Brain Hypoxia Secondary to Diffusion Limitation in Hypoxic Ischemic Brain Injury Postcardiac Arrest.

OBJECTIVES: We sought to characterize 1) the difference in the diffusion gradient of cellular oxygen delivery and 2) the presence of diffusion limitation physiology in hypoxic-ischemic brain injury patients with brain hypoxia, as defined by parenchymal brain tissue oxygen tension less than 20 mm Hg versus normoxia (brain tissue oxygen tension > 20 mm Hg). DESIGN: Post hoc subanalysis of a prospective study in hypoxic-ischemic brain injury patients dichotomized into those with brain hypoxia versus normoxia. SETTING: Quaternary ICU. PATIENTS: Fourteen adult hypoxic-ischemic brain injury patients after cardiac arrest. INTERVENTIONS: Patients underwent monitoring with brain oxygen tension, intracranial pressure, cerebral perfusion pressure, mean arterial pressure, and jugular venous bulb oxygen saturation. Data were recorded in real time at 300Hz into the ICM+ monitoring software (Cambridge University Enterprises, Cambridge, United Kingdom). Simultaneous arterial and jugular venous bulb blood gas samples were recorded prospectively. MEASUREMENTS AND MAIN RESULTS: Both the normoxia and hypoxia groups consisted of seven patients. In the normoxia group, the mean brain tissue oxygen tension, jugular venous bulb oxygen tension, and cerebral perfusion pressure were 29 mm Hg (SD, 9), 45 mm Hg (SD, 9), and 80 mm Hg (SD, 7), respectively. In the hypoxia group, the mean brain tissue oxygen tension, jugular venous bulb oxygen to brain tissue oxygen tension gradient, and cerebral perfusion pressure were 14 mm Hg (SD, 4), 53 mm Hg (SD, 8), and 72 mm Hg (SD, 6), respectively. There were significant differences in the jugular venous bulb oxygen tension-brain oxygen tension gradient (16 mm Hg [sd, 6] vs 39 mm Hg SD, 11]; p < 0.001) and in the relationship of jugular venous bulb oxygen tension-brain oxygen tension gradient to cerebral perfusion pressure (p = 0.004) when comparing normoxia to hypoxia. Each 1 mm Hg increase in cerebral perfusion pressure led to a decrease in the jugular venous bulb oxygen tension-brain oxygen tension gradient by 0.36 mm Hg (95% CI, -0.54 to 0.18; p < 0.001) in the normoxia group, but no such relation was demonstrable in the hypoxia group. CONCLUSIONS: In hypoxic-ischemic brain injury patients with brain hypoxia, there is an elevation in the jugular venous bulb oxygen tension-brain oxygen tension gradient, which is not modulated by changes in cerebral perfusion pressure.

Comparing estimates of child mortality reduction modelled in LiST with pregnancy history survey data for a community-based NGO project in Mozambique.

BACKGROUND: There is a growing body of evidence that integrated packages of community-based interventions, a form of programming often implemented by NGOs, can have substantial child mortality impact. More countries may be able to meet Millennium Development Goal (MDG) 4 targets by leveraging such programming. Analysis of the mortality effect of this type of programming is hampered by the cost and complexity of direct mortality measurement. The Lives Saved Tool (LiST) produces an estimate of mortality reduction by modelling the mortality effect of changes in population coverage of individual child health interventions. However, few studies to date have compared the LiST estimates of mortality reduction with those produced by direct measurement. METHODS: Using results of a recent review of evidence for community-based child health programming, a search was conducted for NGO child health projects implementing community-based interventions that had independently verified child mortality reduction estimates, as well as population coverage data for modelling in LiST. One child survival project fit inclusion criteria. Subsequent searches of the USAID Development Experience Clearinghouse and Child Survival Grants databases and interviews of staff from NGOs identified no additional projects. Eight coverage indicators, covering all the project's technical interventions were modelled in LiST, along with indicator values for most other non-project interventions in LiST, mainly from DHS data from 1997 and 2003. RESULTS: The project studied was implemented by World Relief from 1999 to 2003 in Gaza Province, Mozambique. An independent evaluation collecting pregnancy history data estimated that under-five mortality declined 37% and infant mortality 48%. Using project-collected coverage data, LiST produced estimates of 39% and 34% decline, respectively. CONCLUSIONS: LiST gives reasonably accurate estimates of infant and child mortality decline in an area where a package of community-based interventions was implemented. This and other validation exercises support use of LiST as an aid for program planning to tailor packages of community-based interventions to the epidemiological context and for project evaluation. Such targeted planning and assessments will be useful to accelerate progress in reaching MDG4 targets.

Intraparenchymal Neuromonitoring of Cerebral Fat Embolism Syndrome.

OBJECTIVES: We aimed to characterize the cerebrovascular physiology of cerebral fat embolism using invasive multimodal neuromonitoring. DATA SOURCES: ICU, Vancouver General Hospital, Vancouver, BC, Canada. STUDY SELECTION: Case report. DATA EXTRACTION: Patient monitoring software (ICM+, Cambridge, United Kingdom), clinical records, and surgical records. DATA SYNTHESIS: None. CONCLUSIONS: Our integrated assessment of the cerebrovascular physiology of fat embolism syndrome provides a physiologic basis to investigate the importance of augmenting mean arterial pressure to optimize cerebral oxygen delivery for the mitigation of long-term neurologic ischemic sequelae of cerebral fat embolism.

