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Patients with congenitally corrected transposition of the great arteries (ccTGA) can be treated with a double switch operation (DSO) to restore the normal anatomical connection of the left ventricle (LV) to the systemic circulation and the right ventricle (RV) to the pulmonary circulation. The subpulmonary LV progressively deconditions over time due to its connection to the low pressure pulmonary circulation and needs to be retrained using a surgical pulmonary artery band (PAB) for 6-12 months prior to the DSO. The subsequent clinical follow-up, consisting of invasive cardiac pressure and non-invasive imaging data, evaluates LV preparedness for the DSO. Evaluation using standard clinical techniques has led to unacceptable LV failure rates of ∼15 % after DSO. We propose a computational modeling framework to (1) reconstruct LV and RV pressure-volume (PV) loops from non-simultaneously acquired imaging and pressure data and gather model-derived mechanical indicators of ventricular function; and (2) perform in silico DSO to predict the functional response of the LV when connected to the high-pressure systemic circulation. Clinical datasets of six patients with ccTGA after PAB, consisting of cardiac magnetic resonance imaging (MRI) and right and left heart catheterization, were used to build patient-specific models of LV and RV - M baseline LV and M baseline RV . For in silico DSO the models of M baseline LV and M baseline RV were used while imposing the afterload of systemic and pulmonary circulations, respectively. Model-derived contractility and Pressure-Volume Area (PVA) - i.e., the sum of stroke work and potential energy - were computed for both ventricles at baseline and after in silico DSO. In silico DSO suggests that three patients would require a substantial augmentation of LV contractility between 54 % and 80 % and an increase in PVA between 38 % and 79 % with respect to the baseline values to accommodate the increased afterload of the systemic circulation. On the contrary, the baseline functional state of the remaining three patients is predicted to be adequate to sustain cardiac output after the DSO. This work demonstrates the vast variation of LV function among patients with ccTGA and emphasizes the importance of a biventricular approach to assess patients' readiness for DSO. Model-derived predictions have the potential to provide additional insights into planning of complex surgical interventions., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Radomir Chabiniok reports financial support, administrative support, article publishing charges, and travel were provided by The University of Texas Southwestern Medical Center. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Mean dP/dt ic is a quantitative measurement of ventricular function that can be obtained noninvasively by echocardiography. In adults with mitral regurgitation (MR), it has been shown to be a more sensitive predictor of postoperative left ventricular ejection fraction (EF). The utility of dP/dt ic in pediatric congenital heart diseases with MR has been underexplored. Patients (0 to ≤ 19 years) with MR who underwent mitral valve (MV) repair or replacement from 2015 to 2021 were included. Echocardiographically derived mean dP/dt ic , Tei index, and EF were used to assess and compare ventricular function prior to, shortly after, and late after MV surgery. Study cohort included 61 patients (age 4.5 [IQR 0.14, 18.7] years, 89% MV repair, 11% MV replacement). Median time intervals between surgery and preoperative, early postoperative, and late postoperative echocardiograms were 6 days, 6 days, and 350 days, respectively. Median EF was 62% (z-score - 0.40) preoperatively, 56% (z-score - 1.40) early postoperatively, and 61% (z-score - 0.60) late postoperatively. Median dP/dt ic was 1393 (IQR 1029, 1775) mmHg/s preoperatively, 1178 (IQR 886, 1946) mmHg/s early postoperatively, and 1270 (IQR 791, 1765) mmHg/s late postoperatively. Preoperative median dP/dt ic correlated with early and late postoperative EF. Preoperative EF was not significantly correlated with early postoperative EF, but was correlated with late postoperative EF. Mitral valve intervention in pediatric patients is associated with an initial