Antenatal care service delivery and factors affecting effective tetanus vaccine coverage in low- and middle-income countries: Results of the Maternal Immunisation and Antenatal Care Situational analysis (MIACSA) project.

OBJECTIVES: To map the integration of existing maternal tetanus immunization programmes within antenatal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery. DESIGN: A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) and with country groups were established. PAB was defined as the proportion of neonates protected at birth against neonatal tetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity. SETTING: LMICs. RESULTS: The majority of LMICs had a policy on recommended number of ANC visits, however most were yet to implement the WHO guidelines recommending eight ANC contacts. Countries that recommended > 4 ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of disease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB (<90%). CONCLUSIONS: Recommendations include implementing the current WHO ANC guideline to facilitate increased opportunities for vaccination during each pregnancy. Improved utilisation of ANC services by increasing the demand side by increasing the quality of services, reducing any associated costs and supporting user fee exemptions, or the supply side can also enhance utilisation of ANC services which are positioned as an ideal platform for delivery of maternal vaccines.

Vaccine implementation factors affecting maternal tetanus immunization in low- and middle-income countries: Results of the Maternal Immunization and Antenatal Care Situational Analysis (MIACSA) project.

OBJECTIVES: To examine the characteristics of existing maternal tetanus immunization programmes for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with maternal vaccine service delivery that may impact the introduction and implementation of new maternal vaccines in the future. DESIGN: A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits. SETTING: LMICs. RESULTS: The majority of countries (84/95; 88%) had a maternal tetanus immunization policy. Countries with high protection at birth (PAB) were more likely to report tetanus toxoid-containing vaccine (TTCV) coverage targets > 90%. Less than half the countries included in this study had a TTCV coverage target of > 90%. Procurement and distribution of TTCV was nearly always the responsibility of the Expanded Programme on Immunization (EPI), however planning and management of maternal immunization was often shared between EPI and Maternal, Newborn and Child Health (MNCH) programmes. Receipt of TTCV at the same time as the antenatal care visit correlated with high PAB. Most countries (81/95; 85%) had an immunization safety surveillance system in place although only 11% could differentiate an adverse event following immunization (AEFI) in pregnant and non-pregnant women. CONCLUSIONS: Recommendations arising from the MIACSA project to strengthen existing services currently delivering maternal tetanus immunization in LMICs include establishing and maintaining vaccination targets, clearly defining responsibilities and fostering collaborations between EPI and MNCH, investing in strengthening the health workforce, improving the design and use of existing record keeping for immunization, adjusting current AEFI reporting to differentiate pregnant women and endeavoring to integrate the provision of TTCV within ANC services where appropriate.

Magnetic-Field-Induced Suppression of Jahn-Teller Phonon Bands in (La0.6Pr0.4)0.7Ca0.3MnO3: the Mechanism of Colossal Magnetoresistance shown by Raman Spectroscopy.

A long-standing issue in the physics of the colossal magnetoresistance is the role of electron-phonon coupling, which manifests itself as Jahn-Teller polarons. The origin and architecture of polarons makes it possible to study their behavior by Raman spectroscopy, which allows to analyze the polaronic behavior in an applied magnetic field. We performed magnetic-field-dependent Raman spectroscopy on thin films of (La0.6Pr0.4)0.7Ca0.3MnO3 in a range of H = 0-50 kOe and compared the obtained Raman spectra with the magnetic field behavior of the electrical resistivity. In the vicinity of the Curie temperature, TC = 197 K, the intensity of the Jahn-Teller stretching mode at 614 cm-1 and of the bending mode at 443 cm-1 was found to be suppressed and enhanced, respectively. This observed behavior has a remarkable similarity with the field and temperature dependence of the colossal magnetoresistance in (La0.6Pr0.4)0.7Ca0.3MnO3. Our work provides direct evidence that the reduction of the amount of Jahn-Teller polarons at the phase transition is the main mechanism underlying the colossal magnetoresistance.

The Effectiveness of a Family-Centered Childhood Obesity Intervention at the YMCA: A Pilot Study.

