Midwife-led birthing centres in four countries: a case study.

BACKGROUND: Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC. METHODS: A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff. RESULTS: Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels. CONCLUSION: The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

Is malnutrition a determining factor of health-related quality of life in hemodialysis patients? A cross-sectional design examining relationships with a comprehensive assessment of nutritional status.

PURPOSE: To identify relationships between health-related quality of life (HRQOL) and nutritional status in hemodialysis (HD) patients. METHOD: Secondary data from a cross-sectional survey was utilized. HRQOL was assessed for 379 HD patients using the generic Short Form 36 (SF-36) and disease-specific Kidney-Disease Quality of Life-36 (KDQOL-36). Malnutrition was indicated by malnutrition inflammation score (MIS) ≥ 5, and presence of protein-energy wasting (PEW). The individual nutritional parameters included the domains of physical status, serum biomarkers, and dietary intake. Multivariate associations were assessed using the general linear model. RESULTS: MIS ≥ 5 was negatively associated with SF-36 scores of physical functioning (MIS < 5 = 73.4 ± 8.0 SE vs MIS ≥ 5 = 64.6 ± 7.7 SE, P < 0.001), role-limitation-physical (MIS < 5 = 65.3 ± 14.3 SE vs MIS ≥ 5 = 52.9 ± 14.0 SE, P = 0.006), general health (MIS < 5 = 53.7 ± 7.5 SE vs MIS ≥ 5 = 47.0 ± 7.1 SE, P = 0.003), and PCS-36 (MIS < 5 = 40.5 ± 3.3 SE vs MIS ≥ 5 = 35.9 ± 3.1 SE, P < 0.001); and KDQOL-36 score of symptoms/problems (MIS < 5 = 78.9 ± 5.6 SE vs MIS ≥ 5 = 74.8 ± 5.4 SE, P = 0.022), but not with PEW by any tool. Of individual nutritional parameters, underweight (68.1 ± 5.4 SE, P = 0.031), normal weight (63.8 ± 2.8 SE, P = 0.023), and overweight (64.3 ± 2.9 SE, P = 0.003) patients had significantly higher physical functioning scores compared to obese patients (44.8 ± 5.5 SE). Serum albumin levels were positively associated with physical functioning (P = 0.041) score. HGS was also positively associated with physical functioning (P = 0.036), and vitality (P = 0.041) scores. Greater dietary phosphorus intakes were significantly associated with lower scores for role limitation-physical (P = 0.008), bodily pain (P = 0.043), and PCS-36 (P = 0.024). CONCLUSION: Malnutrition diagnosis by MIS, but not PEW, indicated associations with HRQOL in HD patients. Individual nutritional parameters that related to higher HRQOL were BMI < 30 kg/m2, better dietary phosphorus control, greater muscle strength and higher visceral protein pool.

Perceptions and practices on newborn care and managing complications at rural communities in Bangladesh: a qualitative study.

BACKGROUND: Community misperception on newborn care and poor treatment of sick newborn attributes to neonatal death and illness severity. Misperceptions and malpractices regarding neonatal care and neonatal complications are the leading causes of neonatal deaths in Bangladesh. The study was conducted to explore neonatal care's perceptions and practices and manage complications among Bangladesh's rural communities. METHODS: A qualitative study was conducted in Netrakona district of Bangladesh from April to June 2015. Three sub-districts (Upazilas) including Purbadhala, Durgapur and Atpara of Netrakona district were selected purposively. Five focus group discussions (FGDs) and twenty in-depth interviews (IDIs) were conducted in the rural community. Themes were identified through reading and re-reading the qualitative data and thematic analysis was performed. RESULTS: Community people were far behind, regarding the knowledge of neonatal complications. Most of them felt that the complications occurred due to lack of care by the parents. Some believed that mothers did not follow the religious customs after delivery, which affected the newborns. Many of them followed the practice of bathing the newborns and cutting their hair immediately after birth. The community still preferred to receive traditional treatment from their community, usually from Kabiraj (traditional healer), village doctor, or traditional birth attendant. Families also refrained from seeking treatment from the health facilities during neonatal complications. Instead, they preferred to wait until the traditional healers or village doctors recommended transferring the newborn. CONCLUSIONS: Poor knowledge, beliefs and practices are the key barriers to ensure the quality of care for the newborns during complications. The communities still depend on traditional practices and the level of demand for facility care is low. Appropriate interventions focusing on these issues might improve the overall neonatal mortality in Bangladesh.

