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OBJECTIVES: Telemedicine became the primary mode of delivering care during the COVID-19 pandemic. We describe the impact of telemedicine on access to care for people with HIV (PWH) by comparing the proportion of PWH engaged in care prior to and during the COVID-19 pandemic. DESIGN AND METHODS: We conducted an observational analysis of patients enrolled in the Johns Hopkins HIV Clinical Cohort, a single-center cohort of patients at an urban HIV subspecialty clinic affiliated with an academic center. Due to the COVID-19 pandemic, the clinic transitioned from in-person to mostly telemedicine visits. We compared patients receiving care in two time periods. The pre-pandemic period included 2,010 people with ≥1 visit scheduled between September 1(st) 2019 and March 15(th) 2020. The pandemic period included 1,929 people with ≥1 visit scheduled between March 16(th) 2020 and September 30(th) 2020. We determined the proportion of patients completing ≥1 of their scheduled visits during each period. RESULTS: Visit completion increased significantly from 88% pre-pandemic to 91% during the pandemic (p=0.008). Visit completion improved significantly for patients age 20–39 (82% to 92%, p

Background: Obesity and cesarean section (CS) rates are rising in sub-Saharan Africa (SSA), where risks for complications that adversely affect maternal health, such as infections, are high. Objective: To conduct a systematic review and meta-analysis to report on the incidence and types of body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters)-related complications following CS in SSA. Search strategy: A systematic search was conducted in PubMed/MEDLINE, EMBASE, and Global Health Library up to August 2020 using (MeSH) terms related to CS, BMI, and SSA. Selection criteria: Quantitative studies that evaluated BMI-related complications of CS in English. Data collection and analysis: Data were extracted using a standardized form. The risk of bias was assessed using the Newcastle-Ottawa Scale. The incidence of BMI-related complications at 95% confidence interval was calculated and a meta-analysis conducted. Main results: Of 84 articles screened, five were included. Complications associated with a higher BMI were: wound infection, hemorrhage, post-dural puncture headache, and prolonged surgery time in comparison with patients with a normal BMI. Women with a high BMI (>25.0) have a two-fold increased risk for post-cesarean wound infection compared with women with a normal BMI (20.0–24.9) (odds ratio 1.91, 95% confidence interval 1.11–3.52). Conclusion: Overweight and obesity were associated with CS complications in SSA, but limited research is available.

Objectives: Hypertensive disorders in pregnancy (HDPs) are associated with risk of future metabolic syndrome. Despite the huge burden of HDPs in sub-Saharan Africa, this association has not been adequately studied in this population. Study design: This was a prospective cohort study on pregnant women recruited between August 2017 - April 2018 and followed up to one year after their deliveries and evaluated for presence of metabolic syndrome at delivery, nine weeks, six months and one year. Main outcome measures: Prevalence of metabolic syndrome Results: A total of 488 pregnant women were included: 410 and 78 with HDPs and normotensive, respectively. None of the normotensive had metabolic syndrome until one year (1.7% = 1 out of 59 observations), while among those with HDPs were 17.4% (71 of 407), 8.7% (23 of 263), 4.7% (11 of 232) and 6.1% (17 of 278), at delivery, nine weeks, six months and one year postpartum, respectively. High BMI and blood pressure were the drivers of metabolic syndrome in this population. The incidence rate in HDPs versus normotensive at one year were, respectively, 57.5/1000 persons’ year (95%CI; 35.8 – 92.6) and 16.9/1000 persons’ years (95%CI; 2.4-118.3), with incidence rate ratio of 3.4/1000 person's years. Only parity significantly predicted the presence of metabolic syndrome at one year [(aOR= 3.26/delivery (95%CI; 1.21-8.79)]. Conclusion: HDPs were associated with a higher incidence of metabolic syndrome up to one year postpartum. Women with HDPs should be routinely screened for metabolic syndrome within the first year postpartum to reduce cardiometabolic risks.

To: (1) investigate the importance of outcome measurement instruments (OMIs) within a core outcome set (COS) for multimorbidity (at least two chronic health conditions) risk in individuals with cerebral palsy (CP); (2) investigate the feasibility of OMIs within the COS in international clinical research settings in adolescents and adults with CP; and (3) describe the associations between the COS data and Gross Motor Function Classification System (GMFCS) levels.Eighty-three individuals with CP completed a survey on health outcomes: physical behaviour, nutrition, sleep, endurance, body composition, blood pressure, blood lipids, and glucose. A cross-sectional study assessed the feasibility of the COS in 67 adolescents and adults with CP (mean age 30y, SD 15y 1mo, min-max: 14-68y, 52.2% male) at four centres. Prevalence of multimorbidity risk and associations with GMFCS levels are described.Most participants rated physical behaviour, nutrition, sleep, and endurance as very important. Body composition, blood pressure, nutrition, and sleep were highly feasible since data were collected in 88% or more participants who consented to having the assessments. Physical behaviour, cardiorespiratory endurance, and blood draws were collected in less than 60% of participants. Total time sedentary (ρ=0.53, p0.01) and endurance (ρ=-0.46, p0.01) were significantly associated with GMFCS level.The COS identified that most participants had poor sleep quality and endurance, did not have healthy diets, and showed increased sedentary behaviour. Individuals with CP valued these outcomes as most important, suggesting a need to assess these modifiable behaviours in this population. Objective measures of physical behaviour and cardiorespiratory endurance in the COS required additional personnel, time, and participant burden. We recommend that healthcare providers should perform a simpler first screen using questionnaire-based assessments and then focus the use of the remainder of the COS if required for the patient.UM DESFECHO CENTRAL DEFINIDO PARA RISCO DE MULTIMORBIDADE EM INDIVÍDUOS COM PARALISIA CEREBRAL: OBJETIVO: (1) Investigar a importância dos instrumentos de medição de desfechos (IMD) dentro de um conjunto de desfechos principais (CDS) para risco de multimorbidade (pelo menos duas condições crônicas de saúde) em indivíduos com paralisia cerebral (PC); (2) Investigar a viabilidade de IMD dentro do CDS em cenários internacionais de pesquisa clínica em adolescentes e adultos com PC; e (3) Descrever as associações entre os dados do CDS e os níveis do Sistema de Classificação da Função Motora Grossa (GMFCS). MÉTODO: Oitenta e três indivíduos com PC completaram uma pesquisa sobre desfechos em saúde: comportamento físico, nutrição, sono, resistência, composição corporal, pressão arterial, lipídios no sangue e glicose. Um estudo transversal avaliou a viabilidade do COS em 67 adolescentes e adultos com PC (idade média de 30 anos, desvio padrão de 15 anos e 1 mês, min-max: 14-68 anos, 52,2% do sexo masculino) em quatro centros. São descritas a prevalência do risco de multimorbidade e as associações com os níveis de GMFCS. RESULTADOS: A maioria dos participantes classificou o comportamento físico, nutrição, sono e resistência como muito importantes. Composição corporal, pressão arterial, nutrição e sono foram altamente viáveis, uma vez que os dados foram coletados em 88% ou mais dos participantes que consentiram em realizar as avaliações. Comportamento físico, resistência cardiorrespiratória e coleta de sangue foram coletados em menos de 60% dos participantes. O tempo total de sedentarismo (ρ = 0,53, p0,01) e resistência (ρ = −0,46, p0,01) foram significativamente associados ao nível de GMFCS. INTERPRETAÇÃO: O CDS identificou que a maioria dos participantes tinha má qualidade e resistência do sono, não tinha dietas saudáveis e apresentava um comportamento sedentário aumentado. Indivíduos com PC valorizaram esses desfechos como mais importantes, sugerindo a necessidade de avaliar esses comportamentos modificáveis nessa população. Medidas objetivas de comportamento físico e resistência cardiorrespiratória no CDS exigiram pessoal adicional, tempo e sobrecarga do participante. Recomendamos que os profissionais de saúde realizem uma primeira triagem mais simples usando avaliações baseadas em questionários e, em seguida, concentrem o uso do restante do CDS, se necessário para o paciente.

BACKGROUND: The burden of post-stroke cognitive impairment, as well as affective disorders, remains persistently high. With improved stroke survival rates and increasing life expectancy, there is a need for effective interventions to facilitate remediation of neurocognitive impairments and post-stroke mood disorders. OBJECTIVE: To investigate the effects of Therapeutic Instrumental Music Performance (TIMP) training with and without Motor Imagery on cognitive functioning and affective responding in chronic post-stroke individuals. METHODS: Thirty chronic post-stroke, community-dwelling participants were randomized to one of three experimental arms: (1) 45 minutes of active TIMP, (2) 30 minutes of active TIMP followed by 15 minutes of metronome-cued motor imagery (TIMP+cMI), (3) 30 minutes of active TIMP followed by 15 minutes of motor imagery without cues (TIMP+MI). Training took place three times a week for three weeks, using a selection of acoustic and electronic instruments. Assessments, administered at two baselines and post-training, included the Trail Making Test (TMT) - Part B to assess mental flexibility, the Digit Span Test (DST) to determine short-term memory capacity, the Multiple Affect Adjective Checklist - Revised (MAACL-R) to ascertain current affective state, and the General Self-Efficacy Scale (GSE) to assess perceived self-efficacy. The Self-Assessment Maniqin (SAM) was also administered prior to and following each training session. RESULTS: Thirty participants completed the protocol, ten per arm [14 women; mean age = 55.9; mean time post-stroke = 66.9 months]. There were no statistically significant differences between pooled group baseline measures. The TIMP+MI group showed a statistically significant decrease in time from pre-test 2 to post-test on the TMT. The TIMP group showed a significant increase on MAACL sensation seeking scores, as well as on the Valence and Dominance portions of the SAM; TIMP+cMI showed respective increases and decreases in positive and negative affect on the MAACL, and increases on the Valence, Dominance, and Arousal portions of the SAM. No statistically significant association between cognitive and affective measures was obtained. CONCLUSIONS: The mental flexibility aspect of executive functioning appears to be enhanced by therapeutic instrumental music training in conjunction with motor imagery, possibly due to multisensory integration and consolidation of representations through motor imagery rehearsal following active practice. Active training using musical instruments appears to have a positive impact on affective responding; however, these changes occurred independently of improvements to cognition.

