Frequency of extracardiac findings on "negative" CT coronary angiography studies.

AIM: To evaluate the prevalence and nature of extracardiac findings identified on computed tomography (CT) coronary angiography (CTCA) in patients with chest pain but without evidence of coronary artery disease (CAD). MATERIALS AND METHODS: CTCA studies in patients referred to the hospital between January 2017 to February 2021 with chest pain and a suspected diagnosis of CAD were reviewed retrospectively for the presence of extracardiac findings. Consensus review of CTCA studies was performed by two experienced thoracic radiologists. The presence and severity of extracardiac findings, together with the likelihood that chest pain might be attributed to these, was recorded. Patient records were reviewed to ascertain the recording of extracardiac findings on initial CTCA reports and, where applicable, the nature of the follow-up. RESULTS: Extracardiac findings (n=210) were present in 110/180 patients (61%) with a mean of 1.9 findings per patient. Extracardiac findings were more prevalent in patients aged ≥65 years compared to those <65 years (p<0.001). At least one extracardiac finding with the potential to cause chest pain was present in 40 patients (22%): degenerative disc disease (n=23 [13%]) and hiatus hernia (n=6 [3.3%]) were the most common extracardiac findings. Only 37.6% (79) of all retrospectively identified findings had been initially reported and, of these, 12.7% (10) required further follow-up. CONCLUSION: Extracardiac findings are common in patients with no evidence of CAD on CTCA. The entire dataset should be evaluated for the presence of extracardiac findings that could explain chest pain symptoms on wide field of view reconstructions.

Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme.

OBJECTIVE: To understand why skilled birth attendance-an acknowledged strategy for reducing maternal deaths-has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions. DESIGN: Implementation research was conducted using an institutional ethnographic approach. SETTING AND POPULATION: National programme and local community levels in Pakistan. METHODS: Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together. MAIN OUTCOMES: Alignment of programme theory with real-world practice. RESULTS: Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public-private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography. CONCLUSIONS: Greater attention to programme theory and the 'real-world' setting during design of maternal health strategies is needed to achieve consistent results in different contexts.

Recombinant vesicular stomatitis virus expressing Ebola virus glycoprotein (rVSV-EBOV), a new Ebola vaccine.

Ebola virus (EBOV) causes outbreaks of lethal febrile illness in Africa, the largest of which resulted in over 11,000 deaths and represented a global public health threat. A new biomedical countermeasure, the recombinant vesicular stomatitis virus expressing EBOV glycoprotein (rVSV-EBOV) has been licensed (Ervebo; Merck & Co.). rVSV-EBOV is a replicative viral vaccine engineered to express EBOV antigen. Following rapid development stimulated by the large West African epidemic, an open-label, cluster-randomized ring vaccination trial called Ebola Ça Suffit! in Guinea and Sierra Leone demonstrated strong efficacy. The vaccine has a good safety profile, but is associated with self-limited arthritis and rash in a minority of recipients. rVSV-EBOV is highly immunogenic after a single intramuscular dose with antibody titers persisting for at least 2 years. In the recent outbreak in the Democratic Republic of the Congo, rVSV-EBOV was administered to more than 300,000 individuals and may have contributed, at least in part, to controlling the epidemic.

Daily iron supplementation is more effective than twice weekly iron supplementation in pregnant women in Pakistan in a randomized double-blind clinical trial.

In the context of limited effectiveness of iron supplementation programs, intermittent iron supplementation is currently under debate as a possible alternative strategy that may enhance the effectiveness of operational programs. This field-based trial assessed the outcome of twice weekly iron supplementation compared to daily in Pakistan. A double-blind, randomized, clinical trial was conducted in Northern Pakistan. Anemic pregnant women (n = 191) were assigned to receive daily (200 mg ferrous sulfate) or twice weekly (2 x 200 mg ferrous sulfate) iron supplementation. Hemoglobin was measured at baseline and at 4-wk intervals for up to 12 wk. Serum ferritin was measured at baseline and 8 or 12 wk. Analysis was by intention to treat. The two groups did not differ in age, parity, sociodemographic characteristics, hemoglobin or serum ferritin concentrations at baseline. Women who received iron daily had a greater rise in hemoglobin compared with women who received iron twice weekly (17.8 +/- 1.8 vs. 3.8 +/- 1.2 g/L, P < 0.001). The serum ferritin concentrations increased by 17.7 +/- 3.9 microgram/L (P < 0.001) in the daily supplemented group and did not change in the twice weekly group. Daily iron supplementation remained superior to twice weekly supplementation after controlling initial hemoglobin Z-scores and duration of treatment. The body mass index (BMI) modified the effect of daily versus twice weekly iron supplementation. For every unit increase in BMI, the difference between the two treatment groups was reduced by 0.0014 (final hemoglobin Z-score; P = 0.027). We recommend continuation of daily iron supplementation as opposed to intermittent iron supplementation in pregnant women in developing countries.

The effectiveness of patient referral in Pakistan.

In Pakistan, despite an elaborate network of over 5000 basic health units and rural health centres, supported by higher-level facilities, primary health care activities have not brought about expected improvements in health status, especially of rural population groups. A poorly functioning referral system may be partly to blame. System analysis of patient referral was conducted in a district of Punjab province (Attock) for the purpose of identifying major shortcomings, if any, in this domain. Respondents from 225 households were interviewed. Of the households experiencing serious illnesses less than half were taken to a nearest first-level care facility (FLCF). Major reasons included dissatisfaction with quality of care offered, non-availability of physician, and patients being too ill to be taken to the FLCF. The FLCF utilization rate was less than 0.6 patient visits/person/year. The mean number of patients referred per FLCF during the previous 3 months was 6.5 +/- 5.0. Only 15% of patients were referred on the prescribed referral form. None of the higher-level facilities provided feedback to FLCFS: Records of higher-level facilities revealed lack of information on either patient referrals or feedback. There were no surgical or emergency obstetric services available at any of the first-level referral facilities. Seventy-five percent of the patients attending the first-level referral facilities and 44% of the patients attending higher-level facilities had a problem of a primary nature that could well have been managed at the FLCF. As a result of the study findings, eight principal criteria were identified that need to be satisfied before a referral system may be considered functional.