Stillbirth surveillance and review in rural districts in Bangladesh.

BACKGROUND: An estimated 2.6 million stillbirths occur every year, with the majority occurring in low- and middle-income countries. Understanding the cause of and factors associated with stillbirth is important to help inform the design and implementation of interventions aimed at reducing preventable stillbirths. METHODS: Population-based surveillance with identification of all stillbirths that occurred either at home or in a health facility was introduced in four districts in Bangladesh. Verbal autopsy was conducted for every fifth stillbirth using a structured questionnaire. A hierarchical model was used to assign likely cause of stillbirth. RESULTS: Six thousand three hundred thirty-three stillbirths were identified for which 1327 verbal autopsies were conducted. 63.9% were intrapartum stillbirths. The population-based stillbirth rate obtained was 20.4 per 1000 births; 53.9% of all stillbirths occurred at home. 69.6% of mothers had accessed health care in the period leading up to the stillbirth. 48.1% had received care from a highly trained healthcare provider. The three most frequent causes of stillbirth were maternal hypertension or eclampsia (15.2%), antepartum haemorrhage (13.7%) and maternal infections (8.9%). Up to 11.3% of intrapartum stillbirths were caused by hypoxia. However, it was not possible to identify a cause of death with reasonable certainty using information obtained via verbal autopsy in 51.9% of stillbirths. CONCLUSIONS: Introducing surveillance for stillbirths at community level is possible. However, verbal autopsy yields limited data, and the questionnaire used for this needs to be revised and/or combined with information obtained through case note review. Most women accessed and received care from a qualified healthcare provider. To reduce the number of preventable stillbirths, the quality of antenatal and intrapartum care needs to be improved.

Perceptions of health care providers and patients on quality of care in maternal and neonatal health in fourteen Bangladesh government healthcare facilities: a mixed-method study.

BACKGROUND: Bangladesh has achieved remarkable progress in healthcare with a steady decline in maternal and under-5 child mortality rates in efforts to achieve Millennium Development Goals 4 and 5. However, the mortality rates are still very high compared with high-income countries. The quality of healthcare needs improve to reduce mortality rates further. It is essential to investigate the current quality of healthcare before implementing any interventions. The study was conducted to explore the perception of healthcare providers about the quality of maternal and neonatal health (MNH) care. The study also investigated patient satisfaction with the MNH care received from district and sub-district hospitals. METHODOLOGY: Both qualitative and quantitative methods were used in the study. Two district and 12 sub-district hospitals in Thakurgaon and Jamalpur in Bangladesh were the study settings. Fourteen group discussions and 56 in-depth interviews were conducted among the healthcare providers. Client exit interviews were conducted with 112 patients and their attendants from maternity, labor, and neonatal wards before being discharged from the hospitals. Eight physicians and four anthropologists collected data between November and December 2011 using pretested guidelines. RESULTS: The hospital staff identified several key factors that affected the quality of patient care: shortage of staff and logistics; lack of laboratory support; under use of patient-management protocols; a lack of training; and insufficient supervision. Doctors were unable to provide optimal care because of the high volume of patients. The exit interviews revealed that 85 % of respondents were satisfied with the hospital services received. Seven out of 14 respondents were satisfied with the cleanliness of the hospital facilities. More than half of the respondents were satisfied with the drugs they received. In half of the facilities, patients did not get an opportunity to ask the healthcare providers questions about their health conditions and treatments. CONCLUSION: The quality of healthcare is poor in district and sub-district hospitals in Bangladesh because of the lack of healthcare personnel and logistic support. An integrated quality improvement approach is needed to improve MNH care service in district and sub-district hospitals in Bangladesh.

Reasons for performing a caesarean section in public hospitals in rural Bangladesh.