The contribution of positional asphyxia in opioid-related deaths is currently unknown. Diagnostic criteria for positional asphyxia include finding the decedent in a position that does not allow for adequate respiration and an inability to extricate themselves from the position due to various conditions. Our primary objective was to assess whether positional asphyxia and the resulting airway compromise were a contributing factor to death due to the toxic effects of opioids. We evaluated 225 deaths where the death scene investigation contained adequate information to evaluate for positional asphyxia and performed a Pearson chi-square test to determine if the proportion of deaths found in an airway compromising position was higher when opioid(s) caused the death. The proportion of decedents found in a potential airway compromising position was greater when the death was related to opioid use (p < 0.0001). Further, narrowing the dataset to decedents who were definitely in an airway compromising position [Yes (24.49%) vs. No (11.02%)] showed a statistically significant association between positional asphyxia and deaths related to opioid use (p = 0.0021). Carefully documenting the position in which the decedent was initially found may be a significant factor in accurate reporting and in harm reduction efforts to decrease the opioid mortality rate.

Purpose: To assess the outcomes of arthroscopic primary repair of proximal anterior cruciate ligament (ACL) tears with suture augmentation in the literature. Methods: A systematic search was performed using PubMed, EMBASE, and Cochrane for studies reporting on outcomes of primary repair of proximal ACL tears with suture augmentation between 2015 and 2021. Primary outcomes included failure and reoperation rates, whereas secondary outcomes consisted of functional outcomes. Proportion meta-analysis was performed to assess the overall incidence of failure rates. Outcomes of adults and adolescent were reported separately. Results: Thirteen studies with 418 patients were included in this study (mean age 32 years, mean follow-up 2.0 years, 49% male). There were no randomized studies and overall grade of recommendation was weak. Overall failure rate for primary repair with suture augmentation was 8% (95% CI 3.9–14.4), but this was higher for younger patients (17%; 95% CI 2.5–63.9) than for older patients (6%; 95% CI 3.8–8.9). The risk for additional reoperations, complications, or hardware removal was low (all 80% of maximum score). Conclusion: Current literature shows that primary repair with suture augmentation is a reliable treatment option for proximal ACL tears with a failure rate of 8% and good functional outcome scores at short-term follow-up. Although functional outcomes were good irrespective of age, failure rates were higher in young patients (17% vs 6%, respectively). There is a need for high-quality comparative studies with large group of patients to compare these outcomes with ACL reconstruction.

Traditional chemotherapy agents adversely affect wound healing and need to be held prior to or after surgery. Immune checkpoint inhibitors (ICIs) and targeted agents are now standard of care for the several treatment cancers. We hypothesize that ICI and targeted therapy do not have similar adverse effects on perioperative outcomes. We performed a review of melanoma patients undergoing surgery at an academic hospital between 2011 and 2019. All patients received ICI or targeted therapy ≤ 60 days prior to surgery, including palliative procedures. Preoperative performance status was assessed using Eastern Cooperative Oncology Group score and American Society of Anesthesiologists Classification System. Thirty-day complications were classified by Clavien–Dindo grade. No statistical comparisons were performed. Of 63 patients included in the analysis, 29 (46%) patients received ICI and 34 (54%) received targeted therapy with median of 14 days (IQR 5–27 days) between the last preoperative dose and day of surgery (ICI, median 18 days [IQR 13–34.5]; targeted therapy, median 7 days [IQR 3–22.25]). There were no perioperative mortalities. Among patients treated with ICI, 22 patients (76%) had no complications. Four patients had wound infections (2 readmitted), 1 had reoperation (hematoma) and 2 readmitted for other reasons (fever; volvulus). Among patients treated with targeted therapy, 25 patients (74%) had no complications. Seven patients had wound infections (none readmitted), 1 had reoperation (flap failure) and 1 had dehiscence (not treated). Patients undergoing treatment with ICI or targeted therapies can safely undergo surgery without substantially increased risk of serious intraoperative and postoperative complications.

This article reports results of a study that assessed the efficacy of multiple family therapy (MFT) for helping children of depressed parent(s), using a quasi-randomized controlled trial design. In total, 76 children participated in the study, with 51 children were assigned to the experimental group (EG) and 25 to the comparison group (CG). The EG children and their parents completed the three-month MFT program, while the CG children and their parents attended two psychoeducational talks scheduled at the same time as the MFT. A group × Time repeated measure ANCOVA did not discern the intervention types having any effect on children's lives in the post-treatment phase or at the three-month follow-up. However, the MFT brought some promising positive changes in the EG children's perceived social support, both overall and that from the father and other family members at three-month follow-up; compared to the CG children, the EG children also attached more importance to the support from their mothers in the post-treatment phase and that from other family members at the three-month follow-up. The results implied the potential efficacy of the MFT in facilitating an increase in the overall social support of children of depressed parents and their positive interactions with both the healthy and the depressed parent and other family members. Owing to multiple statistical limitations, caution is required while interpreting the results. A larger sample and a more sophisticated research design were suggested for future studies examining the efficacy and therapeutic mechanism of the MFT.En este artículo se informan los resultados de un estudio que evaluó la eficacia de la terapia familiar múltiple (TFM) para ayudar a hijos de padres deprimidos usando un diseño de ensayo controlado cuasialeatorizado. En total, participaron 76 niños en el estudio, con 51 niños asignados al grupo experimental y 25 al grupo comparativo. Los niños del grupo experimental y sus padres completaron el programa de TFM de tres meses, mientras que los niños del grupo comparativo y sus padres asistieron a dos charlas psicoeducativas programadas al mismo tiempo que la TFM. Un ANCOVA de medidas estandarizadas de grupo × tiempo no percibió que los tipos de intervención tuvieran ningún efecto en las vidas de los niños en la fase posterior al tratamiento ni tres meses después. Sin embargo, la TFM trajo algunos cambios positivos prometedores en el apoyo social percibido por los niños del grupo experimental, tanto en general como en el padre y otros familiares en el seguimiento de los tres meses. En comparación con los niños del grupo comparativo, los niños del grupo experimental también dieron más importancia al apoyo de sus madres en la fase posterior al tratamiento y al de otros familiares en el seguimiento de los tres meses. Los resultados indicaron la posible eficacia de la TFM a la hora de facilitar un aumento en el apoyo social general de los niños de padres deprimidos y sus interacciones positivas con el padre sano y el padre deprimido y otros familiares. Debido a las múltiples limitaciones estadísticas, es necesario interpretar los resultados con cuidado. Se sugirió una muestra más grande y un diseño de investigación más sofisticado para futuros estudios que analicen la eficacia y el mecanismo terapéutico de la TFM.本文报告了一项研究结果, 该研究采用的是准随机对照试验设计, 对多元家庭疗法 (MFT) 进行评估, 主要是看其对那些家长患有抑郁症的子女们是否起到辅助效果。总共有76名儿童参加了这项研究, 其中51名儿童被分配到实验组 (EG), 25名儿童被分配到对比组 (CG) 。EG组的儿童和他们的父母完成了三个月的MFT计划, 而CG组的儿童和他们的父母则参加了与MFT同时进行的两次心理教育讲座。小组X时间的ANCOVA重复测量方差分析没有发现干预类型在治疗后阶段或三个月的跟踪调查中对儿童的生活有任何影响。然而, MFT给EG儿童带来了一些可喜的积极变化, 包括总体上的社会支持以及来自父亲和其他家庭成员的支持, 在三个月的随访中; 与CG儿童相比, EG儿童在治疗后阶段也更重视来自母亲的支持, 在三个月的随访中也更重视来自其他家庭成员的支持。这些结果暗示了MFT在促进增加抑郁症父母子女的整体社会支持以及他们与健康父母和抑郁症父母及其他家庭成员的积极互动方面的潜在功效。由于多种统计限制, 在解释结果时需要谨慎。建议今后研究MFT的疗效和治疗机制时, 采用更大的样本和更复杂的研究设计。.

