Virtue Ethics among Physicians who serve Individuals with Chronic Spinal Cord Injury in Indonesia.

Individuals with chronic spinal cord injury (CSCI) require complex and lengthy health services based on ethical philosophy. The virtue character that is most relevant to the egalitarian concept is fairness. The aim of the study is whether the character of fairness becomes the character of a doctor serving individuals with CSCI. It is a mixed method cross-sectional explanatory study, with questionnaires sent to doctors and individuals with CSCI, interviews with doctors, and healthcare system field observation. Sixty-two doctors and 33 patients with CSCI participated in the study. The virtues most frequently chosen by doctors were love, gratitude, spirituality, zest, fairness, and kindness. The CSCI patients' views regarding doctors' characters were a postponement of personal interest, compassion, and loyalty to trust. All interviewed doctors indicated that they supported more than five of the 24 virtues. Doctors serve with ethical principles of virtue, even though the rewards received are inadequate. In fact, the use of health services by CSCI is still limited. Virtue ethics, especially the character of fairness, is necessary as a base of positive relationships between doctors and patients, to achieve equality of benefits for CSCI patients. Data obtained that the doctors' character of fairness is still not the main choice.

Neonatal mortality in small for gestational age infants based on reference local newborn curve at secondary and tertiary hospitals in Indonesia.

BACKGROUND: Small for gestational (SGA) infants during the neonatal period have risks of mortality and sequelae for survival. Two - third of neonatal mortality occurs in the first weeks of life. Prevalence of SGA depends on the newbon curve used. Objectives of the study were to know the conditions that posed the risk of early neonatal and neonatal mortality, to identify preterm/full-term and SGA/appropriate gestational age (AGA) infants with cumulative mortality incident (CMI), to compare 5- year-period of early and neonatal mortality, and to investigate CMI on neonatal mortality of four categories during 5-year-period. METHODS: A retrospective cohort study on all live births, during 1998-2017, was conducted in Sleman and Sardjito hospitals, Yogyakarta, Indonesia. Based on the reference local curve, the eligible subjects were categorized into SGA and AGA infants. The analyses were based on preterm/full-term and SGA/AGA, thus resulting in 4 categories: preterm-SGA, preterm-AGA, full-term-SGA and full-term-AGA. Analysis was made with Unadjusted Hazard Ratio (HR) by Simple Cox Regression and Adjusted HR was calculated by Multiple Cox Regression, survival analysis to calculate CMI, and analysis mortality for 5-year period ( 1998-2002, 2003-2007, 2008-2012, 2013-2017). RESULT: There were 35,649 live births eligible for the study. Respiratory distress was the highest risk with HR 9,46, followed by asphyxia with HR 5,08, mother's death with HR 227, extra-health facility with HR 1,97, symmetrical SGA with HR 1,97, preterm-AGA with HR 1,75, low birth weight (LBW) with HR 1,64, primary health facility with HR 1,33, and boys with HR 1,16 consecutively. Early neonatal mortality in 4 categories by survival analysis revealed the highest CMI in preterm SGA. Similar result was found in neonatal mortality. Analysis of 5-year period unveiled the highest CMI during 1998-2002. The highest CMI based on the four categories, however, was found in preterm-SGA. CONCLUSION: Respiratory distress posed the highest HR in early and neonatal mortality. Survival analysis showing the highest CMI on early and neonatal mortality was identified in preterm-SGA. The 5 - year - period of neonatal mortality showed the highest CMI during 1998-2002 period, whereas based on 4 SGA categories, preterm-SGA demonstrated the highest CMI.

The Effect of Parenting Peer Education Interventions for Young Mothers on the Growth and Development of Children under Five.

One of the contributing factors in the growth and development of children under five is the mother's ability to provide childcare, but young mothers do not have enough parenting skills. The goal of the current study was to examine the effect of the parenting peer education (PPE) programme on young mothers' parenting self-efficacy and behaviour, and the growth and development of children under five. There were two groups, which were a control group (without intervention) and an intervention group, in which there were 15 participants in each group. Analysis covariance with the pre-test scores as covariates was used in this study. The results showed that, compared with the control group, the intervention group reported significantly better parenting self-efficacy, parenting behaviour, children's growth, and children's development, including cognitive, language, and motoric aspects. The PPE programme can exchange the young mothers' experiences on how their children grow and develop, and the mothers will also receive psychological support. In conclusion, the PPE programme affected the young mothers' parenting self-efficacy and parenting behaviour and the children's growth and development.

Respiratory distress in small for gestational age infants based on local newborn curve prior to hospital discharge.