BACKGROUND: It is estimated that 18.5 million Caesarean Sections (CS) are conducted annually worldwide and about one-third of them are done without medical indications and described as "unnecessary". Although developed countries account for most of the rise in the trend of unnecessary CS, more studies report a similar trend in developing countries, putting a strain on existing but limited healthcare resources, jeopardizing families' financial security and presenting a barrier to equitable universal coverage. We examined indications for CS in public hospitals of one district in Bangladesh and explored factors influencing decision to perform the procedure. METHODS: Retrospective review of case notes of 530 women who had CS in 5 public hospitals in Thakurgaon District of Bangladesh. Key Informant Interviews (KII) with 18 service providers to explore factors associated with the decision to perform a CS. RESULTS: The commonest recorded indications for CS were: previous CS (29.4%), fetal distress (15.7%), cephalo-pelvic disproportion (10.2%), prolonged obstructed labor (8.3%) and post-term dates (7.0%). The majority (68%) of CS were performed as emergency; mainly during daytime working hours. Previous CS and "post-term dates" were common indications for elective CS with "post dates" - the commonest indication for CS in primiparous women. 16.0% of all CS were conducted for cases where alternative forms of care might have been more appropriate. Providers reported not using protocols and evidence based guidelines even though these are available. Pressure from patients and relatives to deliver by CS strongly influenced decision making. External agents from private hospitals receive a financial reward for every CS performed and are present in public hospitals to "lobby" for CS. CONCLUSION: Factors other than evidence based practice or the presence of a clear medical indication influence providers' decision to perform both elective and emergency CS in public hospitals in Bangladesh.

Oral paricalcitol versus oral calcitriol in continuous ambulatory peritoneal dialysis patients with secondary hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism (SHPT) is common in end-stage renal disease. Our primary objective was to evaluate the efficacy of oral paricalcitol versus oral calcitriol on serum intact parathyroid hormone (iPTH) and mineral bone parameters in continuous ambulatory peritoneal dialysis (CAPD) patients with SHPT. The secondary objective was to analyze highly sensitive C-reactive protein (hsCRP) and peritoneal membrane function in both groups. METHODS: This was a prospective randomized control trial. CAPD patients with SHPT were randomized to paricalcitol or calcitriol for 15 weeks. Serum intact iPTH, calcium, phosphate and alkaline phosphatase (ALP) were measured at baseline and every 3 weeks. Serum hsCRP and peritoneal membrane functions were measured at baseline and at week 15. RESULTS: A total of 26 patients were enrolled and randomized-12 to paricalcitol and 14 to calcitriol. Serum iPTH reduced significantly in both groups and there was no difference in the incidence of ≥50 % reduction of iPTH between both groups. There was a significant increase in serum calcium in both groups but there were no differences in serum phosphorus across the visits. The incidence of hypercalcemia was the same in both groups. Serum calcium-phosphorus (Ca × P) product increased in the paricalcitol group but decreased in the calcitriol group. Serum ALP decreased significantly in both groups. There were also no differences in pre- and post-treatment serum hsCRP and peritoneal function test (PFT) in both groups. CONCLUSION: Both oral paricalcitol and calcitriol were equally efficacious in reducing serum iPTH but were associated with significantly higher serum calcium. Serum Ca × P product increased in the paricalcitol group and decreased in the calcitriol group. Serum hsCRP level and PFT were not affected by either treatment. A larger randomized controlled trial is indicated to confirm these initial findings.

Laparoscopic cholecystectomy: experience at a tertiary level hospital.

BACKGROUND: Cholecystectomy is the most frequently performed abdominal operation and currently laparoscopic cholecystectomy (LC) is considered gold standard being performed in 90% cases of symptomatic gallstones in USA since 1992. The aim of the study was to determine results obtained with LC at our setup. METHODS: This observational case series study was conducted in department of General Surgery, Combined Military Hospital, Rawalpindi, from August 2009 to August 2011. The study participants were patients of both gender aged 14-75 years undergoing LC. Surgery was performed by consultant as well as resident surgeon. Demographic variables, intraoperative findings, mean operation time, hospital stay, conversion rate, morbidity and mortality were evaluated. Factors influencing rate of conversion were also studied. RESULTS: A total of 504 patients were included. Mean age was 42.64 years (range 14-75 years) with a female: male ratio of 3.9:1.2. Comorbidities were found in 36.7% patients. Main indication of surgery was symptomatic cholelithiasis (78.57%). Mean operative time was 40.1 ± 6.9 minutes which increased to 75.12 ± 8.9 minutes in converted cases (p-value .000). Mean hospital stay was 1.89 ± 1.1 days that significantly increased in converted cases (5.7 ± 1.6 days) (p-value .000). Major surgical complications occurred in 3.17% patients. Common bile duct injury (CBDI) was found in 04 cases (0.79%). Conversion to laparotomy was required in 3.97% cases. Factors that influenced the rate of conversion included: age > 60 years, acute cholecystitis, coexisting diseases, ASA grade III/IV and inexperienced surgeon (p-value .000). Total complication rate was 3.56%, morbidity being 3.17% and mortality 0.39%. CONCLUSION: Laparoscopic cholecystectomy offers shorter hospital stay and low morbidity/mortality. The operative time is short and procedure is standard, safe and effective method both for uncomplicated and complicated cholelithiasis.