Background: Hypertensive disorders in pregnancy (HDPs) are associated with lifelong cardiovascular disease risk. Persistent postpartum hypertension in HDPs could suggest progression to chronic hypertension. This phenomenon has not been well examined in low- and middle-income countries (LIMCs), and most previous follow-ups typically last for maximally six weeks postpartum. We assessed the prevalence of persistent hypertension up to one year in women with HDPs in a low resource setting and determined associated risk factors. Methodology: A prospective cohort study of women conducted at eight tertiary health care facilities in seven states of Nigeria. Four hundred and ten women with any HDP were enrolled within 24 hours of delivery and followed up at intervals until one year postpartum. Descriptive statistics were performed to express the participants’ characteristics. Univariable and multivariable logistic regressions were conducted to identify associated risk factors. Results: Of the 410 women enrolled, 278 were followed up to one year after delivery (follow-up rate 68%). Among women diagnosed with gestational hypertension and pre-eclampsia/ eclampsia, 22.3% (95% CI; 8.3–36.3) and 62.1% (95% CI; 52.5–71.9), respectively, had persistent hypertension at six months and this remained similar at one year 22.3% (95% CI; 5.6–54.4) and 61.2% (95% CI; 40.6–77.8). Maternal age and body mass index were significant risk factors for persistent hypertension at one year [aORs = 1.07/year (95% CI; 1.02–1.13) and 1.06/kg/m2 (95% CI; 1.01–1.10)], respectively. Conclusion: This study showed a substantial prevalence of persistent hypertension beyond puerperium. Health systems in LMICs need to be organized to anticipate and maintain postpartum monitoring until blood pressure is normalized, or women referred or discharged to family physicians as appropriate. In particular, attention should be given to women who are obese, and or of higher maternal age.

Hypertensive disorders in pregnancy (HDPs) are a leading cause of maternal morbidity and mortality. Available guidelines for their postpartum management are expected to be optimally utilized. This study aimed to determine adherence to guidelines in selected Nigerian tertiary hospitals. It was nested in a cohort of women with HDPs who delivered in eight facilities between October 2017 and June 2018. Nine weeks after delivery, their cases were evaluated on prespecified indicators and supplemented with interviews. The level of adherence to the guidelines was determined using descriptive analyses, including frequencies, percentages, means, and standard deviations, as well as charts. Of the 366 participants, 33 (9%), 75 (20%), 200 (55%), and 58 (16%) had chronic hypertension, gestational hypertension, preeclampsia, and eclampsia, respectively. Only about a third had their blood pressure measured between postpartum days three and five. Similarly, a third of those with persistent hypertension (≥140/90 mmHg) were not on antihypertensive medications within the first week postpartum. In addition, 37% and 42% of participants were not counseled on contraceptives and early subsequent antenatal visits, respectively. Among those with preeclampsia/eclampsia, 93% were not offered postpartum screening for thromboprophylaxis. Although all women with preeclampsia/eclampsia remained hypertensive two weeks after discharge, only 24% had medical reviews. Overall, only 58% and 44% of indicators were adhered to among all HDPs and preeclampsia/eclampsia-specific indicators, respectively. Level of adherence to guidelines on postpartum management of HDPs in Nigerian tertiary hospitals is poor. It is recommended that institutionalization of guidelines be prioritized and linked to the entire continuum from preconception through longer term postpartum care.

Background Worldwide, hypertensive disorders in pregnancy (HDPs) complicate between 5 and 10% of pregnancies. Sub-Saharan Africa (SSA) is disproportionately affected by a high burden of HDPs and chronic kidney disease (CKD). Despite mounting evidence associating HDPs with the development of CKD, data from SSA are scarce. Methods Women with HDPs (n = 410) and normotensive women (n = 78) were recruited at delivery and prospectively followed-up at 9 weeks, 6 months and 1 year postpartum. Serum creatinine was measured at all time points and the estimated glomerular filtration rates (eGFR) using CKD-Epidemiology equation determined. CKD was defined as decreased eGFR2 lasting for ≥ 3 months. Prevalence of CKD at 6 months and 1 year after delivery was estimated. Logistic regression analyses were conducted to evaluate risk factors for CKD at 6 months and 1 year postpartum. Results Within 24 h of delivery, 9 weeks, and 6 months postpartum, women with HDPs were more likely to have a decreased eGFR compared to normotensive women (12, 5.7, 4.3% versus 0, 2 and 2.4%, respectively). The prevalence of CKD in HDPs at 6 months and 1 year postpartum was 6.1 and 7.6%, respectively, as opposed to zero prevalence in the normotensive women for the corresponding periods. Proportions of decreased eGFR varied with HDP sub-types and intervening postpartum time since delivery, with pre-eclampsia/eclampsia showing higher prevalence than chronic and gestational hypertension. Only maternal age was independently shown to be a risk factor for decreased eGFR at 6 months postpartum (aOR = 1.18/year; 95%CI 1.04–1.34). Conclusion Prior HDP was associated with risk of future CKD, with prior HDPs being more likely to experience evidence of CKD over periods of postpartum follow-up. Routine screening of women following HDP-complicated pregnancies should be part of a postpartum monitoring program to identify women at higher risk. Future research should report on both the eGFR and total urinary albumin excretion to enable detection of women at risk of future deterioration of renal function.

Health-promoting behaviors improve health, prevent disease, and decrease healthcare costs. This study describes the health-promotion behaviors and identifies influencing factors of health-promoting behaviors in low-income patients at a community health center. This cross-sectional study used participants from a center serving a low-income population. Spiritual growth and interpersonal relations were the two most practiced health-promoting behaviors. Age and education influenced participation in health-promoting behaviors. Promoting spiritual growth and interpersonal relations is a critical part of supporting health-promoting behaviors. Findings provide guidance for nurses to contribute to increasing healthy behaviors and develop interventions to improve participation in health-promoting behaviors.

Background Low socioeconomic status (SES) is associated with more adverse perinatal health outcomes, risk factors and lower access to and use of maternal health care services. However, evidence for the association between SES and maternal health outcomes is limited, particularly for middle-income countries like sub-Saharan Ghana. We assessed the association between parental SES and adverse maternal and perinatal outcomes of Ghanaian women during pregnancy, delivery and the postpartum period. Methods A prospective cohort study of 1010 women of two public hospitals in Accra, Ghana (2012–2014). SES was proxied by maternal and paternal education, wealth and employment status. The association of SES with maternal and perinatal outcomes was analyzed with multivariable logistic and linear regression. Results The analysis included 790 women with information on pregnancy outcomes. Average age was 28.2 years (standard deviation, SD 5.0). Over a third (n = 292, 37.0%) had low SES, 176 (22.3%) were classified to have high SES using the assets index. Nearly half (n = 374, 47.3%) of women had lower secondary school or vocational training as highest education level. Compared to women with middle assets SES, women with low assets SES were at higher risk for miscarriage (odds ratio, OR 1.61, 95% CI 1.06 to 2.45) and instrumental delivery (OR 1.74, 95% CI 1.03 to 2.94), but this association was not observed for the other SES proxies. For any of the maternal or perinatal outcomes and SES proxies, no other statistically significant differences were found. Conclusion Women attending public maternal health care services in urban Ghana had overall equitable maternal and perinatal health outcomes, with the exception of a higher risk of miscarriage and instrumental delivery associated with low assets SES. This suggests known associations between SES, risk factors and outcomes could be mitigated with universal and accessible maternal health services. Electronic supplementary material The online version of this article (10.1186/s12978-019-0736-3) contains supplementary material, which is available to authorized users.

Motor learning may be enhanced when a single session of aerobic exercise is performed immediately before or after motor skill practice. Most research to date has focused on aerobically trained (AT) individuals, but it is unknown if aerobically untrained (AU) individuals would equally benefit. We aimed to: (a) replicate previous studies and determine the effect of rest (REST) versus exercise (EXE) on motor skill retention, and (b) explore the effect of aerobic fitness level (AU, AT), assessed by peak oxygen uptake (VO2peak), on motor skill retention after exercise. Forty-four participants (20–29 years) practiced a visuomotor tracking task (acquisition), immediately followed by 25-min of high-intensity cycling or rest. Twenty-four hours after acquisition, participants completed a motor skill retention test. REST and EXE groups significantly improved motor skill performance during acquisition [F(3.17, 133.22) = 269.13, P = 0.001], but had no group differences in motor skill retention across time. AU-exercise (VO2peak = 31.6 ± 4.2 ml kg−1 min−1) and AT-exercise (VO2peak = 51.5 ± 7.6 ml kg−1 min−1) groups significantly improved motor skill performance during acquisition [F(3.07, 61.44) = 155.95, P = 0.001], but had no group differences in motor skill retention across time. Therefore, exercise or aerobic fitness level did not modify motor skill retention.

The study compared the prevalence of the Val66Met Brain-derived Neurotrophic Factor single nucleotide polymorphism (rs6265) in a sample of musicians (N = 50) to an ethnically matched general population sample from the 1000 Human Genome Project (N = 424). Met-carriers of the polymorphism (Val/Met and Met/Met genotypes) are typically present in 25–30% of the general population and have associated deficits in motor learning and plasticity. Many studies have assessed the benefits of long-term music training for neuroplasticity and motor learning. This study takes a unique genetic approach investigating if the prevalence of the Val66Met BDNF polymorphism, which negatively affects motor learning, is significantly different in musicians from the general population. Our genotype and allele frequency analyses revealed that the distribution of the Val66Met polymorphism was not significantly different in musicians versus the general population (p = 0.6447 for genotype analysis and p = 0.8513 allele analysis). In the Musician sample (N = 50), the prevalence of the Val/Met genotype was 40% and the prevalence of the Met/Met genotype was 2%. In the 1000 Human Genome Project subset (N = 424), the prevalence of Val/Met was 33.25% and the Met/Met genotype prevalence was 4%. Therefore, musicians do exist with the Val66Met polymorphism and the characteristics of long-term music training may compensate for genetic predisposition to motor learning deficits. Since the polymorphism has significant implications for stroke rehabilitation, future studies may consider the implications of the polymorphism in music-based interventions such as Neurologic Music Therapy.

