Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions.

OBJECTIVE: Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions. DESIGN: We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered. SETTING AND POPULATION: Pregnancies in SSA in 2012. METHODS: For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates. MAIN OUTCOME MEASURES: Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions. RESULTS: Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth. CONCLUSIONS: Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries. TWEETABLE ABSTRACT: Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.

Biotinylation of histones in human cells. Effects of cell proliferation.

An enzymatic mechanism has been proposed by which biotinidase may catalyze biotinylation of histones. Here, human cells were found to covalently bind biotin to histones H1, H2A, H2B, H3, and H4. Cells respond to proliferation with increased biotinylation of histones; biotinylation increases early in the cell cycle and remains increased during the cycle. Notwithstanding the catalytic role of biotinidase in biotinylation of histones, mRNA encoding biotinidase and biotinidase activity did not parallel the increased biotinylation of histones in proliferating cells. Biotinylation of histones might be regulated by enzymes other than biotinidase or by the rate of histone debiotinylation.

Sensory nerve evoked responses in spinal cord injury.

Previous studies have documented the presence of fibrillations, positive waves, and decreased motor evoked response amplitudes in spinal cord injury (SCI) subjects. The purpose of this study was to further evaluate sensory nerve status in this population. Twenty-eight subjects with SCI for at least five months and evidence of spasticity were included. Sural sensory and tibial motor evoked response amplitudes were measured. The mean sural sensory amplitude was 8.0 +/- 5.9 microV (normal = 15.0 +/- 5.3 microV). The mean tibial motor amplitude was 5.1 +/- 4.3 mV (normal = 11.7 +/- 3.8 mV). In six subjects with significantly reduced sural sensory amplitudes, more extensive electrodiagnostic testing was performed. These studies showed diffusely decreased lower extremity sensory and motor evoked response amplitudes and diffuse positive waves and fibrillations in no particular distribution. Thus, subjects with SCI may have sensory as well as motor nerve abnormalities. An intact connection between the second order and primary sensory neuron may be necessary for maintenance of axonal integrity of the primary neuron.

Internal vessel occlusion: an improved technique for small vessel anastomosis.

During infragenicular bypass, internal occlusion of the distal vessel avoids unnecessary dissection and potentially damaging use of external clamps or vessel loops while improving exposure and patency. This technique is especially useful in patients with small or calcific vessels in whom distal reconstruction is necessary for limb salvage.

Subcutaneous endometriosis diagnosed by fine needle aspiration cytology.

The fine needle aspiration cytology (FNAC) of two patients manifesting cutaneous/subcutaneous endometriosis is presented. Endometrial tissue sampled by the aspiration technique manifested different cytologic characteristics as compared to those of endometrial tissue obtained by standard exfoliative methods. A primary difference was the appearance of the endometrial cells in syncytial clusters in the aspirate, in contrast to the three-dimensional clusters seen in exfoliated material. These cases emphasize the need to include endometriosis in the differential diagnosis of palpable lesions of the abdominal wall, especially in women with healed surgical scars, and the role of FNAC in diagnosing such lesions.

Studies of phosphorus metabolism by isolated nuclei. XII. Some fundamental properties of the incorporation of 32Pi into polyphosphate by rat liver nuclei.

Rat liver nuclei incubated in vitro catalyze a sustained incorporation of 32Pi into polyphosphate. A preliminary estimate indicates a minimal rate of 10 moles of Pi incorporation into polyphosphates/h/mg protein. Polyphosphate is the predominant acid-insoluble product of nuclear phosphorylation; its formation is dependent on the presence of a divalent cation and is catalyzed by a system or systems as yet uncharacterized.

Pheochromocytoma in pregnancy: diagnosis and collaborative management.

Antenatal diagnosis and appropriate management of pheochromocytoma complicating pregnancy offers a reduction in mortality for both mother and fetus. We have presented the successful management of such a case, emphasizing the close collaboration between obstetricians, pediatricians, anesthesiologists, surgeons, and internists that is mandatory for a successful outcome.

Evaluating alcoholism and drug abuse knowledge in medical education: a collaborative project.

A series of six modular examinations, each representing a substance abuse problem, were developed by a National Institute on Drug Abuse task force working with consultants from the National Board of Medical Examiners (NBME). Each examination contained a patient management problem and multiple-choice questions. The examinations were administered to 629 third- and fourth-year U.S. medical students, and the results indicated that students performed less well in this area than on the traditional content of the NBME examinations. Students performed better on items related to pharmacologic effects of drugs of abuse, Alcoholics Anonymous, and the treatment of delirium tremens. Students did less well on items related to metabolic and biochemical areas; emergency room treatment of drug-overdosed, comatose patients; and legal issues in substance abuse. As a result of these data, a syllabus explaining each item in the available modules was developed, score-reporting to participating schools was modified, and the modules were shortened. Implications for medical education in substance abuse are discussed.

The calcar femorale redefined.

The calcar femorale is a spur of thickened bone that lies deep to the lesser trochanter but posterior to the neutral axis of the femoral neck. The calcar is thickest medially where it joins the compression buttress of the neck and gradually thins as it passes laterally. X-ray films taken at right angles to the neutral axis of the femoral neck best portray the calcar femorale, which stands out like a solid bone spur as if viewing along the line of a picket fence. The presence of the calcar femorale affects the configuration of peritrochanteric fractures. It should not be confused with the primary medial compression buttress of the femoral neck.

Tissue distribution of primaquine in the rat.

The distribution of primaquine was measured in seven rat tissues at 15-180 min after the intraperitoneal injection of the antimalarial 8-aminoquinoline. The half-life of unmetabolized primaquine was 4.0 h in lung, 1.7-1.9 h in blood, spleen, kidney and heart, and 1.2 h in liver. At each interval, the concentrations of unmetabolized primaquine were (in order): lung greater than liver, kidney, spleen greater than heart greater than brain greater than or equal to blood. At 3 h after the injection of [6-O-methyl-3H]primaquine, unmetabolized primaquine constituted 10% of the total 3H in blood and 40-60% of the total 3H in liver, brain, heart and kidney.

Traumatic posterior fracture-dislocation of the lumbosacral joint.

An unusual case of traumatic posterior fracture-dislocation of the lumbosacral joint is presented. Spontaneous fusion occurred without attempted reduction. Osteomyelitis and paraplegia were associated with the injury.

Rumination in a 7-year-old child.

Regurgitation of food by rumination has rarely been reported in latency-age children. A 7-year-old boy had symptoms of rumination, gagging, bruxism, and enuresis. During the oppositional stage of development many unresolved conflicts had developed between the patient and his parents. Short-term psychotherapy which focused on resolution of the power struggles produced rapid remission of the symptoms. A two-year follow-up showed no recurrence of difficulty.

Obsidian sources characterized by neutron-activation analysis.

Concentrations of elements such as manganese, scandium, lanthanum, rubidium, samarium, barium, and zirconium in obsidian samples from different flows show ranges of 1000 percent or more, whereas the variation in element content in obsidian samples from a single flow appears to be less than 40 percent. Neutron-activation analysis of these elements, as well as of sodium and iron, provides a means of identifying the geologic source of an archeological artifact of obsidian.