The effects of calcitriol with calcium carbonate supplementation on inflammatory biomarkers in chronic kidney disease patients' with low vitamin D.

INTRODUCTION: Chronic kidney disease (CKD) patients' are at risk of low vitamin D and chronic inflammation. We studied the effect of 12 weeks calcitriol and calcium carbonate supplementation on inflammatory mediators serum; interleukin-6 (IL-6), interleukin-10 (IL-10) and highly sensitive C-reactive protein (hs-CRP). MATERIAL AND METHODS: A prospective randomized study in CKD stages 2-4 with serum 25-hydroxyvitamin D (25-OHD) levels < 30 ng/ml. Patients were randomized into the Vitamin D + Calcium (Vitamin D + C) or Calcium group. Serums were analyzed at baseline, week 6 and 12. RESULTS: Fifty patients, median age of 53 (13.5) years were recruited. Their median IL-10 was 13.35 (25.22) pg/ml. At week 12, serum IL-6 was reduced in both groups (p = 0.001), serum IL-10 was maintained in the Vitamin D + C group (p = 0.06) and was reduced in the Calcium group (p = 0.001). CKD-diabetic patients had reduced serum IL-6 in both study groups (p = 0.001) and a reduction was seen in the Vitamin D + C group of the non-diabetics counterparts (p = 0.005). Serum IL-10 was reduced in the Calcium group (p < 0.05) whereas serum 25-OHD rose in both groups, regardless of their diabetic status (p < 0.05). CONCLUSIONS: Twelve weeks, calcitriol supplementation maintained IL-10, had no effects on hs- CRP and had no additional benefit compared to calcium carbonate in reducing serum IL-6 except in non-diabetics.

Exploring Pseudomonas syringae pv. tomato biofilm-like aggregate formation in susceptible and PTI-responding Arabidopsis thaliana.

Bacterial biofilm-like aggregates have been observed in plants, but their role in pathogenicity is underinvestigated. In the present study, we observed that extracellular DNA and polysaccharides colocalized with green fluorescent protein (GFP)-expressing Pseudomonas syringae pv. tomato (Pst) aggregates in Arabidopsis leaves, suggesting that Pst aggregates are biofilms. GFP-expressing Pst, Pst ΔalgU ΔmucAB (Pst algU mutant), and Pst ΔalgD ΔalgU ΔmucAB (Pst algU algD mutant) were examined to explore the roles of (1) alginate, a potential biofilm component; (2) Pst AlgU, thought to regulate alginate biosynthesis and some type III secretion system effector genes; and (3) intercellular salicylic acid (SA) accumulation during pathogen-associated molecular pattern-triggered immunity (PTI). Pst formed extensive aggregates in susceptible plants, whereas aggregate numbers and size were reduced in Pst algU and Pst algD algU mutants, and both multiplied poorly in planta, suggesting that aggregate formation contributes to Pst success in planta. However, in SA-deficient sid2-2 plants, Pst algD algU mutant multiplication and aggregate formation were partially restored, suggesting plant-produced SA contributes to suppression of Pst aggregate formation. Pst algD algU mutants formed fewer and smaller aggregates than Pst algU mutants, suggesting both AlgU and AlgD contribute to Pst aggregate formation. Col-0 plants accumulated low levels of SA in response to Pst and both mutants (Pst algU and Pst algD algU), suggesting the regulatory functions of AlgU are not involved in suppressing SA-mediated plant defence. Plant PTI was associated with highly reduced Pst aggregate formation and accumulation of intercellular SA in flg22-induced PTI-responding wild-type Col-0, but not in PTI-incompetent fls2, suggesting intercellular SA accumulation by Arabidopsis contributes to suppression of Pst biofilm-like aggregate formation during PTI.

Antioxidant and UV-blocking activity of PVA/tannin-based bioplastics in food packaging application.