decline but subsequent recovery of systolic function. Non-invasively derived mean dP/dt ic may offer advantages over other preoperative echocardiographic indices to predict postoperative systolic function., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Optimal reverse remodeling of the right ventricle (RV), a sentinel goal of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot, is not fully predicted by volume-based pre-PVR parameters. Our objectives were to characterize novel geometric RV parameters in patients receiving PVR and in controls, and to identify associations between these parameters and chamber remodeling post-PVR. Secondary analysis was performed on cardiac magnetic resonance (CMR) data from 60 patients enrolled in a randomized trial of PVR with and without surgical RV remodeling. 20 healthy age-matched subjects served as controls. The primary outcome was optimal post-PVR RV remodeling (end-diastolic volume index (EDVi) ≤ 114 ml/m 2 and ejection fraction (EF) ≥ 48%) vs. suboptimal remodeling (EDVi ≥ 120 ml/m 2 and EF ≤ 45%). RV geometry was markedly different at baseline in PVR patients compared with controls, with lower systolic surface area-to-volume ratio (SAVR) (1.16 ± 0.26 vs.1.44 ± 0.21 cm 2 /mL, p < 0.001) and lower systolic circumferential curvature (0.87 ± 0.27 vs. 1.07 ± 0.30 cm - 1 , p = 0.007) but similar longitudinal curvature. In the PVR cohort, higher systolic SAVR was associated with higher RVEF both pre- and post-PVR (p < 0.001). Among PVR patients, 15 had optimal and 19 had suboptimal remodeling post-PVR. Multivariable modeling showed that among the geometric parameters, higher systolic SAVR (OR 1.68 per 0.1 cm 2 /mL increase; p = 0.049) and shorter systolic RV long-axis length (OR 0.92 per 0.1 cm increase; p = 0.035) were independently associated with optimal remodeling. Compared with controls, PVR patients have lower SAVR and lower circumferential but not longitudinal curvature. Higher pre-PVR systolic SAVR is associated with optimal remodeling post-PVR., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Abnormal left ventricular (LV) rotational mechanics in biventricular hearts are associated with adverse outcomes; however, these are less well characterized for hearts with functionally single ventricles., Objectives: The purpose of this study was to characterize ventricular rotational mechanics in the Fontan circulation and their relationship to outcomes., Methods: Single-center, retrospective analysis of magnetic resonance examinations for 329 Fontan patients (15 [IQR: 10-21] years) and 42 controls. The ventricular cine short-axis stack was analyzed to derive torsion metrics. Torsion calculated as the difference between apical and basal rotation normalized to ventricular length., Results: Fontan patients had higher indexed ventricular end-diastolic volume (97 mL/body surface area 1.3 vs 72 mL/body surface area 1.3 ), lower ejection fraction (53% vs 60%), and lower proportion of basal clockwise rotation (62% vs 93%), apical counterclockwise rotation (77% vs 95%), and positive torsion (82% vs 100%); P < 0.001 for all. A composite outcome of death or heart transplant-listing occurred in 31 (9%) patients at a median follow-up of 3.9 years. Torsion metrics were associated with the outcome; although, on multivariate analysis only right ventricular (RV) morphology and indexed ventricular end-diastolic volume were independently associated. LVs with negative torsion, and RVs regardless of torsional pattern, had worse outcomes compared to LVs with positive torsion ( P = 0.020)., Conclusions: Single ventricles in a Fontan circulation exhibit abnormal torsional mechanics, which are more pronounced for RV morphology. Abnormal torsion is associated with death or need for heart transplantation. Fontan patients with LV morphology and preserved torsion exhibit the highest transplant-free survival and torsion may offer incremental prognostic data in this group of patients., Competing Interests: This study was in part supported by the Fred Lovejoy Housestaff Research and Education Fund and 10.13039/100000002NIH T32 Research Methods in Pediatric Cardiovascular Disease Award Number: 5T32HL007572-38. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Competing Interests: Competing interests: None declared.