This paper explores how care for women with hypertensive disorders of pregnancy (HDP) is practiced in a tertiary hospital in Ghana. Partly in response to the persistently high maternal and neonatal mortality rates in Low- and Middle-income countries, efforts to improve quality of maternity care have increased. Quality improvement initiatives are shaped by the underlying conceptualisation of quality of care, often driven by global (WHO) standards and protocols. However, there are tensions between global standards of care and local clients' and providers' understandings of care practices and quality of care. Implementation of standards is further complicated by structural and organisational restrictions that influence providers' possibilities and priorities. Based on ethnographic fieldwork, we explore how clinical guidelines and professionals' and patients' perspectives converge and, more importantly, diverge. We illuminate local, situated care practices and show how professionals creatively deal with tensions that arise on the ground. In this middle-income setting, caring for women with HDP involves tinkering and navigating in contexts of uncertainty, scarcity, varying responsibilities and conflicting interests. We unravelled a complex web of, at times, contradictory logics, from which various forms of care arise and in which different notions of good care co-exist. While practitioners navigated through and with these varying logics of care, the logic of survival permeated all practices. This study provides important initial insights into how professionals might implement and innovatively adapt the latest quality of maternity care guidelines which seek to marry clinical standards and patients’ needs, preferences and experiences.

Background Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. Objectives To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers. Design This was an individual participant data meta-analysis of cohort studies. Setting Source data from secondary and tertiary care. Predictors We identified predictors from systematic reviews, and prioritised for importance in an international survey. Primary outcomes Early-onset (delivery at Analysis We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I 2 and τ2. A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals. Results The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia. Limitations Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data. Conclusion For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings. Future work Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate. Study registration This study is registered as PROSPERO CRD42015029349. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 72. See the NIHR Journals Library website for further project information.

Background Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk during pregnancy is required to plan management. Although there are many published prediction models for pre-eclampsia, few have been validated in external data. Our objective was to externally validate published prediction models for pre-eclampsia using individual participant data (IPD) from UK studies, to evaluate whether any of the models can accurately predict the condition when used within the UK healthcare setting. Methods IPD from 11 UK cohort studies (217,415 pregnant women) within the International Prediction of Pregnancy Complications (IPPIC) pre-eclampsia network contributed to external validation of published prediction models, identified by systematic review. Cohorts that measured all predictor variables in at least one of the identified models and reported pre-eclampsia as an outcome were included for validation. We reported the model predictive performance as discrimination (C-statistic), calibration (calibration plots, calibration slope, calibration-in-the-large), and net benefit. Performance measures were estimated separately in each available study and then, where possible, combined across studies in a random-effects meta-analysis. Results Of 131 published models, 67 provided the full model equation and 24 could be validated in 11 UK cohorts. Most of the models showed modest discrimination with summary C-statistics between 0.6 and 0.7. The calibration of the predicted compared to observed risk was generally poor for most models with observed calibration slopes less than 1, indicating that predictions were generally too extreme, although confidence intervals were wide. There was large between-study heterogeneity in each model’s calibration-in-the-large, suggesting poor calibration of the predicted overall risk across populations. In a subset of models, the net benefit of using the models to inform clinical decisions appeared small and limited to probability thresholds between 5 and 7%. Conclusions The evaluated models had modest predictive performance, with key limitations such as poor calibration (likely due to overfitting in the original development datasets), substantial heterogeneity, and small net benefit across settings. The evidence to support the use of these prediction models for pre-eclampsia in clinical decision-making is limited. Any models that we could not validate should be examined in terms of their predictive performance, net benefit, and heterogeneity across multiple UK settings before consideration for use in practice. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Dipstick tests are frequently used as bedside proteinuria tests to evaluate women suspected of preeclampsia and may inform diagnosis in low resource settings lacking laboratory facilities. This systematic review and meta-analysis aimed to (1) estimate the diagnostic accuracy of urine dipsticks in diagnosing proteinuria, (2) compare performance of different dipstick types and (3) estimate their related costs.MEDLINE and EMBASE were searched up to August 1, 2020 for primary studies with cross-sectional diagnostic accuracy data on dipstick test(s) compared to a laboratory reference standard (24-hour protein ≥ 300 mg or protein-creatinine ratio ≥ 30 mg/mmol) in pregnant women ≥ 20 weeks of gestation suspected of preeclampsia. Risk of bias and applicability was assessed with QUADAS-2. Data were analysed using a bivariate model with hierarchical addition of covariates for subgroups.Nineteen studies were included. Protein-only dipsticks at 1 + threshold had a pooled sensitivity of 0.68 [95%CI: 0.57-0.77] and specificity of 0.85 [95% CI: 0.73-0.93] (n = 3700 urine samples, 18 studies). Higher specificity was found with automatedly (0.93 [95% CI: 0.82-0.98]) compared to visually (0.81 [95% CI: 0.65-0.91]) read dipsticks, whereas sensitivity was similar and costs were higher. The use of albumin-creatinine ratio (ACR) dipsticks was only reported in two studies and did not improve accuracy. Heterogeneity in study design and prevalence of preeclampsia amongst studies complicated interpretation of pooled estimates.Urine dipsticks performed poorly at excluding preeclampsia in hypertensive pregnant women. Further development of accurate and low-cost bedside proteinuria tests is warranted.

Background Maternal near-miss (MNM) is an important maternal health quality-of-care indicator. To facilitate comparison between countries, the World Health Organization (WHO) developed the "MNM-tool". However, several low- and middle-income countries have proposed adaptations to prevent underreporting, ie, Namibian and Sub-Sahara African (SSA)-criteria. This study aims to assess MNM and associated factors in middle-income country Suriname by applying the three different MNM tools. Methods A nationwide prospective population-based cohort study was conducted using the Suriname Obstetric Surveillance System (SurOSS). We included women with MNM-criteria defined by WHO-, Namibian- and SSA-tools during one year (March 2017-February 2018) and used hospital births (86% of total) as a reference group. Results There were 9114 hospital live births in Suriname in the one-year study period. SurOSS identified 71 women with WHO-MNM (8/1000 live births, mortality-index 12%), 118 with Namibian-MNM (13/1000 live births, mortality-index 8%), and 242 with SSA-MNM (27/1000 live births, mortality-index 4%). Namibian- and SSA-tools identified all women with WHO-criteria. Blood transfusion thresholds and eclampsia explained the majority of differences in MNM prevalence. Eclampsia was not considered a WHO-MNM in 80% (n = 35/44) of cases. Nevertheless, mortality-index for MNM with hypertensive disorders was 17% and the most frequent underlying cause of maternal deaths (n = 4/10, 40%) and MNM (n = 24/71, 34%). Women of advanced age and maroon ethnicity had twice the odds of WHO-MNM (respectively adjusted odds ratio (aOR) = 2.6, 95% confidence interval (CI) = 1.4-4.8 and aOR = 2.0, 95% CI = 1.2-3.6). The stillbirths rate among women with WHO-MNM was 193/1000births, with six times higher odds than women without MNM (aOR = 6.8, 95%CI = 3.0-15.8). While the prevalence and mortality-index differ between the three MNM tools, the underlying causes of and factors associated with MNM were comparable. Conclusions The MNM ratio in Suriname is comparable to other countries in the region. The WHO-tool underestimates the prevalence of MNM (high mortality-index), while the adapted tools may overestimate MNM and compromise global comparability. Contextualized MNM-criteria per obstetric transition stage may improve comparability and reduce underreporting. While MNM studies facilitate international comparison, audit will remain necessary to identify shortfalls in quality-of-care and improve maternal outcomes.

Duration of mechanical ventilation is an important variable used by German Diagnosis-Related Groups (G-DRG) system to establish cost weight values for reimbursement after congenital heart surgery. Infants are commonly ventilated after open heart surgery. As of year 2015, we strived to achieve early postoperative extubation. This work studies how this approach impacted reimbursement after infant open heart surgery.Data of infants who underwent surgery on cardiopulmonary bypass (CPB) from 2014 to 2018 were reviewed. Successful early extubation was defined as end of mechanical ventilation within 24 hours postoperatively, without reintubation at a later point. Mean cost weight values (case mix index [CMI]) of achieved DRGs were used for estimation of reimbursement. Evolutions over years of early extubation and of reimbursement were compared.A total of 521 infants underwent operations on CPB. Of these, 161 (31%) procedures were of higher risk Society of Thoracic Surgery and the European Association for Cardio-Thoracic Surgery (STAT) categories 3 and 4. Early extubation was achieved in 205 (39%) patients. The rate increased from 14% (year 2014) to 57% (year 2018). Case mix index amounted to 8.87 ± 7.00 after early extubation, and 12.37 ± 7.85 after late extubation:Early extubation could be progressively obtained in the majority of infants. This resulted in lower reimbursement. Surgical complexity was disregarded. The current G-DRG system appears to favor longer mechanical ventilation durations after infant open heart surgery.