Background: Respiratory distress in newborns, which may lead to risks of morbidity and death, is one of the reasons for a referral to the more advanced health facilities. Respiratory distress analysis in small for gestational age (SGA) infants remains controversial. SGA infants are a big problem for and burden the low-medium income countries. Frequentness of SGA infants varies, depending on birth weight curve used. Objective: To identify the risks, complications, death induced by respiratory distress in SGA infants prior to hospital discharge. Methods: A retrospective cohort study was conducted on live- born infants at Sardjito Hospital. Singleton and gestational age 26-42 weeks were the inclusion criteria. The exclusion criteria included major congenital anomaly, chromosomal abnormalities, out-born infants admitted >24 h, discharge against medical advice, and incomplete data. The samples were categorized into appropriate gestational age (AGA) and SGA by a local newborn curve. The samples were also classified as full-term (FT)-AGA, preterm (PT)-AGA, FT-SGA, and PT-SGA. Odds ratio (OR) was based on entire respiratory distress. Complications of respiratory distress analyzed were length of hospital stay, administration of oxygen, Continuous Positive Airway Pressure (CPAP), and ventilator. Reverse Kaplan-Meier and Cumulative Mortality Incidence (CMI) were used to analyze respiratory distress-induced mortality. Stata 13 was used to analyze the data. Results: There were 12,490 infants eligible for the study, consisting of 9,396 FT-AGA infants, 2,003 PT-AGA infants, 771 FT-SGA infants, and 320 PT-SGA infants. Nine hundred and thirty-two infants developed respiratory distress. Multiple logistic regression analysis revealed highest risk of respiratory distress in PT-SGA infants with OR 5.84 (4.28-7.99). The highest respiratory distress complications were found in PT- SGA with significant difference on length of hospital stay and IRR 2.62 (2.09-3.27). In addition, the highest use of mechanical ventilator was found in PT-SGA with significant difference. CPAP use was the highest in PT-AGA infants. There was no significant difference in oxygen administration among the groups. Respiratory distress-induced mortality analysis found the highest CMI in PT-SGA infants. Conclusion: PT-SGA had the highest risk of respiratory distress with complications of length of hospital stay, and ventilator use. Mortality analysis discovered the highest CMI in PT-SGA infants. We should therefore be alert when dealing with PT-SGA infants.

Early-onset neonatal sepsis and antibiotic use in Indonesia: a descriptive, cross-sectional study.

BACKGROUND: Early diagnosis and prompt antibiotic treatment are crucial to reducing morbidity and mortality of early-onset sepsis (EOS) in neonates. However, this strategy remains challenging due to non-specific clinical findings and limited facilities. Inappropriate antibiotics use is associated with ineffective therapy and adverse outcomes. This study aims to determine the characteristics of EOS and use of antibiotics in the neonatal-intensive care units (NICUs) in Indonesia, informing efforts to drive improvements in the prevention, diagnosis, and treatment of EOS. METHODS: A descriptive study was conducted based on pre-intervention data of the South East Asia-Using Research for Change in Hospital-acquired Infection in Neonates project. Our study population consisted of neonates admitted within 72 h of life to the three participating NICUs. Neonates who presented with three or more clinical signs or laboratory results consistent with sepsis and who received antibiotics for 5 consecutive days were considered to have EOS. Culture-proven EOS was defined as positive blood or cerebrospinal fluid culture. Type and duration of antibiotics used were also documented. RESULTS: Of 2,509 neonates, 242 cases were suspected of having EOS (9.6%) with culture-proven sepsis in 83 cases (5.0% of neonatal admissions in hospitals with culture facilities). The causative organisms were mostly gram-negative bacteria (85/94; 90.4%). Ampicillin / amoxicillin and amikacin were the most frequently prescribed antibiotics in hospitals with culture facilities, while a third-generation cephalosporin was mostly administered in hospital without culture facilities. The median durations of antibiotic therapy were 19 and 9 days in culture-proven and culture-negative EOS groups, respectively. CONCLUSIONS: The overall incidence of EOS and culture-proven EOS was high in Indonesia, with diverse and prolonged use of antibiotics. Prospective antibiotic surveillance and stewardship interventions are required.

"Sharp downward, blunt upward": district maternal death audits' challenges to formulate evidence-based recommendations in Indonesia - a qualitative study.