OBJECTIVE: Community-based, family-centered obesity prevention/treatment initiatives have been shown to be effective in reducing body mass index (BMI) and improving healthy habits in children if implemented with high intensity and sufficient duration. Let's Go! 5-2-1-0 Program (5-2-1-0) was incorporated into family-centered, monthly physical activity classes and cooking classes over six months delivered by Young Men's Christian Association (YMCA) staff. We hypothesized that implementation of this intervention would improve 5-2-1-0 knowledge attainment, increase healthy behavior (based on 5- 2-1-0 curriculum), and improve BMI and waist circumference measurements in children. METHODS: Children attending YMCA summer camps in Rochester, MN, during 2016 were recruited via study packets mailed to their families. Height, weight, and waist circumference measurements as well as the results of the Modified Healthy Habits Survey and the 5-2-1-0 Knowledge Acquisition Survey were recorded for each participating child at baseline and 6-month follow-up. The intervention group received monthly healthy habit reminder emails, and was invited to monthly evening cooking and physical activity classes for 7 sessions over a 6-month period. RESULTS: Fifteen families in the intervention group attended classes. Of those, 13 families regularly participated in (attended at least 5 out of 7) both the monthly physical activity and cooking classes. The children in the intervention group had a significant improvement in the number of Knowledge Acquisition Survey questions answered correctly (p<0.001), while there was no improvement in the control group. As compared to children in the control group, there was no significant change in BMI or waist circumference or healthy habits in the intervention group. CONCLUSION: Our study findings indicate that our intervention resulted in improved knowledge about healthy habits, but did not significantly impact healthy habits or BMI. Potential reasons for this were the small sample size and the attenuated length and/or intensity of the intervention.

Sex differentials in the uptake of antiretroviral treatment in Zambia.

This study explores socio-structural factors that influence uptake of antiretroviral treatment (ART) in Zambia and assess differences between men and women. We conducted a case-control study nested in a community- and health facility-based survey, between September 2010 and February 2011. Cases were defined as HIV-positive individuals who, while eligible, never started ART and controls were HIV-positive individuals who were on ART. Cases and controls were matched by place of residence. We performed a conditional logistic regression analysis using a discrete logistic model stratified by sex. Overall, a significantly larger proportion of men (32.7%) than women (25.6%) did not uptake ART (Pearson χ(2) = 5.9135; p = 0.015). In the crude analysis, poor health status and low self-efficacy were common factors associated with non-uptake in both sexes. After adjusting for covariates, men were more likely than women to refuse ART even though men's self-rated health was lower than women's. In general, the adjusted analysis suggests that HIV status disclosure affects uptake in both sexes but women's uptake of ART is largely hampered by poverty-related factors while for men, side effects and social pressure, probably associated with masculinity, are more important barriers. Alarmingly men's health seems to deteriorate until they start treatment, in contrast to women. Understanding gender differences in uptake and attitudes to ART is a crucial component to providing effective and appropriate health care to both men and women living with HIV/AIDS in Zambia.

Arthroscopic interposition arthroplasty of the first carpometacarpal joint.

First carpometacarpal joint arthritis is a common condition encountered by hand surgeons. Traditionally, surgical approaches have included arthrodesis, trapeziectomy or reconstructive arthroplasty techniques. Previously, we described a technique for arthroscopic debridement and interposition arthroplasty of the first carpometacarpal joint. Patients with Eaton stages II and III symptomatic first carpometacarpal joint arthritis recalcitrant to >6 months of non-operative therapy underwent arthroscopic debridement of the first carpometacarpal joint with interposition of an acellular dermal matrix allograft (GRAFTJACKET). In this paper, we describe outcomes following this procedure. Postoperatively, all patients reported symptomatic relief and 94% stated that they were partially, or completely, satisfied. More than 70% of patients reported no to mild difficulty in performing activities of daily living (average grip strength = 18.5 kg, pinch strength = 3.9kg). Complications were minimal. Outcomes from this study compare favourably to those of other series, demonstrating that this technique is a viable option for treatment of Eaton stages II and III first carpometacarpal arthritis.

Vitamin D supplementation in Swiss infants.

BACKGROUND: Various recent publications reported clinical manifestations of vitamin D deficiency in infants. Furthermore new research revealed additional properties of vitamin D for bone health and in the prevention of chronic diseases. However, prevalence data on actual supplementation rates are scarce. This study reports the prevalence of vitamin D supplementation in infants in Switzerland and presents risk factors for non-supplementation. METHODS: In 2003, mothers of 2861 randomly selected infants aged 0-9 months received a questionnaire on infant feeding, including a question on vitamin D supplementation. The prevalence of vitamin D supplementation was calculated and its dependency on various factors analysed by multiple logistic regression. RESULTS: 64% of the infants had received vitamin D. The regression analysis yielded various significant risk factors for non-supplementation: young maternal age, German language region, Swiss nationality, siblings and breastfeeding. Protective factors were intake of folic acid during pregnancy and professional information on infant feeding. The protective effect of professional information varied significantly by region. CONCLUSIONS: Given that the supplementation of vitamin D is recommended for all infants, the supplementation prevalence in Swiss infants is unsatisfactorily low. Various risk factors were identified and a positive impact of professional counselling on the supplementation rate could be demonstrated. In view of the new evidence emerging on additional preventive properties of vitamin D and the resurgence of rickets, the importance of vitamin D for infant health and ways to improve its promotion must be discussed anew.

