14 research outputs found
Accuracy of assessment of eligibility for early medical abortion by community health workers in Ethiopia, India and South Africa
No full textTo assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit.; Diagnostic accuracy study.; Ethiopia, India and South Africa.; Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam.; Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa.; The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability
“ASPIRACIÓN MANUAL ENDOUTERINA VS LEGRADO UTERINO INSTRUMENTADO EN PACIENTES ADOLESCENTES CON DIAGNÓSTICO DE ABORTO ATENDIDAS EN EL HOSPITAL GENERAL DR. GUSTAVO BAZ PRADA EN EL PERIODO DE DICIEMBRE DE 2015 A DICIEMBRE 2016”.
No full textTítulo:
Aspiración manual endouterina vs legrado uterino instrumentado en pacientes
adolescentes con diagnóstico de aborto atendidas en el Hospital General Dr.
Gustavo Baz Prada en el periodo de diciembre 2015 a diciembre de 2016.
Método:
Se incluyeron 196 pacientes que cumplieron con los criterios de inclusión, 98
pacientes para cada grupo (1.AMEU y 2.LUI). Se registraron los datos generales
y las variables del estudio (sangrado, tiempo de estancia en Unidad
Tocoquirúrgica, infección, necesidad de maduración cervical y evacuación uterina
incompleta). Se creó una base de datos en Excel y posteriormente se analizaron
los resultados con el programa estadístico SPSS21 utilizando la chi cuadrada y T
de student.
Resultados:
La edad gestacional tuvo una media en las 9SDG encontrando una mínima de
5SDG y una máxima de 12SDG. La maduración cervical fue necesaria en 18.6% y
en el 28.6% respectivamente para el AMEU y el LUI. Respecto al sangrado el
mínimo fue de 10cc para ambos grupos y un máximo de 30cc en el grupo 1 y de
100cc en el grupo 2. El porcentaje de infección fue del 2% para los dos grupos. La
evacuación uterina completa fue del 98% en el grupo de AMEU y del 100% en
grupo de LUI.
Conclusiones:
Los resultados obtenidos en este estudio, concuerdan con la literatura consultada
en los estudios realizados por Rohana Salam, S Abbasi, Olav Meirik, mencionando
que en el AMEU se observa una reducción del tiempo de estancia
intrahospitalaria, la maduración cervical es menos necesaria, si bien las
complicaciones más frecuentes como lo es la infección y la evacuación uterina
incompleta en ambos grupos es similar
Abortion services in South Africa : challenges and barriers to safe abortion care : health care providers' perspectives
No full textIncludes bibliographical references (leaves 199-213).Unsafe abortion is a preventable phenomenon and continues to be a major public health problem in many countries especially in the developing world. Despite abortion being legally available in South Africa after a change in legislation in 1996, barriers to accessing safe abortion services continue to exist. These barriers include provider opposition to abortion, and a shortage of trained and willing abortion providers. The dearth of abortion providers undermines the availability of safe, legal abortion, and has serious implications for women's access to abortion services and health service planning
Enhancing Survival of Mothers and Their Newborns in Tanzania
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The main purpose of the present studies was to examine the problem of maternal and perinantal mortality in an upcountry region of a low-income country. This was done by estimating the magnitude of maternal and perinatal mortality, both in the hospital and in the community, through elucidating the underlying causes of maternal and perinatal mortality, and by initiating low-cost interventions and monitoring mechanisms in order to enhance the survival of mothers and their newborns, in Kigoma, Tanzania. To utilize all available evidence to register the causes, contributory factors and real magnitude of maternal in a regional hospital as well as to estimate the magnitude of maternal mortality in the community. To formulate low-cost interventions to address the identified contributing factors to maternal mortality and to follow these interventions over time. To perform regular audits of the causes of maternal mortality in order to elucidate avoidance causes. To monitor and adjust the interventions during the study period, while assessing the impact of these interventions. To investigate the suspected causes of obstetric risk knowledge among community members, health workers, and traditional birth attendants. To assess the utilization of the simple “three phases of delay model” in the audit of maternal and perinatal mortality. A retrospective analysis of mortality in the hospital setting utilizing all available evidence was undertaken for three years, 1984-1987. The magnitude, causes and contributory factors to maternal mortality were examined in the in the hospital setting. This led to the formulation of 22 