Ventricular pressure-volume (PV) loops offer unique insights into cardiovascular mechanics. PV loops can be instrumental in improving our understanding of various congenital heart diseases, including single ventricular physiology, heart failure, and pulmonary hypertension, as well as guiding therapeutic interventions. This review focuses on the theoretical and practical foundations for the acquisition and interpretation of PV loops in congenital heart disease and discusses their clinical applications., (© 2023 The Authors.)

Background: In repaired tetralogy of Fallot (rTOF), abnormal left ventricular (LV) rotational mechanics are associated with adverse clinical outcomes. We performed a comprehensive analysis of LV rotational mechanics in rTOF patients using cardiac magnetic resonance (CMR) prior to and following surgical pulmonary valve replacement (PVR)., Methods: In this single center retrospective study, we identified rTOF patients who (1) had both a CMR ≤ 1 year before PVR and ≤ 5 years after PVR, (2) had no other intervening procedure between CMRs, (3) had a body surface area > 1.0 m 2 at CMR, and (4) had images suitable for feature tracking analysis. These subjects were matched to healthy age- and sex-matched control subjects. CMR feature tracking analysis was performed on a ventricular short-axis stack of balanced steady-state free precession images. Measurements included LV basal and apical rotation, twist, torsion, peak systolic rates of rotation and torsion, and timing of events. Associations with LV torsion were assessed., Results: A total of 60 rTOF patients (23.6 ± 7.9 years, 52% male) and 30 healthy control subjects (20.8 ± 3.1 years, 50% male) were included. Compared with healthy controls, rTOF patients had lower apical and basal rotation, twist, torsion, and systolic rotation rates, and these parameters peaked earlier in systole. The only parameters that were correlated with LV torsion were right ventricular (RV) end-systolic volume (r = - 0.28, p = 0.029) and RV ejection fraction (r = 0.26, p = 0.044). At a median of 1.0 year (IQR 0.5-1.7) following PVR, there was no significant change in LV rotational parameters versus pre-PVR despite reductions in RV volumes, RV mass, pulmonary regurgitation, and RV outflow tract obstruction., Conclusion: In this comprehensive study of CMR-derived LV rotational mechanics in rTOF patients, rotation, twist, and torsion were diminished compared to controls and did not improve at a median of 1 year after PVR despite favorable RV remodeling.

In the setting of the coronavirus disease 2019 (COVID-19) pandemic, an emergency hospital-wide eWork policy was enacted at Boston Children's Hospital on March 16, 2020. The number of clinicians on campus was restricted to only essential personnel, guidelines limited clinical care delivery to solely non-elective patients, and strict maximums were placed on the numbers of people allowed to congregate in the same physical space. With this abrupt transition to social distancing and electronic communication, the established approach to educating graduate medical trainees became obsolete overnight. Anticipating significant impact on trainee and faculty professional and personal lives, the importance of adaptive teaching strategies was evident. This document details one approach to redesigning the clinical learning system including a description of the learners and environment, the pedagogical principles that guided the approach, and technological tools used in implementation. Additionally, available literature pertinent to this topic is explored, assessment of the work to date is presented, and suggestions are provided regarding future directions related to online graduate medical education., Competing Interests: Traci A. Wolbrink is one of the co-founders and co-directors of OPENPediatrics, but she has no personal financial disclosures to report. The other authors have no conflicts of interest to disclose., (© 2020 Elsevier B.V. All rights reserved.)

Background: There are no established criteria to decide suitability for Fontan fenestration closure. Our institution has the following criteria: an unobstructed Fontan pathway with no significant decompressing venovenous collaterals, baseline Fontan pressure ≤15 mmHg, baseline cardiac index ≥2 L/min/m 2 , and a decrease in cardiac index ≤20% with test occlusion of the fenestration., Objective: The objective of the study was to review midterm outcomes following device closure of Fontan fenestration using institutional criteria., Materials and Methods: A retrospective review was performed of patients who underwent catheterization with prior fenestrated Fontan procedure between May 2005 and January 2015. Patients were classified as those who underwent successful closure (A), had closure deferred due to failure to meet criteria (B), or were not referred for closure (C)., Results: There were 42 patients in Group A, 10 in Group B, and 150 in Group C. The mean Fontan pressure increased from 13.1 ± 2.1 to 14.5 ± 2.1mmHg in Group A and 14.6 ± 1.5 to 15.7 ± 2.2 mmHg in Group B ( P = not significant). With test occlusion, cardiac index fell by 18.12% ± 15.68% in Group A and 33.75% ± 14.98% in Group B ( P = 0.019). At a median of 46 month follow-up, oxygen saturation increased significantly from 85.15% ± 6.29% at baseline to 94.6% ± 4.43% ( P < 0.001) in Group A but with no statistically significant difference in the rates of plastic bronchitis, protein-losing enteropathy, stroke, or heart transplantation between the three groups., Conclusions: Using institutional criteria, transcatheter device closure of Fontan fenestration was followed by significant increase in oxygen saturations and no statistically significant difference in morbidity or mortality between closure and nonclosure groups., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Annals of Pediatric Cardiology.)