BACKGROUND: Indonesia, the largest archipelago globally with a decentralized health system, faces a stagnant high maternal mortality ratio (MMR). The disparity factors among regions and inequities in access have deterred the local assessments in preventing similar maternal deaths. This study explored the challenges of district maternal death audit (MDA) committees to provide evidence-based recommendations for local adaptive practices in reducing maternal mortality. METHODS: A qualitative study was conducted with four focus-group discussions in Central Java, Indonesia, between July and October 2019. Purposive sampling was used to select 7-8 members of each district audit committee. Data were analyzed using the thematic analysis approach. Triangulation was done by member checking, peer debriefing, and reviewing audit documentation. RESULTS: The district audit committees had significant challenges to develop appropriate recommendations and action plans, involving: 1) non-informative audit tool provides unreliable data for review; 2) unstandardized clinical indicators and the practice of "sharp downward, blunt upward"; 3) unaccountable hospital support and lack of leadership commitment, and 4) blaming culture, minimal training, and insufficient MDA committee' skills. The district audit committees tended to associated maternal death in lower and higher-level health facilities (hospitals) with mismanagement and unavoidable cause, respectively. These unfavorable cultures discourage transparency and prevent continuing improvement, leading to failure in addressing maternal death's local avoidable factors. CONCLUSION: A productive MDA is required to provide an evidence-based recommendation. A strong partnership between the key hospital decision-makers and district health officers is needed for quality evidence-based policymaking and adaptive practice to prevent maternal death.

Colorimetric and label free detection of gelatinase positive bacteria and gelatinase activity based on aggregation and dissolution of gold nanoparticles.

A simple and sensitive method was developed for the detection of bacteria gelatinase activity based on their enzymatic hydrolysis effect on the surface plasmon resonance (SPR) of gelatin functionalized gold nanoparticles (Au@gelatin NPs) in bacteria supernatant. Characterization of synthesized NPs showed a very thin gelatin layer on the surface of about 20 nm AuNPs which modified the intrinsic SPR property of AuNPs. The extracted supernatants of applied bacteria were incubated with Au@gelatin NPs. Gelatinase activity of bacteria resulted in gradual gelatin shell removal and subsequent dissolution of bare AuNPs. The presence of inducer agents such as NaCl as the common ingredient in the bacterial medium led to the aggregation process of AuNPs and further bacterial activity resulted in AuNPs dissolution. AuNPs colloid solution color was changed from red to purple after addition of bacteria supernatants with gelatinase activity to the reaction. Also, the spectroscopic studies showed that the gelatinase activity of bacteria resulted in the gradual decrease of absorbance at 529 nm and subsequently led to extinction of SPR characteristics. So, the observed absorbance decrease in UV-Vis spectra at 529 nm was indicated as the gelatinase activity of applied bacteria. Different strains of gelatinase positive Bacillus strains were used as the real sample and their gelatinase activity was determined in the present study. Also, sensitivity analysis of the applied method was determined through this method and the obtained results showed Bacillus subtilis gelatinase activity in the linear range of 0-120 U/mL and detection limit of 0.5 U/mL. This method introduced label free, facile and sensitive assay of the bacterial gelatinase activity without any complicated instrument, affording convenience and simplicity.

Maternal and Neonatal Factors Affecting Bone Mineral Content of Indonesian Term Newborns.

Background: Interactions between the genome and intrauterine environment can affect bone mineralization in newborns and even in adult life. Several studies show that intrauterine fetal bone mineralization or early postnatal bone condition influences the risk of osteoporosis in later life. Objectives: To determine whole body bone mineral content (WB BMC) and factors that influence neonatal WB BMC in Indonesian term newborns. Subjects/Methods: A cross-sectional study was conducted in Dr. Sardjito General Hospital, Yogyakarta, Indonesia. A total of 45 term, appropriate for gestational age (AGA) newborns were included in this study. BMC was assessed by dual-energy x-ray absorptiometry (DXA) in the first week of life. Weight (g), length (cm) and head circumference (cm) were measured at birth. Data on maternal characteristics were obtained from the maternal health records or reported by the mothers. Results: WB BMC measured in the present study (mean ± SD: 33.2 ± 9.3 g) was lower than WB BMC of similar populations in developed countries. Multiple linear regression showed that birth weight, birth length, and gestational age had a positive association with WB BMC (p = 0.048, 0.017, and <0.001, respectively), while maternal cigarette exposure had a negative association with WB BMC (p = 0.012). Male infants had significantly higher of WB BMC than female (p = 0.025). These determinants contribute to 55% variability of WB BMC. Conclusions: WB BMC in Indonesian term newborns is lower than populations in developed countries. Birth weight, length, gestational age, sex, and maternal cigarette exposure during pregnancy are significantly associated with WB BMC observed in Indonesian newborns.

The reliability of maternal audit instruments to assign cause of death in maternal deaths review process: a systematic review and meta-analysis.