In this study, bioplastics with antioxidant and UV protection properties based on tannin and PVA were created for packaging uses. Using a hot water extraction method at various extraction temperatures (60-100 °C), tannins were removed from the bark of Acacia mangium. Tannins with the best antioxidant activity were extracted at 80 °C. In order to create bioplastic formulations (PVA/Tannins), the extract is then employed. The non-heating bioplastic method's preparation (M3) stage produced the highest levels of antioxidant activity. Therefore, subsequent tests were conducted using the non-heating method (M3). On the opacity, UV protective activity, antioxidant capacity, mechanical strength, thermal stability, and water vapor permeability of the resultant bioplastics, the impact of tannin concentration (0.1-0.5 g) was examined. The findings of the experiments demonstrate that PVA/Tannin bioplastics are less transparent than pure PVA. The PVA/tannin bioplastics that are formed, on the whole, show strong antioxidant and UV protection action. Comparing PVA/Tannin bioplastics to pure PVA also revealed a small improvement in thermal stability and tensile strength. In PVA bioplastics with resistant tannins, moisture content was marginally greater even at low tannin concentrations (0.1 g). Based on the findings, bioplastics made from PVA and the tannin A. mangium have the potential to be used to create packaging that is UV and active antioxidant resistant. It can be applied as the second (inner) layer of the primary packaging to protect food freshness and nutrition due to their antioxidant activity.

Evaluation of the Oil Recovery Potential and Cost Implication Analysis of Alternative ASP Formulations for Sandstone and Carbonate Reservoirs.

This study explores alternative chemical agents to enhance oil recovery in sandstone and carbonate reservoirs, aiming to address limitations in alkali-surfactant-polymer (ASP) flooding. Existing ASP methods face technical and environmental challenges, prompting research into alternative chemical agents. However, there are limited field deployments of these alternative chemical agents due to high costs, and ternary combinations of these agents remain unexplored. The study investigates a combination of organic alkali, amino acid-based surfactant/surface-active ionic liquid, and biopolymer. Comparative analysis with conventional ASP formulations reveals promising results. Organic alkali and biopolymer combination mitigates the adverse effects of inorganic alkalis on partially hydrolyzed polyacrylamide, enhancing the oil recovery potential. A unit technical cost (UTC) calculation showed that despite higher chemical costs per incremental barrel of oil, the alternative ASP formulations demonstrate comparable costs due to reduced facility cost. Cost-effectiveness will improve with incorporation of factors such as environmental friendliness and reduced preflush requirements. Mass production of these agents could further enhance the economic feasibility. Therefore, this study reveals that careful cost-benefit analysis, the development of low-concentration formulations, and mass production of these chemical agents could facilitate the implementation of these alternatives, ensuring compliance with environmental regulations and enabling ASP flooding in challenging reservoir conditions.

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites.

INTRODUCTION: Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes. METHODS: The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars. RESULTS: Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted. CONCLUSION: MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

Economic Burden of Patients with End-Stage Kidney Disease and Their Caregivers: A Scoping Review.

Hemodialysis (HD) and peritoneal dialysis (PD) treatments impact the economic burden and psychological distress faced by end-stage kidney disease (ESKD) patients and their caregivers. This review aimed to discuss the concept of an economic burden and the economic burden of different treatment options, and to highlight research gaps regarding the scarcity of previous studies relating economic burden to psychological well-being. We searched five electronic databases for papers published in 2010-2020. Papers focusing on measures of the economic burden from the government's perspective and diseases other than ESKD were excluded. Out of the 6635 publications identified, 10 publications were included. Three categories of economic burden were identified, namely, direct medical costs, direct non-medical costs, and indirect costs. Direct medical costs required the highest expenditure, whereas the lowest economic burden was for indirect costs. HD patients incurred a higher economic burden than PD patients. Most of the studies were carried out in Asia. The results of the research suggest that the economic burden may affect patients and caregivers, but it is unclear whether the economic burden affects the psychological well-being of the patients and caregivers. Very few studies have assessed the relationship between economic burden and psychological well-being, and further research is needed to gain further insight into the relationship between these two variables.

Performance of modified hollow fiber membrane silver nanoparticles-zeolites Na-Y/PVDF composite used in membrane bioreactor for industrial wastewater treatment.

Membrane bioreactor (MBR) deteriorates due to fouling on the membrane pores, which can reduce the membrane performance. To reduce membrane fouling, the addition of inorganic filler can enhance the antifouling properties. This study investigates two different membrane preparation by thermally induced phase separation (TIPS) and dip coating methods to modify hollow fiber membrane with Silver Nanoparticles (AgNPs)-Zeolites used in MBR for industrial wastewater treatment. Performance was evaluated by analyzing the flux of water and wastewater, rejection, water content, and antifouling properties. Characterization result represented the synthesized silver nanoparticles had similar diffraction peak with commercial AgNPs, then the micrograph of AgNPs and zeolites addition membrane showed that the inorganic material had an octahedral shape representing zeolite crystal and irregular shape representing AgNPs. The addition of zeolites and AgNPs resulted in satisfying performance, increased flux, rejection, and antifouling properties.