specific, low –cost interventions, which utilized local resources. These interventions were followed-up for a period of 7years. Monitoring was conducted through monthly audit-oriented meetings. Maternal mortality in the in the community being served by the hospital was assessed utilizing the “sisterhood method”, followed by an assessment of perceptions of obstetric risk among community members, health workers and peripheral staff in order to evaluate factors contributing to futher non-reduction of maternal mortality in the hospital. Finally an assessment utilizing the three phases of delay methodology was conducted focusing on the reduction of maternal and perinatal mortality. There was gross underreporting of martenal death in the official statistics (849 against 350 per 100,000 live births, respectively). Major causes were haemorrhage , obstracted labour , infections and rupture of the uterus. Several other associated factors comprised lack of equipment, drug/blood and issues concerning staff and community distrust of the obstetric unit. The application of the 22 specific interventions saw a progressive reduction in the maternal mortality ratio (from 849 to 275 per 100,000 live birth) after the 7-year period (p<0.001). This was despite an increase in the number admissions to the unit (3,000 to 4,296 respectively). Also the fatality rate for the major causes of death was reduced from 9.2 to 3.1%. However, The community assessment undertaken in 2001 revealed the actual MMR at that time to be 447 (urban) and (rural) per 100,000. The result of the assessment in perceptions of obstetric risk revealed low knowledge among the community, staff and traditional birth attendants and that there was distrust in the health system. A final audit using the “ three phases of delay methodology” revealed that the major causes of perinatal and maternal deaths occurred in the health system. Maternal and perinatal mortality can be reduced through low-cost interventions available in most low-resource settings. Regular audit of maternal and perinatal deaths can be undertaken in the these settings. Low-cost methodology. T o be of value audits must be sustained and used as monitoring mechanisms for service delivery improvements and as managerial tools to reduce maternal and perinatal deaths the “three phases of delay model” is a simple and user-friendly method for the audit of both perinatal and maternal deaths. \u
Protocolized REDUction of non-resuscitation fluids in SEptic shock patients : a protocol for the REDUSE randomized clinical trial
No full textIn septic shock, administration of large fluid volumes is associated with poor outcomes. Recent evidence shows that non-resuscitation fluids are the major modifiable source of fluids for patients with septic shock in intensive care units (ICUs). This clinical trial is designed to test the hypothesis that restrictive administration of non-resuscitation fluids improves outcomes compared to usual care. Adult patients admitted to ICUs with septic shock will be randomly assigned within 12 h of admission to receive protocolized restrictive administration of non-resuscitation fluids or usual care. The primary outcome is all-cause mortality at 90 days. Secondary outcomes are complications during ICU stay up to 90 days (defined as any acute kidney injury or cerebral, coronary, intestinal, or limb ischemia), mechanical ventilation free days within 90 days, and for survivors cognitive function (by the Montreal Cognitive Assessment [MOCA-BLIND]) and Health-Related Quality of Life (by the EQ Visual Analogue Scale [EQ-VAS]), both at 6 months. In addition, the climate impact of the interventions will be assessed. To detect an absolute reduction in mortality of 7.5%, with an alpha of 5% and a power of 90%, we aim to include 1850 patients. The trial is approved by the Swedish Ethical Review Authority. Results of primary and secondary clinical outcomes and the environmental outcome will be submitted for publication in a peer-reviewed journal. Trial Registration: NCT06140147
Relationship between altered myoepithelial phenotype and the inflammatory cell infiltrate in progression of DCIS
No full textThe copyright of this thesis rests with the author and no quotation from it or information derived from it may be published without the prior written consent of the authorChanges in the microenvironment have been implicated in the transition of pre-invasive ductal carcinoma in-situ (DCIS) to invasive breast cancer. Normal myoepithelial cells have a tumour suppressor phenotype but they are altered in DCIS and ultimately lost with transition to invasive cancer. A consistent change in DCIS is up-regulation of the integrin αvβ6 in myoepithelial cells. Preliminary observations identified a correlation between myopeithelial αvβ6 and an increased peri-ductal inflammatory infiltrate.