BACKGROUND: Maternal Death Reviews (MDR) can assist in formulating prevention strategies to reduce maternal mortality. To support MDR, an adequate MDR instrument is required to accurately identify the underlying causes of maternal deaths. We conducted a systematic review and meta-analysis to determine the reliability of maternal death instruments for conducting the MDR process. METHOD: Three databases: PubMed, ProQuest and EBSCO were systematically searched to identify related research articles published between January 2004 and July 2019. The review and meta-analysis involved identification of measurement tools to conduct MDR in all or part of maternal audit. Eligibiliy and quality of studies were evaluated using the Modified Quality Appraisal of Diagnostic Reliability (QAREL) Checklist: Reliability Studies. RESULTS: Overall, 242 articles were identified. Six articles examining the instrument used for MDR in 4 countries (4 articles on verbal autopsy (VA) and 2 articles on facility-based MDR) were included. None of studies identified reliability in evaluation instruments assessing maternal audit cycle as a comprehensive approach. The pooled kappa for the MDR instruments was 0.72 (95%CI:0.43-0.99; p < 0.001) with considerable heterogeneity (I2 = 96.19%; p < 0.001). Subgroup analysis of MDR instruments showed pooled kappa in VA of 0.89 (95%CI:0.52-1.25) and facility-based MDR of 0.48 (95%CI:0.15-0.82). Meta-regression analysis tended to show the high heterogeneity was likely associated with sample sizes, regions, and year of publications. CONCLUSIONS: The MDR instruments appear feasible. Variation of the instruments suggest the need for judicious selection of MDR instruments by considering the study population and assessment during the target periods.

Chemotherapy Negates the Effect of SDF1 mRNA to Distant Metastasis and Poor Overall Survival in Breast Cancer Patients.

OBJECTIVE: Investigate the effect of SDF1a, nuclear, and cytoplasmic CXCR4 breast cancer tissue on metastasis and overall survival in patients with complete-chemotherapy and no-chemotherapy. METHODS: Cohort ambidirectional design was employed with survival analysis that followed the patient's diagnosis until obtaining the outcome, distant metastasis, or death. We analyzed samples in three groups (all-patient, no-chemotherapy, and complete-chemotherapy groups).  Breast cancer cell nuclear and cytoplasm expressions of CXCR4 protein were examined using immunohistochemistry. Amplification of mRNA SDF1a of breast cancer tissue was examined using rtPCR on 131 samples from the same initial paraffin block. RESULTS: In the distant metastasis and Overall Survival (OS) analysis, there was no correlation between cytoplasmic and nuclear CXCR4 in all-patient, no-chemotherapy, and complete-chemotherapy groups. SDF1a was significantly correlated to shorter distant metastasis and poor OS in the all-patient (p=0.004 and p=0.04, respectively) and no-chemotherapy group (p=0.008 and p=0.026, respectively). However, in the complete-chemotherapy group, SDF1a was not correlated to either metastasis (p=0.527) or OS (p=0.993), advanced stage demonstrated a strong association on shorter distant metastatic in no-chemotherapy (p=0.021) and complete-chemotherapy group (p=0.004) and also poor OS in both groups (p=0.006 and p=0.002, respectively). The hormone receptor showed a protective effect on the no-chemotherapy group's OS (p= 0.019). Meanwhile, not undergoing chemotherapy was associated with poor OS in the all-patient group (p= 0.011). CONCLUSION: SDF1a mRNA amplification has a significant correlation with the occurrence of metastasis and OS in all-patient and no-chemotherapy group. Undergoing chemotherapy negates the effect of SDF1a for distant metastasis and OS.

MicroRNA-223 is Associated with Resistance Towards Platinum-based Chemotherapy and Worse Prognosis in Indonesian Triple-negative Breast Cancer Patients.

PURPOSE: Determining the optimal strategy to implement systemic treatment modalities has been challenging in triple-negative breast cancer (TNBC). We aim to investigate the role of microRNA-223 (miR-223) as prognostic factor and predictor of response toward chemotherapy in TNBC. PATIENTS AND METHODS: We retrospectively analyzed the association of pretreatment miR-223 expression with clinicopathologic characteristics and 36-month overall survival (OS) of 53 all stages TNBC patients. Tumor level of miR-223 was measured using real-time quantitative polymerase chain reaction (expressed in fold change). Cutoff value for miR-223 was determined by using receiver operating curve (ROC). Kaplan-Meier curve was used to perform survival analysis. RESULTS: The optimum cutoff value for miR-223 was 23.435 (AUC: 0.706, 95%CI: 0.565-0.848; p:0.01; sensitivity: 78.6%; specificity: 56%) and was used to categorize mir-223 expression into over- and underexpressed group. Overexpression of miR-223 was associated with increased expression of EGFR (69.7% vs 35%, p: 0.022) and lower 36-month OS (33.3% vs 70%; median OS±SE (months): 25.66±1.58 vs 30.23±1.99; log rank p<0.05). Worse survival is observed in miR-223 overexpressed group receiving platinum-based chemotherapy compared to miR-223 underexpressed group (mean OS (95%CI) months: 24.7 (20.3-29.1) vs 34.3 (31.2-37.4); p<0.01), while no significant difference observed in non-platinum containing regimen. No significant association was observed between miR-223 expression with other clinicopathologic characteristics. CONCLUSION: Overexpression of miR-223 is associated with increased expression of EGFR, worse prognosis, and resistance toward platinum-based chemotherapy in Indonesian TNBC patients.