The submental artery island flap for head and neck reconstruction.

BACKGROUND: Following excisional surgery for head and neck cancer, most complex defects are reconstructed using microvascular free tissue transfer. These methods offer many advantages; however, they are of increasing complexity with attendant risks of flap loss and donor site problems. The submental artery island flap is a recently described local flap that may be used for reconstruction of the lower and middle thirds of the face and oral cavity, and offers the advantages of simplicity, reliability and excellent cosmesis. We have been using this flap as an alternative to free tissue transfer, and in this paper we present our series of 11 cases, after a review of the recent literature, anatomy and surgical technique. The advantages and limitations of the use of this flap are presented. METHODS: A consecutive series of 11 patients in which this reconstruction was performed was reviewed retrospectively, and the results studied. Advantages and disadvantages of this reconstructive method were determined to define appropriate indications and contra-indications for its use. RESULTS: We have used this flap in 11 patients for post-excisional soft tissue reconstruction of the head and neck, both as skin and as a mucosal replacement. In all but two patients the results were satisfactory, with excellent cosmesis when used as skin replacement. One patient required secondary debulking and one had complete flap loss. In all, the donor site was satisfactory. CONCLUSIONS: The Submenal Artery Island Flap is a useful addition to the reconstructive surgeon's options and has definite advantages over distant flaps in terms of ease of dissection, final cosmetic appearance and donor site appearance.

Topical negative pressure in wound management.

OBJECTIVE: To investigate the role of topical negative pressure (TNP) therapy in the management of difficult wounds. DESIGN: Prospective consecutive patient series. PATIENTS AND SETTING: 30 patients referred to our tertiary plastic and reconstructive surgical service with wounds deemed unsuitable for reconstructive surgery were treated between November 1997 and the end of December 1998. The mean pretreatment duration of the wounds was 418 days (range, 8-1650 days). All wounds were at least Grade III pressure sores. INTERVENTION: Topical negative pressure therapy (TNP) using the VAC device (KCI Medical, San Antonio, USA). Suction (75-125 mmHg) was continuous for the first 48 hours, then intermittent (2 min on, 5 min off). MAIN OUTCOME MEASURES: Achievement of wound healing endpoints: (1) complete healing of the wound; (2) obliteration of the wound cavity to allow surface dressings; or (3) closure of the wound by suture or skin graft. RESULTS: TNP was successful in 26 out of 30 patients with mean therapy time of 35 days (range, 3-124 days). Healing was more rapid in acute (less than six weeks old) wounds. A reduction in the number of bacterial species and colonies was also observed during therapy. CONCLUSION: TNP can, in some circumstances, promote rapid secondary wound healing. A further randomised trial of TNP versus more traditional wound management modalities is justified.

Peritonectomy and intraperitoneal chemotherapy in appendiceal and colorectal cancer.

BACKGROUND: Peritoneal spread of gastrointestinal malignancies has been regarded as an incurable disease, and treatment has been aimed at short-term palliation. The use of cytoreductive surgery, including peritonectomy procedures and intraperitoneal chemotherapy, has been proposed with the intention of prolonging survival, and perhaps curing patients with peritoneal carcinomatosis from appendiceal and possibly colon cancers. A series of eight patients who have undergone this procedure at St George Hospital is presented, and the results obtained by other groups are reviewed. METHOD: Eight patients fitted the criteria for peritoneal carcinomatosis between January 1996 and November 1998. In seven patients this was secondary to appendiceal or colon cancer. and one patient had signet ring cancer of the uterus. The surgical treatment involved removing all macroscopic evidence of disease, and this was followed by early postoperative intraperitoneal chemotherapy. RESULTS: The eight patients (seven female, one male) ranged in age from 25 to 67 years. There were seven complications, including two patients with pelvic abscesses, and one patient who developed Tenchkoff catheter occlusion. There were three deaths, one due to pelvic sepsis after 30 days, and the other two were due to metastatic disease. Of the remaining five patients, two have developed recurrence and three remain disease-free. CONCLUSION: The results of peritonectomy and intraperitoneal chemotherapy for appendiceal tumours are encouraging. The role in colorectal cancer is less clear, although there are some reports that suggest a benefit.