The pathogenesis of preeclampsia and other hypertensive disorders of pregnancy remains poorly defined despite the substantial burden of maternal and neonatal morbidity associated with these conditions. In particular, the role of genetic variants as determinants of disease susceptibility is understudied. Storkhead-box protein 1 (STOX1) was first identified as a preeclampsia risk gene through family-based genetic linkage studies in which loss-of-function variants were proposed to underlie increased preeclampsia susceptibility. We generated a genetic Stox1 loss-of-function mouse model (Stox1 KO) to evaluate whether STOX1 regulates blood pressure in pregnancy. Pregnant Stox1-KO mice developed gestational hypertension evidenced by a significant increase in blood pressure compared with WT by E17.5. While severe renal, placental, or fetal growth abnormalities were not observed, the Stox1-KO phenotype was associated with placental vascular and extracellular matrix abnormalities. Mechanistically, we found that gestational hypertension in Stox1-KO mice resulted from activation of the uteroplacental renin-angiotensin system. This mechanism was supported by showing that treatment of pregnant Stox1-KO mice with an angiotensin II receptor blocker rescued the phenotype. Our study demonstrates the utility of genetic mouse models for uncovering links between genetic variants and effector pathways implicated in the pathogenesis of hypertensive disorders of pregnancy.

Objectives: Determine the eclampsia prevalence and factors associated with eclampsia and recurrent seizures in Suriname and evaluate quality-of-care indicator ‘magnesium sulfate (MgSO4) coverage’. Study design: A two-year prospective nationwide cohort study was conducted in Suriname and included women with eclampsia at home or in a healthcare facility. Main outcome measures: We calculated the prevalence by the number of live births obtained from vital registration. Risk factor denominator data concerned hospital births. Descriptive statistics and multivariate regression analysis were performed. Results: Seventy-two women with eclampsia (37/10.000 live births) were identified, including two maternal deaths (case-fatality 2.8%). Nulliparity, African-descent and adolescence were associated with eclampsia. Adolescents with eclampsia had significantly lower BPs (150/100 mmHg) than adult women (168/105 mmHg). The first seizure occurred antepartum in 54% (n = 39/72), intrapartum in 19% (n = 14/72) and postpartum in 26% (n = 19/72). Recurrent seizures were observed in 60% (n = 43/72). MgSO4 was administered to 99% (n = 69/70) of women; however 26% received no loading dosage and, in 22% of cases MgSO4 duration was

Background Our study aims to evaluate the current perinatal registry, analyze national childbirth outcomes and study ethnic disparities in middle-income country Suriname, South America. Methods A nationwide birth registry study was conducted in Suriname. Data were collected for 2016 and 2017 from the childbirth books of all five hospital maternity wards, covering 86% of all births in the country. Multinomial regression analyses were used to assess ethnic disparities in outcomes of maternal deaths, stillbirths, teenage pregnancy, cesarean delivery, low birth weight and preterm birth with Hindustani women as reference group. Results 18.290 women gave birth to 18.118 (98%) live born children in the five hospitals. Hospital-based maternal mortality ratio was 112 per 100.000 live births. Hospital-based late stillbirth rate was 16 per 1000 births. Stillbirth rate was highest among Maroon (African-descendent) women (25 per 1000 births, aOR 2.0 (95%CI 1.3–2.8) and lowest among Javanese women (6 stillbirths per 1000 births, aOR 0.5, 95%CI 0.2–1.2). Preterm birth and low birthweight occurred in 14 and 15% of all births. Teenage pregnancy accounted for 14% of all births and was higher in Maroon women (18%) compared to Hindustani women (10%, aOR 2.1, 95%CI 1.8–2.4). The national cesarean section rate was 24% and was lower in Maroon (17%) than in Hindustani (32%) women (aOR 0.5 (95%CI 0.5–0.6)). Cesarean section rates varied between the hospitals from 17 to 36%. Conclusion This is the first nationwide comprehensive overview of maternal and perinatal health in a middle income country. Disaggregated perinatal health data in Suriname shows substantial inequities in outcomes by ethnicity which need to be targetted by health professionals, researchers and policy makers.

Background The majority of the world’s perinatal deaths occur in low- and middle-income countries. A substantial proportion occurs intrapartum and is avoidable with better care. At a low-resource tertiary hospital, this study assessed the quality of intrapartum care and adherence to locally-tailored clinical guidelines. Methods A non-participatory, structured, direct observation study was held at Mnazi Mmoja Hospital, Zanzibar, Tanzania, between October and November 2016. Women in active labour were followed and structure, processes of labour care and outcomes of care systematically recorded. Descriptive analyses were performed on the labour observations and compared to local guidelines and supplemented by qualitative findings. A Poisson regression analysis assessed factors affecting foetal heart rate monitoring (FHRM) guidelines adherence. Results 161 labouring women were observed. The nurse/midwife-to-labouring-women ratio of 1:4, resulted in doctors providing a significant part of intrapartum monitoring. Care during labour and two-thirds of deliveries was provided in a one-room labour ward with shared beds. Screening for privacy and communication of examination findings were done in 50 and 34%, respectively. For the majority, there was delayed recognition of labour progress and insufficient support in second stage of labour. While FHRM was generally performed suboptimally with a median interval of 105 (interquartile range 57–160) minutes, occurrence of an intrapartum risk event (non-reassuring FHR, oxytocin use or poor progress) increased assessment frequency significantly (rate ratio 1.32 (CI 1.09–1.58)). Conclusions Neither international nor locally-adapted standards of intrapartum routine care were optimally achieved. This was most likely due to a grossly inadequate capacity of birth attendants; without whom innovative interventions at birth are unlikely to succeed. This calls for international and local stakeholders to address the root causes of unsafe intrafacility care in low-resource settings, including the number of skilled birth attendants required for safe and respectful births.

This article explores family therapy trainees' subjective experiences of working as cotherapists with a supervisory-level therapist in a Chinese context, regarding their perceptions of and positioning in it and also their opinions on the benefits and/or pitfalls of cotherapy. Individual interviews with a total of six cotherapists revealed three themes: (1) Cotherapy was perceived as an experiential learning journey that evolved from anxiety and excitement to empowerment and nurturing; (2) a collaborative master-apprentice relationship of openness, trust, and mutual respect was developed with both sides' interactive effort, which included common commitment and concern for the client, the supervisor's awareness and explicit address of the role hierarchy, principle setting prior to the cooperation, and honest pre- and-postsession sharing and discussion; (3) the dual-purpose supervisor-trainee cotherapy brought direct benefits for all involved parties and for others. The findings have useful implications for integrating treatment and training for optimal training/learning outcomes and for advancing knowledge transfer from senior to junior and from academia to the field, with reference to local cultural characteristics.Este artículo analiza las experiencias subjetivas de los practicantes de terapia familiar en su trabajo como coterapeutas con un terapeuta supervisor en un contexto chino, con respecto a sus percepciones de la coterapia y a su posicionamiento en ella, y también sus opiniones sobre los beneficios o los inconvenientes de la coterapia. Las entrevistas individuales con un total de seis coterapeutas revelaron tres temas: (1) la coterapia se percibió como un viaje de aprendizaje empírico que pasó de la ansiedad y el entusiasmo al empoderamiento y el estímulo; (2) se desarrolló una relación colaborativa de sinceridad, confianza y respeto mutuo entre el maestro y el aprendiz con el esfuerzo interactivo de ambas partes, que incluyó el compromiso común y la preocupación por el paciente, la comprensión del supervisor y el abordaje explícito de la jerarquía de roles, la fijación de principios antes de la cooperación, y el intercambio y el debate sinceros antes y después de la sesión; (3) la coterapia con doble finalidad entre el supervisor y el practicante tuvo beneficios directos para todas las partes implicadas y para los demás. Los hallazgos tienen consecuencias útiles para la integración del tratamiento y la capacitación a fin de obtener resultados óptimos a nivel de capacitación y aprendizaje, y de fomentar el traspaso de conocimiento desde los profesionales experimentados a los profesionales noveles, y desde el mundo académico al ejercicio de la profesión, con referencia a características culturales locales.本文研究对象是在中国背景下参与家庭治疗培训的学员, 调查了他们与治疗师督导 一起合作实施治疗的主观经验, 包括他们对共同治疗的看法和在共同治疗过程中的自我定 位, 以及他们对共同治疗的好处和/或缺点的认知。本研究涉及总共六位参与共同治疗过 程的学员, 逐个进行单独访谈, 分析后得出了三个方面的主题: （1）共同治疗被视为一 种体验式学习经历, 学员经历了从焦虑和兴奋到被赋权和成长进步的学习之旅;（2） 通 过双方的互动努力, 形成了开放、信任、相互尊重的协作型师徒关系, 包括对来访者承担 共同的责任和关注同样的重要方面、督导对角色等级的认知和明确表述、合作前共同制定 原则、每次治疗会谈后双方进行坦诚的反思分享和讨论;（3）督导-学员共同治疗的实践 实现双重目的, 给所有相关方和其他各方都带来了好处。这些研究发现对于把具体治疗实 践和培训结合起来, 实现培训/学习成果的最优化, 促进知识从高级治疗师到初级学员的 迁移以及从学术界向实际场景转移, 并考虑到当地地域文化特性等等方面都具有有益的启 示意义。.