Preparation of a new fluorescence nanochemosensor for Sn(II) ions by a modified nanoprecipitation method.

A new dialdehyde was designed and synthesized containing naphthalene groups, and then its macrocycle was prepared with 1,4-diaminobuthan. A modified nanoprecipitation method has been reported for the preparation of the nanoparticles. In this method, to obtain nanoparticles with small particle sizes, the nucleation rate was increased with decreasing of the mixing time. The organic nanoparticles were used for turn-off fluorescence response of low concentration of Sn2+ ions over cations such as Cs+, K+, Na+, Ba2+, Ca2+, Mg2+, Al3+, Pb2+, Zn2+, Cu2+, Ni2+, Co2+, Fe2+, Mn2+, Ag+, Cd2+, and Hg2+ and ions in aqueous buffer solution. The limit of detection was 5.4 nM.

Nutritional anemia in Indonesia children and adolescents: Diagnostic reliability for appropriate management.

BACKGROUND: Nutritional anemia in Indonesian children and adolescents is generally regarded and treated as iron-deficient anemia, as it is in individuals in other age groups. OBJECTIVES: Yet, it remains a public health threat without comprehensive management or a sustained solution. METHODS: This review seeks to improve understanding of impediments to its resolution. Relevant studies reported in the past 5 years were identified in PubMed, Science Direct, Crossreff, Google Scholar, and Directory of Open Access Journals databases. RESULTS: In all, 12 studies in several Indonesian cities provided the basis for the review. Most were conducted in schools, indicating the potential of these institutions as targets for intervention but pointing to serious deficiencies in identification of the problem across the archipelago and in remote and rural areas. No study has evaluated coexistent anemia and malnutrition, which likely would have revealed the multi-factoriality of nutritional anemia. Data regarding nutrition education, food-based innovation, and supplementation, which may alleviate anemia in children and adolescents, are available, although study lengths and sample sizes have limited interpretation and comparison. CONCLUSIONS: Broadly, three intervention approaches to nutritional anemia have been undertaken, namely food-based interventions, nutrient supplementation, and nutrition education. Some progress has been made with these approaches, presumably through increases in iron intake. More information is needed regarding the underlying causality and pathogenesis, suboptimal food patterns, and comorbidities, any of which might limit the effectiveness of programs designed to resolve childhood and adolescent anemia in Indonesia.

Skin preparation for preventing infection following caesarean section.