Background: Patients with univentricular heart disease may undergo a superior cavopulmonary anastomosis, an operative intervention that raises cerebral venous pressure and impedance to cerebral venous return. The ability of infantile cerebral autoregulation to compensate for this is not well understood., Materials and Methods: We identified all patients undergoing a superior cavopulmonary anastomosis (cases) and compared metrics of cerebral oxygenation upon admission to the ICU with patients following repair of tetralogy of Fallot or arterial switch operation (controls). The primary endpoint was cerebral venous oxyhaemoglobin saturation measured from an internal jugular venous catheter. Other predictor variables included case-control assignment, age, weight, sex, ischemic times, arterial oxyhaemoglobin saturation, mean arterial blood pressure, and superior caval pressure., Results: A total of 151 cases and 350 controls were identified. The first post-operative cerebral venous oxyhaemoglobin saturation was significantly lower following superior cavopulmonary anastomosis than in controls (44 ± 12 versus 59 ± 15%, p < 0.001), as was arterial oxyhaemoglobin saturation (81 ± 9 versus 98 ± 5%, p < 0.001). Cerebral venous oxyhaemoglobin saturation correlated poorly with superior caval pressure in both groups. When estimated by linear mixed effects model, arterial oxyhaemoglobin saturation was the primary determinant of central venous oxyhaemoglobin saturation in both groups (β = 0.79, p = 3 × 10-14); for every 1% point increase in arterial oxyhaemoglobin saturation, there was a 0.79% point increase in venous oxyhaemoglobin saturation. In this model, no other predictors were significant, including superior caval pressure and case-control assignment., Conclusion: Cerebral autoregulation appears to remain intact despite acute imposition of cerebral venous hypertension following superior cavopulmonary anastomosis. Following superior cavopulmonary anastomosis, cerebral venous oxyhaemoglobin saturation is primarily determined by arterial oxyhaemoglobin saturation.

Anomalous origin of a coronary artery from the pulmonary artery (PA) is a rare congenital anomaly with the most common pattern being an anomalous left coronary artery (LCA) from the pulmonary artery (ALCAPA). A very rare pattern is the anomalous origin of a single coronary artery from the pulmonary artery (ASCAPA) wherein the single coronary ostium supplies both the right and left coronary systems with profound myocardial ischemia developing once PA pressures begin to fall after birth. Previous reports of this anomaly have all been based on post-mortem findings or pre-mortem angiographic diagnosis [1-3]. Notably, these children often present in extremis due to cardiogenic shock. Institution of veno-arterial extracorporeal life support can be catastrophic as it would lead to myocardial ischemia due to PA decompression. We present here the first echocardiographic-only diagnosis of ASCAPA in a 2-month-old child with the use of bubble contrast echocardiography to help confirm the diagnosis. The patient was resuscitated from a cardiac arrest on arrival with subsequent echocardiographic-only diagnosis. Surgical repair was undertaken with administration of cardioplegia into the pulmonary root with snaring of the branch PAs, and re-implantation of the single coronary to the aorta. At 3-month follow-up, he is thriving clinically with echocardiogram showing improving-though still somewhat depressed-left ventricular function.