Induction of specific tolerance to allografts in rats by therapy with non-mitogenic, non-depleting anti-CD3 monoclonal antibody: association with TH2 cytokines not anergy.

BACKGROUND: Anti-CD3 monoclonal antibodies (mAb) are potent immunosuppressives in transplantation but most do not induce tolerance. They induce anergy in Th1 cells but, if they bind to Fc receptors on antigen presenting cells, they activate T cells to release cytokines. METHODS: This study examined the mechanisms of transplant tolerance induction to PVG fully allogeneic grafts in dark agouti rats by G4.18, a mouse immunoglobulinG3 anti-rat CD3 mAb that does not bind rat Fc receptors. Evidence of T cell activation was assayed by flow cytometry, reverse transcription (RT)-polymerase chain reaction (PCR) for cytokine mRNA, and responsiveness in mixed lymphocyte culture. RESULTS: G4.18 treatment modulated T cell receptor/CD3 and CD2 and depleted T cells by <20% but did not induce activation surface markers. mRNA for interleukin (IL)-2, interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, and IL-4 in the lymph node, spleen, and thymus was not increased, and IFN-gamma mRNA was reduced. G4.18-treated and naive rat cells had similar proliferation and expression of IL-2, IFN-gamma, and IL-4 in vitro. G4.18-treated allograft recipients had no induction of mRNA for IL-2, IFN-gamma, TNF-alpha, TNF-beta, IL-4, IL-5, IL-10, perforin, and granzyme A & B in the spleen or grafts, with levels similar to those in isografts. The IL-4 and IL-5 mRNA levels in the spleen but not the graft of G4.18-treated recipients were higher than in rejecting and naive animals. Cells from G4.18-treated graft recipients proliferated more rapidly to the donor than to the third party and had increased IL-4 expression. CONCLUSIONS: G4.18 induced transplant tolerance by a combination of modulation and blocking of the TCR/CD3, associated with increased Th2 cytokines, without depletion, induction of anergy, or nonspecific activation of T cells.

Silicone in nasal augmentation rhinoplasty: a decade of clinical experience.

A number of materials, both biologic and alloplastic, have been used for nasal augmentation. Although biologic bone and cartilage grafts are associated with lower infection rates, they are also associated with long-term resorption and donor-site morbidity. Alloplastic materials, in particular silicone, have been associated in the literature with extrusion and infection but have the advantages of being affordable and easy to reshape with no requirement for harvesting autografts. A 10-year experience with silicone nasal augmentation documenting clinical experience, acute and long-term complications, and patient satisfaction was reviewed. All patients undergoing silicone augmentation rhinoplasty between July of 1985 and December of 1995 were reviewed. Preoperative nasal phenotype, operative data, and postoperative outcome were recorded. Long-term follow-up was undertaken using a telephone survey. There were 422 patients who underwent silicone nasal augmentation from July of 1985 to December of 1995. Only nine were men. The indications were for aesthetic nasal augmentation in 98 percent, and the majority (98 percent) were of South East Asian origin. Mean age was 26 (range 17 to 36), and 41 of the 422 patients had had previous nasal augmentation performed before presentation. Twenty-three patients (5.5 percent) had complications requiring removal of the implant within 30 days of surgery. These included displacement, prominence, hemorrhage, and excessive pressure in addition to obvious supratip deformity. On late follow-up, a further 18 patients (4.3 percent) had subsequent removal of the prosthesis. The most common reason for this was either displacement or over-prominence, more often judged by the surgeon than the patient. There were only two patients (0.5 percent) who had extrusion of the prosthesis. A total of 266 patients (63 percent) were contacted for a telephone interview. The majority of patients (84.2 percent) were satisfied with their nasal shape. Of the 42 patients (15.8 percent) who were not satisfied, 21 patients still wanted further augmentation of their nose. Photographic analysis of 198 patients showed a mean augmentation of 16.5 percent (range 4.0 to 27.5). Amount of augmentation correlated with preoperative nasal phenotype. Silicone nasal augmentation is a safe and effective procedure when used for moderate increases in nasal height. Contrary to previous reports, this series showed no associated infection. If the implant is shaped appropriately to the patient's nasal phenotype, the risk of extrusion may be reduced.