BACKGROUND: The risk of maternal mortality and morbidity is higher after caesarean section than for vaginal birth. With increasing rates of caesarean section, it is important to minimise risks to the mother as much as possible. This review focused on different skin preparations to prevent infection. This is an update of a review last published in 2018. OBJECTIVES: To compare the effects of different antiseptic agents, different methods of application, or different forms of antiseptic used for preoperative skin preparation for preventing postcaesarean infection. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (9 July 2019), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised trials, evaluating any type of preoperative skin preparation (agents, methods or forms). We included studies presented only as abstracts, if there was enough information to assess risk of bias. Comparisons of interest in this review were between: different antiseptic agents (e.g. alcohol, povidone iodine), different methods of antiseptic application (e.g. scrub, paint, drape), different forms of antiseptic (e.g. powder, liquid), and also between different packages of skin preparation including a mix of agents and methods, such as a plastic incisional drape, which may or may not be impregnated with antiseptic agents. We mainly focused on the comparison between different agents, with and without the use of drapes. Only studies involving the preparation of the incision area were included. This review did not cover studies of preoperative handwashing by the surgical team or preoperative bathing. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed all potential studies for inclusion, assessed risk of bias, extracted the data and checked data for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 13 individually-randomised controlled trials (RCTs), with a total of 6938 women who were undergoing caesarean section. Twelve trials (6916 women) contributed data to this review. The trial dates ranged from 1983 to 2016. Six trials were conducted in the USA, and the remainder in India, Egypt, Nigeria, South Africa, France, Denmark, and Indonesia. The included studies were broadly at low risk of bias for most domains, although high risk of detection bias raised some specific concerns in a number of studies. Length of stay was only reported in one comparison. Antiseptic agents Parachlorometaxylenol with iodine versus iodine alone We are uncertain whether parachlorometaxylenol with iodine made any difference to the incidence of surgical site infection (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.04 to 2.99; 1 trial, 50 women), or endometritis (RR 0.88, 95% CI 0.56 to 1.38; 1 trial, 50 women) when compared with iodine alone, because the certainty of the evidence was very low. Adverse events (maternal or neonatal) were not reported. Chlorhexidine gluconate versus povidone iodine Moderate-certainty evidence suggested that chlorhexidine gluconate, when compared with povidone iodine, probably slightly reduces the incidence of surgical site infection (RR 0.72, 95% CI 0.58 to 0.91; 8 trials, 4323 women). This effect was still present in a sensitivity analysis after removing four trials at high risk of bias for outcome assessment (RR 0.87, 95% CI 0.62 to 1.23; 4 trials, 2037 women). Low-certainty evidence indicated that chlorhexidine gluconate, when compared with povidone iodine, may make little or no difference to the incidence of endometritis (RR 0.95, 95% CI 0.49 to 1.86; 3 trials, 2484 women). It is uncertain whether chlorhexidine gluconate reduces maternal skin irritation or allergic skin reaction (RR 0.64, 95% CI 0.28 to 1.46; 3 trials, 1926 women; very low certainty evidence). One small study (60 women) reported reduced bacterial growth at 18 hours after caesarean section for women who had chlorhexidine gluconate preparation compared with women who had povidone iodine preparation (RR 0.23, 95% CI 0.07 to 0.70). Methods Drape versus no drape This comparison investigated the use of drape versus no drape, following preparation of the skin with antiseptics. Low-certainty evidence suggested that using a drape before surgery compared with no drape, may make little or no difference to the incidence of surgical site infection (RR 1.29, 95% confidence interval (CI) 0.97 to 1.71; 3 trials, 1373 women), and probably makes little or no difference to the length of stay in the hospital (mean difference (MD) 0.10 days, 95% CI -0.27 to 0.46; 1 trial, 603 women; moderate-certainty evidence). One trial compared an alcohol scrub and iodophor drape with a five-minute iodophor scrub only, and reported no surgical site infection in either group (79 women, very-low certainty evidence). We were uncertain whether the combination of a one-minute alcohol scrub and a drape reduced the incidence of metritis when compared with a five-minute scrub, because the certainty of the evidence was very low (RR 1.62, 95% CI 0.29 to 9.16; 1 trial, 79 women). The studies did not report on adverse events (maternal or neonatal). AUTHORS' CONCLUSIONS: Moderate-certainty evidence suggests that preparing the skin with chlorhexidine gluconate before caesarean section is probably slightly more effective at reducing the incidence of surgical site infection in comparison to povidone iodine. For other outcomes examined there was insufficient evidence available from the included RCTs. Most of the evidence in this review was deemed to be very low or low certainty. This means that for most findings, our confidence in any evidence of an intervention effect is limited, and indicates the need for more high-quality research. Therefore, it is not yet clear what sort of skin preparation may be most effective for preventing postcaesarean surgical site infection, or for reducing other undesirable outcomes for mother and baby. Well-designed RCTs, with larger sample sizes are needed. High-priority questions include comparing types of antiseptic (especially iodine versus chlorhexidine), and application methods (scrubbing, swabbing, or draping). We found two studies that are ongoing; we will incorporate the results of these studies in future updates of this review.

Concerned and Conscious, but DefenselessThe intersection of gender and generation in child malnutrition in Indonesia: a qualitative grounded theory study.

Background: Several studies in Indonesia have shown the protective effect of women-headed households on the double burden of malnutrition (coexistence of undernutrition and overnutrition in a household). Many other studies have presented a positive impact on children's health and conditions when women are educated, have higher social capital and have control of income and its intra-household allocation. However, how women's status affects the nutritional status of a household and, in particular, of children still remains understudied.Objective: In this study, our aim was to explore the role of gender relations and contextual factors for overnutrition and undernutrition among children within a household.Method: We conducted a qualitative study in two provinces of Indonesia: Central Java (urban and rural) and Jakarta (central and suburban) among 123 community members (59 men and 64 women). We utilised principles of constructivist grounded theory in conducting this study, and focus group discussions were chosen as a tool to collect data.Results: Three categories were constructed, capturing the significance of: (i) the man is dominant within the family (gendered power relations), (ii) the environment that makes the unhealthy choice the easy choice (the emerging obesogenic environment) and (iii) parents' being concerned but unable to control their children's eating habits (intersection of gender and generational relations) in child malnutrition.Conclusion: Community health and nutrition programmes should help both women and men within the context of households to acknowledge and respect women's status. More importantly, these programmes should involve men when it comes to children's nutritional habits and consider them as an important factor in the realisation of gender equality and empowerment. Furthermore, it is increasingly important to recognise the implication of the availability and accessibility of junk food among children.

The potential of adopting struvite precipitation as a strategy for the removal of nutrients from pre-AnMBR treated abattoir wastewater.