Background Accruing epidemiological evidence suggests that prenatal exposure to emissions from cooking fuel is associated with increased risks of adverse maternal and perinatal outcomes including hypertensive disorders of pregnancy, low birth weight, stillbirth and infant mortality. We aimed to investigate the relationship between cooking fuel use and various pregnancy related outcomes in a cohort of urban women from the Accra region of Ghana. Methods Self-reported cooking fuel use was divided into “polluting” (wood, charcoal, crop residue and kerosene) and “clean” fuels (liquid petroleum gas and electricity) to examine 12 obstetric outcomes in a prospective cohort of pregnant women (N = 1010) recruited at Results 34% (n = 279) of 819 women with outcome data available for analysis used polluting fuel as their main cooking fuel. Using polluting cooking fuels was associated with perinatal mortality (aOR: 7.6, 95%CI: 1.67–36.0) and an adverse Apgar score ( Conclusions We report an increased likelihood of perinatal mortality, and adverse 5-min Apgar scores in association with polluting fuel use. Further research including details on extent of household fuel use exposure is recommended to better quantify the consequences of household fuel use. Study registration Ghana Service Ethical Review Committee (GHS-ERC #: 07–9-11).

Plain English summary The World Health Organization (WHO) provides a framework (ICD-MM) to classify pregnancy-related deaths systematically, which enables global comparison among countries. We compared the classification of pregnancy-related deaths in Suriname by the attending physician and by the national maternal death review (MDR) committee and among the MDR committees of Suriname, Jamaica and the Netherlands. There were 89 possible pregnancy-related deaths in Suriname between 2010 and 2014. Nearly half (47%) were classified differently by the Surinamese MDR committee as compared to the classification of the attending physicians. All three MDR committees agreed that 18% (n = 16/89) of the cases were no maternal deaths. Out of the remaining 73 cases, there was disagreement regarding whether 15% (n = 11) were maternal deaths. The Surinamese and Jamaican MDR committees achieved greater consensus in classification than the Surinamese and the Netherlands MDR committees. The Netherlands MDR committee classified more deaths as unspecified than Surinamese and the Jamaican MDR committees. Underlying causes that achieved a high level of agreement among the three committees were abortive outcomes and obstetric hemorrhage, while little agreement was reported for unspecified and other direct causes. The issues encountered during maternal death classification using the ICD-MM guidelines included classification of suicide during early pregnancy; when to assume pregnancy without objective evidence; how to count maternal deaths occurring outside the country of residence; the relevance of direct or indirect cause attribution; and how to select the underlying cause when direct and indirect conditions or multiple comorbidities co-occur. Addressing these classification barriers in future revisions of the ICD-MM guidelines could enhance the feasibility of maternal death classification and facilitate global comparison. Background Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines. Methods The classification of pregnancy-related deaths in Suriname during 2010–2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement. Results Out of the 89 cases certified by attending physicians, 47% (n = 42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n = 16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n = 11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ = 0.53) and underlying cause group (κ = 0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ = 0.69 vs κ = 0.63) was better than between the Surinamese and the Netherlands MDR committees (κ = 0.48 vs κ = 0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ = 0.85) and obstetric hemorrhage (κ = 0.74) and fair for unspecified (κ = 0.29) and other direct causes (κ = 0.32). Conclusions Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.

Background Postpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction. Methods A nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline. Results In 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3–3.3], Creole aOR 1.8[95%CI 1.1–3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7–7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7–3.4]), cesarean section (aOR 3.9[95%CI 2.9–5.3]), stillbirth (aOR 6.4 [95%CI 3.4–12.2]), preterm birth (aOR 2.1[95%CI 1.3–3.2]), and macrosomia (aOR 2.8 [95%CI 1.5–5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117]). Conclusions PPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines.

Objective To quantify the burden of the side effects of radiotherapy on a tertiary referral urology department. Patients and methods A prospective study of all urology admissions to a public urology department at a tertiary hospital in a 6-month period was performed. Patients admitted with complications attributable to radiotherapy were included in the study. Data obtained included patient demographics, radiotherapy details, complication type and management required. Results A total of 1198 patients were admitted; 921 (77%) were elective and 277 (23%) were emergency admissions. Thirteen out of the 921 (1.4%) elective admissions and 20 out of the 277 (7.2%) emergency admissions were attributable to radiotherapy complications. Radiotherapy complications was the fourth most common reason for emergency admission, ahead of acute urinary retention. These 33 admissions were accounted for by 21 patients. A total of 39 separate complications attributable to radiotherapy were diagnosed, with some patients having multiple complications. The median (interquartile range) time to onset of complications was 4 (1-9) years. The surgical intervention rate was 67%. The commonest procedures were washout with/without clot evacuation or diathermy in theatre (15.8%) and urethral dilatation/bladder neck incision (15.8%). Two urinary diversions and two cystoprostatectomies plus urinary diversion were performed. Conclusion Radiotherapy complications are consequential and account for a substantial proportion of a tertiary urology department's emergency workload. These complications generally occur years after radiotherapy and frequently require surgical intervention.

Objective: Medication combined with psychosocial intervention is the recommended treatment for ADHD. What is not clear is which of the parents participate in psychosocial interventions, and whether the impacts are different for fathers and mothers. This is important because of the different roles fathers and mothers have in shaping their child’s development. This article examines the impact of multifamily therapy on a sample of fathers and mothers from Hong Kong whose children suffer from ADHD. Method: Fathers and mothers ratings on ADHD severity, parent–child relationship, parenthood stress, and parental self-esteem were compared between those who attended multifamily therapy and those who attended psychoeducation talks. Results: Fathers and mothers of the multifamily group, but not the psychoeducational group, reported reduction of child ADHD symptom severity. When the reduction was clinically significant, mothers reported an increased sense of competence while fathers reported improved father–child relationship. Conclusion: Fathers and mothers experienced different gains from attending MFT. Fathers’ involvement in their child’s treatment should be encouraged and facilitated.

Background Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). In low- and middle-income countries, implementation of AMTSL is hampered by shortage of skilled birth attendants and a high percentage of home deliveries. Task shifting of specific AMTSL components to unskilled birth attendants or self-administration could be a strategy to increase access to potentially life-saving interventions. This study was designed to evaluate the effect, acceptance and safety of task shifting of specific aspects of AMTSL to unskilled birth attendants. Methods A systematic search was conducted in five databases in September 2015 to identify intervention studies of AMTSL implemented by unskilled birth attendants or pregnant women themselves. Quality of studies was evaluated with an adapted Cochrane Collaboration assessment tool. Results Of 2469 studies screened, 21 were included. All studies assessed implementation of uterotonics (misoprostol tablets or oxytocin injections), administered by community health workers (CHWs), auxiliary midwives, traditional birth attendants (TBAs) or self-administration at antenatal (home) visits or delivery. Task shifting for none of the other AMTSL components was reported. Task shifting of provision of uterotonics reduced the risk of PPH (RR 0.16 to 1) compared to standard care (13 studies, n = 15.197). The correct dose and timing was reported for 83.4 to 99.8% (5 studies, n = 6083) and 63 to 100% (9 studies, n = 8378) women respectively. Uterotonics were recommended to others by 80 to 99.7% (7 studies, n = 6445); 80 to 99.4% (5 studies, n = 2677) would use the drug at next delivery. Willingness to pay for uterotonics varied from 54.6 to 100% (7 studies, n = 6090). Conclusion Task shifting of AMTSL has thus far been evaluated for administration of uterotonics (misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives) and resulted in reduction of PPH, high rates of appropriate use and satisfaction among users. In order to increase AMTSL coverage in low-staffed health facilities, task shifting of uterine massage or postpartum tonus assessment to unskilled attendants or delivered women could be considered. Task shifting of controlled cord traction is currently not recommended. Electronic supplementary material The online version of this article (10.1186/s12884-018-1677-5) contains supplementary material, which is available to authorized users.

Movement is traditionally viewed as a process that involves motor brain regions. However, movement also implicates non-motor regions such as prefrontal and parietal cortex, regions whose integrity may thus be important for motor recovery after stroke. Importantly, focal brain damage can affect neural functioning within and between distinct brain networks implicated in the damage. The aim of this study is to investigate how resting state connectivity (rs-connectivity) within and between motor and frontoparietal networks are affected post-stroke in correlation with motor outcome. Twenty-seven participants with chronic stroke with unilateral upper limb deficits underwent motor assessments and magnetic resonance imaging. Participants completed the Chedoke-McMaster Stroke Assessment as a measure of arm (CMSA-Arm) and hand (CMSA-Hand) impairment and the Action Research Arm Test (ARAT) as a measure of motor function. We used a seed-based rs-connectivity approach defining the motor (seed = contralesional primary motor cortex (M1)) and frontoparietal (seed = contralesional dorsolateral prefrontal cortex (DLPFC)) networks. We analyzed the rs-connectivity within each network (intra-network connectivity) and between both networks (inter-network connectivity), and performed correlations between: a) intra-network connectivity and motor assessment scores; b) inter-network connectivity and motor assessment scores. We found: a) Participants with high rs-connectivity within the motor network (between M1 and supplementary motor area) have higher CMSA-Hand stage (z = 3.62, p = 0.003) and higher ARAT score (z = 3.41, p = 0.02). Rs-connectivity within the motor network was not significantly correlated with CMSA-Arm stage (z = 1.83, p > 0.05); b) Participants with high rs-connectivity within the frontoparietal network (between DLPFC and mid-ventrolateral prefrontal cortex) have higher CMSA-Hand stage (z = 3.64, p = 0.01). Rs-connectivity within the frontoparietal network was not significantly correlated with CMSA-Arm stage (z = 0.93, p = 0.03) or ARAT score (z = 2.53, p = 0.05); and c) Participants with high rs-connectivity between motor and frontoparietal networks have higher CMSA-Hand stage (rs = 0.54, p = 0.01) and higher ARAT score (rs = 0.54, p = 0.009). Rs-connectivity between the motor and frontoparietal networks was not significantly correlated with CMSA-Arm stage (rs = 0.34, p = 0.13). Taken together, the connectivity within and between the motor and frontoparietal networks correlate with motor outcome post-stroke. The integrity of these regions may be important for an individual's motor outcome. Motor-frontoparietal connectivity may be a potential biomarker of motor recovery post-stroke.