The hypothesis of this study is that the altered myoepithelial phenotype influences the peri-ductal inflammatory environment, which in turn mediates a pro-apoptotic effect on myoepithelial cells contributing to their loss.
To investigate this, the inflammatory infiltrate was characterised in a series of DCIS tissue in relation to αvβ6 status. This demonstrated significantly higher levels of CD4+ve and FOXP3+ve T cells around αvβ6+ve DCIS ducts compared to αvβ6-ve ducts (P=<0.01), suggesting an increase in Treg cells. In-vivo, Matrigel plugs containing injected into the flanks of female C57/Blk6 normal mice generated influx of higher levels of CD4+ve cells (p=0.005) and FOXP3+ T cells (p=0.007) in the presence of αvβ6+ve myoepithelial cells compared to αvβ6-ve cells, supporting the findings in human tissue samples.
Since Treg cells produce TRAIL that can induce apoptosis, we investigated the influence of αvβ6 on myoepithelial cells on the levels of TRAIL in T cells and the hypothesis that αvβ6-positive myoepithelial ells may be more susceptible to TRAIL-induced apoptosis, leading to loss of the myoepithelial barrier. Firstly, levels of TRAIL in Jurkat and primary T cell populations co-cultured with β4
(ii)
or β6 myoepithelial cells were measured. This demonstrated a higher level of TRAIL in primary T cells co-cultured β6 myoepithelial cells compared to those co-cultured with β4 myoepithelial cells. β6+ve and β6-ve myoepithelial cells were exposed to TRAIL, and this demonstrated that TRAIL enhanced apoptosis, measured by cleaved PARP, in β6+ve cells. Furthermore, these cells showed loss of the anti-apoptotic protein Galectin-7, and knockdown of Galectin-7 in normal β6-ve myoepithelial cells rendered them more susceptible to TRAIL-induced apoptosis. In DCIS tissues, an inverse relationship between αvβ6 and Galectin-7 in myoepithelial cells was demonstrated, and Cytokine Array analysis showed that αvβ6+ve myoepithelial cells express higher levels of IL-16, which has a role in Treg cell recruitment.
Taken together these results suggest that expression of αvβ6 by myoepithelial cells in DCIS generates a tumour-promoter peri-ductal inflammatory infiltrate through altered cytokine release, is associated with reduced galectin-7 expression and enhances myoepithelial cell apoptosis in response to TRAIL. This provides a potential mechanism by which myoepithelial cells may be lost during evolution of DCIS and so contribute to progression to invasive disease.Libyan government scholarship
Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study
No full textBackground: Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated.Methods: This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy.Results: Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P1/40.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05-1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95-1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60-1.02).Conclusions: In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events
Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries
No full textKey PointsQuestionAmong critically ill patients undergoing tracheal intubation worldwide, how common are major adverse events during the peri-intubation period? FindingsIn this prospective observational study that included 2964 patients from 197 sites across 29 countries from October 2018 to July 2019, at least one major clinical event occurred after intubation in 45.2% of patients, including cardiovascular instability in 42.6%, severe hypoxemia in 9.3%, and cardiac arrest in 3.1%. MeaningAmong an international sample of critically ill patients undergoing tracheal intubation, major cardiopulmonary events occurred frequently.ImportanceTracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. ObjectiveTo evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. Design, Setting, and ParticipantsThe International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. ExposuresTracheal intubation. Main Outcomes and MeasuresThe primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. ResultsOf 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. Conclusions and RelevanceIn this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.This international cohort study describes the incidence and nature of cardiovascular instability, severe hypoxemia, and cardiac arrest surrounding endotracheal intubation
Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients from 29 Countries
No full textImportance: Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. Objective: To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. Design, Setting, and Participants: The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. Exposures: Tracheal intubation. Main Outcomes and Measures: The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. Results: Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. Conclusions and Relevance: In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events - in particular cardiovascular instability - were observed frequently
Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study
No full textBackground: Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated. Methods: This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy. Results: Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P=0.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05–1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95–1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60–1.02). Conclusions: In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events. Clinical trial registration: NCT03616054