The cellular basis of cardiac allograft rejection: VIII. Mechanisms underlying delayed allograft rejection in PVG C6-deficient rats.

BACKGROUND: The delayed allograft rejection in C6-deficient PVG C6- rats compared with normal PVG rats has been attributed to the lack of alloantibody activation of the membrane attack complex of complement. As T cells alone have been shown to effect graft rejection, we examined T-cell responses in PVG C6- rats. METHODS: The cellular infiltrate and its mRNA for cytokines and effector molecules in DA heart allografts to PVG and PVG C6- rats was compared by immunoperoxidase staining and semiquantitative reverse transcriptase polymerase chain reaction. The ability of pure populations of T cells or alloantibody to mediate DA heart graft rejection in irradiated (750 rads) PVG and PVG C6- rats was also compared. RESULTS: The median rejection time of DA heart allografts was 8 days in PVG rats and 17.5 days in PVG C6-. PVG C6- rats sensitized to DA by two skin grafts rejected DA heart grafts in 5-6 days. CD3+, CD4+, CD8+, interleukin-2 receptor-positive T cell, macrophage, and natural killer cell infiltration, as well as class II major histocompatibility complex and intercellular adhesion molecule-1 up-regulation, in grafts was similar in naive PVG and PVG C6- rats. mRNA for T helper 1 cytokine interleukin-2, interferon-gamma, tumor necrosis factor-beta, macrophage molecules tumor necrosis factor-alpha, and inducible nitric oxide synthase, as well as cytotoxic T-cell effector molecules perforin and granzyme A and B, were found to be the same in the grafts from both naive PVG and naive PVG C6- rats. Thus, there appeared to be no difference in the T-cell effector response between the PVG and PVG C6- groups. There were higher alloantibody titers in PVG C6- rats than in PVG hosts. Irradiation ablated rejection and alloantibody responses and reconstitution with naive T cells alone restored rejection in both PVG and PVG C6- rats. Irradiated rats given serum from PVG rats that had rejected DA grafts did not effect rejection of DA grafts even if given naive T cells. Sensitized T cells restored second set. CONCLUSIONS: PVG C6- rats have normal T-cell responses and can mediate allograft rejection in the absence of alloantibody. The failure of PVG C6- to reject allografts rapidly may be a result of the poor clearance of alloantisera leading to enhancement of graft survival rather than a critical role for complement and membrane attack complex in acute rejection.

Effects of ionic and nonionic contrast media on clot structure, platelet function and thrombolysis mediated by tissue plasminogen activator in plasma clots.

Various radiographic contrast agents have anticoagulant or prothrombotic properties. Ionic agents are reported to have greater antithrombotic potential while nonionic agents are considered more thrombogenic. Some agents after fibrin structure and bind to platelets in purified systems. This study compared the effects of iohexol, a nonionic agent, and iothalamate, an ionic agent, on fibrin assembly, clot structure, platelet function and clot dissolution in plasma. Plasma gels containing increasing concentrations of iothalamate were composed of thinner fibers with decreased fiber mass/length ratios (mu) and reduced gel turbidity. Such clots were more rigid and more resistant to fibrinolysis induced by tissue plasminogen activator (tPA). Gel elastic modula increased from 10,000 to 27,000 dyn/cm2 as iothalamate concentration increased from 0 to 20 mM. 50% lysis time increased from 800 to 1,250 s with the addition of 10 mM iothalamate. At 20 mM, iothalamate had no effect on ADP-induced platelet aggregation but prolonged the lag phase seen with collagen-induced aggregation. Platelet force development increased from 15,300 to 20,400 dyn with 20 mM iothalamate. The effect of iohexol were similar. Gel optical density dropped from 0.50 to 0.32, mu fell from 3.3 to 2.2 x 10(13) D/cm, and elastic modulus rose from 11,000 to 24,000 dyn/cm2 as iohexol concentration was increased from 0 to 20 mM. Clots formed in the presence of 60 mM iohexol and tPA did not dissolve in 72 h while control clot 50% lysis time was 450 s. At concentrations > or = 40 mM, iohexol completely blocked collagen-induced platelet aggregation. Platelet force development increased from 7,660 to 19,600 with 40 mM iohexol. Contrast media possess profound fibrin-altering activities in plasma. Fibrin formed in the presence of some agents may be significantly more resistant to fibrinolysis.