third of the survivors had moderate or severe levels of distress, and 74% had at least one unmet need. The most common concerns and unmet needs included oral and eating problems, fear of recurrence and fatigue. Multivariate analysis revealed that being younger, out of work (not retired), ever having had a feeding tube fitted, having a greater number of comorbidities and living alone were associated with higher levels of distress, concerns and unmet needs. The diversity of concerns and unmet needs identified in this study highlights the importance of holistic needs assessment as part of follow-up care for HNC survivors with tailoring of support for particular concerns. Specific information resources and self-management strategies are required to help HNC survivors with the practical and functional consequences of HNC treatment.

A national survey of healthcare professionals' views on models of follow-up, holistic needs assessment and survivorship care for patients with head and neck cancer.

Patterns of follow-up and survivorship care are changing in response to growing numbers of cancer survivors and an increasing recognition that traditional models are unsustainable and result in unmet needs. Clinicians have shown reluctance in changing conventional follow-up practices for patients with head and neck cancer. This study aimed to explore nurses' and allied health professionals' views and practices in relation to follow-up, holistic needs assessment and survivorship care in this patient group. An online survey of members of the British Association of Head and Neck Oncology Nurses was undertaken. The response rate was 43% (74 of 174). Findings revealed a range of existing models of follow-up, rehabilitation and support for people with head and neck cancer across the UK. Specialist staff were open to new models of care and to more responsibility, with adequate training and supervision. There were some gaps in the provision of comprehensive survivorship care and some specific areas of practice in which nurses lacked confidence, knowledge and skills, such as managing medications and complex symptoms. Further research is needed to develop and evaluate effective models of follow-up and support for a growing population of head and neck cancer survivors who have diverse and complex needs.

Separation and characterization of phenolic compounds from U.S. pecans by liquid chromatography-tandem mass spectrometry.

The phenolic acids and proanthocyanidins (PACs) of pecans possess bioactive properties, which might be useful in retarding the onset of and ameliorating the status of certain chronic disease states. There is a general lack of information in the literature regarding such compounds, especially the PACs. Crude phenolic extracts pooled from eight commercially significant cultivars were selected based on their relatively high antioxidant capacities. The pooled extracts were separated via Sephadex LH-20 column chromatography into five ethanolic low-molecular-weight (LMW) fractions and one acetonic high-molecular-weight (HMW) fraction. The preparations were then characterized using RP-HPLC-ESI-MS/MS and diol-phase HPLC-ESI-MS/MS in order to determine the key constituents present in the LMW and HMW fractions, respectively. As previously observed in pecan nutmeat, ellagic acid and (+)-catechin were found to be the major phenolics in the LMW fractions. The last eluting LMW fraction did not contain phenolic acids; rather it possessed PAC monomers and dimers. The HMW fraction comprised a majority of its PACs as dimers; yet, monomers, trimers, tetramers, pentamers, and hexamers were also separated and characterized.

The putative AKH receptor of the tobacco hornworm, Manduca sexta, and its expression.

Adipokinetic hormones are peptide hormones that mobilize lipids and/or carbohydrates for flight in adult insects and activate glycogen Phosphorylase in larvae during starvation and during molt. We previously examined the functional roles of adipokinetic hormone in Manduca sexta L. (Lepidoptera: Sphingidae). Here we report the cloning of the full-length cDNA encoding the putative adipokinetic hormone receptor from the fat body of M. sexta. The sequence analysis shows that the deduced amino acid sequence shares common motifs of G protein-coupled receptors, by having seven hydrophobic transmembrane segments. We examined the mRNA expression pattern of the adipokinetic hormone receptor by quantitative Real-Time PCR in fat body during development and in different tissues and found the strongest expression in fat body of larvae two days after molt to the fifth instar. We discuss these results in relation to some of our earlier results. We also compare the M. sexta adipokinetic hormone receptor with the known adipokinetic hormone receptors of other insects and with gonadotropin releasing hormone-like receptors of invertebrates.

Effectiveness of a psychoeducational parenting group on child, parent, and family behavior: a pilot study in a family practice clinic with an underserved population.

Although integrated care for adults in primary care has steadily increased over the last several decades, there remains a paucity of research regarding integrated care for children in primary care. To report results of a pilot study testing initial feasibility of a parenting psychoeducational group targeting child behavioral problems within a primary care clinic. The participants (n = 35) were parents representing an underserved population from an inner-city primary care clinic. Participants attended a 12-week psychoeducational parenting group and reported pre- and post-measures of family functioning, child misbehavior and dyadic functioning. Paired t-tests and effects sizes are reported. Participants reported statistically significant improvement in family functioning, child misbehavior, and couple functioning after participating in the parenting psychoeducational group. Results suggest initial feasibility of a parenting psychoeducational group within a primary care clinic with an underserved population. This intervention may be useful for other primary care clinics seeking to offer more integrative care options for children and their families.