Background The global increase in Cesarean section rate is associated with short- and long-term complications, including adhesions with potential serious maternal and fetal consequences. This study investigated the prevalence of adhesions and association between adhesions and postoperative complications in a tertiary referral hospital in Accra, Ghana. Methods In this prospective cohort study, 335 women scheduled for cesarean section at Korle-Bu Teaching Hospital in Accra, Ghana were included from June to December 2015. Presence or absence of adhesions was recorded and the severity of the adhesions was scored using a classification system. Associations between presence and severity of adhesions, postoperative complications, and maternal and infant outcomes at discharge and 6 weeks postpartum were assessed using multivariate logistic and linear regression analysis. Results Of the participating women, 128 (38%) had adhesions and 207 (62%) did not. Prevalence of adhesions increased with history of caesarean section; 2.8% with no CS but may have had an abdominal surgery, 51% with one previous CS, 62% with >1 CS). Adhesions significantly increased operation time (mean 39.2 (±15.1) minutes, absolute adjusted difference with presence of adhesions 9.6 min, 95%CI 6.4-12.8), infant delivery time (mean 5.4 (±4.8) minutes, adjusted difference 2.4 min, 95%CI 1.3-3.4), and blood loss for women with severe adhesions (mean blood loss 418.8 ml (±140.6), adjusted difference 57.6 ml (95%CI 12.1-103.0). No differences for other outcomes were observed. Conclusion With cesarean section rates rising globally, intra-abdominal adhesions occur more frequently. Risks of adhesions and associated complications should be considered in counseling patients for cesarean section. Electronic supplementary material The online version of this article (10.1186/s12978-017-0388-0) contains supplementary material, which is available to authorized users.

Network connectivity measured with resting state functional magnetic resonance imaging (rsfMRI) has revealed the contribution of distinct cerebellar lobules to an array of brain wide networks sub-serving motor and cognitive processes. As distinct cerebellar lobules form relatively accessible nodes of different brain networks, this raises the possibility for site-specific modulation of network connectivity using non-invasive brain stimulation techniques such as transcranial magnetic stimulation (TMS). Continuous theta burst transcranial magnetic stimulation (cTBS) induces long-lasting inhibition of cortical areas. Although previous studies have shown that cTBS of the lateral cerebellum modulates motor cortical excitability and improves symptoms in several movement disorders, the effect on cognitive domains has not been examined. We explored the immediate effects of cTBS in a sham-controlled study on the strength of intrinsic functional connectivity between cerebellar and cortical motor and cognitive regions in 12 participants. Lateral cerebellar cTBS significantly decreased functional connectivity with frontal and parietal cognitive regions, while connectivity with motor regions remained unaltered. Sham stimulation had no effect on either motor or cognitive connectivity. These results show that inhibitory cerebellar stimulation reduces intrinsic functional connectivity between different cortical areas, in keeping with the known connectivity pattern of the cerebellum. The results highlight the plasticity of cerebello-cerebral networks and indicate for the first time that this functional connectivity can be downregulated using an inhibitory neurostimulation paradigm. This may shed light on the pathophysiology of network dysfunction and is a potential treatment for cognitive and movement disorders.

Objective To describe longitudinal change in perceived health, presence of health issues, and functional level in adults with cerebral palsy (CP). Design Prospective cohort study. Setting Participants' daily environment. Participants Adults (N=49) with CP (age range, 35–45y; 27 [55%] men; 36 [75%] spastic) formerly known in pediatric rehabilitation care participated. Interventions Not applicable. Main Outcome Measures Postal questionnaires were completed by the adults or their proxies (n=9). Health outcomes included perceived health (adapted from the 36-Item Short Form Health Survey) and presence of health issues such as pain, severe fatigue (dichotomized), and functional level (Barthel Index; walking performance). Results Over a 10-year period, the percentage of adults with CP worrying about their health increased (29%–54%; P =.008) and those indicating that health problems limit their activities increased (19%–45%; P =.002). In the same period, most adults continued to report good general health (93%–86%; P =.148). Presence of some health issues increased over time, such as pain; severe fatigue was a common health issue at follow-up (32%). Over a 14-year period, mobility and self-care deteriorated (Barthel Index, 17.1±4.8 to 16.3±5.6; P =.007). Walking performance, specifically indoors, declined (83%–71%; P =.010). Conclusions Adults with CP experienced deterioration in health outcomes in the long term. Most notably, perceived health and functional level decreased. Pain and severe fatigue were the most common health issues in adult CP. More research is required to explore the mechanisms at work in the process of aging in persons with CP. Systematic follow-up of adults with CP appears necessary to timely detect and intervene in health problems and functional decline.

Traumatic brain injury (TBI) is widely assumed to be causal in neurodegenerative disease, based on epidemiological surveys demonstrating an increased risk of Alzheimer disease (AD) following TBI, and on recent theories surrounding repetitive head movement. We tested this assumption by evaluating 30 consecutive forensic examinations in which neuropathology consultation was sought, and in which a history of remote TBI was uncovered during the course of the investigation. In this series, there was a high frequency of psychiatric co-morbidities (100%), remote contusion (90%), and seizures (63%). Extent of proteinopathy showed no differences with age-matched controls. A subset of the cases showed focal geographic tauopathy that correlated with older age at autopsy, but had no correlation with clinical signs, and was minimal in comparison with the encephalomalacia secondary to trauma. The results suggest that cerebral contusion and post-traumatic epilepsy may be over-represented in civilian TBI, while structural brain damage from trauma is the predominant cause of morbidity following TBI. We found no evidence that TBI initiates a progressive proteinopathy.

Reducing neonatal mortality is one of the targets of Sustainable Development Goal 3 on good health and well-being. The highest rates of neonatal death occur in sub-Saharan Africa. Birth asphyxia is one of the major preventable causes. Early detection and timely management of abnormal labour progress and fetal compromise are critical to reduce the global burden of birth asphyxia. Labour progress, maternal and fetal well-being are assessed using the WHO partograph and intermittent fetal heart rate monitoring. However, in low-resource settings adherence to labour guidelines and timely response to arising labour complications is generally poor. Reasons for this are multifactorial and include lack of resources and skilled health care staff. This case study in a Malawian hospital illustrates how delayed recognition of abnormal labour and prolonged decision-to-delivery interval contributed to birth asphyxia, as an example of many delivery rooms in low-income country settings.

Background Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the ‘bottom-up’ development process of context-tailored national obstetric guidelines in middle-income country Suriname. Methods Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH). Results The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented. Conclusion Development of national context-tailored guidelines is achievable in a middle-income country when using a ‘bottom-up’ approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.

BackgroundAsylum seekers (AS) and undocumented migrants (UM) are at risk of adverse pregnancy outcomes due to adverse health determinants and compromised maternal healthcare access and service quality. Considering recent migratory patterns and the absence of a robust overview, a systematic review was conducted on maternal and perinatal outcomes in AS and UM in Europe.MethodsSystematic literature searches were performed in MEDLINE and EMBASE (until 1 May 2017), complemented by a grey literature search (until 1 June 2017). Primary research articles reporting on any maternal or perinatal outcome, published between 2007 and 2017 in English/Dutch were eligible for inclusion. Review protocols were registered on Prospero: CRD42017062375 and CRD42017062477. Due to heterogeneity in study populations and outcomes, results were synthesized narratively.ResultsOf 4652 peer-reviewed articles and 145 grey literature sources screened, 11 were included from 4 European countries. Several studies reported adverse outcomes including higher maternal mortality (AS), severe acute maternal morbidity (AS), preterm birth (UM) and low birthweight (UM). Risk of bias was generally acceptable, although the limited number and quality of some studies preclude definite conclusions.ConclusionLimited evidence is available on pregnancy outcomes in AS and UM in Europe. The adverse outcomes reported imply that removing barriers to high-quality maternal care should be a priority. More research focussing on migrant subpopulations, considering potential risk factors such as ethnicity and legal status, is needed to guide policy and optimize care.