Large volume of wastewater consisting complex forms of organics, lipids and nutrients, is discharged from the abattoir (red meat) processing industry. In this study, nutrient rich pre-Anaerobic Membrane Bioreactor (AnMBR) treated abattoir effluent was fed to a struvite (MgNH4PO4.6H2O) precipitator to evaluate the possibility of developing an innovative environmentally sustainable treatment technology to produce nutrient free high-quality treated effluent. A series of continuous and batch experiments were conducted to investigate the influence of pH and presence of Ca2+ on struvite precipitation. The study found that Mg2+:Ca2+ molar ratio of 0.8 (or high Ca2+) impacts on the production and quality of struvite significantly. Pre-AnMBR treated abattoir wastewater with negligible Ca2+ (Mg2+:Ca2+ molar ratio > 20) showed over 80% removal of phosphorus via struvite precipitation. The highest removal rates of both nitrogen and phosphorus were achieved at pH 9.5 with Mg2+:PO43- molar ratio of 2:1.

Reaction of 2-[(2-aminoethyl)amino]ethanol with pyridine-2-carbaldehyde and complexation of the products with CuII and CdII along with docking studies.

The reaction between 2-[2-(aminoethyl)amino]ethanol and pyridine-2-carbaldehyde in a 1:2 molar ratio affords a mixture containing 2-({2-[(pyridin-2-ylmethylidene)amino]ethyl}amino)ethanol (PMAE) and 2-[2-(pyridin-2-yl)oxazolidin-3-yl]-N-(pyridin-2-ylmethylidene)ethanamine (POPME). Treatment of this mixture with copper(II) chloride or cadmium(II) chloride gave trichlorido[(2-hydroxyethyl)({2-[(pyridin-2-ylmethylidene)amino]ethyl})azanium]copper(II) monohydrate, [Cu(C10H16N3O)Cl3]·H2O or [Cu(HPMAE)Cl3]·H2O, 1, and dichlorido{2-[2-(pyridin-2-yl)oxazolidin-3-yl]-N-(pyridin-2-ylmethylidene)ethanamine}cadmium(II), [CdCl2(C16H18N4O)] or [CdCl2(POPME)], 2, which were characterized by elemental analysis, FT-IR, Raman and 1H NMR spectroscopy and single-crystal X-ray diffraction. PMAE is potentially a tetradentate N3O-donor ligand but coordinates to copper here as an N2 donor. In the structure of 1, the geometry around the Cu atom is distorted square pyramidal. In 2, the Cd atom has a distorted octahedral geometry. In addition to the hydrogen bonds, there are π-π stacking interactions between the pyridine rings in the crystal packing of 1 and 2. The ability of PMAE, POPME and 1 to interact with ten selected biomolecules (BRAF kinase, CatB, DNA gyrase, HDAC7, rHA, RNR, TrxR, TS, Top II and B-DNA) was investigated by docking studies and compared with doxorubicin.

Beta-ketothiolase deficiency: A case with unusual presentation of nonketotic hypoglycemic episodes due to coexistent probable secondary carnitine deficiency.

Beta-ketothiolase (T2, mitochondrial acetoacetyl-CoA thiolase) deficiency is an autosomal recessive disorder of isoleucine catabolism and ketone body metabolism that is characterized by increased urinary excretion of 2-methylacetoacetate, 2-methyl-3-hydroxybutyrate, and tiglylglycine. Most patients with T2 deficiency develop their first severe ketoacidotic events between 5 and 24 months of age. We encountered a case of T2 deficiency who developed the first hypoglycemic crisis without ketosis during her neonatal period and repeated such nonketotic hypoglycemic crisis during her infancy and early childhood. This is a very atypical clinical phenotype in T2 deficiency. We finally realized that she also has severe carnitine deficiency which might suppress beta-oxidation resulting in nonketotic hypoglycemia. After carnitine supplementation, she actually developed episodes with ketonuria. Her carnitine deficiency was probably a secondary deficiency which is rare in T2 deficiency but if present, may modify the clinical manifestation of T2 deficiency from ketoacidotic events to hypoketotic hypoglycemic events.

Dilute versus full-strength formula in exclusively formula-fed preterm or low birth weight infants.