Measuring sustainability as a programming tool for health sector investments: report from a pilot sustainability assessment in five Nepalese health districts.

Sustainability is a critical determinant of scale and impact of health sector development assistance programs. Working with USAID/Nepal implementing partners, we adapted a sustainability assessment framework to help USAID test how an evaluation tool could inform its health portfolio management. The essential first process step was to define the boundaries of the local system being examined. This local system-the unit of analysis of the study-was defined as the health district.We developed a standardized set of assessment tools to measure 53 indicators. Data collection was carried out over 4 weeks by a Nepalese agency. Scaling and combining indicators into six component indices provided a map of progress toward sustainable maternal, child, health, and family planning results for the five districts included in this pilot study, ranked from "no sustainability" to "beginning of sustainability."We conclude that systematic application of the Sustainability Framework could improve the health sector investment decisions of development agencies. It could also give districts an information base on which to build autonomy and accountability. The ability to form and test hypotheses about the sustainability of outcomes under various funding strategies-made possible by this approach-will be a prerequisite for more efficiently meeting the global health agenda.

Community-based intervention packages facilitated by NGOs demonstrate plausible evidence for child mortality impact.

INTRODUCTION: Evidence exists that community-based intervention packages can have substantial child and newborn mortality impact, and may help more countries meet Millennium Development Goal 4 (MDG 4) targets. A non-governmental organization (NGO) project using such programming in Mozambique documented an annual decline in under-five mortality rate (U5MR) of 9.3% in a province in which Demographic and Health Survey (DHS) data showed a 4.2% U5MR decline during the same period. To test the generalizability of this finding, the same analysis was applied to a group of projects funded by the US Agency for International Development. Projects supported implementation of community-based intervention packages aimed at increasing use of health services while improving preventive and home-care practices for children under five. METHODS: All projects collect baseline and endline population coverage data for key child health interventions. Twelve projects fitted the inclusion criteria. U5MR decline was estimated by modelling these coverage changes in the Lives Saved Tool (LiST) and comparing with concurrent measured DHS mortality data. RESULTS: Average coverage changes for all interventions exceeded average concurrent trends. When population coverage changes were modelled in LiST, they were estimated to give a child mortality improvement in the project area that exceeded concurrent secular trend in the subnational DHS region in 11 of 12 cases. The average improvement in modelled U5MR (5.8%) was more than twice the concurrent directly measured average decline (2.5%). CONCLUSIONS: NGO projects implementing community-based intervention packages appear to be effective in reducing child mortality in diverse settings. There is plausible evidence that they raised coverage for a variety of high-impact interventions and improved U5MR by more than twice the concurrent secular trend. All projects used community-based strategies that achieved frequent interpersonal contact for health behaviour change. Further study of the effectiveness and scalability of similar packages should be part of the effort to accelerate progress towards MDG 4.

Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organizations.

Sustainability continues to be a serious concern for Primary Health Care (PHC) interventions targeting the death of millions of children in developing countries each year. Our work with over 30 Non-Governmental Organizations (NGOs) implementing USAID's Child Survival and Health Grants Program (CSHGP)-funded projects revealed the need for a study to develop a framework for sustainability assessment in these projects. We surveyed NGO informants and project managers through semi-structured interviews and questionnaires. This paper summarizes our study findings. The NGOs share key values about sustainability, but are skeptical about approaches perceived as disconnected from field reality. In their experience, sustainable achievements occur through the interaction of capable local stakeholders and communities. This depends strongly on enabling conditions, which NGO projects should advance. Sustainability assessment is multidimensional, value-based and embeds health within a larger sustainable development perspective. It reduces, but does not eliminate, the unpredictability of long-term outcomes. It should start with the consideration of the 'local systems' which need to develop a common purpose. Our ability to address the complexity inherent to sustainability thinking rests with the validity of the models used to design interventions. A participant, qualitative research approach helped us make sense of sustainability in NGO field practice.

A methodological approach and framework for sustainability assessment in NGO-implemented primary health care programs.

An estimated 10.8 million children under 5 continue to die each year in developing countries from causes easily treatable or preventable. Non governmental organizations (NGOs) are frontline implementers of low-cost and effective child health interventions, but their progress toward sustainable child health gains is a challenge to evaluate. This paper presents the Child Survival Sustainability Assessment (CSSA) methodology--a framework and process--to map progress towards sustainable child health from the community level and upward. The CSSA was developed with NGOs through a participatory process of research and dialogue. Commitment to sustainability requires a systematic and systemic consideration of human, social and organizational processes beyond a purely biomedical perspective. The CSSA is organized around three interrelated dimensions of evaluation: (1) health and health services; (2) capacity and viability of local organizations; (3) capacity of the community in its social ecological context. The CSSA uses a participatory, action-planning process, engaging a 'local system' of stakeholders in the contextual definition of objectives and indicators. Improved conditions measured in the three dimensions correspond to progress toward a sustainable health situation for the population. This framework opens new opportunities for evaluation and research design and places sustainability at the center of primary health care programming.