Tools to kill: genome of one of the most destructive plant pathogenic fungi Macrophomina phaseolina.

BACKGROUND: Macrophomina phaseolina is one of the most destructive necrotrophic fungal pathogens that infect more than 500 plant species throughout the world. It can grow rapidly in infected plants and subsequently produces a large amount of sclerotia that plugs the vessels, resulting in wilting of the plant. RESULTS: We sequenced and assembled ~49 Mb into 15 super-scaffolds covering 92.83% of the M. phaseolina genome. We predict 14,249 open reading frames (ORFs) of which 9,934 are validated by the transcriptome. This phytopathogen has an abundance of secreted oxidases, peroxidases, and hydrolytic enzymes for degrading cell wall polysaccharides and lignocelluloses to penetrate into the host tissue. To overcome the host plant defense response, M. phaseolina encodes a significant number of P450s, MFS type membrane transporters, glycosidases, transposases, and secondary metabolites in comparison to all sequenced ascomycete species. A strikingly distinct set of carbohydrate esterases (CE) are present in M. phaseolina, with the CE9 and CE10 families remarkably higher than any other fungi. The phenotypic microarray data indicates that M. phaseolina can adapt to a wide range of osmotic and pH environments. As a broad host range pathogen, M. phaseolina possesses a large number of pathogen-host interaction genes including those for adhesion, signal transduction, cell wall breakdown, purine biosynthesis, and potent mycotoxin patulin. CONCLUSIONS: The M. phaseolina genome provides a framework of the infection process at the cytological and molecular level which uses a diverse arsenal of enzymatic and toxin tools to destroy the host plants. Further understanding of the M. phaseolina genome-based plant-pathogen interactions will be instrumental in designing rational strategies for disease control, essential to ensuring global agricultural crop production and security.

Barriers and Facilitators to Intradialytic Parenteral Nutrition Implementation Targeting Protein Energy Wasting in Malaysian Hemodialysis Patients.

The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implementation in Health Services (PARIHS) framework used the Likert scale to rate survey outcomes on IDPN implementation to treat PEW, according to the Evidence, Context, and Facilitation elements. IDPN for HD patients was available in 28 of 56 hospitals providing parenteral nutrition services, with only 13 hospitals (23.2%) providing IDPN to outpatients. Outpatient treatment was concentrated to urban locations (12/13) and significantly associated (p < 0.001) with resident nephrologists. The Evidence domain was rated poorly (2.18 ± 0.15) pertaining to IDPN indication when the oral spontaneous intake was ≤20 kcal/kg/day. The Context domain indicated good adherence to international best practice relating to IDPN administration (4.59 ± 0.15) and infusion time (4.59 ± 0.12). Poor adherence was observed in the Facilitation domain on 'Access to pharmacist and dietitian at HD units' (2.65 ± 0.21) and 'Access to continuous medical education on managing PEW patients on HD' (2.53 ± 0.15). The IDPN outpatient service was concentrated to urban hospitals with greater manpower resources. The PARIHS evaluation on IDPN implementation to treat PEW revealed facilitators in good practice adherence for prescribing and administration of IDPN but highlighted major barriers relating to IDPN indication and nutrient calculation.

Movement Disorders Resulting From Bilateral Basal Ganglia Lesions in End-Stage Kidney Disease: A Systematic Review.

OBJECTIVE: The basal ganglia (BG) are susceptible to fluctuations in blood urea levels, sometimes resulting in movement disorders. We described patients with end-stage kidney disease (ESKD) presenting with movement disorders associated with bilateral BG lesions on imaging. METHODS: We report four patients and systematically reviewed all published cases of ESKD presenting with movement disorders and bilateral BG lesions (EBSCOhost and Ovid). RESULTS: Of the 72 patients identified, 55 (76.4%) were on regular dialysis. Parkinsonism was the most common movement disorder (n = 39; 54.2%), followed by chorea (n = 24; 33.3%). Diabetes mellitus (n = 51; 70.8%) and hypertension (n = 16; 22.2%) were the most common risk factors. Forty-three (59.7%) were of Asian ethnicity. Complete clinical resolution was reported in 17 (30.9%) patients, while 38 (69.1%) had incomplete clinical resolution with relapse. Complete radiological resolution occurred in 14 (34.1%) patients. CONCLUSION: Movement disorders associated with BG lesions should be recognized as a rare and potentially reversible metabolic movement disorder in patients with ESKD.