Problem: In Burkina Faso, the coverage of services for family planning is low due to shortage of qualified health staff and limited access to services., Approach: Following the launch of the Ouagadougou Partnership, an alliance to catalyse the expansion of family planning services, the health ministry created a consortium of family planning stakeholders in 2011. The consortium adopted a collaborative framework to implement a pilot project for task sharing in family planning at community and primary health-care centre levels in two rural districts. Stakeholders were responsible for their areas of expertise. These areas included advocacy; monitoring and evaluation; and capacity development of community health workers (CHWs) to offer oral and injectable contraceptives to new users and of auxiliary nurses and auxiliary midwives to provide implants and intrauterine devices. The health ministry implemented supportive supervision cascades involving relevant planning and service levels., Local Setting: In Burkina Faso, only 15% (2563/17 087) of married women used modern contraceptives in 2010., Relevant Changes: Adoption of new policies and clinical care standards expanded task sharing roles in family planning. The consortium trained a total of 79 CHWs and 124 auxiliary nurses and midwives. Between January 2017 and December 2018, CHWs provided injectables to 3698 new users, and auxiliary nurses or midwives provided 726 intrauterine devices and 2574 implants to new users. No safety issues were reported., Lessons Learnt: The pilot project was feasible and safe, however, financial constraints are hindering scale-up efforts. Supportive supervision cascades were critical in ensuring success., ((c) 2019 The authors; licensee World Health Organization.)

Introduction and Methods: Observational retrospective cohort study to evaluate the association between precannulation coagulopathy and the occurrence of hemorrhage during extracorporeal membrane oxygenation (ECMO) in neonatal and pediatric patients at a tertiary children's hospital., Results: Of 241 patients supported with ECMO between January 2009 and December 2014, 175 (72.6%) had precannulation coagulation laboratory data and were included in the study. Of the eligible patients, 84 (48%) were identified as coagulopathic and 91 (52%) were noncoagulopathic. In the coagulopathic group, sepsis (27.3%) was the most common diagnosis leading to ECMO. Over half of the patients in both groups (55.9% of the coagulopathic and 52.7% of the noncoagulopathic group) developed hemorrhagic complications during ECMO support. The most frequent bleeding sites for both groups were the cannulation site (24%), the chest tube site (17%), and intracranial (10%). Pre-ECMO coagulopathy was not associated with higher incidence of hemorrhage during extracorporeal support (p = 0.76)., Conclusions: Pre-ECMO coagulopathy was frequent in our cohort but did not increase the occurrence of hemorrhage during extracorporeal support. Although the identification of factors associated with hemorrhage is key to safely managing ECMO anticoagulation, the implication of precannulation coagulopathy seems to be minimal.

Youth report embarrassment, cost, and poor access as barriers to sexual and reproductive health (SRH) services. Interventions to address barriers like youth friendly services have yet to conclusively demonstrate impact on protective behaviours like condom or contraceptive use. SRH encompasses a range of services so we aimed to assess how perceived barriers differed depending on the service being sought between common services accessed by young people: HIV/STI testing, abortion, and contraception. 1203 Ghanaian youth were interviewed. Data was analysed to identify barriers by service type, demographics, and between high and low HIV prevalence communities. Being embarrassed or shy was the most commonly reported barrier across services. Overall being embarrassed or shy, fear of safety, fear of family finding out and cost were the most reported barriers across all services. Further analysis by service indicated that being embarrassed was a significantly greater barrier for HIV/STI testing and contraception when compared with abortion (p<0.001) and safety concerns and cost were significantly greater barriers for abortion and contraception compared with HIV/STI testing (p<0.001). Efforts to develop interventions that consider the service being sought may help address the range of barriers faced by youth with diverse SRH needs.