A growing body of research has documented positive outcomes of gratitude in personal and interpersonal domains. To uncover the dynamic process of gratitude and relational well-being, we examined the interplay of grateful disposition, grateful mood, and grateful expression in ongoing close relationships. Hong Kong Chinese couples ( n = 100) participated in a three-wave study across three consecutive weeks. Adopting the Actor–Partner Interdependence Model, we found that at Time 1, grateful disposition not only predicted one’s own grateful mood but also the perceived grateful mood of one’s spouse, both of which predicted marital satisfaction. At Time 2, the couples were randomly assigned to two conditions over 2 weeks: having one spouse keeping a private gratitude journal or overtly expressing gratitude to the other. Couples’ grateful mood increased at Time 3, indicating the effectiveness of both interventions. However, the resulting changes in marital satisfaction differed for the beneficiaries (enactors) and benefactors (targets), such that husbands who perceived their wife’s expressed gratitude as less sincere declined in their marital satisfaction. The results reveal the boundary conditions in evaluating expressions of gratitude and improvement of relationships and provide implications for social exchange and couple therapy.

Background Calcium and low-dose aspirin are two potential approaches for primary prevention of hypertensive disorders of pregnancy (HDP). This study aimed to explore the acceptability, views and preferences of pregnant women and primary healthcare providers for a fixed-dose combined preparation of aspirin and calcium (a polypill) as primary prevention of HDP in an unselected pregnant population. Methods In this qualitative study eight in-depth semi-structured interviews were conducted with Dutch primary care midwives and general practitioners. Seven focus group discussions were organised with women with low-risk pregnancies. Topics discussed were: perceptions of preeclampsia; information provision about preeclampsia and a polypill; views on the polypill concept; preferences and needs regarding implementation of a polypill. Thematic analysis of the data transcripts was carried out to identify emerging themes. Results Two major themes shaped medical professionals’ and women’s views on the polypill concept: ‘Informed Choice’ and ‘Medicalisation’. Both could be divided into subthemes related to information provision, personal choice and discussions with regard to the balance between ‘unnecessary medicalisation’ and ‘scientific progress’. Conclusions In general, women and healthcare practitioners expressed a positive attitude towards a polypill intervention as primary prevention strategy with aspirin and calcium, providing some conditions are met. The most important conditions for implementation of such a strategy were safety, effectiveness and the possibility to make a well-informed autonomous decision. Electronic supplementary material The online version of this article (10.1186/s12978-019-0707-8) contains supplementary material, which is available to authorized users.

BACKGROUND: Travel distance to surgical centers may be increased when coverage restrictions prevent children with congenital heart disease (CHD) from receiving care at out-of-state congenital heart surgery centers. We estimated the minimum travel distance to congenital heart surgery centers among publicly insured infants with time-sensitive CHD surgical needs, under two different scenarios: if they were and were not restricted to in-state centers. METHODS AND RESULTS: Using 2012 Medicaid Analytic extract data from 40 states, we identified 4,598 infants with CHD that require surgery in the first year of life. We calculated the minimum travel distance between patients’ homes and the nearest cardiac surgery center, assuming patients were and were not restricted to in-state centers. We used linear regression to identify demographic predictors of distance under both scenarios. When patients were not restricted to in-state centers, mean minimum travel distance was 43.7 miles, compared to 54.1 miles when they were restricted. For 5.9% of patients, the difference in travel distance under the two scenarios exceeded 50 miles. In six states, the difference in mean minimum travel distance exceeded 20 miles. Under both scenarios, distance was positively predicted by rural status, residence in middle-income zip codes, and white/non-Hispanic or American Indian/Alaskan Native race/ethnicity. CONCLUSIONS: For some publicly insured infants with severe CHD, facilitating the receipt of out-of-state care could mitigate access barriers. Existing efforts to regionalize care at fewer centers should be designed to avoid exacerbating access barriers among publicly insured CHD patients.

BackgroundPreterm birth is the leading cause of under-five-mortality worldwide, with the highest burden in low-income and middle-income countries (LMICs). The aim of this study was to synthesise evidence-based interventions for preterm and low birthweight (LBW) neonates in LMICs, their associated neonatal mortality rate (NMR), and barriers and facilitators to their implementation. This study updates all existing evidence on this topic and reviews evidence on interventions that have not been previously considered in current WHO recommendations.MethodsSix electronic databases were searched until 3 March 2020 for randomised controlled trials reporting NMR of preterm and/or LBW newborns following any intervention in LMICs. Risk ratios for mortality outcomes were pooled where appropriate using a random effects model (PROSPERO registration number: CRD42019139267).Results1236 studies were identified, of which 49 were narratively synthesised and 9 contributed to the meta-analysis. The studies included 39 interventions in 21 countries with 46 993 participants. High-quality evidence suggested significant reduction of NMR following antenatal corticosteroids (Pakistan risk ratio (RR) 0.89; 95% CI 0.80 to 0.99|Guatemala 0.74; 0.68 to 0.81), single cord (0.65; 0.50 to 0.86) and skin cleansing with chlorhexidine (0.72; 0.55 to 0.95), early BCG vaccine (0.64; 0.48 to 0.86; I2 0%), community kangaroo mother care (OR 0.73; 0.55 to 0.97; I2 0%) and home-based newborn care (preterm 0.25; 0.14 to 0.48|LBW 0.42; 0.27 to 0.65). No effects on perinatal (essential newborn care 1.02; 0.91 to 1.14|neonatal resuscitation 0.95; 0.84 to 1.07) or 7-day NMR (essential newborn care 1.03; 0.83 to 1.27|neonatal resuscitation 0.92; 0.77 to 1.09) were observed after training birth attendants.ConclusionThe findings of this study encourage the implementation of additional, evidence-based interventions in the current (WHO) guidelines and to be selective in usage of antenatal corticosteroids, to reduce mortality among preterm and LBW neonates in LMICs. Given the global commitment to end all preventable neonatal deaths by 2030, continuous evaluation and improvement of the current guidelines should be a priority on the agenda.

Objective To assess the feasibility of the application of International Classification of Diseases-10—to perinatal mortality (ICD-PM) in a busy low-income referral hospital and determine the timing and causes of perinatal deaths, and associated maternal conditions. Design Prospective application of ICD-PM. Setting Referral hospital of Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania. Population Stillbirths and neonatal deaths with a birth weight above 1000 grams born between October 16th 2017 to May 31st 2018. Methods Clinical information and an adapted WHO ICD-PM interactive excel-based system were used to capture and classify the deaths according to timing, causes and associated maternal complications. Descriptive analysis was performed. Main outcome measures Timing and causes of perinatal mortality and their associated maternal conditions. Results There were 661 perinatal deaths of which 248 (37.5%) were neonatal deaths and 413 (62.5%) stillbirths. Of the stillbirths, 128 (31%) occurred antepartum, 129 (31%) intrapartum and for 156 (38%) the timing was unknown. Half (n = 64/128) of the antepartum stillbirths were unexplained. Two-thirds (67%, n = 87/129) of intrapartum stillbirths followed acute intrapartum events, and 30% (39/129) were unexplained. Of the neonatal deaths, 40% died after complications of intrapartum events. Conclusion Problems of documentation, lack of perinatal death audits, capacity for investigations, and guidelines for the unambiguous objective assignment of timing and primary causes of death are major threats for accurate determination of timing and specific primary causes of perinatal deaths.

Malingering is relatively common in criminal forensic evaluations as base rates of malingering have ranged from 20% to 30%. Given that the most prevalent criminal forensic evaluation is the assessment of competency to stand trial, the assessment of feigning during competency evaluations is necessary for accurate findings. Most of the response style literature focuses on feigning mental health symptoms, but in competency evaluations, individuals may attempt to feign legal knowledge deficits in order to be found incompetent to stand trial. The current investigation includes two studies: 195 students instructed to simulate feigned mental illness or incompetence to stand trial and one using a sample of 130 state psychiatric hospital residents who had been adjudicated incompetent to stand trial. The purpose of the study was to evaluate the Inventory of Legal Knowledge’s (ILK; Musick & Otto, 2010) ability to detect individuals who are feigning legal knowledge deficits. Classification utility statistics, including sensitivity, specificity, positive predictive power, and negative predictive power are provided for each cut-score on the ILK beginning with a cut-score of 24 (which is the lower end of the range of chance) are provided. The current cut-score of 47 provided in the professional manual of the ILK was shown to create a large number of false positives and suggests that modifications to this cut-score are required.

Zika virus has recently emerged as a new public health threat. An arthropod-borne virus named after the Zika forest in Uganda, it was first discovered in 1947. The virus caused only sporadic cases of Zika infection in Africa and Southeast Asia until 2007, when the first large outbreak occurred in the Yap State in the Federated States of Micronesia. Another outbreak in French Polynesia in 2013 was notable for being associated temporally with an increase in cases of Guillain-Barré syndrome. In 2015, the virus was first reported in Brazil and since then has spread explosively through several additional countries in South and Central America and the Caribbean. Simultaneously, several of these countries have seen a dramatic increase in the incidence of infants born with microcephaly. The rapid spread of Zika virus through the Americas, together with the association of infection with microcephaly and Guillain-Barré syndrome, has resulted in the World Health Organization declaring a public health emergency. Zika virus has the potential to spread to new areas where the Aedes mosquito vector is present and therefore presents a risk to the United States. This concise review describes the clinical features of Zika virus infection and provides advice for clinicians on counseling travelers and others about the disease.