The effect of phytoestrogens on the female genital tract.

Environmental oestrogens have been implicated in the pathogenesis of hormonally treated cancers (such as breast and prostate cancer), male infertility, and abnormalities of the male and female reproductive tracts. They may be derived from plants (phytoestrogens), pharmaceuticals, or other synthetic compounds not originally intended to have oestrogenic activity (including soy based infant formulas). This review will discuss the evidence from both animal studies and humans for an effect of these ubiquitous compounds on the development of the human female genital tract, in addition to prolonging the menstrual cycle, alleviating symptoms of the menopause, and protecting against the development of endometrial carcinoma.

Standard osteopathic manipulative treatment acutely improves gait performance in patients with Parkinson's disease.

Patients with Parkinson's disease exhibit a variety of motor deficits which can ultimately result in complete disability. The primary objective of this study was to quantitatively evaluate the effect of osteopathic manipulative treatment (OMT) on the gait of patients with Parkinson's disease. Ten patients with idiopathic Parkinson's disease and a group of eight age-matched normal control subjects were subjected to an analysis of gait before and after a single session of an OMT protocol. A separate group of 10 patients with Parkinson's disease was given a sham-control procedure and tested in the same manner. In the treated group of patients with Parkinson's disease, statistically significant increases were observed in stride length, cadence, and the maximum velocities of upper and lower extremities after treatment. There were no significant differences observed in the control groups. The data demonstrate that a single session of an OMT protocol has an immediate impact on Parkinsonian gait. Osteopathic manipulation may be an effective physical treatment method in the management of movement deficits in patients with Parkinson's disease.

Substituted salicylanilides as inhibitors of two-component regulatory systems in bacteria.

A new class of inhibitors of the two-component regulatory systems (TCS) of bacteria was discovered based on the salicylanilide screening hits, closantel (1) and tetrachlorosalicylanilide (9). A systematic SAR study versus a model TCS, KinA/Spo0F, demonstrated the importance of electron-attracting substituents in the salicyloyl ring and hydrophobic groups in the anilide moiety for optimal activity. In addition, derivatives 8 and 16, containing the 2, 3-dihydroxybenzanilide structural motif, were potent inhibitors of the autophosphorylation of the KinA kinase, with IC50s of 2.8 and 6. 3 µM, respectively. Compound 8 also inhibited the TCS mediating vancomycin resistance (VanS/VanR) in a genetically engineered Enterococcus faecalis cell line at concentrations subinhibitory for growth. Closantel (1), tetrachlorosalicylanilide (9), and several related derivatives (2, 7, 10, 11, 20) had antibacterial activity against the drug-resistant organisms, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecium (VREF).

Establishment of behavioral parameters for the evaluation of osteopathic treatment principles in a rat model of arthritis.

Unilateral arthritis was produced in rats by use of methylated bovine serum albumin in a model of antigen-induced arthritis. The progression of arthritis was measured by computerized motion analysis, bilateral joint circumference, voluntary extension force of the hindlegs, and length of ankle extension. Animals with induced arthritis were assigned to treated and untreated groups on the basis of approximately equal deficits by the parameters measured. A third group of rats, which did not have arthritis induced and received no treatment, served to establish mean normal parameters. Modified techniques of muscle energy, passive movement of the ankle and knee, and passive myofascial stretch were applied to the animals, and the animals were exercised in a mechanized exercise wheel. Parameters associated with gait were examined by computerized motion analysis of walking. Animals treated with manipulation and exercise improved significantly relative to untreated animals with antigen-induced arthritis in vertical ankle lift, ankle-based and foot-based stride lengths, knee circumference, and normalized extension of the ankle. The results demonstrate that the parameters identified can be used to detect functional deficits and significant improvement from those deficits can be derived from a nonpharmacologic treatment paradigm that includes osteopathic manipulation and exercise in an animal model of arthritis. These parameters may be useful in the identification of the relative benefits of independent treatment variables including frequency of osteopathic manipulation and exercise and the relative benefits of each in this model. Also, they may elucidate how these treatments produce their beneficial effects clinically.

Early closure of colostomies in trauma patients--a prospective randomized trial.

BACKGROUND: Most traumatic colon injuries can be repaired primarily, but a colostomy may still be required for severe colonic or rectal injury. The current trend is to reverse the colostomy early, rather than to wait the traditional 3 months before closure. METHODS: Forty-nine patients with colostomies after abdominal trauma were entered into the study. All patients had undergone a contrast enema in the second postoperative week to assess distal colon healing. Patients were excluded from early closure for nonhealing of the bowel injury, unresolving wound sepsis, or an unstable condition. We then compared the outcome of the remaining 38 (77.6%) patients allocated to either an early or a late colostomy group in a controlled, prospective, randomized trial. RESULTS: We found no significant difference in morbidity between the two groups, with an overall complication rate of 26.3%. Technically the early closure of colostomies was far easier than late closure and required significantly less operating time (p = 0.036) and with less intraoperative blood loss (p = 0.020). The closure of end colostomies was more time consuming, both early (p < 0.001) and late (p < 0.001) and caused more bleeding (p < 0.001 and p < 0.001, respectively). Total hospitalization was marginally shorter overall for early closure, but late closure of end colostomies resulted in prolonged hospitalization (p = 0.023). CONCLUSIONS: The early closure of colostomies and the use of loop colostomies whenever possible are recommended as both safe and beneficial for patients with colonic injury after trauma. Contraindications for early closure include nonhealing distal bowel, persistent wound sepsis, or persistent postoperative instability.