Objective: Lower limb amputees are at high risk of falling as current prosthetic legs provide only limited functionality for recovering balance after unexpected disturbances. For instance, the most established control method used on powered leg prostheses tracks local joint impedance functions without taking the global function of the leg in balance recovery into account. Here, we explore an alternative control policy for powered transfemoral prostheses that considers the global leg function and is based on a neuromuscular model of human locomotion., Methods: We adapt this model to describe and simulate an amputee walking with a powered prosthesis using the proposed control, and evaluate the gait robustness when confronted with rough ground and swing leg disturbances. We then implement and partially evaluate the resulting controller on a leg prosthesis prototype worn by a nonamputee user., Results: In simulation, the proposed prosthesis control leads to gaits that are more robust than those obtained by the impedance control method. The initial hardware experiments with the prosthesis prototype show that the proposed control reproduces normal walking patterns qualitatively and effectively responds to disturbances in early and late swing. However, the response to midswing disturbances neither replicates human responses nor averts falls., Conclusions: The neuromuscular model control is a promising alternative to existing prosthesis controls, although further research will need to improve on the initial implementation and determine how well these results transfer to amputee gait., Significance: This paper provides a potential avenue for future development of control policies that help to improve amputee balance recovery.

Introduction: Human resource (HR) management is a priority for health systems strengthening in developing countries, yet few studies have empirically examined associations with service quality. The purpose of this study was to assess the relationship between HR management and family planning (FP) service quality., Methods: Data came from the 2010 Kenya Service Provision Assessment, a nationally representative health facility assessment. In total, 912 FP consultations from 301 facilities were analysed. Four indices were created to measure quality on reproductive history taking, physical examination, sexually transmitted infections prevention and pill/injectable specific counselling. HR management variables included training in the past year, any and supportive (i.e. with feedback, technical updates and discussion) in-person supervision in the past 6 months and having a written job description. Multivariate linear regression analyses were conducted to estimate coefficients of HR management variables on each of the four quality indices, adjusting for background characteristics of clients, provider and facilities., Results: The level of service quality ranged from 16 to 53 out of a maximum score of 100 across the indices. Fifty-two per cent of consultations were done by providers who received supportive in-person supervision in the previous 6 months. In 23% and 38% of consultations, the provider was trained in the past year and had a written job description, respectively. Multivariate analyses indicated that having a written job description was associated with higher service quality in history taking, physical examination and the pill/injectable specific counselling. Other HR management variables were not significantly associated with service quality., Conclusion: Having a written job description was significantly associated with higher service quality and may be a useful tool for strengthening management practices. The details of such job descriptions and the quality of other management indicators should be explored to better understand the relationship between HR management and FP service quality., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

Aims: The aim of the present study is to assess the level and areas of stress among care givers nursing their loved ones suffering from cancer., Setting and Design: An assessment of care givers' stress providing care to cancer patients at Cipla Palliative Care Center was conducted. The study involves data collection using a questionnaire and subsequent analysis., Materials and Methods: A close-ended questionnaire that had seven sections on different aspects of caregivers' stress was developed and administered to 137 participants and purpose of conducting the survey was explained to their understanding. Caregivers who were willing to participate were asked to read and/or explained the questions and requested to reply as per the scales given. Data was collected in the questionnaires and was quantitatively analyzed., Results: The study results showed that overall stress level among caregivers is 5.18 ± 0.26 (on a scale of 0-10); of the total, nearly 62% of caregivers were ready to ask for professional help from nurses, medical social workers and counselors to cope up with their stress., Conclusion: Stress among caregivers ultimately affects quality of care that is being provided to the patient. This is also because they are unprepared to provide care, have inadequate knowledge about care giving along with financial burden, physical and emotional stress. Thus interventions are needed to help caregivers to strengthen their confidence in giving care and come out with better quality of care.

Background: The purpose of the study was to test the hypothesis that strengthening health systems, through improved leadership and management skills of health teams, can contribute to an increase in health-service delivery outcomes. The study was conducted in six provinces in the Republic of Kenya., Methods: The study used a non-randomized design comparing measures of key service delivery indicators addressed by health teams receiving leadership and management training (the intervention) against measures in comparison areas not receiving the intervention. Measurements were taken at three time periods: baseline, endline, and approximately six months post intervention. At the district level, health-service coverage was computed. At the facility level, the percentage change in the number of client visits was computed. The t-test was used to test for significance., Results: Results showed significant increases in health-service coverage at the district level (p = <0.05) in the intervention teams compared to the comparison teams. Similarly, there were significant increases in the number of client visits at the facility level in the intervention group versus comparison facilities (P < 0.05)., Conclusions: Strengthening the leadership and management skills of health teams, through team-based approaches focused on selected challenges, contributed to improved health service delivery outcomes and these improvements were sustained at least for six months.