BACKGROUND: Preterm infants have fewer nutrient reserves at birth than full-term infants and often receive artificial formula feeds in the absence of expressed breast milk. Although it is generally agreed that feeding must be initiated slowly and advanced with much greater deliberation than in a healthy, full-term infant, the way in which feeds are introduced and advanced in preterm infants varies widely. This review focuses on whether dilute or full-strength formula is the preferable mode of introducing feeds in preterm infants for whom expressed breast milk is unavailable. OBJECTIVES: To assess the effects of dilute versus full-strength formula on the incidence of necrotising enterocolitis, feeding intolerance, weight gain, length of stay in hosptial and time to achieve full calorie intake in exclusively formula-fed preterm or low birth weight infants. A secondary objective was to assess the effects of different dilution strategies. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to update the search in the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 9), MEDLINE via PubMed (1966 to 1 October 2018), Embase (1980 to 1 October 2018), and CINAHL (1982 to 1 October 2018).We searched clinical trials' registries for ongoing or recently completed trials (clinicaltrials.gov; the World Health Organization's International Trials Registry and Platform; and the ISRCTN Registry). SELECTION CRITERIA: Randomised or quasi-randomised trials comparing strengths of formula milk in exclusively formula-fed preterm or low birth weight infants. We excluded studies if infants received formula as a supplement to breast milk. DATA COLLECTION AND ANALYSIS: We independently assessed studies for inclusion. We collected data using the standard methods of Cochrane Neonatal, with independent assessment of risk of bias and data extraction. We synthesised mean differences using a fixed-effect meta-analysis model. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included three studies involving 102 preterm or low birth weight infants in the review. The studies compared dilute (double-volume, half-strength) formula with full-strength (20 kcal/oz (˜ 68 to 70 kcal/100 mL)) formula. We assessed all three studies as having unclear risk of bias due to the likely absence of blinding of study personnel and the potential for selection bias in the largest trial. Data for the primary outcome of necrotising enterocolitis were not reported in any of the studies. We could combine two of the studies (88 infants) in the meta-analysis. The evidence suggests that dilute formula with double-volume (half-strength) may lead to fewer episodes of gastric residuals per day (one study; mean difference (MD) -1.20, 95% confidence interval (CI) -2.20 to -0.20; low-certainty evidence), fewer episodes of gastric residuals per baby until attaining 100 kcal/kg (one study; MD -0.80, 95% CI -1.32 to -0.28; low-certainty evidence), fewer episodes of vomiting per day (one study; MD -0.04, 95% CI -0.07 to -0.01; low-certainty evidence) and fewer occurrences of abdominal distension greater than 2 cm (two studies; MD -0.16, 95% CI -0.19 to -0.13; low-certainty evidence). For the secondary outcomes, data suggest that infants in the dilute formula with double-volume (half-strength) group may have attained an adequate energy intake earlier than infants in the full-strength group (two studies; MD -2.26, 95% CI -2.85 to -1.67; low-certainty evidence). There was no evidence of a difference between groups for weight gain one week after commencement of intragastric feeds (one study; MD 0.05 kg, 95% CI -0.06 to 0.15; low-certainty evidence). Data were not reported for length of hospital stay. AUTHORS' CONCLUSIONS: There is low-certainty evidence from three small, old trials that use of dilute formula in preterm or low birth weight formula-fed infants may lead to an important reduction in the time taken for preterm infants to attain an adequate energy intake.However, our confidence in this result is limited due to uncertainty over risk of bias and sparsity of available data. Dilute formula may reduce incidence of feeding intolerance, but the clinical significance of the reduction is uncertain. The impact on serious gastrointestinal problems, including necrotising enterocolitis, was not reported in any of the trials. Further randomised trials are needed to confirm these results.

Investigation of the effect of the N-oxidation process on the interaction of selected pyridine compounds with biomacromolecules: structural, spectral, theoretical and docking studies.

Two new N-oxide compounds, namely glycinium 2-carboxy-1-(λ1-oxidaneyl)-1λ4-pyridine-6-carboxylate-glycine-water (1/1/1), C2H6NO2+·C7H4NO5-·C2H5NO2·H2O or [(2,6-HpydcO)(HGLY)(GLY)(H2O)], 1, and methyl 6-carboxy-1-(λ1-oxidaneyl)-1λ4-pyridine-2-carboxylate, C8H7NO5 or 2,6-HMepydcO, 2, were prepared and identified by elemental analysis, FT-IR, Raman spectroscopy and single-crystal X-ray diffraction. The X-ray analysis of 1 revealed an ionic compound containing a 2,6-HpydcO- anion, a glycinium cation, a neutral glycine molecule and a water molecule. Compound 2 is a neutral compound with two independent units in its crystal structure. In addition to the hydrogen bonds, the crystal network is stabilized by π-π stacking interactions of the types pyridine-carboxylate and carboxylate-carboxylate. The thermodynamic stability and charge-distribution patterns for isolated molecules of 2,6-H2pydcO and 2,6-HMepydcO, and their two similar derivatives, pyridine-2,6-dicarboxylic acid (2,6-H2pydc) and dimethyl 1-(λ1-oxidaneyl)-1λ4-pyridine-2,6-dicarboxylate (2,6-Me2pydcO), were studied by density functional theory (DFT) and natural bond orbital (NBO) analysis, respectively. The ability of these compounds and their analogues to interact with nine selected biomacromolecules (BRAF kinase, CatB, DNA gyrase, HDAC7, rHA, RNR, TrxR, TS and Top II) was investigated using docking calculations.