Is dietary erucic acid hepatotoxic in pregnancy? An experimental study in rats and hamsters.

The hypothesis that dietary erucic acid may contribute to the pathogenesis of intrahepatic cholestasis of pregnancy has been examined in pregnant rats and hamsters after prolonged feeding of diets containing 25% rapeseed oil rich in erucic acid (40% of fatty acids) or corn oil, without erucic acid. Both dietary oils were well tolerated, although weight gain was 17% to 20% less in animals receiving rapeseed oil. Rats and hamsters were studied on the last day of pregnancy and compared with age- and diet-matched nonpregnant animals. Histological examination showed no major morphologic abnormalities in liver, heart, kidneys, and adrenals. Similar microscopic deposits of fat were found in the livers and hearts of pregnant hamsters of both dietary groups. Chromatographic analysis of fatty acids in liver, heart, and kidney homogenates of hamsters and in isolated rat liver cells reflected the fatty acid composition of the dietary oils: oleic (18:1) and linoleic (18:2) acids were among the predominant fatty acids. Erucic acid was found in a higher proportion in the heart (14% by weight of total fatty acids) than in the liver (3%) and kidneys (3%) of animals fed rapeseed oil. Bile flow and biliary lipid composition was similar in rats and hamsters fed rapeseed or corn oil. Bile flow tended to be less in pregnant than in nonpregnant animals. Pregnant hamsters fed rapeseed oil tended to have the lowest bile flow. The lithogenic index of bile was slightly decreased in pregnant rats and increased in pregnant hamsters, although these proportional changes were similar for both diets. In all circumstances the lithogenic index remained below a value of 1.(ABSTRACT TRUNCATED AT 250 WORDS)

The medical leech: an old treatment revisited.

The treatment modality of choice for venous insufficiency after free tissue transfer or replantation remains surgical repair. When this is not technically possible, the use of medical leeches is a useful adjunct to treatment. This paper reviews the history of the use of leeches in medicine, the anatomy and physiology of Hirudo medicinalis, the techniques of leech therapy, and the complications and contraindications.

A tangible means of assessing progress. Biofeedback in the management of urinary incontinence.

Biofeedback aims to give people with continence problems tangible information to help them maximise their control over elimination. A number of methods can be used in urinary incontinence, but few centres appear to do so.

Single dose therapy of vaginal candidiasis: a comparative trial of fenticonazole vaginal ovules versus clotrimazole vaginal tablets.

An open, randomized comparative clinical trial was performed in 153 patients suffering from symptomatic vaginal candidiasis confirmed by mycological tests. Patients were allocated at random into two groups: the first group (consisting of 75 subjects) was treated with a single vaginal ovule of fenticonazole (600 mg) and the second group (consisting of 78 subjects) was treated with a single vaginal tablet of clotrimazole (500 mg). Therapeutic efficacy was assessed by microbiological and clinical criteria 7 days and 1 month (when possible) after the single dose treatment. At the first follow-up visit, complete disappearance of the signs and symptoms or a highly significant reduction of their intensity was observed in both treatment groups. No significant difference was evident between the two drugs. At 7 days, the mycological tests gave negative results in 92% of the patients in the fenticonazole group and in 88.5% of the patients in the clotrimazole group. The difference between the two treatment groups was again not statistically significant. The second follow-up visit was performed in 55 (73.3%) patients of the fenticonazole group and in 52 (66.7%) patients of the clotrimazole group. The results indicate that 83.6% of patients in the fenticonazole group and 69.2% of patients in the clotrimazole group were still disease free at the time of this visit. Both drugs were well tolerated. Mild, local and short lasting side-effects were reported in only 5 cases of the group treated with fenticonazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Midwifery services in Madang Province, Papua New Guinea: a proposal.

This report describes socio-cultural similarities and differences which will affect the success of midwifery training programs in Karkar and Negiri, Madang Province, Papua New Guinea. The report acknowledges these communities' concerns about a midwifery project, notes problems in determining accurate perinatal data for these locales, and indicates the need for comprehensive maternal-child care which is commensurate with these peoples' customs and beliefs. While recognizing that in many nations training of midwifery specialists addresses needs in a practical manner, this report recommends training local women as midwifery teachers as a preferred approach for areas such as Karkar and Negiri.