Objective: 'Verbal autopsy' (VA) is used to ascertain cause of death in countries where vital registration systems are lacking. Current VA methods for neonatal deaths vary widely and suffer from several limitations. We aimed to: (1) review current neonatal VA methods, (2) identify gaps and limitations, (3) illustrate some limitations using VA data and (4) identify new approaches in methodology and analysis., Study Design: Rolling techniques and database search terms were used to identify articles that described neonatal VA administration, validation and cause of death assignment., Result: Current VA interviews include open and close-ended modules and are administered by trained interviewers. Causes of death are determined using physician review and/or computer algorithms for various neonatal causes of death. Challenges include lack of a standardized VA instrument and administration of methods, difficulty in identifying gold standards for validation studies, lack of validated algorithms for causes of death, poor existing algorithms, lack of standardized death classification terminology and the use of hierarchy to assign causes of death. Newer probabilistic methods of analysis such as Bayes Theorem or the Symptom Pattern method may improve accuracy for cause of death estimation and alleviate some of the challenges with traditional physician and algorithmic approaches, although additional research is needed., Conclusion: Given the continued reliance on VA to determine cause of death in settings with inadequate registration systems, it is important to understand the gaps in current VA methods and explore how methods can be improved to accurately reflect neonatal disease burden in the global community.

The potential for traditional birth attendants (TBAs) to improve neonatal health outcomes has largely been overlooked during the current debate regarding the role of TBAs in improving maternal health. Randomly-selected TBAs (n=93) were interviewed to gain a more thorough understanding of their knowledge, attitudes, and practices regarding maternal and newborn care. Practices, such as using a clean cord-cutting instrument (89%) and hand-washing before delivery (74%), were common. Other beneficial practices, such as thermal care, were low. Trained TBAs were more likely to wash hands with soap before delivery, use a clean delivery-kit, and advise feeding colostrum. Although mustard oil massage was a universal practice, 52% of the TBAs indicated their willingness to consider alternative oils. Low-cost, evidence-based interventions for improving neonatal outcomes might be implemented by TBAs in this setting where most births take place in the home and neonatal mortality risk is high. Continuing efforts to define the role of TBAs may benefit from an emphasis on their potential as active promoters of essential newborn care.

Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs' continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.

Background: Previous studies on child maltreatment reporting have focused mainly on one level of substantiation. This article analyzes factors influencing the multitiered substantiation process., Method: The 1993 Third National Incidence Study (NIS-3) data of substantiated and non-substantiated reported incidents (N=7,263) of maltreatment were analyzed. Substantiation was classified into three categories: unfounded, indicated, and founded. Independent variables included demographic characteristics, case-processing variables, and maltreatment characteristics., Data Analysis: Bivariate and multiple logistic regression (MLR) analyses were calculated to determine whether demographic and case processing variables predicted unfounded or founded/indicated dispositions. Second-level analysis examined demographic, case processing, and maltreatment characteristics as predictors of founded or indicated status., Results: These results showed that 60.2% of CPS investigations conducted were evaluated as unfounded, about 22% were categorized as founded, and 17% were classified as indicated. In the MLR analysis for the first level of substantiation, case processing variables were highly significant predictors of founded/indicated status. In the second-level substantiation MLR model, cases in the mid-range income level (dollars 15,000-29,999) had a lower probability (adjusted OR = .58, p = .02) of being founded than those of less than dollars 15,000, and reports involving Hispanic children (OR = 3.04, p = .05) were more likely than the "all other" race-ethnic social classification to have been substantiated as founded., Conclusions: This analysis of NIS-3 data suggests that a three-tiered rather than a two-tiered system is a more accurate representation of the CPS substantiation process. Further analysis of substantiation patterns is required to provide a basis for developing more effective investigation systems.